Boston
Medical Library
8 The Fenway
PROCEEDINGS
>
/ :
, O 3
OF THE J,
•v*
LARYNGOLOGICAL SOCIETY
OF
LONDON.
VOL. I.
1893 - 94 .
WITH
LISTS OF OFFICERS. MEMBERS, RULES, ETC.
LONDON:
PRINTED BY ADLARD AND SON, *
BARTHOLOMEW CLOSE, E.C., AND 20, HANOVER SQUARE, W.
1895.
OFFICERS AND COUNCIL
OP THIS
^argngolojjiial S>ocietj> of ^otibon
ELECTED AT
THE ANNUAL GENERAL MEETING,
JANUARY 10th, 1894.
Igrtstbttrt.
FELIX SEMON, M.D., F.R.CP.
#ite-|)rt6ibittf0.
P. McBRIDE, M.D. W. McN. WHISTLER, M.D
Crtasam.
H. T. BUTLIN, Esq.
librarian.
F. de HAVILLAND HALL.
Semtaries.
E. CLIFFORD BEALE, M.B. SCANES SPICER, M.D.
dotraril.
E. CRESSWELL BABER, M.B. DUNDAS GRANT, M.D.
A. BRONNER, M.D. T. MARK HOYELL, Esq.
C. J. SYMONDS, Esq.
PRESIDENTS OF THE SOCIETY
{From its Formation.)
ELECTED
1893 Sib Geoege Johnson, M.D., F.R.S.
1894 Felix Semon, M.D., F.R.C.P.
PROCEEDIN
OP TUB
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, May 1 Oth, 1893.
Felix Semon, M.D., F.E.C.P., Vice-President, in the Chair.
E. Clifford Beale, M.B.,
Scanes Spicer, M.D.,
Secretaries.
Present—16 Members and 3 Visitors.
The following gentlemen were elected Members of the Society:
Herbert Tilley, M.D., F.R.C.S.
Bichard Lake, F.R.C.S.
R. S. Charsley, M.R.C.S.
The following candidates were proposed for election:
Charles Rotherham Walker, M.D., Leytonstone.
Dennis Embleton, M.R.C.S., Bournemouth.
Henry Davis, M.R.C.S., London.
Vincent Dormer Harris, M.D., F.R.C.P., London.
William Arthur Aikin, M.D., London.
The minutes of the previous meeting were read and confirmed.
Dr. de Havilland Hall moved, and Dr. Dundas G-rant seconded, a
vote of thanks to Dr. Semon for his generous gift to the Society of
twelve electric lamps. This was carried by acclamation, and
Dr. Semon replied.
The following case was exhibited by Mr. Cresswell Baber.
Cicatrix of Pharynx.
M. B—, set. 15. At three and a half years of age the patient had
severe scarlet fever with a very bad throat, and subsequently an attack
of measles. Scarlatina left her with purulent discharge from either
ear; also a difficulty in swallowing, which latter has not given her
much trouble till recently. Admitted into the Brighton Throat and
Ear Hospital November 7th, 1892. She takes soft food readily, but
first series—VOL. i. 2
10
for meat requires an unusually loz* time. Li:mis in small quantities
are easily swallowed, but in large quantities produce a feeling of
suffocation. Mates a slight nci^e during sleep. \d dj spaces. No
reliable historr of congenital syphilis. Oro-p narym presents a broad
white band extending across its posterior wall. Behind uvula it
leaves a gap measuring some ^ x \ inch. On depressing the tongue
firmly the upper end of a second opening conies into view. Irregular
granulations on sides of cicatrix. With laryngoscope the cicatrix is
seen to extend to either side of the epiglottis, leaving a heart-shaped
opening about \ inch across, through which the larynx is seen.
Note. —Catarrh.
Bare .— A perforation of either membrane.
November 19th.—Under cocaine the lower opening in cicatrix was
enlarged posteriorly by removal of a piece of the cicatrix of about the
size of half a sixpence. Tne tendency to contraction was as far as
possible prevented by systematic dilatation with the forefinger. The
result is that the opening is slightly larger and the patient swallows
quite well now, but still makes some noise during sleep. It was thought
that a large ulcer on the posterior pharyngeal wall had, in healing,
drawn the two sides of the pharynx together.
Dr. Hall thought that no further treatment was advisable in this
case.
Mr. Charters Stmonds referred to two cases of pharyngeal stric¬
ture. One in a syphilitic child, where the opening was small and
annular, admitting the tip of the forefinger. The child could
swallow freely through the opening. In the other the pharynx was
closed at the root of the tongue by a thin web, in which was a small
orifice. The palate was not adherent, and nasal respiration was
possible. He did not think that dilatation by bougies was of any use
in such cases.
MyX(EDEMA TREATED BY FEEDING WITH FRESH THYROID GLAND.
Mr. Cbesswell Baber showed photographs of a patient, a
married lady, set. 57, who had exhibited symptoms of myxoedema for
about ten years. First seen January 24th, 1893, in consultation
with Dr. Uhthoff. Thyroid gland could not be felt.
January 27th.—Half lobe of raw sheep’s thyroid was given. This
was followed in about thirty hoars by the usual “aching” all over
the body. Temperature, which had been subnormal, rose, and a
teasing, hacking cough came on. Examined on February 3rd the
11
larynx and pharynx were found normal. No abnormal chest-sounds,
except slight rhonchus. Tenderness on pressure over region of
thyroid isthmus. Puffiness slightly diminished.
During next three weeks rather over half a lobe of gland was given.
On 26th her head began to feel queer, as if she were going out of
her mind. She became completely changed from her usual manner,
being very excitable, trying to lock herself into her room, and
exhibiting symptoms resembling subacute mania, with sleeplessness.
Seen March 4th she had a wild look about her eyes, but no delusions.
Her appearance had greatly improved. There had been general
desquamation, which was still going on on hands and feet. Ordered
Ammon. Bromid. gr. x, 4tis horis. Soon after this the head sym¬
ptoms disappeared, sleep returned, and the patient gradually im¬
proved. One third of a lobe of thyroid given at longer intervals
produced slight headache, but no further head symptoms. Previous
to other treatment there had been no mental disturbance, and there
is no insanity in the family.
Between January 25th and April 28th she lost 1 stone 1 lb. 6 oz.
in weight. Very slight return of perspiration, which was absent before
treatment. Some regrowth of hair on head. Marked improvement
in brightness of intellect, quickness of movement, &c. The presence
of tenderness over the region of the thyroid isthmus with cough and
attacks of choking at night are said to have occurred on and off for
several years, and were perhaps temporarily intensified by the treatment.
Dr. Clifford Beale showed a case of myxoedema successfully
treated by small doses of simple glycerine extract of thyroid gland.
Considerable laryngeal dyspnoea had at first been present, owing to
oedema of the uvula, ary-epiglottic folds, and other parts of the
larynx, which had subsided. The skin had been perfectly dry until
small doses of pilocarpin had been given, after which sweating had
been at first profuse but normal ever since.
Syphilitic Disease of Pharynx and Larynx in a Tubercular
Subject.
Dr. Clifford Beale showed a patient with marked family history
of phthisis, and a clear history of infection of syphilis four years
previously. The pharynx was scarred and cicatrised, but the larynx
when first seen presented all the familiar appearances of tubercular
disease, except for detachment, and contraction of the detached end,
OFFICERS AND COUNCIL
OF THE
^axpjologttal $<metg of Hottbon
ELECTED AT
THE ANNUAL GENERAL MEETING,
JANUARY 10th, 1894.
fjmtbent.
FELIX SEMON, M.D., F.R.C.P.
P. McBRIDE, M.D. W. McN. WHISTLER, M.D.
ftrtasam.
H. T. BUTLIN, Esq.
Itibrarian.
F. DE HAVILLAND HALL.
Stmtariw.
E. CLIFFORD BEALE, M.B. SOANES SPICER, M.D.
<£mmnl.
E. CRESSWELL BABER, M.B. DUNDAS GRANT, M.D.
A. BRONNER, M.D. T. MARK HOYELL, Esq.
C. J. SYMONDS, Esq.
PRESIDENTS OF THE SOCIETY.
{From its Formation.)
ELECTED
1893 Sib George Johnson, M.D., F.R.S.
1894 Felix Semon, M.D., F.R.C.P.
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, May 10th, 1893.
Felix Semon, M.D., F.E.C.P., Vice-President, in the Chair.
E. Clifford Beale, M.B.,
Scanes Spicer, M.D.,
Secretaries
Present—16 Members and 3 Visitors.
The following gentlemen were elected Members of the Society:
Herbert Tilley, M.D., F.R.C.S.
Bichard Lake, F.B.C.S.
R. S. Charsley, M.R.C.S.
The following candidates were proposed for election:
Charles Rotherham Walker, M.D., Leytonstone.
Dennis Embleton, M.R.C.S., Bournemouth.
Henry Davis, M.R.C.S., London.
Vincent Dormer Harris, M.D., F.R.C.P., London.
William Arthur Aikin, M.D., London.
The minutes of the previous meeting were read and confirmed.
Dr. de Havilland Hall moved, and Dr. Dundas Grant seconded, a
vote of thanks to Dr. Semon for his generous gift to the Society of
twelve electric lamps. This was carried by acclamation, and
Dr. Semon replied.
The following case was exhibited by Mr. Cresswell Baber.
Cicatrix of Pharynx.
M. B—, set. 15. At three and a half years of age the patient had
severe scarlet fever with a very bad throat, and subsequently an attack
of measles. Scarlatina left her with purulent discharge from either
ear; also a difficulty in swallowing, which latter has not given her
much trouble till recently. Admitted into the Brighton Throat and
Ear Hospital November 7th, 1892. She takes soft food readily, but
FIRST SERIES—VOL. I. 2
10
for meat requires an unusually long time. Liquids in small quantities
are easily swallowed, but in large quantities produce a feeling of
suffocation. Makes a slight noise during sleep. No dyspnoea. No
reliable history of congenital syphilis. Oro-pharynx presents a broad
white band extending across its posterior wall. Behind uvuia it
leaves a gap measuring some £ x \ inch. On depressing the tongue
firmly the upper end of a second opening comes into view. Irregular
granulations on sides of cicatrix. With laryngoscope the cicatrix is
seen to extend to either side of the epiglottis, leaving a heart-shaped
opening about \ inch across, through which the larynx is seen.
Nose. —Catarrh.
Ears .—A perforation of either membrane.
November 19th.—Under cocaine the lower opening in cicatrix was
enlarged posteriorly by removal of a piece of the cicatrix of about the
size of half a sixpence. The tendency to contraction was as far as
possible prevented by systematic dilatation with the forefinger. The
result is that the opening is slightly larger and the patient swallows
quite well now, but still makes some noise during sleep. It was thought
that a large ulcer on the posterior pharyngeal wall had, in healing,
drawn the two sides of the pharynx together.
Dr. Hall thought that no further treatment was advisable in this
case.
Mr. Charters Symonds referred to two cases of pharyngeal stric¬
ture. One in a syphilitic child, where the opening was small and
annular, admitting the tip of the forefinger. The child could
swallow freely through the opening. In the other the pharynx was
closed at the root of the tongue by a thin web, in which was a small
orifice. The palate was not adherent, and nasal respiration was
possible. He did not think that dilatation by bougies was of any use
in such cases.
Myxcbdema treated by Feeding with Fresh Thyroid Gland.
Mr. Cresswell Baber showed photographs of a patient, a
married lady, set. 57, who had exhibited symptoms of myxoedema for
about ten years. First seen January 24th, 1893, in consultation
with Dr. Uhthoff. Thyroid gland could not be felt.
January 27th.—Half lobe of raw sheep’s thyroid was given. This
was followed in about thirty hours by the usual “aching” all over
the body. Temperature, which had been subnormal, rose, and a
teasing, hacking cough came on. Examined on February 3rd the
11
larynx and pharynx were found normal. No abnormal chest-sounds,
except slight rhonchus. Tenderness on pressure over region of
thyroid isthmus. Puffiness slightly diminished.
During next three weeks rather over half a lobe of gland was given.
On 26th her head began to feel queer, as if she were going out of
her mind. She became completely changed from her usual manner,
being very excitable, trying to lock herself into her room, and
exhibiting symptoms resembling subacute mania, with sleeplessness.
Seen March 4th she had a wild look about her eyes, but no delusions.
Her appearance had greatly improved. There had been general
desquamation, which was still going on on hands and feet. Ordered
Ammon. Bromid. gr. x, 4tis horis. Soon after this the head sym¬
ptoms disappeared, sleep returned, and the patient gradually im¬
proved. One third of a lobe of thyroid given at longer intervals
produced slight headache, but no further head symptoms. Previous
to other treatment there had been no mental disturbance, and there
is no insanity in the family.
Between January 25th and April 28th she lost 1 stone 1 lb. 6 oz.
in weight. Very slight return of perspiration, which was absent before
treatment. Some regrowth of hair on head. Marked improvement
in brightness of intellect, quickness of movement, &c. The presence
of tenderness over the region of the thyroid isthmus with cough and
attacks of choking at night are said to have occurred on and off for
several years, and were perhaps temporarily intensified by the treatment.
Dr. Clifford Beale showed a case of myxoedema successfully
treated by small doses of simple glycerine extract of thyroid gland.
Considerable laryngeal dyspnoea had at first been present, owing to
oedema of the uvula, ary-epiglottic folds, and other parts of the
larynx, which had subsided. The skin had been perfectly dry until
small doses of pilocarpin had been given, after which sweating had
been at first profuse but normal ever since.
Syphilitic Disease of Pharynx and Larynx in a Tubercular
Subject.
Dr. Clifford Beale showed a patient with marked family history
of phthisis, and a clear history of infection of syphilis four years
previously. The pharynx was scarred and cicatrised, but the larynx
when first seen presented all the familiar appearances of tubercular
disease, except for detachment, and contraction of the detached end,
12
of the left ventricular band. Under treatment all the acute symptoms
had disappeared, but the oedematous swelling of the epiglottis and the
arytenoid cartilages had only begun to get less after the syphilitic
signs had cleared up.
Rhinitis atrophica fotida.
Dr. William Hill showed a pathological specimen of rhinitis
atrophica foetida in association with—
1. Altenee (? congenital) of—
(a) Septum (mostly absent).
(b) Middle turbinals.
(c) Inferior turbinals.
2. Cleft of hard palate (complete).
There appeared to have been at a former period a cleft of soft
palate and hare-lip, since united by operation. The openings into the
accessory cavities were normal, with the exception that there was a
large accessory opening into the antrum of Highmore on each side.
The sphenoidal sinuses were small.
Mr. Stewart suggested that the absence of the turbinals was due
to the atrophic rhinitis, and not the rhinitis to the absence of the
bones. A congenital malformation might have been present in
addition to the rhinitis.
Mr. Baber thought that the condition was probably the result of
syphilis.
Dr. Hill, in reply, urged that the symmetrical absence of the parts,
the cleft in the palate, and the want of evidence of bone disease,
pointed to a congenital rather than a pathological origin.
Right Hemiplegia; Paralysis op Right Half of Soft Palate
and Abductor-paresis of Right Vocal Cord, the last-
named CERTAINLY NOT OF CORTICAL ORIGIN.
Dr. Felix Semon showed this case. X. H—, set 19, dressmaker.
(The patient is shown by kind permission of Dr. Hughlings Jackson,
F.R.S., under whose care she is at present as an in-patient in the
National Hospital for Epilepsy and Paralysis.)
Hittory .—Previously always well. Family history good. In
December, 1890, a box of matches got alight in the patient’s hand
one night, frightening her very much, although she was not burnt.
But the fumes, she says, went down her throat. Next morning on
IS
waking she was unable to speak or to move her right arm, and leg .
Fluids also regurgitated through the nose. She remained like this
three to four days: then first the speech returned, a little later she
could swallow well, in about fourteen days the leg began to get better,
and she could walk in four to five weeksj about a month after the
attack the arm began to improve, and since then she has gradually
recovered.
Present condition. —No facial or ocular paralysis. Tongue not
wasted, put out in median line. The soft palate on phonation is
decidedly drawn up towards the left. Its right half acts less to
faradism than the left. Tactile sensibility and reflex irritability.
Voice very slightly nasal, but all consonants correctly pronounced.
Larynx. —Fight vocal cord does not stand quite in median line, but
very near it, and on attempted phonation makes a slight but very
distinct inward movement, so that during the act of phonation, the
left cord coming up perfectly normal, the glottis is entirely closed in
the median line. On inspiration the right cord returns to its previous
position very near the median line, whilst the left is well abducted.
In deep inspiration the right cord does not go any further outwards,
whilst the left goes completely to the side of the larynx. The right
Santorinian cartilage stands considerably more inwards than the left,
so that, even apart from position of the right vocal cord, the laryngeal
image is somewhat asymmetrical. The laryngeal conditions appear to
be stationary.
Arms. —The right arm feels colder to the touch than the left.
Eight deltoid appears smaller than the left, and the right arm moves
less perfectly than the left. She cannot put the right hand to the
back of her head, and, as she raises the arm, there is more rotatory
movement of the right scapula than on the left. Flexion and
extension of the right elbow are less powerful than on left. Flexion
and extension on right wrist very imperfect. Eight fingers in a state
of flexion, allowing of passive extension, but can only be moved volun¬
tarily to a small extent. No defect of sensation.
Legs. —Movements are perfectly carried out, but with less power
on right than on left. Plantar reflexes present, more on left than on
right.
Slight systolic murmur over base.
Lungs normal. Catamenia normal.
Remarks. —The interest in this case, of course, centres in the
§
14
question, whether the paralysis of the soft palate and larynx are of
cortical origin or not. With regard to the palate I wish to leave this
question somewhat open, although I do not know of any clinical
case proving the occurrence of cortical paralysis of the palate, because
Mr. Horsley tells me that he and Beevor have obtained unilateral
movements of the opposite half of the soft palate on cortical excitation.
The laryngeal paralysis, however, I feel convinced is not of cortical
origin, and this for the following reasons :
The only experimenter who states that he has obtained isolated
movements of the opposite vocal cord on gentle stimulation of the
phonatory area in the cortex ( i . e. just posterior to the lower end of
the praecentral sulcus at the base of the third frontal gyrus in the
monkey, and in the praecrucial and neighbouring gyrus in the carni¬
vora) is Masini. Previously Krause had found that unilateral irrita¬
tion always produced ^lateral effect, and Horsley and myself in very
numerous experiments, performed both before and after Masini’s pub¬
lications, have also always obtained a ^lateral effect, and have never
been able to corroborate Masini’s statement (vide paper u On the
Relations of the Larynx to the Motor Nervous System," 'Deutsche
medicin. Wochenschrift,’ No. 31, 1890).
On one point, however, all experimenters are agreed, viz. that the
laryngeal movements obtained on stimulation of any part of the cortex,
always —except in the cat—are of the nature of adduction of the
vocal cords, never of adduction. This result is entirely in accord with
our general physiological notions on the two widely different functions
of the larynx, its purposive function, phonation, only being specially
represented in the cortex by the movement of adduction, whilst its
more automatic function, respiration, has its centre in the medulla,
and is manifested by the movement of inspiration, i. e. adduction of
the vocal cords.
Even supposing, therefore, that Masini’s contention were correct,
and that an isolated cross effect could be exercised from one cortical
phonatory centre, this effect could only concern the movement of
adduction. Or, pathologically expressed, supposing that such an
isolated cross-effect existed and that the area from which it proceeded
was destroyed in man by disease or injury, this could only manifest
itself by the opposite vocal cord remaining behind in voluntary adduc¬
tion, i. e. in phonation, just as we see it ^laterally in functional aphonia.
The respiratory position of the vocal cords, however, would in such a
15
hypothetical case of coarse be the same as under normal circumstances,
and the inspiratory movement, i.e. adduction of the affected cord,
would be effected without the least hindrance to its fullest extent, as
this movement is entirely governed by bulbar influences.
In the present case, however, the actual conditions are quite the
reverse from what one would expect them to be, if Masini’s state¬
ments were correct: the right vocal cord is fixed near the median line
fluring respiration, its purposive cortical movement, i. e. adduction
fluring phonation, is still effected, whilst the actual impairment con¬
cerns the automatic and eminently bulbar movement, i. e. adduction
during inspiration.
From these facts the conclusion appears justified, that the laryngeal
paralysis cannot be of cortical origin, and that it must be due to a
lesion further down. The diminished reaction of the right half of the
palate to faradic excitation certainly points in the same direction.
Attention may finally be directed towards the very remarkable case
of hemiplegia, in many respects closely resembling the one now pre¬
sented, and in which there was also adductor-paralysis of one vocal
cord with paralysis of the corresponding half of the soft palate,
which was brought forward as an example of cortical laryngeal para¬
lysis before the Laryngological Section of the Eighth International
Medical Congress of Copenhagen in 1884 by Dr. Bryson Delevan, of
New York, and in which the post-mortem examination made four
years later in the most thorough and painstaking manner, conclusively
proved that the assumedly cortical paralysis of the vocal cord in
reality was due to a focus of softening in the medulla , completely
destroying the motor vagus-nucleus (‘ New York Med. Journal,*
22nd June, 1889).
Isolated Tertiary Syphilts op Naso-pharyngeal Cavity, simu¬
lating Paralysis op Left Half op Sopt Palate.
Exhibited by Dr. Felix Semon. J. W—, set. 30, accountant. Two
months ago the patient suffered from what was declared to be tonsillitis.
On recovering from this the voice assumed a very nasal timbre, which
still persisted when the patient was first seen on April 26th. There
had, however, never been any regurgitation of fluids through the nose,
no paralysis of any other part, and there was no evidence that the
acute attack had been of diphtheritic character.
16
On examination it was seen that the soft palate, which otherwise,
as well as the rest of the mouth, throat, and larynx, seemed qnite
normal, was on pbonation distinctly drawn up towards the right. No
ocular paralysis.
On posterior rhinoscopy almost the whole upper part of the naso¬
pharyngeal cavity was seen to be ulcerated, a deep ulcer with steep
edges especially occupying the posterior surface of the right half of
the soft palate.
On inquiry it was then elicited that the patient had had a chancre
ten years ago, but, according to his statements, there had never been
any secondary symptoms.
It is difficult to say why the palate should be drawn up on phona-
tion towards the right , the ulceration prominently occupying that side
of its posterior surface, and no explanation of this fact is ventured
upon.
The ulceration is rapidly healing under the use of iodide of potassium
and mercury, but is still distinctly visible on the posterior surface of
the right half of the palate.
Pachydermia op the Larynx.
Two cases exhibited by Dr. Pelix Semon. J. G—, set. 42, soli¬
citor, and G. G—, set. 52, clergyman.
The two cases were typical, and only shown on account of the com¬
parative rarity of the affection. In the case of Mr. J. C— the left,
in the case of the Rev. G. G— the region of the right vocal process,
was the part affected, and in both cases the characteristic indenta¬
tions on the top of the tumefaction were very well marked. Special
attention was directed towards the free mobility of the affected cords.
In both cases the voice was but very slightly hoarse and there was
but little local discomfort. The case of Mr. J. C— is of about three
months' standing, that of the Rev. G. G— of nearly a year's ; the
unusual persistence of the latter case is probably to be attributed to
chronic alcoholism of very pronounced type. (It may be also men¬
tioned that this patient, who for fourteen years or more has had two
symmetrical lymphomatous tumours in the nape of his neck, has
recently developed several more of these at the sides and in front of
the neck. They are, however, diminishing under the use of arsenic
in large doses.)
17
The treatment in both cases has consisted in as complete rest of
the voice as possible, iodide of potassium internally, frequent sucking
of ice. In both cases so far the affection has remained almost limited
to the vocal cord first attacked. Only in the case of the clergyman
a very small indentation, corresponding to the summit of the swelling
opposite, is now becoming visible on the posterior end of the left vocal
cord.
Dr. Hall, who had seen one of these patients some six months
previously, concurred in the diagnosis, and commented upon the
slight change that had taken place in the interval.
In reply to various questions, Dr. Semon stated that the disease
did not show any preference for one or the other side. It generally
appeared on the processus vocalis, and usually in voice users. It was
certainly maintained by any condition such as chronic alcoholism
which tended to keep up irritation. As a rule, the disease got well
under the steady use of iodide of potassium. Attempts at removal
were usually unsuccessful, and perichondritis was apt to follow. The
crateriform depression on the tumour and the perfectly free move¬
ment of the cords were very strong diagnostic points.
Tabes Dorsalis ; Bilateral Paralysis of Glottis-openers with
Paralysis of Internal Tensors of more than twelve
years' standing.
Exhibited by Dr. Felix Semon. W. G—, ®t. 02, fishmonger.
The patient, whose initial tabic symptoms dated back, according to his
own statements, to nearly twenty-five years ago, had suffered from fully
developed bilateral paralysis of the posterior crico-arytaenoid muscles
to a certainty as far back as 1881, when he was in Guy’s Hospital under
Dr. Goodhart, by whose permission he was shown to the Laryngological
Section of the International Congress in London ('Trans. Intemat. Med.
Congress/ 1881, vol. iii, p. 332). Since then the general tabic sym¬
ptoms, which are of the ordinary kind, have made, though steady, yet
exceedingly slow progress, and it need only be mentioned that in the
right knee Charcot's joint-disease has developed, and that in the larynx
bilateral paralysis of the internal thyro-arytaenoid muscles, manifested
by elliptic gaping during inspiration of the glottis, which otherwise
remains closed in front, and posteriorly has been superadded to the
bilateral paralysis of the posterior crico-arytsenoid muscles.
Remarks .—The case is again shown :
1. On account of its uncommonly slow course and the persistence
18
for certainly more than twelve years of the paralysis of the glottis-
openers.
2. Because the paralysis of the internal tensors developed since
1881 corroborates the statement made by me in 1883, and since illus¬
trated by Burger, viz. that these muscles are the next in order of occur¬
rence to succumb to progressive organic disease, after the abductors.
S. Because this very paralysis of the internal tensors whilst the
cords remain in the mid-line, incontrovertibly shows that the whole
process is one of primary paralysis, and not one of primary neuropathic
contracture.
4. Because this patient (as well as the one shown at the last meet¬
ing) is able, although his posterior crico-arytaenoid muscles undoubt¬
edly must have undergone almost complete fatty degeneration and
atrophy, to produce without the least effort both high and low notes,
which strongly militates against the supposed existence of a synergy
of the antagonistic laryngeal muscles in the performance of their
functions.
Chronic Induration in Pharynx.
Dr. Scanes Spicer showed a patient, set. 50, a married woman,
who had complained of difficulty of swallowing, especially of solids,
which always required washing down with liquids; no pain, but a bad
taste in mouth. %
Had an injury over right temple ten years ago, leading to an
external swelling. This disappeared and a swelling appeared inside
mouth in region of right ascending ramus, which were lanced with
escape of blood only, and now shows scars and thickening. No
specific history. Catamenia stopped seven years ago.
There was an old perforation of posterior wall of pharynx on right
side, through which was seen a yellow slough with much induration of
right posterior pillar and adjacent parts.
Papillomata of Nostril and Gum.
Dr. Scanes Spicer showed microscopic specimens of the growths
from the patient shown at the last meeting. One had been removed
in 1888 and the other in 1893, and both appeared to be typical
papillomata.
Mr. Charters Symonds thought that the microscopic characters
pointed to the lupoid nature of the case. There was abundant small-
19
celled granulation tissue, arranged in nodules. The papillse were
irregular, and some of them very large.
Lupus of Nose.
Mr. W. R. H. Stewart showed a patient, R. B—, set. 58. Fell
on nose fourteen years ago and broke it. Some little while after the
nose began to get blocked on the left side and sore outside. When
seen last year left nostril was completely blocked by a papillomatous
growth from the septum, and there was some superficial ulceration of
the left side of the nose and upper lip. The growth was destroyed
by the galvano-cautery, and antisyphilitic treatment was tried. The
patient did not much improve. Unna's plaster was then applied to the
outside of the nose and gave the characteristic reaction. The patient
refused further operative treatment.
Mr. W. R. H. Stewart also showed the following case:
E. F—, set. 10, came to the Great Northern Hospital two years
ago, complaining of a stoppage of the nose and swelling outside which
she had had for three years. The skin over the right side of the nose
was smooth and thickened, the inside of the nose was quite normal,
but the naso-pharynx was packed with adenoids. There was some
keratitis and one tooth was decidedly pegged. The parents are both
healthy, have nine children j this one, who is a twin, comes about
seventh or eighth. The adenoids were scraped and there was a great
improvement, but the thickening of the nose never got much less.
Some time after, the nose again becoming stopped, the right nostril was
found blocked with what looked like lupoid tissue. It was well
scraped and lactic acid applied, and the breathing greatly improved,
but the thickened condition of the skin remained, and some brownish
patches and slight superficial ulceration appeared. This, however,
has not yielded any reaction to Unna’s plaster. The left nostril has
now begun to be blocked.
Mr. Cbesswell Baber said that he had found resorcin of some
value in the form of ointment in cases of external lupus of the nose.
Dr. Hall asked if the direct application of cold had been tried in
such cases, as advised by some continental observers.
Dr. Beale related a case of lupus of the cheek, in which he had
used small ice-bags for several hours at a time over a period of about
three weeks, with much discomfort to the patient and no result what¬
ever upon the disease.
Mr. Stewart proposed to try resorcin. He mentioned the case of
sarcoma shown at the last meeting, in which he had been using large
20
doses of arsenic as recommended by some of the members present.
Hitherto it had done no good.
Probable Malignant Disease op Epiglottis and Bight Side
op Larynx.
Mr. Butlin exhibited a patient, set. 62 , a pastrycook, who had been
attacked with almost sudden dysphagia six months ago. Enlarged
gland discovered shortly afterwards. A little blood in expectoration
occasionally (blood-tinged sputa only). Temperature normal. Urine ,
no albumen. Lungs natural. No history of syphilis. One brother
said to have died of consumption. Has been taking Potass. Iod. 5 to
10 gr. for nearly a month. Grows worse instead of better.
Traumatic Perichondritis ? of Larynx.
The patient, a male, set. 62, exhibited by Mr. Charters Symonds,
stated that four months ago he felt sudden pain in the left side of
the larynx while eating fish, since which time he had had a painful
spot on the left side and an irritable cough. When seen some ten
days after there was a good deal of swelling of the left arytenoid,
which looked shiny and smooth. Later it extended along the fold
and the cord became fixed. At the present time there is a rounded
smooth swelling of the arytseuoid and ary-epiglottic fold, with fixation
of this side. There is no rough surface, no ulceration, no purulent
secretion, no external swelling. Antisyphilitic remedies have not done
good. There is a suspicion of phthisis at the left apex. The case
appears either a traumatic perichondritis or a new growth.
Epithelioma of Epiglottis.
Mr. Charters Symonds showed a male patient, set. 60, who gave
a history of ten months. The epiglottis was very much enlarged and
thickened, and deeply ulcerated in its posterior surface. There were
numerous glands in the neck also. A case was referred to in which
the entire epiglottis was removed through the neck, with complete
relief to all the symptoms. In the present case the patient swallowed
fairly well.
Dr. Semon thought that the case was probably one of traumatic
perichondritis, but observed that very little reliance could be placed
on histories of sudden affections of the larynx, as they were often
shown to be misleading.
PROCEEDINGS
OP THB
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, October 11 th, 1893.
Felix Semon, M.D., F.E.C.P., Vice-President, in the Chair.
E. Clifford Beale, M.B.,
Soanes Spicer, M.D.,
Secretaries.
Present—17 Members and 2 Visitors.
The following gentlemen were elected Members of the Society:
Charles Eotherham Walker, M.D., Leytonstone.
Dennis Embleton, M.E.C.S., Bournemouth.
Henry Davis, M.E.C.S., London.
Vincent Dormer Harris, M.D., F.E.C.P., London.
William Arthur Aikin, M.D., London.
The following candidates were proposed for election:
Patrick Watson Williams, M.D., Bristol.
Walter George Spencer, M.B., F.E.C.S., London.
William Hale White, M.D., F.E.C.P., London.
The minutes of the previous meeting were read and confirmed.
An exhibition of pathological specimens, macroscopic and micro¬
scopic, illustrating malignant disease of the larynx, was opened by
Mr. Butlin, who showed the following specimens, brought by the
kind permission of the authorities from the museum of St. Bartho¬
lomew’s Hospital.
1. Eecurrent epithelioma (intrinsic) which had grown through and
around the tracheotomy wound. From a man set. 43; thyrotomy
three months before death ; very rapid recurrence.
2. A larynx from which (intrinsic) epithelioma had been removed.
A man set. 60; large abscess cavity around the tracheotomy wound.
3. Epithelioma (intrinsic) from a man set. 56, who had presented
symptoms for some months, and had been brought in dead of dyspnoea.
4. The parts removed from case of epithelioma of larynx (intrinsic).
Patient set. 50; symptoms of two years’ duration. Disease began as
warty growth of left vocal cord.
FIRST SERIES—VOL. 1. 3
22
5. Epithelioma (extrinsic) from a man set. 40. Symptoms of some
months' duration; dyspnoea and dysphagia; death from sadden
attack of dyspnoea, although tracheotomy was performed.
6. Epithelioma (extrinsic). Man set. 45, who died two days after
admission.
7. Epithelioma (extrinsic), old specimen.
Dr. de Havtlland Hall exhibited a specimen from the West¬
minster Hospital Museum (No. 784), the larynx of F. B—, a gentle¬
man set. 56. The right half of the larynx was the seat of a ragged
epitheliomatous growth, which extended across the middle line and
affected the anterior part of the left vocal cord.
F. B— was examined by Dr. Hall for life assurance in June, 1884,
and as he was hoarse a laryngoscopic examination was made, and a
condition of chronic laryngitis discovered; the applicant stated that he
had had hoarseness for twenty years. He consulted Dr. Semon on
account of hoarseness in January, 1885, who noted “ congestion and
relaxation of vocal cords." In August, 1886, F. B— placed himself
under Dr. Hall's care. He was then suffering from almost absolute
loss of voice, and had some difficulty in swallowing. The right ary-
epiglottic fold was swollen and concealed the vocal cord. There was
some external swelling. There was no history of syphilis. Under the
influence of iodide of potassium marked improvement occurred, but as
there had been an attack of laryngeal spasm, tracheotomy was advised
but refused by the patient. Three months later he was found dead
in his bedroom, evidently from an attack of spasm.
Dr. Felix Semon showed the following specimens :
1. The left half of a larynx removed for epithelioma of the left
ventricle of Morgagni on May 3rd, 1887, by Dr. Hahn of Berlin.
This was the well known case of the late Mr. Montagu Williams. The
patient entirely recovered from the operation, regained his voice to
such a degree that he was able to fulfil for nearly six years the duties
of a police magistrate, and finally died in the commencement of 1892
from cardiac disease, altogether unconnected with the previous laryn¬
geal trouble. The case has been described in the ‘ Transactions of
the Clinical Society,' vol. xx, 1887.
2. The right half of a larynx, removed by Sir William MacCorinac
on November 1st, 1887, on account of infiltrating epithelioma, from
a gentleman mt. 57. The patient had been strongly advised to
23
undergo the operation at a considerably earlier date, but could not at
once make up his mind, and when he finally consented the operation
had become considerably more extensive than had been originally
contemplated, the growth by that time having perforated externally
beneath the crico-thyroid muscle. The patient died on the second
day after the operation, apparently from septic pneumonia. No post¬
mortem examination was permitted. A remarkable feature of the
case was the circumstance that there was an epitheliomatous insula in
the middle of the left vocal cord, probably due to contact. The
specimen well illustrates the necessity of arriving at a definite dia¬
gnosis in certain cases of malignant disease of the larynx from clinical
symptoms only, without the aid of the microscope, as the infiltrating
nature of the growth in this case rendered the intra-laryngeal removal
of a fragment for the purposes of microscopic examination impossible.
The case has been described as Case 2 in a paper read by Dr. Semon
and Mr. Shattock before the Pathological Society of London under
the title, “ Three cases of Malignant Disease of the Air-passages.”
‘ Transactions of the Pathological Society,’ 1888.
3. Two specimens, one showing what remained of the larynx, the
other a great part of the necrosed cartilaginous framework expector¬
ated during life of a case of laryngeal cancer in which haemorrhages,
perichondritis, and exfoliation of the greater part of the laryngeal
cartilages occurred. Subsequently pleurisy, gangrenous pneumonia,
and death ensued. The case has been described under the above
title in vol. xxii, 1889, of the Clinical Society’s ‘ Transactions.’ It was
shown again to illustrate the fact that cancerous perichondritis in no
way, clinically or histologically, differs from any other form of peri¬
chondritis. During life the symptoms of perichondritis had for a
considerable time completely masked the phenomena of malignant
disease.
4. The case to which this specimen belonged had been described in
considerable detail in the Collective Investigation of the * Interna¬
tionales Centralblatt fur Laryngologie ’ concerning the question of the
transition of benign laryngeal growths into malignant ones, especially
after laryngeal operation, on p. 160, et seq. The patient was a lady
who first began to suffer from hoarseness and later on aphonia at the
age of twenty-five. When, five years later, she consulted Dr. Semon,
another London laryngologist had already operated in her larynx for
a considerable time without improving the voice. When first seen by
24
Dr. Semon the larynx was in such a condition of swelling and con¬
gestion that it was impossible to decide whether the vocal cords had
grown together anteriorly or whether there jas a growth between
them. Only after nearly a year’s interval could it be seen that there was
actually a papillomatous growth below the anterior commissure. The
growth was removed and the patient fully regained her voice. For
fully two and a quarter years after this she remained well, periodical
laryngoscopic examination showing the complete integrity of the vocal
organ. In May, 1888, it was seen that fresh growth began to
appear at some distance from the original attachment of the papil¬
lomata, viz. on the lower surface of the epiglottis. The vocal cords
were somewhat swollen and congested, their movements more sluggish
than under normal circumstances. Within the next one and a quarter
years, during which time the patient was under the care of
Dr. Barclay Baron of Bristol, rapid development of growth took
place in the larynx, an abscess formed in front of the thyroid carti¬
lage, which had to be opened and never healed; and the patient, in
whose case a radical operation for various reasons was quite out of
the question, died in September, 1889. For fuller details of this
very interesting case the original must be consulted. At the post¬
mortem examination it was seen that the whole larynx was involved in
new growth, which microscopically was found to be a squamous-celled
carcinoma. The vocal cords and ventricular bands could no longer
be distinguished. The greater part of the thyroid cartilage had been
eaten away, and the tumour, having perforated the anterior wall of the
larynx, externally formed an extensive swelling below the anterior
muscles of the neck. Within the tumour itself a large cavity was
found lined by a markedly papillary surface, which only in some
small portions was ulcerated.
The case is most remarkable in many respects, first, in its exces¬
sively long duration (from the beginning of aphonia to the death of
the patient not less than 10£ years). Second, in the fact that herein
reality, a malignant new growth appeared to have followed a benign
one, inasmuch as the two and a quarter years’ interval between the
removal of the original papillomata, during which repeated examina¬
tions showed the complete anatomical integrity of the larynx, practi¬
cally excluded the idea that the disease had been a priori malignant.
This interval equally excludes the interpretation that a transformation
might have been produced by the irritation caused by the intra-laryngeal
25
operations. Thirdly, the marked tendency in this case to retain the
original papillary type is very interesting indeed. When a year and
a half before death recurrence was first manifested, the intra-laryngeal
appearances were still those of papillomata, and the walls of the abscess
cavity resulting from the perichondritis and disappearance of the thy¬
roid cartilage, although epitheliomatous in character, show even how
this papillary type most markedly.
Finally, it deserves to be mentioned that both the original papilloma
and the subsequent development more than five years later of malignant
disease of the larynx followed childbirth.
5. Two specimens of a case of malignant disease of the larynx,
which originally appeared in the form of a pedunculated growth,
springing from the left arytseno-epiglottidean fold. The patient was a
gentleman aged 44, who was sent to Dr. Semon in 1891 by Dr.
Malbranc of Naples, with the diagnosis of angioma of the larynx, and
the appearances fully justified that diagnosis. The tumour was easily
removed with the galvano-caustic loop, and on microscopical examina¬
tion turned out to be not an angioma but an apparently typical papil¬
loma surrounded by a shell of partly fresh, partly organised blood-clot
(microscopic preparations shown). So far the case has been fully
described by Dr. Semon aud Mr. Shattock in the ‘ Transactions of the
Pathological Society ’ of 1891, page 37 et seq. Four and a half
months later the tumour had recurred, and on being again removed
showed distinct evidence of epitheliomatous nature. Subhyoid
pharyngotomy was performed, and the basis of the growth entirely
removed. On the third day after the operation the patient suddenly
became comatose, the temperature rose to 107°, and twenty-four
hours later death ensued.
At the post-mortem examination oedema and congestion of the brain,
and considerable fatty degeneration of the liver were found (the
patient was a hard drinker), but no clue as to the cause of the coma
and the fatal issue was obtained (see ‘ Internationales Centralblatt fur
Laryngologie/ vol. viii, p. 317).
The microscopic preparations (which were demonstrated) were most
curious, in so far as they showed the simultaneous existence of epi¬
thelioma and papilloma in almost all the specimens without any evidence
of transition of the one into the other. Apart from this, the case
was of importance because it was the first instance known in which
malignant disease of the larynx had been observed to appear origi-
26
nally in the form of a pedunculated angioma- Besides several clinical
points which were present in this case, and which had already on pre¬
vious occasions been urged by the reporter as characteristic for the
malignancy of an apparently innocent tumour,—such as repeated
haemorrhages, quick recurrence, spontaneous pains, difficulties in
swallowing,—the unusual situation of the growth and the patient’s age
were referred to as giving valuable aid in diagnosis.
6. The specimen shown was removed by partial laryngectomy from
the larynx of a gentleman aged fifty, who was sent to Dr. Semon by
Dr. Kendal Franks of Dublin, and who had been suffering for several
years from a curiously irregular tumefaction of the left vocal cord,
the nature of which for a long time was doubtful, it being in part
almost transparent. The diagnosis was left open between fibro-cystic
degeneration of the cord, fibroma, and malignant disease. At last, in
1891, rapid changes took place in the appearances, and when the
reporter saw the patient in the spring of that year, a general infiltra¬
tion of the left half of the larynx had occurred. Radical operation
was advised. The patient agreed, and only stipulated that no chloro¬
form should be given, as he was supposed to suffer from weakness of
the heart. It was suggested that ether should be given by the rectum,
and the suggestion was followed, but this method certainly did not
show to advantage in the present case. It took more than half an
hour before the patient was sufficiently under the influence of the
anaesthetic to commence the operation, large quantities of ether had to
be used, and when the operation was finished the patient looked very
white, and the pulse was very irregular. He also towards the end of
the operation coughed up considerable quantities of fluid watery blood,
the appearance of which was totally different from the expectoration
sometimes met with in cases in which no complete occlusion of the
trachea has been obtained. This expectoration continued, and three
hours afterwards copious bloody discharges took place from the rectum,
which in appearance was absolutely the same as the bronchial expec¬
toration, and only in addition were very offensive. Within a few hours
from the operation the temperature began to rise, the patient sweated
profusely, and gradually got more and more comatose. With increas¬
ing coma, a temperature of 107°, and continuance of the bronchial
and rectal secretions, the patient died twenty-four hours after the
operation.
At the post-mortem examination, intense congestion of almost the
27
whole of the intestinal tract and of the bronchial mucous membrane
was found, and there could be no doubt that death was due to ether.
The reporter added that nothing but a strong sense of duty could
have induced him to report this lamentable case which might serve as
a warning to future operators. It will later on be published in extenso.
7 and 8. The two last specimens illustrate the tendency of infiltrat¬
ing malignant disease of the thyroid gland to become pedunculated when
perforating into the large air-passages. The first was removed at the
post-mortem examination of a man aged thirty-nine. It was a case
of cylinder-celled carcinoma, and has been fully described in Dr. Semon
and Mr. Shattock's paper, “ Three cases of Malignant Disease of the
Air-passages,” ‘ Transactions of the Pathological Society of London/
1888.
The second one is a specimen of epitheliomatous disease of the
thyroid gland, in which repeatedly pedunculated projections grew into
the trachea. At one time a projection which had been seen in the
trachea by two competent observers completely sloughed away, so
that two other distinguished observers could not detect a trace of its
former existence ten months afterwards. The case is described in full
in the forthcoming volume of the ‘ Transactions of the Royal Medical
and Chirurgical Society/
Discussion with especial reference to the present position of the
question of radical operation.
Mr. Butlin, after referring to some of the specimens which he had
brought from St. Bartholomew’s Hospital Museum, said that to
condense his remarks he would divide them under three headings:
first, the circumstances under which laryngeal cancer should be
removed; second, the operation which should be practised; third, the
after-treatment of patients who had been operated on. Under the
first heading he had little to add to what he had before said, but
would repeat that the most favorable cases are those in which the
disease is of intrinsic origin, and still limited to the interior of the
larynx, is of small extent, uncomplicated, and particularly in which it
lies towards the front of the larynx. Under the second heading, also,
he had little to add to what he had previously said. The more he
had seen of the operative surgery of malignant disease of the larynx,
the more convinced he was that removal of the whole or a large part
of the larynx for malignant disease was seldom followed by sufficiently
good results to justify the operation. The best results had followed
and were likely to follow thyrotomy with very free removal of the
soft parts in the interior of the larynx. He could look back on one
case in which the patient was alive and free from disease more than
28
five years after operation (sections of this growth, epithelioma, were
under the microscope on the table), and on another case in which the
patient was still well four years after operation. Compared with
operations for extensive or extrinsic disease, such thyrotomies were
comparatively free from danger. Out of many of the latter he had
lost only one case; out of few of the former he had lost two cases.
On the question of after-treatment he had more to say, because he
had given a good deal of attention to it, and had regularly during the
last three years carried out the suggestions he had made at Berlin.
He removed Habn’s tube directly the operation was over. He made
no attempt to close the wound. No tracheotomy tube was used, and
no dressing was inserted into the interior of the larynx. But the
surface was dusted with iodoform, and the iodoform was frequently
applied; this was easily effected. Watching these patients, he had
found that when they swallowed, the two sides of the wound into the
larynx separated to such an extent that the nozzle of the insufflator
could be easily inserted between them, and the powder blown directly
on to the raw surface. He regarded this as of the highest importance;
he had a great opinion of iodoform in wounds of the mouth and
larynx, but it was not likely to do good unless it reached the actual
surface of the wound, and this was difficult to effect when the powder
was insufflated through the mouth. He covered the external wound
with a piece of iodoform gauze, which was changed as often as was
necessary, even if this were fifteen or twenty times a day. Instead of
propping the patient up in bed, he took away all the pillows except
one, so that the head lay low, placed the patient on his side, and thus
did what he could to diminish the tendency of discharges to pass
down into the bronchi. And, last, he fed the patients chiefly by
means of nutrient enemata during the first few days; but, usually, on
the day following the operation, he encouraged an attempt to take
fluids by the mouth. Water was first tried, and the patient was made
to sit up and lean well forward, or to lean over the edge of the bed,
so that the fluid which passed into the larynx ran out through the
wound immediately. If the patient succeeded in taking water with¬
out getting any quantity of it into the larynx, he was allowed to take
beef-tea, milk, &c., and to try soft solids, Mr. Butlin had not lost a
case of thyrotomy since he had employed these measures, and he fully
hoped that his later success was due to the better measures which
had been adopted in the after-treatment of the patients.
Mr. Ceesswbll Babes made a few remarks on perichondritis of
the larynx, not associated with malignant disease.
Dr. Semon, first in reply to the question addressed to him by
Mr. Cresswell Baber, said that he did not deny the possibility of
primary perichondritis of the larynx, but that such an event in his
experience must be exceedingly rare. He had never seen a case in
point. The poor vascularisation of the perichondrium d priori made
the occurrence of a primary perichondritis a very unlikely event, and
in all his cases, either at the time or later, a true explanation of a
traumatic or diathetic character had been found. With regard to
the indications for, and the technique of, radical operation as laid
down by Mr. Butlin, he agreed practically, with the exception of a
29
few details, to everything that Mr. Butlin had said, and wished
especially to emphasise the desirability of arriving early at a decision
as to the nature of the laryngeal growth and of operating early. The
chances then were infinitely better than if the operation were post¬
poned to a later period. Altogether the number of cases suitable for
operation was small in comparison to the total of cases seen. He had
now seen about 100 cases of malignant disease of the larynx in
private practice, and had only in about 10 per cent, of all these felt
justified in advising a radical operation, such as partial extirpation of
the larynx or thyrotomy. The latter was, of course, not a very serious
operation; at the same time he could not go so far as some of the
continental surgeons did, and altogether deny or underrate its risks.
Against septic pneumonia great care could perhaps protect to a
certain degree, but the coma with rise of temperature which occurred
in two of his cases, without the post-mortem examination giving a clue
as to the cause of these phenomena, certainly formed a very serious
feature, and one to be always taken into account when the prognosis
of the operation was discussed. Broadly speaking, radical operation
had been successful in his cases in exactly 50 per cent., i. e. in five
cases the patients having survived in good health and without any
recurrence for periods now varying from one and a quarter to seven
years. Of the remaining five cases, in three earlier and hence less
extensive operation might possibly have averted the fatal result, but
in two cases death could not be accounted for. The methods of
operation selected in his cases had been (1) partial extirpation of
the larynx; (2) subhyoid pharyngotomy; (3) thyrotomy with and
without resection of parts of the cartilaginous framework. The
chances were, of course, the better the more the operation could be
limited to the soft parts, hence he once more urged the desirability of
early diagnosis and operation.
3 *
PROCEEDINGS
07 THB
LARYNGOLOGICAL SOCIETY OF LONDON
Ordinary Meeting, November 8th, 1893.
P. McBride, M.D., Vice-President, in the Chair.
E. Clifford Beale, M.B.,
Scanes Spicer, M.D.,
Secretaries.
Present—20 Members and 8 Visitors.
The following gentlemen were elected Members of the Society:
Patrick Watson Williams, M.D., Bristol.
Walter George Spencer, M.B., F.R.C.S., London.
William Hale White, M.D., F.R.C.P., London.
The following candidates were proposed for election:
W. Milligan, M.D., Manchester.
P. R. W. de Santi, F.R.C.S., London.
Edmund H. Colbeck, M.D., London.
Charles S. Ayres, M.D., London.
Ernest B. Waggett, M.D., London.
L. H. Pegler, M.D., London.
Michael Foster, M.B., San Remo.
The Chairman briefly referred to the loss the Society had sustained
by the death of Mr. Arthur Hensman, one of its original members.
The minutes of the previous meeting were read and confirmed.
The following case was exhibited by Mr. E. Cress well Baber.
Congenital Occlusion of Posterior Naris, relieved by
Operation.
Master H—, set. nearly 6 years. Was first seen on August 16th,
1892, in consultation with Mr. H. H. Taylor.
History .—He had always had more or less difficulty in breathing
through the nose, slept with his mouth open, and snored. Slight
deafness at times. When an infant had great difficulty in sucking,
both the breast and bottle, and had had discharge from right nostril
since birth.
Present state .—Partial nasal obstruction and difficulty in keeping
4
FIRST series—VOL. I.
32
the mouth closed. Anterior rhinoscopy showed on the right side a
good deal of mucous discharge, inferior turbinated body much
enlarged, firm to the probe, and a slight bending of the anterior part
of the septum to the left. Eight middle turbinated body normal.
Left side, normal. Palpation only a few small adenoids; right choana
blocked by an obstruction which did not project into the naso-pharynx.
Left choana clear. After one or two unsuccessful attempts a view of
the posterior nares by posterior rhinoscopy was obtained. Eight
choana was found completely blocked by a smooth, slightly concave
membrane, with a small, round, dark depression at its lower part, but
no perforation visible. The membrane was pale, and had a small
vessel running across it, and was also slightly depressed at its upper part.
Left choana normal. Posterior margin of the septum not deflected.
No air whatever passes through the right nostril on forcible expiration.
Further examination from the front showed that on the floor of the
right nasal cavity a probe passed in just over 2 inches, whilst a little
above this it was arrested at a point rather over 1£ inches deep. On the
left side the probe passed through the inferior meatus into the naso¬
pharynx to the depth of SJ inches. On October 19th, under chloro¬
form given by Mr. Taylor, the probe encountered an obstruction at the
right choana, but with pressure passed through it; a band of obstruc¬
tion appeared, however, to extend outwards from the posterior septum
across the choana. This was broken down with forceps, and with a
blunt chisel introduced through the nose, all being guided by a finger
in the naso-pharynx. Down’s No. S bougie with oval diameter then
passed through into the naso-pharynx, and a probe introduced from
the front moved vertically for about j inch in the choana. No. 3
bougie was at first passed daily, afterwards less frequently. The dis¬
charge gradually ceased, the right nostril became fairly clear, and on
posterior rhinoscopy a vertical slit, measuring about ^ inch, was seen
near the centre of the membrane. But as some difficulty occurred in
passing bougies Nos. 3 and 4, owing to their hitching on to a promi¬
nence on the back* part of the septum, he was again put under
anaesthetic on December 31st, and the projection on the septum
attacked with a hollow chisel and mallet. The inferior turbinated
body was at the same time crushed outwards by dilating freely with
forceps, and as the result No. 4 bougie passed easily, and there has
been no difficulty in passing it since. Posterior rhinoscopy showed that
33
the edges of the opening had healed, the opening itself being consider¬
ably larger, pear-shaped, and broader below than above. The right
nostril was freely pervious, and there was no discharge. The bougie,
which was at first frequently used, was now only passed by the mother
once a month as a precautionary measure.
In regard to the nature of the obstruction in this case, the treatment
showed that it was partly membranous and partly bony, the latter con¬
sisting in a projection on the bony septum about half an inch thick, but
whether it was adherent to the inferior turbinated body in front of the
membrane was uncertain. There was some asymmetry of the face, the
right cheek being rather more prominent than the left, which helped to
confirm the congenital character of the obstruction. The operative
treatment in this case had been of benefit by producing considerable
improvement in nasal respiration, and by arresting the discharge from
the nose.
Dr. Dundas G-rant remarked on the rarity of the affection, having
only seen one case, and that in an adult. Forcible perforation of the
obstruction was effected by means of a trocar; the opening was further
enlarged by means of a probe-pointed knife, and a vnlcanite tube was
introduced. The patient was ultimately able to introduce the tube
for herself, and to retain it for periods extending as long as a fortnight
at a time. He referred to the hemiatrophy of the face, but on being
reminded by Mr. Cresswell Baber that the atrophy was on the opposite
side to the obstruction, expressed the opinion that the value of hemi¬
atrophy as an evidence of the congenital nature of the condition was
more than doubtful.
Leprosy with Throat Lesions.
Dr. J. B. Ball showed this case. G. F —, set. 30, stableman, had
been under Dr. Abraham’s observation for some years, and was admitted
at his recommendation into West London Hospital on October 12th,
1893, on account of gradually increasing laryngeal dyspnoea. On
October 13th Mr. Bidwell performed tracheotomy.
Patient was born in England, and went to India with his father (a
soldier) at six weeks old. He returned to England at ten years old,
and appeared to have been quite free from symptoms of leprosy for at
least ten years after his return home. Por the last nine years the dis¬
ease had gradually developed and increased, and was now well marked
on the face, forearms, hands, legs, and feet.
The voice had been hoarse for three years. Difficulty of breathing
34
first commenced about a year ago. There had been some blood¬
stained discharge from the nose for about two to three years. He had
not complained of any particular soreness of the throat, and had no
idea how long ago it became affected. The cicatrised appearance of
the throat, however, showed evidence of former ulceration over a con¬
siderable area.
Along the centre of the dorsum of the tongue were some large, broad
tubercles. There were numerous small nodules on the hard and soft
palate, and a small ulcerated area on the anterior aspect of the soft
palate. The soft palate and pharynx were pale, and there was a good
deal of cicatricial tissue in these parts. The uvula had almost entirely
disappeared. The posterior faucial pillars were cicatrised to the poste¬
rior pharyngeal wall, and approximate to each other, thus narrowing
the passage from the naso- to the oro-pharynx.
The epiglottis was thick and infiltrated, and the glosso-epiglottic
folds, especially the median, were thickened. The regions of the ary¬
tenoids and ary-epiglottic folds were occupied by two pale irregularly
pear-shaped swellings, with a somewhat uneven nodular surface. These
swellings approached other in the middle line, and prevented a view of
the glottis and cords.
There was some superficial ulceration over the cartilaginous nasal
septum on both sides, and a cicatricial band running from the septum
to the middle turbinated bone on the right side. No perforation.
Mr. Bidwell referred to the method of performing tracheotomy in
this case. He had found it advisable to stitch the skin to the edge
of the tracheal wound, thus making a permanent opening and
obviating the necessity for the constant use of a tube.
Dr. Clifford Beale exhibited a new form of portable oxy-
hydrogen lantern, which had been designed at his suggestion by
Mr. J. H. Steward, Optical Instrument Maker, 406, Strand, London.
The lantern being very compact and portable was especially adapted
for use in laryngoscopic work at the bedside.
Mr. R. S. Cuarsley exhibited an improved form of galvano-
cautery snare for nasal use.
Dr. de Havilland Hall had used this snare and had found it
very convenient, and a decided improvement on some of the older
forms.
35
Stenosis of the Larynx.
Dr. de Havilland Hall showed this case. C. A—, aet. 25,
contracted a sore in August, 1892. On October 19th he attended
at the Westminster Hospital with acute laryngeal and pharyngeal
catarrh and ulceration of soft palate. He continued under speciGc
treatment until November 9th; he then left London, and did not
attend again until January 25th, 1893, when he was admitted into
the hospital, as he was suffering from grave dyspnoea. The epiglottis
was much swollen, and there was general infiltration of the ary-
epiglottic folds and arytsenoids, but no ulceration. Tracheotomy was
performed on January 28th. About a week later he expectorated
some pieces of necrosed cartilage. Six weeks after the tracheotomy,
dilatation with Schroetter’s bougies was commenced, but had to be
discontinued on account of the formation of an abscess in the larynx.
In May thyrotomy was performed by Mr. Spencer, and necrosed
cartilage scraped away. No attempt was made at the time to bring
the parts together. Later on, strapping was employed to bring the
two halves of the larynx together. Eventually union took place, and
the patient was left breathing through the original tracheotomy wound.
Dilatation with bougies was then resumed, and in the course of two
months Dr. Hall was able to pass No. 9 easily. At the present time
the patient can expire through the larynx, but on attempting inspira¬
tion the ventricular bands are sucked together and hardly any air
enters. Dr. Hall attributed this to the collapse of the walls of the
larynx from necrosis of cartilage, and asked the opinion of the
members as to what further could be done for the patient.
Stenosis of Larynx after Tracheotomy.
Dr. Clifford Beale brought forward a case of stenosis of the
larynx in a man set. 46, who had suffered from hoarseness for nearly
eight months before his admission to the Chest Hospital, Victoria
Park, in August, 1893. He gave a clear history of a syphilitic infec¬
tion some twenty years before, but no manifestations of syphilis had
shown themselves of late years except in the larynx. A few days after
admission he suffered from acute laryngeal dyspnoea. The vocal cords
were seen to be fixed midway between complete adduction and the
cadaveric position. Sudden obstruction of the larynx occurred, but
tracheotomy was promptly performed, and in a short time he made a
§
36
good recovery, but the stenosis of the larynx continued. His general
health was now very good, and he could breathe with difficulty through
the larynx and speak hoarsely and with an effort by covering the
tracheal opening. The right cord appeared to move slightly, but the
left hardly at all, and the glottic chink remained very narrow.
What further operative treatment was advisable in such a case ?
Dr. Felix Semon discussed the question of radical operation in
syphilitic stenosis of the larynx. Whilst admitting that in certain
cases methodical dilatation by means of Schrotter’s bougies or of
O’Dwyer’s intubation tubes might yield good results, ne warned
against their premature application in recent cases of ulceration, as
acute perichondritis might be produced under such circumstances by
forcible introduction. He then dwelt upon the question whether
in cases in which tracheotomy had been performed, and the patient
could breathe comfortably, wearing the tube, whilst his voice was
either normal or at any rate good enough not to interfere with his
business, any radical operation ought to be performed, which, though
enabling the patient to dispense with the tube, yet at the same time
rendered him more or less aphonic. Although he admitted that every
case of that sort ought to be judged on its own merits, yet from a
general point of view he opined that preservation of voice with
wearing of a tracheotomy tube was preferable to dispensation with
the tube with more or less complete loss of voice, and illustrated'this
opinion by briefly detailing several cases in point, which had been
under his own notice. More especially he referred to one example
which he promised to show soon to the Society, in which in a case of
syphilitic stenosis in which the tracheotomy tube had been worn for
fully ten years, quite recently such a spontaneous improvement in the
size of the glottis had taken place, that there was now a reasonable
chance of removing the tube without performing any further opera*
tion. At the same time, in this case, the voice had improved to a
marvellous degree.
Dr. de Havilland Hall agreed that in such a case as his any
further attempts at dilatation would be useless as the cartilaginous
framework of the larynx was already so much destroyed. A perma¬
nent opening in the trachea would remain, and the tube need not be
worn.
Dr. Kirk Duncanson exhibited a specimen of Epithelioma of the
Larynx complicated with Bronchocele.
Tubercular Ulceration op Vocal Cord cured by Lactic
Acid.
Dr. Percy Kidd showed this case.
The larynx presented the following appearances:—Vocal cords
37
somewhat reddened and thickened, movements normal. Plate-like
prominence of interarytaenoid fold.
Physical examination of the lungs reveals slight weakness of breath-
sounds at the right apex, but no further change.
History .—The patient, J. M—, set. 29, a married woman, was first
seen in May, 1892, when she came as an out-patient to the Brompton
Hospital, complaining of a chronic winter cough and frequently re¬
curring loss of voice, extending over a period of six years. Physical
examination of the chest gave a negative result. The larynx showed
general congestion, but no further abnormality.
The patient was transferred to the Throat Department, where the
larynx was painted a few times with a solution of chloride of zinc
(gr. xx ad A fortnight later swelling of the interarytsenoid
fold and slight irregularity of the surface of the cords were noted.
Local treatment was discontinued. In September, 1892 (four months
later), fusiform swelling of the middle third of the right cord and a
small whitish patch on the left processus vocalis were observed.
Iodide of potassium in 10-grain doses, three times a day, was then
prescribed ; but in a few weeks superficial ulceration developed on
both vocal cords. A solution of iodine in glycerine was then
brushed over the vocal cords, and several times without avail, the
ulceration slowly extending. In January, 1893, the cords throughout
their whole length presented a crumbling, ragged, greyish, ulcerated
surface. The sputum, which was very scanty, had been twice
examined for tubercle bacilli with a negative result, but nevertheless
it was determined to apply lactic acid without further delay. After
two applications of a 50 per cent, solution, followed by nine applica¬
tions of the pure acid, the cords showed distinct evidence of healing,
having acquired a reddish, irregular aspect. The patient’s general
condition also manifested marked improvement about this time, viz.
March, 1893. Early in the month tubercle bacilli were found in the
sputum, although no physical signs of disease could be detected in the
lungs. Owing to the development of fresh ulceration in the larynx
pure lactic acid was again applied on nine occasions in April and
May. By the beginning of June the larynx had assumed very much
the same appearance as it now presents. No further relapse has
occurred.
38
Septal Growths.
Dr. Dundas Grant exhibited a patient, a dairyman, who for six
or eight weeks had complained of a feeling as of a foreign body in the
throat. No foreign body could be found either by Dr. Grant or by
Dr. Hugh Smith, by whom the case was first seen. By posterior
rhinoscopy, growths could be seen projecting from both sides of the
septum touching the hypertrophied inferior turbinated body on the
left side. They were soft, corrugated, and easily compressible, and
were visible also on anterior rhinoscopy.
The posterior extremities of the inferior turbinated bodies were
removed with the ring-knife, and a week later a portion of the growth
on the left side was removed with uvula scissors passed through the
nostril. On examination by Mr. Wyatt Wingrave the growth proved
to be little more than local hypertrophy of normal structures, and as
comfort had been restored to the patient no further operation was
thought necessary.
Functional Spasm of the Muscles closing the Jaws.
Dr. Felix Semon exhibited this case. The patient, J. W. D—>
set. 42, a clergyman, began to experience difficulties in opening his
mouth, but only when talking , after a second attack of influenza about
one and a half years ago. For all other purposes he could and can
use the parts perfectly well; thus he can eat, bite, open and shut the
mouth at command, yawn, &c. The difficulty in moving the lower
jaw when talking quickly increased. At present he can only talk
with his teeth firmly set, and after talking for a long while he has
some difficulty in opening his mouth. The difficulty is said to be
less in the mornings, and also when the patient has to speak unexpect¬
edly, whilst every mental effort to overcome the trouble only leads to
its aggravation. The movements of the lips, tongue, palate, larynx,
&c., are perfectly unimpeded.
The case is, so far as Dr. Hughlings Jackson’s (who sent the case
to Dr. Semon) and the latter’s own experiences go, unique. The fact
that the spasm only occurs during the volitional effort of speaking
seems to ally it to the professional neuroses, and even more closely,
perhaps, to spastic aphonia. The localisation of the source of this
form of spasm is likely to be in the cortical or subcortical areas for
the movement of chewing, which have been described by various
89
authors, and most recently been accurately localised by B&hi* as
situated iu front and laterally from the cortical centres for the limbs.
{Trilateral irritation of one of these centres would, in accordance with
Rdthi’s experiments, suffice to produce bilateral spasm, just as in
Semon’s and Horsley’s experiments unilateral irritation of aphonatory
cortical centre sufficed to produce bilateral spasm of the vocal cords.
Should the affection in the present case, as the reporter suspects, be
analogous to the functional spasm of the glottis in spastic aphonia,
the functional prognosis would not be favorable. The internal
administration of arsenic has failed; at present the patient is about
to take iodide and bromide of potassium in ten-grain doses.
Dr. Vivian Poore referred to the case of a clergyman who, in order
to overcome a similar spasm whilst speaking, habitually used a ping
between the teeth. The condition of Dr. Semon’s patient appeared
to be allied to stammering, but he was not aware that stammering had
been known to come on after influenza. He related the case of an old
lady who suffered from spasms of the muscles of the jaw and of the
tongue which always came on when she attempted to eat, and which
at times jerked the food out of her mouth. The spasm of the jaw in
this case was clonic, and some amount of jaw clonus could be elicited.
He thought that some senile degeneration might be going on in the
cortex to give rise to these symptoms. He believed that the best way
to overcome such forms of stammering was to use the voice in an un¬
accustomed manner, to “ spout,” like a pompous actor, and not to
attempt the natural way of speaking. He mentioned a notable instance
where such a tone was successfully used in the pulpit to overcome a
tendency to stammering, although the artificial tone produced was very
foreign to the character of the preacher.
Traumatic Perichondritis op the Larynx; Cure.
Dr. Felix Semon showed the patient, M. V—, set. 21, a sister of
mercy, who in February, 1892, swallowed a piece of rabbit bone
which stuck in her throat on the right side. A practitioner attempted
to push it down, but from that moment the patient lost her voice and
experienced considerable pain in the right side of the throat, whilst
she was feverish in the evenings.
When seen on April 2nd, 1892, the right half of the thyroid
cartilage was acutely tender on pressure, and internally the whole
jright half of the larynx was much swollen, thickened, and, in part,
oedematous. The swelling extended over the right hyoid fossa,
• * Sitzangsberichte der k. k.. Academic der Wissenscliaften,’ vol. cii, part 3,
July, 1893.
40
arytseno-epiglottidean fold, ventricular band, vocal cord, and arytsenoid
cartilage, all these parts being so much glued together that they could
hardly be distinguished from one another. The whole right half of
the larynx was immobile during phonation and respiration, the voice
was quite aphonic, and there was considerable dysphagia, but at that
time there was no dyspnoea. The diagnosis of perichondritis of the
right ala of the thyroid cartilage was made, it being supposed that the
foreign body had been pushed into the larynx, and was probably still
embedded in the inflammatory mass.
Antiphlogistic treatment and iodide of potassium failed to improve
matters. On the contrary, the internal swelling and thickening gradu¬
ally extended along the front wall of the larynx to the left side, and
in about four weeks the latter was even more swollen and tender than
the right side had originally been. At that time large masses of
granulation tissue filled the whole anterior part of the larynx. The
pain, difficulty in swallowing, and the fever had further increased. The
patient was taken into St. Thomas’s Hospital, and on May 25th Sir
William MacCormac performed thyrotomy, and this seemed to offer
the only chance of recovery. The larynx having been opened, and
the granulation tissue having been scraped away, extensive necrosis of
the left ala of the thyroid cartilage was discovered. On a probe being
introduced into a fistulous tract, leading into the interior of the car¬
tilage itself, an abscess cavity was entered, in the midst of which a
piece of bone was found. This was examined by Mr. Shattock, and
declared to be a piece of rabbit bone. The walls of the abscess
cavity having been thoroughly scraped, the wound was dusted with
iodoform and drainage was provided for. The patient made an unin¬
terrupted recovery, and has to a considerable extent recovered her
voice. There is still a good deal of thickening in the front part of the
larynx at the level of the vocal cords, but the normal constituent
parts can now be clearly distinguished from one another.
The case is put on record as illustrating (1) the danger of forcibly
pushing down angular foreign bodies which have entered the mouth;
(2) the possible peregrinations of foreign bodies under such circum¬
stances (in this case the bone had certainly wandered from the right
into the left half of the larynx); (3) the fact that even an acute peri-
chrondritis is no contra-indication against opening the larynx with a
view of removing the source of irritation in the event of foreign
bodies having entered it.
41
Symptoms of Incomplete Graves* Disease, and later on Com¬
plete Premature Baldness, following Removal of Nasal Polypi.
Dr. Felix Semon exhibited this case. A. M—, set. 39, a clergy¬
man. The patient had been shown to the Clinical Society of London
on April 12th, 1889, when exophthalmos of the right eye with Grafe’s
and Stellwag*s symptoms had developed after repeated operations (by
means of the snare and galvano-cautery) for removal of recurrent nasal
polypi from both nostrils. His case, so far, has been fully described
in vol. xxii of the ‘ Clinical Society's Transactions/ In the discussion
which followed the paper doubt was expressed as to the causal
connection of the symptoms last named with the operation, especially
as neither enlargement of the thyroid gland nor cardiac symptoms had
then occurred. Shortly after the demonstration, however, it. was
noticed that the pulse-rate, which so far had been normal, had increased
to over 100, and ever since it had varied between 100 and 110.
There had been no heart palpitations, and the thyroid gland had not
increased in size. The patient in 1889 left for India. On his return
in the spring of the present year the exophthalmos had somewhat
decreased, but the pulse-rate on the average was still about 100, and
complete baldness—extending over both sides of the head—had
developed shortly after the patient left Europe. The hair had also
come off from other parts of the body. In what relation, if any, this
alopecia stood to the symptoms formerly observed seemed quite
obscure. The patient, whilst abroad, had not suffered from any other
disease which could produce alopecia. Treatment by feeding with
thyroid glands, which was tried at the patient's own suggestion, had
not yielded any results.
Mr. Cresswell Baber mentioned the case of a man, set. 26, under
his care, in whom, after removal of polypi with the cold snare diplopia
occurred on looking to the right, with want of power of the right
external rectus. The ocular symptoms disappeared in about six weeks
under the administration of perchloride of mercury and iodide of
potassium. Numerous small growths were subsequently removed, but
there was no return of the ocular disturbance. He stated that he had
had a similar attack when operated on with forceps two years previously.
There was marked erection of the inferior turbinated bodies.
Mr. R. S. Charsley had observed marked enlargement of the
glands in the neck and protrusion of eyeballs, lasting for a period of
three months after operation for removal of turbinate body with the
galvano-cautery. The pulse had ranged as high as 110, but complete
recovery ensued.
PROCEEDINGS
OP THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, December 13 th, 1893.
Felix Semon, M.D., F.R.C.P., Vice-President, in the Chair.
E. Clifford Beale, M.B.,
Soanes Spicer, M.D.,
Secretaries.
Present—21 Members and 2 Visitors.
The following gentlemen were elected Members of the Society:
W. Milligan, M.D., Manchester.
P. R. W. de Santi, F.R.C.S., London.
Edmund H. Colbeck, M.D., London.
Charles S. Ayres, M.D., London.
Ernest B. Waggett, M.D., London.
L. H. Pegler, M.D., London.
Michael Foster, M.B., San Remo.
The following candidates were proposed for election:
C. E. M. Hey, M.A.Cantab., M.R.C.S., L.R.C.P., Hornsey, N.
St. Clair Thomson, M.D.Lond., Queen Anne Street, W.
The minutes of the previous meeting were read and confirmed.
The following members were nominated by the President to serve
on the Audit Committee :—Dr. W. Hill, Mr. W. R. H. Stewart.
Perichondritis.
The following case was exhibited by Mr. Anthony Bowlby. R.
Z—, - set. 50, a coachman. Disease began with sore throat eight
months ago. Lost voice three months ago. Pain in swallowing for
several months. Has had slight winter cough for some years, and he
has got worse since the throat became affected. Abscess formed over
cricoid cartilage three months ago, and burst. History of syphilis
twenty-five years ago.
Present condition .—Enlargement and thickening of soft tissues over
5
FIRST SERIES—VOL. 1.
44
larynx. Enlarged glands in submental and submaxillary regions.
Much pus in and about larynx. Epiglottis swollen and ulcerated.
Soft red granulating mass on left side of larynx in subglottic region.
General swelling of laryngeal mucous membrane with ulceration in
parts.
Dr. Scanes Spicer thought that the case was probably tubercular.
Dr. Dundas Grant also thought that it might be tubercular. The
formation and discharge of an abscess was not a rare occurrence in
cases of perichondritis. He related a case somewhat similar to that
exhibited in which the disease was certainly tubercular, and in which
similar perichondritis had occurred.
Syphilitic Stenosis of the Larynx.
Dr. Felix Semon exhibited the following cases.
Cask 1 . —Mrs. G— , set. about 55. Date of primary affection not
exactly known, certainly very, many years ago. Throat troubles began
more than twelve years ago. In 1883 tracheotomy on account of
steadily increasing dyspnoea ; has worn tube ever since. The arytse-
noid cartilages were for many years greatly thickened and almost
immobile, the glottis reduced to a very small triangle, formed by the
internal aspects of the arytsenoids and the posterior wall of the larynx,
whilst in its anterior three fourths the vocal cords were seen to lie
close to one another. The voice was quite aphonic all these years.
From time to time superficial ulceration used to occur in various parts
of the larynx, which could always be promptly checked by the use of
iodide of potassium. Quite recently, i. e. within the last three weeks,
without any apparent cause a surprising improvement had taken place
in every respect. The glottis had become much larger, the swelling
of the arytaenoid cartilages had much diminished and their mobility
improved ; the previously aphonic voice had regained tone, and there
. was now a fair prospect that the tube could be ultimately dispensed
with without any further operation.
Case 2.—This had been fully described by Mr. E. C. Stabb, in vol.
xxvi, p. 239 of the ‘ Clinical Society’s Transactions/—W. M—, set.
37, contracted syphilis in 1884. In 1891 tracheotomy had to be
performed. On February 10th, 1893, Mr. Stabb performed thyro-
tomy, excised large quantities of cicatricial tissue, including the right
vocal cord and ventricular band, and removed a large piece of the
45
necrosed cricoid cartilage. Quick recovery and remarkable return of
voice, but still considerable narrowness of glottis.
Acute (Edema followed by Hjbmatoma of Left Half of
Larynx and Transitory Immobility of Left Yocal Cord
after Football Accident.
Exhibited by Dr. Felix Semon. T. R. C—, aet. 32, a medical
man. On November 25th, 1893, at 3.30 p.m., patient received a
kick with a foot against the left half of the larynx whilst playing foot¬
ball. Immediate aphonia, but no pain and no dyspnoea. Patient
came immediately to town, sucking ice on the way. When seen at
7 p.m. there was enormous oedema of whole left half of larynx
except the epiglottis. Yoice quite aphonic, considerable pain on
swallowing, no dyspnoea. Expectoration of slightly blood-stained
mucus just beginning. No crepitation to be detected. Patient
taken into St. Thomas's Hospital. Four leeches to left half of larynx.
Leiter’s coil with iced water round neck, sucking of ice. Everything
in readiness for intubation or tracheotomy. Night pretty restless,
good deal of blood-stained expectoration. Temperature never went
beyond 99° on second day after accident.
On November 26th, at noon, left half of larynx changed into
brilliantly red, tense tumour, circumference of which, however, was
slightly smaller than the extent of the oedema seen on previous
evening, but the left half of the epiglottis and left pyriform sinus were
also enormously swollen and congested. Antiphlogistic treatment
continued.
November 30th.—Circumference of swelling about the same as on
26th, but colour markedly purple. Still complete aphonia; no
dyspnoea. Slight pricking sensations in left half of throat; Leiter’s
coil continued. Potass. Iod. gr. x, ter die.
December 4th.—Colour of swelling now very dark blue. Circum¬
ference slightly smaller. Sounds can be produced with effort. Left
cord in part seen, intensely congested and motionless in middle line.
Iodide continued, but coil left off.
9th.—Yoice much better. Swelling almost entirely gone. Left
vocal cord still intensely congested, motionless in mid-line. Several
patches of ecchymoses on left ventricular band. Iodide gr. v, and
Liq. Strychn. n\.ij ter die. Massage of neck.
46
12th.—Mobility of left cord slightly improved. Front part of left
ventricular band somevhat more swollen, covering anterior half of
corresponding vocal cord. In its midst one large extravasation of
blood. Voice much better. No subjective inconvenience.
Dr. Semon mentioned another case of direct injury somewhat
similar to the foregoing, in which the bruising appeared on the
opposite side of the larynx, and was apparently an instance of “ con-
trecoup.” Such an occurrence he believed to be extremely rare and
most difficult to explain, but the blow had undoubtedly been inflicted
on the left side of the larynx, and extreme ecchymosis had appeared
on the right side, the left remaining to all appearances healthy.
Stenosis op Fauces with other Palato-pharyngeal Lesions,
the Results op Ulceration, and Subsequent Adhesions in
a Syphilitic Subject.
Dr. Scanes Spicer brought forward the case of E. M—, aet. 31, a
servant. In 1884 patient had a rash and sore throat, followed by
hair falling out. Had had throat troubles, and been under treatment
privately and in hospitals ever since.
Mr. G. Batchelor, of Staines, saw patient in August, 1892, for
ulceration of fauces and dysphagia. There was then marked constric¬
tion of fauces. Under iodide the ulceration rapidly improved, the
stenosis and dysphagia increasing.
She was sent by him to the Throat Department at St. Mary’s
Hospital on January 10th, 1893. She could then swallow ordinary
food only after prolonged chewing, and it occasionally returned
through nose; fluids usually came back that way. The isthmus
faucium was so narrowed by adhesions of the anterior faucial pillars
to the tongue that the channel would only admit an ordinary lead
pencil; it was made out also that the soft palate was perforated, the
uvula almost gone,—the soft palate adherent to the posterior pharyn¬
geal wall. There was no existing ulceration to be seen; no difficulty
of breathing or marked voice alteration.
It was then proposed to divide the cicatricial tissue constricting the
fauces with a galvano-caustic knife, and keep channel enlarged with
bougies, but before this could be arranged the cicatricial tissue spon¬
taneously and rapidly ulcerated and a good isthmus was reproduced,
allowing comfortable swallowing. The patient had remained thus for
nine months, and only reappeared for treatment on November 28th,
47
complaining that the dysphagia was increasing again; and on exa¬
mination it was seen that there was mnch narrowing, the faucial walls
being also ulcerated.
Suggestions were invited (1) as to the best way of dealing radically
with the faucial stenosis in this interesting case; (2) as to whether
the palatal perforation and palato-pharyngeal adhesion should be
simultaneously or subsequently treated, and if so, what method of
dealing with these had hitherto given the best results.
"Dr. Dundas Grant asked if the patient had much trouble in
swallowing, as, unless she had, he thought it was best not to attempt
any operations. He considered that to enlarge the small opening
between the pharynx and naso-pharynx would only make her worse.
If it were thought proper to divide the bands extending on to the
tongue from the anterior pillars he thought the case would be a
favorable one for inserting wires like earrings into the bands, and
when the apertures became permanent for making horizontal cuts
from these apertures to the free edges. This might afford a chance
of attaining permanent division as in the old operation for webbed
fingers. Simple incisions would soon close up.
Mr. Cresswell Baber referred to a case of cicatrix of the lower
pharynx, exhibited by him at a previous meeting (‘ Proceedings of the
Laryngological Society,’ No. II, p. 9), which showed the tendency
that existed to contraction after excision of a portion of the cicatrix,
and argued against excision in cases of that description unless there
was difficulty in deglutition or respiration.
Mr. Charters Symonds thought that so long as an opening was
maintained which was sufficient for its functions of deglutition it was
best to leave the case untouched. He mentioned an instance of a boy
in whose pharynx the opening had been reduced to the size of a lead
pencil, and yet was sufficient for all purposes.
Dr. Clifford Beale, referring to the closure of the naso-pharynx,
mentioned two cases recently seen, in one of which there was complete
closure, and in the other a tiny opening. The opening being guarded
by healthy muscular tissue retained its function and permitted nasal
respiration, while it prevented the entrance of food into the nose. In
the other case no muscular tissue appeared to be present, and any
perforation made by operation would leave the patient worse than
before. Syphilitic contraction was the cause of the stenosis in both.
Dr. Bronner suggested the possibility of transplanting mucous
membrane to restore the normal shape of the pharynx. He had seen
one such case, but did not know what the final result had been.
Dr. Bennett asked whether any member of the Society had expe¬
rience of the results of dividing the soft palate longitudinally, between
the hard palate and the pharyngeal wall, in cases of completely adhe¬
rent palate ?
Dr. William Hill thought that it might be taken as a general law
48
that it was best not to operate in the presence of a liability to syphilitic
ulceration if possible.
Dr. Scanes Spicer, in reply, thought that the suggestion made by
Dr. Bennett was a good one. He did not think that it would be pos¬
sible to exclude a liability to ulceration in a syphilitic case such as
the one he had brought forward, and this would not deter him from a
radical operation if he considered the swallowing would be permanently
improved thereby.
Occlusion op Posterior Naris.
The following case was exhibited by Dr. Dundas Grant. —H. M—,
set. 27, had complained of deafness in the right ear three years ago.
She had then complete obstruction of the right nostril, which was full
of thick mucus. On rhinoscopic examination the right choana was
seen to be completely closed by what looked like a uniform cicatrix.
There was no history such as would account for its formation as the
result of disease or injury, and it was in all probability congenital. She
had been told that at the time of her birth she breathed with great diffi¬
culty, and that the doctor " probed ” her nose.
Dr. Grant perforated it by means of a bistoury and inserted an india-
rubber tube, which was left in situ for three days. Unfortunately,
this woke up the dormant ear-mischief and she had perforative inflam¬
mation, which had, however, left no trace on the drum-membrane. The
opening in the choana soon closed on the removal of the tube, and the
operation had to be repeated. She soon got accustomed to the intro¬
duction, retention and removal of one of Dr. Grant's vulcanite nasal
tubes, and the perforation still remained. She had at times worn the
tube as long as a fortnight. She now wore it at night. It was in¬
teresting to see how it caused absorption of the irregularities on the
right side of the septum, which at first rendered its introduction much
more difficult than it was at present.
The case had been exhibited before the Hunterian Society, in
November, 1891.
Mr. Cresswell Baber thought that the greater tendency to closure
which existed in this case compared with the one shown by himself at
the last meeting was perhaps due to the difference in age of the patient.
He pointed out not only the asymmetry of the face, but also the
deflection of the septum to the left (the normal) side, present in both
cases.
Mr. Symonds thought in such cases it was better to make a free
opening by removing a piece from the posterior margin of the vomer.
In one case he had cut through the membranous centre with a knife,
49
then enlarged with a saw. Then by two horizontal cuts a piece of
the septum was isolated and removed. No after-treatment was
required, and the success was complete.
Intra-laryngeal Growth.
Dr. Dundas Grant exhibited the case of Miss D—, set. 73.
Occupation: house and needlework.
The patient had applied to him on the 27th of last month on
account of extreme hoarseness which had been gradually developing
between three and four years. There was also a bleating or croaking
sound in her voice, and her breath was short but not markedly
stridulous. Swallowing was normal, and there was no cough. She
was free from pain except a slight burning after prolonged talking.
Externally there was found a considerable enlargement of the right
lobe of the thyroid gland pushing the trachea to the left side, but no
enlargement of lymphatic glands. Laryngoscopic examination revealed
a growth of irregular shape, broad-based, and sessile in the anterior
part of the larynx. Its base extended from near the anterior ex¬
tremity of the right ventricular band across the commissure and along
the anterior two thirds of the left ventricular band, apparently filling
the ventricle and having the ventricular band stretched over and attached
to it. It was seen to cover the corresponding portions of the vocal
cords, but they appeared to move quite independently of the growth.
The portion over the commissure seemed to have a downward offshoot
intruding between the vocal cords so as to prevent complete closure
and apposition. The surface was somewhat irregular, but in no part
. denuded of mucous membrane. The colour of the growth was almost
that of normal mucous membrane, but with a slightly bluish tinge
suggestive of its being more or less angiomatous. It was probably a
diffuse papilloma.
The hoarseness was no doubt produced by the intra-laryngeal
growth.
The dyspnoea and the peculiar “ bleat ” or “ croal$ " was attributed
to the compression of the trachea by the thyroid tumour, a symptom
peculiarly characteristic of tracheal stenosis. Dr. Dundas Grant
proposed to attempt to remove the portion intervening between the
vocal cords by means of his intra-laryngeal forceps, but he was not
very sanguine and would steer clear of the tiimis diligentia. A
portion of the growth would be examined microscopically.
50
Dr. A. B eonn ee exhibited a new form of forceps for the removal
of nasal polypi in cases which could not be attacked successfully with
the snare. The action of the forceps was cutting and not tearing,
and had been found useful in clearing the way for the subsequent use
of the snare.
Calculus op Soft Palate.
Dr. Charles A. Parker showed a drawing of the soft palate
before removal of the calculus, and the stone itself.
W. R—, set. 29, was first seen on October 17th.
History .—Had always suffered more or less with his throat, and
three years ago had post-nasal growths, removed on account of deaf¬
ness which was greatly relieved thereby. For the last six or eight
months had constantly suffered from painful and difficult deglutition,
accompanied by a sharp pricking sensation, the slightest cold greatly
aggravating these symptoms. No marked family history of gout or
rheumatism.
Condition when first seen .—Complained of great soreness of the
throat, especially on swallowing; sharp pain shooting to right ear,
and some deafness on the same side.
On looking into the mouth, the right side of the soft palate was
seen to be very swollen and inflamed, and was bulging forward into
the cavity of the mouth, and felt to the touch excessively hard and
solid. Just to the right of the base of the uvula was what looked
exactly like a dirty sloughing ulcer, extending backwards a considerable
way. The right side of the post-nasal space was entirely blocked, and
the swelling was pressing against the Eustachian tube. There were
some enlarged glands on the right side of the neck. These appear¬
ances were evidently misleading, for the patient informed me that
several doctors had told him it was an indolent ulcer.
On further examination, what looked like this ulcer was found to
be the free surface of a calculus, the rest being embedded in the sub¬
stance of the soft palate, lying apparently in a cul-de-sac between the
muscular layers.
On October 21st chloroform was administered, and the stone re¬
moved.
The case seemed interesting chiefly from the position of the calculus.
Formations of equal size had been reported as occurring in the
crypts of the tonsil, but Dr. Parker was not aware of one in this
position being on record.
51
The stone when dry weighed 54 grains, and Mr. Lake, who had kindly
examined it, reported as follows :—“ It was hard, but easily crushed and
pulverised. It dissolved for the most part in dilute hydrochloric acid,
the insoluble remainder consisted of epithelial debris , spores, and glado-
thrix mycelium. The earthy salts consisted for the most part, if not
entirely, of carbonates and phosphates of lime and potash. It should
be added that when heated on platinum it kept its shape, and became
porous by destruction of its animal and vegetable constituents.”
In Lennox Browne’s * Diseases of the Throat' it is stated, on the
authority of Gruening, that all tonsillar and pharyngeal concretions
are of parasitic origin, and are composed of leptothrix elements.
This, too, seemed to be undoubtedly parasitic, but Mr. Lake thought
it was due to the gladothrix, and not to the leptothrix mycelium.
Dr. Felix Semon remarked upon the rarity of such a calculus, of
which he had never before seen or heard of an example. He was
inclined to support the theory that it had been originally started by
some injury to the soft palate, possibly during operation.
Dr. Ball suggested that the calculus might originally have been
formed in the tonsillar crypt, and might have worked its way along
the submucous tissue of the soft palate.
Mr. Tiaxe mentioned the occasional presence of adventitious
masses of adenoid tissue in the soft palate, within which it was pos¬
sible that the concretion might have begun.
Dr. Spiceb asked whether there was any relation between the
position of the calculus and the two small orifices sometimes seen, one
on each side of the median line, at the junction of the hard and soft
palate. The exact significance of these orifices was unknown to him,
but they looked like the openings of small secreting glands.
Dr. William Hill asked whether the stone was removed any¬
where near the epitonsillar fossa, which was sometimes very large
and a potential crypt. It that were not so, he made the suggestion
that the calculus bad formed around the residuum of an extra-
tonsillar abscess, and asked whether there had been any history of
quinsy.
Dr. Parker, in reply, pointed out that the stone was nearer to the
uvula than the tonsil, and could hardly have worked its way so far
inwards. For the same reason it appeared to be unconnected with
the epitonsillar fossa. There had been no history of quinsy.
5 *
PROCEEDINGS
OP THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Annual General Meeting, January 10/&, 1894.
Felix Semon, M.D., F.R.C.P., Vice-President, in the Chair.
E. Clifford Beale, M.B.,
Scanes Spicer, M.D.,
Secretaries.
Present—28 Members and 5 visitors.
The Minutes of the first Annual General Meeting were read and
confirmed.
Dr. E. Law and Mr. L. A. Lawrence were appointed Scrutineers of
the ballot for Officers and Council.
The Beport of the Council for the past year was then read as follows:
In presenting their first Annual Report, the Council have much
pleasure in recording the successful launching of the Society in Feb¬
ruary, 1893, and its steady and increasing prosperity since that time.
Starting with forty-five original members, the Society now numbers
sixty-eight ordinary members and one honorary member. One
member only has been lost to the Society by the lamented death of
Mr. Arthur Hensman. Five ordinary meetings have been held, all of
which have been well attended, and many cases and specimens of in¬
terest have been exhibited and discussed. The Society’s * Proceed¬
ings’ have beeD edited by the Secretaries, and placed in the hands of
members as soon as possible after each meeting. A list of members has
also been prepared. It will be noted that the ‘ Proceedings,’ the Rules
of the Society, and the List of Members have been issued of uniform
size, in order to fit them for binding together. The examination of
the cases exhibited has been greatly aided by the generous gift of
twelve electric lamps to the Society by Dr. Felix Semon. In order to
facilitate the use of these lamps, it was found necessary to re-wire the
large room at 20, Hanover Square, and this work has been satisfactorily
carried out, with the sanction and co-operation of the House Committee
of the Royal Medical and Chirurgical Society. The Society’s Library
has already been established by the presentation of works on laryn-
FIB8T SERIES—VOL. I. Q
54
gology, and by exchange of special periodicals in return for copies
of the * Proceedings.'
The Librarian would, however, be pleased to receive and acknow¬
ledge as many original contributions from the members as possible,
whether published in pamphlet or book form.
The Report was adopted.
The Treasurer's Annual Statement was then presented as follows:
THE LARYNGOLOGICAL SOCIETY OF LONDON.
BALANCE-SHEET, 1893.
Income.
£ 8. d. £ 8 . d.
By Donation from
Dr. Semon to¬
wards electric
lamps ... 30 0 0
„ 61 Subscrip¬
tions—
42 at 21/- 44 2 0
19 at 42/- 39 18 0
- 84 0 0
Total . . £114 0 0
Expenditure.
£ 8 • dm £ 8m dm
To Adlard & Son,
Printers—
Sept. 29 . 19 6 0
Dec. 29 . 11 0 10
-
30 6 10
„ Miller&Woods,
lamps and in¬
stallation . •
47 0 0
„ Royal Med. &
Chir. Soc.,
Rent for J year
15 0 0
„ Petty Cash
Account—
Dr. Spicer
2 5 9
Dr. Beale. .
3 14 1
6 19 10
„ Balance in
Treasurer’s
hands, Jan. 1,
1894 . . .
15 13 4
Total . . £114 0 0
Expenditure of
the year • . 114 0 0
15 13 4
£98 6 8
Audited and found correct. W. R. H. STEWART.
January 1,1894. WILLIAM HILL.
The Treasurer’s Report was adopted.
The Librarian reported the presentation of the following works to
the Society’s Library.
55
Presented by Dr. Lichtwitz (Bordeaux).
Ueber de Hauflgkeit des doppelseitigen latenten Empyems der HighmorshShle, und
fiber die Nothwendigkeit der Methodischen Probeausspiilung dieser Hohle in Fallen
von Nasenblennorrhoe (Lichtwitz).
Du Diagnostic de PEmpyfcme “ Latent ” de TAntre d’Higbmore (Lichtwitz).
Entfernung der multiplem Papillome des Kehlkopfes beim Kinde auf naturlichem
Wege mit Hulfe einer neuen Methode; Intubation mit gefensterter Tube (Licht¬
witz).
Carcinome de la Corde Vocale Gauche (Lichtwitz).
Instruments pour l’ablation des Neoplasmes Laryngiens de Penfant (Lichtwitz).
Contribution h P6tudede PHydrorrhee Nasale (Lichtwitz).
Les Anesthesies hysteriques des muqueses et des organes des sens et les zones
hysterogenes des muqueses (Lichtwitz).
Ueber die pathologische Anatomie der Sangerknoten (Sabrazfes und Fr&che).
The employment of accumulators in medicine, and the best means of charging
them (Lichtwitz).
Instrumente fur die Entfernung der Kehlkopfneubildungen des Kindes mittels
der Methode der Intubation mit gefensterter Tube.
Sur les maladies des sinus ou cavites accessoires du Nez. “ Le Bulletin medical,”
25 et 29 Octobre, 1893.
Presented by the author , Dr. Felix Petesohn.
Ueber einen von der Nase ausgeheilten Fall von Gesichtskramf.
Ueber Apsithyria.
Ueber Larynxfldem.
Presented by the author , Dr. Edward Aronsohn .
Dermatol zur Nachbehandlung nach galvanokaustischen Operationen in der
Nase.
Presented by the author , Dr. Hopmann.
Nasenpolypen in Alter unter 16 Jahren.
Ueber Messungen des Tiefendurchmessers der Nasenscheidewand bzw. des Nasen-
rachenraums.
Presented by the author , Dr. Max Thomer.
Imaginary Foreign Bodies in the Throat.
Report of a Case of Partial Laryngectomy for Carcinoma of the Larynx.
Case of Persistent Tinnitus Aurium relieved by the Removal of a Nasal Obstruc¬
tion.
Rheumatic Throat Affections.
Thrush of the Pharynx and Nose in an Adult occurring during an Attack of the
“ Grippe.”
Benign Tumours of the Larynx.
The Treatment of Tuberculous Laryngitis with Modified Tuberculin.
Some Experiments with Modified Tuberculin (Joseph Eichberg).
The Management of Foreign Bodies in the Air-passages.
Intubation in an Adult followed by a Fatal (Edema of the Larynx after Extraction
of the Tube.
Un cas d’Atrophie d’une Tumeur laryngee chez une enfant.
Presented by the author , Dr. 0. H. Beschomer.
Operation der Hasenscharte.
Heuftebi.*.
56
Doppelseitige Paralyse der Glottis-Erweiterer.
Subcutane Injectionen von Cocain- salicylic bei Asthma nnd nervosen Hasten.
Ueber Bancbrednerknnst.
Ueber Hasten.
Beitrag zur endolaryngealen Operation von Eehlkopfpolypen.
Ueber chronische essentielle fibrindse Bronchitis.
Presented by Dr. de Havillcmd Hall.
Hay Fever (Morell Mackenzie).
On Epistaxis and the Heemorrhoidal Flax (Dr. Alexander Haskin).
Presented by the author , Dr. Felix Semon.
Syphilis of the Larynx.
Mechanical Impairments of the Functions of the Crico-arytmnoid Articulation.
A Case of Myxoedema.
Removal of a Pin from the Larynx.
Case of Partial Extirpation of the Larynx.
Case of Laryngeal Cancer.
Unilateral Incomplete Graves’ Disease after Removal of Nasal Polypi.
Obscure Affection of the Soft Palate.
A Case of Congenital Malformation of the Larynx and Trachea, with Diverticulum
of the (Esophagus.
The Throat Department of St. Thomas’s Hospital, 1882, 1883, 1884.
The Study of Laryngeal Paralysis since the Introduction of the Laryngoscope.
On the Position of the Vocal Cords in Quiet Respiration in Man, and on the
Reflex-tonus of their Abductor Muscles.
Doable Stenosis of the Upper Air-passages.
A Case of Rhinoscleroma (Payne and Semon).
Three Cases of Malignant Disease of the Air-passages (Semon and Shattock).
Two Cases of Laryngeal Growths.
Syphilis in the Larynx and Trachea.
Electric Illumination.
Empyema of Antrum.
An Address on Laryngology and Rhinology.
Intra-laryngeal Surgery and Malignant Disease of the Larynx.
Ueber die Lahmung der einzelnen Fasergattungen des Nervus laryngeus-inferior.
Ditto.
Zur Lehre von der verschiedenen Vulnerabilit&t der Recurrensfasem.
Die Krankheit Kaiser Friedrich des Dritten und die Laryngologie.
Ditto.
Sir Morell Mackenzie.
Proceedings of the Subsection—Diseases of the Throat— of the Seventh Inter¬
national Medical Congress.
The Culture of the Singing Voice.
On an apparently Peripheral and Differential Action of Ether upon the Laryngeal
Muscles (Semon and Horsley).
On the Relations of the Larynx to the Motor Nervous System (Semon and Horsley).
On the Central Motor Innervation of the Larynx (Semon and Horsley).
Ditto.
Ein Schlusswort in der Controverse uber die centrale motorische Innervation des
Kehlkopfs (Semon and Horsley).
Erwiderung auf Vorstehenden Aufsatz (Semon and Horsley).
Du centre cortical Moteur Larynge et du Trajet intra-cerebral des Fibres qui en
emanent (Semon and Horsley).
57
Presented by Dr. Felix Semon.
The Abductor and Adductor Fibres of the Recurrent Laryngeal Nerve (Risien
Russell).
On Infantile Respiratory Spasm (John Thomson).
Micro-organism of Diphtheria with Experimental Results in Animals (Albert
Wilson).
Some Questions with regard to Tuberculosis of the Upper Air-passages (P.
McBride).
Two Cases of Bezold’s Perforation of the Mastoid Antrum (Guye).
Invalids suited for Treatment at Colorado Springs (S. E. Solby).
Quelques Observations relatives a FErysip&le du Larynx (Sokolowski).
Le Nez et la Bouche comme organes de la respiration (W. Schutter).
Ueber das Ansaugen der Nasenfliigel (Moritz Schmidt).
Empyema antri Highmori (Wilhelm Repp).
Sing- und Sprech-Gymnastik (G. Gottfried Weisz).
Krankheiten des Kehlkopfes, der Luftrohre, der Nase, und des Rachens
(L. v. Schrotter).
Die Laryngealen Storungen der Tabes Dorsalis (H. Burger).
Das Sclerom der Schleimhaut der Nase, des Rachens, des Kehlkopfes, und der
Luftrdhre (G. Juffinger).
Die Entwicklung der Lehre von den motorischen Kehlkopflahmungen seit der
Einfuhrung des Laryngoskops (Felix Semon).
An Experimental Investigation of the Central Motor Innervation of the Larynx
(Semon and Horsley).
Presented by author , Dr. J. Mount Bleyer.
The Primary Action of the Galvanic Current.
The Value of Aero-tonic Treatment.
The Influence of Climate on Temperament.
Presented by author. Dr. L. Bayer.
Observations demontrant Finfluence de la Menstruation sur les Affections laryngees.
Ueber den therapeutischen Werth der Kohlenwasserstoffe.
Des Kystes osseux de la Cavite nasale.
Erapyems der Highmorshohle.
Ein Fall von Bewusstlosigkeit nach Korpererschiitterung; Riickkehr des Bewusst-
seins nach Lufteintreibung ins Mittelohr.
Accumulator und Galvanocaustik.
Ueber die Transformation von Schleimpolypen in bosartige (krebsige oder
sarkomatose) Tumoren.
Einfluss des weibliclien Geschlechtsapparats auf Stimmorgan und Stimmbildung.
Deux cas de Mycosis Tonsillaire, lingual et pharyngien.
Epithelioma primaire du Larynx—Intubation—Tracheotomie—Laryngotomie—
Laryngectomie—Larynx artificial—Affections de FAppareil respiratoire— Prodromes
de la Fifevre typhoide.
Ulcerations typiques pharyngees.
Presented by the author, E. Gresswell Baber.
A Guide to the Examination of the Nose.
Remarks on Adenoid Vegetations of the Naso-pharynx.
Feeding with Fresh Thyroid Glands in Myxcedema.
Further Remarks on the Self-retaining Palate Hook; including its use in Post¬
nasal Catheterism.
A Recent Improvement in Posterior Rhinoscopy.
Lymphoma of the Tonsils.
58
Reflex Nasal Cough.
Remarks on the Theory of Bronchial Asthma.
Case of Rhinolith ; with Remarks.
Contributions to the Minute Anatomy of the Thyroid Oland of the Dog.
Researches on the Minute Structure of the Thyroid Gland.
The following Bye-law proposed by the Council was then presented
and confirmed:
“ If a member wish to propose for ballot any candidate for office
other than those whose names stand on the list recommended by tlie
Council, the name of such candidate, duly proposed by one member
and seconded by two other members, shall be sent to the Senior
Secretary at least a week before the Annual General Meeting. It
shall be the duty of the Senior Secretary to see that the name of such
candidate with the office for which he is nominated, together with the
names of his proposer and his seconders, be sent to all members at
least two days before the Annual General Meeting.”
The Chairman then, in the names of the Council, nominated the
following gentlemen, all of whom had rendered distinguished service to
the Science of Laryngology, for election as Honorary Members:
Sir George Johnson, F.R.S.
Dr. Wilhelm Meyer, Copenhagen.
Prof. B. Frankel, Berlin.
Prof. L. von Schrotter, Vienna.
Prof. Stoerk, Vienna.
Dr. J. Solis Cohen, Philadelphia.
Dr. G. M. Lefferts, New York.
Prof. Massei, Naples.
Dr. E. J. Moure, Bordeaux.
The Scrutineers reported the result of the ballot as follows:
President. —Felix Semon, M.D.
Vice-Presidents. —P. McBride, M.D.; W. McN. Whistler, M.D.
Treasurer. —H. T. Butlin, Esq.
Librarian. —F. de Havilland Hall, M.D.
Secretaries. —E. Clifford Beale, M.B.; Scanes Spicer, M.D.
Council. —E. Cresswell Baber, M.B.; A. Bronner, M.D.; Dundas
Grant, M.D.; T. Mark Hovell, Esq.; C. J. Symonds, Esq.
An Ordinary Meeting of the Society was subsequently held, the
President, Dr. Felix Semon, being in the Chair.
The President briefly returned thanks for his election. The
minutes of the previous Ordinary Meeting were read and confirmed.
The following candidates were elected Members of the Society:
C. E. M. Hey, Hornsey.
St. Clair Thomson, M.D., M.R.C.P.Lond.
59
The following gentlemen were proposed as candidates for election:
Dr. J. H. Drysdale, Liverpool, by Dr. Kanthack, Mr. Butlin, and
Mr. Spencer.
Mr. Edmund Boughton, London, by Dr. W. Hill, Dr. Scanes
Spicer, and Mr. Butlin.
Dr. James Cagney, London, by Dr. W. Hill, Dr. Scanes Spicer, and
Dr. Hall.
Dr. Bronnbr exhibited some laryngeal syringes which had been so
constructed as to admit of their being rendered aseptic by boiling.
He also showed some portions of deviated septum removed by means
of a cutting trephine, which he had found useful in dealing with such
cases.
Mr. Cbe8Swell Baber expressed a preference for the saw in these
operations in place of the knife or the trephine.
Dr. Scanes Spicer agreed that the saw was preferable for the larger
spurs, but would use the cylinder trephine in the cases where the pro¬
jection extended completely into the inferior meatus.
Mr. W. R. H. Stewart thought the best treatment for any but the
very large spurs was to leave them alone.
The President deprecated the too hasty removal of spurs as a cure
for neuroses.
Dr. Bronner would only remove spurs and deviations when they
were productive of actual obstruction.
Rhinitis Atrophica F(etida with Aphonia.
This case was exhibited by Drs. Hill and Cagney. A. H—, set.
24, a domestic servant, had suffered from dry nose and throat for
four and a half years; aphonia three years. One and a half years
ago voice returned for a week only when in Guy’s Hospital, when the
throat was faradised.
In May, 1893, consulted Dr. Cagney at St. Mary’s Hospital for
“ loss of voice.” Found to have rhinitis sicca, pharyngitis sicca, and
laryngitis; under appropriate local treatment these conditions had so
far improved that there was now no dryness of the pharynx and larynx,
but the aphonia was unrelieved, and recently neuralgia of the left side
of pharynx and head had become developed.
Galvano cautery to the nose and base of tongue had been tried, also
electrolysis to the nasal fossse. Faradism and galvanism to the larynx
had been applied three or four times a week for about two months
with no practical benefit. Suggestions were invited as to best line of
treatment.
60
Dr. Dundas Gbant considered the laryngeal condition secondary to
the disease of the nose, of which there was evidence in the right middle
meatus, and which was probably of the nature of sinus suppuration,
as the patient’s consciousness of the offensive smell indicated. He
believed that irritating material was simply displaced into the larynx
by the action of inspiration, and this had given rise to a sodden con¬
dition. The aphonia was a remnant of the laryngitis so caused, and he
believed that after successful treatment of the nasal suppuration, the
laryngeal condition would yield to the judicious use of local applications
and electricity.
Dr. Bronner mentioned that such cases were very common in
Bradford. Of about 250 cases, at least forty would be cases of dry
catarrh, but he had seen many cases where the larynx was alone
affected, and which were successfully treated by intra-laryngeal injec¬
tion.
The President was not convinced of the connection between the
nasal and the laryngeal trouble in this case. The aphonia was still
complete although the crusts and dryness were no longer visible. Mr.
Symonds had restored the voice by faradisation, but it had been again
lost. He suggested that the case should be shown again at a later
stage.
Dr. W. Hill, in reply, agreed with the President’s view. He did
not think that the laryngeal affection was simply secondary to a sup¬
purating sinus. There appeared to be a general atrophy of the
mucous membrane.
The Function and Anatomy of the Epiglottis.
Dr. A. A. Kanthack read the following notes and showed the
drawings referred to. The exact function of the epiglottis was not
even yet fully understood. It was a respiratory organ as much as a
phonatory one, but in man was more or less abortive. With the base
of the tongue it also belonged to the complex protective mechanism of
the glottis during deglutition. This had been denied by Prof.
Anderson Stuart, but his method in demonstrating that the epiglottis
comes forward and does not fold down was faulty. Mr. Anderson and
the speaker had shown that if animals such as Stuart used be allowed
to swallow in the natural position, with flexed and not over-extended
neck, the epiglottis acts as a laryngeal lid. Allusion was made to the
work of Moritz Schmidt and others.
In adult guinea-pigs, rabbits, cats, dogs, goats, oxen, horses, and pigs
an intra-nasal epiglottis could always be demonstrated by means of
frozen vertical sections. These were illustrated by an extensive set of
drawings. Mention was made of the exhaustive work of Howse and
Gegenbauer, and also that of Bowles and others.
61
According to Bowles the epiglottis of sucking pigs was small and
intra-oral, and at a later age became intra-nasal, i. e. ascended behind
the velum. The same change occurred in kittens and puppies. In
foetal kittens the epiglottis was as often intra-nasal as intra-oral.
With age, therefore, changes in position of the epiglottis took place
which required fuller investigation. In cats, rabbits, and guinea-pigs
the velum palati extended vertically down to the base of the tongue
in front of the epiglottis, so that in these animals swallowing under
natural conditions could only take place with an epiglottis folded over
the larynx.
In rats the epiglottis was found either in the oral or naso-pharyngeal
cavity, in mice as a rule in the former; but the parts in smaller
animals were so delicate that they were easily deranged.
In man and anthropoid apes the epiglottis was rudimentary, and did
not show the intra-nasal arrangement. Gegenbauer had shown, how¬
ever, that developmentally it was not connected with the mouth. In
some monkeys the velum descended in front of the epiglottis, but in
most the relations resembled those of man, and the epiglottis did not
reach the velum. The human epiglottis was at times greatly enlarged,
so as to be plainly visible on opening the mouth, and to hide the
posterior wall of the pharynx from view. Dr. Kanthack asked
whether in such cases the velum and uvula descended in front or behind
the elongated epiglottis.
Dr. Scanes Spicer thought that the epiglottis, as seen clinically,
was always posterior to the soft palate and uvula. The discharge
from the uvula certainly dripped on the oral side of the epiglottis.
The President asked Dr. Kanthack to follow out this question of
the epiglottic function. To what extent was the epiglottis concerned
in phonation ? It had been shown that timbre depended on the
position of the epiglottis. In the production of open tones the
epiglottis was said to be always more upright.
Dr. Percy Kidd mentioned the case of an aphonic boy, in whom
any attempt at phonation resulted in the pulling down of the epiglottis
to a nearly horizontal position.
Dr. Kanthack called attention, in reply, to the extreme difficulty
attending all experiments as to function.
Recurrent Papilloma of Larynx twice operated on by
Thyrotomy.
Dr. Percy Kidd showed this case. Chas. W—, aet. 9, was
admitted into the Brompton Hospital on September 7 th, 1893, on
62
account of loss of voice and slight inspiratory stridor. His voice had
been lost since April, 1893. Laryngoscopic examination showed the
presence of growths on the anterior portions of both vocal cords,
especially the right.
On September 19th Mr. Godlee performed thyrotomy, and removed
the growths with a sharp spoon. Nitrate of silver was applied to the
base of the growths. Eapid healing ensued.
A fortnight later, October 3rd, a flattish outgrowth was detected
on the laryngeal aspect of the right half of the epiglottis, and the
corresponding vocal cord at its anterior third presented a pale
cedematous fusiform enlargement. The patient then went to his home.
On November 21st he was readmitted, as the growth had recurred
in the old site and was larger than ever.
On November 27th Mr. Godlee again performed thyrotomy, and
cleared out all the growths with a sharp knife. A great part of the
left vocal cord had to be removed with the growth. Eapid healing
again took place, but on December 17th, less than three weeks after
the operation, another recurrence took place. Both cords were then
red, thick, and irregular, but moved fairly well. A large growth was
attached to the right cord at its anterior half, and the corresponding
part of the left cord was somewhat swollen. The outgrowth on the
right side of the epiglottis remained unchanged.
Microscopically the growth was a papilloma.
Mr. Btjtlin recalled two cases in which he had performed thyro¬
tomy on the same day. In one the operation was simple and suc¬
cessful, with good recovery of voice. In the other case the growth
was diffuse and difficult to distinguish from healthy tissue; it was
removed by scraping, but recurred again and again, and the patient
was now wearing a tracheotomy tube.
Dr. Dundas Grant referred (1st) to the reported spontaneous
disappearance of papillomata which sometimes occurred after tracheo¬
tomy ; (2) to the reported curative action of arsenic given internally;
(3) to the frequent coincidence of post-nasal adenoids; (4) to the
value of applications of strong solutions of perchloride of iron. In
the case reported he would attack the growth by means of his safety
endo-laryngeal forceps under anaesthesia, and at the same time
administer arsenic.
Dr. Soanes Spicer thought that the growth might be removed
endo-laryngeally, and recommended the use of chloroform supple¬
mented by frequent mopping with cocainised mops to produce complete
anaesthesia and paralyse secretion
The President mentioned a case in which no less than seventeen
thyrotomies had been performed on the same patient, the result after
63
each being simply recurrence of the growth. He agreed that
Dr. Kidd’s case might be treated endo-laryngeally with Dr. Dundas
Grant’s forceps. As a general rule he would prefer to leave such
growths alone in young children, unless they were causing dyspnoea.
Although brilliant results might occasionally occur, recurrence
generally took place and perpetual operations had to be performed.
Even where there was dyspnoea it was sometimes better to perform
tracheotomy and wait until the child grew older before removing the
growth.
Angioma op the Larynx.
Specimen exhibited by Dr. Percy Kidd. Microscopical section of
a portion of the tumour showing the characters of an angioma.
The patient, a Russian woman set. 30, came to the out-patient
department of the London Hospital in March, 1893, complaining of
hoarseness and a sore feeling in the throat which had existed for a
period of twelve months.
Laryngoscopic examination revealed the presence of a rounded
tumour of the size of a pea springing from the left vocal cord, about
the junction of the anterior and middle thirds. The growth presented
a pinkish-grey colour, and was attached by a broad flat pedicle which
permitted a considerable degree of movement. After cocainisation of
the larynx the tumour was removed in two pieces with Mackenzie's
cutting forceps. No bleeding of any note resulted.
Three days later the left vocal cord presented a reddish irregular
appearance, but no trace of the growth remained. The patient ceased
attending after this, and had not been seen again.
Enlargement op Posterior Faucial Pillars.
Mr. L. A. Lawrence showed a patient, F. P—, a man-servant
set. 30, who had suffered with his throat as long as he could remember.
A diagnosis of enlarged tonsils had been made when he was eight
years old.
The present trouble dated more especially from Christmas, 1884, as
the result of a bad cold caught by exposure in a severe snowstorm.
The tonsils were large. Posterior faucial folds very large, smooth,
red, and hard to the feel, and extending some considerable way down
the back wall of the pharynx. Uvula also swelled. Vocal cords
normal. The turbinate bones were slightly enlarged, but the nostrils
64
not blocked. Patient could blow out a candle through either nostril.
The pharynx was greatly narrowed laterally by the projection of the
large posterior pillars.
In October last these conditions had been rather more aggravated
than they were at present, and the voice was then nasal in tone. He
had been using a paint of chloride of zinc, 30 gr. ad 3j, till November
17th, since which time it had been increased by ten grains.
What further treatment was advisable in such a case ?
Mr. W. G. Spencer thought it would be possible to divide the
thickened faucial pillars with the cutting cautery and shell out the
tonsil.
Laryngeal Papillomata.
Pathological specimen exhibited by Dr. Scanes Spicer. A. L—,
®t. 8, a schoolgirl, lost her voice about January, 1887, during an
attack of measles, and had not recovered it up to the period of coming
under treatment in October, 1887.
On laryngoscopic examination the whole length of the right vocal
cord on its upper surface and inner margin was covered with sessile
warty growths.
She was given chloroform, placed in a sitting position in a nurse's
lap in a chair, the tongue held out by an assistant on the right, the
head steadied and kept square by an assistant behind. Anaesthesia
was completed by spraying the throat with a 10 per cent, solution of
cocaine. The growth was then removed piecemeal at two sittings by
means of the laryngoscope and Mackenzie's lateral cutting forceps.
Much mopping was required on account of exudation of secretions
and bleeding.
Her restoration to health of voice and larynx was perfect. At the
end of 1893 she presented herself for examination. There had been
no trouble since, and on examination, six years after the operations, she
had a perfectly normal larynx and voice.
This patient had a papilloma on her lip as well, and nasal obstruc¬
tion from post-nasal adenoid hyperplasia, which were treated at same
time.
The points of interest in the case appear to be the early age of the
patient, and the methods which it was found necessary to adopt in
order to see and remove the growth, and its successful removal
without tracheotomy.
65
Mr. Cresswell Baber remarked upon the difficulty attending
operations under chloroform alone in such young children. The plan
of combining it with the local use of cocaine was a decided improve¬
ment.
Mr. Kanthack observed that in experiments upon animals it was
always found that an exceptional amount of chloroform was required
to paralyse the act of deglutition.
The President referred to the increased flow of saliva induced by
chloroform, and agreed that the laryngeal reflex was the last to dis¬
appear under anaesthetics.
Dr. Spicer thought that chloroform alone was not sufficient to para¬
lyse the pharynx. He used the cocaine mops persistently till all secre¬
tion had ceased.
Papilloma of Uvula.
Pathological specimen exhibited by Dr. Scanes Spicer. The
patient, A. H—, set. 15, a servant, came complaining of tickling in
the throat, which led to irritating cough and “ spasm ” of the throat.
These symptoms had been noticed three months.
On examination a papillomatous pedunculated mass the size of a
pea was seen to be attached to a somewhat elongated uvula.
It was considered that the symptoms would be relieved by shorten¬
ing the uvula about the attachment of the growth, which proved to
be the case.
Dr. Spicer had never before seen a papillomatous growth of this
size attached to the uvula or in the pharynx, and he believed that
such cases were uncommon.
Carcinoma of the (Esophagus.
Specimen exhibited by Mr. W. R. H. Stewart. L. G—, set. 29,
a cook, an ansemic and somewhat emaciated woman, attended at the
London Throat Hospital at the end of May, 1893. She stated that
up to the preceding February, when she caught cold, she was well.
She then had a sore throat, with dryness and difficulty of swallowing,
taking fluids better than solids. After two or three weeks she went
to Hastings for a fortnight, where she seemed to be quite well. On
returning to London, however, the symptoms all returned with greater
intensity. She began to lose flesh, and the food occasionally regur¬
gitated through the nose. There was no history of syphilis or injury
66
to the throat of any description. The father and one brother died of
phthisis. The voice was hoarse. There was tenderness over the right
side of the larynx, and she expectorated a white frothy fluid.
Laryngoscopic examination showed some irregular swellings situ¬
ated about half an inch above the arytenoids and more to the right of
the middle line, and from one point pus was oozing; through this a
fine probe could be passed into the oesophagus, some roughness being
felt as it went through. Larynx normal. Patient gradually got
weaker, the difficulty in swallowing, tenderness and pain in the right
side of the neck increased, and there was a good deal of swelling in
this region. Gastrostomy appeared to be imminent, and the patient
was therefore transferred to the Great Northern Central Hospital.
There on July 21st, the swelling in the neck having increased, Mr.
Stewart dissected down to it, and found a mass of tough, thickened
tissue, which proved to be the thickened wall of the oesophagus. This
was removed, and a large drainage-tube inserted; but the patient
gradually got worse, and as it was found impossible to feed her either
through a catheter or by the tube in the wound, gastrostomy was
performed by Mr. Macready, and a good meal was given through the
tube during the operation; she seemed greatly relieved, but gradually
sank, and died two days after.
Post-mortem ,.—The upper portion of the oesophagus for about four
inches was found to be affected, and the microscope proved the growth
to be carcinoma.
There were several points of interest in this case. First, with
regard to the unusually early age—twenty-nine. The disease was
thought to be very rare before thirty-five years, and although it
occurred earlier in women than men, forty-five to fifty-five was the
usual time. Again, it was an instance of the reputed disposition of
children of tuberculous parents to develop cancer of the oesophagus.
There was no traceable exciting cause, and the disease did not spread
from an adjacent organ. Death took place very rapidly, within five
months of the patient feeling any symptom, and the upper portion of
the tube was affected ; but it was probable that the disease had no
special preference to any part. Does ulceration occur at an earlier
stage when the upper part of the oesophagus is first affected P
67
Suppuration in the Ethmoidal Cells.
(This case was reported in the * Lancet/ April 29th, 1893.)
Mr. W. R. H. Stewart showed the case of M. W—, a married
woman, who was sent to him at the Great Northern Hospital by his
colleague, Mr. Morton, with the following history:—Scarlet fever
twenty years previously. During convalescence a large abscess
formed in the corner of the right eye, and she was slightly deaf. The
abscess burst and both ears discharged. She had no further trouble
in the eye for ten years, but suffered occasionally from severe head¬
aches. When out one day she suddenly felt a most violent pain
which lasted for a week, during which time she could not sleep or lie
down, and was at times unconscious. She consulted an oculist, who
told her she had a tumour at the back of her eye. He incised a hard
lump in the corner, and a lot of discharge came away. Eighteen
months afterwards the eye was again very painful, and once more
opened without relief. The pain in the head was very severe, and the
swelling was incised a third time. Since then, nine years ago, the
pain in the head has been almost unbearable, from time to time lasting
from a few hours to two or three days. The swelling in the forehead
and temple was always much inflamed whilst the pain lasted. Five
years ago, after using a very hot lotion, large quantities of discharge
came down into the throat, and have continued ever since. During
the past few months the substance in the corner of the eye had
become larger, the eye itself was more prominent, the attacks of pain
more frequent, and affected the teeth so much at times that she could
not bite. The parts seemed numb when not painful. When seen,
now three years ago, the eye was pushed outwards and downwards,
and there was a round swelling in the interior and superior corner of
the orbit; the canaliculi had been slit up, and there was some discharge
oozing from them. Rhinoscopy showed a large, hard, and tense
swelling occupying the place of the right middle turbinate. Naso¬
pharynx free. Under an anaesthetic he punctured the turbinate
swelling with a trocar, and then on inserting his little finger into the
nostril the tumour crackled up before it, and he was enabled to pass
his finger on into the orbit. He therefore made a free incision into
the internal and superior corner of the orbit, found a large quantity
of dead bone and the orbit full of stringy pus, which was pushing out
68
the eyeball; the pus had also hollowed oat a cavity in the direction
of the frontal sinus, into which he could insert the tip of his little
finger. The dead bone was removed, and the pus and debris well
washed out with a warm boric acid lotion; a large drainage-tube was
then inserted through the nostril and brought out through the wound.
The patient did remarkably well, and now, three years after the opera¬
tion, the nose remained free. There was, however, some slight hyper-
sesthesia round the orbit, and some bone had recently come away.
The late Sir W. Bowman saw the case with Mr. Morton before she
came to him, and pronounced it one of suppuration in the post-
ethmoidal cells.
Recent Syphilitic Stenosis op Larynx.
Mr. Symonds showed this case, a man, set. 45, with syphilitic
stenosis of the larynx of recent origin. There was a general diffused
thickening of the mucous membrane, with much narrowing of the
glottis and impeded respiration. The affection had existed for one
year, and though so recent had not yielded to a vigorous course of
remedies. A prophylactic tracheotomy was recommended.
Swelling op Ventricular Band and Arytenoid Cartilage
op Uncertain Nature.
Mr. Symonds showed, for the second time, a man of 75 who was
exhibited in May, 1893. At that time he had a swelling of the left
band and arytsenoid, with fixation of the cord. The symptoms arose
suddenly while eating, and at first it was thought that the part had
been wounded by a bone. There was no history to support this
view. He had, when shown in May, a painful short cough with
much dysphagia. At the present time, after an interval of eight
months, there was still swelling on the left side, with fixation of the
cord. It appeared hard and had lost its glazed appearance. There
was a depression in the centre that looked like a superficial ulceration.
The arytsenoid was not so swollen as before. The cough and the pain
disappeared, and he could swallow easily. In May the diagnosis lay
between a growth and some form of perichondritis. At the present
time the diagnosis was still open. The appearances did not closely
resemble any known growth. Iodide of potassium had been tried.
69
There was no external change in the larynx. The case would come
before the Society again.
The President thought that the diagnosis must still remain un¬
certain, but he inclined to his former view that it was originally a
perichondritis. He expressed thanks to Mr. Symonds for the further
exhibition of the case, and suggested that all such doubtful cases
might with advantage be shown again and again to the Society, in
order that their progress might be watched and studied.
Epithelioma op the Soft Palate and Fauces.
Dr. Watson Williams brought forward this case. F. F —, set.
65, was admitted to the Bristol Royal Infirmary in August, 1893,
with a large epitheliomatous growth occupying the soft palate, well
displayed in the coloured drawing exhibited. It probably commenced
in the soft palate on the right side eleven months before admission,
when the patient first began to notice pain and difficulty in swallowing.
The case had previously been diagnosed and treated for syphilis,
but there was no history of syphilis, nor any family history of
malignant disease.
The main portion of the growth showed light pink, granular, but
deep ulceration, covered with greyish muco-pus and disintegrated tissue
which gave a characteristic foetor to the breath. The surface of the
ulcerated portion was fissured, nodular, and of a cauliflower aspect,
while the margin was seen to be elevated, distinct, and hard. There
was no glandular enlargement or infiltration in the neck at first, nor
was the pain intense. It had been relieved by iodide of potassium for
a time, and when it became more severe by ten-grain doses of
analgen. The growth gradually spread and disintegrated. The
gland of neck became rapidly involved, and the patient sank and died
two months later. An attempt was made to arrest the growth by
inoculations with pure cultures of the Streptococcus erysipelatosus,
but without success.
6 *
PBOCEEDINGS
OF THE
LARYNGOLOGICAL SOCIETY OF LONDON
Ordinary Meeting, February 14 th, 1894.
Felix Semon, M.D., F.R.C.P., President, in the Chair.
E. Clifford Beale, M.B.,
Scanes Spicer, M.D.,
Secretaries.
Present—22 Members and 2 Visitors.
The following gentlemen, nominated by the Council at the previous
meeting, were elected Honorary Members of the Society:
Sir George Johnson, M.D., F.R.S.
Prof. B. Fraenkel, Berlin.
Prof, von Schroetter, Vienna.
Prof. Stoerk, Vienna.
Dr. Wilhelm Meyer, Copenhagen.
Dr. J. Solis-Cohen, Philadelphia.
Dr. G. M. Lefferts, New York.
Prof. Massei, Naples.
Dr. E. J. Moure, Bordeaux.
Tbe following gentlemen were elected Ordinary Members of the
Society:
Dr. J. H. Drysdale, Liverpool.
Dr. James Cagney, London.
Mr. Edmund Roughton, London.
The Minutes of the previous Meeting were read and confirmed.
Tubercular Tumour of Larynx.
Dr. Clifford Beale showed a patient, aet. 22, who had been under
observation for the last four years, suffering on and off from tubercular
disease of both apices. The active pulmonary disease had always
subsided whilst the patient remained in hospital. The throat had at
first been affected with occasional attacks of simple laryngitis. During
the last year a nodular swelling had formed at the posterior part of
the right arytaenoid cartilage, projecting into the larynx and cover¬
ing the right processus vocalis. It was smooth, rounded, and not
first series—vol. i. 7
72
ulcerated, and only gave rise to occasional hoarseness. The firm
character of the swelling, its position, its relation to the inactive
disease in the lung, and the fact that it showed no tendency to disinte¬
gration placed it in the class of conglomerate tubercular tumours of
the larynx, described by Stoerk and others.
Dr. Tilley thought that the tumour must be classed as tubercular,
and mentioned an exactly similar case. The position of the swelling
was, he thought, sufficient in itself to warrant the diagnosis of
tubercle.
Dr. de Havilland Hall, agreeing as to the tubercular nature of
the tumour, would deprecate any interference with it so long as it
gave rise to so little trouble.
The President described the case of a man, aged fifty, in whom
no tubercular disease of the lung was manifest, but who had a slowly
growing tumour in the anterior commissure of the cords. This was
proved to be tubercular by examination of a portion of it, and was
checked by applications of lactic acid. Possibly some tubercular
lesion of the lung was present, but no physical signs of it could ever
be discovered.
Complete Paralysis of the Right Vocal Cord.
Mr. Butlin showed a patient with complete paralysis of the right
vocal cord. The cord stood almost in the middle line, and its free
border was incurved. The other vocal cord moved well, and came in
contact with the paralysed cord, but the voice was gruff and unsteady.
There were no signs of disease in the interior of the larynx, and the
two cords were quite white and clean.
The patient said he had become gradually hoarse in the course of
June, 1893, and was not conscious at that time of having suffered
from a cold.
He had been an inmate of St. Bartholomew's Hospital for some
days, during which a careful examination had been made, in order to
discover a cause for the paralysis, but without success. There wiere
no evident signs of central or peripheral nerve lesion; no signs of
aneurism or tumour in the neck and chest; no signs of malignant
disease of the larynx or oesophagus.
There was a history of venereal disease many years (thirty) pre¬
viously, but no clear history of syphilis. The man stated that he had
lately lost a stone in weight, but that was apparently only due to a
sharp attack of influenza.
73
No physical signs of affections of the apices of the lungs were
discovered.
The patient was a miller 52 years old.
The President thought it possible that the paralysis might he the
forerunner of tabes. He had been struck with the frequency of early
abductor paralysis in cases of commencing tabes, but agreed that in
the present case no symptoms were as yet evident which could justify
such a diagnosis.
Carcinoma of Right Side of Larynx.
Mr. Butlin also showed for Mr. Bowlby a man, between 40 and
50 years of age, with considerable swelling and ulceration of the right
ary-epiglottic fold and right half of the larynx, which was immoveable.
There were enlarged, hard, fixed glands on the right side of the neck,
particularly below the angle of the jaw. The larynx was broader than
natural.
The patient suffered much from pain, dysphagia, and occasional
sharp attacks of dyspnoea. His symptoms dated from September,
1893, when he first began to experience pricking sensations about the
right side of the larynx.
Rhinitis Fcetida, with Antral Disease and Hypertrophy of
Uncinate Process and Mucous Membrane covering it,
simulating so-called “ Cleavage."
Clinical case exhibited by Dr. William Hill. Miss G—, aet. 45.
History .—The foetid rhinitis was of five or more years 1 duration,
and had been treated by removal of crusts, antiseptic sprays and
douches, galvano-cautery, trichloracetic acid, iodol ointment, &c.
In January, this year, an attempt was made to drain the antrum
through a tooth socket. A considerable quantity of pus escaped
through this opening. The antrum had been syringed until within
the last week, when the operation became too painful.
Rhinoscopic appearance .—In the right nostril could be seen the
condition corresponding to the descriptions of “ cleavage ” of the
middle turbinated body (Woakes). The body on the outer side of
the cleft in this case was clearly a pathological enlargement of the
uncinate process of the ethmoid, together with the mucous membrane
covering it; this process normally bounds the hiatus semilunaris in
74
front and below. The hypertrophy of the nncinate process and its
mucous covering might be conveniently described as the " uncinate
body.’* The body on the inner (septal) side of the cleft was the middle
turbinated itself. The cleft was choked with granulations, and it was
inferred that the antrum contained granulations or polypi, or some
other diseased condition of the mucous membrane.
Proposed further treatment:
1. Removal of the hypertrophied area (“ uncinate body* 1 ).
2. Opening of the maxillary antrum through the canine fossa.
3. Establishing an accessory opening between nose and antrum,
either in middle or inferior meatus.
Note. —Although the “ uncinate body ” is usually composed of
overgrowth of bone and mucous membrane, the bone occasionally is
of normal size, but covered by such an overgrowth of the muco-
periosteum as to appear as a fibrous or mucous tumour which can
readily be severed.
Obscube Pharyngeal Ulceration in a Case ,of Arrested
Laryngeal and Pulmonary Tuberculosis.
Dr. Felix Semon showed the case of N. W—, set. 36, a gentleman
who, coming of a healthy family, began to suffer with severe sore throat
in August, 1892. Had never had syphilis. Nevertheless in
November, 1892, a London laryngologist considered the affection to
be specific, having found considerable ulceration of the epiglottis. In
December, 1892, Dr. Davison of Bournemouth pronounced distinct
disease of right apex. He treated the larynx with lactic acid, and
ordered constitutional measures. The throat got gradually better, and
in April, 1893, Dr. Davison stated that the laryngeal ulceration had
been definitely arrested. In June, 1893, the soreuess started again,
and the patient consulted the reporter, who found consolidation of the
right apex and tubercular tumefaction and ulceration of the epiglottis,
a diagnosis which was subsequently corroborated by Sir William
Broadbent. The epiglottis was treated by energetic curetting followed
by applications of lactic acid (30 to 50 per cent.), and the ulceration
again healed, leaving a large loss of substance about the middle of the
part, covered by a peculiarly white scar. The right half of the epi¬
glottis has ever since remained tumefied. Internally the patient was
75
given, and had ever since taken, large doses of creasote. The condition
of the right lung had remained perfectly stationary, and the general
health very good. On the epiglottis once more, at the beginning of
November, slight ulceration took place in the scar tissue, which was
again promptly stopped by lactic acid.
At the commencement of this year Dr. Davison observed on the pos¬
terior wall of the pharynx some small, well-defined, clean, steep ulcers,
which he at first was inclined to look upon as tubercular, but which
did not yield to lactic acid. The patient states that he has once
before had a similar ulceration, which gradually disappeared. The
theory of syphilis once more being revived, the patient took for a
fortnight iodide of potassium. This only resulted in the production
of considerable oedema of the left arytaenoid cartilage, with transitory
immobility of the left vocal cord. The pharyngeal ulcers were now
again spontaneously subsiding, and suggestions were invited as to their
probable nature.
Mr. Symonds suggested that the pharyngeal ulceration should be
curetted and treated with lactic acid.
The President had used lactic acid without any result, but not
after curetting. The fact that the larynx had healed under lactic acid
made it appear that the pharyngeal condition must be due to some
other cause besides tubercle.
(Edema and Infilteation of Arytenoid Mucous Membrane
of Uncertain Origin.
Clinical case exhibited by Dr. Scanes Spicer. J. F—, set. 51,
labourer, was sent to the throat department at St. Mary’s Hospital by
Dr. Maguire January 23rd, 1894.
i Symptom .—Shortness of breath; feeling of choking and suffocation;
paroxysmal cough; excessive secretion of frothy mucus; constant dis¬
comfort in throat day and night ; voice weak, but not otherwise
affected; difficulty of swallowing extreme ; had lasted two years.
Laryngoscopic examination. —Pale, glistening, semi-transparent,
bladder-like swelling seen filling upper orifice of larynx, and obscuring
glottis completely. After cocainisation this swelling somewhat subsided,
and the left pyramid was seen to be cedematous and lobulated in the
situation of cartilages of Santorini and Wrisberg. The left ventricular
band was considerably infiltrated and red, but no ulceration could be
76
made out, and it overlapped the left vocal cord. Both vocal cords
moved normally on phonation, and glottis widened at inspiration.
The diagnosis appeared to lie between—
1. Perichondritis with secondary thickening and oedema.
2. Malignant disease with secondary oedema.
3. Tertiary syphilis with secondary oedema.
4. Tubercular disease with secondary oedema.
(1) appeared to be excluded by free mobility of cords, and by
long duration of case without much alteration in symptoms.
(2) by the same signs, by absence of ulceration or by glandular
enlargement, and by absence of sufficiently marked cachexia.
(3) . There was a history of syphilis, but had this laryngeal affection
been gummatous, it must have led to ulceration and destruction of
soft parts at all events, especially as there had been no antiseptic
treatment.
(4) . The case was probably of tubercular origin, on which had
supervened an unusual amount of oedema. It is the observer’s experi¬
ence that such marked laryngeal disease in tuberculosis is seldom con¬
fined so entirely to one side. The emaciation, history of repeated
attacks of bronchitis, slight haemoptysis, together with depression
about clavicular fossae and upper intercostal spaces (in the absence
of any marked pulmonary lesions), taken all together, confirm the
tubercular view. Examination of sputa for tubercle bacilli had given
negative result.
Dr. de Havilland Hall thought that the condition was one of
perichondritis, and not of tubercle.
The President, Mr. Butlin, and Dr. Tilley supported Dr. Spicer’s
view that the disease was tubercular.
Multiple Sarcoma.
Mr. W. R. H. Stewart mentioned the case of E. P—, a fireman,
who had been exhibited by him at the first Clinical Meeting of the
Society in April, 1893. A full account of the case appeared in the
first number of the f Proceedings/ At the suggestion of two or three
members Mr. Stewart had pushed the arsenic treatment, and within a
month the patient was taking Liq. Arsenicalis TT^xv, t. d. s., and
sometimes even larger doses. The result as far as the tumours were
concerned was marvellous. The glands in the neck gradually got
softer and disappeared ; the edges of the ulcers, to use Dr. Freeborn’s
77
description, who kindly looked after the case at Oxford, seemed to
melt away, and the naso-pharynx became fairly free. The swelling in
the tongue, however, did not get less, but it ulcerated, and a lump
came away from it, which under the microscope proved to be simply a
blood-clot. About six weeks after commencing the arsenic his fingers
and toes began to feel numb, the feet swelled, his knees began to give
way, and he fell on them occasionally when walking. The arsenic was
then left off until July 4th, when it was recommenced, but it could
not be continued in such full doses again. The trouble in the throat
had gradually become worse, until it had reached its present condition,
viz. much the same as it had appeared last April.
Retraction of Al.e Nasi—Oza:na.
Mr. W. R. H. Stewart showed the case of M. H—, who for the
last eight years bad noticed a bad smell from the nose, gradually getting
worse. The nose became blocked and very sore. As the soreness
passed away the sides of the nose fell in. On examination there was a
contraction on both sides about half an inch from the opening. The
patient had been under treatment for ozsena for about a fortnight
with applications of laetic acid, 80 per cent, solution, and the passage
of nasal bougies. Mr. Stewart had not much hope of greatly benefiting
the contracted condition of the openings.
Dr. Tilley suggested that the patient should wear the small
celluloid alse nasi dilators introduced by Dr. Spicer, which, by a little
trimming down to suit the case, would be found to give the patient
relief from the obstruction to breathing.
Dr. J. B. Ball did not think that any special treatment was called
for, as the patient seemed to have room for respiration.
Absorbed Gumma over Right Arytenoid Cartilage—
Impaired Movement of Yocal Cord.
Dr. Hale White showed this case. Ed. 8—, set. 33, admitted
December 19th, 1893. In Guy's Hospital three years ago for rupia,
and nine months ago for sloughing gummatous testicle. Six weeks
before admission he lost his voice, and this had not returned. Diffi¬
culty of breathing had slowly come on, and any slight excitement
brought on choking attacks.
On admission cyanosis, enlarged glands in neck, specific scars on
78
legs, perforated nasal septum; voice very husky; cough difficult.
Inspiratory stridor so bad that tracheotomy appeared imminent.
Larynx did not move much. Some sucking in over lower part of
chest. Any excitement increased the dyspnoea. Over the right ary-
tsenoid was a rounded, greyish, (Edematous-looking swelling as large as
a Barcelona nut. The right arytsenoid could be seen, but the
posterior part of the laryngeal aperture was blocked by the swelling ;
the right cord moved, but not the left. Under treatment with gr. x
of Pot. Iod., gradually increased to gr. xxx ter die, and £ gr. of
perchloride of mercury injected into the gluteal muscles, the swelling
slowly subsided, and now there was scarcely any swelling, but the
left cord moved but little.
Dr de Havilland Hall mentioned a similar case where trache¬
otomy was often threatened, but where the use of iodide again and
again averted its necessity. Tracheotomy was finally unavoidable,
and subsequently thyrotomy had to be performed. The patient died
of pneumonia somewhat later, and the laryngeal disease was found to
be malignant, although it had apparently healed on several occasions.
The President thought that while it was not well to wait too long
for tracheotomy, it was always advisable to use iodide and mercury in
the first instance if possible. Cases had occurred of rapid improvement
by such means. In some cases the disease had been seated in the
trachea, and a too hasty tracheotomy would only have complicated
matters without giving relief. Replying to Dr. Hale White, he had
found that the movement of the affected cord in a case similar to the
one exhibited had been completely restored in course of time.
Gummata op Epiglottis (?).
Dr. Willcocks showed a patient, R. C—, set. 27, a Covent Garden
porter, who had contracted a primary sore three years ago, followed
by slight sore throat and erosions on edges of tongue. Rash on skin.
Voice husky for last two and three quarter years; affected shortly
after primary sore.
Present condition .—Epiglottis much thickened and irregularly
nodulated; somewhat fixed; no visible ulceration; feels hard; view
of interior of larynx imperfect ; no enlarged glands to be felt under
jaw.
Mr. Stewart referred to a similar case which cleared up under
the use of iodide, but with occasional severe laryngeal spasm, necessi¬
tating the use of an anaesthetic. In another case the disease simply
went from bad to worse, the iodide showing no result.
Dr. Bronneb advised the use of mercurial inunction.
Dr. Willcocks proposed to treat the case with iodide and mercury.
PBOCEEDINGS
OP THB
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, March 14 th, 1894.
Felix Semon, M.D., F.R.C.P., President, in the Chair.
E. Clifford Beale, M.B.,
Scanes Spicer, M.D.,
Secretaries.
The minutes of the previous meeting were read and confirmed.
The President referred in feeling terms to the great loss that the
Society had experienced in the death of Dr. Ernest Jacob, of Leeds.
His wide range of interest in scientific work of all kinds, not limited
to professional subjects only ; his cordial sympathy and co-operation
in the work of the Society, of which he was an original member, and
above all his kindly and genial personal qualities, would always be
held in remembrance by those who had the privilege of knowing him.
Fixation of Left Vocal Cord.
Dr. J. B. Ball showed the case of Mrs. A. O—, set. 81. The left
vocal cord was immoveable in position of complete paralysis. Right
vocal cord moved freely. No other sign of disease in larynx. In
January, 1891, she had influenza and congestion of the lungs. She
lost her voice during the illness, and though it had improved it had
never returned to its natural condition. Was thin and anaemic.
Catamenia scanty and infrequent. Breath short on exertion. Suf¬
fered from palpitation of heart. The feet and legs swelled at times.
Never had rheumatic fever. Heart’s apex beats in fifth space, an
inch outside nipple. Systolic and pre-systolic apex murmurs present.
Lungs normal.
Tumour of the Larynx in a Case of Goitre.
Dr. J. B. Ball showed this case. Mrs. C. B—, aet. 48, was
admitted into the West London Hospital on September 27th, 1892
FIRST SERIES—VOL. I. 8
80
with a very large goitre, which had been growing for ten years and
was beginning to cause some dyspnoea. A considerable portion of
the tumour was removed by Mr. Keetley. Larynx examined at this
time was normal.
Readmitted on August 5th, 1S93, suffering from severe dyspnoea.
Tracheotomy was performed immediately, and she bad worn tube
since. On August 25th, 1S93, a swelling was found involving right
ary-epiglottic fold and almost hiding glottis. Not examined again till
March 9th, 1S91, when a rounded, smooth red swelling was seen
involving the right ary-epiglottic fold, and covering nearly the whole
of the upper aperture of the larynx.
Since the original operation by Mr. Keetley in September, 1892,
there had been a considerable increase in the size of the portion of the
goitrous tumour which was left. Microscopical sections of the tumour
were exhibited.
Mr. Spencer thought that the case was certainly one of thyroid
carcinoma, both from its clinical appearance and from the characters
of the specimen shown.
Mr. Symonds agreed as to the carcinomatous nature of the growth,
and thought that the internal swelling was due to projection of the
growth inwards, as it seemed to be continuous when manipulated
externally, the larynx being examined internally at the same time.
The President suggested that the internal swelling might be a
part of the thyroid, but not of necessity a part of the growth.
Dr. Dundas Grant suggested that the appearance of invasion of
the larynx bv the growth might be due to the displacement caused
by the external swelling pushing parts of the larynx itself inwards.
Laryngeal Symptoms in a Case of Insular Sclerosis.
Dr. F. W. Bennett showed this case. R. P—, set. 38, complained
in April, 1892, of difficulty in swallowing, hoarseness, and attacks at
night-time as if “some one were clutching the throat, preventing
breathing.” He attributed the symptoms to a bad cold, and had
noticed also tingling and cramps in the hands, arms, and legs, espe¬
cially of the left side, pain in the hips and spine, and severe occipital
pain. He suffered occasionally from vertigo.
On examination the pharynx and larynx were found chronically
inflamed, the uvula elongated. During inspiration the cords separated
widely, the right moving most freely. In phonation the right cord
81
moved slightly over the middle line, but the left moved fairly freely.
The vocal processes met, leaving an oval opening between the cords
anteriorly and a triangular opening posteriorly. Occasional tremor
of the cord was noticeable.
The pupils were very unequal in size ; there was frequent spasm of
the left orbicularis; fundus of the eye normal ; the tendon reflexes
were lively. Nothing abnormal could be detected in the chest or
urine. The patient was thought to be suffering from insular sclerosis.
March, 1894.—The patient stated that he would feel well if it were
not for his throat. His life was “ made a misery to him ” by attacks
of “ spasm of the throat/’ which prevent him from lying down at night.
The voice was now better, but the spasms were much worse. The
appearance on phonation did not show any important change. Occa¬
sionally, however, the left cord failed to meet the right, and retained
a general concavity inwards.
The sensitiveness of the larynx was not impaired. The crico-thyroid
muscle contracted moderately during attempts at singing.
Dr. Scanes Spicer called attention to the marked degree of nasal
obstruction which existed in this case. He thought the laryngeal
spasms occurring on lying down at night were due to the accidental
passage of secretion from the naso-pharynx and pharynx into the
larynx. It was observed that the naso-pharynx and pharynx were in
a state of subacute inflammation, the palate and uvula inflamed,
“ dropped,” and hypertrophied. He believed that these conditions
could only be cured by first rendering the nose patent, and that if
the catarrh were subdued, the nocturnal laryngeal spasms would cease.
He did not regard the spasms as of central origin, nor as reflexly
started in the nose, but as a direct mechanical irritation from excessive
catarrhal secretions.
The President did not think that there was any connection between
the nasal condition and the spasmodic movements of the cords. These
he regarded as evidences of some central defect of co-ordination, and
pointed out that the position of the cords was constantly changing
even during examination, and especially on attempted phonation.
Dr. McBride suggested that the nocturnal spasms and the peculiar
movements of the cords might be due to hysteria. He could not
accept the explanation offered by Dr. Spicer, but believed that if the
catarrh and its consequences were relieved by operative measures the
laryngeal affection might or might not be cured, but still ought to be
regarded as of an hysterical nature. Any severe shock, such as a
surgical operation either in the nose or elsewhere, might bring about
a cessation of such symptoms.
Dr. Bennett agreed with Dr. Spicer that the nose should receive
attention. He had noted the changes of position to which th
President had referred, and recalled the fact that at an earlier stage in
82
the case some temporary relief had been afforded by removal of a
portion of the elongated uvula, but that no permanent benefit had
resulted. He had no doubt that the general symptoms indicated the
slow progression of insular sclerosis.
Tracheal Fistula.
Clinical case exhibited by Dr. de Havilland Hall. —M. S—,
set. 40. Tracheotomy was performed at the age of twelve on account
of gradually increasing difficulty of breathing. A cannula was worn
up to the age of nineteen, but a tracheal fistula remained after its
removal. Closure of the opening with the finger caused dyspnoea.
On laryngoscopic examination the glottis was found to be very much
contracted by'papillomatous growths springing from the vocal cords
and the anterior commissure. After these were removed with the
cutting forceps, Mr. Pearce Gould did a plastic operation, and closed
the tracheal fistula, which had existed for twenty-one years.
Syphilitic Stenosis op Larynx.
Specimen exhibited by Dr. de Havilland Hall. —Larynx of a
patient who was shown at a previous meeting of the Society suffering
from syphilitic stenosis. During a wrangle in the street the canula
came out, and being unable to replace it, the patient was brought into
the hospital dead.
Mr. Spencer, who had originally performed tracheotomy in this
case, observed that there had probably been some affection of the
superior laryngeal nerve, as evidenced by certain disturbances of
circulation from which the patient had suffered, which had decided
him against undertaking any further operative measures. There
was probably some amount of neuritis of the superior laryngeal
nerve, and it was most likely that the sudden death was not due
merely to the loss of the tube, but to some sudden disturbance of the
heart’s action.
Dr. Hall agreed with this view, and mentioned that the patient
had on several occasions suffered from syncopal attacks and vomiting.
83
Laryngeal Stenosis (? Tubercular) .
Dr. Percy Kidd showed this case.— C. H—, set. 42, an ex-police¬
man. The patient had some venereal disease, whether syphilis or not is
uncertain, fourteen years ago.
Two years ago he had “ influenza and bronchitis/* since which time
his voice became weak, and a few months later was lost altogether.
There had not been much cough or expectoration, but the patient had
lost flesh considerably, and had suffered from dyspnoea on slight exer¬
tion.
Larynx .—The glottis was bounded by two dull red irregular bands,
occupying more or less the position of the vocal cords, but apparently
attached posteriorly at a lower level than usual with the normal cords.
On each of these bands at their upper and inner aspects there was a
fleshy, flattish, polypoid outgrowth. These bands were situated close
together, causing considerable stenosis of the glottis, and were quite
motionless. There was some partially healed ulceration over the left
arytaenoid cartilage close to the processus vocalis, extending to the
interarytsenoid fold.
Chest .—Weak breath-sounds on both sides. Muffled rales on
cough at the right apex in front and behind. Slight dulness at the
right infra-spinous fossa.
The patient had been under observation since last summer. The
larynx had not altered much. A course of iodide of potassium and
mercury had no effect. The pulmonary physical signs had varied consi¬
derably, at times no rales being audible, at other times r&les had been
heard at the left apex only. The sputum had been frequently examined
for tubercle bacilli with negative result. The patient had wasted much,
and his general condition had deteriorated sensibly.
Small Subglottic Tumour of Uncertain Nature in a Case of
Laryngeal Tuberculosis.
Dr. Percy Kidd showed the case of P. B—, set. 38, a caretaker.
Larynx .—Puckered and partly healed ulceration of tip of epi¬
glottis. Ventricular bands much swollen, partly hiding vocal cords.
§
84
Ary-epiglottic folds both much swollen. In subglottic region just
below anterior commissure, and slightly to the left of the middle line,
a sessile, oval, smooth, reddish tumour, of the size of a coffee bean.
The tumour was at first regarded as tubercular, but although the
patient had been under observation for three months, no change had
occurred in its appearance.
Tubercular ulceration of the epiglottis was arrested by the applica¬
tion of pure lactic acid.
The patient was the subject of chronic pulmonary tuberculosis.
His general condition had improved greatly, and he had gained
much weight during the last three months.
No history of any venereal disease could be obtained.
Two Cases op Malignant Disease op the Larynx cured by
Thyrotomy and Excision op the New Growth.
Exhibited by Dr. Felix Semon.
Case 1 (already described in Clinical Society's ( Transactions,*
vol. xxv, 1892, p. 300).—F. C—, gentleman set. 40, sent by Dr. Bower
of Gloucester, consulted the reporter in May, 1891. He was then
suffering from an infiltrating tumour in the larynx, occupying the left
ventricle and the left ventricular band, which almost completely
covered the left vocal cord. He had been suffering for more than
twelve months from hoarseness. Latterly, slight pain had occasion¬
ally been felt on the left side of the throat, extending into the ear. A
small piece of the growth was removed with Mackenzie’s forceps, and
turned out, on microscopic examination by Mr. Shattock, to be a
squamous-celled carcinoma. On June 2nd, 1891, thyrotomy was
performed; the patient recovered without any incident, and had never
shown a trace of recurrence. The phonatory result obtained was
remarkably good, although all the soft parts on the left side of the
larynx, including the left vocal cord, which was found to be somewhat
infiltrated in the course of the operation, had been removed; his voice
was practically normal. The situation of the former growth was occu¬
pied by a smooth cicatrix with a prominent ridge corresponding to where
the left vocal cord had been, and the right cord crossed the middle
line to some extent and almost touched this ridge.
85
Case 2.—The Rev. Canon B—, aet. 59. Sent by Mr. Lawford
Knaggs, of Leeds, and Mr. Arthur Lucas, of Woburn, on account of
a bipartite growth occupying the posterior part of the left vocal cord,
which extended almost to the arytaenoid cartilage; the cord showed a
very slight defect of mobility. The voice was marvellously clear in
spite of the situation and size of the growth, and of the congestion,
not only of the base of the latter, but also of the rest of the vocal cord.
The patient complained of pain in the left side of the throat, and of
tenderness on pressure of the left side of the larynx. There was also
some blood-stained expectoration in the mornings. The diagnosis
of malignancy was further confirmed by Mr. Butlin. On June
25th, 1892, thyrotomy was performed, and the left vocal cord,
together with a part of the left arytaenoid cartilage, removed. The
growth, on microscopic examination by Mr. Shattock, turned out to
be a cavernous fibro-sarcoma. The patient recovered without the
slightest incident, and in his case too the voice was nearly normal, a
cicatricial ridge having formed in the situation of the former vocal
cord very much as in the first case described.
Dr. Semon observed that this tendency to the formation of cicatricial
ridges doing duty for a removed vocal cord did not appear to be an
isolated phenomenon, exactly the same formation having also been
observed in the case of the late Mr. Montagu Williams.
A Laryngeal Neoplasm of apparently Sudden Origin
(Pachydermia).
Dr Scanes Spicer showed the case of J. C—, aet. 42, salesman,
who attended St. Mary's Hospital Throat Department on March 2nd,
1894, complaining of hoarseness of about fourteen days' duration,
which came on with a severe cold. Voice was clear and strong before
this attack. History of catarrhs, syphilis, rheumatism, and alcoholic
excess, the latter ten years ago. Took snuff, but not a smoker. Not
a voice user specially. Pupils markedly contracted, very slight reac¬
tion to light. Gait and patellar reflex normal.
Tongue showed smooth depressed cicatrices and rhagades. In
region of right processus vocalis was a small oval swelling with long
diameter parallel to vocal cord, papillated on surface, reddish in colour.
86
and on phonation dipping into reddened depression on opposite cord,
bnt there was no hyperplasia. Cord mobility perfect. Slight thick¬
ening on posterior wail. Mucosa generally red and rough.
The crateriform depression of the top of the tumefaction described
as characteristic of pachydermia was not to be made out, but the
situation of the swelling, the nipple-like surface, and the persistence of
the cord mobility pointed to the diagnosis of pachydermia in an early
stage, to the exclusion of malignant, tubercular, or syphilitic disease.
According to Sommerbrodt pachydermia favoured the right side, and
according to Chiari often originated in catarrh, points with which this
case was consonant.
The question must remain open whether the neoplasm had arisen
suddenly, or whether, during the present catarrh, a sudden increase
had taken place in a mass previously too small to cause hoarseness.
Pachydermia Laryngis.
Mr. C. J. Symonds exhibited a patient, Win. F—, set. 52, a tailor,
who stated that his voice had been affected since a boy. He came to
Guy’s Hospital in February, 1893, with some hoarseness. The
appearance of the cord was then identical with that seen now. He
returned February, 1894. When he first came he was given iodide of
potassium, and he believed that he was better for it. He had served
in the navy and army. He then drank spirits, beginning as a boy
with rum, which he took daily. Ten years ago he became a teetotaler
and remained so till three months ago. He said he had never drunk
to excess.
The principal elevation was on the left side. The summit was
yellow and depressed. On the right the projection was much smaller,
and was more definitely arising from the inner aspect of the cord.
Since February he had taken iodide of potassium, with the
effect apparently of reducing the prominence and rendering it more
glazed. He had had syphilis, and recently had nodes in his tibiae.
His face showed much acne.
The points of interest were the definite evidence of syphilis; and
the early consumption of alcohol, followed by a period of abstinence.
87
Dr. McBride though that Dr. Spicer’s case was analogous to the
condition of pachydermia. Tbe indentation on the upper surface of
the swelling, and its adaptation to the similar swelling on the opposite
cord, in Mr. Symonds’s case, was characteristic. He considered that
other forms of contact ulceration with induration, such as the
“ singer’s nodules,” might be classed as pachydermia.
Dr. Clifford Beale mentioned a case seen in a tubercular subject
in which for a short time the physical signs were precisely those of
pachydermia, but in which the signs were rapidly and markedly
altered under treatment. Could pachydermia laryngis safely be
diagnosed by its appearance only, without reference to symptoms, or
might not certain cases of chronic local ulceration be easily confused
with it ?
The President stated that the characteristic signs were not
present during the whole duration of such cases, and that they must he
taken in association with the other symptoms present.
A Fold of Mucous Membrane protecting the Middle
Meatus.
The specimen, exhibited by Mr. C. J. Symonds, showed the pre¬
sence of a lunated fold on the outer wall of the nasal fossa, opposite
the anterior extremity and the middle turbinated bone. It was con¬
vex forward, and ran from above downwards and backwards. Behind
and above it was the opening into the antrum.
The object of showing the specimen was to suggest that it offered
an explanation for the projecting (mass of hypertrophied mucous
membrane or) granulations seen in cases of suppuration of the
antrum, of the ethmoidal cells, and in some cases of polypi. The
projecting granulations in these cases were often in contact with the
middle turbinated bone, the pus escaping through the slit between.
This was, no doubt, the appearance described by Dr. Woakes as a
“ cleft turbinated.”
Though Dr. Greville Macdonald had correctly described this appear¬
ance, and was the first to publish a correct description, he had not
described the existence of this fold. The fold was often absent, though
there was always a ridge of greater or less prominence.
It might perhaps represent the fold usually found below the
orifice of the antrum, somewhat anteriorly situated. In order to ex¬
pose the meatus, Mr. Symonds was in the habit of cutting off this
fold with a knife, or removing by an antero-posterior acting curette.
88
Dr. Hai considered the specimen originally a perfectly normal
one which had been decalcified through long pickling in spirit, and
thus the relative position of the uncinate process and the middle tur-
binal had been disturbed by shrinkage. The so-called luuated fold of
mucous membrane represented the decalcified uncinate process; this,
when hypertrophied, had even been mistaken for “ cleavage ” of the
middle turbinal.
Mr. Symonds thought that Dr. Hill’s view might be correct, but
the position of the fold seemed to be too far forward for it to be
regarded as normal.
Tracheal Stenosis (?Cicatricial Stricture).
Dr. Percy Kidd exhibited the case of Chas. N—, set. 38, who had
syphilis thirteen years ago with secondary skin eruption and sore throat.
For the last two years he had suffered from an irritable cough with
profuse expectoration. About the middle of January, 1894, he first
noticed dyspnoea and stridor.
There was now dyspnoea on slight exertion, and stridor both inspi¬
ratory and expiratory. No recession of soft parts. No respiratory
excursions of larynx.
Pharynx .—Scarring of posterior wall and soft palate.
Larynx .—Vocal cords pinkish, but movements normal. The trachea
could be seen for a considerable distance. There appeared
to be a narrowing of the lower end, but the bifurcation was not
visible.
Chest. —Breath-sounds weak over both lungs, expiration prolonged.
Snoring sounds heard with inspiration and expiration. No other ab¬
normal sign.
The President observed that he had not been able to detect any
stricture.
Case of Adductor Paralysis of Left Vocal Cord.
Dr. Herbert Tilley related the following case. R. H—, set. 23,
a cab trimmer, came to hospital complaining of hoarseness.
History .—Five months ago patient complained of "sore throat,”
which produced a slight choking sensation, and was usually worse in
the morning. This discomfort increasing, he applied for hospital
relief February 20th, 1894. Fifteen months ago he had had abscesses
on the front of the neck, which were lanced, but his throat did not
89
trouble him at that time. On two or three occasions during the past
winter he had spat up blood. He gave a good family history.
Examination of larynx showed complete paralysis of the left vocal
cord. There was no swelling of the arytaenoids or ary-epiglottic folds,
nor was there any laryngeal or palatal anaemia. Tubercular mischief
was present in both apices. The scars of the abscesses on the front of
the neck were not deeply pitted, and were above the level of the
larynx.
Dr. Tilley suggested that pressure of enlarged bronchial glands
might produce paralysis, but did not know of any cases.
The President had seen a few cases which could only be attributed
to the pressure of such glands.
Case of Advanced Tubercular Disease of Larynx.
Dr. Herbert Tilley exhibited the case of Mrs. G—, set. 314 years,
a housewife.
Patient first complained of her throat in March, 1893, when it was
sore on swallowing, and painful on speaking. She had spat blood
previous to this, and noticed that she was losing flesh. She was
confined October 14th, and before and after that occasion her throat
got worse, so that she could scarcely swallow anything on account of
the pain. Latterly the pain had much diminished, and she could
swallow without difficulty any semi-solid food.
Examination showed marked anaemia of palatal muscles and larynx.
The epiglottis had almost completely disappeared, only a small stump
being left. The cords were much ulcerated, and there was a small
prominent tubercular granulation in the interarytaenoid space. The
case was exhibited to bear out Dr. Kanthack's recent communication
to the Society on the function of the epiglottis, which did not seem to
be so necessary for successful deglutition as was generally supposed.
PROCEEDINGS
OF THB
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, April Ilf A, 1894.
Felix Semon, M.D., F.R.C.P., President, in the Chair.
E. Clifford Beale, M.B.,
Scanes Spicer, M.D.,
Secretaries.
Present—14 Members and 13 Visitors, of whom 12 were members
of the Society of Anaesthetists (specially invited by the Council to
take part in the discussion).
The minutes of the previous meeting were read and confirmed.
The following candidates were then balloted for and unanimously
elected:
Dr. Hector Mackenzie, London.
Dr. Alfred Brown, Manchester.
Mr. E. Jessop, Hampstead.
The President briefly reported that the delegates of the Society
had been most hospitably received at the meeting of the International
Congress recently concluded in Rome, and that the work done in the
department of Laryngology had been such as to bind together still
more closely the interests of laryngologists of all nations.
DISCUSSION ON THE CHOICE OF THE ANAESTHETIC
IN OPERATIONS FOR REMOVAL OF POST-NASAL
ADENOID GROWTHS.
The President, in the name of the Society, offered a cordial welcome
to the members of the Society of Anaesthetists present, and explained
that the principal object of the discussion to which they had been
invited was to ascertain clearly what views were held by those who had
most experience of the subject as to the best form of anaesthetic to
be employed in cases of operation for the removal of adenoid growths.
Statements had been made which had to some extent alarmed the
public mind, that the administration of chloroform for this purpose
was not only likely to be dangerous, but was even to be regarded as
a criminal procedure. As to the actual danger or safety of any anaes¬
thetic, the anaesthetist’s opinion must be taken in preference to that
FIRST SERIES — VOL. I* 9
92
of the surgeon, and that opinion had already been expressed at the
Anaesthetists’ Society. But there were other questions with regard to
this special operation upon which the surgeon’s opinion must have
considerable weight, and it was upon the whole question that the com¬
bined discussion was invited.
Dr. Dudley Buxton opened the discussion, and deprecated any
hard and fast rule being made as to the choice or method of giving
the anaesthetic in these cases. The operator and the anaesthetist
should discuss and decide the matter in each case. No class of opera¬
tions varied so much in duration or degree of severity, and this fact
had to be carefully remembered in selecting the anaesthetic for each
individual patient. The ideal anaesthetic was one which could be
rapidly administered, and yet could be capable of prolongation if
necessary. This result was, in his opinion, best assured by the
employment of nitrous oxide at first, then by allowing gas to pass
over ether, and finally by giving ether itself, but no break in the
administration should be allowed. Subsequently, by means of a
metal mouth-tube, the vapour of chloroform or of A. C. E. mixture
could be blown through a Junker’s inhaler if it was necessary to pro¬
long the anaesthesia. The reflexes should not be altogether abolished.
Nitrous-oxide gas might be sufficient in a percentage of cases, but, as
a rule, it produced too brief an anaesthesia; a second administration
when haemorrhage was proceeding introduced an unnecessary element
of danger. Re-administration in the course of an operation was
undesirable, and any anaesthetic which restricted the administrator to
a limited period must be open to adverse criticism. The current
objections to the use of ether for these operations were, he thought,
traceable to incorrect methods of using it. Chloroform was in many
ways the most pleasant anaesthetic, but in young children it materially
added to the extent of “ shock,” which might be considerable in any
case from the operation and from haemorrhage.
A communication from Mr. Butlin was read, expressing regret at
his inability to be present, concluding as follows:—“ With regard to
the performance of the operation under gas, I would say that, while
there are occasional cases in which this is possible, there are very many
cases, on the other hand, in which the operation could not be satisfac¬
torily and thoroughly completed, at least by me.”
Mr. Tyrrell advocated chloroform from the commencement, espe¬
cially for children, given very slowly from a Junker’s inhaler through
a flannel face-piece, and carried just to that degree of anaesthesia which
abolished the conjunctival reflex without abolishing the cough and
swallowing reflexes He believed that with no other agent could that
degree of anaesthesia be kept so completely under control. He was
strongly of opinion that the danger of chloroform, thus given, was in
attempting to place the patient under its influence too rapidly. He
had not infrequently placed young children under chloroform without
awaking them from sleep, which proved the very gradual method
employed. Mr. Tyrrell always had the Junker’s apparatus with two
bottles, one containing chloroform and the other ether, so that with
weakly children a small addition of ether could be made.
Dr. William Hill remarked that it had been assumed by previous
93
speakers that some general anaesthetic was in most instances desirable.
Some surgeons rather ridiculed this idea, but he thought the very
best argument against such a position was the case of a boy who had
been operated on without anaesthesia by a skilled laryngologist, and
who fell down dead from fright on the operator visiting the patient
some four hours after the operation. Dr. Hill did not doubt that in
a certain minority of instances the naso-pharynx could be more or less
cleared of hypertrophies under nitrous oxide anaesthesia, but for those
who were not content unless they had very deliberately and very
thoroughly removed all overgrowths in Rosenmuller’s fossa, and from
around the posterior nares, the question lay between some form of
prolonged anaesthesia. He was very satisfied with the use of gas and
ether, but he thought that of even greater importance than the
question of the anaesthetic was the skill and familiarity of the anaes¬
thetist with the requirements of the throat surgeon in naso-pharyngeal
operations. Only skilled anaesthetists should be employed if possible.
Dr. Hill summed up strongly in favour of prolonged anaesthesia and
deliberate thorough removal. He considered gas alone insufficient in
the majority of cases.
Dr. Hewitt said that whilst he agreed that nitrous oxide followed
by ether and subsequently by chloroform gave the best results in most
cases, very brief operations upon the naso-pharynx were to be very
satisfactorily performed under nitrous oxide mixed with oxygen. The
anaesthesia obtained by the last-named method was of somewhat
longer duration, and more satisfactory than that from nitrous oxide
alone. The absence of cyanosis, venous congestion, and muscular
twitching was an advantage. It was particularly necessary, in
operating for post-nasal growths, that the patient should take no food
for some hours before the administrations, owing to the inconvenience
and possible danger from vomiting. Ether had the great advantage
of allowing the patient to be placed in any position. He thought it
best to place the patient fairly well under ether before the operation
was begun, as temporarily suspended breathing from spasm or
struggling was avoided. But the patient should be allowed to regain
his reflexes before the chloroform was commenced. In conclusion he
strongly advocated the lateral posture immediately after the operation,
so that all blood might drain away, stertor subside, and free elimi¬
nation of the anaesthetic take place.
Mr. W. R. H. Stewart quite agreed with Dr. Dudley Buxton’s
remarks with regard to the nature of the anaesthetic and the mode of
administration. He thought that perhaps he was the first to use the
G-ottstein’s curette in this country, as one was sent to him from Berlin
some time before they were made in England. Since then he had
used no other instrument, but always supplemented its use by a
thorough and free scraping with the finger to destroy the very small
soft growths (which the forceps cannot attack) which produce the
so-called recurrence. For this operation he considered nitrous oxide
gas with sometimes a whiff or two of ether amply sufficient. If
tonsils had to be removed as well, the addition of the ether was
always necessary. The patient should lie flat on the back, and as
soon as the curette had been used he should be turned well on his
94
side. The practice of hanging the head down over the end of the
table was quite unnecessary, and made a great mess. At the Great
Northern Central Hospital the anaesthetist usually gave chloroform
for these cases, and at the London Throat Hospital the A. C. E.
mixture. If chloroform was used, he preferred that the patient
should not be thoroughly under its influence, as it was only in those
cases where the chloroform had been pushed to absolute anaesthesia
that there had been cause for anxiety. With regard to the reported
death of patients after the operation was over, he unfortunately had
had such a one in his practice, but in that case no food had been
given to the patient for upwards of seven or eight hours, and be put
the death down to the faintness produced by under-feeding. He
considered that if a skilled anaesthetist was employed he ought to be
entirely responsible for the safety of the patient as far as the anaes¬
thetic was concerned. If the surgeon had confidence in his anaesthetist,
and employed one who knew his ways, all that was necessary for the
operator to do was to tell the anaesthetist the nature and probable
extent of the operation, and to leave the rest to him.
Dr. Silk observed that if the term “ best anaesthetic ” could be
used as being synonymous with “ safest anaesthetic,” he thought
that there could be no doubt as to the advantages of gas or gas and
ether. But he thought that the comfort of the patient and the con¬
venience of the operator were points which ought likewise to be taken
into consideration. Dr. Silk thought that there were three methods
of operating in vogue:—1. The rapid operation; the patient being
seated, anaesthetised, the mouth opened, and the post-nasal space
thoroughly scraped with the finger. For these cases, which could be
completed in a few seconds, or, at any rate, under the minute, gas
and ether was sufficient and satisfactory. 2. The deliberate operation ;
the patient being recumbent, and the adenoids removed by means of
instruments of some sort. For these cases Dr. Silk much preferred
to commence with A. C. E. mixture, and, if need be, to maintain the
anmsthesia by means of chloroform blown through the tube of a
Junker’s inhaler. Dr. Silk objected to the use of ether in these
operations, partly because of the additional bleeding, and partly be¬
cause it was not at all easy to maintain the continuity of the anaes¬
thesia by means of chloroform. He thought that the dangers which
had been ascribed to the use of chloroform were due mainly to faulty
administration. He insisted very strongly upon two points: 1. The
desirability of the surgeon being accustomed to the particular anaes¬
thetist. 2. That the anaesthetist should remember that the presence
of blood, the surgeon’s finger, instruments, &c., in the mouth tended
to obstruct the respiration, consequently the heavy chloroform vapour
might accumulate at the back of the throat. A strong, and may be fatal
strength of vapour was thus liable to be suddenly inhaled. Hence
he would insist upon the importance of not administering more of the
vapour than was absolutely necessary. The third method of operating
might be termed the intermediate method, i. e. the patient was seated,
and a somewhatextensive and rapid operation was performed, including
the removal of both tonsils. It was said that for this form of opera¬
tion gas or gas and ether was sufficient; but he thought it probable
95
that under such circumstances the patient would be simply asphyxiated
for three parts of the time.
Dr. Scanes Spiceb, while granting the immense advantage to the
patient, both as to safety and to freedom from after effects of gas
alone, thought that it was a lesser evil to induce ether or chloroform
anaesthesia than to operate imperfectly, and leave behind hyperplastic
tissue, or to run risk of neglecting a smart haemorrhage from tonsils
in cases in which the double operation bad to be performed. Adenoids
alone might be removed with gas only in most cases. For simple
tonsillotomy with the guillotine, gas also would suffice, or in adults
or non-neurotic children even cocaine might render the operation pain¬
less. On the other hand, if abnormal adhesions rendered a careful
dissecting operation necessary with scalpel and forceps, it was better
in adults to anaesthetise with cocaine, and in children to give ether or
chloroform preceded by gas. Rapid operations might be performed
if no smart haemorrhage took place, and if the tumours were soft
and easily removed ; but these conditions could not be foretold,
and he was of opinion that if the combined operation was to be done
thoroughly, the prolonged anaesthesia obtained by chloroform or ether,
preceded or not by gas, was necessary. Rather than risk an imperfect
operation he would infinitely prefer the sma^l increase in danger, for
the risk was very small in the hands of an experienced anaesthetist.
Mr. Davis gave chloroform in young children under six or seven
years of age, but he never put them off very deeply, always keeping
the cough and swallow reflex present, and when once the patient was
ready for the operation, did not give, as a rule, any more anaes¬
thetic. Above the age of six or seven years Mr. Davis administered
nitrous oxide and ether, afterwards continuing with the latter drug.
He preferred that the patient should lie on the back with the head
drawn well over the table, so that the roof of the mouth acted as a cup
to receive the adenoid fragments and blood, which could be sponged
out at will. In that position the air-passages were free, and the epi¬
glottis was raised from the larynx, as Dr. Howard bad so clearly proved.
Dr. Dundas Grant wished to approach the question without
prejudice, although he had more or less identified himself with the
advocacy of the use of nitrous oxide with or without a few whiffs of
ether. Referring to the fatal chloroform cases, he thought the
quantity used was by no means a negligible one. He had in his
hands references to nine cases in which death had occurred under
chloroform, given for operations in the nose and throat within the last
eighteen months. The risk in nitrous oxide ansesthesia with or
without a whiff of ether was insignificant. The combination of
oxygen with nitrous oxide obviated the tendency to asphyxia without
detracting from the anaesthetic effect, and gave the most perfect
result. The objection to nitrous oxide was the shortness of the time
allowed. This was to be neutralised (1) by practice on the part of
operators, (2) by the adoption of a rapid method, (3) by systematic
employment of skilled assistants, (4) by repeating the administration
if necessary. Dr. Grant considered the quickest mode of operation to
consist in commencing with the finger-nail to scrape the growths out of
the fossse of Rosenmuller and up off the posterior wall, so as to collect
96
them into a heap in the vault, whence they could be rapidly removed
with the forceps. Gottstein’s curette was often of use, and should be
at hand. He failed to find any evidence that recurrence took place
with any frequency after such an operation as he had described. He
had seen recurrence of symptoms without recurrence of the growths,
the return of nasal obstruction being really due to such conditions as
hypertrophic rhinitis, or to the development of follicular granulations
on the back of the pharynx, below the level of the hard palate. Re¬
currence of symptoms might sometimes be the result of neglecting the
practice of nasal respiration.
Mr. Richard Gill thought that too empty a stomach was as
mischievous as too full a one, and that it was most important to
observe the interruption of breathing brought about by the operator’s
finger, Ac., in the naso-pharynx. He laid great stress upon regulating 1
the anaesthetic according to respiration ; as the latter became shallow
the agent should be diminished, whether chloroform or a mixture
containing it be in use. He generally employed chloroform, some¬
times preceding it by ether. He measured the degree of anaesthesia
by the state of the pupil, which usually remained contracted through¬
out. He classified the dangers under three heads: (1) from excessive
haemorrhage; (2) from sickness; and (3) from fainting. He quoted
two cases, one of haemorrhage and another of fainting, which had
occurred to him in an experience of over two thousand cases.
Dr. Whistler advocated prolonged and complete anaesthesia by
chloroform, sometimes preceded by gas and ether, although in excep¬
tional cases nitrous oxide might suffice for the simplest operations.
He called special attention to the fact that almost all the patients
requiring these operations were “ bad breathers ” to start with, and
hence additional care should be taken to block the pharynx as little
as possible with the fingers. He preferred Lowenberg’s forceps,
supplemented by Gottstein’s curette, and always employed skilled
assistance. In seventeen years he had had no fatal cases in his own
practice.
Mr. Bailey observed that it was clearly impossible to lay down
dogmatic rules as to the best anaesthetic. Each preferred his own,
and would probably continue to do so. There was no absolute safety
under any form of anaesthetic, but it was very desirable that the exact
facts of reported deaths should be made known. Children might die
under chloroform just as well as adults, but no one who was subject
to fainting should inhale chloroform in the first instance. It was
usually at the onset of the inhalation that accidents had occurred.
Operations on the naso-pharynx took, as a rule, a much shorter time
than was supposed, but anaesthesia ought to be complete and all
reflexes abolished before the operation was begun. He preferred the
use of gas and ether, but agreed that every anaesthetist must follow
his own liking in the choice.
Mr. Walsham mentioned cases of recurrent adenoid disease, and
spoke in favour of complete removal, however much time might be
expended. He objected to the induction of complete anaesthesia.
Mr. Parker recorded the results of his experience as Resident
Officer at the Throat Hospital, which went to prove that cases operated
07
on under chloroform and with forceps had been more satisfactory in
their results than others in which the curette was used without anaes¬
thetic or with gas only, the operation being rapidly performed. In
many instances the latter cases recurred, or more probably were from
the first incomplete. He though that, as long as the operation was
done thoroughly, it did not matter what instrument was used, but to
insure thoroughness chloroform must be given.
The President wound up the discussion, and pointed out that it
had served to show the impossibility of laying down compulsory laws
on the subject. The habit of every operator must, to some extent,
determine the best method of inducing anaesthesia for his operation.
Some preferred to work slowly, others rapidly, but in any case the
safety of the patient and the completeness of the operation must be
the chief care. He disapproved most strongly of the practice of ope¬
rating upon out-patients, since no control could be exercised over them
either before or after the operation, and the most precise instructions
were very often neglected. The anaesthetic should always be given by
a skilled man, and the surgeon should be free to attend only to the
operation. He was very strongly opposed to the induction of complete
anaesthesia. The experiments made by Mr. Horsley and himself had
proved that the cough reflex was the last to go; after its abolition,
however, nothing could prevent the entry of blood into the larynx.
The administration should cease when the conjunctiva was insensitive.
The initial stages of the anaesthesia might be taken slowly. Time was
not of importance at that stage, but no further anaesthetic should, if
possible, be given when the operation was once begun. He had
reason to believe that a rapid operation was not always a complete one,
and he urged the necessity for thoroughness as a means of limiting
the number of so-called recurrent cases. Lastly, he thought that the
debate had proved that the choice of the particular anaesthetic must
be free, and that no blame or “ criminality ” could attach to the selec¬
tion of any one of them.
Dr. Dudley Buxton, in the name of the Society of Anaesthetists,
expressed his thanks for the invitation extended to them, and his
appreciation of the value of the discussion that had taken place.
PROCEEDINGS
OP THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, May 9th, 1894.
Felix Semon, M.D., F.B.C.P., President, in the Chair.
E. Clifford Beale, M.B.,
Scanes Spicer, M.D.,
Secretaries.
Present—16 Members and 3 Visitors.
The minutes of the previous meeting were read and confirmed.
Lupus of Nose and Larynx.
Clinical case exhibited by Dr. Dundas Grant. —Edna H— came
under observation on the 23rd of April complaining of “ hoarseness " of
two years' duration, which came on gradually and painlessly after a
slight cold, with increasing obstruction in the left nostril of the same
duration. Within the last four months the left half of the tip of the nose
had become red and swollen, and a few spots had appeared on her left
cheek near the nose, which were of a semi-translucent appearance, the
smallest ones being of a red colour, the larger ones brownish yellow.
They varied in size from that of a pin's head to a hempseed.
She had always been somewhat “ delicate," but had not lost flesh,
and had no cough except in winter. Her chest was normal. She was
subject to chapped hands in winter, but not to chilblains. There was
no family tendency to phthisis. The mouth and fauces were normal,
with the exception of a cicatricial-looking patch at the junction of the
left posterior pillar with the soft palate. The palate was thickened,
and behind the uvula showed a transverse cicatricial band going from
one posterior pillar to the other, and causing the uvula to point
forwards. The hack wall of the pharynx was occupied by a number
of granular masses, chiefly in the lateral halves, the intermediate
mucous membrane being dry and scar-like.
The epiglottis was symmetrically thickened and covered with pale,
FIR8T SERIES—VOL. J» 10
100
dr?, tubercular granulations of considerable size. The ary-epiglottic
folds were also thickened and irregular, and the ventricular bands,
especially the right one, were so much swollen as nearly to conceal the
vocal cords, the congested edges of which were alone visible. In the
interarytaenoid space was a mass of very pale moist granulations, which
prevented the complete approximation of the cords.
In the nose the interior of the left vestibule was occupied by a soft
granular mass covered with crusts, and a slight sticky discharge.
This mass was found to grow from the walls of the vestibule and the
anterior portion of the inferior turbinated body.
The lupous tissue in the nose had been scraped away with a sharp
spoon under cocain, and lactic acid had been applied with benefit.
The same treatment had been adopted in the larynx. Internally she
was taking Liq. Arsenicalis.
Probable Epithelioma Laryngis.
Clinical case exhibited by Dr. Dundas Grant. —John C. E—, set.
67, a retired schoolmaster, complained of hoarseness and want of voice,
which came on three years ago after a cold. At first this was was only
troublesome after talking for some time, but for a year it had been
constant, and had been worse during the last six months.
He had no cough, very slight discomfort in swallowing, with the
singular feature that “ eating hard or hot things seems to do him good.”
There was no pain except a slight occasional pricking, and no sign of
reflex otalgia. He had no dyspnoea, but his family observed an audible
blowing sound accompanying his breathing. He had no pain in his
chest, where there was no sign of aneurism or other disease. The patient
had been a schoolmaster and an inordinate voice user. The thyroid
cartilage was not definitely expanded, and there was no enlargement of
lymphatic glands. The whole length of the left vocal cord was occu¬
pied by a pale pink, slightly granular ulcer, the surface of which was
somewhat convex in its middle part. This cord was fixed immoveably
near the middle line during inspiration and phonation alike. There was
a small granulation below the anterior commissure. At the same time
there was considerable mobility of the capitula, and the rest of the
larynx was relatively normal.
The case was thought to be one of intrinsic carcinoma, but further
101
opinions were desired in view of the absence of many of the usual sym¬
ptoms of the disease. At the same time the appearance of the cord,
the fixation of the arytsenoid cartilage, and the age of the patient left
little doubt as to the nature of the case, which seemed a favorable one
for thyrotomy and hemilaryngectomy.
The President agreed as to the diagnosis, and thought that in such
a case it would be right to perform thyrotomy, in order to find out the
extent of the disease, and to remove it by a major or minor operation,
according to the result of the inspection.
Dr. Grant pointed out that it was not possible to remove any part
endolaryngeally for examination, and agreed with the suggestion of the
President.
Paralysis of the Thyro-aryt^enoid Muscles.
Dr. Dundas Grant showed the case of H. A. J—, set. 24, a post
office clerk, who had suffered from hoarseness of three years’ duration,
unaccompanied by cough, dysphagia, or dyspnoea.
He had no illness beyond the hoarseness, which had continued
almost stationary up till the present, and was attributed to “ catching
cold.” There were no symptoms or signs of phthisis, his family
history was good, and there was no evidence of specific infection, nor
any history of specific disease. The patient had been a player on wind
instruments from boyhood. He formerly sang as soprano in a church
choir, and later had used his voice as a high tenor. His chest was
normal.
On inspection of the larynx during quiet breathing there was nothing
abnormal to be seen except a slight congestion and duskiness of the
vocal cords. The respiratory movements of the cords were normal,
but on phonation there was a very marked elliptical gap between the
edges of the cords, except at their most anterior and at their arytsenoid
portions. The arytsenoids met with striking promptness and com¬
pleteness, while the middle portions of the cords seemed rather to
recede under the expiratory blast. The ventricular bands approxi¬
mated to an extreme degree, especially during forced efforts at vocali¬
sation. They were hypertrophied, and probably shared in the produc¬
tion of some of the tones.
The voice was, for speaking, continuously hoarse and low-pitched,
but he could produce husky whispering tones ranging through nearly
102
three octaves. This range of voice seemed to indicate activity of the
crico-thyroid tensor muscles, which was confirmed by the obvious
approximation of the cricoid and thyroid cartilages during the singing
of musical intervals, as felt by means of the finger in front of the neck
in the crico-thyroid space.
The laryngeal picture was that of paralysis of the apposing muscles,
the thyro-arytaenoids. He proposed to try the effect of intra-laryngeal
electrisation.
Dr. Spicer suggested that the case might be one of pachydermia
laryngis. There seemed to be a definite swelling at the tip of one of
the vocal processes, which on phonation was received into a corre¬
sponding depression on the Other. He thought that the hoarseness
and loss of voice were to be accounted for by the mechanical inter¬
ference with the movements of the cords.
The President had not observed any such swelling, and agreed with
Dr. Grant in regarding the case as paralytic. He would treat it by
vocal rest and local astringents.
Dr. Beale had noticed a very definite pink fleshy swelling at the
point where the vocal processes came together on attempted phonation.
Dr. Grant expressed his intention of bringing the case forward again
at a future meeting.
Removal of Right Lobe of Thyroid for Graves' Disease.
Mr. R. Lake showed a case of removal of the right lobe and isthmus
for Graves’ disease. The patient, a young woman of nineteen years of
age, who always had prominent eyes, first developed symptoms of
Graves’ disease in August, 1893, especially exophthalmos, fainting, and
palpitation ; her evening temperature was 100° F., and her pulse-rate
100. She was uninfluenced by drugs. On February 11th, 1894, the
right lobe, which was the larger, was removed. The temperature fell
immediately after the operation, being normal in ten days’ time; the
the pulse fell to 80 in ten days. The exophthalmos was almost gone
except when she vomited, as she did frequently from some gastric
trouble, and both palpitation and faintness had disappeared; she
declared herself to be in very good health. The left lobe was certainly
smaller, and had fallen away from the trachea more under the sterno-
mastoid. Microscopically the goitre was partly composed of small cysts,
and partly of acini, showing active cell formation as described by
Greenhill.
103
Mr. Lake, in reply to the President, said that he had removed the
portion of the gland with a view of checking the further progress of
the disease, as success had thus been obtained by others. He regarded
the morbid condition of the gland as being the primary cause of the
train of nervous symptoms that were characteristic of the disease.
The President suggested the possibility of the subsequent occur¬
rence of myxcedema.
Mr. Lake, at the suggestion of Mr. Stewart, promised to keep the
case in view, and to show it again later in the year.
Dr. Spicer commented on a case of Graves’ disease in which the
use of tablets of thyroid extract had done much more harm than good.
Mr. Lake, on the other hand, recorded a case in which the use of
the tablets had had very good results.
Lupus of Pharynx and Larynx.
Clinical case exhibited by Dr. Felix Semon. —E. C—, set. 10,
■complained of loss of voice for three months, and ulceration of
gums and palate for two months. Family history good. No syphilis,
tuberculosis, or rheumatism. The patient’s voice began gradually to
get weaker, and finally disappeared about three months ago. About
two months ago, the gums were noticed to be ulcerated and to bleed
frequently. The roof of the mouth got into the same condition, but
■did not bleed. Slight cough.
Patient was a fair, somewhat strumous-looking child. The gums
are unequally ulcerated, and in one or two places bleeding. On the
hard palate, and stretching back to the soft, was a roughened worm-
eaten patch, which consisted of a number of small ulcers, clumps of
granulation tissue, and minute cicatrices. The same appearance was
seen on the posterior palatinal arches. On laryngoscopic examination
the epiglottis was seen to be pale, worn away by ulceration, and pre¬
senting a rough nodular appearance; the ventricular bands were
similarly affected, and their free borders were uneven; the right band
completely covered the vocal cord; the left cord was visible, and about
its centre presented an excavation. The arytsenoids were swollen but
not ulcerated, the mucous membrane was pale.
The patient had not had the slightest pain from either larynx or
mouth, and there were no traces of affection of either skin or nares.
There was slight flattening of chest on left side, and the percussion
note was slightly impaired. On auscultation a few rales and rhonchi
§
104
were heard over the left lung, especially at the apex j the right lung-
was normal. No other abnormalities.
Remarks .—The patient was shown because lupus of the pharynx
and larynx was in itself rather rare, but more especially when un¬
accompanied by nasal or epidermidal manifestations. No local
treatment had as yet been adopted, because it was desired to show the
patient without any local interference having taken place. The case
would now be treated with scraping and subsequent application of
lactic acid, and, if necessary, with the galvano-cautery, whilst inter¬
nally cod-liver oil and arsenic would be given, and it was intended to-
show the result of the treatment at some future time.
Two Cases of Doubtful Malignant Disease of the Larynx
TREATED BY THYROTOMY AND BaDICAL BeMOVAL OF THE
Growths.
Exhibited by Dr. Felix Semon. —The two following cases have this
in common, that neither clinical observation nor histological examina¬
tion had established the diagnosis of malignancy beyond doubt. Still
in both cases it was deemed prudent to perform a radical operation.
Case 1 . —Mr. M. H— , set. 63. In this case an ill-defined papillary
growth occupied the anterior half of the right vocal cord, the anterior
commissure, and the front part of the left vocal cord. The disease had
commenced several months previously, and the voice was quite aphonic.
Bepeated recurrences taking place after intra-laryngeal removal, thyro-
tomy was performed on July 12th, 1893, after consultation with Mr.
Butlin. The front part of both vocal cords and the anterior angle of the
thyroid cartilage, which appeared to be infiltrated, were removed, and
the wound treated in the usual way with iodoform insufflation and
packing with iodoform gauze. The patient recovered after a violent
attack of bronchitis, and left the home six weeks after the operation.
No recurrence had taken place, but the voice remained aphonic, owing
to a large gap in the anterior part of the glottis, caused by removal
of the front parts of both vocal cords. The fragments of growths
originally removed were apparently papillomatous, but distinguished
by very unusual thickness of epithelium, which gradually became
more and more horny as subsequent pieces were removed and exa-
105
mined, there being at the same time an increasing quantity of small
round cells visible in the specimens. It was on Mr. Shattock’s urgent
recommendation that the radical operation was decided upon. Even
the examination of the pieces removed by radical operation left it still
doubtful whether this was a case of commencing malignant disease,
possibly in what was called in growths of the tongue the “ precan-
cerous stage/’
Case 2. —Colonel G. W. H—, set. 55, first seen on April
28th, 1893. Patient had been suffering from hoarseness for about
a month past, and a small reddish growth was observed on the
free margin and underneath the middle of the left vocal cord.
It was semi-globular, about the size of a split pea, slightly granu¬
lar and broad-based, so as to pass over very gradually into the
congested left vocal cord, the movement of which was unimpaired
There was at first nothing to suggest malignancy, but in the eourse of
the next twelve months the growth gradually spread, infiltrating more
and more over the left vocal cord, with which it became intimately
blended, and finally in April of this year an almost uniform thickening
of the whole vocal cord had taken place, the movements of which also
had become a little more sluggish. Prom the uniform nature of the
infiltration it was quite impossible to remove a piece for microscopic
examination. The whole development, however, taken in conjunction
with the patient’s age, rendered the nature of the growth very
suspicious, and after consultation with Mr. Butlin on April 26th,
thyrotomy was performed. When the larynx was opened the left cord
appeared as a cylindriform, slightly irregular and granulated body,
which was much thickened, especially in its middle third, but not
adherent to parts in the neighbourhood. It was removed in toto and
the basis scraped. In accordance with the suggestions recently made
by Mr. Butlin (see ( Proceedings/ pp. 27, 28), Hahn’s tube was
removed immediately after the operation, no other tube was intro¬
duced, the patient was placed in an absolutely horizontal lateral
position in bed, and the wound merely dusted with iodoform. He
made ah uninterrupted and rapid recovery. He was able to drink
milk by the mouth three hours after the operation; the temperature
never rose above 99°; he got up on the third day; the external wound
now was closed and the voice was fairly strong, whilst the place of the
left vocal cord was occupied by a freely granulating surface. The
106
microscopic examination of the removed vocal cord was not yet com¬
pleted. So far it appeared to be what Mr. Shattock calls a “ continuous
fibroma,” i. e. a new growth which insensibly passes over into the
normal structure of the matrix, just as in molluscum fibrosum. There
was also considerable thickening of epithelium, with very slight tendency
to ingrowth of the same. A further report on the results of the
microscopic examination would be given.
These cases illustrated the difficulty of deciding on the treatment
when it was impossible to remove a portion of the growth for exami¬
nation. The suggestions made by Mr. Butlin as to the slow use of
Hahn’s tube, its removal after the operation, the patient remaining in
the horizontal lateral position with the wound quite open, had made
exploratory thyrotomy so much simpler and easier that it might
safely be adopted as the operation of the future for dealing with such
cases as those shown.
Sequel to a Case of Obscure Ulceration of Pharynx in a
Case of Arrested Pulmonary and Laryngeal Tuberculosis.
Exhibited by Dr. Pelix Semon. —The patient was shown to the
Society at the Pebruary meeting of the present year (see ‘ Proceedings,*
p. 74). After his return to Bournemouth Dr. Davison scraped the
pharyngeal ulcerations, and submitted the scrapings to a bacteriological
expert, Mr. Turner, who on careful examination of three different
specimens did not discover any tubercle bacilli. The view expressed
by Dr. Semon in his paper and in the discussion, viz. that the pharyn¬
geal condition was due to some other cause besides tubercle, had
therefore received some further corroboration. The ulceration has
now healed under further use of lactic acid, but as the patient
stated that he had once before had a similar ulceration which gradually
disappeared (see ‘ Proceedings,* p. 75) the relation of the post hoc and
propter hoc was by no means fully settled.
The President commented on the fact that the patient had through¬
out been treated by creasote internally, and expressed the opinion that
it was most useful in its action on such cases, especially when given in
large doses.
Dr. Dundas Grant had also found it very useful.
Dr. Clifford Beale had watched its use for many years at the
Chest Hospital, where it had been given in large and small doses, and
107
in very concentrated vapour. It was exceedingly well borne by tbe
delicate stomachs of tubercular persons, but as yet there was no evi¬
dence to show that it exercised any effect upon the cases of active
or progressive tuberculosis. Chronic cases did very well under it.
Fixation op Left Vocal Cord.
Dr. Scanes Spicer showed a patient, Mrs. C. D—, a widow in service,
who had complained of hacking cough and hoarseness, lasting over
seven years, with shortness of breath on exertion. Symptoms were all
worse when she had a cold, and she had at times completely lost her
voice.
History .—Syphilitic infection soon after marriage. Bight basic
phthisis, chest otherwise normal. Never had rheumatic fever. No
source of pressure on nerve discoverable.
Laryngoscopic examination .—Left vocal cord immoveable, fixed in
cadaveric position ; right vocal cord moved freely ; slight congestion of
larynx. Cause of immobility of cord assumed to be ankylosis of left
crico-arytsenoid articulation, in absence of other discoverable lesion.
Treatment being pursued—internally, iodide of potassium; locally,
inunction of mercurial ointment.
Unilateral Laryngitis.
Mr. W. B. H. Stewart showed the following case. Mrs. L—
had suffered from her throat off and on since the winter of 1892-8.
Voice was reduced to a whisper. No history of syphilis could be made
out. Chest and sputum normal. When seen last November, the right
vocal cord was red and swollen, and the right arytsenoid puffy, and there
was some hypertrophic rhinitis. About a week afterwards there was a
pyriform oedematous swelling, such as is seen in tubercular laryngitis.
On inquiry it was found that the patient had used the inhalation
ordered for her at boiling-point. This swelling soon went down
and had completely disappeared j the cord, too, was less thick, but was
still red. She was taking iodide of potassium gr. xxv three times a
day, and the larynx had a daily application of zinc chloride (gr. xxx to
^j). The points of chief interest were the unilateral condition of the
trouble, and also the fact that the boiling steam seemed to have acted
on that one side of the larynx only, and to have caused the temporary
arytsenoid swelling.
108
Dr. Dundas Grant thought that the disease had probably been
syphilitic perichronditis, with ulceration of the vocal cord.
The President agreed with this diagnosis, and thought that the
effect of the steam had been to irritate the diseased parts only.
Carcinoma Laryngis.
Mr. W. B. H. Stewart showed the case of P. H—, set. 50, a
gardener, who had had a sore throat since Christmas, which came on
after a cough. Two months ago the breathing became bad, and for
the last month he could not lie down in bed. He had difficulty in
taking solid food and in getting up phlegm. He had slight dull,
aching pain; no history of syphilis. There was considerable swelling
of the right side of the larynx, and some slight granular enlargement
on both sides. Mr?nr/s-
j
The President would limit operative treatment to the intrinsic
cases. Luschka had shown that the lymphatics of the larynx do not
anastomose with other groups of lymphatics, but open into the two
small glands on either side of the thyroid. Hence the lymphatic
enlargement was always less in the purely intrinsic cases. Where
other sets of glands also were involved the disease was generally
extensive, and attempts at removal were generally followed by rapid
recurrence.
Dr. Bond expressed his concurrence in this view.
Dr. Spicer observed that cases which appeared to be intrinsic were
sometimes found to have extended more deeply than was supposed.
Congenital Abnormality of the Larynx.
Dr. J. B. Ball exhibited the following case. P. E—, set. 25,
clergyman, came under observation complaining of symptoms due to
enlargement of the right tonsil, the crypts of which contained cheesy
plugs, and to adenoid hypertrophy in the naso-pharynx. In the
larynx the left arytsenoid appeared larger than the right, the latter
seeming to be abnormally small. The left arytsenoid appeared to be
tilted over towards the right side, and when the cords were in the
position of rest the left capitula Santorini lay to the right of the middle
line, and the left ventricular band was drawn inwards towards the
middle line at its posterior part. When the cords were adducted the
the left arytsenoid passed in front of the right, the two arytsenoids lying
one in front of the other instead of side by side during complete
adduction.
There was no peculiarity of the voice except that it was not
powerful, and was said to be easily fatigued.
An Intra-laryngeal Syringe for Submucous Injections.
Dr. Watson Williams (Bristol) exhibited a syringe for submucous
injections in the treatment of laryngeal tuberculosis, which had been
made to his design about three years ago by Messrs. Down Bros., and
its employment had given very satisfactory results in properly selected
cases.
It was simply a hypodermic syringe with a long curved needle, the
curve of the needle being the same as that of Mackenzie’s laryngeal
forceps. Three eighths of an inch from the point of the needle was a
rounded shoulder, which served the double purpose of preventing the
needle suddenly piercing the tissues too deeply, and of rendering the
position of the needle more readily followed when in the larynx.
The use of the syringe involved no ulcerating surface, and was
especially useful in cases of early localised tubercle. Solutions of
pyoktanin, 2 per cent, aristol with menthol, - f o\)0 solution of iodide of
mercury had been the most serviceable, especially the 2 per cent, solu¬
tion of aristol in almond oil.
Sarcoma of Nose and Tonsils.
Cases shown by Dr. Bond. —1. A woman of 71, first seen in De¬
cember, 1893, with both sides of nose and naso-pharynx filled with gela¬
tinous vascular growth. The tonsils were not affected. There was
much thickening of left posterior pillar. Large masses of enlarged
glands extended on both sides from the angles of jaw to the clavicles.
Under TT\iv doses of Liq. Fowleri the growths in nose and naso¬
pharynx and the enlarged glands in neck disappeared. Simultaneously
the left tonsil became affected, and steadily grew larger, till at the
present time the sloughing mass practically filled all the central part
of pharynx. Larger doses of Liq. Fowleri could not be tolerated.
lio
Epithelioma op Cervical Glands.
2. Patient came to Golden Square on account of a large, knobby
fixed mass of glands the size of half a cricket ball on left side of neck
He had no discomfort in throat internally, though on examination
the corresponding side of pharynx and larynx was found affected.
The patient had remained singularly comfortable under the combined
use of large doses of iodide and morphia. Tracheotomy had been per¬
formed to relieve dyspnoea. The skin over the glands was on the
point of giving way.
INDEX
PAGH
Abductor-paresis of right vocal cord, not of cortical origin (Felix Semon,
M.D.).. .12
Abductors: bilateral paralysis of abductors of vocal cords (Felix Semon,
M.D.) . . . . .5
Abscess of septum (F. Semon, M.D.) . . . .4
Adductor paralysis of left vocal cord (Herbert Tilley) . . .88
Adenoid growths: discussion on the choice of the anaesthetic in operations
for removal of post-nasal adenoid growths :
- remarks by Felix Semon, M.D. ... 91, 97
-Dudley W/Buxton, M.D. ... 92, 97
- communication from H. T. Butlin . . . .92
- remarks by W. Tyrrell . . . . .92
-William Hill, M.D. . . . .92
-F. W. Hewitt, M.D. . . . .93
-W. R. H. Stewart . . . .93
-J. F. W. Silk, M.D. . . . .94
--Scanes Spicer, M.D. . . . .95
-- H. Davis . . . . .95
-J. Dundas Grant, M.D. . . . .95
1 --- Richard GUI . . . .96
---W. McNeill Whistler, M.D.. . . .96
-G. H. BaUey . . . . .96
-W. J. Walsham . . . . .96
—-C. A. Parker . . . . .96
Ala nasi: retraction (W. R. H. Stewart) . . . .77
Anasthetic: discussion on the choice of the anasthetic in operations for
removal of post-nasal adenoid growths:
-remarks by Felix Semon, M.D. ... 91, 97
-Dudley W. Buxton, M.D. ... 92, 97
- communication from H. T. Butlin . . . .92
- remarks by W. Tyrrell . . . . .92
-William Hill, M.D. . . . .92
-F. W. Hewitt, M.D. . . . .93
-W. R. H. Stewart. . . . .93
-J. F. W. SUk, M.D. . . . .94
--Scanes Spicer, M.D. . . . .95
-H. Davis . . . . .95
-J. Dundas Grant, M.D. . . . .95
-Richard Gill . . . . .96
-W. McNeill Whistler, M.D.. . . .96
-G. H. Bailey . . . . .96
-W. J. Walsham . . . . .96
-C. A. Parker . . . . .96
Angioma: submucous hamorrhage and angioma of the vocal cord (J.
Dundas Grant, M.D.) . • • • .2
-of larynx (Percy Kidd, M.D.) . . . .63
Annual General Meeting, Jan. 10th, 1894 . . . .63
112
VkQiB
Antrum: empyema of left antrum (F. Semon, M.D.) . . .4
—— rhinitis foetida with antral disease (William Hill, M.D.) . . 73
-a fold of mucous membrane protecting the middle meatus (Charters
J. Symonds) . . . . . .87
Aphonia in case of rhinitis atrophica foetida (W. Hill, M.D., and James
Cagney, M.D.) . . . . . .59
Arytenoid cartilage : swelling of ventricular band and arytenoid cartilage
of uncertain nature (Charters J. Symonds) . . .68
- - - absorbed gumma over right arytenoid cartilage—impaired
movement of vocal cord (W. Hale White, M.D.) . . .77
— 1 mucous membrane: oedema and infiltration of arytenoid mucous
membrane, of uncertain origin (Scanes Spicer, M.D.) • . 75
Babbb (E. Cresswell), cicatrix of pharynx • • . .9
- ■ 1 ■ myxcedema treated by feeding with fresh thyroid gland . . 10
- . . congenital occlusion of posterior naris relieved by operation . 31
Bails Y (G. H.), discussion on the choice of the anaesthetic in operations
for removal of post-nasal adenoid growths • . .96
Balance-sheet . . . . . . .54
Baldness: complete premature baldness following removal of nasal polypi
(Felix Semon, M.D.) • . . • .41
Ball (J. B., M.D.), leprosy with throat lesions . . .33
- fixation of left vocal cord . . . . .79
- - - tumour of the larynx in a case of goitre . . .79
- congenital abnormality of the larynx . . . 108
Bbalb (E. Clifford, M.B.), syphilitic disease of pharynx and larynx in a
tubercular subject . . . . • .11
- — ■ exhibition of new form of portable oxy-hydrogen lantern . 34
- stenosis of larynx after tracheotomy . . .35
■- tubercular tumour of larynx . . . .71
Bbkwbtt (F. W.), laryngeal symptoms in a case of insular sclerosis • 80
Bond (J. W., M.D.), sarcoma of nose and tonsils . . • 109
— epithelioma of cervical glands .... 110
Bowlbt (Anthony), perichondritis . . . .43
Bronchocele : exhibition of specimen of epithelioma of larynx complicated
with bronchocele (T. J. Kirk Duncanson, M.D.) • . .36
Butlin (H. T.), probable malignant disease of epiglottis and right side of
larynx . • . . • .20
— - exhibition of pathological specimens illustrating malignant disease
of the larynx . • • • • .21
-complete paralysis of right vocal cord . . .72
— - . carcinoma of right side of larynx . . . .73
■ ■ communication (in absence) to discussion on the choice of the
ansBsthetic in operations for removal of post-nasal adenoid growths . 92
Buxtok (Dudley W., M.D.), discussion on the choice of the anaesthetic in
operations for removal of post-nasal adenoid growths • 92, 97
Caokby (James, M.D.) and Hill (W., M.D.), rhinitis atrophica foetida with
aphonia . . . . . . .59
Calculus of soft palate (Charles A. Parker) . . . .50
Cancer: see Carcinoma ; Epithelioma .
113
PAGE
Carcinoma laryngis (W. R. H. Stewart) .... 108
-of right side of larynx (H. T. Bntlin) . . .73
-of the oesophagus (W. R. H. Stewart) . . .66
Caries and necrosis of nasal bones and superior maxilla (F. Semon, U.D.) . 4
Cervical glands : see Neck.
Chabsley (R. S.), exhibition of improved form of galvano-cautery snare • 34
Cicatrix of pharynx (E. Cresswell Baber) . . . .9
“ Cleavage” (so-called) simulated by hypertrophy of uncinate process in
case of rhinitis foetida with antral disease (William Hill, M.D.) . 73
Congenital abnormality of the larynx (J. B. Ball, M.D.) . . 108
Davis (H.), discussion on the choice of the ansBsthetic in operations for
removal of post-nasal adenoid growths . . . .95
Dinner: inaugural dinner of Society, April 12th, 1893 . . 8
Duncahbon (T. J. Eirk, M.D.), exhibition of specimen of epithelioma of
larynx complicated with bronchocele . . . .36
Electric lamps presented to the Society by Dr. Felix Semon . . 1, 63
Empyema of left antrum (F. Semon, M.D.) . . . .4
- of the frontal sinus (J. Dundas Grant, M.D.) . . .1
Epiglottis: function and anatomy of the epiglottis (A. A. Kanthack, M.D.) 60
- epithelioma of epiglottis (Charters J. Symonds) . . 20
- gummata of epiglottis? (F. Willcocks, M.D.) . .78
- probable malignant disease of epiglottis and right side of larynx
(H. T. Butlin) . . . . . .20
Epithelioma of cervical glands (J. W. Bond, M.D.) . . . 110
■ of epiglottis (Charters J. Symonds). . . .20
- exhibition of specimen of epithelioma of larynx complicated with
bronchocele (T. J. Kirk Duncanson, M.D.) . . .36
- - probable epithelioma laryngis (J. Dundas Grant, M.D.) . 100
- of the soft palate and fauces (Watson Williams, M.D.) . . 69
Ethmoidal cells : suppuration in the ethmoidal cells (W. R. H. Stewart) . 67
Excision of new growth in two cases of malignant disease of larynx; cure
(Felix Semon, M.D.) • . . . .84
- radical removal of the growths in two cases of doubtful malignant
disease of the larynx (Felix Semon, M.D.) . . . 104
Exophthalmos: see Gravet disease.
Fauces : epithelioma of the soft palate and fauces (Watson Williams, M.D.) 69
- stenosis of fauces from ulceration and subsequent adhesions in a
syphilitic subject (Scanes Spicer, M.D.) . . . .46
- enlargement of posterior faucial pillars (L. A. Lawrence) . 63
Fistula: tracheal fistula (F. de Havilland Hall, M.D.) . # 82
Fixation of left vocal cord (Scanes Spicer, M.D.) . . . 107
Football accident cause of acute oedema followed by hsematoma of left half
of larynx, and of transient immobility of left vocal cord (Felix
Semon, M.D.) . • . . . .46
Galvano-cautery snare, exhibited by R. S. Charsley • . .84
Gill (Richard), discussion on the choice of the anmthetic in operations
for removal of post-nasal adenoid growths . . .96
Glottis-openers; bilateral paralysis of glottis-openers (Felix Semon, M.D.) 17
114
PAGH
Goitre: tumour of the larynx in & case of goitre (J. B. Bell, M.D.) . 79
GlilT J. M.D.l eTEpTexi of the frccul sinus . . 1
- submucous nseuLorm^ge end angioma of the vocal cord . . 2
■ septal growths . . . . .38
- occlusion of posterior naria . . . .48
- in tra-laryngeal grtwth . . . . .49
— ■ discussion on the choice of the anesthetic in operations for re¬
moval of post-nasal adenoid growths . . . .95
- lupus of nose and larynx . . . . .99
- ■ - probable epithelioma larrncis .... 100
— — ■■ paralysis of the thyro-arytaenoid muscles . . . 101
Graves 9 disease: symptoms of incomplete Graves 9 disease following
removal of nasal polypi (Felix Semon, M.D.) . . .41
- removal of right lobe of thyroid for Graves 9 disease (R. Lake) . 102
Gam: papillomata of nostrils and gum (Soanes Spicer, M.D.) . 6, 18
Gumma: absorbed gumma over right arytaenoid cartilage—impaired move¬
ment of vocal cord (W. Hale White. M.D.) . . .77
- gummata of epiglottis (?) (F. Willcocks, M.D.) . . 78
Hematoma of left half of larynx following acute oedema after football
accident (Felix Semon, M.D.) .
Hemorrhage: submucous haemorrhage and angioma of the vocal cord
(J. Dundas Grant, M.D.) .....
Hall (F. de Havilland, M.D.), inherited syphilis
- syphilitic disease of the tonsil ....
- exhibition of pathological specimens, illustrating malignant disease
of the larynx ......
- stenosis of the larynx .....
- tracheal fistula ......
- syphilitic stenosis of larynx ....
Hemiplegia: right hemiplegia (Felix Semon, M.D.)
Hdwitt (F. W., M.D.), discussion on the choice of the anaesthetic in ope¬
rations for the removal of post-nasal adenoid growths
Hill (William, M.D.), rhinitis atrophica foetida
- rhinitis foetida with antral disease and hypertrophy of uncinate
process and mneons membrane covering it, simulating so-called
M cleavage
- discussion on the choice of the anaesthetic in operations for removal
of post-nasal adenoid growths ....
- and Cagnby (James, M.D.), rhinitis atrophica foetida with aphonia
Hovhll (T. Mark), lupus of larynx and pharynx
Hypertrophy of uncinate process and mucous membrane covering it, simu¬
lating so-called “ cleavage 99 (William Hill, M.D.)
45
2
3
3
22
35
82
82
12
93
12
73
92
59
4
73
Jaws: functional spasm of the muscles closing the jaws (Felix Semon, M.D.) 38
- see also Maxilla .
Kakthaox (A. A., M.D.), the function and anatomy of the epiglottis 60
Kidd (Percy, M.D.), tubercular ulceration of vocal cord cured by lactic
acid . . . . . • .36
— recurrent papilloma of larynx twice operated upon by thyrotomy . 61
• . — angioma of the larynx . . .63
115
Kidd (Percy, M.D.), continued — paqb
- laryngeal stenosis (? tubercular) . . , ,83
- small subglottic tumour of uncertain nature in case of laryngeal
tuberculosis . . . . . .83
- tracheal stenosis (? cicatricial stricture) . . .88
Lactic acid: tubercular ulceration of vocal cord cured by lactic acid (Percy
Kidd, M.D.) . . . . . . 36
Laxb (R.), removal of right lobe of thyroid for Graves’ disease . . 102
Lantern s portable oxy-hydrogen lantern, exhibited by Dr. B. Clifford Beale 84
Laryngitis: unilateral laryngitis ( W. R. H. Stewart) . , . 107
Larynx: laryngeal and other crises in case of tabes dorsalis (Felix Semon.
M.D.). : 5
-intra-laryngeal growth (Dundas Grant, M.D.) . . 49
-laryngeal symptoms in a case of insular sclerosis (F. W. Bennett) 80
- congenital abnormality of the larynx (J. B. Ball, M.D.) . 108
- an intra-laryngeal syringe for submucous injections (Watson
Williams, M.D.) . . . . . .109
- angioma of larynx (Percy Kidd, M.D.) . . .63
- carcinoma of right side of larynx (H. T. Butlin) . . 73
— carcinoma laryngis (W. R. H. Stewart) . . . 108
- exhibition of specimen of epithelioma of larynx complicated with
bronchocele (T. J. Kirk Duncanson, M.D.) . . .36
- probable epithelioma laryngis (J. Dundas Grant, M.D.) . . 100
■ ■■ lupus of larynx and pharynx (Mark Hovell) . . .4
-lupus of nose and larynx (J. Dundas Grant, M.D.) . . 99
— lupus of pharynx and larynx (Felix Semon, M.D.) . . 103
- probable malignant disease of epiglottis and right side of larynx (H.
T. Butlin) . . . . . .20
- pathological specimens illustrating malignant disease of the larynx
(H. T. Butlin) . . . . . .21
-(F. de Havilland Hall, M.D.) . . .22
-(Felix Semon, M.D.) . . . .22
-two cases of malignant disease of the larynx cured by thyrotomy
and excision of the new growth (Felix Semon, M.D.) . . 84
-two cases of doubtful malignant disease of the larynx treated by
thyrotomy and radical removal of the growths (Felix Semon, M.D.) . 104
-acute oedema followed by hsematoma of left half of larynx after foot¬
ball accident (Felix Semon, M.D.) . . # .46
-pachydermia of the larynx (Felix Semon, M.D.) . . 16
-(Scanes Spicer, M.D.) . . . . 85
-(Charters J. Symonds) . . . .86
-recurrent papilloma of larynx twice operated upon by thyrotomy
(Percy Kidd, M.D.). . . • . . 61
-laryngeal papillomata (Scanes Spicer, M.D.) . . .64
-traumatic perichondritis ? of larynx (Charters J. Symonds) . 20
— traumatic perichondritis of the larynx; cure (Felix Semon, M.D.) . 39
-stenosis of larynx (F. de Havilland Hall, M.D.) . . 35
-after tracheotomy (E. Clifford Beale, M.B.) . . 35
-laryngeal stenosis (? tubercular) (Percy Kidd, M.D.) . . 83
-- syphilitic stenosis of larynx (Felix Semon, M.D.) . . 44
-(Charters J. Symonds) . . . .68
-(F. de Havilland Hall, M.D.) . # .82
-syphilitic disease of pharynx and larynx in a tubercular subject (E.
Clifford Beale, M.B.) . . . . . .11
-chronic laryngeal tuberculosis (W. McNeill Whistler, M.D.) . 7
-tuberculosis of larynx and lung (Scanes Spicer, M.D.) . # 5
■ ■ case of advanced tubercular disease of larynx (Herbert Tilley, M.D.) 89
$
116
Larynx {continued )— PA &1
■ ■ - obscure pharyngeal ulceration in a case of arrested laryngeal and
pulmonary tuberculosis (Felix Semon, H.D.) . . 74, 106
■ ■ small subglottic tumour of uncertain nature in a case of laryngeal
tuberculosis (Percy Kidd, M.D.) . . . .83
—— tubercular tumour of larynx (E. Clifford Beale, M.B.) . . 71
■ . tumour of the larynx in a case of goitre (J. B. Ball, M.D.) . 79
Lawuxob (L. A.), enlargement of posterior faucial pillars • • 63
Leprosy with throat lesions (J. B. Ball, M.D.) • . .33
Library: gifts to the Library • . . . .56
Lung : tuberculosis of larynx and lung (Scanes Spicer, M.D.) . . 6
- obscure pharyngeal ulceration in a case of arrested laryngeal and
pulmonary tuberculosis (Felix Semon, M.D.) . . 74,106
Lupus of larynx and pharynx (Mark Hovell) . . .4
- of nose (W. R. H. Stewart) . . .19
-and larynx (J. Dun das Grant, M.D.) . . .99
- of pharynx and larynx (Felix Semon, M.D.) . . . 103
Malignant disease of the larynx: exhibition of pathological specimens (H.
T. Butlin) . . . . . .21
■ ■■ (F. de Havilland Hall, M.D.) . . . .22
- (Felix Semon, M.D.) . . . . .22
' ■ ■■■ probable malignant disease of epiglottis and right side of larynx
(H. T. Butlin) . . . . • .20
- two cases of malignant disease of the larynx cured by thyrotomy
and excision of the new growth (Felix Semon, M.D.) . . 84
-two cases of doubtful malignant disease of the larynx treated by
thyrotomy and radical removal of the growths (Felix Semon, M.D.) • 104
Maxilla: caries and necrosis of nasal bones and superior maxilla (F. Semon,
M«I)t) . . . • • . .4
Mucous membrane: a fold of mucous membrane protecting the middle
meatus (Charters J. Symonds) . . . .87
Muscles: functional spasm of the muscles closing the jaws (Felix Semon,
M.D.) • • • • • • .38
-paralysis of the thyro-arytenoid muscles (J. Dundas Grant, M.D.) 101
MyxoBdema treated by feeding with fresh thyroid gland (E. Cresswell Baber) 10
Naris: congenital occlusion of posterior naris relieved by operation
(E. Cresswell Baber) • . . • .31
- occlusion of posterior naris (J. Dundas Grant, M.D.) . . 48
Naso-pharynx: multiple sarcomata of naso-pharynx and tonsils (W. B.
H. Stewart) • . • • . .6
- isolated tertiary syphilis of naso-pharyngeal cavity, simulating
paralysis of left half of soft palate (Felix Semon, M.D.) . . 15
Neck : epithelioma of cervical glands (J. W. Bond, M.D.) . . 110
Necrosis: caries and necrosis of nasal bones and superior maxilla (Felix
Semon, M.D.) . . . . . .4
Nose: retraction of ale nasi (W. R. H. Stewart) . . .77
■ » ■ discussion on the choice of the anesthetic in operations for
removal of post-nasal adenoid growths:
- remarks by Felix Semon, M.D. . . . 91, 97
-- - Dudley W. Buxton, M.D. ... 92, 97
- communication from H. T. Butlin . . . .92
—■ remarks by W. Tyrrell . . . . .92
— . . William Hill, M.D. . . . .92
117
Nose, discussion on the choice of anesthetic (continued )— page
-p. W. Hewitt, M.D. . • • .93
■ - W. R. H. Stewart . . . • 93
-J. F. W. Silk, M.D. . . . .94
-Scanes Spicer, M.D. . . . .95
■ ■ - H. Davis . . . . .95
-J. Dundas Grant, M.D. . . . .96
-Richard Gill . . . . .96
-McNeill Whistler, M.D. . . . .96
-G. H. Bailey . . . . .96
- - W. J. Walsham . . . . .96
-C. A. Parker . . . . .96
- — caries and necrosis of nasal bones; abscess of septnm (Felix Semon,
M*D.) . . . . . . .4
- lupus of nose (W. R. H. Stewart) . . . .19
-— lupus of nose and larynx (J. Dundas Grant, M.D.) . . 99
- a fold of mucous membrane protecting the middle meatus (Charters
J. Symonds) . . . . . .87
- removal of nasal polypi, followed by symptoms of incomplete
Graves* disease and, later on, complete premature baldness (Felix
Semon, M.D.) . . . . . .41
- sarcoma of nose and tonsils (J. W. Bond, M.D.) . . 109
Nostril: papillomata of nostrils and gum (Scanes Spicer, M.D.) . . 6,18
- see also Nari #•
Occlusion of posterior naris (J. Dundas Grant, M.D.) . . .48
(Edema: acute oedema of larynx after football accident (Felix Semon, M.D.) 45
(Esophagus: carcinoma of the oesophagus (W. R. H. Stewart) • . 65
Officers: list of Officers of the Society . . . .58
Oxy-hydrogen lantern (portable), exhibited by Dr. E. Clifford Beale • 84
Ozaena with retraction of alse nasi (W. R. H. Stewart) . • 77
Pachydermia of the larynx (Felix Semon, M.D.) • . .16
- (Scanes Spicer, M.D.) . . . . .85
- (Charters J. Symonds) . . . . .86
Pfelate : calculus of soft palate (Charles A. Parker) . . .50
- epithelioma of the soft palate and fauces (Watson Williams) .. 69
- paralysis of right half of soft palate (Felix Semon, M.D.) . 12
- complete motor paralysis of palate in case of tabes dorsalis (Felix
Semon, M.D.) . • . . • .5
- isolated tertiary syphilis of naso-pharyngeal cavity simulating
paralysis of left half of soft palate (Felix Semon, M.D.) . . 15
Papilloma: recurrent papilloma of larynx twice operated upon by thyro-
tomy (Percy Kidd, M.D.) . . . . .61
- laryngeal papillomata (Scanes Spicer, M.D.) . . .64
- papillomata of nostrils and gum (Scanes Spicer, M.D.) . . 6 , 18
- papilloma of uvula (Scanes Spicer, M.D.) . . .65
Paralysis: bilateral paralysis of glottis-openers with paralysis of internal
tensors of more than twelve years* standing (Felix Semon, M.D.) • 17
- of right half of soft palate (Felix Semon, M.D.) . . 12
- of left half of soft palate simulated by isolated tertiary syphilis of
naso-pharyngeal cavity (Felix Semon, M.D.) . . .16
.- of the thyro-arytffinoid muscles (J. Dundas Grant, M.D.) • 101
- bilateral paralysis of abductors of vocal cords, and complete motor
paralysis of palate in case of tabes dorsalis (Felix Semon, M.D.) . 5
- complete paralysis of right vocal cord (H. T. Butlin) . . 72
- case of adductor paralysis of left vocal cord (Herbert Tilley) . 88
118
PAOl
Paresis: abductor paresis of right vocal cord, not of cortical origin (Felix
Semon, M.D.) . . . . . .12
Parker (Charles A.), calculus of soft palate. . .50
-discussion on the choice of the anaesthetic in operations for re¬
moval of post-nasal adenoid growths . . .96
Perichondritis (Anthony Bowlby) . . . . .43
-perichondritis ? (Charters J. Syraonds) . . .68
-traumatic perichondritis of the larynx; cure (Felix Semon, M.D.) 39
—— traumatic perichondritis ? of larynx (Charters J. Symonds) . 20
Pharynx: cicatrix of pharynx (E. Cresswell Baber) . . .9
- chronic induration in pharynx (Scanes Spicer, M.D.) . . 18
- lupus of larynx and pharynx (Mark Hovell) . . .4
- lupus of pharynx and larynx (Felix Semon, M.D.) . . 103
- syphilitic disease of pharynx and larynx in a tubercular subject (E.
Clifford Beale, M.B.) . . . . .11
- obscure pharyngeal ulceration in a case of arrested laryngeal and
pulmonary tuberculosis (Felix Semon, M.D.) . . 74,106
Polypi: removal of nasal polypi followed by symptoms of incomplete Graves’
disease, and later on complete premature baldness (Felix Semon, M.D.) 41
Rhinitis atrophica foetida (William Hill, M.D.)
-with aphonia (W. Hill, M.D ,and James Cagney,M.D.)
-foetida (William Hill, M.D.) . . .
Sarcoma: multiple sarcoma (W. R. H. Stewart)
- of nose and tonsils (J. W. Bond, M.D.)
- multiple sarcomata of naso-pharynx and tonsils (W. R. H. Stewart)
Sclerosis: laryngeal symptoms in a case of insular sclerosis (F. W. Bennett)
Semon (Felix, M.D.), present of twelve electric lamps to the Society . 1,
- caries and necrosis of nasal bones and superior maxilla; abscess of *
septum; empyema of left antrum ....
- tabes dorsalis; laryngeal and other crises; bilateral paralysis of
abductors of vocal cords; complete motor paralysis of palate
-right hemiplegia; paralysis of right half of soft palate and
abductor-paresis of right vocal cord; the last named certainly not of
local origin .....
--isolated tertiary syphilis of naso-pharyngeal cavity, simulating
12
59
73
76
109
6
80
63
paralysis of left half of soft palate
- pachydermia of the larynx «...
- tabes dorsalis; bilateral paralysis of glottis-openers with paralysis
of internal tensors of more than twelve years’ standing .
-exhibition of pathological specimens illustrating malignant dw nnc
of the larynx
-functional spasm of the muscles closing the jaws ! *
-traumatic perichondritis of the larynx; cure .
— symptoms of incomplete Graves’ disease, and later on complete
premature baldness following removal of nasal polypi
- syphilitic stenosis of the larynx ..."
— acute oedema followed by haematoma of left half of larynx and
transitory immobility of left vocal cord, after football accident
— obscure pharyngeal ulceration in a case of arrested laryngeal and
pulmonary tuberculosis .
—-seqtfel to same case .
— two
12
16
16
17
38
39
41
44
45
74
106
84
cases of malignant disease of the larynx cured by thyrotomy
and excision of the new growth . . . J
— discussion on the choice of the ansesthetic in operations for removal’
of post-nasal adenoid growths . . . 91 97
— lupus of pharynx and larynx . . * jOg
119
Sncox (Felix, M.D.) (continued )— page
-- two cases of doubtful malignant disease of the larynx treated by
tbyrotomy and radical removal of the growths . . . 104
Septum: abscess of septum (Felix Semon, M.D.) . . .4
■ - - septal growths (J. Dundas Grant, M.D.) . . .38
Silk (J. F. W., M.D.), discussion on the choice of the anesthetic in opera¬
tions for removal of post-nasal adenoid growths . . .94
Sinus: empyema of frontal sinus (J. Dundas Grant, M.D.) . . 1
Snare: galvano-cautery snare exhibited by R. S. Charsley . . 34
Society: Inaugural Dinner, April 12th, 1893 . . .8
- Annual General Meeting, Jan. 10th, 1894 . . .53
- list of officers of the Society . . . .68
Spasm: functional spasm of the muscles closing the jaws (Felix Semon,
M.D.) ■•••••• 38
Spicxb (Scanes, M.D.), tuberculosis of larynx and lung . . 6
- papillomata of nostrils and gum . . . . 6, 18
- chronic induration in pharynx . . . .18
- stenosis of fauces with other palato-pharyngeal lesions, the results
of ulceration, and subsequent adhesions in a syphilitic subject • 46
■ laryngeal papillomata . . . . .64
- - papilloma of uvula . . . . .66
-- oedema and infiltration of arytssnoid mucous membrane of
uncertain origin . . • . • .76
■■■ a laryngeal neoplasm of apparently sudden origin (pachydermia) . 86
- discussion on the choice of the anesthetic in operations for
removal of post-nasal adenoid growths . . . .95
- fixation of left vocal cord ..... 107
Stenosis of fauces from ulceration and subsequent adhesions in a syphilitic
subject (Scanes Spicer, M.D.) .....
- of larynx (F. de Havilland Hall, M.D.)
after tracheotomy (E. Clifford Beale, M.B.)
syphilitic stenosis of the larynx (Felix Semon, M.D.)
- (Charters J. Symonds) ....
(F. de Havilland Hall, M.D)
- laryngeal stenosis (? tubercular) (Percy Kidd, M.D.)
- tracheal stenosis (? cicatricial stricture) (Percy Kidd, M.D.)
Stbwabt (W. R. H.), multiple sarcomata of naso-pharynx and tonsils
- lupus of nose
- carcinoma of the oesophagus
— - suppuration in the ethmoidal cells .
■ 1 multiple sarcoma
- retraction of al© nasi—ozena
- discussion on the choice of the
anesthetic in operations for
removal of post-nasal adenoid growths
- unilateral laryngitis
— carcinoma laryngis
Suppuration in the ethmoidal cells (W. R. H. Stewart)
Stmoxds (Charters J.), traumatic perichondritis ? of larynx
- epithelioma of epiglottis .....
. - recent syphilitic stenosis of larynx .
- swelling of ventricular band and arytenoid eartilage of uncertain
nature .••••..
- pachydermia laryngis .....
- a fold of mucous membrane protecting the middle meatus
Syphilis: inherited syphilis (F. de Havilland Hall, M.D.)
- stenosis of fauces with other palato-pharyngeal lesions, the results
of ulceration and subsequent adhesions in a syphilitic subject (Scanes
Spicer, M.D.) «.*•..
46
35
35
44
68
82
83
88
6
19
65
67
76
77
93
107
108
67
20
20
68
68
86
87
3
46
120
Syphilis ( continued )— PA0B
- syphilitic stenosis of the larynx (Felix Semon, M.D.) . • 44
- (Charters J. Symonds) . . . . .68
-(F. de Havilland Hall, M.D. . .82
- isolated tertiary syphilis of naso-pharyngeal cavity, simulating
paralysis of left half of soft palate (Felix Semon, M.D.) . . 16
- syphilitic disease of pharynx and larynx in a tubercular subject (E.
Clifford Beale, M.B.) . . . . .11
- syphilitic disease of the tonsil (F. de Havilland Hall, M.D.) . 3
Syringe: an intra*laryngeal syringe for submucous injections (Watson
Williams, M.D.) . . . . . .109
Tabes dorsalis (Felix Semon, M.D.) . . . .17
- with laryngeal and other crises (Felix Semon, M.D.) . . 6
Tensors: paralysis of internal tensors of more than twelve years' standing
(Felix Semon, M.D.) . . . . .17
Throat: leprosy with throat lesions (J. B. Ball, M.D.) . . 33
Thyro-arytaenoid muscles: paralysis of the thyro-arytssnoid muscles
(J. Dundas Grant, M.D.) ..... 101
Thyroid gland: myxcedema treated by feeding with fresh thyroid gland
(E. Cresswell Baber) . • . . .10
- - removal of right lobe of thyroid for Graves' disease (R. Lake) . 102
Thyrotomy twice performed for recurrent papilloma of larynx (Percy
Kidd, M.D.) . . . . .61
- and excision of new growth in two cases of malignant disease of
the larynx; cure (Felix Semon, M.D.) . . . .84
- and radical removal of the growths in two cases of doubtful
malignant disease of the larynx (Felix Semon, M.D.) . . 104
Tillbt (Herbert, M.D.), case of adductor paralysis of left vocal cord . 88
- case of advanced tubercular disease of larynx . . .89
Tonsils: multiple sarcomata of naso-pharynx and tonsils (W. R. H.
Stewart) . . . . . . .6
- sarcoma of nose and tonsils (J. W. Bond, M.D.) . . 109
- syphilitic disease of the tonsil (F. de Havilland Hall, M.D.) . 3
Trachea: tracheal fistula (F. de Havilland Hall, M.D.) . . 82
- tracheal stenosis (? cicatricial stricture) (Percy Kidd, M.D.) . 88
Tracheotomy: stenosis of larynx after tracheotomy (E. Clifford Beale,
M.B.) . . . . . . .36
Traumatic perichondritis of the larynx; cure (Felix Semon, M.D.) . 39
- perichondritis ? of larynx (Charters J. Symonds) . . 20
Tuberculosis: syphilitic disease of pharynx and larynx in a tubercular
subject (E. Clifford Beale, M.B.) . . . .11
- chronic laryngeal tuberculosis (W. McNeill Whistler, M.D.) . 7
- small subglottic tumour of uncertain nature in case of laryngeal
tuberculosis (Percy Kidd, M.D.) . . . .83
- case of advanced tubercular disease of larynx (Herbert Tilley, M. D.) 89
- - laryngeal stenosis (? tubercular) (Percy Kidd, M.D.) . . 83
- of larynx and lung (Scanes Spicer, M.D.) . . .6
- obscure pharyngeal ulceration in a case of arrested laryngeal and
pulmonary tuberculosis (Felix Semon, M.D.) . . 74, 106
- tubercular tumour of larynx (E. Clifford Beale, M.B.) . . 71
- tubercular ulceration of vocal cord cured by lactic add (Percy
Kidd, M.D.) . . . . . 86
Tumour of the larynx in a case of goitre (J. B. Ball, M.D.) . . 79
- small subglottic tumour of uncertain nature in a case of laryngeal
tuberculosis (Percy Kidd, M.D.) . . . .83
■■■ * tubercular tumour of larynx (E. Clifford Beale, M.B.) , , 71
121
PAGH
Ttbbbll (W.), discussion on the choice of the anaesthetic in operations for
removal of post-nasal adenoid growths . . . .92
Ulceration: obscure pharyngeal ulceration in a case of arrested laryngeal
and pulmonary tuberculosis (Felix Semon, M.D.) . 74,106
- tubercular ulceration of vocal cord cured by lactic acid (Percy
Kidd, M.D.) . . . . . .86
Uncinate process: hypertrophy of nncinate process and mucous membrane
covering it, simulating so-called “ cleavage 99 (William Hill, M.D.) • 73
Uvula: papilloma of uvula (Scanes Spicer, M.D.) . . .65
Ventricular band: swelling of ventricular band and arytenoid cartilage of
uncertain nature (Charters J. Symonds) • . .68
Vocal cord: fixation of left vocal cord (J. B. Ball, M.D.) . . 79
-(Scanes Spicer, M.D.) .... 107
-submucous haemorrhage and angioma of the vocal cord (J. Dundas
Grant, M.D.) . . . . . .2
- transitory immobility of left vocal cord after football accident
(Felix Semon, M.D.) . . . . .45
-impaired movement of vocal cord in case of absorbed gumma over
right arytenoid cartilage (W. Hale White, M.D.) . . 77
—_< case of adductor paralysis of left vocal cord (Herbert Tilley) . 88
-bilateral paralysis of abductors of vocal cords, and complete motor
paralysis of palate, in case of tabes dorsalis (Felix Semon, M.D.) . 5
-complete paralysis of right vocal cord (H. T. Butlin) . . 72
-abductor-paresis of right vocal cord, not of cortical origin (Felix
Semon, M.D.) . . . * . .12
■ — — - tubercular ulceration of vocal cord cured by lactic acid (Percy
Kidd, M.D.) . . . . . .36
Walsh AM (W. J.), discussion on the choice of the anaesthetic in operations
for removal of post-nasal adenoid growths . . .96
Whibtlbb (W. McNeill, M.D.), chronic laryngeal tuberculosis . . 7
.. ■ Discussion on the choice of the ansesthetic in operations for re¬
moval of post-nasal adenoid growths . . • .96
White (W. Hale, M.D.), absorbed gumma over right arytenoid cartilage ;
impaired movement of vocal cord . . . .77
Willcocks (F., M.D.), gummata of epiglottis ? . . .78
Williams (Watson, M.D.), epithelioma of the soft palate and fauces . 69
- an intra-laryngeal syringe for submucous injections . . 109
FEINTED BY ADLABD AND SON,
BARTHOLOMEW CLOSE, B.C., AND 20, HANOVEB SQUABS, W.
PROCEEDINGS
OF THE
LARYNGOLOGICAL SOCIETY
OF
LONDON.
VOL. II.
1894-95.
WITH
LISTS OF OFFICERS, MEMBERS, ETC.
LONDON:
PRINTED BY ADLARD AND SON,
BARTHOLOMEW CLOSE, E.C., AND 20, HANOVER SQUARE, W.
1896 .
OFFICERS AND COUNCIL
OF THE
Ifargttgolojital J&Mittji of |f<ntb<m
ELECTED AT
THE ANNUAL GENERAL MEETING,
JANUARY 9th, 1895.
^rtsibtni.
FELIX SEMON, M.D., F.R.C.P.
©i«-|!rmbtjrt8.
E. CRESSWELL BABER, M.B. CHARTERS SYMONDS, F.R.C.S.
ftreasartr.
H. T. BUTLIN, F.R.C.S.
librarian.
E. C. BEALE, M.B., F.R.C.P.
Stmtaries.
SCANES SPICER, M.D. W. R. H. STEWART, F.R.C.S.
dotmtil.
F. W. BENNETT, M.D. J. W. BOND, M.D.
A. BRONNER, M.D. DUNDAS GRANT, M.D.
PERCY KIDD, M.D.
PRESIDENTS OF THE SOCIETY.
(From its Formation.)
ELECTED
1893 Sib Geobgk Johnson, M.D., F.R.S.
1894 Felix Semon, M.D., F.E.C.P.
PROCEEDINGS
OP THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, October 10th, 1894.
Felix Semon, M.D., F.R.C.P., President, in the Chair.
E. Clifford Beale, M.B.,
Scanes Spicer, M.D.,
Secretaries.
Present—18 Members and 3 Visitors.
The minutes of the previous meeting were read and confirmed.
The following candidates were proposed for election:
Dr. J. M. Hunt, Liverpool.
Mr. A. E. Shaw, Wandsworth.
Mr. E. F. Potter, Kensington.
Adenoma of Tongue.
Clinical case exhibited by Mr. Cresswbll Baber. —E. W—, set. 16,
came as out-patient to the Brighton Throat and Ear Hospital on July
2nd, 1894, with a history of difficulty in swallowing and thickness of
speech for nine months. A tumour was found at the base of the tongue
about the size of a small walnut, which hid the larynx from view. There
was no dyspnoea. On July 16th she was admitted into the hospital
as in-patient, and the following notes were made:—“ The affection of
voice and deglutition began in September after a ‘ sore throat/ and
for a week before she first applied she is said not to have been able
to eat anything. The tumour is globular, now about the size of a walnut,
in the median line of the tongue, attached by a large base just in front
of the epiglottis. It has a smooth surface, of a mottled red and white
colour, with numerous veins coursing over it. It is seen on depress¬
ing the tongue forcibly, and when retching is induced it starts up
filling the whole faucial space. The tumour, which presents the appear¬
ance of a cyst with thick walls, can be well seen in the laryngeal mirror.
It hides the epiglottis, and only the posterior half of the cords (which
FIRST SERIES—VOL. II. 1
2
are clear and pale) can be seen when the patient phonates a high
* e* On palpation the tumour also gives the impression of a cyst,
and below it the epiglottis can be indistinctly felt.” On July 19th the
growth was seized with catch forceps which caused rather free venous
haemorrhage. This was arrested with the galvanic cautery. The
tumour was then punctured in the centre with a galvanic cautery
point, and a probe passed in nearly one inch, but no contents escaped,
and the growth became only slightly, if at all, reduced in size. The
opening was kept patent with probe and cautery for a short time, but
as no appreciable diminution in size took place, the tumour was
removed on August 31st with the galvanic snare, which was adjusted
without any difficulty. There was no haemorrhage of consequence,
and the growth came off on a level with the surface of the tongue. No
untoward symptoms occurred beyond slight haemorrhage ten days
afterwards. Before she left the hospital on September 24th the sur¬
face had quite healed, but had become rather more raised into an irre¬
gular flat growth, which was reddish at its posterior part. It felt firm to
the touch. The epiglottis, which was clearly seen, was so pendulous
that only a glimpse of the cords was obtainable. There was no pain
or difficulty in swallowing, but the voice remained about the same,
partly hoarse and partly nasal in character. There was no swelling
in the median line of the neck or enlargement of the thyroid gland.
On October 2nd the remains of the growth appeared rather flatter,
though still raised at the back part, and the epiglottis was somewhat
less pendulous.
Remarks .—This case closely resembles those described by Mr. Butlin
in the ‘ Transactions of the Clinical Society of London 'for 1890, vol.
xxiii, p. 118, under the head of “ Glandular Tumours of the Tongue.”
Mr. Butlin could only find eight cases of this description, two of which
were under his own care. In one of the eight the tumour was
situated on the under surface of the tongue near the tip, in the re¬
mainder, as in this case, its position was on the back of the tongue
just in front of the epiglottis. As in Button's first case, in the present
one the growth felt so elastic that it gave the impression of being
cystic. All the cases mentioned by Butlin occurred in females, whose
ages varied from extreme infancy to thirty-two years.
The microscopical examination was kindly made by Mr. H. H. Taylor,
who reported as follows:—“ The minute structure of the growth closely
resembles that described by Mr. Butlin in the f Clinical Society's
3
Transactions,' vol. xxiii. Bound or oval spaces of small size, lined by
a single layer of cubical epithelium, and containing in some cases
granular, in others hyaline material. The interstitial tissue is made
up of fine nucleated fibres. Towards the capsule the spaces are larger
and more irregular in outline. Here and there (but very few in
number) some of the spaces are elongated and flattened, somewhat re¬
sembling ducts, but I do not think they are of this nature. I cut
vertical and horizontal sections to see if ducts were present, but
failed, with the exception of the appearances mentioned above, to find
any.
tf The growth closely resembles thyroid tissue, and may well be con¬
nected with some foetal remains of the lingual duct. There are no
cysts, nor does the tumour present any tubular structure."
This case, therefore, seemed to support the theory advocated by
Bernays and Bland Sutton, that these tumours are of the nature of
accessory thyroid glands.
Mr. Lake mentioned a similar case.
The President, replying to Mr. Baber, advised that the growth
should be again removed by the snare, but no more radical operation
undertaken unless the symptoms became serious.
Immobility op the Left Vocal Cord.
Dr. Bennett showed the case of Mrs. C—, set. 47. Onset about
two years ago. Loss of voice had been progressive, but more rapid
since influenza some ten months ago.
First seen three months ago. There was no congestion, no
ulceration, and no symptoms which pointed to any other affection.
There were no certain signs of chest mischief either in the lungs or
in the vessels. There was no difficulty in swallowing. There was at
first a sensation of aching over the larynx, but this soon disappeared.
She took iodide of potassium for a short time but without any benefit.
There was no suspicion of syphilis.
Dr. Dtjndas Grant thought it difficult to account for the immo¬
bility. There seemed to be no special cause within the larynx, and no
evidence of pressure upon the nerve-trunk unless by a deep-seated
gland. The further history of the case might explain it.
Dr. Tilley suggested that the spasms might be indicative of tabes.
He had seen a similar case in a male whose pupils had subsequently
been contracted and the knee-jerks lost.
4
Dr. Spicer had noticed some fulness in the left pyriform fossa, and
thought that there might possibly be a local lesion.
The President could not tell the exact cause of the lesion in the
present case; fixation of one cord was often seen and was not incom¬
patible with good health. Such cases ought to be carefully kept in
view, and post-mortem as well as clinical evidence recorded. Gou-
guenheim had suggested that some enlargement or inflammation of
one of the chain of glands accompanying the recurrent laryngeal
nerve might account for such cases. It was very desirable that the
whole course of the recurrent laryngeal and vagus should be closely
examined when opportunities occurred. The first case of paralysis
preceding tabes had been shown in 1878, two years after the onset of
the paralysis. The patient lived for eight years afterwards. Many
cases had been reported since. He had examined many cases at
Queen Square Hospital and found some without paresis of any kind,
unilateral or bilateral. The relative frequency was difficult to deter¬
mine. In his first twelve cases he had found seven cases of paralysis
or paresis, but not another case in the next fifty or sixty cases of
tabes. Hence the discrepancy of frequency among different observers.
Cystic Fibroma of the Left Vocal Cord.
Dr. Adolph Bronner (Bradford) showed microscopical specimens
of a tumour removed from a clergyman aged 76. The veins were
very distended and numerous, and there were several large cavities
lined with endothelium.
Drawings of similar growths were shown as demonstrated by Pro¬
fessor Chiari in ( Archiv fur Laryngologie/ ii, 1.
The growths were situated on the upper surface of the cord, and
had been first noticed three years ago. Fibromata of the small cords
were rare in old age.
Epithelioma of the Epiglottis.
Dr. Bronner also showed a man of 7 8, suffering from a growth of
three years' duration. There were unmistakable symptoms of secon¬
dary affections of the liver and lungs. The growth was partly
removed by cutting forceps, and the patient could now eat and speak
without any difficulty. It was very rare indeed to find secondary
deposits in cases of epithelioma of the larynx.
Case of (?) Chronic Tuberculosis of the Larynx.
Dr. de Havilland Hall showed the case of B. M. V—, set. 51.
The patient stated that he had had syphilis twenty-six years ago.
He first began to be troubled with his throat ten years ago.
5
bat he was not much inconvenienced until five years ago. For the
last three years he had been under the care of Dr. Valentin of Berne.
He first consulted Dr. de Havilland Hall on May 26th, 1894.
The epiglottis, ary-epiglottic folds, and arytenoids were found to be
greatly tumefied, and the glottis was reduced to a mere chink, the
vocal cords not being visible. The mucous membrane of the posterior
wall of the pharynx was replaced by cicatricial tissue. The septum
nasi was completely destroyed. At the apex of the left lung posteriorly
there was impaired resonance, with bronchial breathing and occasional
rfiles.
On making a forcible expiration with the mouth closed, two
tumours appeared on each side of the larynx. ? Dilated ventricles
of Morgagni. A distinct “ pop ” accompanied the appearance of the
tumours.
As the symptoms of laryngeal stenosis steadily increased, the
patient was admitted into the Westminster Hospital, and tracheotomy
had to be performed rather suddenly on June 3rd by the house surgeon,
Mr. S. A. Bull.
At the present time the patient was taking carbonate of guaiacol
internal, and the galvano-cautery was being applied to the larynx.
The patient had gained weight and improved generally since the
tracheotomy, and the application of the galvano-cautery had been
followed by marked diminution of the swelling of the epiglottis, so
that the vocal cords were now visible.
Dr. de Havilland Hall regarded the case as having been of a
syphilitic nature at the commencement, but thought that the present
condition was due to chronic tuberculosis.
Dr. Beale referred to a somewhat similar case shown in 1893, in
which the laryngeal conditions had remained unaltered for a twelve-
month. The patient had taken iodide persistently, and believed that
it kept the disease in check. The passive, swelled, and congested
condition, occurring in association with tubercle and syphilis, as in
Dr. Hall’s case and his own, seemed to he due to the combined pro¬
cesses.
Dr. Bronner suggested the use of mercurial inunction.
Dr. Hall had found that the most relief was given to the dysphagia
by cauterisation of the swollen epiglottis, which was tough and
leathery.
Dr. Dtjndas G-rant thought that in the combined cases of tubercle
and syphilis, there was generally ulceration. The dry appearance of
the larynx in the present case was very striking.
J
6
Tonsillar Mtcosis.
Mr. R. Lake showed two cases of tonsillar mycosis, both females.
He wished to raise the question, whether there was any more rapid
method of dealing with these cases than that of galvano-cautery ?
One of these cases had been freely and carefully cauterised once a
week for three months, and was not yet cured; the second had not
had more than one application.
Dr. Hall advised continued use of the cautery, as that treatment
gave relief at any rate.
The President thought that these cases might well be left alone
if they gave rise to no distress. He had quite given up the use of
the cautery to the disease on the base of the tongue, and had seen
disastrous results ensue where it had been used. Patients as a rule
only became aware of the disease by seeing the white patches in the
mirror, which they described as “ ulcers,” and often declared that
no discomfort was caused by them. To destroy the colonies of mycosis
on the surface was easy, but it did not cure the disease. Change of
air and general treatment gave better results than operation.
Mr. Cresswell Baber thought it best to leave the milder cases
alone. When the growth was extensive he had seen good results from
the application of absolute alcohol.
Dr. Spicer had used the galvano-cautery in such cases very fre¬
quently without permanent benefit. He preferred to cut away the
tonsillar tissue, and so to destroy every crypt that could harbour the
growth. At the base of the tongue he preferred to apply antiseptic
remedies.
Dr. Bennett advocated forcible syringing out of the crypts and
application of pure carbolic acid to the openings.
Dr. Dundas Grant pointed out that pharyn go- mycosis was very
distinct from pharyngitis with accretions, but the distinction was not
always recognised, and the condition was sometimes mistaken for
syphilis. He had used the galvano-cautery in each individual crypt,
but had found very good results from the daily use of a lotion of
tincture of iodine with fifteen grains of bicarbonate of soda. In
one case it had completely checked recurrence.
Mr. Lake, in reply, thought that patients generally complained of
subjective symptoms and sought relief, without always being aware
of the white patches in the throat.
Lupus of the Nose treated by Thyroid Extract.
Mr. Lake also showed the two following cases:
The first, a boy of 11 years of age, had suffered for fourteen months.
The soft palate and posterior pillars of the fauces were also affected.
7
He had been taking 74 grains of thyroid extract daily since July 14th,
and was very much improved.
The second case, that of a girl of 16 years, had been affected for
three years, and when put on thyroid treatment at the same time as
the boy, also had a patch of lupus below the right eye over the nasal
duct; this was now almost healed, and the nose was very much
improved; she was now taking 174 grains daily. Mr. Lake wished
to show these cases to the Society in order that, if successfully cured
by this treatment, the result might subsequently be verified.
Dr. Dundas Grant expressed some doubt as to the nature of the
disease in the girl’s case. He pointed out that the thyroid extract
had not been the sole treatment.
Dr. Jessop related a case in which marked improvement had
followed the use of three hundred tablets in a case where the disease
had existed for thirty years.
Tonsillar New Growth.
Dr. Soanes Spicer showed Thomas H—, set. 70, who had a
vascular tumour the size of a large walnut, spreading from the lower
part of the right tonsil on to the base of the tongue. Two years ago
thorough tonsillotomy was performed for growths which were too
large to lie laterally in pharynx, so that one passed upwards, the
other downwards; the symptoms were dysphagia, dyspnoea, and
unintelligible articulation. The reappearance on the right side had
been very gradual, and its growth was slow. Microscopically, it was
made up of closely packed round cells. Repetition of removal was
proposed, but suggestions were invited.
Dr. Bbonner referred to the value of arsenic in large doses in such
cases.
Dr. Tilley mentioned the case shown to the Society by Mr.
W. R. H. Stewart last session, in which arsenic had given very
marked relief for a time.
Dr. W. Hill thought that such cases showed varying degrees of
malignancy, but they all tended to spread if left alone. He would
not use the guillotine, but preferred enucleation.
Dr. Pegler regarded the case as one of lympho-sarcoma and not
ordinary hypertrophy.
The President remarked that after the age of forty such cases
were generally lympho-sarcoma or adenoma.
Dr. Dundas Grant suggested that the tumour chould be enucleated
8
by snipping through the mucous membrane and turning the growth
out by means of the finger.
Mr. de Santi thought that such a growth might be removed by
external incision, and referred to two cases thus treated.
Dr. Spicer replied.
Laryngeal Stenosis supervening on Typhoid Fever.
Dr. Soanes Spicer showed a young man set. 20, who was under
Dr. Cheadle in St. Mary’s Hospital six months ago for typhoid fever.
Acute stenosis of larynx supervened and tracheotomy was performed.
Some weeks afterwards he was sent to the throat department for
examination. The vocal cords were found to be adherent at anterior
fourth, and on attempting breathing with finger on trachea tube, a
red subglottic mass was seen to almost completely occlude lumen.
He could phonate, but a probe could not be put through stricture
after cocainising, nor was intubation, attempted with some force,
successful. The case was shown preliminary to division of stricture
under general ansesthesia by Whistler’s dilators and use of O’Dwyer's
intubation tubes.
The President agreed that an attempt should be made to divid
the stricture and dilate it, but he was not sanguine as to the result in
such a case.
PKOCEEDINGS
OP THB
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, November 14th, 1894.
f
Felix Semon, M.D., F.R.C.P., President, in the Chair.
E. Clifford Beale, M.B.,
Scanes Spicer, M.D.,
Secretaries.
Present—30 Members and 6 Visitors.
The minutes of the previous meeting were read and confirmed.
The following candidates were balloted for and duly elected:
Mr. E. F. Potter. Mr. A. E. Shaw.
Dr. J. M. Hunt.
The following candidates were
members:
Dr. C. C. Cripps.
Mr. A. L. Roper.
Dr. G-eorge Mackem.
Dr. Henry Sharman.
proposed for election as ordinary
Mr. A. E. Hill-Wilson.
Dr. W. J. Horne.
Mr. Reginald Poulter.
Swelling of Left Side of Larynx, with Paralysis and Atrophy
of Left Half of Tongue and Soft Palate, and Peri¬
chondritis.
Mr. A. A. Bowlby showed this case. John T—, set. 52, a meat
porter, had had good health previous to December, 1893, when he
began to suffer from a painful lump about the size of a walnut on the left
side of the front of the neck. There were no other symptoms. Under
treatment he improved j the pain left him, but the lump remained.
When seen again, in August last, there was a large and ex¬
tremely indurated mass, nearly as large as an orange, in front of and
first series—VOL. II. 2
10
to the left of the larynx. There were pain, dysphagia, and blood¬
spitting. AVith fomentations the mass softened, and an incision let
out about an ounce of pus. He improved for a while. On October
2nd he again came under observation. Then there were inability to
swallow solids, constant cough with glairy expectoration but no
haemoptysis, and some loss of weight. There was still a hard mass,
softening nt-ar site of old scar. He was admitted to the hospital.
On October 10th some pus was discharged through the old scar, and
patient was relieved. There was also some haemoptysis. He then
came under observation in the Throat Department, and examination
found—
Externally, an old scar situated over and adherent to the thyroid
cartilage, discharging pus, but no tenderness on manipulation.
Beneath the left maxilla there was felt an enlarged stony hard gland,
with the superjacent skin intact. Some slight loss of facial symmetry
noticed. The tongue was protruded with difficulty and pushed over
to the left. The left half was in an advanced state of atrophy. The
left half of the soft palate was also atrophied, and hung lower than
right; it had but little movement, being only dragged up by right
half. Slight rigidity of soft palate noticed in attempting to raise it
up on back of a throat mirror. No scars on soft palate or tongue.
Larynx : epiglottis twisted out of the median line, so that the tip was
looking towards the left. Occupying the greater part of the left half
of the larynx there was a smooth reddish mass, obscuring the posterior
two thirds of the left cord and ventricular band. The right cord was
fixed and partly hidden by the overhanging ventricular band. No
ulceration or scar.
Since this examination the mass referred to had increased in size,
and now only part of right cord was to be seen.
Examination of chest yielded no definite morbid signs. No history
of syphilis.
Remark8 .—Much of the swelling was evidently due to perichon¬
dritis ; hut the question was, whether this, in its turn, was due to a
malignant growth. In favour of this event was the extreme hardness
and fixity of the glandular swelling. It was, further, a very rare thing
for paralysis of nerves to be caused by any merely inflammatory
swelling. The atrophy of the tongue was probably due to pressure
on the hypoglossal by the mass of glands which lay just over its
course. On the other hand, the prolonged history, and the fact that
11
the patient had improved under treatment, seemed to point to peri¬
chondritis without new growth. The only operation which appeared
at all likely to be useful was one for exposing the thyroid cartilage
opposite the swelling, and seeing if there was any necrosed portion to
be removed.
The President thought that there was no evidence that the growth
was causing the paralysis. There were no other symptoms of dis¬
turbance of the vagus. It must be remembered that both centripetal
and centrifugal fibres had been demonstrated in the pneumogastric,
but in the recurrent laryngeals the existence of centripetal fibres had
never yet been shown, although many observers believed in their
existence. Unilateral pressure on the recurrent laryngeal did not
cause bilateral paralysis or spasm.
Tubercular Disease of Soft Palate, Larynx, Pharynx, and
Lungs.
Mr. A. A. Bowlby showed the case of P. R—, set. 22, a bootmaker,
seen first on October 24th, 1894, on account of a sore throat he had
had five weeks. When first seen, there was spreading over the soft palate
and uvula and on the pharynx, a greyish membranous-like deposit,
which at a glimpse was suggestive of diphtheritic membrane; but there
was no swelling nor oedema of the parts, the tonsils were eaten into and
excavated, and appearing through the secretion were a number of small
pin-head glistening nodules, which clustered thickly around the base
and tip of uvula. On cleaning the part a bleeding surface was left,
which was irregularly ulcerated. The pulse was quickened, and the
temperature raised between 101° and 102°.
The tongue was free from disease; by depressing it the tip of the
epiglottis could be seen thickened and reddened. The epiglottis was
turban-shaped, and on the tip one or two whitish pin-point nodules, but
no ulceration. The arytsenoids were somewhat reddened and enlarged,
the left more so than the right, but their surfaces intact. The cords
and ary-epiglottic folds were very slightly affected, and presented no
ulceration, the cords moving well and equally. No particular change in
voice.
There were well-marked signs of chronic but progressive disease in
the lungs.
November 9th.—Some scrapings from the soft palate, and also the
sputum, yielded tubercle bacilli.
12
Since the 24th of October, when he was first seen, there had been no
very appreciable increase in the extent of the ulceration of the soft palate,
but what there was had become deeper. The laryngoscope showed
further epithelial changes along the tip of the epiglottis and on the
summit of the left arytaenoid.
In his general health the patient had improved, and the disease in
the lungs was not so active.
There was no history of syphilis, nor any family history of phthisis.
Mr. Bowlby observed that there seemed to be no doubt of the nature
of the affection in this case, and it did not appear that any radical treat¬
ment of an operative nature could be undertaken, considering that the
disease was vei*y widely spread. He had, however, seen one similar
case of even greater extent, which recovered under the use of iodoform
locally and cod-liver oil internally, and he proposed to continue the
same lines of treatment in this case.
Pachydermia with Perichondritis.
Dr. Adolph Bronner (Bradford) showed a specimen of diffuse pachy¬
dermia of the larynx with perichondritis of the right arytaenoid cartilage.
The man, a brushmaker of 72, had been hoarse for four years, and
there had been difficulty in breathing for three or four weeks. He
was admitted into the Bradford Infirmary; tracheotomy was performed
on the following day, but the patient died of broncho-pneumonia
in eight days. No tubercle bacilli could be found in the sputum or
lungs. There was a scar on the glans of the penis, probably specific.
The long duration of the hoarseness and loss of voice, and the short
duration of the dyspnoea, seemed to point to the pachydermia as the
primary condition, and that the perichondritis was due to the pachy¬
dermia. It was possible, however, that the perichondritis had caused
the pachydermia. The vocal cords were very thick, and showed several
small growths. The ventricular bands were also much enlarged, and
the mucous membrane of the right ventricle was so enlarged as to
project to some extent.
Similar cases have been recorded by B. Praenkel in the * Archiv fur
Laryngologie/
Mr. Butlin observed that so-called perichondritis was frequently
neither more nor less than syphilis, and he thought that it was so in the
present case. It was always difficult to distinguish at first sight be¬
tween pachydermia and fiat epithelioma.
13
Dr. Milligan (Manchester) commented on the difficulty in deter¬
mining whether perichondritis or pachydermia was the primary con¬
dition when both were present.
Case op Lymphadbnoma with Obstructed Breathing.
Dr. James Donelan showed a patient, J. B—, set. 43, first seen
at the Italian Hospital four weeks ago. His father died of “ cancer
of the throat.” His health has been always good, except a slight
tendency to bronchitis.
On November 9th, 1893, a discharge from right ear began almost
painlessly, and continued for two months. A swelling next appeared
on the right side of the neck, followed by a similar swelling on the
opposite side. Dyspnoea soon set in, and he was obliged to give up
his trade of baker. There was marked enlargement of the cervical
glands along both borders of the stemo-mastoids, with dulness over
the sternum. A small group of enlarged glands could also be felt
near the xiphoid appendix. There was bronchial catarrh and con¬
siderable venous congestion of the head, neck, arms, and hands, from
which gradual closure of the superior vena cava was to be inferred.
The spleen was moderately enlarged but painless; there was, however,
some pain over the liver. No microscopic examination of the blood
had yet been made, but there appeared to be little anaemia. Up to
the present the patient had been taking three minims of Liq. Arseni-
calis three times daily, but the stomach did not seem able to stand
any larger dose.
Mr. W. G. Spencer mentioned a case in which there had been
marked intolerance of arsenic until a portion of the adenomatous mass
was removed, after which the patient was able to take the Liquor
Arsenicalis Hydrochloricus with marked benefit.
Dr. de Havilland Hall pointed out that where intolerance of
arsenic was present, it was advisable to change the form of adminis¬
tration, since patients could sometimes assimilate one preparation
while quite unable to bear another.
Papilloma Nasi with Rodent Ulcee in an Aged Patient.
Mr. P. de Santi showed a patient, David P —, aet. 82, who was
admitted to Westminster Hospital June 6th, 1894, with a growth in
left nostril. Five years previously he had noticed a small pimple on
the inner and upper part of the left nostril. It had gradually in-
14
creased in size, and interfered with nasal breathing. It had never
been painfnl. About one year ago he noticed that he had a foetid
discharge occasionally from left nostril, perceptible to himself as well
as to others.
About one year ago he noticed a similar kind of pimple on the skin
over the right side of the nose. It increased very slowly in size, was
painless, but itched. He therefore scratched it, and it ulcerated
and then became covered with a scab.
On admission the left anterior naris was occupied by a pear-shaped
growth which occluded the passage, and protruded slightly from the
nostril. The part protruded was rather dry and blackish, but not
ulcerated. The part within the naris was of a pinkish colour, and a
pedicle could be easily traced up to the septum nasi at the junction of
bone and cartilage. The attachment of the pedicle was small, there
was no hardness or sense of infiltration at its base. No ulceration
anywhere. The growth resembled a small cauliflower, and was freely
moveable. The man's general health was excellent. There had been
no loss of flesh, there were no enlarged glands; no history of syphilis.
The rodent ulcer was about the size of a Spanish nut, raised and hard,
its surface was covered with a scab; there was no attempt at
cicatrisation.
The growth in the nostril was removed with a pair of scissors, and
its base cauterised on June 19th; the rodent ulcer was excised on
July 10th.
Congenital Fistula of the Neck.
Mr. W. R. H. Stewart showed the case of C. G—, set. 19. First
noticed a slight enlargement over the apple of the throat five years ago,
quite in the middle line. Was then taken to a general practitioner,
who pronounced it a goitre, and after some external treatment with no
result, consulted with another general practitioner, who agreed with the
diagnosis, and decided to remove the growth. The wound did not
heal, and when seen by Mr. Stewart, in November, 1893, there
was a veritable rabbit warren of sinuses running in every direction,
and the scar tissue was bound down to the thyroid cartilage. He slit
up the sinuses and thoroughly scraped them with a sharp spoon and
freed the larynx, but could not, with the finest probe, find any further
channel. The wound not healing he dissected out the whole scar
15
tissue, following it up as far as it went. The wound healed, but some
weeks afterwards broke out again. After trying remedies such as
nitrate of silver, chromic acid, and the galvano cautery without avail
he again operated, following the new track as far as the hyoid bone.
This was once more unsuccessful, except that the new sinus was much
shorter and straighter. He was now trying the injection of a 40 gr.
solution of chloride of zinc. The first injection went into the throat,
and created a large amount of inflammation there. The second did
not reach the throat, and now there was next to nothing in the way
of a discharge, and the probe would only go about a quarter
of an inch. There was a difficulty in obtaining a correct history of
the earlier stages of the trouble, but he looked upon this as one of
those cases of congenital branchial fistula which are very rarely met
with, and still more rarely cured.
Mr. Butlin thought that the fistula had probably begun as a cyst
in connection with the lower part of the thyro-lingual duct.
Mr. Bowlby believed that as a general rule these cases were not
really benefited by operation. The difficulty of removing the whole
sinus, and the impossibility of keeping the parts at rest, led to alter¬
nate healing and breaking down, but not to cure.
Dr. Dundas Grant mentioned a recent case in which he had
obtained a successful result.
The President would avoid operative treatment if possible.
The operation in itself seemed simple, but was sometimes very
troublesome and often incomplete.
Mr. Stewart observed that the operation in the present case had
given marked relief.
Disease of Tongue (for Diagnosis).
Clinical case exhibited by Mr. C. A. Parker. E. W—, set. 8, a
schoolboy.
History .—In August last the child began to be poorly, lost his
appetite, and was languid, but improved under treatment. About this
time the mother noticed a rash on the patient's body and thighs, which
consisted of dull red spots; the largest was about as big as a pin’s
head, and it only lasted three days. Shortly after its disappearance
the child began to complain of soreness of the tongue, the surface of
which looked rough and uneven. This trouble had got steadily worse
until the present date.
Family history .—Father and mother both alive and well. The
lac-nr tts me mnmriw hit me u ^__r3. ”:m- a: ▼ mm rr“
*.;•'». Stnr.-r ir-r i::; ;:.:ttro. in,: nes^rf mu. ne:^ i-taihs-
_L_:vr me mim mu nr.r.:rr i.hi me m-ir-ms. T: msmey if
m'M.li.-i m'Uti at ;crm:iet la lcmrrnj m emer ::irm mi lie
:;u n-m miT ii: ?-ms il :::n_rmiraL ri'ma mom ma sn zc e~r?s y
ci. Tir-m Tie u: im-mr^ :r
T:e :;i: fir ♦ j >m i..-~:-t ns r.'V..
2 rz'bi: ■ i. —Tie wm^i :f me msmrur rr: imria :: lie
v.my Tie t*i a.~m mom me n,: :c m t.imrme-i
imie'iiie. mu saiimea :c f mi t i.iim-'ie'i. iitrm >: nm±r mmr
mi me rtsn ;l me -mrnie. T0-7 t tm m inn. m me mici- Timre
Tt* in bsrma mil in 3mm. mi m maiieif inm_ ici «*;me
virune-y. .a me x.c: :;ixi mert Tin me :rrr: simmer ramie*
T.m m met :c mr^c .c mii.m mr. ee-s rmi: mum. mmse in
me v.crie. Tiers Tsrt *>: me iim.m. iiri mi simiilj leiier
r ii.:.+ leieam me mm mil m me lerm Am 11 me iiimck 1 :-t
* m.i . l ime me: * me*. m i 1 ^irrsr som sm-i leiiri lie rig 11 knee.
Tiese w~Tt a i m :e me res mi :■: mms.
Tie mil »3 mitrree m r:o: rmeni realm. He iid all tie
slim* 1 : r-iet-ra-ti. tierim t m-mi.:m
_• A —
Mr. Emu ir;
T 1 T *1 01 "T-i
He mi li lim 1
Hr. 5?£5ci2 re
li:.mmi tonsil. H
at eOToral p>mls.
1 mm lie mse wi£ me of micrei.rssi. The
lie z-ui imiei i-ieime of lie eeriral lump
e r resene •: 1 eimrea ims <m to it.
‘ -ITt'Ji - —-T—* * msii C < 4 w present.
31 ire grysui as an armormal extension of the
i'leiiei mi 11 sr.m.*i te gTauuiLUy u.estrove»i
r Axgioila of Vocal Coed.
Mr. Ernest H. Crisp showed a patient art. 36, who had been
primarily inoculated with syphilis ten years ago. He was religiously
under treatment for two years, and the secondary symptoms, which
were rnild in character, entirely disappeared.
Three years after discontinuing treatment, i. e. about five years from
the primary inoculation, be complained of pain in the larynx about the
level of the left vocal cord. He was again treated constitutionally
and rapidly recovered, and had no recurrence of symptoms until on
December 30th, 1802, i. e. ten years after origin of disease, he con¬
sulted Mr. Crisp.
17
On examination the pharynx and soft palate were in a red irri¬
table condition. There was subacute laryngitis, and both cords were
deeply congested. Treatment with large doses of iodide of potas¬
sium and green iodide of mercury rapidly reduced the more acute
inflammatory processes, but both vocal cords were left congested and
showed defective movement. The voice was husky, but there was no
particular pain. Under the influence of local application the con¬
gestion of right vocal cord entirely disappeared, but no treatment up
to the present had cured the red raised condition of the left vocal
cord.
The diagnosis lay between chronic congestion and angioma of the
cord. Gould it be improved by means of the galvano-cautery ?
Mr. Cresswell Babes thought that the swelling was simply
syphilitic thickening, and that cauterisation was not called for.
Chronic Congestion op Larynx.
Dr. E. W. Bennett (Leicester) demonstrated the case of A. B—,
aet. 47, saddler. He had always lived a temperate life. There was
no history of syphilis or of tuberculosis. He became slightly hoarse
about May last, and with slight variations this had been progressive. On
examination about six weeks ago there was a general congestion of
the larynx. The anterior extremity of the right cord was thickened
and red, and there was a slight thickening of the tissue below the
level of the cord. The movements were slightly tardy, but equally so
on the two sides. This redness did not subside with the treatment
adopted. The opinion of members of the Society was invited as to
the nature of the case, and especially as to whether this slight ful¬
ness was more than could be accounted for by a catarrhal process.
The President thought that much of the impairment of move¬
ment was of a neurasthenic chaiacter. He suggested that the
patient should be taught to speak in a deeper tone than normal, a
mode of treatment often successful with boys at the period of
“ broken voice.” The congested condition was probably catarrhal.
Early Epithelioma? op the Vocal Cord.
Mr. Charters Symonds exhibited a man set. 48, who had com¬
plained of a little hoarseness at times during the last two months.
He had taught for some years in a board school, and now was an
2 *
18
inspector. In addition to this he used the voice a good deal on
Sunday. In July the larynx was examined by Dr. Warner of Wood¬
ford, who saw nothing amiss, but in September observed the condi¬
tion now present. On the left cord at the processus vocalis was a
nodular elevation with a depressed summit. It resembled pachy¬
dermia laryngis closely, but seemed to differ somewhat from this
affection in its nodularity. The colour on the whole was pale. The
cord moved freely and the voice was clear. The opposite cord was free.
The condition was either an early epithelioma or a stage of pachy¬
dermia, and Mr. Symonds had advised rest of the voice and further
observation, in the hope that it would prove to be pachydermia
laryngis, and not epithelioma. The special point in favour of the
latter diagnosis appeared to be the nodular character of the growth.
Dr. Milligan thought that the ease was either pachydermia or
epithelioma. He thought that the latter was the correct diagnosis,
and would advise thyrotomy and removal of the cord.
Dr. Spicer suggested endolaryngeal removal, and if that should
prove unsuccessful he would perform thyrotomy.
Dr. Hill observed that if the condition was pachydermia the
amount of swelling indicated long duration of the disease.
The President felt absolutely certain that the case was simply
pachydermia. A malignant growth on the inner side of the ary-
tsenoid cartilage was not compatible with such free movement. The
patient was not suffering in any way, and there could be no need to
operate unless the condition got worse. He would simply advise rest
to the voice, and a course of iodide of potassium.
Mr. Symonds intended to pursue a waiting treatment, as he did not
regard the case as malignant.
Tubercular Disease of the Larynx.
Mr. Charters Symonds also showed a man of 35, with exten¬
sive swelling of the left arytsenoid and ulceration extending down to
the cord. The noticeable features were the small amount of distress
and dysphagia, and in this particular the resemblance of the disease
to syphilis.
PROCEEDINGS
OF THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, December 12th, 1894.
Felix Semon, M.D., F.R.C.P., President, in the Chair.
E. Clifford Beale, M.B.,
Scaneb Spicer, M.D.,
Secretaries.
Present—28 Members and 4 Visitors.
The minutes of the previous meeting were read and confirmed.
The following gentlemen were elected members of the Society:
Charles Cooper Cripps, M.D., London.
A. L. Roper, M.B., Lewisham.
Henry Sharman, M.D., Hampstead.
George Mackern, M.D., Buenos Ayres.
William Jobson Home, M.B., London.
A. E. Hill-Wilson, London.
Reginald Poulter, London.
The following candidates were proposed for election:
Dr. Barclay J. Baron, Clifton.
Mr. Percy Warner, Woodford.
Dr. J. Walker Downie, Glasgow.
Double Abductor Paralysis op Uncertain Origin, associated
with Cystic Bronchocelb and Dyspncea; Operation; Im¬
provement.
Mr. A. A. Bowlby showed a patient, a man set. 60, who was
admitted into St. Bartholomew’s Hospital on March 17th, 1894, on
account of dyspnoea and bronchocele.
He said that the enlargement of the thyroid gland had existed for
about two years; that for about three months he had suffered from
first series—VOL. ii* 3
20
some difficulty in swallowing, and for a month from difficulty in
breathing. He had had several attacks of sadden and argent
dyspnoea.
Examination showed a very large thyroid cyst, situated on the left
side of the neck, and about as large as a cocoa-nut. The larynx and
trachea were a good deal displaced to the right of the middle line.
The thyroid gland was not itself hypertrophied to any appreciable*
extent. Voice not affected, except that it was not strong; swallowing
decidedly difficult and slow. Laryngoscopic examination showed
double abductor paralysis, the cords not separating in respiration
more than one eighth of an inch.
On March 22nd the cyst was removed by operation without trouble,
and the wound healed throughout by first intention. The dyspnoea
and dysphagia were immediately relieved, and three weeks later the
patient was discharged. He had one slight attack of dyspnoea a few
days afterwards, but since then had had no return of such attacks.
His breathing was now quiet, but on exertion he was “ short of
breath.” His voice was normal. There was no alteration in the
condition of the cord. Daring inspiration there was a lozenge-shaped
aperture between the anterior attachments of the cords and the vocal
processes, and a smaller and similar shaped aperture between the
vocal processes and the interarytsenoid mucous membrane.
There was no evident cause for the paralysis, and no sign of tabes
dorsalis or of any cerebral affection.
Aneurism of the Aortic Arch compressing the Left Pneumo-
GASTRIC AND RECURRENT LARYNGEAL NERVES AND THE TRACHEA,
AND ASSOCIATED WITH ABDUCTOR PARESIS OF THE RlGHT
Cord.
Mr. A. A. Bowlby showed a specimen taken from a patient,
W. S—, set. 60, sent by Dr. Furber of Oxted on November 24th,
1893.
Patient had had some difficulty in breathing for a year, but it had
not prevented him from doing his work. Four weeks before he came
to the department for diseases of the throat at St. Bartholomew's Hos¬
pital he had partially lost his voice, and since that time he had con¬
tinued to be hoarse, and his difficulty in breathing had increased.
There had been no difficulty in swallowing.
21
The patient was a very large, heavily built man of about seventeen
stone in weight. His breathing was not hurried when he was sitting
still, but he said that he could not walk without suffering from shortness
of breath. There was slight stridor.
No swelling was visible in the region of the air-passages, and the
fauces and pharynx were natural. The left vocal cord was almost
fixed in the cadaveric position, neither abduction nor adduction being
complete. The right cord was but little affected, although it was
thought that abduction was sluggish. Otherwise the larynx appeared
quite normal. No cause for the paralysis, and no evidence of either
disease of the central nervous system or of any thoracic tumour or
aneurism could be detected. As respiration was not dangerously
interfered with, no operation was advised, and the patient was not seen
again until December 8th. He was then much worse, the breathing
being very laboured and stridor well marked, with a good deal of
cough and expectoration of a considerable quantity of mucus.
The left cord was found to be completely paralysed and fixed in the
cadaveric position, while the right cord was very imperfectly abducted,
the abduction movement failing to place the cord quite as far from
the mid-line as its paralysed fellow. The dyspnoea appeared more
than could be accounted for by the deficiency of space in the larynx,
but no evidence could be detected of any pressure on the trachea.
The patient was put to bed and kept on fluid diet, with steam
inhalation and expectorants, but without real relief to the dyspnoea.
Two days later he had several severe attacks of dyspnoea which were
transient, and on December 12th, after consultation with Mr. Butlin,
tracheotomy was performed without anaesthesia.
The operation gave but slight relief, however, but it was now con¬
cluded that there must be some intra-thoracic pressure, such as had
been suspected from the beginning. Two days later the patient had an
attack of syncope, and suffered from similar attacks on subsequent days.
Death occurred suddenly from cardiac syncope on December 17th.
The post-mortem examination was made by Mr. James Berry, to
whom he was indebted for the great care with which all the affected
parts have been removed and dissected. The abdominal viscera were
normal. The right lung was oedematous and congested. The whole
aorta was dilated, and just beyond the origin of the left subclavian
artery a sacculated aneurism commenced, involving about 4 inches
of the length of the vessel. The sac itself was about 4 inches wide
22
by 24 inches broad, and extended chiefly in a backward direction and
a little to the left side. It had slightly eroded the third and fourth
dorsal vertebra, and had pushed its way between the trachea and
oesophagus, displacing the latter considerably to the left, and flattening
it. The trachea was compressed from a point about 2 inches below
the cricoid to the bifurcation of the bronchi, the seat of maximum
pressure being just behind the manubrium sterni, where the tracheal
walls were only a quarter of an inch apart.
The right pneumogastric and recurrent laryngeal nerves were found
to be quite free from all pressure, separated from the aac by an
interval of about three eighths of an inch; they lay in normal loose
connective tissue.
The left pneumogastric and recurrent laryngeal nerves lay stretched,
flattened, and adherent over the front of the sac. They had evidently
been subjected to very severe compression.
The interest of this case is mainly in the paresis of the right cord
as a sequel to pressure on the left pneumogastric nerve. The
dyspncBa was chiefly the result of tracheal compression, but the
laryngeal aperture was also certainly diminished. The aneurismal
sac did not touch any part of the thoracic parietes with the exception
of two vertebra, hence the absence of physical signs during life could
be easily understood.
Mr. de Sahti suggested that intubation might have been employed
with advantage in this case in lieu of tracheotomy.
The President observed that the case taught several lessons.
Double paralysis caused by pressure upon one vagus was very rare,
but the course of events in this case had borne out the truth of the law
as to the earlier affection of the abductor fibres. Where the source
of pressure was within the chest it was advisable not to commit
oneself to a promise of relief by tracheotomy, owing to the possi¬
bility of mechanical pressure obstructing the trachea at a lower level.
Dr. Mac keen (Buenos Ayres) mentioned a case of double abductor
paralysis in a tubercular patient, which recovered completely under
iodide of potassium and electricity.
Chronic Laryngitis.
Mr. Butlin showed the case of James D—, set. 35, regimental
bandsman (wind instrument), first seen on Nov. 30th, 1894, suffering
from aphonia. The voice, previously strong, had begun to get weak
one year and nine months previously, but fifteen months ago it became
suddenly aphonic, and had so remained.
23
The patient had syphilis, primary and secondary, five yean ago, but
‘without sore throat, and the skin showed definite signs of former
syphilitic lesions. In his throat he complained of occasional choking
sensations, and difficulty of breathing, coming on at night, about twice
a week. The disease affected the true cords, which were red and
thickened. There were several outgrowths on each cord, especially
towards the commissure. One of these which hung below the glottis
•flapped up and down during inspiration.
The question of diagnosis lay between syphilis, of which there was
a past history, tubercle, of which there was no history and no other
symptom, and multiple papilloma.
Tracheotomy Tube worn for Eleven Years.
Mr. Richard Lake exhibited a silver tracheotomy tube which had
been worn by a patient for eleven consecutive years. The outer tube
was much eroded.
Foreign Bodies in the Air-and Food-Passages.
The President showed several cases of foreign bodies removed or
•expelled from the air- and food-passages. These were—
1. A piece of holly-wood removed from the nostril of a child of four.
2. A pin removed by forceps from the arytseno-epiglottidean fold
of a boy of thirteen, where it had stuck for many months.
3. A counterfeit earring which first was lodged underneath the left
vocal cord, and afterwards penetrated into a bronchus on the left side
of the chest, whence it was expelled by coughing.
4. A blade from a tooth-forceps removed after tracheotomy from
the right main bronchus of a young woman.
5. Two halfpennies removed from the glottis of small children who
had swallowed them. (A specimen was also shown illustrating the
results of coins remaining undetected in the oesophagus.)
6. A piece of meat, with a long sharp bone attached to it, removed
from the oesophagus of an adult.
The history of all these cases, some of which had previously been
reported, were detailed.
Mr. Butlin mentioned a case of pleuro-pneumonia, following the
impaction of a foreign body, which had recently ended fatally.
Dr. Bronner observed that the rule given in the text-books did not
§
16
patient was the youngest but one of thirteen children, eight of whom are
alive. Scarlet fever, diphtheria, and measles had caused the five deaths.
After the third child mother had three miscarriages. No history of
syphilis could be obtained as occurring in either parent, and the
patient showed no signs of congenital syphilis about his teeth or eyes,
&c. There was no history of tuberculosis.
The patient’s previous history was good.
Present condition .—The whole of the posterior two thirds of the
tongue was covered with large bosses, about the size of an elongated
sixpence, the surfaces of which were flattened, uneven, and rather paler
than the rest of the tongue. They were all firm to the touch. There
was no ulceration and no discharge, and no marked pain, but some
tenderness. On the soft palate there were one or two smaller patches
with an area of congestion around them, less raised than those on
the tongue. There were some enlarged, hard, and slightly tender
glands beneath the chin and in the neck. About the buttock a few
small pigmented spots, and a larger scaly spot behind the right knee.
These were said to be the result of boils.
The child was otherwise in good general health. He had all the
signs of post-nasal adenoid vegetation.
Mr. Butlin thought that the case was one of macroglossia. The
youth of the patient, the papillated appearance of the central lump
on the tongue, and the presence of enlarged glands all pointed to it.
He did not think that any treatment was advisable at present.
Mr. Spencer regarded the growth as an abnormal extension of the
lingual tonsil. He suggested that it should be gradually destroyed
at several points.
? Angioma of Yocal Cord.
Mr. Ernest H. Crisp showed a patient set. 36, who had been
primarily inoculated with syphilis ten years ago. He was religiously
under treatment for two years, and the secondary symptoms, which
were mild in character, entirely disappeared.
Three years after discontinuing treatment, i. e. about five years from
the primary inoculation, he complained of pain in the larynx about the
level of the left vocal cord. He was again treated constitutionally
and rapidly recovered, and had no recurrence of symptoms until on
December 30th, 1892, i. e. ten years after origin of disease, he con¬
sulted Mr. Crisp.
17
On examination the pharynx and soft palate were in a red irri¬
table condition. There was subacute laryngitis, and both cords were
deeply congested. Treatment with large doses of iodide of potas¬
sium and green iodide of mercury rapidly reduced the more acute
inflammatory processes, but both vocal cords were left congested and
showed defective movement. The voice was husky, but there was no
particular pain. Under the influence of local application the con¬
gestion of right vocal cord entirely disappeared, but no treatment up
to the present had cured the red raised condition of the left vocal
cord.
The diagnosis lay between chronic congestion and angioma of the
cord. Could it be improved by means of the galvano-cautery ?
Mr. Cbesswell Babee thought that the swelling was simply
syphilitic thickening, and that cauterisation was not called for.
Chronic Congestion op Larynx.
Dr. E. W. Bennett (Leicester) demonstrated the case of A. B—,
set. 47, saddler. He had always lived a temperate life. There was
no history of syphilis or of tuberculosis. He became slightly hoarse
about May last, and with slight variations this had been progressive. On
examination about six weeks ago there was a general congestion of
the larynx. The anterior extremity of the right cord was thickened
and red, and there was a slight thickening of the tissue below the
level of the cord. The movements were slightly tardy, but equally so
on the two sides. This redness did not subside with the treatment
adopted. The opinion of members of the Society was invited as to
the nature of the case, and especially as to whether this slight ful¬
ness was more than could be accounted for by a catarrhal process.
The President thought that much of the impairment of move¬
ment was of a neurasthenic chaiacter. He suggested that the
patient should be taught to speak in a deeper tone than normal, a
mode of treatment often successful with boys at the period of
“ broken voice.” The congested condition was probably catarrhal.
Early Epithelioma? op the Vocal Cord.
Mr. Charters Symonds exhibited a man set. 48, who had com¬
plained of a little hoarseness at times during the last two months.
He had taught for some years in a board school, and now was an
2 *
18
inspector. In addition to this he used the voice a good deal on
Sunday. In July the larynx was examined by Dr. Warner of Wood¬
ford, who saw nothing amiss, but in September observed the condi¬
tion now present. On the left cord at the processus vocalis was a
nodular elevation with a depressed summit. It resembled pachy¬
dermia laryngis closely, but seemed to differ somewhat from this
affection in its nodularity. The colour on the whole was pale. The
cord moved freely and the voice was clear. The opposite cord was free.
The condition was either an early epithelioma or a stage of pachy¬
dermia, and Mr. Symonds had advised rest of the voice and further
observation, in the hope that it would prove to be pachydermia
laryngis, and not epithelioma. The special point in favour of the
latter diagnosis appeared to be the nodular character of the growth.
Dr. Milligan thought that the case was either pachydermia or
epithelioma. He thought that the latter was the correct diagnosis,
and would advise thyrotomy and removal of the cord.
Dr. Spicer suggested endolaryngeal removal, and if that should
prove unsuccessful he would perform thyrotomy.
Dr. Hill observed that if the condition was pachydermia the
amount of swelling indicated long duration of the disease.
The President felt absolutely certain that the case was simply
pachydermia. A malignant growth on the inner side of the ary¬
tenoid cartilage was not compatible with such free movement. The
patient was not suffering in any way, and there could be no need to
operate unless the condition got worse. He would simply advise rest
to the voice, and a course of iodide of potassium.
Mr. Symonds intended to pursue a waiting treatment, as he did not
regard the case as malignant.
Tubercular Disease of the Larynx.
Mr. Charters Symonds also showed a man of 35, with exten¬
sive swelling of the left arytenoid and ulceration extending down to
the cord. The noticeable features were the small amount of distress
and dysphagia, and in this particular the resemblance of the disease
to syphilis.
PKOCEEDINGS
OF THB
LA.RYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, December 12 th, 1894.
Felix Semon, M.D., F.B.C.P., President, in the Chair.
E. Clifford Beale, M.B.,
Soanes Spiceb, M.D.,
Secretaries.
Present—28 Members and 4 Visitors.
The minutes of the previous meeting were read and confirmed.
The following gentlemen were elected members of the Society:
Charles Cooper Cripps, M.D., London.
A. L. Boper, M.B., Lewisham.
Henry Sharman, M.D., Hampstead.
George Mackern, M.D., Buenos AyreB.
William Jobson Home, M.B., London.
A. E. Hill-Wilson, London.
Beginald Poulter, London.
The following candidates were proposed for election:
Dr. Barclay J. Baron, Clifton.
Mr. Percy Warner, Woodford.
Dr. J. Walker Downie, Glasgow.
Double Abductor Paralysis of Uncertain Origin, associated
with Cystic Bronchocele and Dyspncea j Operation ; Im¬
provement.
Mr. A. A. Bowlby showed a patient, a man set. 60, who was
admitted into St. Bartholomew’s Hospital on March 17th, 1894, on
account of dyspnoea and bronchocele.
He said that the enlargement of the thyroid gland had existed for
about two years; that for about three months he had suffered from
first series—VOL. II. 8
20
some difficulty in swallowing, and for a month from difficulty in
breathing. He had had several attacks of sudden and urgent
dyspnoea.
Examination showed a very large thyroid cyst, situated on the left
side of the neck, and about as large as a cocoa-nut. The larynx and
trachea were a good deal displaced to the right of the middle line.
The thyroid gland was not itself hypertrophied to any appreciable -
extent. Voice not affected, except that it was not strong; swallowing
decidedly difficult and slow. Laryngoscopic examination showed
double abductor paralysis, the cords not separating in respiration
more than one eighth of an inch.
On March 22nd the cyst was removed by operation without trouble,
and the wound healed throughout by first intention. The dyspnoea
and dysphagia were immediately relieved, and three weeks later the
patient was discharged. He had one slight attack of dyspnoea a few
days afterwards, but since then had had no return of such attacks.
His breathing was now quiet, but on exertion he was “ short of
breath.” His voice was normal. There was no alteration in the
condition of the cord. During inspiration there was a lozenge-shaped
aperture between the anterior attachments of the cords and the vocal
processes, and a smaller and similar shaped aperture between the
vocal processes and the interarytsenoid mucous membrane.
There was no evident cause for the paralysis, and no sign of tabes
dorsalis or of any cerebral affection.
Aneurism of the Aortic Arch compressing the Left Pneumo-
GASTRIC AND RECURRENT LARYNGEAL NERVES AND THE TRACHEA,
AND ASSOCIATED WITH ABDUCTOR PARESIS OF THE RlGHT
Cord.
Mr. A. A. Bowlby showed a specimen taken from a patient,
W. S—”, set. 60, sent by Dr. Furber of Oxted on November 24th,
1893.
Patient had had some difficulty in breathing for a year, but it had
not prevented him from doing his work. Four weeks before he came
to the department for diseases of the throat at St. Bartholomew’s Hos¬
pital he had partially lost his voice, and since that time he had con¬
tinued to be hoarse, and his difficulty in breathing had increased.
There had been no difficulty in swallowing.
21
The patient was a very large, heavily built man of about seventeen
stone in weight. His breathing was not harried when he was sitting
still, but he said that he could not walk without suffering from shortness
of breath. There was slight stridor.
No swelling was visible in the region of the air-passages, and the
fauces and pharynx were natural. The left vocal cord was almost
fixed in the cadaveric position, neither abduction nor adduction being
complete. The right cord was but little affected, although it was
thought that abduction was sluggish. Otherwise the larynx appeared
quite normal. No cause for the paralysis, and no evidence of either
disease of the central nervous system or of any thoracic tumour or
aneurism could be detected. As respiration was not dangerously
interfered with, no operation was advised, and the patient was not seen
again until December 8th. He was then much worse, the breathing
being very laboured and stridor well marked, with a good deal of
cough and expectoration of a considerable quantity of mucus.
The left cord was found to be completely paralysed and fixed in the
cadaveric position, while the right cord was very imperfectly abducted,
the abduction movement failing to place the cord quite as far from
the mid-line as its paralysed fellow. The dyspnoea appeared more
than could be accounted for by the deficiency of space in the larynx,
but no evidence could be detected of any pressure on the trachea.
The patient was put to bed and kept on fluid diet, with steam
inhalation and expectorants, but without real relief to the dyspnoea.
Two days later he had several severe attacks of dyspnoea which were
transient, and on December 12th, after consultation with Mr. Butlin,
tracheotomy was performed without anaesthesia.
The operation gave but slight relief, however, but it was now con¬
cluded that there must be some intra-thoracic pressure, such as had
been suspected from the beginning. Two days later the patient had an
attack of syncope, and suffered from similar attacks on subsequent days.
Death occurred suddenly from cardiac syncope on December 17th.
The post-mortem examination was made by Mr. James Berry, to
whom he was indebted for the great care with which all the affected
parts have been removed and dissected. The abdominal viscera were
normal. The right lung was oedematous and congested. The whole
aorta was dilated, and just beyond the origin of the left subclavian
artery a sacculated aneurism commenced, involving about 4 inches
of the length of the vessel. The sac itself was about 4 inches wide
22
by 24 inches broad, and extended chiefly in a backward direction and
a little to the left side. It had slightly eroded the third and fourth
dorsal vertebra, and had pushed its way between the trachea and
(esophagus, displacing the latter considerably to the left, and flattening
it. The trachea was compressed from a point about 2 inches below
the cricoid to the bifurcation of the bronchi, the seat of maximum
pressure being just behind the manubrium stemi, where the tracheal
walls were only a quarter of an inch apart.
The right pneumogastric and recurrent laryngeal nerves were found
to be quite free from all pressure, separated from the sac by an
interval of about three eighths of an inch; they lay in normal loose
connective tissue.
The left pneumogastric and recurrent laryngeal nerves lay stretched,
flattened, and adherent over the front of the sac. They had evidently
been subjected to very severe compression.
The interest of this case is mainly in the paresis of the right cord
as a sequel to pressure on the left pneumogastric nerve. The
dyspnoea was chiefly the result of tracheal compression, but the
laryngeal aperture was also certainly diminished. The aneurismal
sac did not touch any part of the thoracic parietes with the exception
of two vertebra, hence the absence of physical signs during life could
be easily understood.
Mr. de Santi suggested that intubation might have been employed
with advantage in this case in lieu of tracheotomy.
The President observed that the case taught several lessons.
Double paralysis caused by pressure upon one vagus was very rare,
but the course of events in this case had borne out the truth of the law
as to the earlier affection of the abductor fibres. Where the source
of pressure was within the chest it was advisable not to commit
oneself to a promise of relief by tracheotomy, owing to the possi¬
bility of mechanical pressure obstructing the trachea at a lower level.
Dr. Mackebn (Buenos Ayres) mentioned a case of double abductor
paralysis in a tubercular patient, which recovered completely under
iodide of potassium and electricity.
Chronic Laryngitis.
Mr. Butlin showed the case of James D—, set. 35, regimental
bandsman (wind instrument), first seen on Nov. 30th, 1894, suffering
from aphonia. The voice, previously strong, had begun to get weak
one year and nine months previously, but fifteen months ago it became
suddenly aphonic, and had so remained.
23
The patient had syphilis, primary and secondary, five years ago, bat
■without sore throat, and the skin showed definite signs of former
syphilitic lesions. In his throat he complained of occasional choking
sensations, and difficulty of breathing, coming on at night, about twice
a week. The disease affected the trae cords, which were red and
thickened. There were several outgrowths on each cord, especiaUy
towards the commissure. One of these which hung below the glottis
flapped up and down during inspiration.
The question of diagnosis lay between syphilis, of which there was
a past history, tubercle, of which there was no history and no other
symptom, and multiple papilloma.
Tracheotomy Tube worn for Eleven Years.
Mr. Richard Lake exhibited a silver tracheotomy tube which had
been worn by a patient for eleven consecutive years. The outer tube
was much eroded.
Foreign Bodies in the Air- and Food-Passages.
The President showed several cases of foreign bodies removed or
expelled from the air- and food-passages. These were—
1. A piece of holly-wood removed from the nostril of a child of four.
2. A pin removed by forceps from the arytseno-epiglottidean fold
of a boy of thirteen, where it had stuck for many months.
3. A counterfeit earring which first was lodged underneath the left
vocal cord, and afterwards penetrated into a bronchus on the left side
of the chest, whence it was expelled by coughing.
4. A blade from a tooth-forceps removed after tracheotomy from
the right main bronchus of a young woman.
5. Two halfpennies removed from the glottis of small children who
had swallowed them. (A specimen was also shown illustrating the
results of coins remaining undetected in the oesophagus.)
6. A piece of meat, with a long sharp bone attached to it, removed
from the oesophagus of an adult.
The history of all these cases, some of which had previously been
reported, were detailed.
Mr. Butlin mentioned a case of pleuro-pneumonia, following the
impaction of a foreign body, which had recently ended fatally.
Dr. Bronner observed that the rule given in the text-books did not
§
24
seem to be justified. They generally advised waiting until definite
symptoms appeared, but he thought there should be no delay after the
diagnosis was once made certain.
The President agreed that no foreign body ought to be allowed to-
remain in the air-passages, but it was sometimes better to try the
effect of complete inversion of the patient if the foreign body was
round and likely to be expelled by gravitation.
Fibrosis of the Thyroid; Partial Thyroidectomy, Tracheo¬
tomy, and Dilatation of the Stenosed Trachea.
Mr. Walter G. Spencer exhibited a patient, a pale, thin do¬
mestic servant who had always lived in London. More than seven
years ago her parents had noticed a soft swelling in the region of the
thyroid, which gradually got smaller and harder. With this decrease
difficulty in breathing came on.
Her mother had had for years a soft thyroid tumour at the junction
between the isthmus and the right lobe, which was either a flaccid cyst
or an adenoma. When she first attended as an out-patient at the
Westminster Hospital the thyroid gland appeared of normal shape
and size, but it was of stony hardness. The pulse was 130 to 140
per minute, but without exophthalmos. There was stridor, loudest in
the trachea at the level of the isthmus, but heard over the whole
chest. There were no t signs of phthisis. The stridor gradually increased,,
cyanosis became marked, and the pulse was never less than 130.
The duration of the affection and the decrease in the size of the
thyroid supported the diagnosis of calcification of a formerly enlarged
bronchocele.
On April 11th, 1894, a median incision was made down to the
isthmus. The texture of the isthmus when cut into was that of the
hardest fibrous tumour, but there was no calcification. In spite of
careful attempts no line of demarcation could be made out between
the isthmus and the trachea; therefore the isthmus and the adjacent
parts of each lateral lobe were shaved off from the trachea, leaving a
portion of the gland on either side about as large as the end joint of
the thumb. The trachea thus exposed felt like a soft tube, and was
sucked in and blown out by inspiration and expiration. The carti¬
laginous rings had softened or disappeared. As the breathing was
none the better for the removal of the isthmus, the trachea was
opened immediately below the cricoid cartilage, where the rings were
natural. On retracting its sides the lumen was seen to be narrowed
25
to a chink below, and so the trachea was incised longitudinally down¬
wards through the part which had been in contact with the thyroid
until cartilaginous rings were again reached. The mucous membrane
appeared normal, being merely thrown into folds in the narrow part.
A Parker’s silver tracheotomy tube was inserted, and the breathing
became free. After the patient had worn the tube for a fortnight
she was gradually able to discard it, so that at the end of a month
from the operation the wound in the neck had entirely closed. Six
months after the operation the girl was in better health, although still
thin; her breathing caused her no trouble, but a little stridor could
be heard in the trachea. The remainder of the gland had not altered.
The pulse was still 120 per minute.
On examination of the tissue removed a part showed, under the
microscope, thyroid alveoli in no way dilated, and containing normal
colloid matter, but the alveoli were separated from one another by an
increased amount of fibrous tissue. In the rest of the material
removed all glandular structure had been replaced by dense fibrous
tissue without any sign of sarcomatous elements or of cysts, but
showing vessels with well-marked walls.
Between these two parts the thyroid alveoli were smaller in size
and filled with epithelial cells, or clumps of epithelial cells sur¬
rounded by small cells marked the position of a former alveolus, or
lastly groups of small round cells alone were visible. The fibrosis
seemed to have spread inwards from the capsule of the gland.
The longitudinal division of the stenosed trachea might possibly
result in a persistence of the dilatation, as in the case of other stric-
tured tubes, and.the unaltered condition of the mucous membrane might
be considered as favorable to the maintenance of the dilatation. The
rapid pulse would seem to date from the time when an enlarged
bronchocele was present. It was remarkable that it should remain
26
rapid when so much of the gland had been put out of action. On the
other hand, no myxcedematous symptoms had supervened, for
doubtless there was some active thyroid tissue still left, and the stony
hardness of the gland differed widely from the soft and withered gland
in myxoedema.
The most important feature, from a surgical point of view, was the
fact that the trachea had become intimately included in the disease and
the cartilaginous rings softened, whereas the clinical and microscopical
features of the case presented no signs of malignancy.
Fibrosis or fibrous degeneration of the thyroid gland must be a very
rare disease, for no case of the kind appeared to have been yet put on
record. Ziegler alone simply mentioned the occurrence of the disease.
Fibro-sarcoma had been met with, e.g. by Mr. Bowlby (‘ Lancet,' 1884,
ii, 1001), from which this case was distinguished by the clinical course
of the disease and by the microscopical appearances of the portion
removed.
P AT? AT, Y STS OF LEFT VOCAL CORD ASSOCIATED WITH PARALYSIS OF
Soft Palate (? of Diphtheritic Origin).
Dr. Scanks Spicer showed the case of C. H—, set. 34, stableman,
who had complained of hoarseness and regurgitation of flnids through
nose on attempted swallowing since the middle of September, 1894.
Illness commenced with an “ ordinary cold.” There were no
patches or ulcers on the throat at the time, but little soreness and
pain on swallowing at first. The voice was distinctly nasal in
character, and patient had dyspnoea on exertion. Hand-grasp good
and equal on both sides. Knee-jerk, elbow reflex, and pupil reflexes
normal. Mechanical stimulation of palate felt, but no reflex con¬
traction. Laryngoscope showed left vocal cord in cadaveric position
almost entirely immobile. Nothing abnormal detected in chest. No
history of syphilis, influenza, or diphtheria to be obtained.
The patient was gradually improving under five drops of Liq.
Strychnia, large doses of iodide of potassium for some weeks having
had no effect.
Dr. Ball considered that the paralysis of the soft palate and left
vocal cord was probably diphtheritic in origin.
Dr. Hale White had seen somewhat similar conditions associated
with lead poisoning.
Dr. McBride thought it possible that some changes might have
been set up in the muscles supplied by the spinal accessory nerve.
27
Aneurism op the Aortic Arch with Paralysis op the Bight
Vocal Cord.
Dr. Scanes Spicer showed a specimen obtained from a sailor, W.
S—, set. 48, who was under treatment at St. Mary's Hospital under
the charge of Dr. David B. Lees and the reporter, for severe attacks
of spasmodic dyspnoea, hoarseness, and breast pain.
The laryngoscope disclosed paralysis of right vocal cord, while left
vocal cord remained freely moveable throughout the illness. Physical
examination of the chest showed undue prominence of right upper
chest front, dulness, and stridulous breathing.
Intubation, venesection, and injections of morphia and atropine gave
relief from time to time. The patient died from cardiac syncope of
gradual onset.
The specimen was a saccular aneurism of aortic arch involving the
second and third parts, and due to the yielding of the posterior wall
of the vessel. The left recurrent nerve appeared stretched over the
back of the sac. The tumour had displaced the lower part of the
trachea backwards and to the right, in such a way that the convexity
of the deflected trachea pressed on the right recurrent and pneumogastric
nerves. The tumour also bulged into the trachea and opened into
its lumen. The large vessels were not involved in the aneurism, as
their site of origin was anterior to that part of the wall forming the
tumour.
Ankylosis (?) op the Left Arytenoid Joint.
Mr. Symonds showed the case of Eliza P—, ®t. 56, seen at Guy's
Hospital for hoarseness in May, 1894. The condition had existed
more or less for a year, and when seen again in November it was
unchanged.
The whole of the left half of the larynx was fixed, the arytenoid
and cord showing no movement on phonation. The cord lay in the
median line, and the right moved up to it. The right arytenoid
moved up to, but did not cross the left. The line of the glottis where
the cords were in contact was oblique.
There was no evidence of destructive ulceration of the cord or
arytenoid, and no cause of pressure could be discovered in the neck or
elsewhere. The patient could swallow ordinary food with ease. A
bougie passed readily without encountering obstruction. There was
28
no sign of syphilis. The patient was stone deaf and of an excitable
temperament.
The diagnosis lay between paralysis and fixation of the arytenoid,
and Mr. Symonds inclined to the latter view on account of the
position of the arytenoid, the oblique line of the glottis, and the fact
that the moving arytenoid did not displace the immoveable one.
Dr. Peecy Kidd had seen this case at an earlier stage, and thought
the fixation of the cord was mechanical rather than paralytic, due to
ankylosis of the crico-arytsenoid joint.
Tubercular Ulceration of the Epiglottis treated by
Curetting and Lactic Acid.
Mr. Symonds exhibited a patient, Mr. E. S —, set. £9, who com¬
plained in August, 1891, of some pain in swallowing, the expectora¬
tion of much frothy mucus, alteration of voice, and nocturnal congh.
On examination the epiglottis was thickened, red, and shiny, especially
on the right side; mucus entirely concealed the laryngeal view. On
the posterior surface of the epiglottis was extensive ulceration, more
particularly on the right half and edge. The change of voice was due
to the presence of mucus only. He had lost two stone in two years,
but considered himself in good general health. There was no family
history of tubercle and no evidence of pulmonary disease.
The disease seemed so extensive that at first he was treated with
sedative powders and general remedies. In five weeks he had
improved a good deal, and had gained in weight. A better view
obtained showed that the left arytenoid was involved and the ary-
epiglottic fold.
October 31st.—The epiglottis was freely curetted and lactic acid at
once applied.
November 24th.-—The local condition was much improved; he
could swallow well and eat anything. He had been curetted four
times. All expectoration had disappeared. He had gained 9 lbs. in
the three months.
December 5th.—Some recurrence took place, giving rise to dys¬
phagia due to increased swelling of the ary-epiglottic fold. This was
scraped well and rubbed with lactic acid.
January 12th, 1892.—Both cords were well seen owing to the greater
mobility of the epiglottis, and were healthy. A small smooth swelling
remained in front of the left arytenoid. The epiglottis looked irre¬
gular and nodular from cicatricial contraction.
November, 1892.—A small grey surface appeared in the left side of
epiglottis. This was curetted off and lactic acid applied.
The treatment never interrupted the patient's business engage¬
ments. Since the last date he had continued well.
Dr. Clifford Beale referred to the occasional occurrence of
spontaneous healing of localised tubercle of the epiglottis without
any special treatment.
Mr. Butlin mentioned the case of a boy with destructive ulceration
of the epiglottis, which healed completely under the simple application
of iodoform.
Dr. McBride quoted a case of spontaneous cure, in which the
pharynx had been affected with a pale bluish cedema similar to that
seen in the larynx in tubercular cases. Lactic acid was applied, but
not very regularly, and the swelling disappeared. No bacilli were
found in the case.
Mr. Cresswell Baber referred to a case of apparently tubercular
disease of the epiglottis, and commented on the great variety in the
course taken by laryngeal tubercle in different cases.
Mr. Stmonds pointed out that in his case relief was rapid after the
conditions had remained unaltered for six weeks.
The President observed that without the presence of bacilli it was
not always possible to be sure of the tubercular nature of some cases.
Pachydermia Laryngis.
Mr. C. J. Symonds brought forward the patient shown at the last
meeting {vide ‘ Proceedings/ vol. ii, p. 17). Some change had taken
place since the previous examination, but the condition was still
characteristic of pachydermia in the opinion of the President, Dr.
Kidd, Dr. McBride, and Dr. Ball.
Dr. Bronner and Dr. Spicer advocated the removal of a sm all
piece of the projecting tissue for microscopic examination.
The President thought that the diagnosis was sufficiently clear
without the use of the microscope. Changes took place very rapidly
in these cases, and the results of microscopic examination were not
always positive, but sometimes brought confusion into a simple case.
Venous Angioma of Pharynx.
Dr. P. McBride showed a sketch taken from this case. The
patient, a young married woman with tendency to varicose veins,
$6
noticed the tumour accidentally one day on looking into her throat.
The angioma consisted of tolerably large veins, and occupied the
whole palatal margin from the uvula inclusive of the left side.
Smaller separate patches were seen on the anterior and posterior
pillars of the fauces, while a bluish tinge was communicated to the
anterior portion of the soft palate of the corresponding side.
As the tumour produced no symptoms it was not intended to apply
any treatment.
PROCEEDINGS
OF THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Annual General Meeting, January 9th, 1895.
Felix Semon, M.D., F.R.C.P., President, in the Chair.
E. Clifford Beale, M.B.,
Soanes Spicer, M.D.,
Secretaries.
Present—27 Members and 7 visitors.
The minutes of the last Annual Meeting were read and confirmed.
Dr. W. Law and Dr. George Mackern were appointed as Scruti¬
neers of the ballot for Officers and Council for the ensuing year, 1895.
The Report of the Council for the past year, 1894, was then read,
as follows:
During the past year, 1894, the Society has held the full number of
meetings, all of which have been well attended. Sixteen new members
have joined the Society, and the Council have only to report the loss
of one member by the lamented death of Dr. Ernest Jacob of Leeds.
In response to a request from the House Committee of the Royal
Medical and Chirurgical Society, the Council have entered into a new
and inclusive agreement as to rent, accommodation for the Society’s
Library, and supply of electric current through the lamps used in
the clinical examinations. An inclusive annual rent of <£31 10s. has
been agreed to.
It having been suggested by some of the country members of the
Society that a scale of compounding fees should be established in
lieu of annual subscriptions, the Council, having carefully considered
the matter, have to submit the following propositions for confirmation
by the Society:
1. That it is undesirable to establish a compounding fee for town
members at present.
2. That country members should be allowed to compound for the
sum of ten guineas (£10 10s.) on entrance, which sum should include
the entrance fee.
3. That country members who have not paid five annual subscrip¬
tions should be allowed to compound for the sum of nine guineas
(£9 9s.).
4. That these fees should entitle the compounding members to
IIR8T SERIES—VOL. II. 4
32
enjoy all the privileges at present accorded to ordinary members of
the Society.
It was then proposed, seconded, and carried unanimously—“ That
the Beport be received and adopted, and that the Recommendations
with respect to Compounding Fees be approved, and that the
Council be empowered to alter Buie 10 of the Society’s Buies in
accordance therewith.”
The Treasurer’s Beport was then presented as follows:
THE LABYNGOLOGICAL SOCIETY OF LONDON.
BALANCE-SHEET, 1894.
ExPBITDITTmB.
£ t. d.
To Rent, 20, Hanover Square 20 0 0
„ Adlard for Printing and
Postage.36 13 10
„ Corbyn and Co., Spirit
Lamps, Ac.1 18 0
„ Cheque-book,4*. 2d.; col¬
lecting two Cheques, 3d. 0 4 5
„ Petty Cash—
Dr. Spicer . £1 18 2
Dr. Beale . . 0 15 0
Attendant ..200
Water low —
Diploma of
Hon.Member-
ship ... 0 9 6
- 5 2 8
„ Balance in
Treasurer’s
hands, Jan. 1,
1896 . 38 17 5
Total . . £102 16 4
Expenditure of
the year . £102 16 4
38 17 5
£63 18 11
Audited and found correct, WALTER G. SPENCER.
January 4,1895. RICHARD LAKE.
The Beport was unanimously received and adopted.
The Report of the Librarian was read as follows:
Numerous monographs, pamphlets, periodicals, and a few books
have been received during the year. Amongst the latter are ‘Me¬
dical Essays and Lectures,’ and an ‘ Essay on Asphyxia ’ by Sir
George Johnson, presented by the Author. Additional accommoda-
Irrooxs.
£ «. d.
By Balance in hand from
1893 .. 16 13 4
„ Subscriptions—
49 members at
£1 Is.. .£51 9 0
17 members at
£2 2s.. . 85 14 0
- 87 3 0
The 17 subscriptions at
£2 2s. include 15
entrance fees and 2
subscriptions for the
coming year, 1895.
Total . . £102 16 4
33
tion has now been provided in the Library of the Royal Medical and
Chirurgical Society for the Society’s Library, and negotiations are in
progress which, it is hoped, will render the use of the Library more
available to the members of the Society.
The Report was unanimously received and adopted.
The President then called attention to the first bound volume of the
Society’s * Proceedings,’ to which a complete index had been added,
and stated that the Society’s printers, Messrs. Adlard and Son, 20,
Hanover Square, were prepared to bind any sets of * Proceedings ’
sent to them by the members, together with the new title-page and
index, in the same manner as the specimen volume exhibited.
The Scrutineers then presented the result of the ballot for Officers
and Council, as follows:
President. —Dr. Felix Semon, M.D., F.R.C.P.
Vice-Presidents. —Charters J. Symonds, M.S., F.R.C.S.; E. Cress-
well Baber, M.B.
Treasurer. —H. T. Butlin, F.R.C.S.
Librarian. —E. Clifford Beale, M.B., F.R.C.P.
Secretaries. —Scanes Spicer, M.D.; W. R. H. Stewart, F.R.C.S.Ed.
Council. —J. Dundas Grant, M.D.; Adolph Bronner, M.D.; Percy
Kidd, M.D., F.R.C.P.; J. W. Bond, M.D.; F. W, Bennett, M.D.
The President briefly returned thanks for the election of himself and
the other members of the Council.
The following recommendation of the Council was then considered,
and after some discussion agreed to:
The Council propose that a Reception should be given to the
Foreign and Provincial Laryngologists attending the Annual Meet¬
ing of the British Medical Association in London in July, 1895.
They suggest that a Conversazione should be held in the rooms of
Messrs. Erard in Marlborough Street at 10 p.m. on the night of
July 29th, and that the expenses should be borne by voluntary con¬
tributions from the members, the amount of subscription not to be
limited.
It was agreed that a small Sub-Committee should be appointed at
a later date to make arrangements for the Conversazione.
Ordinary Meeting.
The minutes of the last Ordinary Meeting were read and confirmed.
The following gentlemen were elected Members of the Society :
Mr. Percy Warner, Woodford.
Dr. Barclay Baron, Clifton.
Dr. J. Walker Downie, Glasgow.
34
Moriform Growths springing prom the Posterior Border of
the Nasal Septum.
Dr. William Hill showed this case.—C. H—, set. 40, presented
himself at St. Mary’s Hospital in July, 1894, suffering from slight
catarrh of the Eustachian tube and tympanum; he had a congenital
cleft in the hard and soft palate. On post-rhinoscopic examination
two elongated moriform tumours were observed, about the size of
broad beans, springing symmetrically from the posterior border of the
septum. As these were not large enough to cause obstruction it was
decided to watch their growth. Since that date the right one of the
two tumours had nearly doubled in size.
Growths in this situation must be comparatively rare, though the
exhibitor of this case had removed two such tumours, springing from
the same site, from a patient whose posterior nares were quite blocked
by them ; their removal by snare, scissors, and knife had proved by
no means easy. As far as Dr. Hill was aware, the only recorded case
was the one shown some time since at this Society by Dr. Dundas
Grant, in which moriform tumours sprang from the same site.
Ulcerative Disease of the Left Nasal Fossa of Undoubted
Tubercular Nature followed by Lupoid Disease of the
Left Ala.
Dr. William Hill showed this case.—E. H—, ®t. 30, sought
advice in May, 1893, for a blocked and ulcerated condition of the left
nasal fossa. There was no evidence of syphilis. The patient had been
dismissed from the army four years previously for tubercular disease
of the lung with hemorrhage, but there had been no active pulmo¬
nary disease for three years.
Granulations and exposed bone were found on the middle fossa
in the region of the uncinate body. Dr. Semon saw the case in
consultation, and whilst advocating the administration of iodide of
potassium he concurred in the view that the disease was probably
tubercular, and required energetic local treatment as well. The dia¬
gnosis was eventually confirmed by bacteriological examination. The
granulations were frequently curetted, and applications of lactic acid,
chromic acid, sulphoricinate of phenol, and trichloracetic acid were
tried, the last apparently with most benefit; a small sequestrum came
35
away, and after this the ulceration was found to be practically healed
at the end of two months, though the patient was recommended to
continue to medicate the nose daily with an alkaline douche.
When seen again on December 15th, 1894, there was an abundant
purulent discharge from the nostril and ulcers on the floor and on the
outer wall of the middle meatus, together with excoriation and
swelling of the upper lip near the anterior naris, and evidently ex¬
tending by continuity from the vestibule; in spite of appropriate
treatment the disease had extended to the ala, which at the present
time, presented a tuberculated appearance, and looked just like
lupus. The patient had recently been under the care of Mr.
Stanford Morton for purulent ophthalmia, probably caused by the
irritating nasal discharge having been conveyed accidentally to the eye.
The case was of interest, inasmuch as an undoubted tubercular disease
of the nasal mucosa had been followed after nearly two years by ex¬
tension to the cutaneous covering of the ala, and this more recent
lesion would have been unhesitatingly diagnosed as ordinary lupus had
not the course of the disease and the continuity of the lesion been
known. Ichthyol ointment was now being applied locally, but it was
proposed to scrape the affected skin.
Dr. Eddowes thought that the disease was probably lupus. He
suggested getting rid of infection by means of mercurial plasters and
ointment, and then attacking the diseased surface by the cautery,
using great care to keep the wound aseptic.
Dr. Hill still regarded the case as tubercular.
Dr. Alexander Hodgkinson (Manchester) exhibited—
1. A throat mirror for laryngoscopic purposes in which quartz
was substituted for the glass of the ordinary mirror. It was thus
rendered far more durable.
2. A magnifying laryngoscope. This consisted of a magnifying
throat mirror and an ordinary frontal reflector to which were adapted
magnifying lenses. The throat mirror consisted of a plano-convex
lens mounted in the usual way, and having the convex surface silvered
so as to constitute a concave reflector when seen through the plane face.
The magnifying power was varied by having two such mirrors with
focal lengths of eight and eleven inches respectively. The frontal
mirror, of the ordinary size and form, was fitted with four double
convex lenses, two for each eye, and capable of being used separately
36
or together, so as to allow of farther varying the amplifying power.
The focal length of each of these lenses was twenty inches. When
properly constructed for varying width of eyes it was easy to use, and
gave excellent results.
Laryngeal Stenosis ; Polypoid Growth from Left Yooal Cord,
(?) Syphilitic.
This case was shown by Dr. Percy Kidd. —William I—, set. 44,
polisher, admitted into the Brompton Hospital December 15th, 1894*,
on account of dyspnoea.
Patient had syphilis sixteen years ago, followed by a rash, and was
treated at the Middlesex Hospital for eighteen months. His tongue
has been cracked and covered with whitish patches for thirteen or
fourteen years. Hoarseness began three years ago, and he ultimately
lost his voice. For the last four months he had suffered from gradu¬
ally increasing dyspnoea with cough and slight expectoration, which
he found much difficulty in expelling. Slight haemoptysis (one
teaspoonful) occurred a fortnight ago. He stated that he had lost
much flesh.
On admission marked stridor and dyspnoea, mainly inspiratory.
Nutrition of body poor. Chest slightly hyperresonant ; breath-
sounds weak generally. Tongue showed leucoplakia and some scar¬
ring. Larynx moderately congested. Glottis represented by a mere
chink bounded by two motionless fleshy bands, which showed a kind
of fusiform swelling at their middle two thirds. Just below the
posterior third of the left band a pale pink, irregularly rounded, poly¬
poid outgrowth projected inwards, and almost touched the opposite
side of the larynx. The posterior wall was marked with numerous
coarse nodular elevations ; no definite ulceration. Sputum examined
for tubercle bacilli with negative result.
The case was regarded as one of laryngeal syphilis, and was treated
with large doses of iodide and mercury.
The stridor and dyspnoea had diminished slightly, but there had
been no change in the larynx beyond a slight decrease in the nodular
appearance of the posterior wall.
The case resembled somewhat that of C. H—, shown at the March
meeting of the Society in 1894, which proved to be syphilitic.
37
Mr. W. G. Spencer thought that thyrotomy should be performed,
as the larynx was very narrow.
Dr. Hall considered that the disease was undoubtedly syphilitic,
and that it would be best to perform tracheotomy, and to attack the
larynx with the forceps at a later stage.
The President thought that the possibility of malignant disease
should not be disregarded. There seemed to be an excessive out¬
growth for a simply syphilitic condition, but antisyphilitic treatment
should be tried.
Dr. Kidd, in reply, stated that no attempts had yet been made to
remove the growths with the forceps. He had, at first, thought that
the disease was tubercular, but now regarded it as syphilitic. He
proposed to treat the case by tracheotomy, and subsequently to try
removal of the outgrowths with the forceps.
(Edematous Swellings of the Palate and Pharynx.
Dr. Edward Law showed a patient, Mrs. S. B—, aged 62, widow,
first seen on November 20th, 1894, on account of the sudden occur¬
rence of great difficulty in respiration and deglutition, associated with
much discomfort and swelling at the back of the throat. The patient
had been under the care of Dr. Alfred Eddowes for nine months suf¬
fering from so-called Quincke's disease or acute circumscribed oedema,
a malady which had been also described as urticaria tuberosa, nodosa,
or gigans.
During childhood she was said to have suffered from one attack of
nettle-rash, and her father is reported to have been very gouty.
The patient had always enjoyed fairly good health with the ex¬
ception of occasional dyspepsia. Three years ago she lost her hus¬
band, and suffered from severe and lasting shock, but it was not until
eighteen months later that the disease began from which she now
suffered. Before the rash appeared she took chillies for indigestion,
but neither Dr. Eddowes nor the patient had been able to ascertain
that the ingestion of any particular condiment or food had any influence
in the causation of the eruption.
The patient was now practically never free from the disease. She
described the lesions as coming on with little hard isolated lumps under
the skin, which were about the size of a pea or bean and very irritable.
The redness and oedema appeared later, and were apparently accom¬
panied by a feeling of heat, tension, and smarting rather than of true
itching. No factitious urticaria could be produced by scratching.
38
although a little excessive congestion followed the irritation of the nail,
but no distinct urticarial wheals had been observed in her case, either
from the disease or from artificial excitement.
The appearance of a patch when the oedema was well established and
the redness at its height was somewhat similar to erythema nodosum,
but it differed from that affection in the history of the case and in
many other respects.
The size and shape of the patches varied greatly, sometimes involv¬
ing nearly the whole of a limb. They caused most distress when they
affected the mouth, throat, or face. Occasionally the eyelids had been
so swollen as to be completely closed for one or two days.
She had had previous attacks of a less urgent character in the
throat and mouth, with and without swelling of the lips and tongue.
The patient gave the following history on the occasion when first
seen by Dr. Law. She woke up suddenly in the early morning with
the feeling of a lump at the back of the throat, which she was unable
to dislodge by coughing or swallowing. There was great discomfort
and uneasiness, but little or no pain. She noticed, by means of a
looking-glass, that her throat was so much swollen that the uvula
was in contact with the two sides of her mouth. The difficulty in
swallowing greatly increased, and the sense of suffocation became so
oppressive that the patient was very nervous and alarmed through the
fear of impending death. This critical condition lasted for two or
three hours, when the symptoms gradually subsided and the swelling
rapidly disappeared.
On examination a few hours later an oedematous swelling of the
uvula was found with slight serous infiltration of the left half of the
palate and of the left aryepiglottic fold. The left ventricular band
appeared to be more prominent and congested than the one on the
opposite side. The neighbouring parts of the pharynx were only
slightly hypersemic, and a few enlarged follicles were visible upon the
posterior pharyngeal wall. There was increased redness of the epi¬
glottis and laryngeal mucous membrane, but the vocal cords moved
freely, and, with the exception of streaky redness, were normal in
appearance.
No active treatment was called for, as the urgent throat sym¬
ptoms had evidently already passed away. Dr. Eddowes stated
that the following internal and local remedies had been employed
with only questionable advantage:—arsenic, quinine, ichthyol, colchi-
89
cam, iron, citrate and chlorate of potash, bromide of potassium,
creoline, tincture of iodine, and solution of alum.
Brocq, Riehl, Unna, Crocker, Pringle, and others had reported
similar cases in which the tongne or mucous surfaces of the eye,
throat, or stomach were affected by the disease. Striibing had also
probably described the same disease as an angioneurotic (edema.
The President observed that these cases were excessively rare.
He had been watching a case for some time, but had never been able
to see it while the local swellings were visible. In that case the
swellings came on without warning on the soft palate, and lasted for a
few minutes or sometimes for an hour. The condition had been well
described by Striibing as angioneurotic oedema.
Dr. Hall suggested that 10 or 20 per cent, solution of cocaine
might afford temporary relief if applied to the swellings directly they
appeared.
Mr. Btttlin objected to the term “Quincke’s disease” as being
altogether unknown. These temporary oedematous swellings, when
causing obstruction to the respiration, might very well be overcome by
means of intubation.
Mr. Roper mentioned a case in which oedematous swellings of
the lips, tongue, soft palate, arms and back occurred to an old
lady of seventy-five without any warning. The swellings were of
short duration, and seemed to call for no treatment.
Dr. Law, in reply, had not been able to find any reference to
“ Quincke’s disease ” as such in any text-book, but a case was reported
in the ‘ Archiv fur Laryngologie.’
Lupus op Pharynx and Larynx.
The President showed the little girl affected with lupus of the
pharynx and larynx whom he had demonstrated at the April meeting
1894 (‘ Proceedings/ p. 103). The treatment then proposed, viz.
curetting and application of lactic acid locally with the internal
administration of cod-liver oil and arsenic, had been carried out
methodically in such a way that the local applications had been
limited to the pharynx, and the larynx had not been treated at all
locally. Nevertheless a very general improvement had taken place,
also in the condition of the larynx. The patches of lupus from the
gums, palate, and pharynx had entirely disappeared; the larynx was
much less ulcerated, though still swollen, and the previously aphonic
voice was now loud and strong. The case offered a fresh illustration
of the fact that certain cases of lupus will get better or even tempo¬
rarily well under almost any medication.
40
Dr. Hennig’s Oil Studies or Laryngeal and Nasal Disease.
The President also demonstrated Dr. Arthur Hennig* s (of Konigs-
berg) admirable studies in oil for teaching purposes of normal and
diseased conditions of the upper air-passages. These studies represented
forty illustrations very considerably enlarged from nature. It was
mentioned that the artist greatly wished that these paintings should
be reproduced for teaching purposes, but that the great cost of such
reproductions stood in the way, and that it would only be possible to
take the matter into serious consideration if a large number, at least
800 subscribers were found.
Dr. Soanes Spicer proposed a vote of thanks to Dr. Arthur
Hennig for the trouble he had taken to bring the pictures to the
notice of the Society, and expressed the opinion that they should be
reproduced if possible for teaching purposes.
Mr. Cresswell Baber seconded the resolution, which was carried
by acclamation.
At the invitation of the President, several members offered criticisms
on the drawings.
Mr. Cresswell Baber, whilst complimenting Dr. Hennig on some
of his excellent paintings, thought that the representations of the nasal
cavities as seen from the front were not satisfactory, owing to their not
showing the parts in perspective. In the drawings made and published
by him some years ago this point was specially attended to, and
therefore, in his opinion, they gave a true idea of what was actually
seen. Dr. Hennig’s drawings also did not show the neck of the middle
turbinated body.
Dr. Ball did not think that the reproduction of some of the com¬
moner affections would be worth while, especially as they were by no
means typical.
Dr. Hill pointed out that in these pictures, as in many of the text¬
books, the post-rhinoscopic image was represented in the ideal manner,
but not as it was actually seen. The upper turbinal was, as a rule,
quite invisible, while the position of the middle turbinal was quite
inaccurate.
Dr. Bronner observed that for teaching purposes a good set of
typical conditions was required.
The President undertook to convey these criticisms to the artist.
The method of reproduction proposed was chromo-lithography, but the
cost as at present estimated was almost prohibitive. It was intended by
the artist that the pictures should be made useful for teaching pur¬
poses by means of pieces of frosted glass which could be laid over the
pictures, and variations sketched upon the glass by means of coloured
chalks.
41
Radical Cobb op Obstinate Suppuration op th* Antrum op
Highmore, combined with Intra-nasal and Intra-antral
Polypi.
Dr. Scanes Spicer showed P. H —, lawyer’s clerk, set. 80. Sent
by Dr. J. Q. Bown in autumn, 1890, for foetid suppuration in the
right nasal cavity. On examination polypi were seen in region of
ostium maxillare, and were removed. Suppuration continued, and
antral empyema was diagnosed, and confirmed by transillumination.
On December 27th, 1890, the antrum was tapped through the socket
of a tooth which had been previously removed, and a gold tube fitted
to a plate by Mr. Boyd Wallis. Irrigation was practised, and there
was temporarily much improvement. After some months the tube
caused pain and irritation, and had to be several times altered, and
finally removed altogether, and purulent nasal discharge became worse
than ever. In May, 1892, patient desired to have something more
done, and he was operated on in St. Mary’s Hospital by a large
opening made with chisel and mallet through the canine fossa into the
antrum, and its cavity was well curetted, much thickened granulation
tissue being removed. Subsequently drainage apparatus was used,
lead spigots, vulcanite plugs, rubber drainage-tubes, and Ellis’s tube.
All these from time to time caused local pain, and the suppuration,
though at first less, finally relapsed to its former condition. In April,
1893, the drainage of the antrum being still deficient, patient was
advised to have a further operation, in which an attempt should be
made to render drainage better. With this view the opening in the
anterior wall was opened up and enlarged, the cavity again curetted,
and a large naso-antral opening made from inferior meatus (well behind
entrance of nasal duct) into antrum with a Krause’s trocar, the index
finger being introduced into antrum through anterior opening to act as a
guard. The antrum was flushed out with boracic lotion, and was then
tightly packed with creolin gauze, and especially so as to distend the
bucco-antral opening. After forty-eight hours the gauze was removed,
and from that time irrigation practised thrice daily. No drainage appa¬
ratus was used. The patient was directed to blow frequently from nose
through antrum to mouth, and vice versa, so as to move on any secre¬
tions tending to loiter in antral recess, and also to force boracic
lotion from mouth through antrum into nose. The result of this was
that the discharge gradually subsided, and soon ceased entirely. The
42
patient had now seen no pas for eighteen months, and at the present
time the nasal cavity looked healthy, and he coaid blow air through
the antram from mouth to nose or vice versa.
Dr. Scanes Spicer also showed the debris which he had curetted
from other cases of chronic maxillary empyema, and which were seen
to consist of fungous granulation tissue, mucus polypi, cholesteatoma-
tous cysts, and in one case a portion of necrosed ethmoid.
He advocated the adoption of the double opening into the antrum
in chronic cases in which there was reason to suspect the above
complications, in which drainage was defective, and in which drainage
apparatus caused irritation, or in which there was marked intra-nasal
disease, under which category all his cases heretofore had come, for
none of them had yielded to the simple method of alveolar puncture
and drainage-tube.
Mr. Butlin had had several such cases. He generally scraped the
antrum, but called attention to the necessity for making the opening
in the floor and not at the side of that cavity in order to ensure
perfect drainage.
Dr. Bees doubted whether such operations were necessary in every
case. They caused considerable deformity, and many cases could be
simply relieved by removal of a tooth. The large openings were
often an annoyance to patients who were smokers.
Dr. Dundas Grant had been able to cure a few cases without
operation. He thought that the extent of the operation must depend
upon the condition of the lining membrane of the antrum. He had
obtained good results in patients who possessed a good set of front
teeth by the use of Krause’s trocar.
Dr. Spicer had not tried dry treatment in these cases. In the
present case all simpler methods had already been tried and found
unsuccessful.
“ Recurrent" Tumour at the Back of the Tongue; Operation,
June, 1889.
Mr. Butlin showed this patient, whose case is described in the
'Clinical Transactions' for 1889.
The tumour stood up in front of the epiglottis; it was cut off with
a galvano-cautery loop in June, 1889. Its structure was similar to
that of the thyroid gland.
At present there was a prominent lump far back in the left half of
the tongue.
43
Hoarseness confined to the Lower Register of the Voice.
Dr. Dundas Grant showed a patient, Miss D—, set. 30, a
school teacher, who had for about three years been the subject of
hoarseness characterised by a "bleating ” or "croaking” vibration
accompanying her ordinary speaking voice and her singing in the
lower part of its range. This entirely disappeared above the note
where, when she sang softly, the change of register occurred,
and the tones became perfectly clear. On laryngoscopic examination
the vocal cords were seen to approximate imperfectly in their posterior
thirds during the utterance of the lower notes. (On subsequent more
close observation the inner portions of the cords were seen to be
thrown into loose visible vibrations.) During the emission of the
higher notes the cords appeared to act normally. Dr. Grant attri- >
buted the condition to inactivity of a portion of the internal thyro¬
arytenoid muscle. The chest was normal, and the patient, though
spare, was fairly muscular. He had recommended instruction in the
use of the breath under Mrs. Emil Behnke.
The President pointed out that the condition was one of diplo-
phonia. So long as all the elastic fibres in the cords were acting they
might act unequally, and an imperfect tone was produced; but if only
certain bundles of fibres were acting they might, within their own
range, produce a clear tone as in Dr. Grant’s case. He advised rest
to the voice, electric stimulation both inside and outside the larynx,
and a course of strychnia.
Fixation of Right Cord.
Dr. Willcocks showed a patient, R. M—, a boatman, who had
had a severe blow on nose about thirteen weeks ago, and felt as if
his backbone was broken in pieces. Eight weeks after he woke up
one night complaining of his throat. On speaking he noticed his
voice was hoarse. Since then he had got no better and no worse.
Present condition .—Right cord somewhat oblique and immoveable.
Right arytenoid cartilage prominent. No evidence of intra-thoracic
tumour. No history of syphilis.
44
Dr. Bbonxes and Mr. Stewart expressed the opinion that the case
was one of perichondritis, causing mechanical interference with the
mo.vement of the cord.
The Annual Dinner of the Society was held after the meeting at the
Cafd Royale. The President occupied the Chair, and was supported
by Sir Bussell Beynolds, President of the Boyal College of Physicians,
the President of the Pathological Society, Sir George Johnson, Senor
Manuel Garcia, Sir W. McCorinac, Dr. Ord, and a large gathering of
members and guests.
PROCEEDINGS
OP THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, February 13^, 1895.
Felix Semon, M.D., F.E.C.P., President, in the Chair.
Scanes Spicer, M.D., 7 Secretariea
W. E. H. Stewart, F.E.C.S., $ » ecretanes -
Present—23 Members and 8 visitors.
The minutes of the previous meeting were read and confirmed.
Before the usual business of the meeting, the President referred in
feeling terms to the loss laryngology had sustained by the death of
Professor Gottstein of Breslau.
Mr. Arthur Eeginald Poulter, M.R.C.S., L.R.C.P., was called to
the table, and admitted a member of the Society by the President.
The following candidates were proposed for election :
George C. Cathcart, M.B., C.M., London.
Alec H. Gordon, M.B., B.C., Loudon.
Bruce Hamilton, M.E.C.S., L.E.C.P., London.
Percy Jakins, M.E.C.S., London.
T. E. Foster Macgeagh, M.D., M.E.C.S., London.
G. Calwall Stephen, M.D., L.E.C.P., London.
The following gentlemen were nominated as a committee to carry
out the arrangements for the entertainment of the Laryngological
Section of the British Medical Association in July:—The President,
the Secretaries, Dr. St. Clair Thomson, Dr. Hill.
The President stated that the subject for discussion at the next
Ordinary Meeting was the diagnosis and treatment of empyema of the
maxillary sinus, and that an invitation would be sent to the members
of the Odontological Society, asking them to be present and to join
in the discussion.
7IR8T SERIES—VOL. II.
5
46
A Case eor Diagnosis, whether Tuberculous, Malignant, or
Syphilitic.
The President asked the opinion of the members on the following
case. J. P—, set. 55, a porter, came to the Throat Department of
St. Thomas’s Hospital on September 28th, 1894, complaining of
hoarseness, which commenced fourteen days previously, a slight
cough which came on after the hoarseness, with dryness, and a tickling
sensation in the throat, causing frequent “ hawking; ” expectoration
scanty; no blood; complains of drawing pain at left apex. Family
history good. Past history good. No history of syphilis.
Examination.—Fauces and pharynx congested. Posterior pharyn¬
geal wall granular, with distended veins and adherent secretion.
Larynx: considerable congestion of larynx, and some swelling of
ventricular bands.
November 9th.—Ventricular bands more swollen, some ulceration
of both vocal cords. Was put on iodide of potassium, grs. v, three
times a day.
December 21st.—More ulceration spreading to interarytaenoid
commissure. Patient says he feels as if he were going to be choked.
Complains of pain on swallowing.
February 8th.—Voice slightly improved; has been taking Pot.
Iodidi three months. Cough worse, and has pain in right side in
region of hyoid bone on deglutition. Larynx: ventricular bands
irregularly swollen; ulceration on posterior end on the right side.
Vocal cords: posterior end of right side considerably thickened ; left
side similar, though in a less degree. Movements free both sides.
Distinct superficial ulceration in the considerably tumefied inter-
arytsenoid fold. Chest at first normal, but on February 8th was in
the following condition. Resonance slightly impaired, but equal.
Breath-sounds, right apex, harsh, with a few rides; left apex, the
rides more numerous; breath-sounds almost inaudible over rest of
lung. No loss of flesh. No night sweats. No haemoptysis. Sputum:
no tubercle bacilli found after repeated examination.
Dr. Cresswell Baber thought it was a case of syphilis, and
inquired if large doses of iodide of potassium had been given.
Dr. Dundas Grant thought it was a case of tubercle of the dry
warty kind. Had seen a case of this sort, in which there were no
47
physical chest signs during life, but post mortem pulmonary tubercle
had been discovered. He thought there was too much movement for
epithelioma. Suggested curetting and lactic acid applications.
Dr. Percy Kidd had seen two or three cases where the disease was
situated in the angle formed by the vocal cords and aryteenoids, which
had proved to be tubercle.
Mr. Charters Symonds had one in which the vocal cords were
fringed with growths in a tuberculous case.
Dr. Hill asked if the use of tuberculin was justifiable in such a
case for the purpose of diagnosis.
The President, in reply, stated that he had used large doses of
iodide of potassium with no result. He had given up the use of
tuberculin, but considered it quite justifiable for the purpose of dia¬
gnosis, and also the removal of a portion of the growth for micro¬
scopic investigation.
Pathological Specimen of Adenoid Growths and one of
Perforation of the Nasal Septum.
Dr. Kanthack showed these specimens, and pointed out that the
growths were not in the position usually depicted in books, but were
situated on the walls of the naso-pharynx and around Luschka’s tonsil.
The President in the name of the Society expressed their indebted¬
ness to Dr. Kanthack for bringing before them such excellent patho¬
logical specimens.
Drs. Cresswell Baber and Dundas Grant suggested that if Dr.
Kanthack was able to obtain another specimen of adenoid growths,
the anterior wall should be removed so as to give a view from the
front.
Dr. Ball thought the perforation in the nasal septum was a case
of simple perforating ulcer, as the voice was not affected.
Dr. Dundas Grant suggested that frequent epistaxis was dia¬
gnostic of simple ulcer.
Dr. Tilley quoted a case where a perforation occurred without local
symptoms during an attack of typhoid fever.
Dr. Law had a case of perforation caused by the removal of a carti¬
laginous spur by means of the galvano-cautery.
Dr. Cresswell Baber frequently removed cartilaginous spurs by the
galvano-cautery, and had never seen a perforation follow; he always
attacked the apex of the spur.
Dr. Scanes Spicer had never seen perforation follow the applica¬
tion of the galvano-cautery to the spur; he thought Dr. Kanthack* s
case was one of simple ulcer from the shape.
48
Case illustrating Various Morbid Conditions op the Nose
and Ears.
Dr. E. Law showed this case. A patient, set. 26, came to the London
Throat Hospital complaining of deafness. Had suffered from ear and
eye troubles during childhood, and had contracted syphilis four years
ago. Examination showed general catarrhal conditions of the upper
air-passages—deflected nasal septum—a papillomatous-looking growth
from the anterior third of the left inferior turbinate bone, extensive
polypoid proliferation of the left middle turbinate, enlarged Luschka’s
tonsil, sequelae of otitis media superior (perforation cicatrices, &c.),
hyperostosis of external auditory meatus, eczema of both auricles, and
various affections of the eyes. Dr. Law asked if the papillomatous-
looking growth was a true papilloma, or a simple enlargement of the
anterior extremity of the turbinate.
Dr. Pegler considered this a case of papilloma.
Mr. Stewart and Dr. Cresswell Baber thought it was a simple
hypertrophic condition.
Mr. Santi, Dr. Hill, and Dr. Scanes Spicer also thought it was not
papillomatous.
Dr. Law, in reply, stated that he would remove a portion and have
it microscopically examined.
Laryngeal Stenosis, probably Lupus.
Case shown by Mr. Parker. M. D—, a girl set. 16, first suffered
from hoarseness and loss of voice a year and eight months ago, was
treated by Dr. Macdonald at the Throat Hospital, Golden Square,
and soon got quite well for the time, but has since then lost her voice
off and on. Present attack followed influenza eight weeks ago, became
steadily worse, causing complete aphonia and much dyspnoea until
February 11th. The aphonia and dyspnoea were now very marked,
there was loss of flesh and general debility.
Examination .—Distinct scars on the soft palate, and considerable loss
of substance of the epiglottis were found ; the aryepiglottidean folds
were much distorted, and covered by a number of small pale irregular
nodules. The arytsenoids, seen with great difficulty, were swollen and
oedematous. Cords and ventricular bands could not be made out; base
49
of tongue was covered with small nodules. On account of the scars on
soft palate was put on iodide of potassium; has been taking it for one
monthingr. v doses, but the condition of the partshas remained unaltered.
Family history good. No suggestion of tuberculosis or syphilis,
congenital or acquired. Lungs normal.
Mr. Sant i thought the case more like syphilis than lupus.
Mr. Milsom Rees considered it a case of lupus, and very like some
cases he had seen treated with tuberculin. .
Mr. Parker, in reply, said he would try lactic acid applications.
The President suggested that arsenic should be given internally.
Anterior Nasal Stenosis from Cicatricial Contraction after
Ulceration, with Consecutive Chronic Laryngitis.
Dr. Scanes Spicer showed a patient, Mrs. I. K—, set. 52, a
monthly nurse, who contracted "blood-poisoning” two years ago
while attending a case. She had suffered from glandular en¬
largements, rash, frontal headaches, and showed scars on arms and
legs resembling those left by rupial sores, and ulceration about
anterior nares and vestibula narium. These latter had healed, but had
been followed by such narrowing as to give rise to subjective dis¬
tress. Mouth breathing and obstinate laryngitis with thickening of
the posterior wall of the larynx. Suggestions were invited as to the
treatment of the cicatricial stenosis, which did not appear to the ex¬
hibitor to be capable of material improvement.
Mr. Stewart referred to a case he had shown at a previous meet¬
ing, where the alee of the nose were completely drawn in and the throat
was secondarily affected; had tried all sorts of forms of dilatation with¬
out success, but the patient was kept fairly comfortable by the use of
menthol. Thought Dr. Spicer’s case was one of syphilis, did not
think any operation would be successful.
Dr. Milsom Rees and Mr. Symonds thought Dr. Spicer’s case was
syphilitic, as she had nodes on legs and arms.
The President suggested iodide of potassium and mercurial in¬
unction ; he thought an operation might be successful if the stenosis
was incised, pyoktanin applied, and the wound stuffed with slips of
iodoform gauze. He drew attention to the fact that in cases of
syphilis of the upper air-passages it was peculiar that the disease
attacked intensely one part and passed quite over another.
In reply, Dr. Scanes Spicer thought that the laryngitis presented no
syphilitic characters, but was of that form seen in simple catarrhal
conditions.
50
Paralysis op the Left Vocal Cord.
This was shown by Mr. Charters Symonds. J. C—, set. 40, a
butcher sent to Guy’s Hospital by Dr. Dodwell, complaining of altera¬
tion in his voice. Up to October, 1894, resided in California; at the
commencement of that month, while still there, he “caught a cold”
and had a severe “ chill,” but does not seem to have had any cough or
even nasal catarrh. Woke up one morning with altered voice as it
is now. Had no previous hoarseness. No joint pains, though says
he has had rheumatism. No history of injury or debauch.
Family history excellent. Married with healthy family. Declares
he never had a day’s illness in his life, and now feels perfectly well.
He is a strong-looking, healthy man. Voice exactly the same as when
first noticed to be different from the normal. No dysphagia, but he
cannot drink large gulps of anything—all his fluid he is obliged to
sip. Eyesight good, pupil reflexes normal; knee-jerks normal. Can
stand perfectly with eyes shut. Chest normal. No dulness. No
dyspntea. When first seen, on January 25th, mucous membrane of
larynx healthy. No swelling anywhere. The left cord fixed and
moveable, quite on the middle line. The cord itself appeared quite
healthy. The right moved well, and was in all respects normal.
The voice is somewhat gruff, but is loud and fairly strong. There
is no evidence of perichondritis nor of intra-thoracic disease.
The case seems to be one of paralysis of the cord without a
discoverable cause. May it be an early stage of some central disease ?
Dr. Milsom Rees thought the case was one of simple rheumatic
paralysis from cold.
Dr. Scanes Spicer considered the paralysis due to intra-thoracic
trouble, as there was no abnormality in the larynx.
Mr. Symonds, in reply, stated that he had not examined the chest
himself, but would do so. It had been examined by his clinical
assistant and pronounced normal.
Paralysis op Left Vocal Cord after Injury.
This case was shown by Mr. Symonds. L. H—, set. 56, came to
Guy’s Hospital, January 11th, 1895. One week before was looking
after a steam elevator, which was above him. As he was speaking to
some one below it came down, crushing him severely about the upper
51
part of the chest. Does not think his neck was hurt. Immediately on
recovering he found his voice had disappeared. No haemorrhage. No
pain. No dysphagia. No history of syphilis, phthisis, or rheuma¬
tism.
Examination .—Left cord red and fixed on phonation, not quite in
middle line, nearer adduction than abduction. The arytaenoid did not
move at all. Nothing found in chest to account for symptoms. No
sign of external injury. Eight cord normal. On January 25th the
left cord has approached the middle line and occupied a mid position ;
is immoveable. Some dysphagia the last ten days.
February 8th.—Larynx remains the same. A full-sized bougie
passed is caught at the cricoid, evidently from muscular spasm.
The man speaks in a whisper, but can copy a low laryngeal note;
the aphonia is presumed to be nervous. No sign of aneurism or
malignant disease.
Mr. Symonds was disposed to think that the paralysis may have
existed before the injury.
The President said it was difficult to say if it was caused by the
injury, but as the position of the cord had altered at different times
he would say yes. He considered the aphonia to be neurotic.
Pachydermia Laryngis.
Mr. Symonds again showed the case of Mr. H—. The swelling on
the left cord was still present. It has gradually diminished in size ;
the nodular character has nearly all disappeared. At the present time
the swelling is more marked posteriorly, where it is abrupt and
elevated while in front it is flatter and smoother. The cord itself is
fairly normal, and the opposite side is free. The cord moves freely.
The voice is strong and clear for the most part, but at times is gruff.
The patient at first took iodide of potassium, but has for some weeks
taken mercury. No local treatment beyond rest has been employed.
Drawings illustrating the various stages, which had been made by
Dr. Waggett, were shown.
Dr. Warner said this case had more or less redness of the throat
for some time, but this had increased considerably two days ago.
Some years ago he suffered from granular pharyngitis.
Dr. Waggett suggested absolute silence as treatment, and men¬
tioned a case he had seen in conjunction with the President which
under this treatment had greatly improved; Leiter’s tubes and iodide
52
of potassium had also been used. He thought in Dr. Symonds’ case
the vocal cords had become much redder, and over an increased area.
Pachydkrmia Laryngis.
This case was shown by Dr. Tilley. Mrs. S—, set. 52, came to
the London Throat Hospital complaining of a feeling of suffocation
in the throat, more especially at night, occasional darting pain in left
ear, and hoarseness. Complaint came on twenty years ago, six months
before a confinement, and some sixteen years after coming to Eng¬
land—was born in Germany. Has been twice married; first husband
died of cancer, second husband had suffered for five years from ulcers
on the legs. Has drunk beer freely since childhood, and latterly has
taken in addition a half quartern of rum when the suffocating feelings
come on, which is pretty frequently. Had tonsils removed at Middlesex
Hospital two years ago. At London Throat Hospital some varicose
veins at the base of the tongue were burnt, and gave great relief for
two or three months.
Examination .—Yocal cord congested and thickened; outward move¬
ments limited. Shreds of dry adherent mucus in various parts of larynx.
In interarytsenoid fold is a large and well-marked swelling of somewhat
triangular outline; traversing this mass in a direction from above down¬
wards is a fissure. The points of interest are the rarity of the affection
in women; the important setiological factor of alcohol; the position
of the disease in the interarytsenoid fold; the fissure through the
growth, which probably accounted for the pain; and the slight immo¬
bility of the vocal cords, probably due to chronic inflammation.
Dr. Waggett had seen the case at the London Throat Hospital,
had painted it regularly with perchloride of iron, and the voice was
quite recovered for three weeks.
The President said these cases were extremely rare here, but very
common in Vienna, and in answer to Dr. Law attributed this fre¬
quency to beer-drinking.
Mr. Hill supposed that attrition must be present in pachydermia.
PROCEEDINGS
07 THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, March 13 th, 1895.
Felix Semon, M.D., F.R.C.P., President, in the Chair.
Soanes Spiceb, M.D.,
W. R. H. Stewart, F.R.C.S.,
| Secretaries.
Present—19 Members and 10 visitors.
The minutes of the previous meeting were read and confirmed.
The following gentlemen were elected members of the Society :
George C. Cathcart, M.B., C.M., London.
Alex. H. Gordon, M.B., B.C., London.
Bruce Hamilton, M.R.C.S., L.R.C.P., London.
Percy Jakins, M.R.C.S., London.
T. E. Foster Macgeagh, M.D., M.R.C.S., London.
G. Calwall Stephen, M.D., L.R.C.P., London.
The following candidate was proposed for election:
Arthur Sandford, M.D., M.Ch., Cork, Ireland.
Discussion on the Diagnosis and Treatment of Empyema of
the Antrum of Highmore.
The President in the name of the Society offered a cordial welcome
to the members of the Odontological Society present, and stated that,
although the diagnosis and treatment of empyema of the antrum had
of late years been frequently discussed, yet at a recent meeting of the
Laryngological Society such a difference of experience with regard
to the results of treatment and to the methods employed had become
apparent, that the Council of the Society had considered it desirable to
choose this subject for general discussion. What was required was not
any academic discussion of the whole subject of empyema of the
maxillary sinus, but brief and practical statements as to the methods
employed by various observers, and as to the final results they had
FIRST SERIES—VOL. II. 6
54
obtained, together with such points of diagnostic importance as
they had found of particular value. He invited remarks to be made
in this spirit.
Dr. Adolph Bbonneb thought that one ought to distinguish be¬
tween the mild and severe cases. The former were mostly due to
nasal disease, and could be cured by treatment through the middle or
inferior meatus, as suggested by Mikulicz. If syringing with boric
acid did not effect a cure, the insufflation of powder was to be recom¬
mended. At first boric acid and iodoform should be used, and then the
iodoform should be discontinued and aristol be used. Iodoform often
caused abnormal growth of granulation tissue. If a diseased tooth
were found, this should be removed, and the antrum opened through
the alveolus. The patient could syringe or blow in powder through a
small eustachian catheter. In cases where there was a polypus or much
granulation tissue the canine fossa should be opened and the finger
introduced, and if necessary the antrum scraped with a sharp spoon.
It was not always necessary to introduce through and keep a tube in
the alveolar process when this was opened. In answer to the President
he stated that 40 per cent, of his cases were cured, the length of time
taken being under five or six months. In answer to Dr. Spicer, he
stated that the deformities caused by a large opening in the canine
fossa were a falling in of the face, which thus did not present
a symmetrical appearance, and the growth in a wrong direction of
the teeth.
Dr. Gbeville MacDonald maintained that it was the custom to
trust for diagnosis too implicitly on the replacement of pus in the
middle meatus on bending forward the head. He had seen at least a
dozen cases, some of them associated with antrum disease, others not,
where suppuration in the frontal sinus produced the same phenomenon.
He likened the condition of the latter case to a narrow-necked bottle,
which, held in an inverted position, would not allow its contents to
escape without ocaasionally being placed on its side to allow the air to
enter. As far as treatment was concerned, and his remarks did not
refer to cases with co-existent nose disease, he believed that the explo¬
ratory opening through the alveolar border, and drainage with the
smallest size drainage-tube, were sufficient for the cure of recent cases,
t. e. of not more than six months’ duration. In those of longer exist¬
ence he had occasionally found it necessary to make the large opening
for the insertion of the finger, and after scraping away granulations, &c.,
he had always secured a cure. But in speaking of cure he would have
it undertsood that he did not mean more than the cessation of suppu¬
ration, believing that chronic catarrh frequently remained in spite of
all endeavours; and he maintained that such a catarrh would often
make it desirable that some form of drainage should be permanently
secured.
A letter was read from Dr. Cresswell Babeb, who stated that in
his opinion transillumination was a valuable aid in the diagnosis of
empyema of the antrum. He attached special importance to the
illumination of the outer half of the infra-orbital region, this being
the part least accessible to rays transmitted through the nose
and not through the antral cavity. Certainty of diagnosis could
55
only be arrived at by flushing out the antrum through the socket
of a tooth or other opening, or aspirating through the inferior nasal
meatus after the method of Moritz Schmidt. With regard to treatment,
he always tried the alveolar method, first allowing the patient to syringe
out himself with an antiseptic solution through a metallic eustachian
catheter attached to a Higginson’s syringe; and only when this method
failed to arrest discharge did he resort to a larger opening in the same
position or though the canine fossa for the purpose of exploration, and
if necessary scraping and packing the cavity.
Dr. William Hill read part of a letter from his colleague, Mr.
Ernest Lane, who had been associated with him in the treatment of
several cases of antral disease at St. Mary’s Hospital, and who was
unavoidably prevented from taking part in the discussion. Mr. Lane
wrote, “ From the experience gained, and on reviewing our cases, I
am led to the conclusion that the most appropriate and rational
method of treatment is that of opening the antrum above the alveolar
process through the canine fossa, and thoroughly clearing out the
cavity with Volckmann’s spoon or other appropriate instrument.
Bearing in mind the fact that in the majority of our cases—six out
of seven—the walls of the maxillary antrum were covered with either
soft and polypoid granulations or with genuine polypi, in addition to
caseous debris, it seems to me to be an essential point in the treat¬
ment that the antrum should be thoroughly inspected, digitally
explored, and radically treated by an adequate opening at a dependent
part of the cavity, through which efficient drainage can afterwards be
carried out.” Dr. Hill, whilst endorsing Mr. Lane’s remarks,
explained that in the cases referred to the ordinary method of
drainage and syringing, by a hole drilled through the socket of a
tooth, had been first carried out for many months, and in one case for
two years, with most unsatisfactory results. He felt certain that the
morbid contents of the antral cavities in these cases could never have
been cured by the application of any lotions or powders at present in
surgical use. It was as futile to expect such a result in the case of
antral polypi and granulomata as in the case of similar disease
in the nose and ear. Instrumental removal was the only rational
treatment. If a case with obvious antral disease associated
with nasal polypi, granulations about the uncinate body, came
under his care, and was unrelieved after two months’ treatment
by the ordinary alveolar method, he would have no hesitation in
recommending the thorough exploration of the antrum through a
large opening in the canine fossa. He believed an additional opening
in the nasal cavity, as recommended by Dr. Spicer, was often useful,
especially when the ostium maxillare was blocked by an hypertrophied
granular condition of the uncinate process. The radical operation he
advocated was devoid of danger; he had never seen any deformity
result. The oedema and pain in the cheek occasionally observed rarely
lasted more than a week or two; certainly in one patient, an early case,
the nasal duct had been slightly injured, either by a too vigorous
curetting of the nasal wall of the antrum, or else from the counter
opening into the nose having been made too far forward.
In answer to a question from the President as to the proportion
56
of cases in which the canine fossa operation had been resorted to.
Dr. Hill admitted that his experience had not been large, but that
the seven cases operated on radically had been very marked ones,
and due to nasal disease; in three others he had been content with the
alveolar method, but inasmuch as they had not long remained under
observation he could only say they were relieved. Perhaps it was
accidental that he had seen so large a proportion of cases in which the
antrum was choked by growths, and which therefore could only be
treated by a large opening; but it might be that he had failed to
attach much importance, and even failed to diagnose the milder cases
which had been described by members of the Society as yielding so
readily to applications syringed into the cavity through a small hole.
Mr. Walsham said he considered that in empyema of the antrum,
as elsewhere, the only absolute sign was the actual detection of pus
on exploration. He, however, held that transillumination was of
much value, and had practised it as a matter of routine in all cases in
which pus in the antrum was suspected. In some cases in which pus
had been detected, there had been merely a shadow below the eyelid
of the affected side, the rest of the face lighting up. In two or three
instances of what turned out subsequently to be empyema of the
antrum no pus could be discovered in the nose, the only symptom
calling attention to the affection having been intermittent fcetor, and
this in one instance was only evident to the patient himself. A
marked dulness to percussion on the affected side has been observed
in a few cases. He had practised exploration through the inferior
meatus, an empty alveolus, and the canine fossa. The first method
he considered a useful one in nervous patients, since the puncture
could be made under cocaine. As he was accustomed, however, to
drain either through an alveolus or canine fossa, he preferred as a
rule to puncture at one of these situations under gas, as the one
operation then sufficed. Of the two last methods, he only punctured
through an alveolus when a tooth was absent or carious. He would
on no account remove a sound tooth for the purpose. He gener&Uy
succeeded by merely washing out, leaving the small spiral tube in situ
during the intervals. In exceptional cases he had had to make a
larger opening through the canine fossa, introduce his finger, and scrape
out the cavity. In answer to Dr. Hill, he said the material removed
was granulation-like matter. He had not had to remove anything
like true polypi from the cavity. He had met with an instance in his
own practice where the large opening thus made had not closed, but
remained as a discharging sinus, and he had seen another case in
which such an opening had been made by a distinguished rhinologist
several years previously, which had also remained open and continued
to discharge. He wished to know the experience of others on the
subject. He had not found patients had been troubled, where the
spiral tube had been used either in an alveolus or in the canine fossa,
by food passing into the antrum. Dr. Hill said that so far from
having to complain of the hole in the canine fossa remaining patent,
the difficulty in his experience had been to prevent it healing too soon.
Dr. Greville Macdonald, on the other hand, stated that in his ex¬
perience the wound never healed.
57
Dr. Dundas Gbant agreed with Dr. Greville Macdonald that the
presence of muco-pus in the middle meatus was in itself quite insuffi¬
cient evidence on which to found a diagnosis of empyema of the antrum.
He considered transillumination of the greatest value; by its means
we could sometimes eliminate antrum empyema absolutely from
the presence of translucency, and thus prevent unnecessary operative
interference. Opacity was not of equally positive significance. He
relied chiefly on the exploratory puncture and irrigation of the
antrum by the introduction of Lichtwitz’s fine trocar and cannula
through the outer wall of the inferior meatus. The revelation of
pus by this method was very convincing to the patient, the temporary
comfort obtained inducing greater readiness to undergo further re¬
medial treatment. He had not found irrigation through the
natural orifice, as Garel had described, at all easy, even when he
employed a cannula of Garel’s own pattern. He thought it of great
importance to diagnose the cause if possible. He attributed the
disease to nasal causes in tbe absence of the characteristic dental
feetor, and of obvious dental disease, especially if the affection ap¬
peared to originate in a well-marked coryza, or there were some
other intra-nasal cause, such as a frontal sinusitis. (He had a case
of frontal sinus suppuration without at first any antral disease.
The nasal suppuration persisted in spite of the apparent cure of the
frontal condition. On re-investigating the antrum a secondary sup¬
puration of that cavity was detected, which yielded readily to
intemasal treatment by means of Krause’s trocar.) In presence
of a diseased tooth in the appropriate position, or with a history of
dental pain preceding the nasal dischage, he would ascribe the
antral empyema to dental disease. His cases had, as a rule, been
treated by the alveolar method, but some by means of a small per¬
foration in the canine fossa. Those cases seemed to have done
best in which a tube was carefully fitted by the dentist, and in which
peroxide of hydrogen was the antiseptic employed. He thought it
possible the alveolar puncture was too exclusively employed, for
although the opening was in the lowest position it was not used
for drainage, but as an orifice of entrance for the irrigating
fluid. It was a possible source of infection of the antrum by
some of the numerous bacteria inhabiting the mouth; and in those
cases in which pus did not appear at the time of the puncture, but
later on, he thought that in some instances at least this process of
infection would account for it. Alveolar puncture was not always
easy, as the antrum was sometimes very small and situated far
inwards, while the alveolar process extended far outwards. Under
such circumstances it was easily possible to miss the antrum, and he
had seen even in the hands of an experienced operator the puncture
so made that the fluid used for irrigation was extravasated into the
tissues over the antrum, causing a large painful swelling of the
cheek. The great facility with which the patient could practise irri¬
gation for himself was the crowning advantage of the alveolar
operation. He had, however, seen several cases in which, after long-
continued alveolar irrigation, a degree of improvement was obtained
which remained stationary. Rapid advance took place when there
58
was superadded the method of treatment by means of Krause's
trocar, and still more as soon as the alveolar opening was got
to close. Dr. Grant had by latter method of treatment effected
cures in two cases in a few weeks. The irrigations were practised
thrice, then only twice a week. After each irrigation, air was
blown in to dry out the cavity, and europhen or iodoform insuf¬
flated. He recommended the adoption of this method in cases in
which (1) there was no evidence of dental origin or the presence of
diseased teeth, (2) when the patient could easily attend for irriga¬
tion by skilled hands, or (3) in which the alveolar opening had
been maintained for a long time and the disease had reached a
stationary stage, before resorting to the more extensive operation
through the outer wall of the antrum. In cases where alveolar
puncture was badly borne or unsatisfactory the nasal operation
was certainly advisable.
Dr. Scanes Spices said that transillumination was in many cases
of decided value and clinched the diagnosis. Relative opacity of one
side combined with positive rhinoscopic and symptomatic evidence
afforded the strongest presumption of antral empyema, and justified ex¬
ploratory puncture. Taken alone, however, transillumination was not
conclusive, since the bones may not be bilaterally symmetrical in
thickness, or the antra in size, shape, and partitioning—circumstances
which must affect the transmission of light through the face. He
attributed more value to the comparison of the arese below the lower
lids than to the lighting up or not of the pupils, which latter phe¬
nomenon appeared to be much less common normally than the former.
On the other hand, bilaterally symmetrical opacity of cheek tissues and
non-illumination of pupils do not indicate double antral empyema,
nor do they exclude empyema of one or both cavities. In a large
number of healthy subjects such opacity is found. With reference
to the subjective perception of light on transillumination, a dull red
glow may be felt on the healthy side to contrast strongly with the
absence of such on the side of the empyema. This observation was made
for the first time, it is believed, by a former colleague when the latter
was transilluminated four years ago for antral empyema. He had nothad
a single cure on treating chronic antral empyema by the usual openings
through the alveolar ridge. He had, with the co-operation of skilled
dentists, for some time made these openings, and had had adapted to
them gold tubes fitted to artificial palates, or to small plates attached
to adjacent teeth. Such tubes (and plates), in his experience, always
caused, sooner or later, irritation, pain, and perpetuated suppuration.
The cases went on washing out for many months or years, and were
not followed by cure. He had treated all his earlier cases in this
way. It is true they were chronic cases, and had well-marked intra¬
nasal disease, polypi, granulations, necrosis, or foetid purulent rhinor-
rhoea. He had therefore been led to look about for some method of
shortening the period of treatment, and that of Dr. Robertson appeared
to meet some of the indications, in removing the membrane secreting
the pus and in providing freer drainage; but it had the disadvantage
of requiring a mechanical drain. He had therefore conceived the idea
of adding to the canine fossa opening a large one from the inferior
59
nasal meatus, well behind nasal duct, opening into the antrum with
a Krause’s trocar and cannula, so that the patient could keep the
antrum clear, after curettement, by blowing air from nose through
antrum to mouth and vice vexed constantly, and also washing antrum
out frequently by forcing antiseptic washes through from mouth.
This addition largely diminishes the tendency of the bucco-antral
opening to close, though should it do so the passage is easily restored
after cocainisation by incision and dilating forceps, and renders
abolition of drainage apparatus practicable. After curettement
suppuration diminishes pari passu with contraction of bucco-antral
opening, and often entirely ceases, leaving a small permanent potential
bucco-antral nasal fistula which gives rise to no symptoms, and is
rather to be treasured as an emergency exit for antral secretions, or
safety-valve through which the antrum can be blown out. The objec¬
tions which had been raised against this operation were its severity,
that deformity was caused, that chronic toothache followed, and that
smokers could not draw their pipes properly. As to the severity, the
temperature frequently never rose at all, and patients need not usually
be confined to their room more than a few days. In all the cases in
which he had operated by this method (now about twenty) he had
never on any occasion found any approach to either of the other objec¬
tions which had been raised, and he could only regard them as
theoretical as applied to the operation he had described. The real
objections to the operation lay in the time and patience requisite to
effect it thoroughly and without injury to nasal duct, infra-orbital
nerve, or dental nerves, and the impossibility of guaranteeing in
every case that the bucco-antral opening would not require incision
and dilation owing to growing over of soft parts too soon. These
appeared to him small inconveniences compared with the positive
advantages of measuring the period of cure of antral empyema by
weeks instead of by months or years, which was what he claimed
for it.
Dr. Ball considered the important practical point was whether any
very radical treatment should be employed at the outset, or whether
this should be deferred until simple means had failed. His own
opinion was that simple means should be tried first. An opening
should bo made in the alveolar border whenever this was possible;
otherwise in the canine fossa, and irrigation of the cavity should be
practised in the usual manner. He had followed this plan in sixteen
cases. In all these cases the opening was made in the alveolar
process. Of these sixteen cases, six had got well after a varying
number of months, and had remained well after removal of the tube
and closure of the orifice. Of the remaining ten cases, three were
abroad, and one had been lost sight of, and he could not say what
their condition was. Three declined any further interference, as they
were satisfied to keep themselves comfortable by washing out the
antrum daily. In three cases he had enlarged the alveolar opening
sufficiently to pack the cavity with iodoform gauze, and had kept it
packed for a week or two, changing the gauze daily, until the opening
had contracted so much that it was no longer easy to pack the cavity.
After that the cavity was washed out daily. Two of these cases got
60
well, the third was not in any way benefited. He therefore quite
agreed that there would always be a residuum of cases which would
require very radical treatment, aud probably in these cases Dr. Spicer’s
method would prove the most effectual.
Mr. Walter Spencer mentioned three cases of pus in the antrum
which differed widely from those upon which the discussion had taken
place, since the pus was formed in connection with acute necrosis of
the jaw. In one case he removed the alveolar process of the superior
maxilla, which had become necrosed, thus taking away the floor of the
antrum. The case was shown some time ago at the Clinical Society,
when the whole dome of the antrum could be easily seen. Another
case had been previously treated by an incision through the cheek,
and several attempts had been made to remove portions of the
maxilla. When first seen by Mr. Spencer, a most ugly puckering of
the cheek had been produced without any relief to the suppuration.
A wide alveolar opening was made, and the case soon got well. A
third case seen post mortem had died of septicaemia from acute
necrosis of the maxilla, and pus was found in the antrum and in the
spheno-maxillary fossa. All three cases were considered to be syphilitic
in origin.
The President observed that the discussion had clearly shown how
widely the experiences and opinions of various members differed in
this question, and how impossible it was as yet to draw from it any
general lessons. He must range himself decidedly by the side of
Dr. Ball in believing that the more heroic measures ought only to be
adopted after the failure of the milder means. He may perhaps have
been fortunate in his own results, but, having treated in conjunction
with Mr. England between twenty and twenty-five cases in private
practice during the last few years, in the overwhelming majority of
cases the alveolar method, with subsequent insertion of a golden tube
and washing out the antrum through that tube by means of a
Christopher Heath’s apparatus, had answered admirably. He wished,
however, to lay particular stress upon the necessity of giving most
minute directions to the patients as to the after-treatment which they
had to carry out themselves. One always was between the Scylla and
Charybdis of their doing either too little, and thereby allowing pus to
decompose in the antrum itself, or of their overdoing the washing out,
and thereby never allowing the mucous membrane to come to a con¬
dition of rest. The rules which he had adopted were as follows:—
The operation having been performed, and the tube having been
inserted, he saw the patients once again after the operation. On that
occasion he prescribed for them a weak solution of some astringent,
usually sulphate of zinc, not stronger than ten grains to the ounce, of
which solution one teaspoonful was to be added to a tumblerful of
tepid water for each injection. The patient was to sit before a mirror,
so as to be able to see the fluid come out from his nose. As soon as
the patient observed that the fluid returned clean from the nostril,
i. e. neither being turbid nor having flecks of pus mixed with the
water, he was to stop injecting immediately. This proceeding was to
be adopted at first twice daily; later on, as soon as the pus diminished,
once daily. When, after the lapse of twenty-four hours, hardly any
61
pus was evacuated on syringing, the washing out was only to be per¬
formed on alternate days; on further diminution occurring every third
day, and so on, until finally a week’s interval was reached. When,
after the lapse of a full week, on injection no pus was evacuated, the
patient was directed to make an appointment with him (the speaker)
a week afterwards, and meanwhile to leave the part quite alone. On
the occasion of the interview he (the speaker himself) washed the
antrum out, and if then no pus came out, the time had come for re¬
moving the tube. In this manner he had not merely succeeded in
curing the great majority of his patients, although amongst them
cases had been in which the disease had in all probability existed for
a great many years, but he had been able to convince himself of the
actual fact that the cure had been obtained, and he therefore warmly
recommended this method. Should it fail, as no doubt occasionally
it must if there were either necrosed bone or formation of granula¬
tions or polypi, &c., in the antrum, more energetic measures were of
course indicated. But he regretted to say that in the few cases in
which he had been compelled to!resort to a broad opening through the
canine fossa, with scraping out of the cavity and subsequent packing
with dry iodoform gauze, &c., his results had not been very satisfactory.
Mr. England showed the tube he always made for these cases fitted
to a cast of the mouth. It consisted of a plain straight gold tube,
attached to a plate which fitted to the alveolus aud round the teeth
on either side. The mouth of the tube was closed with a split plug,
which could be removed easily by the patient.
Erratum.
Dr. Pegler desires to correct an error appearing under his name
in the last report of * Proceedings ' with reference to Dr. Law's case
of nasal obstruction. He intended to imply at the time that he
disapproved of the term papilloma as applied to anterior hypertro¬
phies of the inferior turbinal, since after making a number of micro¬
scopical sections of such growths he had never succeeded in tracing
any analogy between that structure and that of a true papilloma.
6 *
PBOCEEDINGS
OF THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, April 10th, 1895.
Felix Semon, M.D., F.R.C.P., President, in the Chair.
Scanes Spicer, M.D.,
W. R. H. Stewart, F.R.C.S.,
Secretaries.
Present—29 members and 4 visitors.
The minutes of the previous meeting were read and confirmed.
The following gentleman was elected a member of the Society :
Arthur Sandford, M.D., M.Ch., Cork, Ireland.
The following candidate was proposed for election :
David Moore Lindsay, L.R.C.P., L.R.C.S.I., Salt Lake City, TJ.S.A.
Dr. Foster Macgeagh and Dr. A. Knyvett Gordon were called to
the table, and having signed the Register were admitted members of
the Society by the President.
Papilloma of the Nose.
Mr. Cresswell Baber showed this case. Rev. —, set. 36, first
noticed a growth in his left nostril two years ago. In August, 1894,
it was removed by another surgeon, and pronounced after micro¬
scopic examination to be a papilloma. It grew from the floor of the
nose, and was entirely removed, the left ala being slit up for the
purpose. Two months after the operation it appeared again as a
small papilla on the floor of the nose. Condition when seen on March
7th, 1895, was as follows:—In the left nasal cavitv there is a firm
mainmillated growth, like a small mulberry, projecting into the ves¬
tibule, and extending backwards about three quarters of an inch.
FIRST SERIES—VOL. II. 7
It is attached by a broad base to the floor of the nasal cavity and to
the septum. Just behind the tumour is a deflection of the septum,
through which there is a clear-cut perforation about one eighth of
an inch in diameter. Eight nasal cavity normal except that it shows
the concavity of the deflection and the perforation. By posterior
rhinoscopy (with palate hook) the parts are found normal excepting
a slight swelling on the left side of the septum, probably unconnected
with the growth. There are no enlarged glands. There is no history
N of syphilis. A small piece from the upper part of the growth was
removed for microscopical examination with the cold snare, but it
proved so firm that the screw of the snare had to be brought into
requisition. The microscopic examination showed only hyperplasia
of structure, and no malignant elements. The patient has a flat wart
on his head, which he is in the habit of picking, and it has been sug¬
gested that the nasal cavity may have been directly inoculated by
means of the finger.
Mr. Babes wished to have the opinion of the members with regard
to the nature of a further operation.
Mr. Butlin advised the free excision of the growth, and the de¬
struction of the remains with the galvano-cautery. He considered
the growth extremely active for an innocent one.
Case of Lupus of the Throat and Nose.
This case was shown by Dr. J. B. Ball. Emma K—, set. 14, was
admitted to the West London Hospital on March 5th, 1895, suffering
from hoarseness and laryngeal dyspnoea. She first complained of
her throat about eighteen months previously, and had attended at a
London hospital for some months, when she was told that she was
suffering from lupus of the palate. Has had no treatment during
the last nine months. Has suffered from obstruction and crusting in
the nose for some months. Two months previous to admission had a
sore patch on the left side of the neck. The hoarseness commenced
about the end of December, 1894, and for two or three weeks pre¬
vious to admission the breathing had been noisy, especially at night.
Patient was a fairly healthy-looking girl, though rather thin. No
history of phthisis. The voice was husky, and there was well-marked
laryngeal stridor and slight cough ; no pain or dysphagia. There was
some enlargement of the glands under the angles of the jaw, especially
65
on the right side. On the left side of the neck, a little below the ear,
was a patch of lupoid ulceration about the size of a florin, covered
with crust. The gums were normal. The whole of the anterior
aspect of the soft palate presented a coarsely granular surface, with
here and there some fine cicatricial striae. The granular appearance
extended forward on to the hard palate for a little distance. The
pillars of the fauces, especially the right, were thickened, and studded
with fine granules. Epiglottis appeared to be partially eaten away;
it was thickened, and its free edge presented some large pale nodules.
The aryepiglottic folds and arytsenoids were swollen and pale. The
ventricular bands thickened, slightly nodular, especially the left, and
the edges of the cords, which were just visible, seemed uneven. On
deep respiration the cords were not freely abducted. Both nostrils
were blocked with crusts. On removal of these an ulcerated surface
was exposed, occupying both sides of the septum nasi, extending from
a little above the columna for about three quarters of an inch, and
involving the floor of the nose and the fore-part of the inferior tur¬
binated body on each side. About half an inch above the columna
there was a small perforation through the septum. Chest normal.
Patient has been in the hospital since March 5th, and has taken cod-
liver oil and arsenic. The ulcerated patch on the neck has been
scraped, and has cicatrised. The nose has also been scraped, and is
much improved. The laryngeal dyspnoea has quite disappeared,
apparently owing to a diminution of the nodular thickening of the
ventricular bands, and there is a freer mobility of the vocal cords.
The general condition of the throat is improved.
In view of the apparent improvement, and of good results obtained
in a similar case recently exhibited by the President, under the admin¬
istration of cod-liver oil and arsenic, it is intended for the present
not to apply any active local treatment to the throat.
Mr. C. Symonds inquired if thyroid extract had been given, as he had
seen cases in which remarkable results had followed its administra¬
tion.
In reply, Dr. Ball stated that he had not yet used the extract, as
the case was doing so well without it.
66
A Case ok Nasal Deformity of Traumatic Origin.
Shown by Dr. J. B. Ball. May M— , set. 15, a healthy-looking
girl, came to the West London Hospital with a view to having an
operation done to improve the appearance of her nose. When
four and a half years old she had received a violent blow on the
nose with the fist. The nose bled very much, the under part was
severed from the face, and it was a long time before the parts
were healed. At present the nose is broad and flattened, the nasal
bones being depressed and spread out. There is a transverse groove
across the nose at the line of junction of the nasal bones and lateral
cartilages. The plane of the anterior nares is directed somewhat
forwards. The anterior part of the septal cartilage is destroyed, as
well as a portion of the columna, only a stump of the latter remaining
in front and behind. There is a communication running from the
anterior part of the floor of the nose into the mouth, between the
upper lip and the alveolar process.
The general appearance of the parts rather suggests some destructive
disease, such as syphilis, as the cause, but the history of a traumatic
origin is very definite, and there is nothing in the family or personal
history to indicate syphilis. My colleague, Mr. Keetley, proposes to
operate, and the case is shown partly on account of the peculiar defor¬
mity of traumatic origin, and partly with a view of eliciting sugges¬
tions as to the best means of remedying the deformity.
Mr. Knyvett Gordon showed—
1. A section of a middle turbinate body with polypus formation.
Though there was no dead bone to be seen or felt in the nose, and
no operation had been performed n that situation, yet there was,
microscopically, well-marked caries of the bone, as shown by the
destruction of tissue with well-marked small-celled infiltration and
numerous osteoclasts.
Dr. Hill thought the specimen was exactly like that described by
Woakes.
Mr. Symonds asked how the specimen differed from normal bone.
He could see some change at the edge of the specimen, but none in
the bone itself.
Dr. S. Spicer said that clinically this was a case of ordinary polypus;
was he to infer that ordinary polypi lead to absorption of bone ?
Mr. Gordon, in reply to Dr. William Hill, stated that he was in¬
clined to regard cases such as this as an early stage of Dr. WOakes’s
“ cleavage.”
67
In reply to Mr. Charters Symonds, he said that the presence and
position of the osteoclasts with the small-celled infiltration had led
Him to the diagnosis of caries.
2. Sections of masses curetted from the antrum maxillare in cases
of empyema, by Dr. Scanes Spicer.
These showed marked proliferation of the mucous glands in the
lining membrane, the epithelium of which was in a state of active
secretion. The proliferation was so great as almost to justify him in
describing the growth as an adenoma.
Empyema op Antrum entirely cured by Treatment by means
op Krause’s Trocar.
Shown by Dr. Dundas Grant. Diagnosis was made by means of
transillumination and Lichtwitz’s exploratory irrigation in June, 1894,
while under care of Dr. Wallis Ord for epileptic fits. The nasal dis¬
charge and obstruction had existed for some years.
A perforation was made through alveolus on July 9th, when fluid
came through the nose, but pain and swelling occurred in the cheek.
It was later determined to try intra-nasal treatment only.,
Krause’s trocar was used in September, and through it the antrum
was washed out twice or thrice a week with sanitas lotion. In a few
weeks the discharge had completely stopped, and has not since
returned. Since the improvement in the condition of his nose the
epileptic fits have almost entirely disappeared, though of course he has
not left off his regular bromide.
Empyema op the Antrum of Highmore, complicated with
Suppuration op (probably) the Frontal Sinus.
Shown by Dr. Dundas Grant. A young Scotchman, who for
about two and a half years had a foetid nasal discharge on the left side,
and had suffered a good deal of treatment at various hands, came to
me in October last.
Empyema of the antrum was diagnosed by means of transillumina¬
tion and Lichtwitz’s trocar. Krause’s trocar treatment was instituted
and some relief afforded, but still more when the alveolar perforation
63
was made and daily irrigation practised. The discharge fluctuated in
amount to an unusual degree, and it was observed that after washing out
the antrum with apparent completeness a return of discharge occurred
within a few minutes. On inspection this could be seen to spring
from the upper part of the semilunar hiatus, and more could be
washed out by means of Hartmann’s frontal sinus tube. Puncture of
the bulla ethmoidalis revealed no ethmoidal pus. I have recommended
external opening of the left frontal sinus, but the patient is unwilling
to submit to it.
Case of Empyema of the Antrum under Treatment by means
of Krause’s Trocar.
Shown by Dr. Dundas Grant. A young married woman, suffer¬
ing from nasal suppuration of old standing.
Her antrum was opened through the alveolus of an extracted tooth
two years ago, and she practised irrigation with soda solution, followed
by the injection of a little peroxide of hydrogen. Irrigation was to
be practised twice or thrice a week, and in seven months she seemed
well, the condition remaining apparently stationary till five months
ago. She returned to me about two months ago.
Krause’s trocar was ntroduced about five weeks ago; the antrum
was freely washed out and inflated, so as to blow out the remaining
moisture, and europhen was insufflated through the cannula.
Great diminution in the amount of discharge has taken place, and
she can get on comfortably with much less frequent irrigation, though
at present she is unable to go for a week without it.
Case of Empyema of the Antrum greatly benefited by the Use
of Krause’s Trocar and Cannula, and Closure of the
Alveolar Perforation.
Shown by Dr. Dundas Grant. A gentleman aet. 55, who first
suffered from nasal discharge about 1884. Numerous polypoid growths
were removed from time to time down to 1894.
Autral empyema was diagnosed in February, 1894, and alveolar
irrigation was carried on up till the last two months, when no further
improvement seemed to accrue.
69
In October, 1894, Krause’s trocar was used, and irrigation followed
by drying and insufflation of antiseptic powders (of which europhen
was found to be the best) was continued at gradually increasing
intervals. Alveolar irrigation was gradually left off, and the dis¬
charge diminished. The alveolar opening was allowed to close in
February of this year, and still greater improvement took place.
He left town five weeks ago, and omitted all treatment, the nasal
condition causing hardly any inconvenience. He has just returned,
but on irrigation fetid muco-pus could be evacuated.
Empyema of the Antrum secondary to Suppuration in the
Frontal Sinus treated by means of Krause’s Trocar with
Good .Result.
Shown by Dr. Dondas Grant. Referred to him by Dr. Graham
Grant in July, 1892, on account of pain in left front region and dis¬
charge of fetid pus from the left nostril. Antral disease was excluded
by means of transillumination and Lichtwitz’s puncture.
A small external opening was made in February, 1893, and pus
revealed. Drainage and irrigation were practised with very slight
improvement. The anterior part of middle turbinal was removed, but
even then the discharge persisted in spite of apparent improvement of
the condition of the frontal sinus.
The sinus was widely opened by means of gouge-forceps in June,
1894, and the granulating lining was thoroughly scraped. The
nasal discharge continuing, the antrum was again examined, and proved
to be the seat of an empyema. In a few weeks the suppuration
entirely disappeared under treatment by means of Krause’s trocar.
A Case of Tubercular Laryngitis.
Previously shown at an early meeting of the Society by Dr.
Dundas Grant. The ulceration was on the former occasion almost
entirely confined to the region of the right vocal process, and
may be remembered as presenting, on a mass of pale granulations at
that point, a white spot where the galvano-cautery had been applied.
Since that time the patient has been residing in Jersey, his voice has
got more hoarse again, and his cough more frequent. Tubercle
70
bacilli have been detected (though formerly absent) but no pulmonary
lesion can be demonstrated. The granulations in the region specified
have become more exuberant, and there has developed a shallow longi¬
tudinal fissure just below the edge of the opposite (left) vocal cord.
The laryngeal symptoms are diminishing, and the local signs
becoming less marked under almost daily application of pure lactic
acid.
The President said he had been asked how long his cases treated
by the simple methods lasted. He would say, taking them in the
broadest sense, an average of three or four months. He had a letter
for Dr. Brady about one case which had gone to Australia, and which
had lasted between one and two months.
Dr. Hall suggested that in this case the pure air of the sea voyage
had operated beneficially.
Mr. C. Symonds said that as it was presumed the good effect in
these cases was due to drainage, he did not see that the meatal
opening was superior to the alveolar.
Dr. Ball thought the advantages of Krause’s trocar depended on
whether it was better to use the dry treatment with powder once a
week, or fluid daily.
Dr. Law asked if europhen was more efficacious than iodoform.
Dr. Grant, in reply, said he had been led to try the meatal plan on a
patient who had a beautiful set of teeth, and would not agree to the
alveolar operation. Also many cases operated on by the alveolar
method became stationary, and one case improved greatly when the
alveolar opening closed. He also thought it was possible for infection
to spread through the opening. He would suggest it, too, as an
alternative method of treatment. He had not given iodoform such a
trial as he had europhen, but it was much better than any of the
substitutes for iodoform, and had not the distinctive odour.
A Case of Mycosis Fungoides.
Shown by Dr. de Havilland Hall. A man set. 52, suffering from
mycosis fungoides. The disease had existed for about two years and
a half. There are numerous tumours all over the body and limbs.
In October, 1894, he complained of sore throat, and has had more
or less pain in the throat since, but the speech has not been affected.
On the posterior and lateral walls of the pharynx there are small oval
tumours, and on the left arytsenoid cartilage there is a tumour about
the size of a hazel-nut; the surface is superficially ulcerated. This is
thought to be the first case in which the larynx has been attacked by
mycosis fungoides.
PLATE I.
Proc. Laryng. Soe. Vol. II.
Wist % Ke*vrnan, chi'
Dr. de Havilland Hall: Case of Mycosis Fungoides.
(See page 70.)
71
The President suggested, and it was agreed to by the Society, that
as Dr. Hall’s case was unique, a drawing of it should be made for
insertion in the ‘ Proceedings,’ and Dr. Waggett was asked to
make it.
Disease op the Frontal, Ethmoidal, and Maxillary Sinuses in
Association with Nasal Polypi.
Dr. William Hill showed a patient, A. K—, set. 34, who
recently sought his advice at St. Mary’s Hospital for pain in the nose
and chronic headache. Nasal polypi had been removed fifteen years
before. She suffered from a profuse purulent discharge, and the left
nostril was blocked with mucous polypi ; these were removed, and pus
was then seen issuing from under the anterior extremity of the left
middle turbinal, which was enlarged and bulbous ; this end of the
turbinal was cut off, and an ounce and a half of pus immediately came
away, giving the patient instant relief. Granulations could then be
seen and diseased bone felt in the neighbourhood of the ethmoidal
cells. The left frontal sinus was tender on percussion, and the skin
over it was red, and at times puffy; the left maxillary sinus was dark
when tested by transillumination.
Whilst the amount of discharge in the neighbourhood of the hiatus
semilunaris was not now abundant, a profuse flow of matter was con¬
stantly to be seen coming down between the middle turbinal and
septum from the superior meatus, presumably from the posterior
ethmoidal cells. The middle turbinal was very enlarged, but not
cystic, and Dr. Hill thought that nothing short of removal of
this bone would relieve the ethmoidal disease which was the prominent
factor in the case. He was also prepared to open the frontal sinus by
a vertical incision, and the antrum through the canine fossa. He
hoped to show the patient again later.
Epithelioma op the Pharynx.
Dr. William Hill also showed a man, set. 44, who consulted him
at St. Mary’s Hospital a week previously complaining of pain in the
throat rendering swallowing difficult, and a shooting pain in the ear.
On laryngoscopic examination an ulcer was seen in the right glosso-
72
epiglottic fossa, extending into the pyriform fossa; the right pos¬
terior pillar and the right side of the epiglottis were cedematous, the
edges of the ulcer were hard and prominent to the touch; there were
some tender and slightly enlarged glands on the right side of the
neck at the level of the hyoid bone. There was no history or
indication of syphilis. The patient had the day before been digit¬
ally examined by students at the College examinations, and the
pharynx was much swollen and cedematous in consequence, and less
typical in appearance. It was proposed to perform pharyngotomy, and
endeavour to remove the growth and the enlarged glands. Mr.
Pepper has recommended and offered to carry out this treatment.
Microscopical Specimens illustrating Case of Multiple
Papillomata of Larynx.
Shown by Dr. Hunt. C. W—, set. 12, was operated on by Mr.
Paul at the Liverpool Royal Infirmary on September 28th, 1893,
when a large growth, which had so completely obstructed the larynx
as to demand tracheotomy two months previously, was removed by
thyrotomy (see Liverpool ‘Med.-Chir. Journal/ January, 1894).
This growth was described by Mr. Paul as having "all the micro¬
scopic characters which point to the least malignant form of spindle-
celled sarcoma, without allowing any question that it is a genuine
sarcoma, and not a simple benign growth.”
Six months afterwards I made a laryngoscopic examination of the
patient, as his breathing was again becoming difficult, and recurrence
was feared. I then found the cavity of the larynx filled by two pale
warty-looking growths, springing from the left ventricular band, evi¬
dently pedunculated, and freely moveable with the breath current. A
third growth of a similar character was situated on the posterior
surface of the left arytsenoid. These growths were easily removed by
means of Schroetter’s forceps, and on microscopic examination were
found to present the characters of simple papilloma.
During the past year I have on many occasions removed similar
growths from this patient’s larynx, originating from the vocal cords,
the ventricular bands, and the ary epiglottic folds, but so far there
has been no recurrence of the original growth which sprung from the
under surface of the left cord.
73
The President asked if anyone had seen a similar case in which
the usual order of events had been transposed, and papillomata had
followed sarcoma.
Mr. Btjtlin had never seen such a case.
Dr. Hunt, in reply, stated that there was no real recurrence, and that
the papillomata were situated on a different site though close to the
former scar.
Laryngeal Stenosis ; Polypoid Growth from Left Vocal
Cord.
Case shown at the January meeting, 1895, by Dr. Percy Kidd.
After tracheotomy had been performed, the growth on the left side
and portions of the fleshy swollen vocal cords were removed with
Mackenzie’s cutting forceps. Much increase of the glottic space was
obtained, the tracheotomy wound was allowed to close, and, for a
time, the patient experienced considerable relief.
Microscopical examination of the tumour revealed a well-marked
papillomatous structure, with slight, small-celled infiltration of the
submucosa, but no appearances of tuberculosis.
Early in March the patient’s general condition began to deteriorate,
the chief symptoms being progressive weakness, loss of flesh, moderate
remittent pyrexia, and pain on swallowing.
The laryngoscope now showed swelling over both arytsenoid carti¬
lages, with some ulceration over the right. Examination of the chest
gave no constant results. The sputum was examined seven times
with a negative result, but a week ago tubercle bacilli were detected
on two occasions. The physical signs now indicate infiltration of the
apices of both lungs.
Present condition of the larynxEpiglottis swollen on right side.
Much pale tumefaction over both arytsenoid cartilages, with sloughy
ulceration of the superior and laryngeal surface of the right. Both
vocal cords of pale pink colour, and irregularly thickened. At the
posterior end of the right cord is a small sessile reddish outgrowth
Vocal cords motionless, lying close together and causing considerable
stenosis of the glottis.
74
Case of Empyema op the Anircm op Highuore.
Dr. Scanes Spicer showed this case.
The President congratulated Dr. Spicer on the improved condition
of the patient, he having since the operation fourteen days previously
gained 11 lbs. The result of treatment in these cases by the members
of the Society was most gratifying.
A Case in which a very Large and Hard Fibro-papilloma op
the Larynx has caused Indentation of thb Opposite
Vocal Cord.
Shown by The President. The patient is a man aged about
40, who two years ago began to suffer from hoarseness, soon followed
by dyspnoea and complete loss of voice. The difficulty of breathing
became so great that tracheotomy had to be performed. Laryngo-
scopic examination showed an enormous tumour growing from the
left side of the larynx, the exact origin of which could at that time not
be made out, and completely filling the vocal organ. A fear was ex¬
pressed that this might be malignant, and external operation had
already been contemplated, when Dr. Johnson Smith, of Greenwich,
sent the patient to Dr. Semon. The intra-laryngeal removal and sub¬
sequent microscopic examination (Mr. Shattock) of some fragments,
however, showed that the tumour was of benign character, and it has
in the course of several sittings been reduced to its present size, which
is about that of a large bean. The interesting feature of the case is
the fact that the right vocal cord is deeply eroded, corresponding to
the pressure which the growth in its original size exercised upon it.
Mr. Symonds asked whether the opposing vocal cord in this case
was absorbed or eroded.
The President stated that he could not say at present, as the time
since the growth was removed was too short. It was quite possible,
however, that absorption had taken place.
Suppuration of Frontal Sinus.
Mr. Symonds showed this case. Rev. J. E— consulted me on
November 1st, 1892, for a foul discharge from the left nostril of seven
years* duration. The left upper first molar had been removed just
75
after the discharge began. For six years he had been under treat¬
ment for what was described to him as “ necrosing ethmoiditis,” and
had been cauterised regularly, but without relief. Three years ago a
little discharge appeared on the right side, and this was also cauterised.
The case was obviously one of empyema of the antrum, probably
bilateral. Through the alveolus the left antrum was perforated, and
much thick, foul pus forced through the nose. The nasal opening
of the antrum was evidently small, and, on examining the nose, the
middle turbinated was adherent to the outer wall, and the whole
middle meatus blocked with adhesions, the result of the cautery.
After removing the anterior end of the middle turbinated the stream
came freely. Granulations still remained in the nose, and some
pus escaped. In February, 1893, the right antrum was drained through
the incisor fossa j much foul pus was found. In May this side
was well, and the tube removed. Though little if any pus came
through the nose when the antrum was syringed, pus, sometimes
blood-stained, was always visible high up. In December, 1894, bare
bone could be felt amongst easily bleeding granulations. These were
curetted. The diagnosis now was suppuration in the ethmoidal or
frontal sinuses, or both.
January 21st, 1895, he called with swelling in the centre of the fore¬
head, evidently suppuration. A week later (January 28th) I incised
in the median line over the centre of the fluctuating area, and let out
a good deal of foul pus. A large opening in the frontal bone to the
left of the median line led into the frontal sinus. All nasal discharge
had ceased while the pus was collecting; a curved probe was easily
passed into the nose. A piece of gum-elastic bougie was passed into
the nose and retained. Later, a small silver cannula of a length to just
enter the sinus was inserted, and through this the bougie was passed.
The sinus was daily irrigated with boric acid, and later sanitas.
When shown to the Society rather less than three months from the
opening of the abscess the discharge was mucus only, no pus escaped
from the nose, no granulations were visible, and the bare bone felt by
a probe passed through the nose into the sinus no longer existed.
The left antrum for a long time gave no pus, the tube being retained
as a precaution only.
Remarks .—The site at which the spontaneous opening formed seems
the best at which to open the sinus, i. e. just to the left of the median
line, and half an inch above the level of the eyebrow. From here a
76
drain can easily be passed into the nose, and retained by means of a
projecting lip. This, covered with a piece of plaster, is by no means
disfiguring. I think it much superior to the opening at the inner
corner of the eye, through which it is difficult to pass a probe or
drain into the nose, and I would suggest this site as the appropriate
one for making the external opening. When both sides are involved,
a median opening, either a long one or with a flap, will be best. The
long period covered by treatment in this case was partly due to
the neglect of the irrigation of the left antrum. The rigid tube at
first employed gave much pain when introduced, but so soon as the
wire one was substituted this inconvenience disappeared, and the
antrum rapidly became healthy.
PROCEEDINGS
OF THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, May 8th, 1895.
Felix Semon, M.D., F.E.C.P., President, in the Chair.
Scanes Spicer, M.D.,
W. E. H. Stewart, F.E.C.S.,
| Secretaries.
Present—31 members and 3 visitors.
The minutes of the previous meeting were read and confirmed.
The following gentleman was elected a member of the Society:
Mr. David Moore Lindsay, L.E.C.P. and L.E.C.S.I., Salt Lake
City, U.S.A.
The following candidate was proposed for election :
Mr. George Vincent Fourquemin, London.
Dr. C. Couper Cripps, Dr. G. Caldwell Stephen, and Mr. Bruce
Hamilton were called to the table, and having signed the Eegister,
were admitted members of the Society by the President.
Occlusion op Eight Posterior Naris.
Shown by Dr. J. B. Ball. F. H—, set. 21, has had obstruction
of the right nasal passage as long as she can remember. She has
always been troubled with frequent discharge of mucus from right
nostril. A probe passed through the right nostril is arrested at the
region of the posterior cavity by a hard, resisting structure apparently
bony. There is no passage whatever for air through the right nostril,
either with inspiratory or expiratory effort. By anterior rhinoscopy the
right nasal passage is seen to contain a quantity of clear, viscid mucus.
There is a slight deviation to the left of the anterior part of the
septum near the floor. By posterior rhinoscopy the left choana
FIRST SERIES—VOL. II. 8
78
appears larger than normal, the distance of the posterior margin of
the septum from the left Eustachian tube being greater than from the
right tube. The right choana is completely occluded by a smooth
reddish structure which joins the septum, not at its posterior margin
but a little anterior to this, there being a distinct depression along
the line of junction. To the finger the occluding structure feels firm
and resisting. This patient was seen by me some six and a half years
ago, when the condition and appearances were the same as now. The
occlusion is no doubt congenital. Operative treatment was declined
on the former occasion, but the patient is now inclined to have some¬
thing done.
Mr. Cresswell Baber thought this was a case of congenital occlu¬
sion like a case he had shown to the Society. He had pushed through
the obstruction and dilated under an an»sthetic; no tube was worn
afterwards.
Dr. Dundas Grant had a case he had treated by perforating with a
trocar and introducing a vulcanite tube, which, in answer to Mr. C.
Symonds, he stated the patient had to wear from time to time.
Mr. C. Symonds had a case in which the edge of the septum touched
the outer wall. He had sawn out a portion with a Bosworth’s saw.
Paralysis of Eight Vocal Cord.
Shown by Dr. J. B. Ball. M. A—, set 18, came under ob¬
servation at the West London Hospital in October, 1894. He com¬
plained of some weakness of the voice which had existed for about
three months. On laryngoscopic examination the right vocal cord
was found to be fixed in the position of complete paralysis, although
there was some slight movement of the right arytaenoid on phonation.
He had no cough, and repeated examination of the chest at this time
failed to discover any definite physical signs, and there was nothing
in the case to point to the cause of the paralysis. He was next seen
towards the end of December, when he had some cough, and then
there was found to be some impairment in the percussion note at the
right apex, front and back, and some crackling r&les in the same
region. His cough has left him for the last two months and he has
gained in weight, but the breath-sounds are weak at the right apex
and there is some dulness on the right supraspinous fossa together
with some crepitant rales in deep inspiration. The diseased process at
79
the right apex, which is probably tubercular, gives a clue to the cause
of the paralysis of the right recurrent laryngeal nerve, but the para¬
lysis of the right vocal cord was in this case the first sign of disease
to be discovered.
Dr. Clifford Beale had some doubt whether the paralysis could
fairly be put down to the presence of apical disease. Cases of uni¬
lateral paralysis of one cord were by no means uncommon where no
pleural or pulmonary disease existed, and as no pathological cause
could be found for them they were generally classed as “ functional.”
Cases of adhesion of the pleura at the right apex were, on the other
hand, exceedingly common, but seldom produced paralysis.
Case of Large Mass of Malignant Glands in the Neck, with
Paralysis of the Corresponding Sympathetic Nerve, and
Immobility of the same side of the Larynx.
Shown by Mr. Butlin. An engine driver, 56 years old, who four
months ago had noticed a lump on the left side of the neck. About
the same time he had begun to experience slight difficulty in
At the present time he had a large mass of apparently malignant
glands in the neck, extending from the clavicle up to the level of the
hyoid bone. His voice was very hoarse, and he could only swallow
solids with difficulty. The left side of the larynx was completely
fixed, but healthy in appearance.
There were typical signs of paralysis of the cervical sympathetic,
narrowing of the palpebral fissure, contraction of the pupil, absence of
sweating on the corresponding side of the head and face. There was
no reddening of the left side of the face and ear, which were a little
paler generally than the corresponding parts on the right side.
Mr. Butlin believed the primary affection to be malignant disease
of the left side of the oesophagus very high up, and not producing so
much stricture as it does when the disease is lower down. He had
reported an almost precisely similar case in the * St. Bartholomew’s
Hospital Eeports,’ vol. xxix, p. 103, 1893. In that case there was
scarcely any suspicion of malignant disease of the oesophagus until it
was found after death. Yet there was a very large mass of glands in
the neck, which had produced paralysis of the cervical sympathetic
nerve, and immobility of the same side of the larynx.
Mr. C. Symonds stated that he had asked Mr. Butlin whether it was
not a case of malignant disease of the thyroid, as there was a large
nodule on the right side, and Mr. Butlin had replied that he had a
80
similar case previously, which he thought had been disease of the
thyroid, but that, post-mortem, carcinoma of the oesophagus was
found.
Case of Paralysis of the Bight Vocal Cord of Uncertain
Origin.
Shown by Mr. Butlin. A woman, 28 years of age, a cook, who
was suffering from chronic enlargement of the tonsils, and complete
paralysis of the right vocal cord, which was in a position midway be¬
tween adduction and abduction.
In the middle of January of the present year she had been attacked
suddenly by a very severe cough. In March the cough ceased, and
she lost her voice quite suddenly.
The exhibitor had expected, from the history of the case, to find
* functional aphonia/ and was surprised to discover immobility of the
vocal cord. The cause of the condition had been diligently sought for,
but thus far without success. There was no history or appearance of
catarrh (the larynx was perfectly healthy in appearance). No sym¬
ptoms of disease of the brain or spinal cord. No tubercular or specific
history. No history of injury.
No improvement took place during her stay in the hospital, except
that her voice improved, and became almost of normal strength.
Dr. S. Spicer considered that as the paralysis was unilateral, func¬
tional paresis was excluded.
Case of Laryngeal Stenosis.
Shown by Dr. Dundas Grant. F. P —, set. 28, was admitted on
the 31st January, 1895, complaining of inability to breathe, except
through the tracheotomy tube he was wearing in September, 1894.
He had been sitting up ten days convalescent from typhoid fever,
when he complained of a sore throat. Difficulty of breathing set in
three or four days later, and tracheotomy was performed.
Condition of the larynx on admission .— Vocal cords considerably
obscured by the swelling existing around each arytanoid were swollen
and red. The cartilages were more or less fixed and immobile, the
right one completely so. There was a rounded inflammatory swelling
at the posterior part of the right vocal cord, merging into the inter-
81
arytenoid fold, which was much swollen. Perichondritis was pro¬
visionally diagnosed. A later examination showed granulations at the
posterior extremities of the vocal cords, and evidence of web formation
in the anterior commissure.
On the 4t.h February, after removing some valve-like portions
of tissue projecting into the tracheotomy wound, dilatation of the
stenosed glottis was attempted by introducing an india-rubber conical
dilator through a special tube introduced upwards into the wound.
On February 7th a laminaria tent was introduced from the tracheo¬
tomy wound, and left for some hours in the glottis.
By these means the breathing aperture was enlarged, so that by
the 11th February some amount of breathing could be performed
through it.
On the 11th March, after recovery from an attack of influenza,
complicated with pneumonia, the web formation was divided with a
Whistler's knife, and the smallest intubation tube passed in. The next
day a larger one was used ; the breathing was distinctly improved, but
the effect was not sufficient to justify the postponement of operation.
On the 17th the larynx was opened. The tracheotomy wound was
enlarged three inches upwards in the middle line. All the soft parts
over the thyroid cartilage were found to be matted together, and the
latter was with difficulty exposed. Some granulation tissue was scraped
away from the posterior wall of the larynx and bare cartilage was felt,
but whether cricoid or left arytaenoid was uncertain. The original
opening in the trachea was also enlarged, granulations were scraped
away, and the finger introduced in both directions found plenty of room.
The breathing was much improved. The parts were then transfixed
with silver wire and brought together.
A tracheotomy tube with an upward limb was introduced, but the
patient could not tolerate it.
On April 8th, the glottic chink was so much more patent that the
tube was taken out during the daytime, and the hole plastered over.
May 6th, introduced a dilator. Patient has passed a whole night
with wound closed, but still wears tube during a portion of the day.
§
82
Case op Syphilitic Perichondritis op the Larynx.
Shown by Dr. William Hill. A female, set. 34, who had applied
at St. Mary’s Hospital a week before, suffering from sore throat and
loss of voice. There was a clear history of syphilis, and on exami¬
nation the swollen and congested ventricular bands were seen to meet
on the middle line, except for a short distance posteriorly, where a little
of the right cord could be observed fixed and ulcerated; the right
arytenoid region was swollen, and pus could be seen issuing from an
ulcerated surface on the pharyngeal aspect of this region; the larynx
was distinctly tender on pressure. Under iodide of potassium the
local condition had slightly improved.
Specimen of Pachydermia Syphilitica Dippusa.
Shown by Drs. A. A. Kanthack and W. Jobson Horne. The
larynx with portions of tongue and trachea attached was sent by
Dr. Engelbach to the Pathological Department at St. Bartholomew’s
Hospital, with a note that it had been removed from a woman,
aged 20 (married—one child—no miscarriage), who kept a brothel,
and who for two years and a half had suffered from a very bad throat.
In December of 1894 she had extreme dyspnoea, and died suddenly
before tracheotomy could be performed.
The glottis was much narrowed. The epiglottis was entirely de¬
stroyed. The surface of the root of the tongue and of the interior of
the larynx and trachea was studded with closely-set papillomatous-like
excrescences.
Vertical sections were made through the anterior end of the right
ventricular band, through the posterior parts of the ary epiglottic
folds, and horizontal sections were made through the trachea.
Under the microscope there was found no loss of substance, nor
destruction of epithelium, but the sections showed a thickening and
heaping up of the epithelium together with a metaplasia of the cells
from the cylindrical to the squamous variety, even in the trachea.
Immediately beneath the epithelium there was an abundant small
round cell proliferation, which extended into the deeper parts, and
cells were found scattered between the muscle fibres. In places where
83
the cells were more closely packed, retrogressive changes had com¬
menced.
Dr. Clifford Beale observed that confusion was likely to arise
if such cases were to be indiscriminately classed as “ pachydermia,”
as the lesions both in form and situation differed absolutely from
that which was usually described under that name.
Mr. C. Symonds thought the case looked more like diffuse syphilitic
ulceration rather than pachydermia.
Case of Tubercular Ulceration of Nose and Pharynx.
Shown by Mr. C. A. Parker. P. McC— came to the hospital
about February 7th, 1894, complaining of stoppage in nose of two
to three years* duration, and was found to have hypertrophy of his
inferior turbinate bone, which was removed on the right side with
the cold snare.
Two or three days afterwards there was some epistaxis. About two
weeks after the operation, ulceration was found to be present over the
turbinate bone. This was at first treated by simple means, but it
spread steadily and made its appearance on the pharynx.
Some little time later it was curetted, and painted with lactic acid
frequently, and was improving rapidly towards the end of the year, at
which time—in October—he went into the country. After his return,
he attended at the Brompton Hospital for Diseases of the Chest.
In March, 1895, his weight was 8 st. 84 lbs.; on May 7th, 8 st. 3 lbs.
Examination of Chest .—In April, 1894, marked flattening of left
apex anteriorly with diminished movement and impaired percussion
note. Vocal resonance and fremitus were both 4-. Bronchial
breathing with numerous moist crepitations.
Night sweats occurred, but not much expectoration.
May 4th, 1895, examined again. But slight impairment of note.
Respiration jerky ; expiration prolonged, with tendency to hollowness.
No crepitations could be heard. Vocal resonance and fremitus
slightly -f.
Dr. Clifford Beale commented on the comparative rarity of
tubercular lesions in the nose and the importance of their early recog¬
nition and treatment by lactic acid. The corresponding lesions on the
tongue and soft palate were more often recognised in their early stages,
and were quite amenable to such treatment.
84
Microscopical Sections Illustrating thb Histology op
Turbinal Hyperplasias.
Shown by Dr. Pkglrr. The sections largely corroborated the
views put forth by Wingrave, in a paper read before the last meeting
of the British Medical Association at Bristol. Dr. Pegler had, how¬
ever, been led to take a somewhat simpler view of the morbid changes,
so far as his observation had gone, since, in every specimen examined,
he had found mucoid degeneration in greater or less degree, and in no
instance a true hypertrophic condition of the sinus walls. This applied
to growths taken from any point along the free border of the inferior
turbinate, from the middle turbinate, and from the septum. Special
attention was directed in section (1)—(normal inferior turbinate)—to
the walls of the sinuses, constituted by strands of visceral muscle-fibre
crossing in all directions, and interlaced with bands of the wavy areolar
tissue of the part. No. 2 was taken from a typical " anterior hyper¬
trophy " of the inferior turbinate, the external contour of which was
deeply convoluted, showing long finger-like processes in the section.
This character was probably answerable for the fact of “ papilloma ”
being commonly applied to such growths, but instead of a dense
coating of stratified epithelium (altered by irritation ?) with a thin line
of vessels included, we had here a primary vascular outgrowth in a
mucoid matrix, put forth apparently from the main body, and bordered
by delicate ciliated epithelium. Attention was next called to the
mucoid degeneration of areolar tissue, conspicuous in the lymphoid
and general submucous area of the growth. Comparing carefully
with the normal, it would be seen that this change had conspicuously
attacked the walls of the venous sinuses, the mucoid thinning out of
the areolar element throwing into prominence the muscular constituent,
and creating an appearance of actual muscular hypertrophy. Sections
3 and 4 showed what were probably later stages of the pathological
process (apparently progressive in character), the muscular trabeculae
themselves disappearing, till a mere rim surrounding some of the spaces
remained. Wingrave believed that dilatation followed this atrophic
stage, and proposed the term turbinal varix to designate it, but he also
recognised a hypertrophic condition of the sinus walls in other cases.
The remaining sections were from polypoid hypertrophies of the middle
85
turbinate, and wall of the septum. The septal growths were mucoid,
and oedematous in the dependent portions, but contained numerous
glands and sinuses towards the pedicle. This was evidently the struc¬
ture of most septal proliferations, true papillomata being quite rare.
Mr. Chabtebs Symonds had not sufficient experience in these
cases to criticise.
Dr. Bronner considered them most interesting.
Dr. S. Spicer thought we ought to get rid of the name hypertrophic
rhinitis, and call the condition by some more suitable one.
Dr. Pegler in reply stated that his observations were strictly
limited to the sections he had shown, and though he had not as yet
met with what appeared to him to constitute true tissue proliferation
or hypertrophy of the sinus walls, he did not deny the existence of
those conditions. He might have to alter his views; there were many
sources of fallacy, and much still remained to be worked out.
Case of Fistula in the Neck.
Shown by Mr. W. R. H. Stewart. C. G—, set. 19, was shown at
the January meeting of the Society. He had been operated on several
times, and when shown the sinus was nearly healed. It was quite
healed a few days afterwards. Owing to adverse criticism as to whether
an operation in this case was justifiable, Mr. Stewart brought the
case again forward to show that it was possible to cure these cases by
operation. In answer to Dr. Hill, Mr. Stewart stated that the dissec¬
tion was carried back to the foramen caecum.
Specimens of Polypi from the Antrum.
Mr. Symonds showed several polypoid masses, some of them three-
quarters and half inch long, which he had removed from the right
maxillary sinus. The patient, a woman set. 25, had the right second
bicuspid extracted for pain. There was no discharge from the nose.
Soon after this a swelling projected through the socket, and was re¬
moved ; a second soon followed. When first seen by Mr. Symonds,
two pear-shaped gelatinous masses projected from the socket for¬
merly occupied by the tooth. That these were not connected with
the gum was shown by the fact that a probe could be passed all
round them, and entered the antrum. The anterior wall of the
86
antrum wa s removed, and the poljrpi which were attached to the inner
and posterior wall were removed by a sharp spoon. The largest measared
about seven eighths of an inch in length. They were all attached about
the same site and projected downwards. The aperture in the alveolus
was much enlarged, and the polypi which projected through the opening
were paler in colour and bad a denser covering.
Large Nasal Polypus prom a patient aged eighty-seven.
Shown by Mr. C. Stmonds. This was a large mass with a portion
of the middle turbinated, that had been removed by the cold snare.
It is composed of many pendulous masses, and when removed was in
outline as large as the palm of the hand. The walls of the nasal cavity
had been much absorbed.
A Post-nasal Sarcoma.
Shown by Mr. C. Stmonds.
Case or Pachydermia Laryngls.
Shown bv Mr. C. Stmonds. This case was that of Mr. H—, exhi-
bited on several previous occasions.
The mass had nearly disappeared, so that the original view of the
case has been confirmed. For three weeks the patient has resumed
his duties as a schoolmaster, and during this time the greatest change
has taken place for the better.
Case or Laryngeal Disease.
Shown by Dr. Herbert Tilley. S. E—, male set. 49. “ Com¬
plains of hoarseness and sore throat.” Patient had syphilis about ten
years ago, and was treated for it. About eighteen months after con¬
tracting the disease, he began to complain of his throat. It has been
getting worse and worse, and he applied to the hospital early in
February last, when he was at once put on anti-syphilitic treatment.
At first he improved, complained of less pain and easier breathing,
but recently he has remained in statu quo.
87
There is no history of phthisis in family. There is a history of
haemoptysis when he was eighteen years of age. Recently he has been
getting weaker. Altogether the history of phthisis is very indefinite,
and the only physical signs in the lungs are those pointing to slight
consolidation in the left apex.
There is a prominent granulation in the arytsenoid space on left side.
Left processus vocalis swollen. Over position of right vocal cord is a
swollen mass of tissue which looks something like a large granu¬
lation. There is no fixation of the vocal processes beyond that due
to inflammatory thickening. There is considerable laryngeal stenosis.
Dr. Tilley was inclined to consider it a case of syphilis.
Dr. Spiceb and Mr. Stewart considered it a case of tubercle.
Dr. Brunker thought it was syphilitic, and recommended mercurial
inunctions.
Dr. Tilley stated that Mr. Butlin had suggested that it might
possibly be malignant.
INDEX
PAGE
Abductor paralysis (double) of uncertain origin (A. A. Bowlby) . . 19
-paresis: aneurism of the aortic arch compressing the left pneumo-
gastric and recurrent laryngeal nerves and the trachea, associated with
abductor paresis of the right cord (A. A. Bowlby) . . 20
Adenoid growths: pathological specimen (A. A. Kanthack, M.D.) . 47
Adenoma of tongue (E. Cresswell Baber) • . . .1
Air-passages: foreign bodies in air*passages (Felix Semon, M.D.) . 23
Ala: see Nose.
Aneurism of the aortic arch compressing the left pneumogastric and recur¬
rent laryngeal nerves and the trachea (A. A. Bowlby) . . 20
-with paralysis of right vocal cord (Scanes Spicer,
M.D.) ••••••• 27
Angioma : ? angioma of vocal cord (Ernest H. Crisp) . . .16
-(venous) of pharynx (P. McBride, M.D.) . . .29
Ankylosis (?) of the left arytsenoid joint (Charters J. Symonds) • • 27
Annual General Meeting, Jan. 9th, 1895 . . . .31
Antrum: radical cure of obstinate suppuration of antrum of Highmore
(Scanes Spicer, M.D.) .....
discussion on the diagnosis and treatment of empyema of the
41
antrum of Highmore
-remarks by Felix Semon, M.D.
-Adolph Bronner, M.D.
Greville MacDonald, M.D.
communication from E. Cresswell Baber
-J. Ernest Lane
remarks by William Hill, M.D.
-W. J. Walsham
-J. Dundas Grant, M.D.
-Scanes Spicer, M.D. .
-J. B. Ball, M.D.
-W. G. Spencer
exhibition of tube by W. J. England
53-61
53,60
54
54
54
55
55
56
57
58
59
60
61
— sections of masses curetted from antrum maxillare in cases of em¬
pyema (Knyvett Gordon) . . .
empyema of antrum under treatment by means of Krause’s trocar
67
(J. Dundas Grant)
and cannula (J. Dundas Grant, M.D.)
empyema of antrum of Highmore (Scanes Spicer, M.D.)
specimens of polypi from antrum (Charters J. Symonds)
67, 68, 69
. 68
. 74
. 85
FIRST SERIES—VOL. II.
9
TAGB
00
Aorta: aneurism of the aortic arch coin*.'resins: the left pneuniogastric
and recurrent larynjcul^ierves and the trachea (A. A. Bowlhy) . 20
-with paralysis of the right vocal cord (Scanes
Spicer, M.D.) . . . . . .27
Arytienoid joint: ankylosis (?) of left arytamoid joint (Charters J.
SyuioiuU) . . . . • .27
Baber (K. Cresswell), adenoma of toiiL'ue ....
-communication (in absence) to discussion on the diagnosis and
treatment of empyema of the antrum of Highmore
- papilloma of the nose .
Balance-sheet, 1894 ......
Ball (J. B., M.D.), discussion on the diagnosis and treatment of empyema
o! the antrum of Highmore .
-case of lupus of the throat and nose .
-a case of nasal deformity of traumatic origin .
- occlusion of right posterior naris .
-paralysis of right vocal cord .
Bennett (F. \\\), immobility of the left vocal cord
-chronic congestion of lary nx .
Bowlby (A. A.), swelling of left side of larynx, with paralysis and
atrophy of left half of tongue and soft palate, and perichondritis
-tubercular disease of soft palate, larynx, pharynx, and lungs
-double abductor paralysis of uncertain origin, associated with
cystic bronchocele and dyspnoea; operation ; improvement .
-aneurism of the aortic arch compressing the left pneumogastric
and recurrent laryngeal nerves and the trachea, and associated with
abductor paresis of the right cord .
Breathing: case of lymphadenoma with obstructed breathing (James
Donelan, M.B.) ......
Bronchocele: cystic bronchocele and dyspnoea associated with double
abductor paralysis of uncertain origin (A. A. Bowlby)
Bronnbr (Adolph, M.D.), cystic fibroma of the left vocal cord .
-epithelioma of the epiglottis .
-pachydermia with perichondritis .
-discussion on the diagnosis and treatment of empyema of the
antrum of Highmore
Butlin (Henry T.), chronic lary ngitis .
-“ recurrent ” tumour at the back of the tongue ; operation, June,
1889 . . .
-case of large mass of malignant glands in the neck, with paralysis
of the corresponding sympathetic nerve and immobility of the same
side of the larynx ......
-case of paralysis of the right vocal cord of uncertain origin
1
54
63
32
59
64
66
77
78
3
17
9
11
19
20
13
19
4
4
12
54
22
42
79
80
Cannula: Krause’s cannula in treatment of empyema of antrum (J. Dundas
Grant, M.D.) . . . . . .68
Council: report of Council, 1894 . . . . .31
--list of Officers and Council. . . . .33
Crisp (Ernest H.), ? angioma of vocal cord . . . .16
Curetting and lactic acid in treatment of tubercular ulceration of epiglottis
(Charters J. Symonds) .
28
91
PAGE
Diphtheria: supposed diphtheritic origin of paralysis of left vocal cord
associated with paralysis of soft palate (Scanes Spicer, M.D.) . 26
Donelan (James, M.B.), case of lymphadenoma with obstructed breathing 13
Dyspnoea: double abductor paralysis of uncertain origin associated with
cystic bronchocele and dyspnoea (A. A. Bowlby) . . .19
Ears: morbid conditions (E. Law, M.D.) . . . .48
Empyema : discussion on diagnosis and treatment of empyema of antrum
-Adolph Bronner, M.D. . . .54
-Greville MacDonald, M.D. . . .54
-communication from E. Cresswell Baber . . 54
-J. Ernest Lane . . . .55
-remarks by William Hill, M.D. . . .55
-W. J. Walsh am . . . .56
-J. Dundas Grant, M.D. . . .57
-Scanes Spicer, M.D. . . .58
-J. B. Ball, M.D. . . . .59
-W. G. Spencer . . . .60
-exhibition of tube by W. J. England . . .61
— sections of masses curetted from antrum maxillare in cases of
empyema (Knyvett Gordon) . . . . .67
Dundas Grant, M.D.) .... 67,68,69
-- and cannula (J. Dundas Grant, M.D.) . . 68
- of antrum of Highmore (Scanes Spicer, M.D.) . . , 74
-radical cure (Scanes Spicer, M.D.) . . 41
--complicated with suppuration of (probably) the
frontal sinus (J. Dundas Grant, M.D.) . . .67
England (W. J.), exhibition of gold tube attached to plate used in treat¬
ment of cases of empyema of the antrum of Highmore . . 61
Epiglottis: epithelioma of the epiglottis (Adolph Bronner, M.D.) . 4
- tubercular ulceration of epiglottis treated by curetting and lactic
acid (Charters J. Symonds) . . . . .28
Epithelioma of the epiglottis (Adolph Bronner, M.D.) . . 4
-of the pharynx (William Hill, M.D.) . . .71
- early epithelioma? of the vocal cord (Charters J. Symonds) . 17
Fibroma : cystic fibroma of the left vocal cord (Adolph Bronner, M.D.) . 4
Fibro-papilloma of larynx causing indentation of opposite vocal cord (Felix
Semon, M.D.) . . . . . .74
Fibrosis of the thyroid (Walter G. Spencer) . . .24
Fistula in the neck (W. R. H. Stewart) . . . .85
-congenital (W. R. H. Stewart) . . .14
Fixation of right vocal cord (F. Willcocks, M.D.) . . .43
Food-passages : foreign bodies in food-passages (Felix Semon, M.D.) . 23
Foreign bodies in air- and food-passages (Felix Semon, M.D.) . . 23
Glands: large mass of malignant glands in the neck (Henry T. Butlin) . 79
Gordon (Knyvett), a section of a middle turbinate body with polypus
formation . . . . . .66
-sections of masses curetted from the antrum maxillare in cases of
empyema by Dr. Scanes Spicer . . . .67
92
PAGE
Grant (J. Dundas, M.D.), hoarseness confined to the lower register of the
voice . . . . . . .43
-discussion on the diagnosis and treatment of empyema of the
antrum of Highmore . . . . .57
-empyema of antrum entirely cured by treatment by means of
Krause’s trocar . . . . . .67
-of the antrum of Highmore complicated with suppuration
of (probably) the frontal sinus . . . .67
- case of empyema of the antrum under treatment by means of
Krause’s trocar . . . . . .68
-of the antrum greatly benefited by the use of Krause’s
trocar and cannula and closure of the alveolar perforation . . 68
-empyema of the antrum secondary to suppuration in the frontal
sinus, treated by means of Krause’s trocar with good result . 69
-a case of tubercular laryngitis . . . .69
■ ■ case of laryngeal stenosis . . . . .80
Hall (P. de Havilland, M.D.), case of (?) chronic tuberculosis of the
larynx .... . . . 4
-a case of mycosis fungoides . . . .70
Hennig (Dr. Arthur), his oil studies of laryngeal and nasal disease demon¬
strated by Felix Semon, M.D. . . . .40
Hill (William, M.D.), moriform growths springing from the posterior
border of the nasal septum . . . . .31
-ulcerative disease of the left nasal fossa of undoubted tubercular
nature, followed by lupoid disease of the left ala . . .34
-discussion on the diagnosis and treatment of empyema of the
antrum of Highmore . . . . .55
1 disease of the frontal, ethmoidal and maxillary sinuses in associa¬
tion with nasal polypi . . . . .71
-epithelioma of the pharynx . . . .71
-case of syphilitic perichondritis of the larynx . . .82
Histology of turbinal hyperplasias (L. H. Pegler, M.D.) . . 84
Hoarseness confined to lower register of the voice (J. Dundas Grant, M.D.) 43
Hodgkinson (Alexander), exhibit of (1) quartz throat mirror for laryngo-
scopic purposes; (2) a magnifying laryngoscope . . .35
Horne (W. Jobson) and Kanthack (A. A., M.D.), specimen of pachy¬
dermia syphilitica diffusa . . . , .82
Hunt (C.), microscopical specimens illustrating case of multiple papillomata
of larynx . . . . . .72
Hyperplasias (turbinal) : histology (L. H. Pegler, M.D.) . . 84
Immobility of the left vocal cord (P. W. Bennett) . . .3
Injury causing paralysis of left vocal cord (Charters J. Symonds) . 50
Kanthack (A. A., M.D.), pathological specimen of adenoid growths and
one of perforation of the uasal septum .
-and Hobne (W. Jobson), specimen of pachydermia syphilitica
diffusa .......
Kidd (Percy, M.D.), laryngeal stenosis; polypoid growth from left vocal
cord, (?) syphilitic ......
--laryngeal stenosis ; polypoid growth from left vocal cord
47
82
36
73
93
68
PAGE
Krause’s trocar in treatment of empyema of antrum (J. Dundas Grant,
M.D.) . . . • 67,68,69
-and cannula in treatment of empyema of antrum (J.
Dundas Grant, M.D.) ....
Lactic acid (after curetting) in treatment of tubercular ulceration of epi
glottis (Charters J. Symonds)
Lake (Richard), tonsillar mycosis ....
-lupus of the nose treated by thyroid extract .
• tracheotomy tube worn for eleven years
Lane (J. Ernest), communication (in absence) to discussion on the diagnosis
and treatment of empyema of the antrum of Highmore
Laryngitis (chronic) (H. T. Butlin)
-with anterior nasal stenosis, from cicatricial contraction
after ulceration (Scanes Spicer, M.D.)
(tubercular) (j. Dundas Grant, M.D.)
Larygoscope exhibited by Dr. A. Hodgkinson
Larynx: chronic congestion (F. W. Bennett)
-oil studies of laryngeal disease by Dr. Arthur Hennig
-case of laryngeal disease (Herbert Tilley, M.D.)
-large and hard fibro-papilloma of larynx, causing indentation
opposite vocal cord (Felix Semon, M.D.)
immobility of left side of larynx in case of large mass of malig
__/II_m n Jl- \ ®
of
nnnt glands in neck (Henry T. Butlin) _
— lupus of pharynx and larynx (Felix Semon, M.D.)
— pachydermia laryngis (Charters J. Symonds) .
— (Herbert Tilley, M.D.)
29,
79
39
51, 8G
52
— microscopical specimens illustrating case of multiple papillomata
of larynx (C. Hunt) . . . t .72
— syphilitic perichondritis (William Hill, M.D.) . ] ! 82
— laryngeal stenosis (Percy Kidd, M.D.) . . 36, 73
-(J. Dundas Grant, M.D.) . . . . * 80
---supervening on typhoid fever (Scanes Spicer, M.D.) ! 8
-— probably lupus (C. A. Parker) . . . 48
— swelling of left side of larynx, with paralysis and atrophy of left
half of tongue and soft palate with perichondritis (A. A. Bowlby)
— tubercular disease (Charters J. Symonds) .
of soft palate, larynx, pharynx, and lungs (A. A. Bowlby)
1 i/» fnKor/»n India rv-P Inuunv (H A * _1 TT.11 -ar -rw v
-? chronic tuberculosis of larynx (F. de Havilland Hall, M.D.)
Law (Edward, M.D.), cedematous swellings of the palate and pharynx
-case illustrating various morbid conditions of the nose and ears
Librarian : report of Librarian ....
Lungs: tubercular disease of soft palate, larynx, pharynx, and lungs (A
A. Bowlby) . . . , . V
Lupus of the nose treated by thyroid extract (Richard Lake) .
-lupoid disease of left ala, following ulcerative disease of left nasai
» , - -O
fossa of undoubted tubercular nature (William Hill, M.D.)
— of pharynx and larynx (Felix Semon, M.D.) .
— laryngeal stenosis, probably lupus (C. A. Parker)
— of the throat and nose (J. B. Ball, M.D.)
Lymphadenoma with obstructed breathing (James Donelan, M.B.)
McBbide (P., M.D.), venous angioma of pharynx . ,
MacDonald (Greville, M.D.), discussion on the diagnosis and treatment
of empyema of the antrum of Highmore .
28
6
6
23
55
22
49
69
35
17
40
86
74
9
18
1L
4
37
48
32
11
6
34
39
48
64
13
29
54
94
PAGE
Malignant disease : ease for diagnosis whether tuberculous, malignant, or
syphilitic (Felix Senion, M.I).) . . . . 46
-glands in the neck (Henry T. Butlin) . . .79
Mirror : quartz throat mirror exhibited by Dr. A. Hodgkinson . . 35
Moriform growths springing from the posterior border of nasal septum
(William Hill, M D.) . . . . .34
Mycosis: tonsillar mycosis (Richard Lake) . . . .6
■ fungoides (F. de Havilland Hall, M.D.) . . .70
Naris : occlusion of right posterior naris (J. B. Ball, M.D.) . . 77
Neck : congenital fistula of neck (W. R. H. Stewart) . 14, 85
Nerve (cervical sympathetic) : paralysis in case of large mass of malignant
glands in neck (Henry T. Butlin) . . . .79
Nose: nasal deformity of traumatic origin (J. B. Ball, M.D.) . . 66
■ — — oil studies of nasal disease by Dr. Arthur Hennig . . 40
. ■ ■ lupus of nose treated by thyroid extract (Richard Lake) . 6
■ — ■ of the throat and nose (J. B. Ball, M.D.) . . 64
■ " morbid conditions (E. Law, M.D.) . . . .48
-moriform growths springing from posterior border of nasal septum
(William Hill, M.D.) . . . . .34
-papilloma (E. Cresswell Baber) . . . .63
-papilloma nasi with rodent ulcer in an aged patient (P. de Santi) . 13
■ pathological specimen of perforation of nasal septum (A. A.
Kanthack, M.D.) . . . . . .47
-section of a middle turbinate body with polypus formation (Knyvett
Gordon) . . . . . . .66
disease of frontal, ethmoidal and maxillary sinuses in association
with nasal polypi (William Hill, M.D.) . . .71
- ■ ■ large nasal polypus from a patient aged eighty-seven (Charters J.
Symonds) . . . . . .86
-post-nasal sarcoma (Charters J. Symonds) . . .86
-anterior nasal stenosis from cicatricial contraction after ulceration
(Scanes Spicer, M.D.) . . . . .49
-ulcerative disease of left nasal fossa of undoubted tubercular nature
followed by lupoid disease of left ala (William Hill, M.D.) . 3 t
-tubercular ulceration of nose and pharynx (C. A. Parker) . 83
Nostril: see Naris .
Occlusion of right posterior naris (J. B. Ball, M.D.) . . .77
(Edema: oedematous swellings of the palate and pharynx (Edward Law,
M.D.) • • • • • . . 3 /
Officers: list of Officers and Council • • . .33
Pachydermia with perichondritis (Adolph Bronner, M.D.) . . 12
-laryngis (Charters J. Symonds) . . . 29, 51, 86
-(Herbert Tilley, M.D.) . . . .52
-syphilitica diffusa (A. A. Kanthack, M.D., and W. Jobson Horne) 82
Palate : oedematous swellings of palate and pharynx (Edward Law, M.D.) 37
-(soft) : paralysis and atrophy of left half of soft palate in case of
swelling of left side of larynx (A. A. Bowlby) . . .9
-paralysis of left vocal cord, associated with paralysis of soft
palate (? of diphtheritic origin) (Scanes Spicer, M.D.) . . 26
■ -tubercular disease of soft palate, larynx, pharynx, and lungs
(A. A. Bowlby) . . . . . .11
Papilloma: microscopical specimens illustrating case of multiple papillo¬
mata of larynx (C. Hunt) • . • • .72
95
PAGE
Papilloma of nose (E. Cresswell Baber) . . . .63
-nasi with rodent ulcer in an aged patient (P. de Santi) . . 13
-see also Fibro-papilloma.
Paralysis: double abductor paralysis of uncertain origin (A. A. Bowlby) . 19
-of corresponding sympathetic nerve in case of large mass of
malignant glands in the neck (Henry T. Butlin) . . .79
-of right vocal cord (J. B. Ball, M.D.) . . .78
-in case of aneurism of aortic arch (Scanes Spicer, M.D.) . 27
-of uncertain origin (Henry T. Butlin) . . 80
-of left vocal cord (Charters J. Symonds) . . .50
-associated with paralysis of soft palate (? of diphtheritic
origin) (Scanes Spicer, M.D.) . . . . .26
-after injury (Charters J. Symonds) . . .50
Paresis (abductor): aneurism of the aortic arch compressing the left
pneumogastric and recurrent laryngeal nerves and the trachea asso¬
ciated with abductor paresis of the right cord (A. A. Bowlby) . 20
Parker (C. A.), disease of tongue (for diagnosis) . . .15
-laryngeal stenosis, probably lupus . . . .48
-case of tubercular ulceration of nose and pharynx . . 83
Peuler (L. H., M.D.), microscopical sections illustrating the histology of
turbinal hyperplasias . . . . .84
Perichondritis in case of swelling of left side of larynx (A. A. Bowlby) . 9
-pachydermia with perichondritis (Adolph Bronner, M.D.) . 12
-(syphilitic) of larynx (William Hill, M.D.) . . .82
Pharynx : venous angioma of pharynx (P. McBride, M.D.) . . 29
-epithelioma (William Hill, M.D.) . . . .71
-lupus of pharynx and larynx (Felix Semon, M.D.) . . 39
-oedematous swellings of palate and pharynx (Edward Law, M.D.) . 37
- tubercular disease of soft palate, larynx, pharynx, and lungs (A. A.
Bowlby) . . . . . . .11
-tubercular ulceration of nose and pharynx (C. A. Parker) . 83
Polypus : specimens of polypi from the antrum (Charters J. Symonds) . 85
-nasal polypi associated with disease of frontal, ethmoidal, and
maxillary sinuses (William Hill, M.D.) . . . .71
-large nasal polypus from a patient aged eighty-seven (Charters J.
Symonds) . . . . . .86
geal stenosis (Percy Kidd, M.D.) . . . 36, 73
Quartz substituted for glass in throat mirror for laryngoscopic purposes,
exhibited by Dr. A. Hodgkinson . . . .35
Respiration, see Breathing .
Santi (P. de), papilloma nasi with rodent ulcer in an aged patient , 13
Sarcoma (post-nasal) (Charters J. Symonds) . . . .86
Sbmon (Felix, M.D.), foreign bodies in the air- and food-passages . 23
■ lupus of pharynx and larynx . . . .39
-demonstration of Dr. Arthur Hennig’s oil studies of laryngeal and
nasal disease . . . . * .40
-a case for diagnosis, whether tuberculous, malignant, or syphilitic 46
- discussion on the diagnosis and treatment of empyema of the
antrum of Highmore . . . . 53, 60
— - - a case in which a very large and hard fibro-papilloma of the larynx
has caused indentation of the opposite vocal cord . . 74
96
PA GB
Septum (nasal). See Nose .
Sinus : empyema of antrum of Highmore complicated with suppuration of
(probably) the frontal sinus (J. Dundas Grant, M.D.) . . 67
-empyema of antrum secondary to suppuration of frontal sinus
(J. Dundas Grant, M.D.) . . . . . 69
■ — disease of the frontal, ethmoidal and maxillary sinuses in association
with nasal polypi (William Hill, M.D.) . . . .71
- suppuration of frontal sinus (J. Dundas Grant, M.D.) . 67, 69
-(Charters J. Symonds) . . . .74
Spbncbb (Walter G.), fibrosis of the thyroid; partial thyroidectemy, tracheo¬
tomy and dilatation of the stenosed trachea
—— discussion on the diagnosis and treatment of empyema of the antrum
of Highmore ......
Spicbb (Scanes, M.D.), tonsillar new growth
-laryngeal stenosis supervening on typhoid fever
— paralysis of left vocal cord associated with paralysis of soft palate
(? of diphtheritic origin) .....
-aneurism of the aortic arch with paralysis of right vocal cord
-radical cure of obstinate suppuration of the antrum of Highmore,
combined with intra-nasal and intra-antral polypi
■ "" anterior nasal stenosis from cicatricial contraction after ulceration,
with consecutive chronic laryngitis ....
* discussion on the diagnosis and treatment of empyema of the
antrum of Highmore .
- case of empyema of the antrum of Highmore .
Stenosis of larynx (Percy Kidd, M.D.) ... 36,
- -(J. Dundas Grant, M.D.) ....
-supervening on typhoid fever (Scanes Spicer, M.D.)
. .probably lupus (C. A. Parker)
-anterior nasal stenosis from cicatricial contraction after ulceration
(Scanes Spicer, M.D.) .....
24
60
7
8
26
27
41
49
58
74
73
80
8
48
49
Stbwabt (W. R. H.), congenital fistula of the neck . . .14
-case of fistula in the neck . . . . .85
Suppuration of frontal sinus (J. Dundas Grant, M.D.) . 67, 69
-(Charters J. Symonds) . . . .74
- - ■ (obstinate) of antrum of Highmore; radical cure (Scanes Spicer,
M.D.) . . . . . . .41
Symonds (Charters J.), early epithelioma ? of the vocal cord . . 17
-tubercular disease of the larynx . . . .18
1 ankylosis (?) of the left arytsenoid joint . . .27
-tubercular ulceration of the epiglottis treated by curetting and
lactic acid • • . . . .28
-pachydermia laryngis . . . .29,61, 86
-paralysis of the left vocal cord . . . .60
-after injury . . . .60
-suppuration of frontal sinus . . . .74
■ ■ specimens of polypi from the antrum . . .85
-large nasal polypus from a patient aged eighty-seven . . 86
-a post-nasal sarcoma . . . . .86
Syphilis: polypoid growth from left vocal cord (? syphilitic) (Percy Kidd,
M.D.) . . . . . . .36
-case for diagnosis, whether tuberculous, malignant, or syphilitic
(Felix Semon, M.D.) . . . . .46
-pachydermia syphilitica diffusa (A. A. Kantliack, M.D., and W.
Jobson Horne) . . . . . .82
-syphilitic perichondritis of larynx (William Hill, M.D.) . ! 82
97
PAGE
Throat: lupus of throat and nose (J. B. Ball, M.D.) . . .64
Thyroid extract in treatment of lupus of nose (Richard Lake) . . 6
-: fibrosis of the thyroid (Walter G. Spencer) . . .24
Thyroidectomy (partial) in case of fibrosis of thyroid (Walter G. Spencer) 24
Tilley (Herbert, M.D.), pachydermia laryngis . . .52
-case of laryngeal disease . . . . .86
Tongue : disease of tongue (for diagnosis) (C. A. Parker) . .15
-adenoma of tongue (E. Cresswell Baber) . . .1
-paralysis and atrophy of left half of tongue in case of swelling of
left side of larynx (A. A. Bowlby) . . . .9
-recurrent tumour at back of tongue; operation, June, 1889 (Henry
T. Butlin) . . . . . .42
Tonsils : tonsillar mycosis (Richard Lake) . . . .6
-tonsillar new growth (Scanes Spicer, M.D.) . . .7
Trachea: dilatation of stenosed trachea in case of fibrosis of thyroid
(Walter G. Spencer) . . . . . 24
Tracheotomy in case of fibrosis of thyroid (Walter G. Spencer) . . 24
-tube worn for eleven years (Richard Lake) . . .23
Traumatic origin of case of nasal deformity (J. B. Ball, M.D.) . . 66
Trocar: Krause’s trocar in treatment of empyema of antrum (J. Dundas
Grant, M.D.) . . . . .67,68, 69
Tuberculosis : case for diagnosis, whether tuberculous, malignant, or
syphilitic (Felix Semon, M.D.) . . . .46
■ - tubercular ulceration of epiglottis treated by curetting and lactic
acid (Charters J. Symonds) . . . . .28
- tubercular disease of the larynx (Charters J. Symonds) . . 18
■ ■ case of tubercular laryngitis (J. Dundas Grant, M.D.) . . 69
— ? chronic tuberculosis of larynx (F. de Havilland Hall, M.D.) . 4
-ulcerative disease of left nasal fossa of undoubted tubercular nature
(William Hill, M.D.) . . . . .34
-tubercular ulceration of nose and pharynx (C. A. Parker) . 83
-tubercular disease of soft palate, larynx, pharynx, and lungs (A. A.
Bowlby) . . . . . . .11
Tumour: recurrent tumour at back of tongue; operation, June, 1889
(Henry T. Butlin) . . . , . . .42
Turbinal hyperplasias : histology (L. H. Pegler, M.D.) . . 84
Turbinate body, see Nose.
Typhoid fever followed by laryngeal stenosis (Scanes Spicer, M.D.) . 8
Ulcer: rodent ulcer on nose (P. de Santi) . . . .13
Ulceration : tubercular ulceration of nose and pharynx (C. A. Parker) . 83
Venous angioma of pharynx (P. McBride, M.D.) . .29
Vocal cord : ? angioma of vocal cord (Ernest H. Crisp) . . 16
-early epithelioma ? of the vocal cord (Charters J. Symonds) . 17
- (right) aneurism of the aortic arch, compressing the left pneumo-
gastric and recurrent laryngeal nerves and the trachea, associated
with abductor paresis of the right cord (A. A. Bowlby) . . 20
-large and hard fibro-papilloma of larynx causing indenta¬
tion of opposite vocal cord (Felix Semon, M.D.) . . .74
-fixation (F. Willcocks, M.D.) . . .43
FIRST SERIES—VOL. II. 10
98
Vocal cord (right) : paralysis (J. B. Ball, M.D.) . . .78
-of uncertain origin (Henry T. Bntlln) . . 80
-in case of aneurism of aortic arch (Scanes Spicer,
MD ) • . . . . .27
-(left) cystic fibroma of the left vocal cord (Adolph Bronner, M.D.) 4
-immobility of left vocal cord (P. W. Bennett) . . .3
-paralysis (Charters J. Symonds) . . .50
-after injury (Charters J. Symonds) . . 50
-associated with paralysis of soft palate (? of diph¬
theritic origin) (Scanes Spicer, M.D.) . . . .26
-polypoid growth from left vocal cord (? syphilitic) in case
of laryngeal stenosis (Percy Kidd, M.D.) . . 36, 73
Voice: hoarseness confined to lower register of voice (J. Dundas Grant.
M.D.).. . 43
Walsham (W. J.), discussion on the diagnosis and treatment of empyema
of the antrum of Highmore . . . . .56
Willcocks (F., M.D.), fixation of right cord . . .43
PBINTED BY ADLABD AND SON,
BABTHOLOMEW CLOSE, E.C., AND 20, HANOVER SQUABS, W.
PROCEEDINGS
OP THE
LARYNGOLOGICAL SOCIETY
OF
LONDON.
VOL. III.
1895—96.
WITH
LISTS OP OFFICERS, MEMBERS ETC.
LONDON
PRINTED BY ADLARD AND SON,
BARTHOLOMEW CLOSE, E.C., AND 20, HANOVER SQUARE, W.
1897.
OFFICERS AND COUNCIL
OF THE
Ifargngo logical Societg of ^fottbon
ELECTED AT
THE ANNUAL GENERAL MEETING,
JANUARY 8th, 1896.
gresibent.
FELIX SEMON, M.D., F.R.C.P.
#ice-$)re6ibettts.
E. CRESSWELL BABER, M.B. A. HODGKINSON, M.D.
CHARTERS SYMONDS, F.R.C.S.
Ureasam.
W. J. WALSHAM, F.R.C.S.
librarian.
E. C. BEALE, M.B., F.R.C.P.
Secretaries.
W. R. H. STEWART, F.R.C.S. ST CLAIR THOMSON, M.D.
Cmraril.
J. B. BALL, M.D. J. W. BOND, M.D.
F. W. BENNETT, M.D. SCANES SPICER, M.D.
P. WATSON WILLIAMS, M.D.
PRESIDENTS OF THE SOCIETY.
(From its Formation.)
ELECTED
1893 Sir George Johnson, M.D., F.R.S.
1894 Felix Semon, M.D., F.R.C.P.
1895 Felix Semon, M.D., F.R.C.P.
1896 Felix Semon, M.D., F.R.C.P.
LARYNGOLOGICA.L SOCIETY
OF
LONDON.
LIST OF MEMBERS.
1896.
LONDON:
PRINTED BY ADLARD AND SON,
BARTHOLOMEW CLOSE, E.C., and 20, HANOVER SQUARE, W.
1896.
HONORARY MEMBERS.
Fraenkel, Professor B., 12, Neustiidtische Kirelistrasse N.W.,
Berlin.
Garcia, Maxcel, Mon Abri, Shoot-up hill, Crieklewood.
Johxsox, Sir George, M.D., F.R.S., 11, Savile row, W. P.
Lefferts, G. M., 6, West Thirty-third street, New Tork, U.S.A.
Massei, Professor, 4, Piazza Municipio, Naples, Italy.
Moere, E. J., 25 bis., Cours da Jardin Publique, Bordeaux,
v. Schrotter, Professor, 3, Marianengasse I, Vienna.
Stork, Professor, 9, Wallfischgasse I, Vienna.
Solis-Cohex, J., 1431, Walnut street, Philadelphia, U.S.A.
ICarpjjflIopial jsotictjr of bonbon.
LIST OF MEMBERS,
JANUARY, 1896.
INDEX TO ABBREVIATIONS
Indicating Past or Present Officers of the Society.
(P.) President. (L.) Librarian.
(F.-P) Vice-President. (S.) Secretart.
(T.) Treasurer. (C.) Councillor.
(O.M.) Original Member.
LONDON.
Elected.
1893 Aikin, William Arthur, M.D., 14, Sumner place,
Onslow Square, S.W.
1893 Ayres, Charles James, M.D., 47a, Welbeck street,
Cavendish square, W.
O.M. Ball, James Barry, M.D., M.R.C.P., 12, Upper Wimpole
street, W. C.
O.M. Beale, Edwin Clifford, M.B., F.R.C.P., 23, Upper
Berkeley street, W. 8. L.
O.M. Bond, James William, M D., 26, Harley street, W. C.
O.M. Bowlby, Anthony Alfred, P.R.C.S., 24, Manchester
square, W.
O.M. Butlin, Henry Trentham, F.R.C.S., 82, Harley street,
W. T.
1895 Cathcart, George E., M.B., C.M., 47, Welbeck street,
Cavendish square, W.
1895 Cheatle, Arthur W., F.R.C.S., 117, Harley street, W.
IT
LIST OF MEMBERS.
Elected.
1893 Colbeck, Edmund Henrt, M.D., M.R.C.P., 14, Porchester
terrace, W.
1894 Cripps, Charles Cooper, M.D., 187, Camberwell grove,
S.E.
O.M. Crisp, Ernest Henry, 43, Fencburch street, E.C.
1893 Davis, Henry, 60, Queen Anne street, Cavendish square, W.
1893 Donelan, James, M.B., 2, Upper Wiiupole street, W.
1894 Drysdale, John Hannah, M.B., M.R.C.P., 25, Welbeck
street, W.
1895 Fourquemin, George Vincent, L.R.C.P., The London
Throat Hospital, 204, Great Portland street, W.
1895 Gordon, A. Knyvett, M.B., B.C., 37, Howley place, W.
O.M. Grant, J. Dundas, M.D., F.R.C.S., 8, Upper Wimpole
street, W. G.
O.M. Hall, Francis de Havilland, M.D., F.R.C.P., 47, Wim¬
pole street, W. L.
1895 Hamilton, Bruce, M.R.C.S., L.R.C.P., 9, Frognal, West
Hampstead.
1893 Harvey, Frederick George, F.R.C.S.Ed., 10, George
street, Hanover square, W.
1894 Hey, Charles Edward Milnes,M.R.C.S., L.R.C.P., West-
bury, Hornsey lane, N.
O.M. Hill, G. William, M.D., 24, Wimpole street, W.
1894 Hill-Wilson, A. E., M.R.C.S, L.R.C.P., 217, Goldhawk
road, W.
O.M. Holmes, W. Gordon, M.D., 10, Finsbury square, E.C.
1894 Horne, Walter Jobson, M.B., 8, Glazbury road, West
Kensington.
O.M. Hovell, T. Mark, F.R.C.S.Ed., 105, Harley street, W.
1895 Jakins, Percy, M.R.C.S., 121, Harley street, W.
1894 Jessop, Edward, M.R.C.S., L.R.C.P., 81, Fitzjohn’s Avenue,
Hampstead, N.W.
O.M. Kanthack, Alfredo Antunes, M.D., F.R.C.S., St. Bartho¬
lomew’s Hospital, E.C.
O.M. Kidd, Percy, M.D., F.R C.P., 60, Brook street, Grosvenor
square, W. G.
1895 Lack, Lambert Harry, M.B., F.R.C.S., 55, Welbeck
street, W.
1893 Lake, Richard, F.R C.S., 19, Harley street, W.
O.M. Law, Edward, M.D., 35, Harley street, W.
LIST OP MEMBERS.
V
Elected.
O.M. Lawrence, Laurie Asher, F.R.C.S., 125, Harley street, W.
O.M. Macdonald, Greville, M.D., 85, Harley street. C.
1895 Macgeagh, T. E. Foster, M.D., M.R.C.S., L.S.A., 23, New
Cavendish street, W.
1894 Mackenzie, Hector William Gavin, M.D., F.R.C.P., 59,
Welbeck street, W.
1893 Pegler, Louis Hemmington, M.I)., 12, Radnor place,
Gloucester square, W.
1895 Perkins, J. J., M.B.Cantab., Hospital for Consumption, &c.,
Brompton.
O.M. Pollard, Bilton, F.R.C.S., 24, Harley street, W.
O.M. Poore, George Vivian, M.D., F.R.C.P., 30, Wimpole
street, W.
1894 Potter, Edward Furniss, M.D., 24, Addison gardens, W.
1894 Poulter, Reginald, 27, Harley street, W.
O.M. Rees, John Milsom, F.R.C.S.Ed., 53, Devonshire street,
Portland place, W.
1894 Roper, A. L., M.B., Colby, Lewisham hill, S.E.
1894 Roughton, Edmund, F.R.C.S., 33, Westbourne terrace, W.
1893 Santi, Philip Robert William, F.R.C.S., 37, Queen Anne
street, Cavendish square, W.
O.M. Semon, Felix, M.D., F.R.C.P., 39, Wimpole street, W.
P. F.-P.
1894 Sharman, Henry, M.D., 16, Frognal, Hampstead.
1893 Spencer, Walter George, M.S., F.R.C.S., 35, Brook
street, Grosvenor square, W.
O.M. Spicer, Scanes, M.D., 28, Welbeck street, Cavendish
square, W. 8. C.
1895 Stabb, Ewen C., F.R.C.S., St. Thomas’s Hospital, S.E.
1895 Stephen, G. Caldwell, M.D., L.R.C.P., 54, Evelyn gardens,
South Kensington.
O.M. Stewart, William Robert Henry, F.R.C.S.Ed., 42,
Devonshire street, Portland place, W. 8.
O.M. Symonds, Charters James, M.S., F.R.C.S., 26, Weymouth
street, Portland place, W. C. F.-P.
1894 Thomson, St. Clair, M.D., F.R.C.S., M.R.C.P., 28, Queen
Anne street, Cavendish square, W. 8.
1893 Tilley, Herbert, M.D., 64, Welbeck street, W.
1893 Waggett, Ernest Blechynden, M.B., 66, Park street,
Grosvenor square, W.
VI
LIST OF MEMBERS.
Elected.
1893 Walker, Charles Rotherham, M.D., Gainsborough
House, Leytonstone, N.E.
O.M. Walsham, William Johnson, F.R.C.S., 77, Harley street,
W. T.
O.M. Whistler, William MacNeill, M.D., M.R.C.P., 17,
Wimpole street, W. V.-P. C.
1893 White, William Hale, M.D., F.R.C.P., 65, Harley street,
W.
O.M. Willcocks, Frederick, M.D., F.R.C.P., 14, Mandeville
place, Manchester square, W.
O.M. Wills, William Alfred, M.D., M.R.C.P., 29, Lower
Seymour street, W.
LIST OF MEMBERS.
Vll
COUNTRY.
Elected.
1895 Armstrong, W. G., M.B.Sydney, Sydney, New South
Wales. #
O.M. Baber, Edward Cresswell, M.B., 97, Western road,
Brighton, and 32, New Cavendish street, London, W.
C. F-P.
1895 Bark, John, F.R.C.S.Ed., M.R.C.P.I., 54, Rodney street,
Liverpool.
1865 Baron, Barclay J., M.B., Clifton.
O.M. Bennett, Frederick William, M.D., 25, London road,
Leicester. C.
1895 Brady, Andrew John, L.R.C.P.&S.I., Sydney, New South
Wales.
O.M. Bronner, Adolph, M.D., 33, Manor row, and 8, Mount
Royd, Bradford. C.
1894 Brown, Alfred, M.D., Claremont, Higher Broughton,
Manchester.
1895 Browne, John Walton, M.D.I., M.R.C.S., 10, College
street North, Belfast.
1893 Charsley, Robert Stephen, M.R.C.S., L.R.C.P., The
Barn, Slough, Bucks.
1893 Davison, James, M.D., M.R.C.P., Streate Place, Bath road,
Bournemouth.
1895 Downie, J. Walker, M.B., Glasgow.
1893 Duncanson, J. J. Kirk, M.D., F.R.C.P.Ed., 22, Drums-
heugh gardens, Edinburgh.
1893 Embleton, Dennis Cawood, M.R.C.S., L.R.C.P., St.
Wilfrid’s, St. Michael’s road, Bournemouth.
1893 Foster, Michael, M.B., Villa Anita, San Remo.
O.M. Hayes, Richard Atkinson, M.D., F.R.C.S.I., 82, Merrion
square South, Dublin.
O.M. Hodgkinson, Alexander, M.B., 18, St. John street,
Manchester. F.-P.
1894 Hunt, John Middlemass, M.B., C.M., 55, Rodney street,
Liverpool.
VU1
LIST OF MEMBERS.
Elected
O.M. Johnston-, Robert McKenzie, M.D., F.R.C.S.Ed., 44,
Charlotte square, Edinburgh.
1805 Lindsay, David Moore, L.R.C.P., L.R.C.S.I., 373, Main
street. Salt Lake City, Utah Territory, U.S.A,
1805 Macintyre, John, M.B., C.M.Glasgow, 179, Bath street,
Glasgow.
1804 Mackern, George, M.D., Buenos Ayres, Argentina.
O.M. McBride, Peter, M.D., F.R.C.S.Ed., 16, Chester street,
Edinburgh. V.-P. %
1803 Milligan, William, M.D., 337, Oxford road, Manchester.
O.M. Newman, David, M.D., 18, Woodside place, Glasgow. C.
O.M. Parker, Charles Arthur, M.R.C.S., High street,
Rickmansworth, Herts.
O.M. Paterson, Donald Rose, M.D., M.R.C.P., 18, Windsor
place, Cardiff.
1803 Permewan, William, M.D., F.R.C.S., 7, Rodney street,
Liverpool.
1895 Reynolds, Arthur R., M.D.New York, 36, Washington
street, Chicago, U.S.A.
1805 Ridley, W., F.R.C.S., Ellison place, Newcastle.
1895 Sandford, Arthur W., M.D., M.Ch., 13, St. Patrick’s
place, Cork, Ireland.
O.M. Tebb, William Scott, M.D., Charlcombe, Boscombe hill,
Bournemouth.
O.M. Walker, Thomas James, M.D., 33, Westgate, Peter¬
borough.
1895 Warner, Percy, M.R.C.S., L.R.C.P., Woodford.
1893 Williams, Patrick Watson, M.D., 2, Lausdowne place,
Victoria square, Clifton, Bristol. C.
PROCEEDINGS
OF THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, October 9th, 1895.
Felix Semon, M.D., F.R.C.P., President, in the Chair.
Scanes Spicer, M.D.,
W. R. H. Stewart, F.R.C.S.,
Secretaries.
Present—22 members and 5 visitors.
The minutes of the previous meeting were read and confirmed.
The President, before the ordinary business of the meeting com¬
menced, alluded in feeling terms to the loss the Society had sustained
by the deaths of Mr. Arthur Durham and Herr Hans Wilhelm Meyer.
The following gentleman was elected a member of the Society :
Mr. G-eorge Vincent Fourquemin, London.
The following gentlemen were proposed for election at the next
Ordinary Meeting:
Mr. John Back, F.R.C.S.Ed., M.R.C.P.Irel., 54, Rodney Street,
Liverpool.
Dr. John Walton Browne, M.D.Irel., M.R.C.S.Eng., 10, College
Street North, Belfast.
Mr. Andrew John Brady, L.R.C.P. & R.C.S.Irel., Sydney, New
South Wales.
Mr. Arthur H. Cheatle, F.R.C.S., 117, Harley Street, W.
Mr. John Macintyre, M.B., C.M.Glas., 179, Bath Street, Glasgow.
Dr. Arthur R. Reynolds, M.D.New York, 36, Washington Street,
Chicago.
Mr. Walter Ridley, F.R.C.S., Ellison Place, Newcastle.
Mr. Edwin C. Stabb, F.R.C.S., St. Thomas’s Hospital.
Dr. Cathcart and Mr. Fourquemin having signed the Register were
admitted members of the Society by the President.
FIRST series—VOL. III.
1
2
Case op Congenital Syphilis op Palate and Laeynx.
Shown by Dr. Leonard Roper. E. W —, a girl set. 21, came to
Guy’s with the following history.
Six months ago she gradually lost her voice, which has been getting
worse. Has been liable to sore throat, but never lost her voice before.
At sixteen her upper front teeth loosened and dropped out. Three
years ago sores appeared on the upper lip and right side of nose. She
was treated at Gray’s Inn Road for lupus. While in the hospital she
contracted erysipelas of face, after which the lupus (?) cleared up.
The ulceration of face lasted twelve months. At the end of this time
two swellings appeared on right arm, and now the lower end of right
radius is much thickened. She never had any eye trouble.
The soft palate and pharynx are greatly hypertrophied. The epi¬
glottis is thickened and “ truncated.” The false cords are thickened,
and there is some infraglottic swelling.
Dr. William Hill said that the case much more closely resembled
lupus than anything else, and he should require very strong evidence
to convince him that the condition was due to syphilis.
Dr. Dundas Grant had seen the case before, and had considered it
lupus.
The President, Mr. Butlin, and Mr. Stewart also considered it
a case of lupus, and the President suggested that it should be micro¬
scopically examined, and the results submitted to the Society.
Dr. Roper, in reply, said no reference had been made to the swellings
on the arm. There had been some slight improvement under Pot.
Iod. He would remove and examine microscopically a piece of the
hypertrophic tissue.
A Case of Tertiary Syphilis of Larynx and Nose.
Shown by Dr. Furniss Potter, with Dr. Law’s permission.
Henry G—, set. 28, a carman, with a history of venereal disease three
or four years, and sore throat about eighteen months.
He came to the London Throat Hospital on July 23rd, complaining
of hoarseness, cough, and difficulty of swallowing solids. Slight dys¬
pnoea. On examining him a large scar was found on the hard palate.
Uvula was almost detached from velum, and had contracted an adhesion
to the left posterior pillar of the fauces. The epiglottis had been
almost entirely destroyed, a mere stump remaining. There was much
3
infiltration and oedema of the aryepiglottic folds and larynx generally ;
and this, together with much viscid secretion, rendered it impossible to
obtain accurate details, but the rima glottidis appeared as a very small
chink.
On the 25th inst. a much clearer view was obtained, the left cord
being visible with some difficulty, owing to the view being obstructed
by a large polypoid-looking mass which appeared to be attached to the
stump of the epiglottis. There was also a smaller mobile hyperplasm
in the arytsenoid region. Pot. Iodid. grs. x and daily mercurial
inunctions were administered till the gums became affected, then Pot.
Iodid. grs. xx thrice daily, with the result that the man has steadily
improved, and he has now a fair-sized glottic opening.
Case op Cicatricial Obstruction of Anterior Nares.
Shown by Dr. Scanes Spicer.
Mr. Btjtlin suggested a plastic operation by turning down a flap
at the side of the nose. He had a case in hospital in which both
nostrils were affected. He would bring his case and show it at the
next meeting.
Dr. Dundas Grant would suggest that if this operation failed, then
the columna should be cut through, and a silver saddle inserted to
raise the tip.
A Case op Tubercular Ulceration op Septum op Nose.
Shown by Mr. C. Symonds. W. H. C—, set. 48, came to Guy's for
“ stoppage of nose and pain." Fifteen months ago had influenza.
Soon after pain commenced, and a small pimple appeared in left
nostril. This got better, but appeared again and got worse; he had
at this time an offensive smell in his nose,—he noticed it himself. One
day on rising in the morning found his nose completely blocked. The
smell now has ceased, and no odour can be detected. Has blown
“ casts *' from his nostrils. Has been in Army, and when at Malta
was invalided for consumption. Passed into Navy and invalided out for
chronic bronchitis. Declares he has never had syphilis.
Family history .—Father died of phthisis; mother has phthisis now.
There are no definite signs of phthisis in patient's chest.
4
A Case op Tubercular Disease op Septum.
Shown by Mr. C. Symonds. A. H—, set. 16, sought advice for
blocked nostril, right side. Has had it blocked for eight months.
Came on gradually; bleeds at times, especially after blowing his nose.
Has no history of any injury. No pain at any time. No history of
phthisis. Lungs healthy.
On examination there is a mass projecting from anterior part of car¬
tilaginous portion of septum; pale, firm. Does not bleed readily. Left
nostril has some ulceration on septum quite anteriorly. Larynx and
naso-pharynx normal.
Mr. Cresswell Baber considered that the case of the boy was one
of tubercular disease of the septum nasi, and should be treated by
removal with snare, scraping, and subsequent cauterisation with lactic
acid or galvano-cautery.
Dr. C. Beale mentioned a case of a tubercular patient in whom
the nodular thickening in the nose dried up of itself without any
treatment.
Dr. Dundas Grant considered the case to be either tubercle or
new growth, but thought the boy’s general condition pointed rather
to tubercle.
A Case in which the Left Vocal Cord was removed for
Cicatricial Stenosis.
Shown by Mr. C. Symonds. H—, set. 50. First seen some six years
ago, when he was suffering from urgent dyspnoea. Immediate tracheo¬
tomy was performed in the scar of an old operation. He had been
tracheotomised once before for the same trouble.
On examination the cords were red and swollen. Later several
tags were seen on each cord and removed. The tracheal wound was
closed, and patient resumed work. Again, four years ago, dyspnoea
occurred, tracheotomy was performed, and later Mr. Durham divided
the thyroid with a view of removing a supposed obstruction. After
this latter operation he again came under Mr. Symonds* care, wearing a
tube, and with great stenosis resulting from the irregular cicatrisation,
so that it was impossible to remove the tube.
In February, 1895, the thyroid was again divided, and the left cord
with its muscles removed, leaving the arytsenoid.
5
In September last, finding the laryngeal aperture sufficiently wide
for respiration, the tracheal fistula was closed.
Now, October 9th, the man breathes well, and his voice is improving
in power.
Dr. C. Beale wished to know if the voice was now produced by the
ventricular bands.
The President thought the voice was produced by the cicatricial
bands.
Case op Frontal Sinus Disease.
Shown by Dr. Wm. Hill. Miss K — had previously been shown at
this Society. She had then exhibited the classical signs of frontal sinus
disease, but the chief symptom for which the patient sought relief was
the profuse thick discharge of pus which flowed from the region of
the nasal opening of the infundibulum. With the assistance of
his colleague, Mr. Ernest Lane, the frontal sinus was opened by a
vertical incision, exuberant granulomatous growths were removed, and
the infundibulum dilated. The frontal wound was allowed to heal in
the hope that the sinus would efficiently drain through the dilated and
curetted infundibulum. In three weeks, however, there was pain,
puffiness, and swelling, showing that the secretions of the sinus did
not drain efficiently through the artificially dilated infundibulum.
The wound was reopened, an Ellis drainage-tube inserted, and the
patent was taught to pass a curved probe (as recommended by Luc)
from the forehead through the sinus into the nose daily before using
the syringe. Under this treatment there was no smell or excessive dis¬
charge, but directly the use of the probe was omitted, retention occurred.
Dr. Hill proposed to enlarge the wound in the forehead and inspect
the sinus again, and by some means so enlarge the opening into the
nose as to insure efficient drainage; it might be found necessary to
remove a little more of the middle turbinal.
Dr. Tilley and Mr. C. Baber suggested that Griinwald’s method of
removing the front wall of the sinus, packing the wound, and allowing
the sinus to granulate up should be tried.
Mr. W. Hill, in reply, said that he would first try and carry out his
idea of establishing good drainage into the nose. If this failed he would
consider the suggestion Dr. Tilley and Mr. C. Baber recommended.
The idea was, however, absolutely opposed to the general surgical
principles which had hitherto guided us in the treatment of accessory
sinuses, for we had regarded efficient drainage as indispensable. The
disfigurement, too, must be taken into account.
6
Specimen of Carcinoma of the Larynx.
Shown by Dr. Kanthack. Patient complained of stiffness and
hoarseness in February, 1889, but did not seek medical advice till
September, 1892. November 14th, 1892, tracheotomy was per¬
formed on account of severe dyspnoea, which greatly relieved him.
Laryngoscopic examination showed a growth on right side of larynx,
involving both false and true cords. December 24th, thyrotomy was
performed, and a sessile growth removed from right half of larynx.
January 23rd, 1893, much swelling of neck, edges of tracheotomy
wound everted and ulcerated. March 19th, 1893, patient died.
The specimen shows that the whole larynx is completely filled up
with the malignant growth, which also invades the whole peri¬
laryngeal and peri-pharyngeal region. The rapidity with which the
growth has extended is striking, so that the question is, how and in
what manner paths are opened up for the dissemination of the growth
by wounds ?
Mr. Butlin did not think the splitting the thyroid had anything
to do with the increased rapidity of the growth. It was not an un¬
common thing for malignant growths to suddenly take on increased
action in the way of rapidity of growth.
Mr. Bowlby had a case in which the thyroid was split for the re¬
moval of growth and was well united; but a few weeks after the carti¬
lages were burst open, and a fungating tumour appeared in the neck.
Dr. S. Spicer asked whether the increased blood-supply and the
more free anastomosis of the lymphatics had anything to do with
the rapid increase of the growth.
Specimen of Carcinoma of Pharynx from a Woman.
Shown by Dr. Kanthack. It shows extensive necrosis of the
posterior plate of the cricoid cartilage with ulceration of the pharynx,
ocdematous swelling and infiltration of the arytaenoid area.
Specimen of Diffuse Papillomatous Hyperplasia of Laryngeal
Mucous Membrane in a Child.
Shown by Dr. Kanthack. 'The whole surface is covered by
numerous small warty growths, so that we have a verrucose condition
7
of the mucosa, which must not be confounded with the condition
described by Virchow as pachydermia diffusa. Tracheotomy had been
performed during life, and papillomatous growths have sprouted from
the laryngeal mucosa through and along the track of the tracheotomy
wound, and appear outside at the skin opening.
Mr. Bowlby said the patient had been under treatment for growth
in the larynx. Tracheotomy had been performed, but there was no
material stenosis. The child suddenly had a choking fit in the ward
and died. Nothing was discovered post mortem to account for the
fit, which must be put down to spasm or some inspissated mucus.
The President had a case of papilloma. The growth was removed,
but returned two years after, during pregnancy. Tracheotomy was
performed; an abscess formed. The nature of the growth was
changed. Post mortem specimen showed carcinoma, and the whole
of the walls of the abscess cavity were lined by the growth.
Specimen op Necrosis and Ulceration of Tip of Epiglottis,
WHICH OCCURRED IN THE COURSE OF TYPHOID FEVER.
Shown by Dr. Kanthack.
Dr. Beale said it was an important point that these ulcers did not
occur at the active stage, but occurred at the end of the disease. If
due to the poison, why do they not occur at an earlier stage ?
Mr. Butlin thought the ulceration was a perichondritis—a sequel
to typhoid, same as periostitis in other parts.
Mr. Bowlby had seen a case when the ulceration had occurred at
an earlier stage—third week. There was great swelling of the larynx,
tracheotomy was performed, and the patient still had to wear his tube
on account of the stenosis.
The President said that evidently in some epidemics ulcerative
throat symptoms occurred more frequently than in others. Greisinger
found ulceration of the larynx in one in every five cases.
Specimens shown by Dr. Felix Semon.
1. Large Nasal Polypi removed from tiie Right Nostril of a
Lad aged Nineteen.
The two polypi are remarkable for their enormous size, and also for
the fact that they both were removed within three weeks from the right
nostril of so comparatively young a patient, whilst the left nostril was
quite free. The polypi did not show much in the nose itself, but were
visible with the naked eye behind the soft palate, the naso-pharyngeal
8
cavity being almost completely filled with the growths. The patient
stated that when a boy of twelve he had some polypi removed from the
right nostril, but had been free until about one and a half years pre¬
vious to the present removal, which was effected in October of last year
at St. Thomas’s Hospital. The aggregate size of the two polypi
shown would seem to equal if not to surpass the largest mucous polypi
put on record.
2. Tubercular Ulceration of the Soft Palate, Uvula, Eight
Tonsil, and Larynx.
The patient was a young man set. 26, who died with general
phthisis in St. Thomas’s Hospital. The larynx was diseased previous
to the palate, and the disease did not spread by continuity. The
development of the tuberculosis of the palate could be followed from
its very beginning, and it was not possible to check the disease by
curetting and applications of lactic acid. In the specimen it is seen that
the upper part of the epiglottis and the edges of the arytseno-epiglottic
folds have been destroyed by tubercular ulceration, whilst the rest of
the laryngeal cavity is ulcerated in different degrees from the same
disease. In the cavity below the glottis, extensive areas of the mucous
membrane are destroyed, the posterior border of the soft palate and
the tonsil of the right side are similarly ulcerated, the uvula is thickened
and nodular from the formation apparently of tubercles in its sub¬
stance.
3. Large Laryngeal Papilloma.
The specimen dates from the pre-laryngoscopic era, and has been
preserved for a long time in the museum of St. Thomas’s Hospital.
The brief clinical history appended to it simply states that the patient,
an adult, had suffered for several months from increasing dyspnoea,
and finally died from suffocation. The papilloma springs from the
anterior part of the right vocal cord and fills the whole glottic cavity.
4. Myxoma of the Larynx.
The specimen is shown on account of the great rarity of laryngeal
myxoma. The growth was situated in the anterior commissure of a
girl set. 26, who came in October, 1893, to the Throat Department
9
of St. Thomas’s Hospital with the statement that she had been hoarse
ever since sbe could remember. The growth, which looked like a
bunch of granulation tissue, and was of the size of a cherry-stone,
filled the anterior commissure of the vocal cords. It was removed
without difficulty, and on microscopic examination proved to be a
true myxoma. No recurrence so far as is known has taken place.
The microscopic section will be shown at the next meeting.
5. Syphilitic Endotracheitis.
This specimen has already been shown by Mr. It. W. Parker
before the Pathological Society of London (' Pathological Society’s
Transactions/ vol. xxxvii, p. 119), but is again demonstrated on
account of the great rarity of the affection.
The specimen represents two transverse sections of the trachea of a
boy fifteen years of age, affected with inherited syphilis. There is a
large amount of dense fibrous tissue produced in connection with the
mucous membrane and submucous tissue, the lumen of the tube being
at one part not more than a quarter of an inch in extreme diameter.
The patient had been subjected to tracheotomy in consequence of a
nearly fatal attack of asphyxia in 1877. In March, 1882, the tracheal
fistula resulting was closed by operation by Mr. R. W. Parker. Some
time later, the fistula having closed, an attack of catarrhal pneumonia
set in, but did not prove fatal; death occurred, however, from a similar
attack in February, 1885. After death the effects of the endotracheal
inflammation were found to commence somewhat abruptly about an
inch and a half above the bifurcation, and to increase in amount below.
The lungs presented the appearances of extreme interstitial inflamma¬
tion, and showed large tracts of dense fibrous tissue, in which lay
groups of compressed alveoli; the smaller bronchial tubes and alveoli in
the more peripheral parts of the lungs were filled with foetid pus.
Dr. C. Beale stated he had a similar case of obstruction a few
years ago, and on looking through the records, found it always
occurred at the lower end of trachea.
1*
PROCEEDINGS
OP THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, November 13 th, 1895.
Felix Semon, M.D., F.E.C.P., President, in the Chair.
Scanes Spicer, M.D., ) gecretarieg
W. E. H. Stewart, F.E.C.S., j becretaries -
Present—29 Members and 8 visitors.
The minutes of the previous meeting were read and confirmed.
The following gentlemen were elected members of the Society:
Mr. John Back, 54, Eodney Street, Liverpool.
Dr. John Walton Browne, 10, College Street North, Belfast.
Mr. Andrew John Brady, Sydney, New South Wales.
Mr. Arthur H. Cheatle, 117, Harley Street, W.
Mr. John Macintyre, 179, Bath Street, Glasgow.
Dr. Arthur E. Eeynolds, 36, Washington Street, Chicago, U.S.A.
Mr. Walter Eidley, Ellison Place, Newcastle.
Mr. Edwin C. Stabb, St. Thomas’s Hospital.
The following gentlemen were proposed for election at the next
Ordinary Meeting :
Mr. J. J. Perkins, M.B.Cantab., Hospital for Consumption and
Diseases of the Chest, Brompton.
Mr. W. G. Armstrong, M.B.Sydney, Sydney, New South Wales.
Mr. H. Lambert Lack, M.B.Lond., F.E.C.S., 55, Welbeck Street, W.
Dr. Arthur E. Eeynolds, having signed the Eegister, was admitted
a member of the Society by the President.
first series—vol. hi.
2
12
A Microscopical Section op Myxoma op Larynx.
Shown by the President. The section, which includes the entire
tumour, consists throughout of an open meshwork of delicate fibrillae,
in which lie moderate numbers of multiform cells, furnished with deli¬
cate processes which construct the reticulum mentioned.
The growth is moderately vascular, and is covered with normal
stratified squamous epithelium.
Case op Paralysis of Left Vocal Cord.
Shown by Dr. J. B. Ball. A. N—, set. 36, a clerk, came to the
West London Hospital on the 7th September last) complaining of
weakness of voice and hoarseness, which had lasted for six weeks. He
attributed his symptoms to having over-exerted his voice during the
Hammersmith election, a few days after which the voice trouble began.
The left vocal cord was found fixed in the position of complete para¬
lysis, and has so remained. He had syphilis eight years ago. No other
illness of importance. No cause, intra-thoracic or otherwise, can be
found for the laryngeal condition. He took ten-grain doses of iodide
of potassium for the four weeks following his first attendance at the
hospital.
Dr, de Havilland Hall mentioned a case of complete paralysis of
the left vocal cord, in which the paralysis preceded the signs of aneu¬
rism by about twelve months; at the post-mortem some eighteen
months later an aneurism of the transverse part of the arch of the
aorta was found. He also mentioned a case he had seen with the
President in which physical signs of aneurism were very imperfectly
marked for some months, but they afterwards became distinct. He
suggested that the case in question was possibly due to aneurismal
pressure.
Dr. Bronner suggested that the paralysis might be of central
origin. It was frequently so in the case of the eye, why should it not
be so in these cases ?
The President said it was possible the paralysis was of central
origin. It was impossible to find out the cause of these cases in five
minutes. The more they were seen, the more inexplicable they were.
It was very desirable to keep them under observation, and not to
neglect the post-mortem. Tabes should be borne in mind, and the
reflexes always examined.
Dr. Ball, in reply, stated that the reflexes iu this case were normal.
18
A Case op Neurosis op the Larynx due to Laryngitis compli¬
cating Typhoid Fever.
Shown by Mr. Bowlby. The patient, a lad set. 18, was admitted
to St. Bartholomew's Hospital under the care of Dr. Hensley on
August 27th, 1894. He suffered from typhoid fever without complica-
tion until September 1st, when he began to be deaf, and by September
11th had completely lost his hearing. On September 30th, when the
fever had nearly subsided, he began to be hoarse, and on October 2nd
had symptoms of laryngitis. On October 3rd, as he was suffering from
severe dyspnoea, Mr. Bowlby was asked to see him. There was great
swelling of the whole larynx, especially of the arytaenoid cartilages and
the ventricular bands, and slight ulceration of the posterior attach¬
ment of the left cord. Neither cord moved at all freely, the left
being almost fixed. The opening of the glottis was very narrow.
There was much stridor, the patient was cyanosed, and recession was
marked. Tracheotomy was at once performed, with immediate relief.
On October 9th there was great swelling of the arytaenoid region,
simulating that of tubercle.
November 5th.—Left arytaenoid flattened, but general swelling less
and no ulceration. Cords very fixed, especially left.
18th.—Tube removed for a few hours, but had to be replaced.
December 11th.—Can breathe through larynx for some time with
tube plugged.
January 4th.—No further improvement. Left cord fixed. No
sign of present inflammation. A good deal of subglottic thickening.
In February and March, 1895, repeated attempts were made to
dilate the larynx. After it the patient could do without the tube for a
few hours; he could not, however, continue to breathe without it.
His voice was nearly restored, being only a little hoarse. From
February to the present time there has been no material change.
There is now general thickening of the whole larynx at the subglottic
region; the left cord is practically fixed, and the right moves imper¬
fectly. The patient is very anxious for any operation that will enable
him to dispense with his tracheotomy tube, and it is suggested that
the left cord and adjacent mucous membrane and scar tissue might be
excised with advantage.
14
Dr. Scales Spicer stated that he had brought a similar case before
the Society a year ago. It was then su22ested that dilatation should
be tried with Whistler’s dilator and Schrotter’s tubes. It was found
impossible to use the latter. The larynx was opened and some
mucous membrane removed. An intubation tube was inserted, but
as soon as it was removed dyspnoea occurred, and the patient had to go
back to the tracheotomy tube attain.
Dr. Dundas Grant had a similar case, in which intubation did no
good.
Mr. C. Symonds referred to the case he showed at the last meeting
of the Society, in which the results of removal of the cord and soft
tissues adjacent were shown.
The President remarked that in a case in which he had been
consulted, tbyrotomy had been performed against his wish, as he felt
sure the voice would become worse; the results, however, had been
very good. He stated that it was astonishing the amount of voice
retained in these cases where the cord and adjacent soft tissues were
removed.
Mr. Bowlby, in reply, stated that he would put the risks with
regard to the loss of voice before the boy, and leave it to him to say
whether he would have the operation performed or not.
Case for Diagnosis.
Shown by Mr. Bowlby. This patient had a swelling externally on
the left side of the middle line, and there was a blackish-looking mass
in the larynx.
Mr. Butlin thought the external swelling was either a high
thyroid cyst or a low hyoid one. The internal mass looked suspicious,
but he should be inclined to try the effects of mopping well with a
brush, as it might be hardened mucus.
The President thought it was most likely mucus, and related a
case that he had seen at Golden Square many years ago, which he had
thought was an angioma, but which had turned out to be hardened
mucus.
Microscopic Specimen of Hemorrhagic Myxoma of Lingual
Tonsil (in Albuminuric Patient).
Shown by Dr. A. Bronner. The specimen was from a woman set.
85 . Bor eight days had difficulty in swallowing, with expectoration
of blood. There was a large tumour about the size of a walnut on
the right side of the lingual tonsil, which came away spontaneously
in three days. There was a thick capsule with concentric layers of
red tissue. There is now the stump with small branches to be seen
on the right side of the lingual tonsil.
16
Dr. Pegler said he thought the growth consisted of adenoid, lym¬
phoid, and fibrous tissue; could not distinguish any myxomatous
tissue.
A Case showing Regeneration of Tissue along Inferior Crest
AFTER TURBINECTOMY.
Shown by Dr. William Hill. This was the case of a female, set.
21, whose left inferior turbinal he had completely removed six months
previously for the relief of marked obstruction in association with a
narrow choana. After the operation granulations sprang up along
the inferior turbinal crest; these organised, and the left nostril now
presented a regeneration of tissue which in appearance simulated a
fair-sized, soft, inferior turbinal body. The result was at present
excellent, and did not bear out the fears that had been expressed in
some quarters that turbinectomy would lead to atrophic changes in
the nose.
Dr. Pegler said the regrowth appeared to him to consist of a
moveable body, which on being pushed back with a probe nearly
touched the septum, and constituted a source of obstruction to free
nasal respiration on that side. He did not distinguish any regenera¬
tion of turbinal erectile tissue in front of or behind it. The portion
of growth he referred to was, he thought, distinctly oedematous, and if
Dr. Hill decided to snare it off, he should be glad to know the result
of the microscopic examination.
In reply to Dr. Pegler, Dr. Hill did not think the appearance of
the regenerated tissue in any way suggested a localised oedema. He
was inclined to expect that the granulation tissue had become
organised into gland tissue covered by mucous membrane, and it was
just possible that vascular tissue might also have been regenerated.
The following pathological specimens were shown by Dr. A. A.
Kanthack :
1. Typhoid Ulcer of Larynx.
There is a large ulcer just below the left processus vocalis. There
was also perichondritis; a probe passes easily down as far as the
upper margin of the cricoid cartilage.
Dr. William Hill said that the ulceration seemed to be just
where the cartilages of Elsberg are in the vocal cords. It was possible
that this was the cause of the ulceration here.
2 §
2. Diffuse Papillomatous Hypeb.tb.ophy of the Laryngeal
Mucosa.
This specimen somewhat resembles the one exhibited at the last
meeting. The child from whom it has been removed died suddenly of
asphyxia. Looking into the aditns laryngis from above, we see that
it is completely blocked by a dense papillomatous growth which filled
up the whole of the larynx. The posterior wall of the trachea and a
portion of the cricoid plate have been removed, so as to allow of a
glance into the larynx from below. We find that the growth extends
not only below the cords as far as the lower, border of the cricoid, but
even lower down, just below the tracheotomy wound (tracheotomy
being done too late to save the child), a few small warty growths can
be seen.
On microscopic examination the tracheal growths are distinctly
papillomatous, and lined by a thick layer of a squamous epithelium.
The epithelium at either side of the warts is of the stratified columnar
type, heaped up in many layers, and in fact in the transition or meta¬
plastic condition from the single columnar layer through the stratified
columnar type to the squamous or epidermal type. In the sinuses
which we find between the papillary outgrowths of the tracheal mucosa
the epithelium, though several layers deep, is typically columnar.
A microscopical specimen of the tracheal wart is shown under
the microscope.
3. Empyema of the Maxillary Antrum.
The specimen was removed from the body in the condition in which
it is now. The bicuspids have disappeared (through caries and removal
probably); the anterior plate of the alveolar process is thinned and in
part destroyed. A glass rod is passed up through the opening in the
alveolus into the antrum, there being therefore a direct communication
between the antrum and the cavity of the mouth.
The lining of the antrum is much thickened, especially below and
posteriorly, where a thick polypoid mass projects into the dilated cavity
of the antrum. Through the deficiency in the anterior alveolar plate,
the inflammatory material must have found a ready exit into the sub¬
cutaneous tissue of the cheek.
Dr. Scanes Spicer remarked that a very large opening would have
been necessary in this case to remove thoroughly the growths.
17
Case of Pachydermia of the Interaryt^noid Fold.
Shown by Dr. Percy Kidd. The patient, Elvina P—, set. 83, has
suffered from hoarseness for seven or eight years.
On examination the interarytsenoid fold shows marked swelling of a
greyish pink colour. The prominence is irregularly divided into two
parts, that on the left side being the larger. The vocal cords are both
somewhat thickened, and the movements of the right are distinctly
impaired. When the patient was first seen, five or six months ago,
the interarytsenoid fold presented two symmetrical plate-like promi¬
nences separated by an indistinct furrow, but this appearance is now
less marked. There is no evidence of syphilis or any other disease.
The treatment has consisted in the exhibition of iodide of potassium,
the local application of Mandl’s solution of iodine, and the use of lactic
acid, 1 to 2 per cent, solution, in a Siegle's steam spray apparatus.
The spray was suggested by Prof. Moritz Schmidt, who saw the
patient at Brompton last July.
On the whole the swelling has slightly diminished, but the voice
remains unaltered.
Mr. Butlin thought the case might be one of tubercle, from the
situation and oedema. He should take a portion off for microscopical
examination; suggested the application of the galvano-cautery.
Dr. Bronner had a case he treated with the galvano-cautery;
this had made the patient worse. He then removed a portion with
forceps. There was, after this, some slight improvement.
Mr. C. Symonds thought it was tubercle, as there was so much
hoarseness; he would suggest treatment by the curette and lactic acid.
Dr. Tilley remarked that he had shown a case about six months
previously with exactly the same appearance. The pain caused waB,
he thought, due to the fissure. His case had lactic acid applied twice
a week, which made no difference. He removed a portion with the
curette, and the voice at once improved. He thought the throat had
got better since the patient had given up alcohol,
The President remarked that these cases were first noticed to occur
exclusively in drinkers, when Htinnermann wrote an inaugural thesis
on the disease at Virchow’s request.
Dr. Scanes Spicer looked upon them as cases of ordinary inflam¬
matory thickening; the tonsils and upper part of throat were also
thickened.
Dr. Dundas Grant inquired whether the electrolytic treatment had
been tried.
Dr. Kidd, in reply, said that he did not think the case was one of
tubercle. He would try and remove a portion with the curette.
18
Although there no distinct history of alcoholism the patient had
teen a uinnAil. He thought these cases were localised overgrowth
of tissue.
Pathological Specimen of Stphilitic Ulceration of the Trachea
with Cicatricial Stenosis of both Mate Bronchi.
Shown by Dr. Perct Kidd. The specimen shows diffuse ulceration
and thickening of the mucous membrane of the trachea, the ulceration
being more recent in the upper third, with some whitish cicatrices
toward the lower end. Xo definite stricture of trachea.
Ulceration extends into both main bronchi, which are slightly
stenosed from cicatricial contraction.
In the left lung there are circumscribed areas of fibrosis, one small
gummatous nodule, and two small cavities, probably due to softened
gum mat a.
The soft palate and pharynx were also scarred, and a cicatrix was
found on the penis.
Xo trace of tuberculosis could be discovered in any organ.
Case of Lupus of the Pharynx and Larynx.
Shown by Dr. Ed. Law. Patient, G. E—, set. 10, came to the
London Throat Hospital in September on account of “ something in
the throat.” Twice had chicken-pox, once measles; scarlet fever two
years ago, and has never been well since. Seven months ago the
mother first noticed the frequent efforts of the child to clear the throat.
Breathing was occasionally troublesome at night. At no time was
there pain or difficulty in swallowing. Patient is the seventh of
eight children ; the eighth died of “ consumption of the bowels/' One
sister has been to Yentnor with a bad cough, and has suffered from
lupus on the back of the hand for five years. There was much
infiltration of the soft palate and pillars of the fauces, with cicatricial
patches on the velum and right posterior pillar. Epiglottis was
greatly thickened and nodular, the tip destroyed by ulceration. Ary-
epiglottic folds and ventricular bands were cedematous and swollen.
The cervical glands are enlarged, and granulations are present in the
left ear. Dr. Law saw the patient for the first time ten days ago, and
was informed that she had gained in weight and the local trouble
had improved, whilst taking powders of Hyd. cum Cret. and syrup of the
10
iodide of iron. No local treatment has as yet been employed, but he
should scrape and apply lactic acid with the internal administration
of arsenic.
Case of Nasal Obstruction from Septal Deflection and other
Causes.
Shown by Dr. E. Law. Patient set. 17. Consulted Dr. E. Law
on August 14th for a stoppage in the nose, a discharge from the left
nostril, a desire to hawk in the morning, slight deformity, head¬
ache, sickness, liability to colds with loss of smell and taste. Exami¬
nation showed extensive deflection of septum to left, with a ridge-like
projection at the base; bony enlargement of right middle turbinate
pressing against concave surface of the septum. Large clusters of
adenoid growths, polypoid hypertrophies of the posterior extremities
of the turbinate bodies blocking up the choana ; a large accumulation of
mucus; very anaemic. Iron and arsenic were given and the adenoids
removed. The secretions diminished, and for a time patient was
slightly relieved. At the present time there is great discomfort and
inconvenience from nasal obstruction. The opinion of the members
is requested as to the most suitable operative procedure.
Dr. Tilley recommended that the anterior nasal spur on the left
side should be removed, then the posterior end of the turbinate on
that side. He suggested the use of Jones’s turbinotome, a modifica¬
tion of which he had had made by Hawksley.
Dr. Dundas Grant also suggested the use of the turbinotome.
Dr. Hill said that when it was desired to remove only the posterior
extremity of the inferior turbinal, but not the whole body, he had
found it useful to detach the posterior extremity of the turbinal from
the turbinal crest for half an inch or more with Carmalt Jones’s
turbinectome, and then remove the portion desired by a snare, which
was readily inserted and retained in the groove thus made.
Dr. Law, in reply, stated that he should feel inclined to try and
remove the hypertrophied tissue from the choana and the anterior
extremity of the right turbinate before interfering with the septum.
If such treatment did not relieve the obstruction, he would then
remove the spur.
A Warty Growth of Suspicious Nature on Left Vocal Cord
in a Man aged Fifty-four.
Dr. Scanes Spicer showed this case. Patient has had hoarseness
for two years.
20
On examination the left vocal cord ia injected, projects slightly, and
lags a little in movements; at centre of ligamentous portion is a dusky,
purplish, well-defined, spherical, sessile nodule ; no ulceration to be seen.
There is no difficulty of swallowing or breathing; no pain, no loss
of weight, no history of syphilis, no enlarged glands externally. The
age of the patient, the lagging of the cord, and the injection surrounding
the growth suggest the possibility of malignancy, against which the long
duration of hoarseness in statu quo militates. The patifent had been tak¬
ing Pot. Iod. gr. xv t. d. s. for a fortnight. Opinions were invited.
Dr. Percy Kidd thought the case one of angioma, and would
attempt removal.
The President and Mr. Butlin both recommended an attempt at
endolaryngeal and microscopical examination before splitting larynx.
They regarded growth as suspicious, but more probably it was recur¬
rent.
The President also said that some time ago he had a patient aged
sixty-three, on whom he performed tbyrotomy; the right vocal cord
was removed, recurrence occurred as a red round growth without
infiltration at the anterior commissure. Examination after removal
showed this to be a granuloma.
Case of Malignant Disease of the (Esophagus in a Girl
aged Twenty-three.
Shown by Mr. W. JR. H. Stewart. E. H—, set. 23, female servant,
came to the London Throat Hospital on September 11th, complaining of
difficulty in swallowing solids. Three months previously she began to feel
soreness in the throat, especially on swallowing. This increased so that
deglutition became quite painful, chiefly in respect to solids, though at
times she could not get down liquids. Father died of “ consumption
one brother and two sisters died young, cause unknown. Has two
brothers and two sisters alive and in good health. No history of
syphilis obtainable.
Examination .—On the wall of oesophagus is an ulcerating swelling.
On digital examination a firm mass can be felt, which bleeds readily.
Both ary taenoids are swollen and reddened. Had haemorrhage from throat
during the night of October 21st. Secretions removed from growth,
and examined by Mr. Waggett, showed no tubercle bacilli. Patient
has been on Pot. Iodid. gr. xv three times a day without improvement.
She has also had arsenic. Mr. Stewart had no doubt about the dia¬
gnosis, notwithstanding the age of the patient, more especially as it is
21
exactly like a case he had about a year ago in a young woman aged
twenty-nine, the specimen from which case he showed to the Society.
Mr. Bxttlin said there was no doubt about the diagnosis ; he had
recently a case in a girl aged twenty-four.
Case of Enlargement of Thyroid Gland in a Boy which
ALMOST BLOCKED THE LUMEN OF THE PHARYNX.
Shown hy Mr. Stabb.
A Case for Diagnosis—Tubercle or Cancer.
Shown by Dr.. Clifford Beale. The patient, a sailor set. 47, had
suffered for about two years from chronic tubercular infiltration of the
apex of one lung, and for about four months from a steadily increasing
loss of voice. The disease in the lung had never been very active, nor
had there been any marked emaciation. The voice was not entirely
lost, but was generally reduced to a hoarse whisper if the patient
attempted to use the voice much. On examination the left side of the
larynx was seen to be affected. The left ventricular band was swelled,
and just below it was an angry-looking fleshy prominence which seemed
to project from the ventricle, partly concealing the cord below, which
appeared to be irregularly thickened. When first seen the left side of
the larynx hardly moved at all on attempted phonation, and by palpa¬
tion externally a small enlarged gland could be felt. Under observa¬
tion, but with no local treatment, these conditions improved consider¬
ably in the course of three weeks. The movement of the left side
became free, although not so good as that of the opposite side. The
enlarged gland could no longer be felt, and the internal swelling,
although not much altered in size, was much less angry in appearance.
This improvement, which took place pari passu with a similar improve¬
ment in the lung, suggested that the infiltration in both organs was
probably tubercular.
Mr. Butlin was not sure of the diagnosis; would suggest closely
watching the case.
The President said the movements of the cord were not quite free.
He suggested malignant disease, but would try the effect of iodide of
potassium.
Dr. Hall had a similar case, which was undoubtedly tubercular.
22
A Case of Swelling of the Submaxillary Gland (dub to a
Salivary Calculus).
Shown by Dr. Dundas Grant. A. S. P—, set. 15, complained of
a lump in the throat, namely, in the right submaxillary region. A
small swelling had been present for about twelve months, but within
the last two weeks it had got much larger. When first seen there
was a considerable swelling, slightly lobulated, corresponding in
shape and position to the submaxillary salivary gland, and it was
found that it increased considerably in size during eating, and subsided
afterwards. There was considerable redness and swelling in the
neighbourhood of the orifice of Wharton's duct, which was covered
with a whitish exudation, and was extremely tender. The duct felt
harder than normal to the touch. It appeared that for about three
months there had been a swelling under the tongue, from which there
occasionally issued a little matter having a saltish taste. No calculus
was detected. Small doses of calomel and a mouth-wash of chlorate
of potash were prescribed.
On the 13th November the glandular swelling was much less, the
duct less swollen; there was a fistular orifice of the size of an ordinary
pin-head opening into the duct in the hollow between it and the tongue,
about three eighths of an inch to the right of the frsenum. On
closer inquiry it was elicited that a few days previously, while the
patient was gargling, two small “stones ” emerged, which were thrown
away.
Mr. Spencer had a similar case under him, in which he could find
no calculi when the duct was slit up ; he then scraped out the gland,
but this did not improve. So he had to excise the gland, which on
examination showed calculoid disease.
PROCEEDINGS
OF THB
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, December 11th, 1895.
Felix Semon, M.D., F.R.C.P., President, in the Chair.
Scanes Spicer, M.D.,
W. R. H. Stewart, F.R.C.S.,
Secretaries.
Present—29 Members and 2 visitors.
The minutes of the previous meeting were read and confirmed.
The following gentlemen were elected members of the Society:
Mr. W. Q-. Armstrong, M.B., C.M.Syd., Sydney.
Mr. H. Lambert Lack, M.B.Lond., F.R.C.S., 55, Welbeck Street, W.
Mr. J. J. Perkins, M.B.Cantab., Consumption Hospital, Brompton.
Mr. Ewen Stabb, having signed the Register, was admitted a
member of the Society by the President.
Dr. de Havilland Hall and Mr. Spencer were nominated as
Auditors.
The President announced that the Annual Dinner would take place
in January at the Caf6 Royal.
Papilloma of Nose.
Mr. Cresswell Baber gave a further account of the case (Rev. —,
set. 36) which was shown before the Society on April 10th, 1895.
On April 22nd the growth, which was attached to the floor of the
nasal cavity and lower part of the septum, was removed (under gas
and ether) with knife and curette, bringing away in addition to the
soft tissue a small piece of cartilage apparently from the floor of the
nose. The wound, which extended down to the bone, was then freely
3
FIRST SERIES—VOL. III.
24
touched with the galvanic cautery. It healed satisfactorily. There
was a slight growth of soft tissue on the septum, further back behind
the original growth, which appeared on removal to be mostly granula¬
tion tissue. When the patient was last seen (November 29th) there
was no sign of any recurrence of the growth, and the healed surface
was quite smooth. Microscopic examination showed the growth to
be papilloma; the detailed report (for which I am indebted to
Mr. H. H. Taylor) is to the effect that the growth consists of a
number of branched processes. Each process is made up of:—(1) A
central fibro-nucleated tissue which is sharply defined from and
supports (2) a thick layer of epithelium, the deepest cells of which
are from eight to ten in thickness, placed longitudinally to the surface,
with oval nuclei. The cells above these are larger, irregular in
outline, and contain large nuclei. The most superficial cells are
flattened, and all, right up to the surface, contain flattened nuclei.
Mr. de Santi referred to a case shown by him at this Society a
year ago. It was that of a man who had a growth from the septum,
which on removal proved to be a true papilloma. It had not
recurred.
Dr. Hill stated that Dr. Scanes Spicer had shown a case of true
papilloma a little while ago. We had now had three cases of true
papilloma shown to the Society, and they all had grown from a point
near the entrance to the nose.
Case op Growth on Left Vocal Cord.
Shown by Dr. J. B. Ball. T. D—, set. 48, a mechanic, has
suffered from hoarseness for three years, which appears to slowly get
worse. On laryngoscopic examination a small tumour is seen,
pedunculated and freely moveable, attached by a broadish base to
the inner edge of the left vocal cord, about the junction of the anterior
third with posterior two thirds of the cord. It is about the size of a
small pea, smooth, and of a pale red colour. On phonation it lies
between the cords, preventing complete approximation. It has the
appearance of a soft fibroma.
Dr. de Havilland Hall considered it a soft fibroma of the vocal
cord.
Dr. W. Hill and Mr. W. R. H. Stewart thought the growth came
rather from the under surface of the cord than the outer edge.
25
Pathological Specimens op Tubercular Infiltration op
Pharynx and Tongue.
Shown by Dr. Clifford Beale. The two specimens were taken
from cases of long-standing tuberculosis of the lung. The ulceration
bad only appeared within a few weeks of the end, and seemed clinically
to be only of a superficial character. The microscopic examination,
however, very carefully carried out by Dr. Hugh Walsham, proved
that the infiltration of the tissues beneath the ulcers had extended
deeply into the muscular layers, both in the pharynx and on the
tongue. There had been remarkable enlargement of the papillae of
the dorsum of the tongue, but there did not appear to be any
connection between this and the tubercular infiltration. In one case
the tonsil was found to be free of any tubercular affection, although
during life it was constantly bathed in tuberculous debris from the
ulcer. The infiltration of the affected tissues had evidently begun at
a much earlier period than the ulceration.
Microscopical Section of Round-cell Sarcoma of the
Thyroid.
Shown by Dr. Bennett.
Case of Naso-Pharyngeal and Nasal Polypi.
Shown by Mr. L. Lawrence. E. L—, set. 20, a strong healthy-
looking girl, first noticed a stoppage in her nose about a year ago.
Since that time it has gradually been growing worse.
Both nostrils are practically completely blocked with nasal polypi
of the mucous variety. There is a large mass in the naso-pharynx,
chiefly on the right side. This presses on the soft palate. The naso¬
pharynx is not completely blocked. The mass is red and fairly firm
to palpation; no spontaneous bleeding has ever occurred. The patient
is not losing flesh, and there are no enlarged glands.
Mr. de Santi suggested it was a case in which the soft palate
should be^split, and the growth removed that way.
Mr. Cresswell Baber considered this a case of simple mucous
polypi in the nasal cavities and hanging down into the naso-pharynx,
26
which illicit l>c removed by means of a snare. It was important
to use rather stiff wire.
Mr. Spencer suggested that if it was not possible to get the growth
away with the snare, Lowenberg’s forceps should be tried.
Dr. Dundas Gkant would remove with polypus forceps.
Dr. Permewan thought the case simply one of mucous polypi, and
he would hesitate to recommend splitting the palate. He would use
the snare simply, and had lately removed an exactly similar one.
Mr. Waggett had generally found these growths were cystic on
examination.
Dr. Scanes Spicer thought this case was undoubtedly cystic, and
would recommend the use of polypus forceps if the snare failed.
Mr. Lawrence, in reply, thought he would be able to remove the
growth with a snare.
Pathological Specimens op Tubercular Ulceration of
Trachea, Larynx, and Pharynx.
Shown by Mr. de Santi.
1. Male, set. 28, began to be ill October, 1894; signs of phthisis
soon manifested themselves, and he gradually got worse. Throat
became painful and he lost his voice beginning of October, 1895.
Laryngoscopic examination showed well-marked tubercular disease of
larynx. At the beginning of November an ulcer about the size of a
sixpenny piece was found in posterior wall of the pharynx. Patient
died November 20th.
Post-mortem. —Well-marked extensive phthisis and empyema;
well-marked tubercular ulceration of trachea and larynx. Tubercular
ulcer size of a sixpenny piece in posterior w all of pharynx.
2. This man was operated on for tubercular disease of right
metatarso-phalangeal joint in October; he was suffering from phthisis
at the time. The disease rapidly increased. In the beginning of
November miliary tubercles were found on the soft palate, fauces, and
pharynx.
Post-mortem .—The pharynx and fauces are the seat of tuberculous
deposit and ulceration. There is a small ulcer at base of the left
vocal cord.
Dr. de Havilland Hall said he had another similar case under
him ; it was extremely rare to have three cases of tubercular disease of
the pharynx in the ward at the same time.
27
A Case poe Diagnosis.
Shown by Dr. F. Semon. The patient, a gentleman set. 85, was
sent from Western Australia by Dr. H. J. Lotz, an old St. Thomas's
man, with the following history.
He caught cold twenty years ago, and has been hoarse ever since.
Four years ago he had what was called a sarcoma removed from the
testis, but subsequent attendants had thrown doubts on the correctness
of this diagnosis. Fifteen months ago he caught fresh cold, after this
he suffered from dryness of the throat and cough in the morning.
For two or three months at that time he occasionally brought up some
blood. He consulted a specialist in Adelaide, who found thickening
of the vocal cords. After this the throat gradually got weaker, and
ultimately the voice was almost lost. He saw another specialist in
August of this year in Adelaide, who found a growth in the larynx,
and removed a portion for diagnostic purposes. The piece removed,
however, was too small to make microscopic sections. Till this he
had never complained of any pain or feeling of discomfort in the
throat. In October of this year he caught a fresh cold, his throat
began to feel raw and dry, and the cough in the morning increased.
On laryngoscopic examination Dr. Lotz found congestion of the
mucous membrane of the larynx. The left ventricular band was
swollen, particularly anteriorly, and presented here a small excrescence,
which was of the same colour as the surrounding mucous membrane.
The right vocal cord was very much ulcerated. There was no ulcera¬
tion on the left vocal cord, which moved fairly well. On the left side
of the laryngeal surface of the epiglottis there was a narrow streak of
superficial ulceration. Externally the thyroid glands were felt
enlarged. The patient was ordered to take 15 and 20-grain doses of
iodide three times a day for about a month, and during that time he
put on flesh and felt much better; his voice had also improved, but
this, in Dr. Lotz’s opinion, may have been due to the improvement in
the acute laryngitis produced by instrumental interference. Nothing
abnormal could be detected in the lungs. The sputum was repeatedly
examined for bacilli without results. There was no history of syphilis.
Dr. Lotz, who was unable to decide as to whether the affection
was tubercular or syphilitic, sent the patient for diagnosis.
On examination the remnants only of the condition described by
3§
28
Dr. Lotz were found, with exception of the condition of the left ven¬
tricular band, which even now shows the remains of the excrescence
described by him. The right vocal cord, which at the time of the
patient leaving Australia was described as “ very much ulcerated,”
shows only very superficial ulceration in the neighbourhood of the
vocal process, and moves well. On the epiglottis the ulceration on
the left side has been replaced by two spots of white discolouration.
The left vocal cord is still somewhat swollen, but the voice is much
better. Patient has been taking iodide of potassium all through.
The questions arising are:
1. Is the affection tubercular or syphilitic ?
2. Has it anything to do with the “ sarcoma ” removed four years
ago?
3. What is the nature of the excrescence of the left ventricular band ?
Dr. Scanes Spicer thought that the bright redness of the parts
pointed to syphilis.
Dr. Poore noticed that the left vocal cord did not move properly.
Dr. Hill did not think it was tubercular. He stated that in some
parts of Europe there was a kind of ulcerative laryngitis, but in this
case there were no crusts found. The patient had evidently improved
since he left Australia.
Dr. Semon, in reply, said he had not yet made up his mind what
the case was; the epiglottis looked like syphilis, the vocal cord like
tubercle, and the ventricular band—he did not know what it looked
like.
A Case of Laryngeal Stenosis.
Shown by Mr. W. G. Spencer. A woman, set. 53, was at first
under the care of Dr. de Havilland Hall, who then found a chronic
laryngitis secondary to hypertrophic rhinitis. The latter was cured,
but the larynx did not improve. There is now extreme laryngeal
stenosis, so that with the deepest inspiration the larynx does not
dilate to more than 2 mm. at the widest part. There is a hard mass
between the arytsenoids and in front of the cricoid.
On several occasions she has had attacks of dyspnoea, which have
been relieved by lactic acid in increasing strength up to the full
B.P. acid.
Should operative measures become imperative, excision of the vocal
cords will be tried; but there have not yet been indications sufficient
29
for an operation not only dangerous but of doubtful efficacy. In all
probability the framework of the larynx would sink in. Small
operations such as the cautery or curette would only tend, it would
seem, to further narrowing.
The disease is now stationary, a fibrous contracture has involved
the inter-arytaenoid fold, the perichondrium, and probably the nerve-
fibres of the abductor muscles.
Dr. de Havilland Hall stated that the patient had been under
his care, at intervals, for upwards of twelve years. At first the patient
suffered from chronic laryngitis with subacute exacerbations. At
this time there was marked nasal stenosis due to hypertrophic
rhinitis. Dr. Hall suggested that the chronic hypertrophic laryn¬
gitis or fibrosis of the larynx was due to interference with nasal
respiration.
The President said that if such a case as this was due to nasal
obstruction, why was it not more often seen ? He would like to know
on what grounds such a suggestion was made.
Dr. Scanes Spicer agreed with Dr. Hall in maintaining, as a
general truth, that an unfavourable influence was exercised by chronic
nasal obstruction (and its resultant—mouth breathing) on the mucous
membrane of the larynx, trachea, and lower respiratory tracts, in pro¬
ducing and maintaining congestive and inflammatory states. He
thought that in this case the nasal obstruction which Dr. Hall found
must have had a pernicious influence, and that it bad rightly received
attention. With reference to the present condition of the patient, he
advised curettement (with Krause’s double laryngeal curette) of the
large hypertrophic or pachydermatous mass of the posterior wall,
preferably at once, but at any rate on the slightest increase in
laryngeal stenosis.
The President said he would like to know how many cases such as
this, in which the nasal obstruction was supposed to have caused the
condition of the larynx, had occurred. He did not believe it was thus
brought about. Why should the larynx be deemed incapable of
suffering from a chronic inflammation and thickening, independently
of the nasal trouble ? Of course if there was concurrent mischief in
the nose it ought to receive treatment.
Mr. C. Baber did not think that obstruction of the nose could
mechanically produce the condition of larynx seen in this case. He
thought that the inflammatory trouble might be of the same character
in the nose and larynx.
Dr. Dtjndas Grant, while a great believer in the influence of nasal
obstruction in producing laryngeal disease, could not consider the
hypertrophic rhinitis described as sufficient to produce such extreme
changes. He had seen similar conditions follow nasal disease, but
only nasal disease of a purulent nature, presumably suppuration in
the sphenoidal or other sinuses, the infective material inhaled from
these infecting the interior of the larynx, and setting up severe
inflammatory conditions.
30
Dr. Permewan failed to see any real evidence that this laryngeal
condition was secondary to nasal obstruction. He regretted the
tendency to deny to the larvnx a liability to primary disease. In this
case he thought the infiltration was under the perichondrium as well
as in the mucous membrane, and that there was ankylosis from
arthritis of the crico-arytaenoid joint.
Dr. St. Clair Thomson asked if chronic alcoholism as a cause had
been excluded, and if the classical treatment by salt-water spray and
paintings of solution of nitrate of silver had been used.
Dr. de Havilland Hall, in answer to Dr. W. Hill, said that there
was no history of an acute attack of laryngitis.
Mr. Spencer, in reply, said he did not see the case until three years
ago. He thought a purulent catarrh, as suggested by Dr. Dundas
Grant, had taken place, and a thickening of the perichondrium had
been caused. The case had now been stationary for three years.
There was no history of chronic alcoholism; nitrate of silver had been
tried without effect. He thought curretting would do more harm than
good. Lactic acid was now being tried.
A Case op Thyroid Disease after Operation.
Shown by Mr. Ewen Stabb. This was the lad shown at the last
meeting of the Society; the tumonr had been removed and the wound
was quite healed.
Mr. Stabb, in answer to Dr. Poore, said there was a distinctly
cretinous history in this case.
Case of Large Fibroma op the Nasal Septum.
Shown by Mr. W. E. H. Stewart. W. G—, set. between 50 and
60, came to the Great Northern Central Hospital in May last for
complete blockage of the nose and some haemorrhage. He stated
that he had a blow on the nose forty-four years ago. Twenty-five
years ago the nose began to get blocked. He then saw a doctor, who
told him that a serious operation would be necessary to thoroughly
remove the growth. Nothing was done, and the case gradually
became worse until complete blockage of both sides was established.
The nose was considerably bulged on the left side. Examination
revealed a large tumour projecting slightly from the anterior naris and
filling up the naso pharynx. A small portion removed for micro¬
scopical examination proved to be fibrous tissue. Under an anses-
thetic an attempt was made at removal by the ^craseur, but it was found
31
impossible to get the wire between the roof of the naso-pharynx and
the tumour. Further digital examination seemed to indicate that its
origin was the base of the skull. A week afterwards Mr. Macready,
at Mr. Stewart’s request, after a preliminary tracheotomy turned
back the upper jaw on the left side, performing a slightly modified
Mansell-Moullin operation. The tumour was pulled away with some
difficulty, the posterior knob being firmly held by atmospheric
pressure in a rounded hollow in the base of the skull. The growth
measured when fresh 4 x x If inches, and was found to have
grown by a very small pedicle (which contained a piece of bone) from
a ridge on the much distorted septum. Mr. Waggett reports that
the microscopical examination of a section from the centre of the
growth showed it to be composed of a very dense white fibrous
tissue arranged as lobes growing from a less dense central hilum
which contained spicules of bone near the pedicle. The patient made
an uninterrupted recovery. This is, as far as published records go, an
unique case. The only account of a pure fibroma growing from the
nasal septum to be found is one recorded by Lefferts; this was the
size of a hazel-nut, and growing low down near the anterior naris. Mr.
Stewart expressed his indebtedness to Mr. Waggett, not only for his
careful research amongst the literature on the subject, but also for some
excellent drawings of the fresh tumour made a few hours after removal.
Mr. Waggett said that a very small number of firm fibrous septal
tumours are recorded in literature, and in most of these there was a
traumatic history. The largest was the one reported by Lefferts, and
that was the size of a hazel-nut, so that the present case is quite
unique in point of size.
The Pbesident suggested that as this was an unique case, a wood-
cut should be obtained for insertion in the Society’s * Proceedings.’*
Mr. Simonds communicated further notes of two cases of disease of
the septum nasi shown in October. In the case of the man
W. H. C—, set. 48, the ulceration, and thickening of the septum, and
the obstruction rapidly disappeared under iodide of potassium. In
the boy, A. H—, set. 16, the disease proved to be tubercle, both by
tbe microscopical appearance of the section and by the presence of
bacilli. The chief mass was removed, leaving a large aperture iu the
septum, and he was still under treatment by lactic acid and the curette.
* The woodcut will be issued as soon as possible.
32
Case for Diagnosis.
Shown by Mr. E. B. Waogett. A woman, ®t. 54, gave a history
of an impacted fish-bone with symptoms persisting for fourteen
months. The pharynx, examined two months after the accident, was
acutely inflamed. There was a small swelling on the lateral
epiglottic fold, which remained unchanged, with persistence of dis¬
comfort and pain, for fourteen months. There is no localised inflam¬
mation, and no evidence of a wound or of a foreign body.
Dr. W. Hill thought it was a small keloid tumour.
Dr. Poore would like to hear if anyone had ever found a fish-bone
in the throat; and what became of those not found.
The President stated that in nine cases out of ten no foreign body
could be found, but it was necessary to continue the examination for
some time. In one case he had, after half an hour’s search, found a
bone three-quarters of an inch long in the tonsil, only a very small
portion of which was showing.
Mr. Spencer said that after a time ulceration sets up and the fish¬
bone comes out. Sometimes, of course, this becomes a very dangerous
process, the large vessels becoming perforated.
Mr. Waqqett, in reply, said that the swelling was freely moveable,
and therefore probably not keloid as suggested. Dr. Whistler had
removed a fish-bone an inch long which had remained undetected,
after frequent examination extending over several weeks.
Case of Inspiratory Spasm of the Vocal Cords.
Shown by Dr. W. A. Willis. Mrs. M. D—, married, set. 44,
came to the out-patient room at the Westminster Hospital on
November 7th suffering from dyspnoea and huskiness, which had come
on the previous day.
Her respirations were 50 per minute and pulse 120, and there was
some lividity. On examination of the larynx there was slight laryn¬
geal catarrh, and with inspiration spasmodic approximation of the
vocal cords leaving only a narrow chink at the posterior part of the
glottis.
She said she had had similar attacks to the present during the last
six or seven years, but not so severe.
She was ordered to keep in a warm room and to use pine oil
inhalations, and in the course of the next ten days she improved; but
33
the spasm was still present on the slightest excitement or exertion, she
was therefore sent into the ward under Dr. Hall, to whose kindness
Dr. Willis is indebted for the opportunity of showing her to-day.
There she has steadily improved with the exception of one night
about a week after admission, when there was so much spasm that she
had to use chloroform inhalation.
Under ordinary circumstances there is now no spasm, but laryngo-
scopic examination is generally sufficient to reproduce the condition.
There is no evidence of marked hysteria in this patient though she
may perhaps be somewhat emotional, but the laryngeal condition may,
it is presumed, be looked upon as entirely functional; such cases,
however, are not free from danger of asphyxia, notwithstanding the
absence of organic disease.
Dr. Scanes Spicer thought this was a case of real abductor
paralysis.
Dr. Permewan drew attention to the spasm of the soft palate, and
would be inclined to emphasise the connection.
The President thought it was a case of perverted action of the
vocal cords. He remembered a similar case at Golden Square, in
which a cold douche produced functional aphonia.
Dr. W. Hill had a similar case for some months under bromide;
she got better, but she also had functional aphonia.
Dr. C. Beale drew attention to the fact that the glottis did not
completely close, and the patient could breathe during a spasm.
The President said that for making a differential diagnosis
between such a case as this and one of bilateral paralysis it was
necessary to make the patient phonate as long as possible, he then
must take a breath; in these cases at this moment the vocal cords
separate widely, in bilateral paralysis they become tightly closed.
ERRATA
In No. op ‘Proceedings,’ November 13th.
On page 11, for Mr. John Back read Mr. John Bark.
„ 11 „ Mr. Edwin C. Stabb read Mr. Ewen C. Stabb.
„ 13, line 1, for Neurosis read Stenosis.
„ 20 „ 12, after endolaryngeal insert removal.
20 „ 13, in place of the word recurrent read a fibroma.
PROCEEDINGS
OF THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Annual General Meeting, January 8th, 1896.
Felix Semon, M.D., F.R.C.P., President, in the Chair.
Scanes Spicer, M.D.,
W. R. H. Stewart, F.R.C.S.,
Secretaries.
Present—33 Members and 2 visitors.
The minutes of the Third Annual General Meeting were read and
confirmed.
Dr. W. Hill and Dr. Pegler were appointed Scrutineers of the
ballot for the election of Officers and Council for the ensuing year.
The Report of the Council was read as follows and adopted:
Your Council has much pleasure in reporting that the Society con¬
tinues to increase in strength, and that there are now one huudred
ordinary members and nine honorary members.
During the past year the Society has had to lament the loss of one
of its most distinguished honorary members, in the person of
Dr. Wilhelm Meyer of Copenhagen, and one of its original members,
Mr. A. E. Durham. Dr. Y. D. Harris, an original member, has had
to resign, owing to a permanent engagement on the Society’s
meeting day.
As resolved at the last General Meeting, a Conversazione was given
at the Salle Erard, during the Annual Meeting of the British Medical
Association in London, to the foreign and provincial practitioners
taking part in the work of the section of laryngology, and was well
attended.
The Council have instituted a Morbid Growths Committee, to con¬
sist of Mr. Bowlby, Drs. Kanthack, Pegler, Mr. Waggett, and the
Senior Secretary, with power to add to their number.
The Council recommend that in future the Session should com¬
mence in November and end in June, instead of as heretofore, so that
first series—vol. hi. 4
36
a meeting would be held on the second Wednesday in June, instead
of in October.
The Treasurer’s Annual Statement was then presented as follows :
BALANCE-SHEET, 1895.
Income.
£ *. d.
Balance in hand from 1894 . 38 17 5
Subscriptions—
63 members at
£1 1*. . . £66 3 0
21 members at
£2 2*. . . 44 2 0
2 members at
£9 9*. . . 18 18 0
- 129 3 0
The two subscriptions of
£9 9$. each are composi¬
tion fees of Dr. Newman
and Dr. Davison (country .
members).
Total . . £168 0 5
Expexditube.
£ *. d.
Rent (20, Hanover
Square) and Elec¬
tric Light for
1895 .... £31 10 0
For last quarter of
1894, additional 2 17 6
- 34 7 6
Adlard for Printing and
Postage. 55 0 0
Miller and Woods, Electric
Fitting.110
Petty Cash—
Clarke (for index¬
ing volume,1895)£0 18 0
Mayer & Meltzer
(Spray) ... 0 4 0
Doughton, at¬
tendance, 1895 .2 0 0
Do. till May, 1896 1 5 0
Dr. Scanes Spicer
(includes index¬
ing volume,1894,
18*.) .... 1 19 3
Mr. Stewart . . 0 10 0
Bank charges . 0 0 10
- 6 17 1
Frank Rogers, Chemicals . 1 15 O
Balance in Teasurer’s hands,
Jan. 1, 1896 . . .. 68 19 10
Total . . £168 0 5
The expenditure for the year,
£99 7d., includes £315*.6<2.
for rent and indexing, 1894,
and £1 5*. paid in advance
for attendance at meetings
till May, 1896.
£99 0 7
5 0 6
The income for the year,
£129 3*., includes two
composition fees amount¬
ing to £18 18*.
£129 3 0
18 18 0
Ordinary income £110 5 0
Ordinary expen¬
diture . . . £94 0 1
Audited and found correct, F. DE HAVILLAND HALL.
January 6, 1896. WALTER G. SPENCER.
The Treasurer’s Report was then adopted.
37
The Librarian’s Report was then taken. He stated that several
additions had been made to the Society’s Library during the past year,
chiefly by foreign contributors, and that the principal foreign
periodicals had been regularly supplied in exchange for the Society’s
* Proceedings.’
The following works have been added to the Library since the last
catalogue was issued.
Presented by Professor Ferdinand Massei.
L’Intubazione della Laringe (Massarotti).
Lezioni Cliniche, sulla Malattie della Prime Vie del Respiro (Massei).
Presented by the authors .
Gimnastica vocale e polmonare (Grazzi).
Corps iStrengers de l’Oreille (Natier).
Polypes des Fosses Nasales (Natier).
L’Eclairages des Cavities de la Face (Tucker).
I/Ulcere perforant de la Cloison du Nez (Moure).
Cas de Rhinolithe Spontanee (Moure).
Empy&me du Sinus Sphenoidale (Moure).
Cas d’Angio-keratome de la Corde Vocale (Moure).
L’Obliteration Congenitale Osseuse des Choanes (Gouguenheim and Helary).
Vasogene (Bayer).
Du Catarrhe Naso-pharyngien (Vittorio Grazzi).
Fistule Brauchiale du Cou (Lichtwitz).
Angiome au Pharynx (Lichtwitz).
Laryngeal Paralysis in Chronic Nervous Disease (W. Permevvan).
Diseases of the Upper Respiratory Tract (P. Watson Williams).
Presented by Dr. Edward Law.
Textbook of Diseases of the Ear (Gruber, translated by Edward Law and C.
Jewell), 1st English edition, 1890; 2nd Eng. ed., 1893.
Reports.
Rendiconto delPAnno Scolastico, 1892-3; della R. Universita di Napoli.
Proceedings of u Nederlandsche Keel—Neus en Vorheelkundige Vereenigung.”
Med.-Chir. Soc. of Glasgow—Report of Discussion on Anaesthetics.
Proceedings of Brighton and Sussex Med.-Chir. Soc., 1893-4.
Verhandlungen der Laryngolischen Gesellschaft zu Berlin.
Corso Complimentaire di Oto-Rhino-Laringologia della R. Universita di Pisa
(Vittorio Grazzi).
Periodicals.
Revue Internationale de Rhinologie, Laryngologie, et Otologic,
ltevue de Laryngologie, d’Otologie, et de Rhinologie.
Archivi italiani di Laringologia.
Bolletino delle Malattie deirOrecchio, della Gola e del Naso.
Archiv fur Laryngologie, Bd. ii, Heft. iii.
Journal of Laryngology, June, 1895.
II Policlinico, Ann. 1, No. 8.
The Report was adopted.
38
It was proposed as a recommendation from the Council, that the
Sessions of the Society should in future commence in November
instead of October, and end in June instead of May. This was unani¬
mously adopted, and the Rules were directed to be altered to this effect.
The Scrutineers reported the result of the ballot as follows :
President .—Felix Semon, M.D.
Vice-Presidents. —E. Cresswell Baber, M.B.; A. Hodgkinson, M.B.;
Charters Symonds, F.R.C.S.
Treasurer. —W. Johnson Walskam, F.R.C.S.
Librarian. —E. Clifford Beale, M.B.
Secretaries. —W. R. H. Stewart, F.R.C.S.; St Clair Thomson, M.D.
Council. —J. B. Ball, M.D.; F. W. Bennett, M.D.; J. W. Bond,
M.D.; Scanes Spicer, M.D.; P. Watson Williams, M.D.
The Ordinary Meeting of the Society was subsequently held, the
President being in the Chair.
The President briefly returned thanks for his re-election for the
third time.
The minutes of the previous meeting were read and confirmed.
The following gentlemen were elected Members of the Society :
Mr. F. A. N. Bateman, L.R.C.P., M.R.C.S., 4, Charles Street,
St. James’s, S.W.
Mr. J. R. Whait, M.D., C.M.Edin., L.R.C.P.,M.R.C.S., Charlton’s
Fair, Hazel Gardens, South Hampstead.
The following gentleman was proposed for election at the next
Ordinary Meeting.
Dr. W. Bolton Tomson, M.D.Durh., M.R.C.S., L.R.C.P., Park
Street, West Luton, Beds.
Proposed by Mr. W. R. H. Stewart, Mr. H. T. Butlin, Mr. R. Lake.
Before commencing the business of the day the President stated
that he had received a letter from Professor Massei of Naples, an
honorary member of the Society, in which the latter, with reference
to a discussion which had taken place at a recent meeting of the
Society concerning the explanation of obscure cases of laryngeal
paralysis, again drew attention to his view first brought forward at
the Paris Congress of Otology and Laryngology in September, 1889,
viz. that in many of these cases the cause of the paralysis was to be
sought for in a primary neuritis of the trunk of the recurrent
laryngeal nerve; and in which he further contended that the more
recent experiences of transitory paralysis of the recurrent laryngeal
after influenza strongly pointed towards the conclusion that this
statement corresponded to actual facts.
39
Case of Bulbar Paralysis, Progressive Muscular Atrophy,
Complete Paralysis of Left Abductor, Paresis of Bight
Abductor.
Shown by Dr. P. Semon. J. S —, labourer, set. 54. The patient
is an inmate of the Queen Square Hospital for Epilepsy and Paralysis,
under the care of Dr. Hughlings Jackson, F.R.S., who kindly
allowed Dr. Semon to show him. Duration of illness about fifteen
months. After influenza in October, 1894, a difficulty in swallowing
and articulation was noticed; this was soon followed by progressive
weakness of movements of right arm and leg. In September, 1895,
the same process began in limbs of left side. Ever since gradual
progress of affection. The muscles of the hands, particularly of the
right, are much wasted. There is no power over the explosives in
articulation, and he cannot pucker up his lips well. The right
orbicularis oris et palpebrse is weaker than the left; the right pupil
larger than the left. There is fibrillary twitching in the thigh and
calf muscles. The pharyngeal reflex is diminished on the right side
more than on the left. On phonation the palate is drawn up a little
to the right. No affection of sterno-mastoids and trapezii muscles.
The movements of the tongue are performed with some difficulty, the
organ is considerably wasted, and there are tremors on movement.
He loses breath when walking quickly, and has occasionally slight
choking attacks.
On November 12th, 1895, Dr. Semon made the following note :—
“ During quiet respiration the vocal cords stand nearer one another than
under normal circumstances, the distance being about 4 mm. On deep
inspiration no further opening of the glottis takes place, but, on the
other hand, the cords are not sucked together. The movements of the
left vocal cord are distinctly more defective than those of the right. On
phonation complete closure of the glottis occurs/' On December
19th it was seen that the abductor paresis of the left side had advanced
into total abductor paralysis, and that the free borders of both cords
appeared slightly excavated. Since then no changes have occurred.
Mr. Spencer, basing his remarks on bis experiments upon monkeys,
as well as on the results of other observers, maintained that although
the case was one of a wide-spread lesion, yet if any localisation could
be made it would be one of the lesions, viz. that which produces
difficulty of swallowing. The difficulty in swallowing, the paralysis
40
of the lower face, and the paralysis of the abductor fibres all agreed
with a lesion some distance above the calamus scriptorius in the floor
of the medulla. On the other hand, the freedom of the tongue, of the
abductor fibres of the larynx, and of the muscles of the neck indicates
that the lowest portion of the floor of the medulla and the upper end
of the spinal cord is not involved.
The President, in reply to Mr. Spencer, stated that it was impos¬
sible to fully discuss the large question as to the ultimate supply of
motor fibres to the larynx in the course of the present discussion, and
that he hoped at no distant date to more fully enter upon this im¬
portant subject. All he could say at present was that whilst fully
admitting the force of the anatomical researches made by Mr.
Spencer, Grabower, Grosmann, and others, he did not yet see his way
to reconcile the resurrection of the view that the vagus supplied the
motor innervation of the larynx with a large number of well-
ascertained clinical facts, and that in view of the frequent changes of
opinion concerning this question which had taken place from the
beginning of this century to the present time, he thought it wiser to
keep his mind quite open on this question. One thing, however,
appeared clear to him, viz. that cases like the one brought forward by
himself were not calculated to elucidate this question. A dis¬
seminated lesion or one extending over so large a tract as undoubtedly
present in this case was open to so many interpretations, that from
the clinical point of view alone it seemed to him impossible to argue
from it for the correctness of either view. It was in cases rather like
those brought forward by Hughlings Jackson, Stephen Mackenzie,
and others, in which there was associated lesion of one half of the
tongue, one half of the palate, the corresponding vocal cord, and the
corresponding sterno-mastoid and trapezial muscles or in cases such
as reported by Gerhardt,. in which clonic spasm of the last named
muscles was associated with twitching movements of the correspond¬
ing vocal cords that conclusions as to the innervation of the larynx
seemed justified, and such cases did not seem to him to speak in
favour of Mr. Spencer’s view.
Case op Excision op Larynx; Myxo-Chondroma of Larynx.
Shown by Dr. Bond. This patient a man of 50, had the whole
larynx removed in September, 1892, save the epiglottis and the
posterior and superior borders of the thyroid cartilage. The cricoid
cartilage, with the growth in lumen of it, weighed 11| drachms,
and was portrayed in * Lancet/ June 3rd, 1893. Eight days after
operation the patient was able to eat a chop. The patient has now
worn his artificial larynx for thirty-nine months and is in robust
health. He presents no signs of recurrence. His voice is good.
The case was shown at Clinical Society in 1893.
41
Case op Complete Excision op Larynx for Epithelioma ;
numerous Glands Eemoved.
Shown by Dr. Bond for Mr. Harvey. Tracheotomy was performed
on this patient in July, 1894, for laryngeal obstruction due to an
epitheliomatous mass affecting right cord, &c. The patient at that
time declined a radical operation. On August 14th, 1894, the whole
larynx was removed, but epiglottis left. Numerous glands were
Temoved from both sides, most of them through the operation wound,
but separate incisions were made to remove others. After the operation
the patient was for a time in a miserable condition owing to the large
flow of saliva through the upper part of wound. Finally, two plastic
operations were performed and the gap above site of artificial larynx
opening closed up. The operation was performed seventeen months
ago. The patient now wears an artificial larynx without reed, can
speak well, swallows solids and liquids without difficulty, looks in
robust health, and states that he can follow his employment as well as
he could before the operation. The larynx, on removal, was found
extensively affected on both sides. Patient is now fifty-one years of
age. At present there is no recurrence.
Dr. Bond, in reply to Dr. Dundas Grant, said the sub perichondreal
operation was performed.
Case op Clonic Spasm op Pharynx and Soft Palate.
Shown by Dr. Bond. This patient, a man of 33, came to the
Throat Hospital, Golden Square, on account of deafness. Both
mallei were found adherent to promontories.
On examining throat the back of pharynx was found to move in a
rhythmical manuer, horizontally to the left and back again, and at the
same time the left side of soft palate was drawn up and then relaxed.
The larynx was not affected. Patient could give no history of the
malady, as he thought his throat was quite healthy. There was no
clicking heard by patient himself, or by others. It is a case of
so-called chorea of the pharynx, but the name is an inappropriate one.
Dr. Clifford Beale thought the case should not be described as
one of chorea, as the movements were so very unlike those of chorea.
42
Dr. Bond, in reply, stated that he had seen a somewhat similar
case in which a small tumour of the medulla was afterwards found.
A Large Nasal Polypus Removed from the Naso-pharynx op
a Man aged 32.
Shown by Dr. A. Bronner. In this case there had been nasal
obstruction for two or three years, and for some months the patient had
seen a round tumour projecting below the soft palate. The tumour
was removed through the mouth by forceps. It was four inches long.
The mucous membrane of the nose was slightly thickened, but there
were no other polypi or polypoid degeneration.
Mr. Cresswell Baber had several times seen these post-nasal
polypi occurring singly, and found that they often did not recur after
removal.
Case for Diagnosis.
Shown by Dr. Couper Cripps. William S—•, Set. 50, presents a
smooth elastic swelling about half the size of a large walnut on the
left side of the thyroid cartilage extending over the middle line. The
patient has been aware of its presence for several years, and it has
noticeably increased during the last two. The larynx appears normal,
but there is considerable enlargement of the lymphoid tissue at the
base of the tongue and some chronic naso-pharyngeal catarrh.
Mr. Bowlby exhibited a similar case at the last November meeting,
which was considered to be either a thyroid or hyoid cyst.
Mr. C. Symonds thought the swelling was either a thyroid or a
hyoid cyst.
Microscopical Section op Regenerated Tissue after
Turbinectomy in Patient Shown at Last Meeting.
Shown by Dr. W. Hill.
Mr. Cresswell Baber thought that the specimen consisted of a
hypertrophy of the remaining tissue.
Mr. C. Symonds did not think that any regeneration bad taken
place, but rather an overgrowth of what was left.
Dr. Peoler thought the cylindrical epithelium was of an CBdematous
character, but also pointed out that the subepithelial connective
tissue was in a similar condition, and probably also the ill-developed
muscular walls of the sinuses. He ventured to think that the opinion
he had given of the case when shown, was so far verified by this section,
43
Two Cases op Tubercular Laryngitis, in which Complete
Recovery took place.
Shown by Dr. David Newman.
J. P—, set. 29, came under Dr. Newman’s care in January, 1889,
for impairment of the voice, which commenced at the beginning of
September of the previous year.
When first seen, the voice was soft, very weak, and aphonic; but
occasionally it suddenly broke into a falsetto note, which was some*
times maintained for a few minutes. The patient had had three slight
attacks of hsemoptysis. The quantity of blood lost was never more
than a few drops at a time. The expectoration was composed of
greyish-white semi-transparent muco-purulent material, which fre¬
quently contained large numbers of tubercular bacilli. It was at no
time profuse.
On examination, the epiglottis and the mucous membrane covering
the arytenoid cartilage on the left side presented the characteristic
appearance of tubercular laryngitis. The vocal cords were normal in
appearance, but the mucous membrane of the larynx was at one point
studded over by numerous miliary tubercles. There were no objective
or subjective evidences of tubercular disease elsewhere than in the
larynx. The patient complained of considerable difficulty in swallow¬
ing, and on account of the pain had been prevented from taking a
proper amount of nourishment. Emaciation and anaemia were marked.
Temperature was practically normal. Appropriate treatment was
adopted, and the patient carefully watched, frequent examinations
being made of the sputa, larynx, and lungs. In May, 1889, physical
signs developed indicative of pulmonary phthisis on the left side.
The second case in many respects resembled the one just described,
it also being a case of primary tuberculosis of the larynx, in which the
lungs became involved secondarily.
The patient, W. B—, set. 19, a tall, slim lad, presenting the
characteristic physiognomy of a tubercular patient, came for consulta¬
tion in June,1887. The previous February he noticed that his voice
was very easily fatigued, and that if he spoke much, even in a quiet
way, he became slightly hoarse. When first seen, the hoarseness had
developed into complete aphonia; dysphagia was very marked, the
pain being so severe that he was unable to take solid food; but fluids
could be taken without great difficulty; cough was short and dry, and
44
expectoration was small in quantity, but very viscid. Occasionally he
suffered from sudden attacks of dyspnoea.
On examination the mucous membrane of the pharynx, palate, and
larynx was very anaemic, while the margins of the pillars were of a
bright red colour. The epiglottis was greatly indurated, and there
was some thickening of the arytaenoid mucous membrane, with ulcera¬
tion of the right vocal cord. The sputa was sometimes free from
tubercular bacilli, but the majority of specimens examined contained
large numbers of these micro-organisms. The only indications of
pulmonary tuberculosis were slight moist riiles at the right apex in
front, and a marked prolongation of expiration over the upper third of
the right lung.
In both these cases the larynx was examined previous to any pul¬
monary signs presenting themselves, and in both a physical examination
of the chest showed the lungs to be ultimately implicated.
The treatment adopted in both cases was a carefully regulated diet.
The patients were kept in a warm, moist atmosphere, impregnated with
menthol, terebine, and eucalyptus. The principal local treatment was
spraying the larynx with cocaine, and when sufficient anaesthesia was
so produced, the larynx and pharynx were freely sprayed with a con¬
centrated solution of iodoform in equal parts of alcohol and ether.
This was repeated at first twice daily, and subsequently three times
a day. At first the patients complained a good deal of the irritation
of the applications, but after a few days they experienced so much
benefit from the spray that they were willing to have it used as fre¬
quently as was desired. Codeia combined with nepenthe was
occasionally given to relieve cough, and the general treatment of
tubercular laryngitis was carried out. In both instances the dysphagia
became less pronounced, the voice improved in strength and tone, and
the patient began to gain in weight.
Dr. Newman has employed the iodoform spray in a considerable
number of cases of tubercular laryngitis, and in almost all, considerable
relief has been experienced; but these are the only two in which a
cure has been effected. The patients are now (1896) to appearance
perfectly healthy. The laryngeal condition in both cases is so much
improved that it was very difficult to discover the remnants of the old
lesion when the larynx was last examined. In the first case the only
distortion is a puckering of the epiglottis, and an undue paleness of
the mucous membrane over the left arytsenoid cartilage.
45
It may be remarked that when the larynx is sprayed with the
iodoform solution, the odour of the iodoform can be detected in the
breath for fully six hours after the application is made. To be
efficient, the iodoform treatment must be adopted before ulceration of
the mucous membrane has set in.
Case of Epithelioma of the Left Tonsil, Left Posterior
Pillar, and Uvula.
Shown by Dr. David Newman. Mr. A—■, set. 55, a farmer, con¬
sulted Dr. Newman in June, 1890, for a swelling in his throat and
pain in the left ear lasting four weeks. Dr. Newman had seen him
two years before for a simple tonsillitis. On examination of the
tumour in the throat, it was found to involve the upper third of the
left tonsil, where it originated, as well as the posterior pillar and the
left side of the uvula.
Prom the appearance of the growth it was at once considered to
be an epithelioma; this was confirmed by a microscopic examination,
and the tumour, with a good part of the surrounding healthy tissue,
was excised within twenty-four hours.
The patient made a good recovery, and no recurrence has taken
place till now January, 1896).
Case of Carcinoma of the Tonsil and Soft Palate.
Shown by Dr. David Newman. Mrs. L—, set. 51, was admitted
into the Glasgow Royal Infirmary on the 20th November, 1891,
suffering from a carcinoma of the left tonsil and soft palate.
The history of the case showed that fifteen weeks previous to admis¬
sion the patient for the first time noticed a difficulty in swallowing, which
soon became very painful, especially on taking hot food. On admission
the patient appeared fairly healthy, but stated that during the last
three months she had been losing flesh and weight. She complained
of little or no pain in the throat unless when swallowing, but great
pain at times in the left ear. This pain never affected her till after
the throat symptoms had developed.
On examination the left tonsil was found to be swollen and
ulcerated. The ulcer extended from the tonsil to the anterior pillar.
46
and to the margin of the soft palate and uvula. There was not much
enlargement of the tonsil, nor were the lymphatic glands involved.
Carcinoma was suspected, and confirmed by an immediate microscopic
examination. Within half an hour, tracheotomy having been previously
performed, the tonsil was excised. A free incision was made with the
electric cautery, and the tumour, together with a considerable portion
of the surrounding healthy tissues was removed.
The wound healed in about three weeks. Now (January, 1896)
the patient is well.
Mr. C. Symonds congratulated Dr. Newman on his success, as
operating in these cases was not usually successful. He would like
to ask Dr. Newman how he operated, and whether it was possible to
do so through the mouth alone. In these cases recurrence so fre¬
quently occurred in the glands that he had determined to always
dissect out the side of the neck whether there was any glandular en¬
largement or not.
Mr. de Santi thought that one case was sarcoma and the other
epithelioma.
Dr. C. Beale remarked that the recoveries from tubercular laryn¬
gitis were very few, and usually in those cases in which the lung tissue
was also slightly improving.
Dr. Newman, in reply, stated that the growth was small, that he
removed it in one case under cocaine, together with a large amount of
healthy tissue, through the mouth with the galvano-cautery; the
other case was done under chloroform and with the cautery. He
thought they were adeno-carcinomatous, and in answer to Dr. Pegler
said that he called them adeno-carcinomatous as they resembled the
type of carcinoma formed in the mamma. In reply to Mr. Spencer,
he stated that he sprayed the iodoform solution three times a day;
at first it was done by himself and afterwards by a nurse, who with a
little trouble was taught to do so efficiently. In reply to Dr.
Spicer, he stated that the solution was composed of equal parts of
ether and alcohol, with as much iodoform as this would take up.
Case of Abductor Paralysis with Laryngeal Crises.
Shown by Mr. C. A. Parker. W. W—, set. 32, a porter, was
first seen on November 26th, 1895. He gave the following history ;
Between three and four years ago he woke up during the night
with difficulty of breathing, coming on quite suddenly and accom¬
panied by a violent cough. Inspiration was very noisy, like whooping-
cough. The dyspnoea became worse and worse, and his limbs began
to twitch, when suddenly he fell back unconscious and motionless.
47
His wife states that he remained unconscious about two minutes, that
he did not become cyanosed, but was perhaps rather paler than usual.
When he recovered consciousness he could breathe quite well. He
has had about five other exactly similar attack at intervals of about
six months. The last one occurred during the day whilst at work, and
was preceded by a tickling sensation in the throat; all the others were
during the night.
On examination of the larynx the left vocal cord was seen to be
fixed in the middle line, whilst the right was paretic, not abducting
beyond the cadaveric position. Phonation was normal.
No knee-jerks could be elicited. Gait slightly unsteady. Tottering
on standing with feet together and eyes closed. Some difficulty in
walking along a line, and in walking backwards. Argyll Robertson's
phenomenon not present. No loss of sensibility.
There is a distinct history of syphilis.
Whilst under observation the patient has had no further laryngeal
crises, and the condition of the cords remains the same, but the tabetic
symptoms are more marked. He now complains that he cannot walk
steadily, that his feet are cold and numb, and he is suffering from
lancinating pains in both legs.
In this case we may note :—The first symptom of tabes was evi¬
dently the laryngeal crises. The length of time between first attack
and other tabetic symptoms. The vocal paralysis is only of left vocal
cord. F Will the right cord pass from paresis to true paralysis.
The President stated that Mr. Parker’s observations deserved
particular consideration, as showing that in tabes laryngeal symptoms
may precede every other symptom, and therefore in these cases the
reflexes should be always examined.
Dr. Watson Williams asked if in this case the pulse-rate was
regular. He considered that an irregular pulse-rate in association
with laryngeal paresis pointed to tabes. He bad recently had a case
illustrating this.
Microscopical Sections of Warty Growth of Suspicious
Nature on Left Vocal Cord.
Shown by Dr. Soanes Spicer. The patient, a man set. 54, was
shown at the November meeting of the Society. The growth was
removed under cocaine, with Mackenzie's cutting forceps, at second
sitting. After a fortnight the voice was strong, and showed a slight
48
roughness only, the cord moved well, though still reddened, and a
slight white projecting point marked site of attachment.
The histological report by Dr. T. H. R. Crowle, Surgical Registrar
at St. Mary’s Hospital, is as follows:
“ The tumour was round, measuring mm. in diameter, firm, and
of a pinkish colour; to it was attached a small portion of mucous
membrane.
“ Microscopical examination shows it to consist of fibrous tissue in
various stages of development, but for the most part fully formed ; in
it there are numerous capillaries, and around these are collected small
cells. On the right of the section is an area consisting almost en¬
tirely of these small cells, which are evidently of inflammatory origin.
The attached mucous membrane also shows collections of small cells
beneath the epithelium.
“ There is no trace of epithelial cells in the nodule, and the mucous
membrane shows no irregular proliferation of the covering epithelium.
The epithelium does not pass over the surface of the nodule, but ends
abruptly on each side, and on the right it is folded back on itself. The
nodule also appears to be more or less isolated from the mucous mem¬
brane. These appearances are probably due to the forceps used at the
operation having squeezed the nodule out of its bed. Although the
epithelium probably extended over the nodule for some distance, I do
not think that the surface was entirely covered by it.
“ The nodule is evidently of inflammatory origin, and the inflamma¬
tion must have been very chronic and of long duration to produce
fibrous tissue such as that found in the nodule.”
Fibroma (? Fibro-Sarcoma) op the Cartilaginous Septum.
Case and Microscopical Specimen.
Shown by Dr. St Clair Thomson. This case was brought forward
as in some way a pendant to the one shown by Mr. Stewart at the
last meeting (‘Proceedings/ page 30), although in the present
instance members might decide that the growth was distinctly malig¬
nant, and not a simple fibroma. M. N—, set. 29, on 28th October
last sought advice for nose bleeding. Two years previously he had
had blood-spitting on and off for three months, and had been treated
for chest disease. He had three attacks of epistaxis during the year
49
1895, and at odd tiroes in previous years. Not noticed difficulty in
nasal respiration. An irregularly ovoid, lobulated growth was
removed from the right middle meatus with a snare. It grew by
a fairly thick pedicle from the centre of the cartilaginous septum.
The free haemorrhage had to be controlled with the galvano-cautery.
A week afterwards the base was touched with the cautery, and at his
third visit two weeks later there was distinct proliferation of the root.
The growth had by this time been cut, and although some skilled
pathologists held it to be a simple growth, others took it to be dis¬
tinctly sarcomatous. Taken in conjunction with the recrudescence,
Dr. Thomson inclined to the latter view. Thinking that the cautery
might have an irritating action, the stump had been touched with
chromic acid. It still tended to sprout, so that a month ago it was,
for the last time, freely seared level with the surface by means of the
galvano-cautery. Members would now see that after four weeks*
interval it was most distinctly recurring. As a stump does not
contract under cocaine, it cannot be a growth of erectile tissue. The
septum itself does not appear to be infiltrated, and the opposite side is
healthy.
An interesting subjective symptom is that for the last twelve
months the patient has constantly had a musca volitante, about the
size of a halfpenny, floating in front of the right eye. With the
removal of the nasal growth this entirely disappeared; but on
reporting himself yesterday the patient remarked that he felt sure
that the tumour was growing again, as a small spot as large as a pin's
head was once*more moving in front of the right eye.
Is the growth a sarcoma, and if so, how radical should the removal
of it be ?
Mr. Santi thought it was a sarcoma.
Mr. Spencer did not agree that it was distinctly sarcomatous; he
would wait a month and see the results.
Mr. C. Symonds said that from the microscopical section he would
not hesitate, but operate freely at once.
Dr. D. Newman considered it undoubtedly sarcoma.
Mr. Waggett thought it was a sarcoma.
Mr. Stewart thought it was a sarcoma, and suggested that it should
be sent to the Morbid Growths’ Committee.
Ca5E or InTERARTT.ES'jID P ACHYI'AiWLA LaIYNGI*.
.Shown by Dr. II. Tilley. Patent is a wcias art. 53. and was
shown at a meeting last tear. All her symptoms are better now than
they were then, when thev consisted of fee.inzs of surxation and
0 9 0 W
darting pains to each ear from the throat.
Examination shows a growth in the icterarytaenoid space, with a
vertical fissure dividing the growth into what at first were two equal
halves. A small portion, however, of that on the right side has
been removed.
Treatment has been by application of lactic acid, from weaker
solutions up to the Pharmacopoeial strength of SO per cent.; nitrate
of silver grs. 30 ad 3j every third day for two or three weeks. The
condition has much improved as far as her personal comfort is
concerned.
In answer to Dr. Scanes Spicer, Dr. Tilley stated that the
anterior portion of one of the turbinate bones had been removed, but
there was nothing wrong with the nose now.
Laryngeal Case eor Diagnosis.
Shown by Dr. H. Tilley. Patient is a man set. 51. Thirteen
years ago he had syphilis, since which time he has had throat trouble.
He came to the London Throat Hospital last January complaining of
difficulty of breathing and hoarseness.
On examination granulation masses on the vocal processes—
which are still present in less degree—were noted, the vocal cords
were moveable, there was a swelling of the left arytsenoid. The
whole laryngeal surface secreted mucus freely, and was very red and
congested.
He has been continually on iodides and mercury, and has improved
to such an extent that he now has no difficulty in breathing, but the
appearances as described are present in less degree, and he has been
in statu quo for three months. The question is whether there is any
other than a syphilitic disease present, e.g. tubercular or even
malignant disease.
The President remarked that it was very difficult to give an
absolute diagnosis. He thought it was either a syphilitic or an
51
ordinary inflammatory growth. He saw no harm in removing a
portion for microscopical examination.
Case of Probable Intrinsic Carcinoma of the Larynx.
Shown by Dr. Dundas Grant. J. W—, set. 45, consulted
Dr. Grant on December 9th, 1895, for hoarseness of two years*
duration and difficulty in breathing, with stridor on inspiration and
to a lesser extent on expiration.
There was no spontaneous pain, but difficulty in swallowing
liquids, which made him cough. He also had an aphonic cough, with
the expectoration of a little mucus tinged with blood.
Had never had haemoptysis nor night sweats, there was no family
history of phthisis, and the condition of the chest was normal. No
direct or indirect history of syphilis. No enlarged glands. No
spreading of the thyroid cartilage.
On laryngoscopic examination there was found to be inward
distortion of the left side of the epiglottis, swelling and immobility
of the left aryepiglottic fold and arytaenoid cartilage. The left
ventricular band was red and infiltrated, and below it, covering the
greater portion of the vocal cord, was a pale granular swelling, sessile
and projecting beyond the median line.
The right side of the larynx was slightly congested, but free from
ulceration or fixation.
Tracheotomy was performed, and the wound healed without the
slightest delay.
The exhibitor thought there would be no difference of opinion as to
the nature of the case.
The President suggested an immediate and radical operation in
this case. He should at once perform thyrotomy and thoroughly
remove contents of larynx.
ERRATA
In December No. of ‘Proceedings/
On pages 32 and 33, for Dr. W. A. Willis read Dr. W. A. Wills.
4 *
PROCEEDINGS
OP THE
LA.RYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, February \Wi, 1896.
Felix Semon, M.D., F.R.C.P., President, in the Chair.
W. R. H. Stewart, F.R.C.S.,
StClair Thomson, M.D.,
Secretaries.
Present—24 Members and 4 visitors.
The minutes of the previous meeting were read and confirmed.
Dr. W. Bolton Tomson, Park Street West, Luton, Beds, was
elected a Member of the Society.
The following gentlemen were proposed for election at the next
Ordinary Meeting:
Mr. M. R. P. Dorman, M.B., B.C.Cantab., M.R.C.S., L.R.C.P., 9,
Norfolk Crescent, Hyde Park, W.
Dr. L. G. Glover, M.D., B.C.Cantab., M.R.C.S., L.R.C.P., 1 College
Terrace, Fitzjohn’s Avenue, N.W.
Discussion on the Nature of the Laryngeal Complications of
Typhoid Fever.
Dr. Kanthack then read the following paper written by himself and
Dr. J. A. Drysdale.
Opinions differ considerably with regard to the frequency of intra-
laryngeal ulcerations during typhoid fever. After a short review of
the literature relative to this point, the authors gave an account based
on an examination of the post-mortem records of St. Bartholomew’s
Hospital during the years 1890 to 1894 and up to October, 1895.
Of 61 cases, 14 showed loss of substance in the larynx j in 8 it was
FIRST SERIES — VOL. III. 5
54
stated in the post-mortem books that the larynx had not been exa¬
mined, so that assuming that the larynx had been examined in all the
remaining o'i cases, which is doubtful, ulceration was found in 26
per cent, of the fatal cases. These defects are situated generally over
the tip and edges of the epiglottis and in the neighbourhood of the
processus vocalis. In these 14 cases the epiglottis alone was affected
four times, the larynx proper seven times, both larynx and epiglottis
once ; in 2 cases the soft palate or pharyux was ulcerated as well as
the epiglottis.
The following associated conditions were noted: iu 8 cases congestion
or oedema of the lung, pleurisy iu 4 cases, otitis media and pyaemia
in l case, gangrene of the luug iu 1 case. The intestinal ulcera¬
tion was extensive iu 8 cases, limited in 2, and healing or healed in 4.
It is therefore not true that the laryngeal lesions invariably appear
during the acute period of the fever before the healing commences.
The next question discussed was the pathological nature of the
lesions—are they specifically typhogeuetic ? Dittrich's assumption
that the ulcers are decubital was set aside as insufficient and erroneous.
Rheiner’s view is more commendable, viz. that the ulcers are produced
by small repeated injuries acting on debilitated tissue. Rokitansky
upheld the typhogenetic nature on anatomical reasons, the ulceration
affecting the adenoid tissues of the larynx. This, they said, is in¬
correct, since along the tip and edges of the epiglottis and over the pro¬
cessus vocalis no such tissue ever develops. Others from analogy of
other post- or intra-typhoidal lesions, such as periostitis and parotitis,
have assumed that the typhoid bacillus produces these ulcers. The
evidence on this point is weak and insufficient, more especially because
until recently the Bacillus coli and the typhoid bacillus have been
constantly confounded, and therefore none but recent observations by
competent bacteriologists can be accepted. E. Fraukel and Brieger
never obtained the typhoid bacillus in these laryngeal ulcers, and they
themselves failed to do so in a recent case. As to other post-typhoidal
suppurative lesions, typhoid bacilli have occasionally been found, and
Janowski has shown experimentally that the typhoid bacillus is
capable of producing suppuration either unaided or with the assistance of
the pyococci. He gives, however, no observations regarding laryngeal
ulcerations, and hence the bacteriological evidence is very incomplete
and such as there is points against their specifically typhogenetic
nature.
55
Farther, the clinical evidence does not support the typhogenetic
specificity ; there seems to be no relationship between the symptoms
of the fever and the laryngeal lesions. The condition of the mucous
membrane of the mouth and pharynx is of importance ; in nine out of
twelve fully reported cases it was described as dry and brown over the
tongue, and in four fissured as well, and in one even bleeding. In
many if not in most cases the patient was in the so-called “ typhoid
state.” This condition must act as a predisposing element, especially
since it may be assumed that in many cases the laryngeal mucosa was
in a similar condition. It is then readily injured and forms a portal
for the pyogenetic cocci always present in the mouth and larynx.
Naturally this would occur most commonly over and in the most
insufficiently vascularised portions, i.e. the tip and edges of the
epiglottis and the processus vocalis. This explanation, however, does
not satisfy all cases, and difficulties still remain.
Undoubtedly the lesions are caused by micro-organisms; there is
the strongest evidence that these are the pyococci, and not, except
rarely, the typhoid bacilli. In some cases no doubt the latter
may be the cause of the trouble, but it is only the soundest possible
observations on this point which can be convincing. The best
accounts (Brieger and Frankel) certainly disprove the view that the
ulcers are truly typhogenetic. Secondary or fresh infections by
pyococci are common enough in other bacterial fevers, and there is
no reason why this should not occur in typhoid fever, especially since
it is well known that in this disease the streptococcus may produce
endocarditis, and that in most suppurative lesions occurring during or
after the fever pyococci are found. To speak of these ulcers as
primarily typhoidal without the soundest and most objective evidence
is mere theorising; the evidence in their possession convinces them
that these laryngeal ulcers occurring during the course of typhoid fever
are caused by fresh infections with pyogenic organisms which always
abound in the larynx, and which gain a firm foothold on the debili¬
tated tissues, although they cannot deny that in an individual case
the typhoid bacillus may have escaped and caused the lesion.
Dr. Watson Williams (Bristol) was of opinion that while the
acute and chronic laryngeal lesions arising in the course of or imme¬
diately after an attack of typhoid fever are [sometimes undoubtedly
secondary, and the result of septic infection, they are in the main
specific and due to the typhoid toxin, and that they are more fre-
56
quently associated with the presence of the Eberth-Gaffky bacillus
than Dr. Kanthack’s observations had led him to believe. He sub¬
mitted the following reasons for arriving at this conclusion.
1. As regards lymphoid tissue, Cornil and Ranvier had found that
while in typhoid cases dying from pulmonary and bronchial complica¬
tions, catarrhal laryngitis was generally present, in a smaller propor¬
tion and in a more acute form of laryngitis, a form characteristic of
typhoid fever, the “ lymph follicles ” were tumefied and formed
nodules in which the multiplication of the nuclei and infiltration of
the retiform tissue were entirely similar to what is observed in the
closed follicles of the small intestine. These tumefactions often give
place to crateriform ulcers.
2. The remarkable frequency of initial lung symptoms in typhoid
fever was suggestive of a specific origin, and in fact the typhoid
bacillus had been found in the lungs in numerous instances (Council¬
man and others), especially when lung complications were marked.
Similarly in renal typhoid complications, Neumann, who has demon¬
strated the typhoid bacillus in eleven out of forty-eight cases, con¬
cluded that the bacilli appear in the urine only when the kidney is
directly involved. The renal lesions, like the pulmonary, formerly
thought to be due to pyrexia, should be regarded as being generally
due to the action of the typhoid bacilli or their toxins.
3. The remarkable frequency as well as the more or less character¬
istic aspect of laryngeal ulcers of typhoid fever, as distinguished from
their rarity in the other exanthemata, pneumonia, and acute bronchitis,
and furthermore the fact that they were especially prone to occur
when the lung complications, probably specific, predominated, was
strong primd facie evidence in favour of their specific nature.
It might appear strange that if the laryngeal and lung lesions were
alike due to specific infection, the latter alone should so frequently
result in ulceration. But in congenital typhoid the intestines do not
present ulceration, and this Dr. Watson Williams attributed to the
absence of saprophytic micro-organisms, especially Bacillus coli, which
abounding in the intestinal tracts in after life, increase the virulence
of the typhoid bacilli, the symbiosis resulting in the characteristic
disintegration and ulceration. So in the larynx the ulcerative pro¬
cess may be attributed to the fact that, unlike the lung, it is much
exposed to the combined action of saprophytic and typhoid bacilli
under conditions which markedly favour the development of extreme
pathogenic properties.
4. It was hardly possible to account for the inoculation of certain
cases except by aerial infection. He referred to cases occurring in
the Bristol Royal Infirmary which he had already reported in detail,*
in which a patient and a nurse apparently caught typhoid fever from
the expectoration of a case with laryngeal ulceration. All three cases
were virulent and fatal, and two at any rate had typical typhoid
ulceration of the larynx. Moreover, from these typhoid ulcers' in the
second case, the Eberth-Gaffky, differentiated from Bacillus coli bacilli,
had been obtained by culture. Lucatello had also obtained typhoid
* ‘ Brit. Med. Jouru.,’ Dec. 15tb, 1894.
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57
bacilli from the laryngeal lesions in a case dying on the twenty-first
day. With all bacteriological precautions he found these bacilli both
in the expectoration and in the tumefied but non-ulcerated mucous
membrane.
5. Just as more general typhoid lesions fell into two groups, the
acute and the chronic secondary focal abscesses, otorrhoea, and osteo¬
myelitis, in which typhoid bacilli had been demonstrated, so likewise
did the laryngeal complications of typhoid fever.
Mr. S. G. Shattock exhibited some preparations showing the ulcers
so typical in situation, viz. over the vocal process of the arytsenoid.
He could say from having examined especially into the point that
there was no lymphoid tissue in this situation in the normal condi¬
tion, and therefore the lesions in the larynx were not strictly com¬
parable to the intestinal lesions.
Dr. Jobson Horne, observing that when ulceration of the larynx
is noted in typhoid fever it is not necessarily typhoid in nature, said
this point had been brought to his notice whilst investigating micro¬
scopically a number of larynges presenting all sorts and conditions of
ulceration. The ulceration in some of the larynges obtained at
autopsies of persons dead from typhoid fever had been found under
the microscope to be of a tubercular nature. This he considered of
interest, having regard to the fact referred to by Dr. Kanthack and
Dr. Drysdale in their statistics, that not infrequently deep ulceration
of the larynx in typhoid is associated with advanced pulmonary
changes. In such cases it would be important to know the condition
of the lungs and larynx before the onset of the fever. In one case
the history suggested that the ulceration was a pre-existing condition.
Bearing in mind that tuberculosis more commonly follows typhoid
than any other fever, it may be that typhoid renders the laryngeal
tissues more vulnerable to the attacks of the tubercle bacillus. He
considered that typhoid may be a possible factor in the aetiology of
tubercular ulceration, and the tubercular diathesis a factor in the
aetiology of typhoid ulceration, of the larynx. This point might be
considered in future statistics.
The President asked Dr. Kanthack why the cricoid cartilage was
so frequently the seat of disease. There were several specimens
showing this apart from ulceration at the vocal processes.
Dr. Kanthack, replying to Dr. Watson Williams, did not accept
the statement with which he credits Cornel and Ranvier with regard
to the lymph follicles in the larynx. His own observations and those
of others have shown the absence even in disease of any adenoid
tissue over the processus vocalis and the tip of the epiglottis. This
anatomical point was beyond discussion. Further, he desired to know
what authority Dr. Williams had for stating that the typhoid bacillus
had been found in the lungs in “ numerous instances.” He could not
obtain any evidence on this point, in fact it was generally acknow¬
ledged that the presence of Eberth’s bacillus in the blood during
typhoid fever was extremely rare and unusual. The comparatively
frequent occurrence of this bacillus in the urine was indisputable,
but from that no one could argue that the tissues generally were in¬
fected ; organisms may readily find their way through the kidneys
58
into the urine and Madder without there being a blood infection.
The bacterium coli, for instance, escapes fairly easily into the kidney,
and yet the tissues are free from it. To argue from congenital
typhoid fever in bis opinion was to argue from the unknown. Dr.
'Williams assumed that the typhoid bacillus in the lungs produces no
ulcerative lesions l>eeause it does not exist there in symbiosis with
the B. coli. Dr. Kanthack, on the other hand, had shown that it
is always present there, so that following Dr. Williams’ own argu¬
ment, necrotic lesions in the lungs should be common. “ since the
typhoid bacillus exists there in numerous instances.” He suspected
that there must have been a confusion between the B. coli and the
typhoid bacillus, if not perhaps in all cases, certainly in almost all
cases. The case cjuoted by Dr. Williams was striking, and although
he could not reject the observation he was by no means prepared to
accept it, because he knew the errors generally committed in the
diagnosis between the B. coli and Eberth’s bacillus. In any case
it had no more value than a single observation could have. Most
authors, including Wassermann and himself, had failed to find typhoid
bacilli in the suppurative or inflammatory complications of enteric
fever. He would not say that the typhoid bacillus never caused such
processes, chiefly because Janowski had found it and because he
himself and also Dr. Klein had discovered it in the blood in ulcerative
endocarditis. Savarelli no doubt was a brilliant writer, but as to the
soundness of his discoveries he was less certain, and he would there¬
fore recommend the use of more than a grain of salt with the con¬
clusions of this versatile writer. Facts and not theories were wanted,
and what Dr. Williams maintains had not been established as yet, viz.
that the typhoid bacillus has been found over and over again in
the typhoidal laryngeal ulcers. With regard to the President’s
question, he was not prepared to answer it without a little more
thought and study, but he had always considered the cricoid peri¬
chondritis to be secondary to the ulceration over the processus
vocalis.
Discussion on Foreign Bodies in the Upper Air- and
Food-Passages.
Mr. Charters Stmonds in opening the discussion said he proposed
to limit his remarks to the questions of diagnosis and treatment. In
the ilose where no history was given he thought the most character¬
istic symptom was a unilateral purulent discharge, with more or
less obstruction, the discharge being often blood-stained. In young
children he suggested that in all such cases a careful examination
under chloroform should be made. He asked for information as to
other causes of a unilateral purulent discharge in children under six or
seven. In his experience he had seen but two cases where no foreign
body was found. He had found a probe and forceps the best instru¬
ments for removal. The plan of forcing a stream of water up the
healthy side he had known to succeed, and asked as to the value of
this method. He had no experience of sternatatones, and doubted
59
their value. In the pharynx, stress was laid upon the importance of
examination with the mirror, and the close resemblance of a string of
glairy mucus to a fish-bone. The site of puncture was to be recog¬
nised as an elevation having a grey centre and showing a ragged
aperture. Where nothing could be seen the finger should be used,
and if the body were felt, a forceps could be guided down. In young
children this was the only method available. The danger of further
driving in sharp bodies was referred to. Attention was next directed
to the persistence of irritation after the removal of the foreign body,
and of the nervous apprehension that frequently ensued. In the
larynx the foreign bodies were divided into those which are small,
and after the first paroxysm do not impede the respiration, but give
rise to local pain, cough, and some dysphagia but no danger; and
those which are large, or being small are so placed as to impede inspi¬
ration. In the first class, removal by intra-laryngeal methods could
be safely undertaken, and a case was given of a small bone success¬
fully dislodged. In the second group he laid stress on the importance
of having everything ready for tracheotomy in the event of a spasm
being set up.
Where death or expulsion had not occurred, tracheotomy should be
performed, and then the body removed through the wound if possible.
If impacted in the glottis, he thought it better, after recovery from the
operation, to attempt removal through the mouth before dividing the
thyroid cartilage. The necessity of submitting such cases to a skilled
operator before resorting to thyrotomy was insisted upon. In children
after tracheotomy a foreign body might be felt by the finger and
removed from the larynx. A case was mentioned of this kind. With
regard to the wound be thought that if all extraneous substances were
removed there was no necessity to retain the tube. He preferred to
put in one suture above and cover with gauze, rather than to suture
the trachea and skin. In young children the danger of a tube itself
was pointed out as a reason for not delaying extraction after tracheo¬
tomy ; for if the body could not be reached and removed by the
forceps guided by the finger, division of the larynx must be carried
out. The confusion liable to arise from the resemblance of the symp¬
toms to those of acute laryngitis was pointed out, and cases given in
illustration.
In the trachea and bronchi the value of the paroxysmal cough
was referred to, also the importance of a knowledge of the nature
of the foreign body. The danger of mistaking the quiet period
for complete recovery was pointed out. A case of impaction of a
pebble in the left bronchus was described, where removal was effected
in the sixth week. Though much emaciated from hectic fever the
child rapidly recovered. The danger of inversion and succussion with¬
out previous tracheotomy was thought to be sufficient to exclude the
method. That tracheotomy should always be performed when a
foreign body is in the trachea or bronchus was held to be a rule of
surgery.
Cases of death from the entrance of food during the administration
of ansesthetics were given, and others in which tracheotomy was
successful.
60
In the oesophagus the main points dwelt upon were : the danger ot
over-manipulation causing fatal laceration; of driving a penetrating
body into the aorta; the wisdom of forcibly pushing down impacted
food rather than waiting a few hours for solution to take place.
With regard to coins, importance was attached to sounding with a
bullet probaug or the money-catcher, and the inadvisability of using
an ordinary bougie. In this connection the speaker asked if the gullet
should necessarily be explored in all cases. If so. and the child proved
refractory, ought we to give an anaesthetic ? He asked for experi¬
ence as to the value of emetics.
The removal of tooth-plates by cesopbagotomy was next discussed,
and a case under the speaker’s care was described. The operation
gave rise to no difficulty in performance, and the tooth-plate was
easily removed. In making suggestions for the management of the
wound, preference was given to packing with gauze, after suture of
the gullet.
Finally the speaker asked for information regarding the utility of
illumination of the oesophagus.
The discussion was adjourned to the next meeting of the Society.
The following regulations have been made by the Council to facili¬
tate the use of the Society’s Library by the members.
Any member who may wish to borrow a work in the Library
(other than single numbers of current periodicals) should
apply to the Librarian by letter at least three days before
any meeting of the Society, at which meeting the work will
be handed to him. Works thus borrowed may be kept for
one month, but if applied for by the Librarian shall be re¬
turned at the next ensuing meeting of the Society. Any
works lost or damaged must be replaced or made good by the
borrower.
A list of the works at present in the Library will be found in the
* Proceedings’ for January, 1894, and January, 1896.
Members wishing to obtain odd numbers of the ‘ Proceedings’ to
complete imperfect set, &c., can do so on application to the Librarian.
The price of such numbers has been fixed at Gd., and the price of full
sets (unbound) at 2s. A few copies of Volumes I and II bound
together will shortly be obtainable, price 2s. Gd.
The Council have confirmed the following regulations of the Morbid
Growths Committee.
That reports be presented to the Society at the January, March,
and June meetings.
61
That the Committee shall receive specimens to report upon from
the Society only, and not from individual members.
That the reports presented by the Committee shall not be open
to discussion.
That if the Society has carried a resolution that a specimen be
sent to the Morbid Growths Committee for examination, the
member shall give the section or specimen to the Senior
Secretary before leaving the meeting if possible, or forward
it on the earliest possible occasion, together with a short
epitome of the case.
That no section or specimen be received for immediate diagnosis.
That a cabinet of sections be formed to be placed under the care
of the Senior Secretary for the use of the members of the
Society only, at the Society’s rooms; no section to be taken
away from the room.
That members be requested to contribute to the formation of
such a collection. The sections so given to be submitted to
the Morbid Growths Committee.
W. R. H. Stewart,
StClair Thomson,
I
Hon. Secs.
5 *
PROCEEDINGS
OP THE
LA.RYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, March 11 th, 1896.
Felix Semon, M.D., F.R.C.P., President, in the Chair.
Present—25 Members and 3 visitors.
The minutes of the previous meeting were read and confirmed.
Mr. M. R. P. Dorman, 9, Norfolk Crescent, Hyde Park, W.; Dr.
L. G. Glover, 1, College Terrace, Fitzjohn’s Avenue, N.W., were
elected Members of the Society.
The following gentlemen were proposed for election at the next
Ordinary Meeting:
Mr. Gustave Schorstein, M.B.Oxon., M.R.C.P.Lond., 11, Portland
Place, W.
Dr. A. Logan Turner, M.D.Edin., F.R.C.S.E., 2, Coates Crescent,
Edinburgh.
The following report of the Morbid Growths Committee on the
microscopical specimen of a growth removed from the nose by Dr.
StClair Thomson, and shown at the January Meeting, was then read.
The Morbid Growths Committee report that they received from
Dr. StClair Thomson specimens consisting of three sections of a growth,
and the following notes of the case:
Microscopic specimen, labelled “ StC. T. &c., No. 126.—Removed
on October 25th, 1895, from the right middle meatus of a man aged
29. Growth was the size of a hazel nut, irregularly ovoid and lobu*
FIRST SERIES—VOL. III. 6
64
lated, with marked and fairly thick pedicle growing from centre of
right cartilaginous septum. Removed with cold snare ; free haemor¬
rhage, checked with cautery. Base freely treated at intervals with the
galvano-cautery, and also (thinking that the cautery might produce
too much reaction) with chromic acid. Recurrence took place, and
after leaving the stump entirely alone for a whole month the recur¬
rence was the size of a nut without its shell. This portion has just
been removed and will also be microscoped. The tumour had had no
treatment whatsoever before being removed. The septum was in no
way infiltrated; the growth was quite localised, and the opposite nasal
fossa was perfectly normal. Since removal three months ago the
growth has not tended to attack neighbouring parts. The growth was
hardened in corrosive sublimate, embedded in paraffin and stained with
logwood and eosin.”—Signed, StClair Thomson.
The report of the examination is as follows :—“ The specimens sub¬
mitted to us comprise three sections, each about the size of the trans¬
verse section of a pea. Each of them is almost completely surrounded
by normal columnar epithelium, beneath which is some loose connec¬
tive and myxomatous tissue in some parts, whilst in others the
epithelium is placed directly on a new growth. This new growth is
composed almost entirely of blood-vessels of very different sizes, whose
walls are formed of cells and do not contain either elastic or muscular
tissue. The stroma between the vessels consists of loose fibrous tissue
with oval and spindle cells which are of uniform character throughout
and arranged concentrically around the vessels, amongst which there
is a good deal of extravasated blood. We consider the tumour to be
an angeioma.”—Signed on behalf of the Committee, W. R. H.
Stewart.
Case of Cyst of Glosso-Epiglottic Fold.
Shown by Dr. Clifford Beale. The patient, a man set. 38, was
admitted to Victoria Park Hospital suffering from bronchitis. He
stated that for some months past he had been aware of something at
the back of his tongue which had. slightly affected his voice, but had
caused him no other inconvenience. On examination, a swelling the
size of a cherry was seen at the back of the tongue, and in contact
with the epiglottis but not attached to it. The walls of the tumour
65
were vascular, and on palpation with a probe the swelling was found
to be soft and yielding to the touch, and to be attached to the tongue
by a broad base. No local treatment was applied, but the patient was
treated by ordinary remedies for his attack of bronchitis, which sub¬
sided in about ten days. During this period the swelling had got
much smaller according to the patient's own statement, and on further
examination this was found to be the case. The question then arose
for decision as to the best means of treatment for its complete destruc¬
tion, and an expression of opinion was asked as to the respective
merits of free incision—excision of a part of the cyst wall, or destruc¬
tion by galvano-cautery.
Dr. Bond asked if Dr. Beale was sure of the cystic nature of the
growth; if such, he would suggest the use of the galvano-cautery and
curette.
The President stated that he had usuallv found a free incision
•/
or the use of cutting forceps under cocaine sufficient.
Mr. Symonds usually cut off the top of the cyst.
Dr. McBride had found them most obstinate to cure.
Dr. Beale, in reply, stated that he had examined most carefully
with a probe, and was certain that the tumour was cystic.
Case op Tubercle or Cancer?
Shown by Dr. Clifford Beale. The patient, who had been pre¬
viously shown to the Society ( f Proceedings/ vol. iii, p. 21), had
been kept under observation for three months, and had been treated
with iodide of potassium and good diet, and latterly, by the advice of
Mr. Stewart, with local applications of zinc chloride. The swelling
springing from the left ventricle of the larynx had become much less
prominent and less angry in appearance. A small amount of thicken¬
ing of the whole cord remained, but the movements had not been in
any way impaired, and no further change had taken place in the small
gland in the neck. The patient himself had maintained his weight
and general nutrition, but his voice was as weak as before.
Dr. Beale was of opinion that the case was one of chronic tubercular
infiltration, and that the disease in the larynx was in all probability
following the course of the disease in the lung, which was gradually
undergoing the usual fibroid shrinking.
66
Case op Larvjs in the Nose.
Shown by Dr. J. W. Bond. Case was brought forward owing to
the great rarity of the condition in this country.
The patient, a woman set. 49, had attended the Throat Hospital for
some eighteen months for chronic pharyngitis, &c. In May, 1895,
she noticed a profuse watery discharge from nose for three weeks, and
sharp shooting pains in left frontal region. The discharge was never
purulent. On examination of nose the passages were found patent,
and indeed the mucous membrane over turbinate a little atrophic. Tor
about six weeks various nose lotions were used without good result.
Then, after using a dilute Mandl solution (ii|xv in 3j) twice, four
grubs came from the nose, and she was relieved. She remained quite
well for another two weeks, during which she attended the hospital.
The grubs were segmented, somewhat stained by the iodine; some
of them developed into flies, which on examination by Mr. Charles 0.
Waterhouse, of the Natural History Museum, were pronounced to be
Piopftila casei , Linnaeus, the larvae of which are said to feed on cheese,
bacon fat, and animal matter generally.
There was no particular smell noticed likely to attract the fly. The
case seems to have been very readily cured, no doubt because the
accessory sinuses were not invaded.
Mr. Spencer would like to know if there had been any dogs about
the patient, and whether this form occurred in dogs.
Dr. Bond had no information as to dogs. Had never come across
any record of a case of this description before.
Specimen of Myxoma of Larynx.
Shown by Dr. Bond. The patient, a man aet. 50, gave a history of
attacks of huskiness and loss of voice for twenty years.
Twelve months ago voice almost went, and on examining the larynx
on January 15th last, a growth about the size of a pea was seen to
occupy the upper surface and edge of the middle of the right vocal
cord. It was transparent in the centre, and had a cyst-like appear¬
ance. On February 15th it was removed by the endo-laryngeal
method, since when the voice has wonderfully improved, and patient
states that it is better than for the past ten years.
67
The growth removed was jelly-like. Microscopically it seems to be
a pure myxoma.
Dr. Bond directed attention to the long history in the case. No
doubt the man may have had chronic laryngitis for some years. It
was common to find some myxoma in a laryngeal tumour, but a pure
myxoma was very rare. He thought it possible there may have been
some growth for a long time, and that a pure myxoma was here, owing
to the time which such growth has had to undergo change.
The President said that with Dr. StClair Thomson’s case, and one
they had a few meetings ago, there had been shown at the Society in
a comparatively short space of time three cases, whilst up till quite
recently only six cases had been recorded. He thought, too, it was
remarkable that in each case there was a history of trouble of nearly
twenty years’ standing.
Dr. Lambert Lack said he had one such case this year, and one
mixed with slight amount of fibrous tissue last year.
Dr. Kanthack stated that he began examining these cases some
years ago. He thought that most of them were more myxomatous
degeneration, which was comparatively common, than pure myxo¬
mata, which were extremely rare. He suggested that the growths
should be sent to the Morbid Growths Committee. [This it was re¬
solved should be done.]
Case op Myxoma op Vocal Cord.
Shown by Dr. StClair Thomson. Marion J—, set. 38, had
taught since the age of seventeen, but always in private schools, the
number in her class never at any time exceeding twelve. She used to
sing, but her voice had been “ thick ” for a year past, and for the
last twelve months she had given np attempting to sing. For three
months she had suffered from hoarseness and partial loss of voice,
especially after using it much. A spherical growth, about the size of
a small pin’s head, smooth, red, and pedunculated, was found pro¬
jecting into the glottic space at the junction of the middle and ante¬
rior thirds of the right vocal cord. There was some injection and
thickening of the adjoining upper surface of the cord, and impaired
approximation of the cords in phonation. The growth was removed
with Mackenzie’s antero-posterior forceps, and sections showed that it
was a myxoma,—unless, indeed, it should be regarded as simply
cedematous mucous membrane. In 1880 Morell Mackenzie spoke of
myxoma of the vocal cords as “ very rare,” and said that he had only
met with a single case (‘ Diseases of the Throat and Nose/ vol. i.
68
page 806). It was therefore noteworthy that this growth was re¬
moved on the same afternoon as the one already referred to by
Dr. Bond. Both cases occurred at the Throat Hospital, Golden
Square, in the clinic of Dr. Bond, to whom he was indebted for kind
permission to show this one.
Case op a Growth on the Hard Palate of a Girl.
Shown by Mr. L. Lawrence. A girl, set. 11, showed a flat, warty-
looking growth growing from the mucous membrane of the hard palate,
attached by a thin pedicle in the centre ; patient is unaware of the
length of time she has had it.
Mr. Svmonds stated that he had a case of small tumour of the soft
palate which had turned out to be a dermoid.
Dr. Peoler said that Dr. Whistler had told him of a poodle that
he had seen that had three small tumours on the hard palate.
Specimen of Growth Removed from the Naso-pharynx.
Shown by Mr. L. Lawrence. This was removed from a case
shown before the Society at the end of last year. The growth was an
ordinary mucous polypus without cysts. It had been removed by
forceps from behind.
Case of Elongated Cervical Sinus resembling a Branchial
Fistula.
Shown by Dr. Dundas Grant. The patient is a girl set. 19, first
seen in October, 1895, complaining of an inflamed swelling in the neck.
This was a fluctuating, thinly-covered swelling at the lower end of the
anterior margin of the right sterno-mastoid muscle, of about the size
of half an ordinary child's marble. To its inner side was another
smaller though similar swelling with which it communicated. There
was an enlarged gland near the angle of the jaw, and a firm cord could
be felt running from the lower swelling close up to this gland. The
lower swellings were both incised, pus evacuated, and the lining
scraped. A drainage-tube was passed through both openings. In a
few days this was removed and the patient went home.
At present the inner of the two openings is represented by a firmly
69
healed dimple, the outer one by an orifice leading into the cord before
observed. A fine celluloid bougie can be passed up the interior of
this for a distance of nearly two inches, where it abruptly stops.
The sinus is probably the result of a gland abscess, but its position
and character somewhat suggest a branchiogenic origin.
After-history of the Case of Carcinoma Laryngis previously
SHOWN AT THE JANUARY MEETING.
Shown by Dr. Dundas Grant. Death took place twenty days after
the operation of thyrotomy. The patient was never able to swallow,
and nutrition was kept up with apparent good result by means of
enemata for a week. The patient then got into a condition of mental
wandering and drowsiness. The iodoform was given up, and bismuth
and boracic acid employed, but no difference took place. Dree stimu¬
lation and stomach feeding were then practised, but the mental
condition became gradually worse, coughing ceased entirely, and after
death the lungs were found congested and oedematous, but free from
pneumonic consolidation. Laryngoscopic examination, about a week
after the operation, showed that the left half of the larynx was
quite inactive, and it will be seen from the notes of the case pre¬
viously given that one of his primary symptoms was a difficulty in
swallowing liquids. There was no fistula to account for this, and it
would be interesting to know whether this symptom may in general
be regarded as unfavourable. There was ample evidence of regrowth
round the site of operation.
Case of Chronic Hoarseness in a Patient with Chronic
Rhinitis and Pharyngitis.
Shown by Mr. Spencer. A maidservant, set. 19, has been hoarse
as long as she can remember. Formerly she had suffered from nasal
obstruction, but did not now complain of the nose. She has never been
aphonic except once or twice when she had a cold. On examination,
there is chronic dry rhinitis and pharyngitis, with crusts. The larynx
can be well seen, as well as the trachea. The vocal cords come together,
but fail to become tense. At the moment of adduction there is
irregular bulgings. The patient was exhibited as a contribution of
the relation between chronic nasal obstruction and the larynx.
70
Dr. Clifford Beale thought there was enough in the larynx to
account for hoarseness without going to the nose for an explanation.
He thought local stimulation might bring the voice back.
Dr. McBride noticed that there was a certain amount of ahductor
paresis of the left vocal cord, which was also much congested. He
did uot think the case was functional, but would look upon it with
great suspicion.
Dr. Tilley had also noticed that there was less movement of the
left vocal cord thau the right.
Mr. Symonds thought the chief complaint was in the nose. He
would treat the nose and leave the larynx alone.
Dr. Scanes Spicer thoroughly supported Mr. Symonds’ views.
Mr. Lake considered that if the laryngeal congestion had been of
recent origin it would get well if the nose was treated alone, but in
this case the congestion was chronic.
The President said that the history of this case showed hoarseness
from birth, with dryness of pharynx and larynx. There was some
abductor paralysis of the left cord. He hoped Mr. Spencer would
give a further history of the case, and would adopt one of two
methods in the treatment of the case, either treat the larynx and leave
the nose alone, or vice vend.
Mr. Spencer said he would treat the larynx first, and leave the nose
alone for a time.
Case of Pharyngeal Tumour, probably Syphilitic.
Shown by Dr. H. Tilley. A woman, set. 33, came to the hospital
on Pebruary 25th, 1896, complaining of a “ stifling sensation in the
throat,” which was worse at night. She noticed the trouble first early
in January.
She has had syphilis. Had two miscarriages; has two children, the
youngest having been treated for congenital syphilis.
On examination, Pebruary 25th, 1896, there is a large ovoid swelling
on the posterior wall of the pharynx, rather low down and about
opposite the epiglottis. The larynx could not be seen. On examining
her again March 10 th, after she had been on anti-syphilitic treatment
for a fortnight, the swelling was considerably smaller, and the larynx
could then be seen.
Case of Tuberculosis of the Nose.
Shown by Dr. W. Hill. The specimen was referred to the Morbid
Growths Committee.
71
Case op Lupus op Palate and Larynx.
Shown by Mr. E. C. Stabb.
Dr. McBride asked what the prognosis was in these cases. He
had a number of cases in which the prognosis was most favorable.
He used the galvano-cautery and chromic acid.
The President stated that where the parts were easily accessible,
he preferred scraping and the application of strong lactic acid. When
the disease was situated in the larynx he would not use the scraping
from fear of stenosis following. He had treated some of his cases
with simply giving arsenic and cod-liver oil, no local remedy being
used.
Mr. W. R. H. Stewart mentioned that he had a case now under
his care that was getting well under the administration of arsenic alone.
Case op Tumour op the Soft Palate.
Shown by Mr. E. C. Stabb.
6 *
PROCEEDINGS
OP THB
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, April 15 th, 1896.
Felix Semon, M.D., F.R.C.P., President, in the Chair.
W. R. H. Stewart, F.R.C.S.,
StClair Thomson, M.D.,
Secretaries.
Present—23 Members and 4 visitors.
The minutes of the previous meeting were read and confirmed.
Dr. A. Logan Turner, M.D., F.R.C.S.E., 2, Coates Crescent,
Edinburgh, and Mr. Gustave Shorstein, M B.Oxon., M.R.C.P.Lond.,
11, Portland Place, W., were elected Members of the Society.
Mr. M. R. P. Dorman, having signed the Register, was admitted a
Member of the Society.
ADJOURNED DISCUSSION ON FOREIGN BODIES IN THE
UPPER AIR AND FOOD PASSAGES.
Dr. Scanes Spicer remarked that in children for removing foreign
bodies impacted in these passages a general anaesthetic should be
given at once uuless asphyxiation is imminent, in which case tracheo¬
tomy should be done, and then anaesthetisation. The distress and
terror of the little patient is thus allayed, calm and gentle procedure
on part of the surgeon is facilitated, the risk of increasing impaction
is lessened, and chances of removal improved. Foreign bodies in the
nose in children, from the smallness of the channels and from the
swelling—usually secondary to previous attempts at removal or to
consecutive rhinitis,—are not usually to be detected even by skilled
rhinoscopy, and the diagnosis must depend on the probe. This must
be used with caution in the right direction, and the finger inserted in
the naso-pharynx to guard against backward dislodgment of the
intruder into the larynx or oesophagus. Forcible injection of water
FIRST SERIES — VOL. III. 7
74
with Higginson's or any other syringe is undoubtedly attended with
risk to the ears, especially if practised through the pervious nostril
with the other oue blocked. Gentle injection of a stream of water,
insufflation of air up the open nostril (Dodd’s method), and sternu¬
tatories he had seen tried without avail. When a suitable case pre¬
sented itself, however, he intended trying these methods again while
holding open the anterior naris of the blocked side with a speculum
tilting up the tip of the nose, so as to enlarge and straighten the
passage, and flexing head well on to sternum. A case was referred to
in which a short vulcanite cylinder got impacted in the anterior
recess of the nose; one in which a lead drainage spigot was acci¬
dentally pushed by a patient into his maxillary antrum, which had
been opened for empyema through the canine fossa some months
before: and one in which a young woman who was having her
larynx brushed out for hysterical aphonia bit on the metal mop
holder with such force that it was divided, and disappeared through
her fauces; careful examination gave no trace of its position then or
afterwards, and for some months she has not suffered any abnormal
symptoms or from aphonia. It is not improbable in the case of
certain metallic foreign bodies, e. g. needles and pins which had
perforated the wall of the oesophagus and were lying more or less
parallel to its axis (such bodies as it is most important to remove
forthwith), that assistance would be given by a strongly magnetised
bougie of flexible steel shaped like an ordinary gum oesophageal
bougie but fluted longitudinally. He had not had a case suggesting
the need of such an attempt since this idea had presented itself.
With reference to the use of emetics for dislodging impacted bodies,
he would fear to initiate the action of a powerful vis-a-tergo which
could not be regulated or controlled. Emesis appeared just as likely
to increase impaction and damage surrounding structures as tbe
vis-a-fronte of the surgeon acting with undue violence at the end of
an oesophageal ramrod—a method now so generally deprecated. He
would be glad to hear what were considered the best methods of
treating (1) the gullet; (2) the external wound after cesophagotomy
for impacted foreign bodies.
Mr. Laurence related the case of a lady who had a whiting bone
in the epiglottis low down close to the left pyriform sinus. The
bone caused no symptoms, except an occasional piick. She localised
the position as in the posterior faucial fold. Mr. Laurence drew
attention to the difficulty of localising throat impressions generally.
Another case, that of a very large rhinolith, was mentioned. The
stone had no nucleus, and the removal piecemeal caused unusual
haemorrhage, not to be accounted for by the operation.
Dr. A. A. Kanthack gave the following account of a specimen of
impacted piece of meat in the larynx, which he showed. A piece of
meat, during hasty swallowing, had become lodged in the aditus
laryngis, and has there been firmly impacted. A sagittal section had
been made, which shows the relation of the parts to the foreign body.
The epiglottis has been pushed forwards against the tongue, and the
piece of meat has been firmly moulded into the upper part of the
larynx. The specimen affords a good example of what happens when
75
the epiglottis does not act and becomes, pushed forward, and refutes
the view expressed by Prof. Anderson Stuart that the epiglottis
during deglutition becomes applied against the basis linguae, and
acts as an inclined plane for the bolus to slide along into the oeso¬
phagus beyond the larynx. Experimentally this view had already
been disproved by the speaker in conjunction with Mr. H. K.
Anderson of Cambridge (‘Journal of Physiology/ 1893).
Dr. Lambert Lack entirely disagreed with Mr. Symonds with
regard to the absence of odour with a unilateral purulent discharge
from the nose in children as diagnostic of the presence of a foreign
body. In a large number of cases he had, the fcetor of the discharge
was expressly noted. In one case an intensely horrible smell pervading
a whole ward was traced to a foreign body (a piece of string) in the
nostril. Dr. Lack had always considered that a unilateral foetid
and purulent, and often irritating discharge from the nose of a child
indicated a foreign body, had usually administered an anaesthetic, and
only once failed to find the foreign body. With regard to fish-bones
in the pharynx, he thought that they were sometimes present when
we did not find them, and that the persistence of symptoms so well
known is really due to their presence. These symptoms usually last
one or more months, and possibly their disappearance at the end of
this time is due to absorption of the bone. If it is a needle or similar
unabsorbable body which is complained of, it will probably be found
or heard of later. Thus in one case which had come under his notice
a needle was complained of. A month later it was found in the
tricuspid valve. The places in which these foreign bodies most often
lodge and escape observation are the tonsils, faucial and lingual;
these should always be examined by palpation as well as illumination.
A most useful and delicate method of palpation was first suggested
by Dr. Sutherland. Having localised the position of the foreign body
as far as possible by the patient’s sensation, the part is well illumined
and palpated carefully all over with a probe. The patient complains
of pain and pricking, the more acutely the nearer we approach the
affected spot, the greatest pain being caused when we touch the
foreign body itself and in this way we may localise accurately, and
remove a foreign body which we can hardly see at all. The follow¬
ing cases of interest were quoted.
Case 1.—The patient, a middle-aged woman, gave the history that
one night, three weeks before, she woke suddenly with a violent
choking attack. She coughed violently, could neither speak nor
swallow, but says her breathing was not obstructed; she vomited
copiously, and the attack subsided. In the morning her throat was
very painful, and a doctor who was called in treated her for tonsillitis.
The patient now missed her tooth-plate for the first time. This
plate she had worn constantly day and night for many years, but had
latterly noticed it was becoming loose. As, however, symptoms had
subsided, it was presumed that the plate had been thrown away with
the vomit. At the end of a week the soreness of the throat had
nearly vanished, and she went to the seaside to complete her cure.
Three weeks later she complained of a pricking in the throat, which
she could not localise definitely. This was increased by swallowing
76
or turning the head suddenly. She could swallow without difficulty,
and could speak easily, although with a perceptible hoarseness. She
had a slight irritable cough, a little mucous expectoration, a fear that
the plate was still in her throat, but no other symptoms. On exami¬
nation the tooth was seen resting on the right arytmnoid. and the
plate extended obliquely across the larynx to tae anterior parts of the
left ventricle, the left ventricular lone, and the arytmuo-epiglottic
fold. The plate was removed with an ordinary Mackenzie forceps. The
parts with which the plate had been in contact were superficially
ulcerated, and soon healed. The chief point of interest in this case
is the slight subjective symptoms caused by such a formidable look¬
ing object—an indefinite pricking sensation, a scarcely perceptible
hoarseness, a slight cough with some scanty expectoration, were all
that were complained of. Case 2.—A male. set. 1 7 years, was intubated
at a general hospital, in the summer of 1-S'dl, for laryngeal obstruc¬
tion, probably of traumatic origin. During a violent fit of coughing
the string broke, and the tube was sucked down into the trachea.
Inversion and exploration by a probe and finger through a laryngotomy
wound failed to detect the tube. Eventually it was assumed that the
patient had swallowed it, and he was discharged from the hospital.
During August, 1801, he gained flesh, and was fairly well, although
suffering from much cough and purulent expectoration. In Sep-
temljer, during a severe fit of coughing, something was felt to slip in
his chest, and signs of occlusion of the left bronchus came on. This
was followed bv increased cough and puruleut expectoration (a pint
or so a day), rapid wasting, and soon by evidence of a bronchiec-
tatic cavity at the left base. Dr. Lack then resected three inches
of the sixth rib, and nine days later opened a large abscess-cavity
deep in the lung. The tube could not be found. The boy was much
relieved by this operation, but died a month later from haemorrhage.
Post-mortem a No. 3 O’Dwyer’s tube was found in the left
bronchus, separated only by a thin membrane from the pulmonary
artery. The left luug was very small and collapsed, and contained a
large abscess-cavity, which had been opened. One point of interest
here is that the tube had remained three months in the trachea, and
yet exploration by a laryngotomy wound by probe and finger, by in¬
version, &c., had failed to remove or even detect it. It is doubtful if
the tube could have been safely removed, considering its anatomical
relations, even if it had been reached. Dr. Lack entirely agreed with
Mr. Symonds’s remarks about the real danger of foreign bodies
entering the windpipe during chloroformisation. A case of post¬
nasal adenoids under his care owes her life entirely to the fact that
tracheotomy instruments were at hand during the operation. He would
also point out that in some cases of foreign bodies in the larynx
breathing may 'not be restored, even after tracheotomy, until the
foreign body is removed, apparently because of the spasm its presence
excites.
Mr. Cresswell Baber showed three rhinoliths to illustrate the
subject under discussion. The first came from the left nasal cavity
of a medical man. He applied with a history of discharge from that
nostril for two or three months, having had no inconvenience at all
77
before that. On inquiry he remembered when three or four years old
putting a boot-button into his nose. Examination showed the rhino-
lith to contain so much iron (over 30 per cent.), that it was evidently
the boot-button, which must have been there for twenty-five years.
The case was interesting as showing that a foreign body may lodge in
the nose for over twenty years without attracting even an intelligent
patient’s attention. Case 2.—A child, set. 12. History of discharge
from left nostril with bleeding six years. No history of introduction
of foreign body. After removal of the foreign body under ansesthetic,
it was found to consist of a concretion having for its nucleus a plug
of tightly folded rag. The rhinolith in this case had produced con¬
siderable distortion of the bones, the left side of the nose and left
cheek were bulged out, the septum deflected to the right, and there
was a deep depression in the centre of the inferior turbinated body.
Case 3.—A man, set. 33, with an intermittent purulent discharge
mixed with blood from the left nostril for about nine months. A
rhinolith, having a glass bead for nucleus, was found deep in the
inferior meatus. It weighed sixteen grains. There was no history of
its introduction. (These cases are published in full in the speaker’s
article on “Foreign Bodies in the Nose, and Epistaxis,” in Burnett’s
‘ System of Diseases of the Ear, Nose, and Throat ’). In addition
to forceps, Mr. Baber found a steel hook, of which the hook itself
measured a quarter of an inch in length and one eighth of an inch in
breadth, very useful for removing foreign bodies in the nose and
rhinoliths. It must be strong, as in the case of rliinoliths it is often
necessary to use considerable force. Mr. Baber remarked on the
necessity of examining the naso-pbarynx in cases in which a foreign
body is felt by the patient in the larynx, as sensations in the naso¬
pharynx are often referred to that region.
Dr. Clifford Beale referred to the possibility of sudden obstruc¬
tion of the larynx during meals, by means of scraps of meat, and
related a case in which by instant inversion of the body and a deep
inspiration, followed by a forcible expiration, the foreign body was
ejected. The necessity for a very deep expansion of the lungs under
such circumstances was insisted upon.
Dr. Herbert Tilley mentioned a case in which a child, set. 4,
swallowed an intubation tube, which was removed from rectum two
days later by means of a nasal polypus forceps. He also mentioned a
case of almost fatal asphyxia during operation for adenoid overgrowths;
the portion of growth which had slipped into the glottis, however, was
loosened by forcible pushing upwards of the larynx. He pointed
out the advantage of having the patient’s head well hanging over in
this operation, and obviating the accident mentioned.
Dr. W. Hill remarked that one of the commonest forms of foreign
body which he had been called upon to deal with had been pledgets
of wool and lint which had been inserted into the nose after operative
measures for the suppression of haemorrhage; from the fact that
several pledgets or pieces of lint are often inserted, one such body is
liable to be overlooked, and great discomfort and stench results from
its retention for more than two or three days. Such an accident had
unfortunately happened in a case under bis care in conjunction with
78
a general practitioner, and undoubtedly one or other of them was
respousible for leaving a piece of blue gauze in the nose; no dis¬
comfort was felt for a week, and the patient was sent to Bournemouth,
where he became very ill with fever, violent headache, noseache and
marked fcetor; it was removed by Dr. Davison, to the immediate relief
of the patient. Dr. Hill had recently removed a stinking pledget of
cotton wool from the posterior naris, which had been inserted for
epistaxis two weeks previously at a general hospital. In reference to
Dr. Spicer’s remark that one-sided nasal suppurations in children
under six years of age did not necessarily point to foreign bodies, but
were frequently associated with deflections and deviations of the
septum, Dr. Hill said the fact that septal deformities were so com¬
paratively rare in young children, and unilateral suppurative rhinitis
being not so very uncommon, would point to this explanation being
far-fetched and inadequate. The speaker had once removed a fair¬
sized turnip from a cow, which had apparently lodged in a pouch of
the oesophagus, and he asked Mr. Svmonds whether he had seen in
his practice foreign bodies lodged in a pouch of the pharynx or gullet.
Dr. Grant recommended the use of the air-bag by the opposite
nostril instead of fluid syringing. Cocain should first be applied,
then an oily spray should be used, and Dr. Spicer’s advice to dilate
the orifice should be carried out. During the use of the bag, both
ears should be plugged by means of pushing in the tragus, and the
patient directed to blow out the cheeks forcibly. Dr. Grant had
found an instrument like a sharp recurved crochet-hook of consider¬
able value. He, on one occasion, used the pan-endoscope for the
oesophagus, and found no difficulty in introducing the instrument,
but the amount of light was small, although sufficient to make it
certain that no foreign body was present. He had seen the coin¬
catcher used with the greatest success for the removal of a tooth-plate
from the oesophagus in a case in which he had endeavoured to remove
it by means of forceps, and in which he was deterred from using the
coin-catcher from fear of the points tearing the mucous membrane
during the extraction. He narrated a case of impaction of a fine
herring-bone in the lingual tonsil, which was invisible when the
laryngoscope mirror was held in the left hand, but easily seen when
it was held in the right one. It could only be extruded sufficiently
for extraction by means of forceps when forcible pressure was made
in the submaxillary region, and the patient phonated. He had in
his experience come across a case of a second fish-bone after the
removal of the first. With the umbrella probang he had only once
withdrawn a fish-bone, although he had used it very many times.
Dr. Adolph Bronner had seen numerous cases of foreign bodies
in the nose. These had in nearly every case been easily removed by
the use of Poitzer’s bag or by a stream of water applied to the
opposite nostril (not the douche). In cases of foreign bodies in the
trachea it was always best to perform tracheotomy, as the body
might at any time become loose and get impacted in the glottis, with
fatal results. Kir stein’s antoscope was often of great use in nervous
patients or in children, who would not allow the laryngoscopic
mirror to be introduced. Dr. Bronner would like to ask Mr. Symonds
79
why cases of cesophagotomy for removal of foreign bodies were so
fatal. Dr. Bronner was of opinion that the use of the continuous
nasal douche was very dangerous, but that the use of Higginson’s
syringe was not attended by any bad after-effects.
Mr. W. R. H. Stewart wished to draw attention to the difference
between forcible syringing up the healthy side of the nose to remove
a foreign body, and the ordinary use of the Higginson douche.
Speaking as an otologist he strongly objected to the forcing of a
stream of water up one nostril if the other was blocked, owing to the
damage that might be done to the ears. The ordinary use of the
Higginson’s douche was one of the best ways of employing nasal
irrigation, but he doubted its efficacy in removing a foreign body
unless force was applied. He disagreed with Mr. Symonds with
regard to the absence of fcetor when foreign bodies were in the
nose. He had frequently met with cases in which a very foetid smell
was present. He had a very uncomfortable personal experience with
regard to the sudden entrance of food into the glottis, some syrupy
matter having suddenly entered and blocked the lumen of the glottis,
causing the greatest distress for some seconds. With regard to rare
foreign bodies, he had that day on removing a pair of tonsils lost one,
and after a long hunt had found it squeezed into the posterior nares.
Mr. Charsley promised to exhibit a specimen showing one vertebra
of a haddock which had passed through the larynx of a child aged
six, and had become impacted immediately below the glottis. The
dyspnoea produced was not excessively urgent. There was no history
of anything having been swallowed. Although the writer saw some
whitish body between the vocal cords when the child was first brought
to the hospital, the house surgeon thought nothing need be done.
Dr. Sherman asked if stiffness of the neck had been noticed as a
symptom of a foreign body in the oesophagus. In Mr. Harvey’s
absence he saw a child at the Throat Hospital, that had swallowed a
halfpenny three weeks before admission. The only symptom was
stiffness of the neck, the child would not put its head either towards
one shoulder or the other, almost as if disease of cervical spine were
present. Nothing could be seen with the laryngoscope. Use of the
coin-catcher immediately brought up the halfpenny.
Mr. Jessop inquired from Mr. Symonds as to any practical method
of getting rid of very viscid mucus occurring after repeated
examination of the throat for foreign bodies. The umbrella probang
was useful in satisfying the feeling of patients after assuring them that
there is really no foreign body present. Patients frequently confess
to feeling much relieved after this operation.
Mi*. Waggett said that he had been working with Mr. Sydney
Rowland to prove the use which could be made of the Rontgen rays
in the diagnosis and treatment of foreign bodies in and about the
larynx. Employing a “ focus ” Crooke’s tube transmitting X rays
transversely through the neck, they had been able to obtain, with an
exposure of five minutes, clear shadow pictures of coins and fish-bones
attached to the surface. As the cartilages of the larynx were trans¬
parent, and gave no land-marks on the picture, projection charts
representing the distorted image of the structures of the neck had been
so
made, reference to which permitted of localisation of any given point.
Further help in this direction was to be obtaiuedby taking more than
one position, and no difficulty was to be expected in obtaining a stereo¬
scopic effect. In order to make exclusion possible, the relative opacities
of a variety of bodies likely to obtain accidental entrance had been deter¬
mined. The cryptoscope, essentially a screen of cardboard coated with
potassio-barium cyanide, proved somewhat less sensitive than the
photographic plate, but has the advantage of permitting of contempo¬
raneous observation. In a darkened room the front portion of the
neck appeared in half shadow, bounded above and behind by the
black shadow of the jaw and spinal column. A defined shadow was
cast by the hyoid bone, and on introduction of a probe into the larynx
or oesophagus, the movements of the instrument could be followed,
without difficulty on the luminous screen. The cryptoscope should
afford a valuable aid in the guidance of the forceps in the removal of
foreign bodies.
[Owing to the kindness of Mr. Rowland, who had brought his appa¬
ratus, photographs were shown, and the cryptoscope demonstrated to
the members.]
The President, before calling upon Mr. Charters Symonds to reply,
thanked Mr. Waggett and Mr. Rowland for their most interesting
demonstration, which in connection with the subject under discussion
opened new and most important possibilities for the diagnosis and
removal of foreign bodies from the upper air passages. He then
briefly summarised the more important points touched upon in the
discussion, and instanced as such (1) the question of danger to the
ear by forcible injection of water iuto the nose for the removal of
foreign bodies from the nasal cavity. This danger he thought was
greater when a continuous than when an interrupted current, such
as produced by Higgiuson’s syringe, was used; (2) the danger of
pieces of adenoid vegetations penetrating into the lower air-passages
when the operation was performed with the patient sitting up; he
warmly advocated the position with pending head; (3) the deficient
power of localisation in the upper air-passages; sensations, even when
originating in the naso-pbaryngeal cavity, frequently being referred
to the laryngo-tracheal region; (4) the desirability of any digital
exploration being preceded by careful inspection of the parts; (5) the
persistence of sensations long after the removal of the foreign body.
In conclusion, he thanked Mr. Symonds in the name of the Society
for having by his careful introduction given rise to so interesting and
important a discussion.
Mr. Symonds, in reply to Dr. Spicer, said he recognised the uni¬
lateral discharge from the nose in young children with adenoids,
where the other side was obstructed, but he bad referred to a purulent
discharge without any such cause. The different opinions expressed
by the speakers as to the danger of syringing the nose, show ed that
the method might be employed with little risk of injury to the ear.
The fatalities after cesopliagostomy were due to septic cellulitis.
He suggested that this might be avoided with certainty by operating
in two stages, or again by plugging the wouud with gauze after
suturiug the gullet.
PBOCEEDINGS
OP THB
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, May 13th, 1896.
Felix Semon, M.D., F.E.GrP., President, in the Chair.
W. E. H. Stewart, F.E.C.S.,
StClair Thomson, M.D.,
Secretaries.
Present—32 members and 10 visitors.
The minutes of the previous meeting were read and confirmed.
Douglas D. Macrae, M.B., C.M.Montreal, was proposed for election
at the next Ordinary Meeting of the Society.
The following report of the Morbid Growths Committee on the
microscopical sections from cases by Dr. Bond, Dr. StClair Thom¬
son, and Dr. W. Hill was read.
The Morbid Growths Committee report that they received from
Dr. Bond a microscopical specimen and the following notes of the
case.
The patient, a man aged 50, gave a history of attacks of huskiness
and loss of voice for twenty years.
Twelve months ago voice almost went, and on examining the larynx
on January 15th last, a growth about the size of a pea was seen to
occupy the upper surface and edge of the middle of the right vocal
cord. It was transparent in centre, and had a cyst-like appearance.
On February 15th it was removed by the endo-laryngeal method,
since when the voice has wonderfully improved, and patient states
that it is better than for the past ten years.
The growth removed was jelly-like. Microscopically it seems to be
a pure myxoma.
Dr. Bond would direct attention to the long history in the case.
first series—VOL. hi. 8
82
No doubt the man may have had chronic laryngitis for some years.
It was common to find some myxoma in a laryngeal tumour, but a
pure myxoma was very rare. He thought it possible there may have
been some growth for a long time, and that a pure myxoma was here,
owing to the time which sucli growth had to undergo change.
The report of the examination is as follows:
Specimen consists of microscopical preparation of three minute
portions of tissue, stained with eosin and hsematoxylin.
Examined under low and high powers it shows a covering of strati¬
fied squamous epithelium.
Immediately beneath this there is a definite layer of fibrous tissue
which is somewhat dense and firm.
Deeper down, in what was probably the centre of the growth, the
tissue is much looser, more cellular; many of the cells are branched,
and in this part the growth has the structure of a myxoma.
In our opinion, the appearances above described point to the con¬
clusion that the growth is a fibroma undergoing myxomatous degene¬
ration.
The following notes are of Dr. StClair Thomson’s case.
Marion J—, aet. 38, had taught since the age of 17, but always in
private schools, the number of her class never at any time exceeding
twelve. She used to sing, but her voice had been “ thick ” for a year
past, and for the last nine months she had given up any attempt at
singing. For three months she had suffered from hoarseness and
partial loss of voice, especially after using it much. A spherical
growth about the size of a small pin’s head, smooth, red, and pedun¬
culated, was found projecting into the glottic space at the junction of
the middle and anterior thirds of the right vocal cord. There was some
injection and thickening of the adjoining surface of the cord, and
impaired approximation of the cords in phonation. The growth was
removed with Mackenzie’s antero-posterior forceps, and sections showed
that it was a myxoma, unless, indeed it should be regarded as simply
cedematous mucous membrane. In 1880 Morell Mackenzie spoke of
myxoma of the vocal cords as “ very rare,” and said that he had only
met with a single case (‘ Diseases of the Throat and Nose,’ vol. i, page
306). It was therefore noteworthy that this growth was removed on
the same afternoon as the one already referred to by Dr. Bond. Both
cases occurred at the Throat Hospital, Golden Square, in the clinic of
83
Dr. Bond, to whom Dr. Thomson was indebted for kind permission to
publish this one.
The following is the report of the examination.
Specimen consists of a single slide with six small sections, stained
with eosin and haematoxylin. The growth is covered by stratified
squamous epithelium, and consists of fibrous tissue. There are no
branched cells and no appearance of true myxomatous tissue. We
consider the growth to be an oedematous fibroma.
The following is the report of Dr. W. Hill's case.
The section presented for examination is about one square centi¬
metre in area, and stained with haematoxylin, rubiu, and orange.
It is of irregular outline, the surface of the tissues being repre¬
sented by a narrow condensed layer on three of its four sides, but
no covering epithelium is present. The central portion is composed
of delicate open fibrous tissue somewhat distorted during preparation,
and other elements of the turbinate body. Roughly speaking, the
peripheral zone of the section, from 1 to 3 millimetres in breadth, is
of a denser structure than the centre, and has failed to take the
haematoxylin stain fully. This zone is formed of detached and
coalesced patches of diseased tissue, the larger patches presenting
a sinuous outline, and sending offshoots towards the centre of
the specimen. In certain spots a very definite line of demarca¬
tion, constituted by a narrow zone rich in inflammatory corpuscles
which take the haematoxylin stain freely, separates the healthy
from the diseased tissue. The latter is found to consist of the
fibrous tissue of the turbinate, the elements of which have lost
definition of outline and the faculty of staining with haematoxylin.
This tissue is densely infiltrated with inflammatory corpuscles, the
larger number of which are in a state of degeneration. The centre of
many of the larger patches are occupied by areas staining yellow, and
of granular appearance. In the neighbourhood of these caseous
centres the lumen of the vessels is obliterated by infiltration and
degeneration of their walls, and the diseased areas are anaemic through¬
out! The inflammatory process appears to result in caseation and not
fibrosis. No typical tubercles are present, but here and there a
concentric arrangement can be made out, and at least two well-
defined giant cells are to be seen. These contain numerous nuclei
placed peripherally. No tubercle bacilli have been detected in other
preparations. We consider the specimen to be tubercular.
84
Case ok Obstruction ok Larynx due to a Web.
Shown by Dr. Barclay Baron (Bristol). A man, aged 39 years,
who had not had syphilis nor other constitutional dyscrasia. In
October, 1894, he had hoarseness and loss of voice with gradually
increasing difficulty of breathing, which induced his own doctor to
perform laryngotomy.
On being admitted into the Bristol General Hospital under Mr.
Baron, there was found to be intense inflammation of the whole of the
larynx, the vocal cords, which were in apposition, were especially
affected, being intensely red, swollen, and motionless.
In spite of all that was done he continued in this condition for
three months. Tracheotomy was then performed, and the laryngo¬
tomy tube removed. The effect of this was soon beneficial,—first one
vocal cord and then the other leaving the middle line, and then the
anterior two thirds of the vocal cords was found to be united by a web.
This has been cut by Whistler's cutting dilator, and dilated by
Schrotter's and other bougies, and now only a small amount of web
tissue uniting the under surface of the vocal cords in front persists.
The tracheotomy tube has been removed, and the man is able to do
his work as a farm labourer. The points of interest in the case are—
1. There is no history of syphilis, and it is believed to be an instance
of a web forming after a common cold.
2. The laryngotomy tube kept up the inflammation in the larynx,
and tracheotomy is therefore to be preferred to laryngotomy.
Dr. Baron asked members of the Society to express an opinion as
to the advisability of doing anything further.
Dr. TTat.t. mentioned a case in which agglutination of the vocal
cords occurred as the result of syphilis. When first seen the cords
were united by only a narrow band; unfortunately the patient declined
admission into the hospital. When he applied a week later the cords
were adherent nearly along the whole length, and tracheotomy had to
be performed at once. Whilst under treatment for removal of the
laryngeal obstruction, stenosis of the trachea occurred. The patient
left the Westminster Hospital after attempts had been made to check
the growth in the trachea by scraping and astringents. Some weeks
later the patient is reported to have died in Paris while being
operated on.
Dr. Cresswell Baber thought the case might be syphilitic.
Dr. Bond would not go any further with the treatment.
The President had a case of suicide in which a web formed where
85
the cut was. A second web had formed above by the agglutination of
the cords. Webbing might occur from inflammation. He thought
laryngotomy ought not to be performed as it caused inflammation
and prevented healing.
Case of Thyrotomy for Epithelioma of the Larynx.
Shown by Dr. Felix Skmon. The patient, a gentleman aged 65,
was first seen on February 18th of this year. The only symptom
was hoarseness dating back nearly a year and a half, and supposed to
have commenced after an attack of influenza, which had also caused
purulent discharge from the right nostril; this, however, troubled the
patient very little. The whole of the left vocal cord, particularly in
its middle part, was considerably tumefied, and showed a granular
appearance. At the same time its mobility was surprisingly free, and
the hoarseness comparatively speaking very slight. Malignant
disease had already been diagnosed by Dr. Madden and Mr. Dudley
Wright. The diagnosis was further corroborated by Mr. Butlin.
The operation was performed on February 27th, and offered no
incidents of importance. On opening the larynx the growth was
seen to extend all over the left vocal cord, and the ventricular band
also appeared somewhat swollen. In front the growth just extended
to the median line. The whole affected portion was delineated by two
semicircular cuts at a distance of about three-quarters of an inch
from the growth, meeting in front and behind and cut out with curved
scissors. Posteriorly the extirpation extended to the front part of the
arytsenoid cartilage, which was also removed.
The patient made an excellent recovery, except that on the third
day some ominous black spots appeared in the wound, supposed to be
due to infection from the purulent nasal discharge. These were
scraped out, and nothing further occurred. The voice is now toler¬
ably good, a cicatricial ridge having formed in the situation of the
left vocal cord, and it will probably be better when a bunch of granu¬
lation tissue, which is at present situated just in the anterior com¬
missure, will have been removed. This removal, however, has been
purposely postponed until after the demonstration to the Society, in
order to show that not every tumefaction which appears in the neigh¬
bourhood, or in the situation itself of the scar after an operation of
this kind, ought to be at once considered to represent a recurrence of
86
the disease. The present case (which is, moreover, remarkable by its
complication with purulent nasal discharge, probably due to empyema
of the right frontal sinus) is particularly suitable for illustrating this
fact, which has been observed by the author in three or four previous
cases. The formation of granulation tissue is not limited to the interior
of the wound, but also extends to the external scar, and is no doubt
due to necrosis and sequestration of small portions of the completely
ossified projecting angle of the thyroid cartilage. Granulations such
as present now in the upper part of the wound also luxuriantly grew
up from the lower parts. This, however, healed spontaneously and
rapidly after elimination of two or three minute particles of necrosed
cartilage, which were eliminated through the external wound, and
there is hardly any doubt that the same will take place with regard to
the parts in which granulations are still at present seen.
Case of Uncontrollable, Intermittent, Laryngeal Cry.
Shown by Dr. Bond. A boy, 11 years of age, began in March,
1895, one night when in bed to utter at irregular intervals a loud
cry. This he continued to do until August, 1895, when he went to
stay for about ten days in the country, and towards the end of the
visit the cry “ gradually ” ceased. At Christmas, 1895, a second
attack came on at 3 a.m., and has continued since. The boy has
lately had measles, during which the cry was emitted as usual. Until
recently the mother states that the cry persisted during sleep.
The boy seems dull and stupid, hands and arms are continually
working, almost like those of a child with chorea. At intervals, varying
from about 12 seconds to 14 minutes, he utters an explosive, sudden
cry of considerable volume, very like part of a milkman's cry, but
not resembling any word. The cry is associated with somewhat
violent action of the diaphragm, and with a lifting of the soft palate.
It is never emitted during a laryngoscopical examination, but directly
after such an examination has been made the cry is emitted. The
boy has double proptosis, also he has adenoids of the naso¬
pharynx.
The child’s mother has had rheumatic fever, a brother has died
from “irritation of the brain.” The child has never had convulsions,
nor worms. There is no history of chorea in the family.
87
The President did not think the mischief organic, and asked
whether malingering might be excluded.
Mr. Stewart thought the trouble might be caused by the presence
of the adenoid growths.
Mr. Spencer said they had a case in Westminster Hospital a little
while ago of spasmodic cough. Patient was hypnotised, when the
cough changed to attacks of sneezing. She ultimately got well.
Dr. Scanes Spicer thought, from the condition of the eyes, that it
was not functional.
Dr. de Havilland Hall suggested a sea voyage. He had a case
in which this had excellent results.
Dr. Bond, in reply, stated that the lowered mental condition, the
almost choreiform restlessness of limbs, the action of the diaphragm,
and the explosive cry taken together, seemed to negative the idea of
malingering. The case was very unlike the cases of nervous laryn¬
geal cough, and seemed to be a case of “ tic convulsif.” After the
removal of adenoids (which would end a source of irritation, and
ensure sounder sleep), in conjunction with the administration of
arsenic and a prolonged change of air in the country, Dr. Bond
thought the patient likely to improve. He disapproved of the em¬
ployment of faradism, thinking such treatment very likely to make
the boy worse. On the other hand, he had seen a cure of nervous
laryngeal cough, with stiffness of one knee of two years’ standing,
cured in a few minutes by faradism.
Case of Tubercular Laryngitis on which Thyrotomy has
been Performed.
Shown by Dr. Bond. This patient, a man of 45, in June, 1895,
had a sore throat which persisted until October last. He was then
having night sweats, had been losing flesh, and had attacks of severe
suffocating cough. He had pain shooting up to left ear. He had
lost three children from phthisis. He was much emaciated, and his
face pinched and sallow. We could find no trace of syphilis, and
there was no history of it. He seemed to have had slight consolida¬
tion at right apex, having slight dulness, bronchial breathing, &c.,
but no r&les could be heard.
The left side of the larynx was fixed. There was great swelling of the
left ventricular band, which was red and coarsely granular, and at the
back was superficially ulcerated. The front of left cord could be seen
with difficulty. There were no enlarged glands ; voice very husky.
The case seemed a doubtful one, and one on which an exploratory
thyrotomy should be performed, and this was done on November 15th.
The whole left ventricular band was found affected and was removed, and
88
also the inner edge of the brim on left and the left cord. On the pos¬
terior commissure were several papillary excrescences, and the mucous
membrane here was also removed. The left thyroid plate was scraped,
and also the anterior commissure.
The patient left hospital a month after the operation with a
narrow sinus unhealed, and with some cough. Since he has con¬
siderably improved, his temperature is normal and his weight has
increased to 12 stone. The larynx is somewhat deformed and con¬
gested, but there is no definite infiltration to be seen, and no ulcera¬
tion. His voice is feeble, owing in part to the escape of air through
the sinus.
The specimen removed was pronounced to be tubercular, and
tubercle bacilli have been found in the sputum.
Case of Sarcoma Recurring in Nose.
Shown by Dr. Bond. The patient, a man of 62 years of age, began
to have severe attacks of epistaxis from left nose in November, 1892.
When seen at the Throat Hospital, in October, 1893, the left side of
nose was congested, greatly swollen, and completely plugged in front
by a fungating, slightly movable mass, which bled freely on exa¬
mination with a probe; enlarged glands could be felt below the
angle of left jaw. The mass was removed piecemeal by a snare, and
its base thoroughly curetted, and the nose firmly plugged. Afterwards
the site of growth was cauterized with the galvano-cautery. The
growth sprang in the front of the nose from the lower part of the
septum, from the floor, and from the front of the lower turbinated
bone. The enlarged glands were also removed. Recurrence
occurred after two and a half years, and in March, 1896, a mass
was removed from lower part of septum and floor of nose. Recur¬
rence has, however, already occurred in nose, and there is an enlarged
gland in neck.
The fact that sarcoma of the nose is so amenable to intra-nasal
operative treatment is noticeable. Dr. Bond had seen several cases of
extensive sarcoma of the nose live for years, where it was impossible
to perform a radical operation, and where occasional extensive
curetting, &c., gave considerable relief. He would like to ask whether
89
others have found cases of sarcoma of nose less malignant than is
commonly supposed.
Mr. C. Babes said these cases bleed very much. He had a case in
which there was great difficulty in stopping the bleeding after removal.
There was no recurrence.
Dr. Bennett would merely keep the passage clear, and do nothing
else.
Mr. Lambebt Lack thought the tumours were not so malignant in
the nose. Extensive operations through the nose did good.
Case of Healed Tubercular Disease of the Larynx.
Shown by Mr. Lambert Lack. Patient, a girl aged 28, was quite
well until 1893, when symptoms of phthisis’developed, and she lost
her voice. In October, 1893, the patient was losing flesh, had
much cough, and a hectic look. She was nearly aphonic.
Examination of lungs showed dulness over the upper half of the
chest on both sides, back and front, with abundant moist sounds and
bronchial breathing at the right apex.
Examination of larynx showed irregular fleshy thickening of both
vocal cords, with very deficient movement on the right side. There
was a prominent ulcerating growth on the anterior surface of the
right arytsenoid, and some oedema of both arytaenoids. Treatment:
cod-liver oil and iron internally, and pure lactic acid well rubbed in
locally once a week. After some months’ rather irregular attendance,
she was much improved, but the tumour remained much the same.
This was then entirely scraped away with the curette, and pure
chromic acid applied to the resulting ulcer. This slowly healed, and
in the spring of 1895 the ulcer of the larynx was quite healed. In
November the larynx appeared almost normal, the movements being
quite free, and there was no trace of swelling or ulceration.
Dr. Hall thought that the only thing to be done was to congratu¬
late Dr. Lack on the success of his treatment. The cords were prac¬
tically normal, and there was hardly any trace of a scar.
Case of Lupus Pharyngis.
Shown by Mr. Lambert Lack. The patient, aged 34, says for
several years he has suffered from occasional dry throat, but for seven
90
weeks the condition has been much worse. He consulted a doctor,
who noticed a small spot in the centre of the pharynx, which he
cauterised, but other spots appearing he sent the patient to me.
The patient has always had good health, has had no special illnesses,
there is no history of syphilis, and no tubercular history in his
family.
The posterior wall of the pharynx is irregularly uodular, in places
red and inflamed, in places abraded, and in others cicatrising. Caseous
scattered nodules can be seen, but no large ulcers.
The condition extends from the level of epiglottis up to the vault of
the pharynx. There is no lupus on the skin, in the nose, palate, or
larynx. A piece removed for examination shows numerous tubercles
with much inflammatory tissue. The treatment has been arsenic
internally and the cautery locally, but no sufficient time has elapsed
to note the effect.
The case is apparently a very acute one, and in its limited distri¬
bution probably a rare one.
Dr. Scanes Spicer could not call the case one of lupus.
Dr. Bond thought it was lupus, and did not consider isolated lupus
of the pharynx rare.
The President was of the same opinion.
Dr. Pkolbr would like a portion removed, and a section made.
Case op Healed Antrum and Frontal Sinus Suppuration.
Shown by Mr. Lambert Lack. Patient, F—, set. 32, for about six¬
teen years has suffered from nasal obstruction, with occasional thick
yellowish discharge, and pains over left side of head. The pain she
describes as almost constant, and at times “ maddening.” Eleven
years ago some polypi were removed from the left nostril. Patient
first seen by Mr. Lack in 1893. She complained then of intense
continuous pains above both eyes and in the left cheek, with a
yellowish discharge from left nostril. The left nostril showed polypi
and pus, the right polypi but no pus. The polypi were removed,
and the left antrum drilled. The antrum contained pus, but was
cured by a few weeks' syringing. The patient was very slightly
improved. In 1894 the left frontal sinus was opened through
an incision in the line of the eyebrow, the field of operation
being bounded by the supraorbital notch and the pulley of the
91
superior oblique. A large piece of bone was removed by the
chisel, and much pus was evacuated. A long rubber tube was passed
through the infundibulum into the nose, and retained for about ten days,
when it was replaced by a short silver tube. After six weeks all
symptoms had disappeared, the tube was left out, and the wound
soon healed, leaving an inconspicuous scar under the eyebrow. The
patient, nearly two years later, remains well.
Case and Specimen op cured Polypi of Frontal Sinus.
Shown by Dr. H. Tilley. Patient was a man aged 45, who came to
the London Throat Hospital complaining of slight discharge from both
nostrils, and occasional frontal headache. Some polypi were seen
under the middle turbinate on the left side, which were removed from
time to time. A discharge of pus was also constantly seen in this
situation.
On further examination a probe could be passed easily into the
frontal sinus. The patient was therefore anaesthetised, and a vertical
incision about two inches long made from the nasion upwards—the
soft parts and periosteum were drawn aside and the anterior surface
of the left sinus removed by means of gouge and mallet, when the
granulations contained in the sinus bulged forward and looked exactly
like haemorrhoids of rectum. The same was the case with the right
sinus. Both sinuses were curetted and then swabbed out with zinc
chloride solution grs. xl to $j, and drainage-tubes were inserted
into both sinuses, by means of which the sinuses were irrigated daily
with boracic lotion for a week, when the tubes were removed. The
wound healed and the patient is now perfectly free from any trouble,
and there is no nasal discharge. The median scar is now almost
invisible.
It should be stated that previously to operating on the frontal
sinus the maxillary antrum was explored and found healthy.
These two cases were discussed at the same time.
Mr. C. Baber thought that Mr. Lack’s case was interesting as having,
after recovery, left only a slight scar hidden by the eyebrow. He
related a case under his care in which there was protrusion of the eye¬
ball from distension of the left frontal sinus with non-fcetid mucous
liquid containing cholesterine crystals. On opening the sinus from
the forehead it was found completely cut off from the nasal cavity,
92
where there existed purulent disease of the ethmoidal cells. The case
was still under treatment.
Dr. Scanes Spicer would always remove the anterior extremity of
the middle turbinate bones before doing anything further.
Dr. Wm. Hill had a case which had left a deep scar. He should
certainly try operating through the brow, more especially in females.
The President related a case he had with Mr. Horsley in which
a transverse incision was made, a portion of the front of the sinus
taken away, and the whole mucous membrane removed. During this
operation the hopelessness of operating through the nose was appa¬
rent, as it was impossible to get at all the disease through the nose.
He asked whether in these cases it would not be possible to fill up
the sinuses with foil or something to prevent the falling in of the
cavity.
Mr. Spencer suggested plaster of Paris as being good for filling
up bone.
Mr. Stewart thought that plaster of Paris would be too heavy for
the frontal sinus.
Dr. Dundab Grant mentioned a case of Waterhouse in which
decalcified bone was used to fill up a hole in the astragalus. He
pointed out the difficulty of any bone healing without a drawing in of
the cavity.
Mr. Lack thought the opening through the eyebrow caused no
deformity. He considered it best to leave the mucous membrane
untouched.
Dr. Herbert Tilley stated that he had recently examined the
frontal sinuses in a large number of skulls (over a hundred), and that
the constant and extreme variation in the size and extent of the sinuses
was in favour of an external opening, and he preferred the vertical
median incision in the majority of cases. He strongly deprecated
any operation from the nose, but thought that syringing the frontal
sinuses from the nose, where possible, might be practised for a short
time before proceeding to the external operation; if, however, the
naso-frontal canal could not be found, no passage should be forcibly
made.
Dr. Bennett suggested that these 130 cases were normal skulls. In
diseased conditions it was more possible to operate through the
nose. He would operate through the nose first to relieve obstruc¬
tion.
Case of Mycosis of Tonsils and Pharynx.
Shown by Dr. Scanes Spicer. Patient, a man set. 35, had a well-
developed thalloid projection from crypts of left tonsil, posterior
pharyngeal wall, and base of tongue. Microscopically it consisted
chiefly of cladothira. It had proved very resistent to paints, washes,
&c. He proposed dissecting out the affected portion of faucial tonsil,
93
and applying the galvano-cautery to the pharyngeal and lingual
crypts.
Dr. Hall recommended the use of the galvano-cautery for the
destruction of the mycotic growths. Absolute alcohol had not given
good results in his hands.
Dr. Bennett suggested the application of pure carbolic acid.
Dr. Beady (Sydney) showed a tonsilotome for removing hypertro¬
phied lingual tonsils. It was an ordinary Mackenzie tonsilotome with
the blade curved to fit over the back of the tongue.
Malignant(?) Disease op Larynx.
Shown by Dr. Furniss Potter. M. C —, widow, aged 69, came
to the London Throat Hospital on the 17th of March last complaining
of difficulty and pain in swallowing (principally solids).
No very definite or satisfactory history obtainable. The patient
states she has had difficulty in swallowing for many years, but has
been worse during the last twelve months. She has had two children
stillborn, and one miscarriage.
On examination with the laryngoscope a large red mass occupying
the arytaenoid region in its whole width was seen; this has increased
considerably since the first examination. It bleeds easily on being
touched, but there is no visible ulceration. Two distinctly enlarged
glands can be felt on the left side of the neck behind the sterno-
mastoid. The patient states that she has lost flesh rapidly lately.
Dr. Potter thought that there was little doubt the growth was malig¬
nant, but would like to have the opinion of members on it.
Obscure Case op Laryngeal Disease.
Shown by Dr. de Havilland Hall. R. M. V — was shown to the
Society on October 10th, 1894 (see p. 6, vol. ii).
The patient has continued in excellent health, and is able to cycle
and dance.
In January, 1896, while at Munich, Prof. Schech detected some
pale growths on the right side of the larynx filling up the glottis.
These were removed with forceps and curette.
On January 21st a piece of the tip of the epiglottis was removed;
very severe haemorrhage followed. In view of the stationary con¬
dition of the laryngeal condition and the patient’s excellent health.
86
the disease. The present case (which is, moreover, remarkable by its
complication with purulent nasal discharge, probably due to empyema
of the right frontal sinus) is particularly suitable for illustrating this
fact, which has been observed by the author in three or four previous
cases. The formation of granulation tissue is not limited to the interior
of the wound, but also extends to the external scar, and is no doubt
due to necrosis and sequestration of small portions of the completely
ossified projecting angle of the thyroid cartilage. Granulations such
as present now in the upper part of the wound also luxuriantly grew
up from the lower parts. This, however, healed spontaneously and
rapidly after elimination of two or three minute particles of necrosed
cartilage, which were eliminated through the external wound, and
there is hardly any doubt that the same will take place with regard to
the parts in which grauulations are still at present seen.
Case op Uncontrollable, Intermittent, Laryngeal Cry.
Shown by Dr. Bond. A boy, 11 years of age, began in March,
1895, one night when in bed to utter at irregular intervals a loud
cry. This he continued to do until August, 1895, when he went to
stay for about ten days in the country, and towards the end of the
visit the cry “gradually” ceased. At Christmas, 1895, a second
attack came on at 3 a.m., and has continued since. The boy has
lately had measles, during which the cry was emitted as usual. Until
recently the mother states that the cry persisted during sleep.
The boy seems dull and stupid, hands and arms are continually
working, almost like those of a child with chorea. At intervals, varying
from about 12 seconds to 1^ minutes, he utters an explosive, sudden
cry of considerable volume, very like part of a milkman's cry, but
not resembling any word. The cry is associated with somewhat
violent action of the diaphragm, and with a lifting of the soft palate.
It is never emitted during a laryngoscopical examination, but directly
after such an examination has been made the cry is emitted. The
boy has double proptosis, also he has adenoids of the naso¬
pharynx.
The child's mother has had rheumatic fever, a brother has died
from “irritation of the brain.” The child has never had convulsions,
nor worms. There is no history of chorea in the family.
87
The President did not think the mischief organic, and asked
whether malingering might be excluded.
Mr. Stewart thought the trouble might be caused by the presence
of the adenoid growths.
Mr. Spencer said they had a case in Westminster Hospital a little
while ago of spasmodic cough. Patient was hypnotised, when the
cough changed to attacks of sneezing. She ultimately got well.
Dr. Scanes Spicer thought, from the condition of the eyes, that it
was not functional.
Dr. de Havilland Hall suggested a sea voyage. He had a case
in which this had excellent results.
Dr. Bond, in reply, stated that the lowered mental condition, the
almost choreiform restlessness of limbs, the action of the diaphragm,
and the explosive cry taken together, seemed to negative the idea of
malingering. The case was very unlike the cases of nervous laryn¬
geal cough, and seemed to be a case of “ tic convulsif.” After the
removal of adenoids (which would end a source of irritation, and
ensure sounder sleep), in conjunction with the administration of
arsenic and a prolonged change of air in the country, Dr. Bond
thought the patient likely to improve. He disapproved of the em¬
ployment of faradism, thinking such treatment very likely to make
the boy worse. On the other hand, he had seen a cure of nervous
laryngeal cough, with stiffness of one knee of two years’ standing,
cured in a few minutes by faradism.
Case of Tubercular Laryngitis on which Thyrotomy has
been Performed.
Shown by Dr. Bond. This patient, a man of 45, in June, 1895,
had a sore throat which persisted until October last. He was then
having night sweats, had been losing flesh, and had attacks of severe
suffocating cough. He had pain shooting up to left ear. He had
lost three children from phthisis. He was much emaciated, and his
face pinched and sallow. We could find no trace of syphilis, and
there was no history of it. He seemed to have had slight consolida¬
tion at right apex, having slight dulness, bronchial breathing, &c.,
but no r&les could be heard.
The left side of the larynx was fixed. There was great swelling of the
left ventricular band, which was red and coarsely granular, and at the
back was superficially ulcerated. The front of left cord could be seen
with difficulty. There were no enlarged glands ; voice very husky.
The case seemed a doubtful one, and one on which an exploratory
thyrotomy should be performed, and this was done on November 15th.
The whole left ventricular band was found affected and was removed, and
94
Dr. Hall was doubtful whether the diagnosis of chronic tuberculosis
could still be maintained.
A portion of the growth removed in January will be submitted to
microscopic examination.
New Tracheotomy Tube.
Shown by Mr. db Santi. This is a tube adapted for patients who
have to wear a permanent tube, and who have sufficient space to expire
through the larynx though not room enough for inspiration. The
tube is fitted with a small metal hollow plug with a small rim below,
and in the plug is fitted a metal hinge valve something like a sewer
trap: on inspiration the valve opens and the patient breathes through
his tube; on expiration the valve closes tightly and air passes through
the larynx.
The danger of the valve getting loose is avoided by the metal rim
below.
The advantages of the plug and valve are—
(1) That the patient can speak distinctly and without putting his
fingers on the tracheotomy tube.
(2) That he coughs up mucus, &c., through the larynx and out of
the mouth normally.
(3) That the patient is able to wear a collar and shirt and go
about comfortably.
In Dr. De Havilland’s case shown at this meeting, Mr. de Santi
has adapted his tube to the case. The patient has worn the tube and
plug, which is removable, for six months, is able to talk well, wear
evening dress, and bicycle twenty miles a day. He has tried the
ordinary pea valve and finds it useless.
If the removable plug becomes at all blocked with mucus, it is
taken out and boiled, and in the meanwhile a fresh plug inserted.
It is of course necessary that there should be an opening in the
tracheotomy tube in the ordinary place at its greatest convexity.
The plug with its valve fits flush with the tube into which it is
inserted.
95
Cask op Abductor Paralysis.
Shown by Mr. Spencer. Patient, a man aet. 35, had worn a
tracheotomy tube since June, 1882. He was a soldier who had served
in Egypt, and an abscess formed in the neck in the site of a scar at
the anterior border of the left sterno-mastoid just above its insertion.
He had felt nothing wrong with his throat, but a few hours after the
opening of the abscess he was eating his dinner when he was suddenly
attacked by difficult breathing, for which tracheotomy was done the
same evening. Subsequently an attempt to leave off the tube failed.
He came concerning a warty growth in the tracheotomy wound, which
has been removed. He can speak well with the finger over the
tracheotomy tube. The vocal cords are apparently normal, but
fixed in adduction, no abduction beyond 1—2 mm. can be done.
The affection is doubtless due to syphilis. A nerve lesion there
may have been distinct from the above. If perichondritis, it is re¬
markable that he should have had no throat trouble beforehand.
Chronic Retro-pharyngeal Abscess in an Adult.
Shown by Dr. Felix Semon. The patient, a gentleman aged 37,
had in September last an “ abscess” in the throat which took about six
weeks to develop, and caused at the time considerable difficulty in
swallowing, but apparently no other symptoms. It was opened, a
large quantity of matter escaped, and he was then sent on a voyage to
South Africa. The incision, however, never healed, and he is still
troubled with much secretion, and at the same time a feeling of dry¬
ness in the throat. There is an indistinct history of syphilis many
years ago, but no secondary or tertiary symptoms have ever occurred.
On examination the posterior wall of the pharynx is enormously
swollen, sodden, and reddened, and particularly the right side bulges
much forward. There is a longitudinal opening filled with sanious
matter at the angle formed between the posterior and right lateral
wall, and a smaller fistulous opening near the middle line. The probe
introduced into these openings does not touch any rough bone. The
swelling extends a long way up into the naso-pharyngeal cavity, the
movements of the head are particularly free, the vertebrae are not
tender to touch at all ; no evidence of any pulmonary affection.
96
The patient was put on 10 grs. of iodide of potassium, and when
he appeared a week after (April 22nd) a diminution of the pharyngeal
swelling was noticeable, but no other change. A consultation was
held with Mr. Horsley, who agreed that there was no bone affection
or evidence of tubercular mischief. The patient is now still taking
iodide of potassium. Should, after another three or four weeks, the
abscess not close spontaneously, it is intended to connect the two
openings by a horizontal incision at the lower part of the abscess, and
to scrape out freely the walls of the abscess.
The case is shown because a chronic retro-pharyngeal abscess in an
adult, without any traumatic or diathetic cause known, is exceed¬
ingly rare.
A D hawing of a Case of Extrinsic Malignant Disease of the
Larynx.
Shown by Dr. Watson Williams.
A Coloured Drawing of a Case of Early Malignant Disease
of the Vocal Cords.
Shown by Dr. Watson Williams. Dr. Williams thought that as
the disease was intrinsic, localised, and early, it was suitable for
radical extirpation after thyrotomy, but the fact that the patient was
74 years of age was considered sufficient to negative such a procedure.
The movement of the vocal cords were greatly impaired. The voice
had been hoarse two months, and this was the only symptom. There
was no alcoholic or syphilitic history. As operation was negatived it
was considered inadvisable to complete the diagnosis by removal of a
fragment of the growth for histological examination, but he believed
that the great impairment of the vocal cord movement in the absence
of any appearance of thickening around the crico-arytaenoid joint,
pointed strongly towards it being a case of early malignant disease
rather than of pachydermia laryngis.
The President did not think it was a case of malignant disease.
Dr. Scanes Spicer thought it was one of pachydermia.
INDEX.
Abductor paralysis (W. G. Spencer) . . % .
-with laryngeal crises (C. A. Parker) .
- complete paralysis of left abductor, paresis of right abductor, in
case of bulbar paralysis (Felix Semon, M.D.)
Abscess: chronic retro-pharyngeal abscess in an adult (Felix Semon, M.D.)
Air and food passages (upper), foreign bodies in: see Foreign bodies.
Albuminuria: microscopic specimen of haemorrhagic myxoma of lingual
tonsil in albuminuric patient (A. Bronner, M.D.)
Annual General Meeting, January 8th, 1896
Antrum: empyema of maxillary antrum (A. A. Kanthack, M.D.)
-and frontal sinus suppuration ; healing (L. Lack)
Atrophy (progressive muscular) in case of bulbar paralysis (Felix
Semon, M.D.) • ••...
Babbb (E. Cre8swell), papilloma of nose .
-discussion on foreign bodies in the upper air and food passages
Balance sheet, 1895
Ball (J» B., M.D.), case of paralysis of left vocal cord
-case of growth on left vocal cord ....
Baboh (Barclay J., M.B.), case of obstruction of larynx due to a web
Bbalb (E. Clifford, M.B.), a case for diagnosis—tubercle or cancer
-pathological specimens of tubercular infiltration of pharynx and
tongue . ......
■ case of cyst of glosso-epiglottic fold ....
-tubercle or cancer ....
-discussion on foreign bodies in the upper air and food passages
Bbnnbtt (F. W., M.D.), microscopical section of round-cell sarcoma of
the thyroid ......
Bond (J. W., M.D.), case of excision of larynx; myxochondroma of larynx
-clonic spasm of pharynx and soft palate .
■ - ■■ -larv© in the nose ....
■ — - specimen of myxoma of larynx ....
-case of uncontrollable intermittent laryngeal cry
■ ■ -tubercular laryngitis on which thyrotomy has been per¬
formed .......
- case of sarcoma recurring in nose ....
— case of complete excision of larynx, see Harvey (F. G.) .
Bowlby (A. A.), a case of stenosis of the larynx due to laryngitis com¬
plicating typhoid fever
-case for diagnosis . .
FIRST SERIES —VOL, III, 9
PAGE
95
46
39
95
14
35
16
90
39
23
76
36
12
24
84
21
25
64
65
77
25
40
41
66
66
86
87
88
41
13
14
90
weeks the condition has been mnch worse. He consulted a doctor,
who noticed a small spot in the centre of the pharynx, which he
cauterised, but other spots appearing he sent the patient to me.
The patient has always had good health, has had no special illnesses,
there is no history of syphilis, and no tubercular history in his
family.
The posterior wall of the pharynx is irregularly nodular, in places
red and inflamed, in places abraded, and in others cicatrising. Caseous
scattered nodules can be seen, but no large ulcers.
The condition extends from the level of epiglottis up to the vault of
the pharynx. There is no lupus on the skin, in the nose, palate, or
larynx. A piece removed for examination shows numerous tubercles
with much inflammatory tissue. The treatment has been arsenic
internally and the cautery locally, but no sufficient time has elapsed
to note the effect.
The case is apparently a very acute one, and in its limited distri¬
bution probably a rare one.
Dr. Scanes Spicer could not call the case one of lupus.
Dr. Bond thought it was lupus, and did not consider isolated lupus
of the pharynx rare.
The President was of the same opinion.
Dr. Peoler would like a portion removed, and a section made.
Case op Healed Antrum and Frontal Sinus Suppuration.
Shown by Mr. Lambert Lack. Patient, F—, set. 32, for about six¬
teen years has suffered from nasal obstruction, with occasional thick
yellowish discharge, and pains over left side of head. The pain she
describes as almost constant, and at times “ maddening.” Eleven
years ago some polypi were removed from the left nostril. Patient
first seen by Mr. Lack in 1893. She complained then of intense
continuous pains above both eyes and in the left cheek, with a
yellowish discharge from left nostril. The left nostril showed polypi
and pus, the right polypi but no pus. The polypi were removed,
and the left antrum drilled. The antrum contained pus, but was
cured by a few weeks* syringing. The patient was very slightly
improved. In 1894 the left frontal sinus was opened through
an incision in the line of the eyebrow, the field of operation
being bounded by the supraorbital notch and the pulley of the
91
superior oblique. A large piece of bone was removed by the
chisel, and much pus was evacuated. A long rubber tube was passed
through the infundibulum into the nose, and retained for about ten days,
when it was replaced by a short silver tube. After six weeks all
symptoms had disappeared, the tube was left out, and the wound
soon healed, leaving an inconspicuous scar under the eyebrow. The
patient, nearly two years later, remains well.
Case and Specimen op cured Polypi op Frontal Sinus.
Shown by Dr. H. Tilley. Patient was a man aged 45, who came to
the London Throat Hospital complaining of slight discharge from both
nostrils, and occasional froutal headache. Some polypi were seen
under the middle turbinate on the left side, which were removed from
time to time. A discharge of pus was also constantly seen in this
situation.
On further examination a probe could be passed easily into the
frontal sinus. The patient was therefore anaesthetised, and a vertical
incision about two inches long made from the nasion upwards—the
soft parts and periosteum were drawn aside and the anterior surface
of the left sinus removed by means of gouge and mallet, when the
granulations contained in the sinus bulged forward and looked exactly
like haemorrhoids of rectum. The same was the case with the right
sinus. Both sinuses were curetted and then swabbed out with zinc
chloride solution grs. xl to 3j> an d drainage-tubes were inserted
into both sinuses, by means of which the sinuses were irrigated daily
with boracic lotion for a week, when the tubes were removed. The
wound healed and the patient is now perfectly free from any trouble,
and there is no nasal discharge. The median scar is now almost
invisible.
It should be stated that previously to operating on the frontal
sinus the maxillary antrum was explored and found healthy.
These two cases were discussed at the same time.
Mr. C. Babes thought that Mr. Lack’s case was interesting as having,
after recovery, left only a slight scar hidden by the eyebrow. He
related a case under his care in which there was protrusion of the eye¬
ball from distension of the left frontal sinus with non-fcetid mucous
liquid containing cholesterine crystals. On opening the sinus from
the forehead it was found completely cut off from the nasal cavity,
92
where there existed purulent disease of the ethmoidal cells. The case
was still under treatment.
I>r. Sc axes Spiceb would always remove the anterior extremity of
the middle turbinate bones before doing anything further.
Dr. \Vm. Hill had a case which had left a deep scar. He should
certainly try operating through the brow, more especially in females.
The President relate*! a case be had with Mr. Horsley in which
a transverse incision was made, a portion of the front of the sinus
tak*-n away, and the whole mucous membrane removed. During this
operation the hopelessness of operating through the nose was appa¬
rent, as it was impossible to get at all the disease through the nose.
He asked whether in these cases it would not be possible to fill up
the sinuses with foil or something to prevent the falling in of the
cavity.
Mr. Spencer suggested plaster of Paris as being good for filling
up bone.
Mr. Stewart thought that plaster of Paris would be too heavy for
the frontal sinus.
Dr. Dundas Grant mentioned a case of Waterhouse in which
decalcified bone was used to fill up a hole in the astragalus. He
pxjinted out the difficulty of any bone healing without a drawing in of
the cavity.
Mr. Lack thought the opening through the eyebrow caused no
deformity. He considered it best to leave the mucous membrane
untouched.
Dr. Herbert Tilley stated that he had recently examined the
frontal sinuses in a large number of skulls (over a hundred), and that
the constant and extreme variation in the size and extent of the sinuses
was in favour of an external opening, and he preferred the vertical
median incision in the majority of cases. He strongly deprecated
any operation from the nose, but thought that syringing the frontal
sinuses from the nose, where possible, might be practised for a short
time before proceeding to the external operation; if, however, the
naso-frontal canal could not be found, no passage should be forcibly
made.
Dr. Bennett suggested that these 130 cases were normal skalls. In
diseased conditions it was more possible to operate through the
nose. He would operate through the nose first to relieve obstruc¬
tion.
Case op Mycosis op Tonsils and Pharynx.
Shown by Dr. Scanes Spicer. Patient, a man set. 35, had a well-
developed thalloid projection from crypts of left tonsil, posterior
pharyngeal wall, and base of tongue. Microscopically it consisted
chiefly of cladothira. It had proved very resistent to paints, washes,
&c. He proposed dissecting out the affected portion of faucial tonsil,
93
and applying the galvano-cautery to the pharyngeal and lingual
crypts.
Dr. Hall recommended the use of the galvano-cautery for the
destruction of the mycotic growths. Absolute alcohol had not given
good results in his hands.
Dr. Bennett suggested the application of pure carbolic acid.
Dr. Brady (Sydney) showed a tonsilotome for removing hypertro¬
phied lingual tonsils. It was an ordinary Mackenzie tonsilotome with
the blade curved to fit over the back of the tongue.
Malignant(?) Disease of Larynx.
Shown by Dr. Furniss Potter. M. C—, widow, aged 69, came
to the London Throat Hospital on the 17th of March last complaining
of difficulty and pain in swallowing (principally solids).
No very definite or satisfactory history obtainable. The patient
states she has had difficulty in swallowing for many years, but has
been worse during the last twelve months. She has had two children
stillborn, and one miscarriage.
On examination with the laryngoscope a large red mass occupying
the arytaenoid region in its whole width was seen; this has increased
considerably since the first examination. It bleeds easily on being
touched, but there is no visible ulceration. Two distinctly enlarged
glands can be felt on the left side of the neck behind the sterno-
mastoid. The patient states that she has lost flesh rapidly lately.
Dr. Potter thought that there was little doubt the growth was malig¬
nant, but would like to have the opinion of members on it.
Obscure Case of Laryngeal Disease.
Shown by Dr. de Havilland Hall. R. M. V — was shown to the
Society on October 10th, 1894 (see p. 6, vol. ii).
The patient has continued in excellent health, and is able to cycle
and dance.
In January, 1896, while at Munich, Prof. Schech detected some
pale growths on the right side of the larynx filling up the glottis.
These were removed with forceps and curette.
On January 21st a piece of the tip of the epiglottis was removed;
very severe haemorrhage followed. In view of the stationary con¬
dition of the laryngeal condition and the patient’s excellent health.
94
Dr. Hall was doubtful whether the diagnosis of chronic tuberculosis
could still be maintained.
A portion of the growth removed in January will be submitted to
microscopic examination.
New Tracheotomy Tube.
Shown by Mr. db Santi. This is a tube adapted for patients who
have to wear a permanent tube, and who have sufficient space to expire
through the larynx though not room enough for inspiration. The
tube is fitted with a small metal hollow plug with a small rim below,
and in the plug is fitted a metal hinge valve something like a sewer
trap : on inspiration the valve opens and the patient breathes through
his tube; on expiration the valve closes tightly and air passes through
the larynx.
The danger of the valve getting loose is avoided by the metal rim
below.
The advantages of the plug and valve are—
(1) That the patient can speak distinctly and without putting his
fingers on the tracheotomy tube.
(2) That he coughs up mucus, &c., through the larynx and out of
the mouth normally.
(3) That the patient is able to wear a collar and shirt and go
about comfortably.
In Dr. De Havilland’s case shown at this meeting, Mr. de Santi
has adapted his tube to the case. The patient has worn the tube and
plug, which is removable, for six months, is able to talk well, wear
evening dress, and bicycle twenty miles a day. He has tried the
ordinary pea valve and finds it useless.
If the removable plug becomes at all blocked with mucus, it is
taken out and boiled, and in the meanwhile a fresh plug inserted.
It is of course necessary that there should be an opening in the
tracheotomy tube in the ordinary place at its greatest convexity.
The plug with its valve fits flush with the tube into which it is
inserted.
95
Case op Abductor Paralysis.
Shown by Mr. Spencer. Patient, a man set. 35, had worn a
tracheotomy tube since June, 1882. He was a soldier who had served
in Egypt, and an abscess formed in the neck in the site of a scar at
the anterior border of the left sterno-mastoid just above its insertion.
He had felt nothing wrong with his throat, but a few hours after the
opening of the abscess he was eating his dinner when he was suddenly
attacked by difficult breathing, for which tracheotomy was done the
same evening. Subsequently an attempt to leave off the tube failed.
He came concerning a warty growth in the tracheotomy wound, which
has been removed. He can speak well with the finger over the
tracheotomy tube. The vocal cords are apparently normal, but
fixed in adduction, no abduction beyond 1—2 mm. can be done.
The affection is doubtless due to syphilis. A nerve lesion there
may have been distinct from the above. If perichondritis, it is re¬
markable that he should have had no throat trouble beforehand.
Chronic Retro-pharyngeal Abscess in an Adult.
Shown by Dr. Felix Semon. The patient, a gentleman aged 37,
had in September last an “ abscess” in the throat which took about six
weeks to develop, and caused at the time considerable difficulty in
swallowing, but apparently no other symptoms. It was opened, a
large quantity of matter escaped, and he was then sent on a voyage to
South Africa. The incision, however, never healed, and he is still
troubled with much secretion, and at the same time a feeling of dry¬
ness in the throat. There is an indistinct history of syphilis many
years ago, but no secondary or tertiary symptoms have ever occurred.
On examination the posterior wall of the pharynx is enormously
swollen, sodden, and reddened, and particularly the right side bulges
much forward. There is a longitudinal opening filled with sanious
matter at the angle formed between the posterior and right lateral
wall, and a smaller fistulous opening near the middle line. The probe
introduced into these openings does not touch any rough bone. The
swelling extends a long way up into the naso-pharyngeal cavity, the
movements of the head are particularly free, the vertebra are not
tender to touch at all ; no evidence of any pulmonary affection.
96
The patient was put on 10 grs. of iodide of potassium, and when
he appeared a week after (April 22nd) a diminution of the pharyngeal
swelling was noticeable, but uo other change. A consultation was
held with Mr. Horsley, who agreed that there was no bone affection
or evidence of tubercular mischief. The patient is now still taking
iodide of potassium. Should, after another three or four weeks, the
abscess not close spontaneously, it is intended to connect the two
openings by a horizontal incision at the lower part of the abscess, and
to scrape out freely the walls of the abscess.
The case is shown because a chronic retro-pharyngeal abscess in an
adult, without any traumatic or diathetic cause known, is exceed¬
ingly rare.
A Drawing of a Case of Extrinsic Malignant Disease of the
Larynx.
Shown by Dr. Watson Williams.
A Coloured Drawing of a Case of Early Malignant Disease
of the Vocal Cords.
Shown by Dr. Watson Williams. Dr. Williams thought that as
the disease was intrinsic, localised, and early, it was suitable for
radical extirpation after thyrotomy, but the fact that the patient was
74 years of age was considered sufficient to negative such a procedure.
The movement of the vocal cords were greatly impaired. The voice
had been hoarse two months, and this was the only symptom. There
was no alcoholic or syphilitic history. As operation was negatived it
was considered inadvisable to complete the diagnosis by removal of a
fragment of the growth for histological examination, but he believed
that the great impairment of the vocal cord movement in the absence
of any appearance of thickening around the crico-arytsenoid joint,
pointed strongly towards it being a case of early malignant disease
rather than of pachydermia laryngis.
The President did not think it was a case of malignant disease.
Dr. Scanes Spicer thought it was one of pachydermia.
INDEX.
PAGB
Abductor paralysis (W. G. Spencer) . . . .95
-with laryngeal crises (C. A. Parker) . . .46
- complete paralysis of left abductor, paresis of right abductor, in
case of bulbar paralysis (Felix Semon, M.D.) . . .39
Abscess: chronic retro-pharyngeal abscess in an adult (Felix Semon, M.D.) 95
Air and food passages (upper), foreign bodies in: see Foreign bodies.
Albuminuria: microscopic specimen of haemorrhagic myxoma of lingual
tonsil in albuminuric patient (A. Bronner, M.D.) . . 14
Annual General Meeting, January 8th, 1896 . • .35
Antrum: empyema of maxillary antrum (A. A. Kanthack, M.D.) . 16
-and frontal sinus suppuration; healing (L. Lack) . . 90
Atrophy (progressive muscular) in case of bulbar paralysis (Felix
Semon, M.D.) • • . • • .39
Babbb (E. Cresswell), papilloma of nose . . . .23
-discussion on foreign bodies in the upper air and food passages . 76
Balance sheet, 1895 • • . . . .36
Ball (J. B., M.D.), case of paralysis of left vocal cord . . 12
-case of growth on left vocal cord . . . .24
Babon (Barclay J., M.B.), case of obstruction of larynx due to a web . 84
Bbalb (E. Clifford, M.B.), a case for diagnosis—tubercle or cancer . 21
-pathological specimens of tubercular infiltration of pharynx and
tongue • • . • . . .25
-case of cyst of glosso-epiglottic fold . . . .64
■-tubercle or cancer . . . .65
-discussion on foreign bodies in the upper air and food passages . 77
Bennbtt (F. W., M.D.), microscopical section of round-cell sarcoma of
the thyroid . • • • . .25
Bond (J. W.,M.D.), case of excision of larynx; myxochondroma of larynx 40
-clonic spasm of pharynx and soft palate . . 41
■ ■■■ --larvfiB in the nose . . . .66
- -- specimen of myxoma of larynx . . . .66
-case of uncontrollable intermittent laryngeal cry . . 86
■ ■ -tubercular laryngitis on which thyrotomy has been per¬
formed . . . . . . .87
' ■■ case of sarcoma recurring in nose . . . .88
-case of complete excision of larynx, see Savvey (F. G.) . . 41
Bowlby (A. A.), a case of stenosis of the larynx due to laryngitis com¬
plicating typhoid fever . . . . .13
-case for diagnosis . . .14
FIRST SERIES—VOL, III,
9
98
PACE
Branchial fistula: see Fistula . . . . .68
Bronchi: cicatricial stenosis of both main bronchi, with syphilitic ulcera¬
tion of trachea; pathological specimen (Percy Kidd, M.D.). . 18
Bbonneb (A., M.D.), microscopic specimen of hamorrhagic myxoma of
lingual tonsil (in albuminuric patient) . . . .14
-a large nasal polypus removed from the naso-pharynx of a man
aged 32 . . • . . . .42
-discussion on foreign bodies in the upper air and food passages . 78
Calculus (salivary) causing swelling of submaxillary gland (J. Dundas
Grant, M.D.) . . . . . .22
Cancer: case for diagnosis—tubercle or cancer (E. Clifford Beale, M.B.) . 21
-case of tubercle or cancer (E. Clifford Beale, M.B.) . . 65
Carcinoma of larynx : specimen (A. A. Kanthack, M.D.) . . 6
-probable intrinsic carcinoma of larynx (J. Dundas Grant, M.D.) . 51
-after-history (J. Dundas Grant, M.D.) . . 69
-of pharynx: specimen from a woman (A. A. Kanthack, M.D.) . 6
-of tonsil and soft palate (David Newman, M.D.) . .45
Cervical sinus: see Neck . . . . .68
Chabsley (R. S.), discussion on foreign bodies in the upper air and food
passages • . . . . . .79
Council: report of Council, 1895 . . . .35
-list of Officers and Council . . . .38
Cbipps (Charles Cooper, M.D.), case for diagnosis . .42
Cry (laryngeal) (J. W. Bond, M.D.) . . .86
Cyst of glosso-epiglottic fold (E. Clifford Beale, M.B.) . . 64
Diagnosis: cases for diagnosis (A. A. Bowlhy), 14; (E. Clifford Beale,
M.B.), 21; (P. Semon, M.D.), 27; (E. B. Waggett), 32; (Charles
Cooper Cripps, M.D.), 42; (H. Tilley, M.D.), 50.
Dbysdale (J. H., M.B.) and Kanthack (A. A., M.D.}, introduction to
discussion on the laryngeal complications of typhoid fever . . 53
Empyema of maxillary antrum (A. A. Kanthack, M.D.) . . 16
Endotracheitis (syphilitic) (Felix Semon, M.D.) . . .9
Epiglottis: specimen of necrosis and ulceration of tip of epiglottis which
occurred in the course of typhoid fever (A. A. Kanthack, M.D.) . 7
Epithelioma of larynx (F. G. Harvey) . . . .41
-. ■■ -thyrotomy (Felix Semon, M.D.) . . 85
-of left tonsil, left posterior pillar, and uvula (David Newman, M.D.) 45
Excision of larynx for myxochondroma (J. W. Bond, M.D.) . . 40
-for epithelioma (F. G. Harvey) . . .41
Fever (typhoid) : see Typhoid fever.
Fibroma (large) of the nasal septum (W. R. H. Stewart) . . 30
_(? fibro-sarcoma) of the cartilaginous septum (StClair Thomson,
M.D.) . . . . . . - 48
Fistula (branchial): elongated cervical sinus resembling branchial fistula
(J. Dundas Grant, M.D.) • . , , ,68
99
PAGE
Food and air passages (upper) : foreign bodies in: see below. Foreign bodies.
Foreign bodies in the upper air and food passages:
_introduction by Charters J. Symonds
-remarks by Scanes Spicer, M.D.
-L. Lawrence
-A. A. Kanthack, M.D.
-L. Lack
_E. Cresswell Baber
-E. Clifford Beale
_H. Tilley, M.D.
_W. Hill, M.D.
_J. Dundas Grant, M.D.
. . --A. Bronner, M.D.
-W. R. H. Stewart
-• R. S. Charsley
-H. Sharman, M.D. .
-E. Jessop .
-E. B. Waggett
-Felix Semon, M.D. .
.... reply by Charters J. Symonds
58
73
74
74
75
76
77
77
77
78
78
79
79
79
79
79
80
80
Glosso-epiglottic fold: cyst of glosso-epiglottic fold (E. Clifford Beale,
M.B.) . . • • *
Grant (J. Dundas, M.D.), a case of swelling of the submaxillary gland
(due to a salivary calculus) . • •
■ _case of probable intrinsic carcinoma of the larynx
---after history . . • •
- i elongated cervical sinus resembling a branchial fistula •
___ discussion on foreign bodies in the upper air and food passages
Growth on left vocal cord (J. B. Ball, M.D.) •
-on the hard palate of a girl (L. Lawrence)
64
22
51
69
68
78
24
68
Ham (F. de Havilland, M.D.), obscure case of laryngeal disease.
HABVBY (F. G.) [shown by Dr. Bond], case of complete excision of
larynx for epithelioma j numerous glands removed
Him. (William, M.D.), case of frontal sinus disease . • •
__ a case showing regeneration of tissue along inferior crest after
turbinectomy . • • , • * ,. *
microscopical section of regenerated tissue after turbinec¬
tomy in patient shown at last meeting .
case of tuberculosis of the nose .•
discussion on foreign bodies in the upper air and food passages
Hoarseness (chronic) in case of chronic rhinitis and pharyngitis (W. G.
Spencer) .
Hobne (W. Jobson, M.B.), discussion on the nature of the laryngeal
complications of typhoid fever •
Hyperplasia (diffuse papillomatous) of laryngeal mucous membrane m a
child (A. A. Kanthack, M.D.) -
Hypertrophy (diffuse papillomatous) of laryngeal mucosa (A. A. Kan¬
thack, M.D.) .
93
41
5
15
42
70
77
69
57
6
16
Inter-arytaenoid fold: pachydermia of the inter-arytienoid fold (Percy
Kidd, M.D.) ...♦•*
100
PAG!
JiflflOP (Edward), discussion on foreign bodies in the upper air and food
passages • • . • • • *79
Kanthack (A. A., M.D.), specimen of carcinoma of the larynx . . 6
- specimen of carcinoma of pharynx from a woman • . 6
■ specimen of diffuse papillomatous hyperplasia of laryngeal mucous
membrane in a child . . • • .6
- specimen of necrosis and ulceration of tip of epiglottis which
occurred in the course of typhoid fever • • .7
- pathological specimens shown s
1. Typhoid ulcer of larynx . . . .15
2. Diffuse papillomatous hypertrophy of the laryngeal mucosa 16
3. Empyema of the maxillary antrum . . .16
■ discussion on foreign bodies in the upper air and food passages . 74
-and Dbybdaxb (J. H., M.B.), introduction to discussion on the
nature of the laryngeal complications of typhoid fever . . 53
- '■ reply by A. A. Kanthack, M.D. . . .57
Kidd (Percy, M.D.), case of pachydermia of the inter-arytsenoid fold . 17
-pathological specimen of syphilitic ulceration of the trachea with
cicatricial stenosis of both main bronchi . • .18
Lack (Lambert), discussion on foreign bodies in the upper air and food
passages .••••••
-case of healed tubercular disease of the larynx.
-lupus pharyngU . .
-healed antrum and frontal sinus suppuration
Larva? in the nose (J. W. Bond, M.D.) .
Laryngitis: stenosis of larynx due to laryngitis complicating typhoid
fever (A. A. Bowlby) .....
-(tubercular) two cases with complete recovery (David Newman,
M.D.) .......
-case on which thyrotomy was performed (J. W. Bond, M.D.)
Larynx: laryngeal crises in case of abductor paralysis (C. A. Parker)
-laryngeal case for diagnosis (H. Tilley, M.D.)
-discussion on the nature of the laryngeal complications of typhoid
fever:
-introduction by A. A. Kanthack, M.D., and J. H. Drysdale, M.B. .
-remarks by P. Watson Williams, M.D.
-S. G. Shattock . .
———-W. Jobson Horne, M.B. ....
-F. Semon, M.D. .....
-reply by A. A. Kanthack, M.D.
-obstruction of larynx due to a web (Barclay J. Baron, M.B.)
-uncontrollable, intermittent, laryngeal cry (J. W. Bond, M.D.)
-obscure case of laryngeal disease (F. de Havilland Hall, M.D.)
-specimen of carcinoma of larynx (A. A. Kanthack, M.D.)
-probable intrinsic carcinoma of larynx (J. Dundas Grant, M.D.) .
-after-history (J. Dundas Grant, M.D.)
-excision of larynx for epithelioma (F. G. Harvey)
-thyrotomy for epithelioma of larynx (F. Semon, M.D.) .
-specimen of diffuse papillomatous hyperplasia of laryngeal mucous
membrane in a child (A. A. Kanthack, M.D.)
-diffuse papillomatous hypertrophy of laryngeal mucosa (A. A. Kan¬
thack, M.D.) ......
-lupus of pharynx and larynx (Edward Law, M.D.)
-of palate and larynx (E. C. Stabb)
-? malignant disease (E. Furniss Potter, M.D.) .
75
89
89
90
66
13
43
87
46
50
53
55
57
57
57
57
84
86
93
6
51
69
41
85
6
16
18
71
93
101
Larynx: extrinsic malignant disease ; drawing (P. Watson Williams, M.D.)
-excision of larynx for myxochondroma (J. W. Bond, M.D.)
—— myxoma of larynx (Felix Semon, M.D.) .
--—-microscopical section (Felix Semon, M.D.)
specimen of myxoma of larynx (J. W. Bond, M.D.)
inter-arytaenoid pachydermia laryngis (H. Tilley, M.D.) .
large laryngeal papilloma (Felix Semon, M.D.)
stenosis of larynx due to laryngitis complicating typhoid fever (A.
Bowlby) ......
laryngeal stenosis (W. G. Spencer) ....
congenital syphilis of palate and larynx (Leonard Roper)
tertiary syphilis of larynx and nose (E. Furniss Potter, M.D.)
tubercular ulceration (Felix Semon, M.D.)
tubercular ulceration of trachea, larynx, and pharynx: patholo¬
gical specimens (P. R. W. de Santi)
— healed tubercular disease of larynx (L. Lack) .
— typhoid ulcer of larynx (A. A. Kanthack, M.D.)
see also Foreign bodies in the upper air and food passages.
Law (Edward, M.D.), case of lupus of the pharynx and larynx .
1 ~ ■ ■ -nasal obstruction from septal deflection and other
causes . . . .
La WHENCE (L.), ease of naso-pharyngeal and nasal polypi .
- ■■ -a growth on the hard palate of a girl
• specimen of growth removed from the naso-pharynx
-discussion on foreign bodies in the upper air and food passages
Librarian: report of Librarian .....
Library: regulations as to use of Society’s Library .
Lupus of palate and larynx (E. C. Stabb) ....
■ pharyngis (L. Lack) . . . . .
- of pharynx and larynx (Edward Law, M.D.) .
PAGE
96
40
8
12
66
60
8
13
28
2
2
8
26
89
15
18
19
25
68
68
74
37
60
71
89
18
Malignant disease (extrinsic) of larynx; drawing (P. Watson Williams, M.D.) 96
-- -(?) of larynx (E. Furniss Potter, M.D.) . . 93
' ■ of the oesophagus in a girl aged twenty-three (W. R. H.
Stewart) . . . . . . .20
-(early) of vocal cords; drawing (P. Watson Williams,
M.D.) . . . . . . .96
Morbid Growths Committee: reports . . . 63 ^ 81
Mucous membrane (laryngeal): specimen of diffuse papillomatous hyper¬
plasia of laryngeal mucous membrane in a child (A. A. Kanthack,
M.D.) • . . , . . .6
- diffuse papillomatous hypertrophy of laryngeal mucosa (A. A.
Kanthack, M.D.) . . . . . .16
Mycosis of tonsils and pharynx (Scanes Spicer, M.D.) . . 92
Myxochondroma of larynx (J. W. Bond, M.D.) . . .40
Myxoma of larynx (Felix Semon, M.D.) . . . .8
-microscopical section (Felix Semon, M.D.) . . 12
-specimen (J. W. Bond, M.D.) . . .66
- microscopic specimen of haemorrhagic myxoma of lingual tonsil
(in albuminuric patient) (A. Bronner, M.D.) . . .14
- of vocal cord (StClair Thomson, M.D.) . . ! 67
Nares : cicatricial obstruction of anterior nares (Scanes Spicer, M.D.) . 3
Neck : elongated cervical sinus resembling a branchial fistula (J. Dundas
Grant, M.D.) . . . . . .68
Necrosis: specimen of necrosis and ulceration of tip of epiglottis which
occurred in the course of typhoid fever (A. A. Kanthack, M.D.) . 7
102
PAGE
Nbwmak (David, M.D.), two cases of tubercular laryngitis in which com¬
plete recovery took place . . . . *43
-case of epithelioma of the left tonsil, left posterior pillar, and uvula 45
-carcinoma of the tonsil and soft palate • . .45
Nose: nasal obstruction from septal deflection and other causes (Edward
Law, M.D.) . . . . . .19
-disease of septum nasi (Charters J. Syraonds) . . .31
-large fibroma of nasal septum (W. R. H. Stewart) . . 30
-fibroma (? fibro-sarcoma) of the cartilaginous septum (StClair
Thomson, M.D.) . • • • • .48
-case of larvae in the nose (J. W, Bond, M.D.) . . .66
-papilloma of nose (E. Cresswell Baber) . . .23
-large nasal polypi removed from the right nostril of a lad aged
nineteen (Felix Semon, M.D.) . . . .7
-naso-pharyngeal and nasal polypi (L. Lawrence) . . 25
-specimen (L. Lawrence) . . . .68
- large nasal polypus removed from the naso-pharynx of a man
aged 32 (A. Bronner, M.D.) . . . , v . 42
- sarcoma recurring in nose (J. W. Bond, M.D.) . . 88
■■■■■■ tertiary syphilis of larynx and nose (E. Furniss Potter, M.D.) . 2
— tubercular ulceration of septum of nose (Charters J. Symonds) . 3
- tubercular disease of septum (Charters J. Symonds) . . 4
- tuberculosis of the nose (William Hill, M.D.) . . .70
(Esophagus: malignant disease of the oesophagus in a girl aged twenty-
three (W. R. H. Stewart) . . . . .20
Pachydermia of the inter-arytaenoid fold (Percy Kidd, M.D.) . . 17
- ■ inter-arytsenoid pachydermia laryngis (H. Tilley, M.D.) . 50
Palate: lupus of palate and larynx (E. C. Stabb) . . .71
- — congenital syphilis of palate and larynx (Leonard Roper) . 2
- (hard): growth on the hard palate of a girl (L. Lawrence) . 68
— - (soft) : tubercular ulceration (Felix Semon, M.D.) . . 8
-carcinoma of tonsil and soft palate (David Newman, M.D.) 45
■ -clonic spasm of pharynx and soft palate (J. W. Bond, M.D.) 41
-tumour of soft palate (E. C. Stabb) . . .71
Papilloma: large laryngeal papilloma (Felix Semon, M.D.) . . 8
-of nose (E. Cresswell Baber) . . . .23
Paralysis (abductor) (W. G. Spencer) . . . .95
-with laryngeal crises (C. A. Parker) . . .46
-case of bulbar paralysis, progressive muscular atrophy, complete
paralysis of left abductor, paresis of right abductor (Felix Semon,
M.D.) . . . . . . .39
-of left vocal cord (J. B. Ball, M.D.) . . . .12
Paresis of right abductor with complete paralysis of left abductor in case
of bulbar paralysis (Felix Semon, M.D.) . . .39
Parker (C. A.), case of abductor paralysis with laryngeal crises . 46
Pharyngitis : chronic hoarseness in case of chronic rhinitis and pharyngitis
(W. G. Spencer) . . . . . .69
Pharynx: case of enlargement of thyroid gland in a boy, which almost
blocked lumen of pharynx (E. C. Stabb). . . .21
-retro-pharyngeal abscess : see Retro -pharyngeal.
— specimen of carcinoma of pharvnx from a woman (A. A. Kanthack,
M.D.) . . . ‘ .
6
103
PAGE
Pharynx: lupus of pharynx and larynx (Edward Law, M.D.) . .18
-pharyngis (L. Lack) . . . . 89
-mycosis of tonsils and pharynx (Scanes Spicer, M.D.) . . 92
-naso-pharyngeal and nasal polypi (L. Lawrence) . . 25
■ ■■ -specimen (L. Lawrence) . . . .68
-clonic spasm of pharynx and soft palate (J. W. Bond, M.D.) . 41
-pathological specimens of tubercular infiltration of pharynx and
tongue (E. Clifford Beale, M.B.) . • . .25
■ ■ tubercular ulceration of trachea, larynx, and pharynx; pathological
specimens (P. R. W. de Santi) . . . .26
■ pharyngeal tumour, probably syphilitic (H. Tilley, M.D.) , 70
■ - see also Foreign bodies in the upper air and food passages.
Pillar (left posterior) : epithelioma of left tonsil, left posterior pillar and
uvula (David Newman, M.D.) . . . .45
Polypus: large nasal polypi removed from the right nostril of a lad aged
nineteen (Felix Semon, M.D.) . . . .7
■ - large nasal polypus removed from the naso-pharynx of a man aged
32 (A. Bronner, M.D.) • • . . .42
-naso-pharyngeal and nasal polypi (L. Lawrence) . . 25
- — --specimen (L. Lawrence) . . . .68
■ - cured polypi of frontal sinus ; case and specimen (H. Tilley,
M.D.) « • . • . . .91
Pott be (E. Furniss, M.D.), a case of tertiary syphilis of larynx and nose . 2
-malignant (?) disease of larynx . . . .93
Regeneration of tissue after turbinectomy (William Hill, M.D.) . 15
-microscopical section (William Hill, M.D.) . . 42
Retro-pharyngeal abscess (chronic) in an adult (F. Semon, M.D.) . 95
Rhinitis: chronic hoarseness in case of chronic rhinitis and pharyngitis
(W. G. Spencer) . . „ . .69
Ropeb (Leonard), case of congenital syphilis of palate and larynx • 2
db Sakti (P. R. W.), pathological specimens of tubercular ulceration of
trachea, larynx, and pharynx . . . . .26
■■ new tracheotomy tube . . . . .94
Sarcoma recurriug in nose (J. W. Bond, M.D.) . . .88
-microscopical section of round-cell sarcoma of thyroid (F. W.
Bennett, M.D.) • • . . . .25
Sbmon (Felix, M.D.). Specimens shown:
1. Large nasal polypi removed from the right nostril of a lad aged
nineteen . . . . . .7
2. Tubercular ulceration of the soft palate, uvula, right tonsil, and
larynx . . . . . .8
3. Large laryngeal papilloma . . . .8
4. Myxoma of the larynx . . . . .8
5. Syphilitic endotracheitis • . . .9
-a microscopical section of myxoma of larynx . . .12
' — — a case for diagnosis . . . . .27
-case of bulbar paralysis, progressive muscular atrophy, complete
paralysis of left abductor, paresis of right abductor . . 39
-discussion on the nature of the laryngeal complications of typhoid
fever . . . . . . .57
-discussion on foreign bodies in the upper air and food passages . 80
-thyrotomy for epithelioma of the larynx . . .85
— — — chronic retro-pharyngeal abscess in an adult • . .95
104
PAGE
Septum (nasal): nasal obstruction from septal deflection and other causes
(Edward Law, M.D.) . . , . .19
■ . ■ see also Nose.
Shabmaw (H., M.D.), discussion on foreign bodies in the upper air and
food passages • . « • , *79
Shattock (S. G.), discussion on the nature of the laryngeal complications
of typhoid fever . . . . . .67
Sinus: elongated cervical sinus resembling branehial fistula (J. Dundas
Grant, M.D.) . . . # . # 68
-frontal sinus disease (William Hill, M.D.) . . .6
- case and specimen of cured polypi of frontal sinus (H. Tilley, M.D.) 91
-■ antrum and frontal sinus suppuration; healing (L. Lack) . 90
Spasm (clonic) of pharynx and soft palate (J. W. Bond, M.D.) . . 41
■■■■■■ (inspiratory) of the vocal cords (W. A. Wills, M.D.) . . 32
Spencer (W. G.) v a case of laryngeal stenosis . . .28
■■ ■ case of chronic hoarseness in a patient with chronic rhinitis and
pharyngitis • . • • . .69
- case of abductor paralysis . . . . .95
Spicer (Scanes, M.D.), case of cicatricial obstruction of anterior nares . 3
- a warty growth of suspicious nature on left vocal cord in a man
aged fifty-four . . . . . 19,47
- discussion on foreign bodies in the upper air and food passages . 73
■ — ■ ■ case of mycosis of tonsils and pharynx , . .92
Stabs (E. C.), case of enlargement of thyroid gland in a boy, which almost
blocked lumen of pharynx • • . . .21
— a case of thyroid disease after operation . . .30
- - — -lupus of palate and larynx . . . .71
- - tumour of the soft palate . . . .71
Stenosis (cicatricial): left vocal cord removed for cicatricial stenosis
(Charters J. Symonds) . . . . .4
-*-of both main bronchi with syphilitic ulceration of trachea,
pathological specimen (Percy Kidd, M.D.) • . , 18
■ (laryngeal): (W. G. Spencer) . . . .28
- of the larynx due to laryngitis complicating typhoid fever
(A. A. Bowlby) , . • . , .13
Stewart (W. R. H.), case of malignant disease of the oesophagus in a girl
aged twenty-three . • . • . .20
-a case of large fibroma of nasal septum . . .30
-discussion on foreign bodies in the upper air and food passages . 79
Submaxillary gland : case of swelling of submaxillary gland, due to sali¬
vary calculus (J. Dundas Grant, M.D.) . . . .22
Suppuration of antrum and frontal sinus; healing (L. Lack) • . 90
Swelling of submaxillary gland (due to salivary calculus) (J. Duudas
Grant, M.D.) • • • . • .22
Symonds (Charters J.) a case of tubercular ulceration of septum of nose • 3
-a case of tubercular disease of septum . . .4
-a case in which the left vocal cord was removed for cicatricial
stenosis • • • • • • .4
- further notes of two cases of disease of septum nasi • .31
- introduction to discussion on foreign bodies in the upper air and
food passages • . • • . .58
-reply . . . . . .80
Syphilis (congenital) of palate and larynx (Leonard Roper) . . 2
• (tertiary) of larynx and nose (E. Furnias Potter, M.D.) . , 2
105
PAGE
Syphilis: pharyngeal tumour, probably syphilitic (H. Tilley, M.D.) . 70
- syphilitic endotracheitis (Felix Semon, M.D.) . . .9
-ulceration of trachea, pathological specimen (Percy
Kidd, M.D.) . . . . . .18
Thomson (StClair, M.D.), fibroma (? fibro-sarcoma) of the cartilaginous
septum ; case and microscopical specimen . . .48
- case of myxoma of vocal cord . . . .67
Thyroid gland: case of enlargement of thyroid gland in a boy, which
almost blocked lumen of pharynx (E. C. Stabb) . . .21
- case of thyroid disease after operation (E. <3. Stabb) . . 30
-microscopical section of round-cell sarcoma of thyroid (F. W.
Bennett, M.D.) . • . . • .25
Thyrotomy for epithelioma of larynx (Felix Semon, M.D.) . . 85
-in case of tubercular laryngitis (J. W. Bond, M.D.) . . 87
Tilley (Herbert, M.D.), case of inter-arytsenoid pachydermia laryngis . 50
- laryngeal case for diagnosis . . . .50
- case of pharyngeal tumour, probably syphilitic . . 70
- discussion on foreign bodies in the upper air and food passages . 77
- case and specimen of cured polypi of frontal sinus . . 91
Tongue: pathological specimens of infiltration of pharynx and tongue
(E. Clifford Beale, M.B.) • • . . .25
Tonsil: carcinoma of tonsil and soft palate (David Newman, M.D.) . 45
-mycosis of tonsils and pharynx (Scanes Spicer, M.D.) . . 92
- (lingual): microscopic specimen of hmmorrhagic myxoma of lin¬
gual tonsil (in albuminuric patient) (A. Bronner, M.D.) . . 14
- (right): tubercular ulceration (Felix Semon, M.D.) . . 8
-(left): epithelioma of left tonsil, left posterior pillar, and uvula
(David Newman, M.D.) • • . . .45
Trachea: syphilitic ulceration of trachea with cicatricial stenosis of both
main bronchi; pathological specimen (Percy Kidd, M.D.) . . 18
-tubercular ulceration of trachea, larynx and pharynx: pathological
specimens (P. R. W. de Santi) . . . .26
-(inflammation) : see Endotracheitis .
Tracheotomy tube (new) (P. R. W. de Santi) . . .94
Tuberculosis: case for diagnosis—tubercle or cancer (E. Clifford Beale,
M.B.) 21
-tubercular ulceration of soft palate, uvula, right tonsil, and larynx
(Felix Semon, M.D.) . . . . .8
-case of tubercle or cancer ? (E. Clifford Beale, M.B.) . . 65
. - two cases of tubercular laryngitis with complete recovery (David
Newman, M.D.) . . . . . .43
-tubercular laryngitis (J. W. Bond, M.D.) . 87
-healed tubercular disease of larynx (L. Lack) . . .89
# -of the nose (William Hill, M.D.) . . . *70
-tubercular ulceration of septum of nose (Charters J. Synionds) . 3
-disease of septum (Charters J. Symonds) . . 4
-pathological specimens of tubercular infiltration of pharynx and
tongue (E. Clifford Beale, M.B.) . . . .25
- tubercular ulceration of trachea, larynx and pharynx; patho-
gical specimens (P. R. W. de Santi) • . . .26
Tumour (pharyngeal), probably syphilitic (H. Tilley, M.D.) . . 70
-of soft palate (E. C. Stabb) . . . .71
Turbinectomy: regeneration of tissue after turbinectomy (William Hill,
M.D.) . . . . . . .15
—•— microscopical section (William Hill, M.D.) . . 42
9 *
106
PAGE
Typhoid fever: specimen of necrosis and nlceration of tip of epiglottis
which occurred in course of typhoid fever (A, A. Kanthack, M.D.) . 7
-— stenosis of larynx doe to laryngitis complicating typhoid fever
(A. A. Bowlby) . . . . . .13
- typhoid ulcer of larynx (A. A. Kanthack, M.D.) . . 15
- discussion on the nature of the laryngeal complications of typhoid
fever:
-introduction by A. A. Kanthack, M.D., and J. H. Drysdale,
M.B. . . . . . . .53
-remarks by P. Watson Williams, M.D. . 55
-S. G. Shattock . . . .57
— -W. Job son Horne, M.B. . .57
— - - Felix Semon, M.D. . . . .57
-reply by A. A. Kanthack, M.D. . .57
Ulcer: typhoid nicer of larynx (A. A. Kanthack, M.D.) . • 15
Ulceration : specimen of necrosis and ulceration of tip of epiglottis, which
occurred in the course of typhoid fever (A. A. Kanthack, M.D.) . 7
- (syphilitic) of trachea; pathological specimen (Percy Kidd, M.D.) 18
■ (tubercular) of soft palate, uvula, right tonsil, and larynx (Felix
Semon, M.D.) . • • • • .8
-of septum of nose (Charters J. Symonds) . . 3
-of trachea, larynx and pharynx: pathological specimens
(P. R W. de Santi). . . . . .26
Uvula: epithelioma of left tonsil, left posterior pillar, and uvula (David
Newman, M.D.) . . . . . .45
-tubercular nlceration (Felix Semon, M.D.) . . .8
Vocal cord: inspiratory spasm of the vocal cords (W. A. Wills, M.D.) . 32
■ - early malignant disease of vocal cords; drawing (P. Watson Wil¬
liams, M.D.) . . . . . .96
■ ■ - case of myxoma of vocal cord (StClair Thomson, M.D.) . 67
■ - - (left): warty growth of suspicious nature on left vocal cord in a
man aged fifty-four (Soanes Spicer, M.D.) . . 19,47
-growth on left vocal cord (J. B. Ball, M.D.) . . 24
-paralysis (J. B. Ball, M.D.) . . . .12
-removed for cicatricial stenosis (Charters J. Symonds) . 4
WAGGBTT (E. B.), case for diagnosis . . . .32
-discussion on foreign bodies in the upper air and food passages . 79
Warty growth of suspicious nature on left vocal cord in a man aged fifty-
four (Scanes Spicer, M.D.) . . . . 19,47
Web causing obstruction of larynx (Barclay J. Baron, M.B.) . . 84
Williams (P. Watson, M.D.), discussion on the nature of the laryngeal
complications of typhoid fever . . . .55
-a drawing of a case of extrinsic malignant disease of the
larynx . . . . . . .96
-a coloured drawing of a case of early malignant disease of
the vocal cords . . . . * .96
Wills (W. A, M.D.), case of inspiratory spasm of the vocal cords . 32
PRINTED BY ADLABD AND SON, BARTHOLOMEW CLOSE, B.C.
/
100
PAGB
JiflfOP (Edward), discussion on foreign bodies in the upper air and food
passages • . • • • • .79
Kanthack (A. A., M.D.), specimen of carcinoma of the larynx . . 6
- specimen of carcinoma of pharynx from a woman • . 6
■ specimen of diffuse papillomatous hyperplasia of laryngeal mucous
membrane in a child . . . • .6
- specimen of necrosis and ulceration of tip of epiglottis which
occurred in the course of typhoid fever • • .7
- pathological specimens shown:
1. Typhoid ulcer of larynx . . . .15
2. Diffuse papillomatous hypertrophy of the laryngeal mucosa 16
3. Empyema of the maxillary antrum • . .16
■ ■ - discussion on foreign bodies in the upper air and food passages • 74
-and Dbysdalb (J. H., M.B.), introduction to discussion on the
nature of the laryngeal complications of typhoid fever • • 53
- 1 reply by A. A. Kanthack, M.D. . . .57
Kidd (Percy, M.D.), case of pachydermia of the inter-arytmnoid fold • 17
-pathological specimen of syphilitic ulceration of the trachea with
cicatricial stenosis of both main bronchi • • .18
Lack (Lambert), discussion on foreign bodies in the upper air and food
passages • • . • • . .75
-case of healed tubercular disease of the larynx. • .89
-lupus pharyngU . . . . .89
-healed antrum and frontal sinus suppuration . . 90
Larv© in the nose (J. W. Bond, M.D.) . . . .66
Laryngitis: stenosis of larynx due to laryngitis complicating typhoid
fever (A. A. Bowlby) . . . . .13
-(tubercular) two cases with complete recovery (David Newman,
M.D.) . . . . . . .43
-case on which thyrotomy was performed (J. W. Bond, M.D.) 87
Larynx: laryngeal crises in case of abductor paralysis (C. A. Parker) . 46
-laryngeal case for diagnosis (H. Tilley, M.D.) . . 50
-discussion on the nature of the laryngeal complications of typhoid
fever:
-introduction by A. A. Kanthack, M.D., and J. H. Drysdale, M.B. . 53
-remarks by P. Watson Williams, M.D. . . .55
-S. G. Shattock . . . .57
-W. Jobson Horne, M.B. . . . .57
-F. Semon, M.D. . . . . .57
-reply by A. A. Kanthack, M.D. . . .57
-obstruction of larynx due to a web (Barclay J. Baron, M.B.) . 84
-uncontrollable, intermittent, laryngeal cry (J. W. Bond, M.D.) . 86
-obscure case of laryngeal disease (F. de Havilland Hall, M.D.) . 93
-specimen of carcinoma of larynx (A. A. Kanthack, M.D.) . 6
-probable intrinsic carcinoma of larynx (J. Dundas Grant, M.D.) . 51
-after-history (J. Dundas Grant, M.D.) . 69
-excision of larynx for epithelioma (F. G. Harvey) . . 41
-thyrotomy for epithelioma of larynx (F. Semon, M.D.) . . 85
-specimen of diffuse papillomatous hyperplasia of laryngeal mucous
membrane in a child (A. A. Kanthack, M.D.) • . .6
-diffuse papillomatous hypertrophy of laryngeal mucosa (A. A. Kan¬
thack, M.D.) . . . . . .16
-lupus of pharynx and larynx (Edward Law, M.D.) . . 18
-of palate and larynx (E. C. Stabb) . . .71
-? malignant disease (E. Furniss Potter, M.D.) . . 93
101
PAGE
Larynx: extrinsic malignant disease; drawing (P. Watson Williams, M.D.) 96
-excision of larynx for myxochondroma (J. W. Bond, M.D.) . 40
■ ■■ — - myxoma of larynx (Felix Semon, M.D.) • . .8
-microscopical section (Felix Semon, M.D.) . 12
-specimen of myxoma of larynx (J. W. Bond, M.D.) . . 66
-inter-arytaenoid pachydermia laryngis (H. Tilley, M.D.) . . 60
-large laryngeal papilloma (Felix Semon, M.D.) . . 8
-stenosis of larynx due to laryngitis complicating typhoid fever (A.
A. Bowlby) . . . . . .13
- laryngeal stenosis (W. G. Spencer) . . . .28
- congenital syphilis of palate and larynx (Leonard Roper) . 2
- tertiary syphilis of larynx and nose (E. Furniss Potter, M.D.) . 2
- tubercular ulceration (Felix Semon, M.D.) . . .8
. tubercular ulceration of trachea, larynx, and pharynx: patholo¬
gical specimens (P. R. W. de Santi) . . . .26
- healed tubercular disease of larynx (L. Lack) . . .89
■ typhoid ulcer of larynx (A. A. Kanthack, M.D.) . . 15
■ see Also Foreign bodies in the upper air and food passages.
Law (Edward, M.D.), case of lupus of the pharynx and larynx . . 18
■■■ ■ ■ — ■ - - nasal obstruction from septal deflection and other
causes . • . • *. . .19
Lawbbncb (L.), case of naso-pharyngeal and nasal polypi . . 25
-a growth on the hard palate of a girl . . 68
- specimen of growth removed from the naso-pharynx . . 68
- discussion on foreign bodies in the upper air and food passages . 74
Librarian: report of Librarian • • • . .37
Library: regulations as to use of Society’s Library • • .60
Lupus of palate and larynx (E. C. Stabb) . . . . 71
-- - pharyngis (L. Lack) . . . . .89
■ ■■ ■ ■ of pharynx and larynx (Edward Law, M.D.) . .18
Malignant disease (extrinsic) of larynx; drawing (P. Watson Williams, M.D.) 96
■■■■ -(?) of larynx (E. Furniss Potter, M.D.) . . 93
— ■ ■■ - - of the oesophagus in a girl aged twenty-three (W. R. H.
Stewart) ..... . . 20
- — ■ (early) of vocal cords; drawing (P. Watson Williams,
M.D.) • • • • • • .96
Morbid Growths Committee: reports ... 63, 81
Mucous membrane (laryngeal): specimen of diffuse papillomatous hyper¬
plasia of laryngeal mucous membrane in a child (A. A. Kanthack,
M.Dt) • . . « • . .6
- diffuse papillomatous hypertrophy of laryngeal mucosa (A. A.
Kanthack, M.D.) . . . . . .16
Mycosis of tonsils and pharynx (Scanes Spicer, M.D.) • . 92
Myxochondroma of larynx (J. W. Bond, M.D.) . . .40
Myxoma of larynx (Felix Semon, M.D.) . . . .8
-microscopical section (Felix Semon, M.D.) . . 12
-specimen (J. W. Bond, M.D.) . . .66
- microscopic specimen of haemorrhagic myxoma of lingual tonsil
(in albuminuric patient) (A. Bronner, M.D.) . . .14
- of vocal cord (StClair Thomson, M.D.) . . .67
Nares : cicatricial obstruction of anterior nares (Scanes Spicer, M.D.) . 3
Neck : elongated cervical sinus resembling a branchial fistula (J. Dundas
Grant, M.D.) . . . . . .68
Necrosis: specimen of necrosis and ulceration of tip of epiglottis which
occurred in the course of typhoid fever (A. A. Kanthack, M.D.)
7
X m j _awd. y[.Z . ran tase* if xnhertular lamrisia in which oom-
2LHS4 r*t:uviir 7 mu* uuii» .
-rwe if ini'-ietiiima jr me Left mnah. Left posterior pillar,;
-ar^auina jf sue mm^ kiii icf * p»L;t.v .
X-iae mk*L liiswmnuuii fr-irn «giul iiidiicrhm xsui ether caries
La-v M l
- ih^ase if ientnin nisi Charter* J. Sysn:*L«Ls} .
- ' jltz * idr:ma :f uuso- jeuc.mi rL H. tMewirs^
- i :r:tn:i - ijn-jarrctna if sue ram. .ag-necs septum
Thomsen. M. I\*
-rose :t uir^'e In the u«:se J. 1 LD.) .
-pagillcuiA :t urse Z. Criifcv ill Hauer*
-luzze pm/ui rtme^id fr*;in me rZrha n:stril of a
aueceen F iux ^emcn. M_I> > ...
-aiisc-searymrnw iu .1 axs*. pclypi L. Lawrence)
¥Z*iM 1 -HiiTl
and uvula
(Edward
(StClair
lad aged
of a man
— -inr* uosa^ po/pm remev-ic max sue r.xsc-jzaryux of a i
iged id A. 5r:cn?r. M.D. > ....
— *ir>!t;ma :i aone J. W. Be-ii. M.D.)
— ternary syy i_s :z Larynx x^L n:*§e E. Furuiss Pokier. M.D.)
— suiemlar m:erasi:a :f segcun. :f ucee - Charters J. Symoads)
— X:*;r;n ilt i-se:*se :c septum t Charter* J. Symocds )
— suiercuaiszs zt sue uo« ^W;..a.ii FLU, MJj.) .
(Esophagus: disease if she cescgm
three (W. R. H. Stewart)
gus in a girl aged twenty
Pjchyiermla oc she httcr-xrytjenMd f;M (Percy K: ii T M.D.)
■ — inser-arysaenoid pachydermia laryngis ^FL Tilley, M.D.)
Palate:
turns ct ra~i:e xml x-m
C. Stabb)
- cocgeuisal *»rhills o: palate and larynx ■ Leonard Roper)
- t hard ■ : growth on she hard palate of a giri (L. Lawrence)
■ ■ - ■■■■ (soft) : tubercular ulceration Fel l Semen, M.D.)
-carcinoma cf tonsil and so ft palate ^ David Newman, M.D.)
■■ -cion: r spasm cf pharynx and so ft palate (J. W. Bond, M.D.)
-tamo or of sets paiate ^E. C. Stabb)
Papilloma : large laryngeal papihoxa (Felix Semon, M.D.)
-of nose V E. Cress we h Barer) .
Paralysis (abductor' (W. G. Spencer) ....
-with laryngeal crises iC. A. Parker)
-case of bulbar paralysis, progressive muscular atrophy, complete
paralysis of left abductor, paresis of right abductor (Felix Semon,
M.D.) . . . . " .
-of left vocal cord ' J. B. Ball, M.D.) ....
Paresis of right abductor with complete paralysis of left abductor in case
of bulbar paralysis (Felix Semon, M.D.)
Parker (C. A.), case of abductor paralysis with laryngeal crises
Pharyngitis : chronic hoarseness in case of chronic rhinitis and pharyngitis
(W. G. Spencer) ......
Pharynx: case of enlargement of thyroid gland in a boy, which almost
blocked lumen of pharynx (E. C. Stabb).
-retro-pharyngeal abscess : see Retro- pharyngeal.
-specimen of carcinoma of pharynx from a woman (A. A. Kanthack,
M.D.) •-.....
6
103
PAGE
Pharynx: lupus of pharynx and larynx (Edward Law, M.D.) . .18
-pharyngis (L. Lack) . . . . 89
-mycosis of tonsils and pharynx (Scanes Spicer, M.D.) . . 92
-naso-pharyngeal and nasal polypi (L. Lawrence) . . 25
. .specimen (L. Lawrence) . . . .68
-clonic spasm of pharynx and soft palate (J. W. Bond, M.D.) . 41
-pathological specimens of tubercular infiltration of pharynx and
tongue (E. Clifford Beale, M.B.) . . . .25
-tubercular ulceration of trachea, larynx, and pharynx; pathological
specimens (P. R. W. de Santi) . . . .26
- ■■ ■ pharyngeal tumour, probably syphilitic (H. Tilley, M.D.) . 70
■ see also Foreign bodies in the upper air and food passages.
Pillar (left posterior) : epithelioma of left tonsil, left posterior pillar and
uvula (David Newman, M.D.) . . . . 45
Polypus: large nasal polypi removed from the right nostril of a lad aged
nineteen (Felix Semon, M.D.) . . . .7
■ - large nasal polypus removed from the naso-pharynx of a man aged
32 (A. Bronner, M.D.) . . . . .42
-naso-pharyngeal and nasal polypi (L. Lawrence) . . 25
- - -specimen (L. Lawrence) . . . .68
■ - cured polypi of frontal sinus; case and specimen (H. Tilley,
M.D.) . • • • . • .91
Pottbb (E. Furniss, M.D.), a case of tertiary syphilis of larynx and nose . 2
-malignant (?) disease of larynx . . . .93
Regeneration of tissue after turbinectomy (William Hill, M.D.) . 15
. — microscopical section (William Hill, M.D.) . . 42
Retro-pharyngeal abscess (chronic) in an adult (F. Semon, M.D.) . 95
Rhinitis: chronic hoarseness in case of chronic rhinitis and pharyngitis
(W. G. Spencer) . . * * . .69
Ropes (Leonard), case of congenital syphilis of palate and larynx • 2
dr Santi (P. R. W.), pathological specimens of tubercular ulceration of
trachea, larynx, and pharynx . . . . .26
■ new tracheotomy tube • . . . .94
Sarcoma recurring in nose (J. W. Bond, M.D.) . . .88
-microscopical section of round-cell sarcoma of thyroid (F. W.
Bennett, M.D.) . . . . . .25
Semon (Felix, M.D.). Specimens shown:
1. Large nasal polypi removed from the right nostril of a lad aged
nineteen • . . . . .7
2. Tubercular ulceration of the soft palate, uvula, right tonsil, and
larynx . . . . . .8
3. Large laryngeal papilloma . . . .8
4. Myxoma of the larynx . . . . .8
6. Syphilitic endotracheitis . . . .9
-a microscopical section of myxoma of larynx . . .12
■ ■ a case for diagnosis . . . . .27
-case of bulbar paralysis, progressive muscular atrophy, complete
paralysis of left abductor, paresis of right abductor . . 39
-discussion on the nature of the laryngeal complications of typhoid
fever . . . . . • .57
-discussion on foreign bodies in the upper air and food passages . 80
-thyrotomy for epithelioma of the larynx . . .85
■ - — chronic retro-pharyngeal abscess in an adult • • .95
104
PAGE
Sept am (nasal): nasal obstruction from septal deflection and other causes
(Edward Law, M.D.) . . # . .19
■ " see also Hose.
S&abmab (H., M.D.), discussion on foreign bodies in the upper air and
food passages . . . . . • 79
Shattocx ($. G), disc ass ion on the nature of the laryngeal complications
of typhoid fever . . . . . .57
Sinus: elongated cenrical sinus resembling branchial fistula (J. Dundas
Grant, M.D.) . . . . . .68
- frontal sinus disease (William Hill. M.D.) . . .5
- case and specimen of cured polypi of frontal sinus (H. Tilley, M.D.) 91
antrum and frontal sinus suppuration; healing (L. Lack) . 90
Spasm (clonic) of pharynx and soft palate (J. W. Bond, M.D.) . . 41
■ (inspiratory) of the vocal cords (W. A. Wills, M.D.) . . 32
Spkkcer (W. G.), a case oflarynereal stenosis . . .28
— ... — - case of chronic hoarseness in a patient with chronic rhinitis and
pharyngitis . . . . . .69
- case of abductor paralysis . . . . .95
Spicer (Soanes, M.D.), case of cicatricial obstruction of anterior nares . 3
- a warty growth of suspicious nature on left vocal cord in a man
aged fifty-four . . . . . 19,47
- discussion on foreign bodies in the upper air and food passages . 73
■ — ■ ■ case of mycosis of tonsils and pharynx • . .92
Stabb (E. G\), case of enlargement of thyroid gland in a boy, which almost
blocked lumen of pharynx • . . . .21
■ a case of thyroid disease after operation . . .30
-lupus of palate and larynx . • . .71
■ - - ■ - — ■ ■ tumour of the soft palate . . . .71
Stenosis (cicatricial): left vocal cord removed for cicatricial stenosis
(Charters J. Symonds) . . . . .4
-of both main bronchi with syphilitic ulceration of trachea,
pathological specimen (Percy Kidd, M.D.) • . .18
-(laryngeal): (W. G. Spencer) . . . .28
- of the larynx due to laryngitis complicating typhoid fever
(A. A. Bowlby) # • • . . .13
Stewart (W. R. H.), case of malignant disease of the (esophagus in a girl
aged twenty-three . . • • . .20
■ a case of large fibroma of nasal septum • • .30
-discussion on foreign bodies in the upper air and food passages . 79
Submaxillary gland : case of swelling of submaxillary gland, due to sali¬
vary calculus (J. Dundas Grant, M.D.) • • • .22
Suppuration of antrum and frontal sinus; healing (L. Lack) • . 90
Swelling of submaxillary gland (due to salivary calculus) (J. Dundas
Grant, M.D.) • • • • . .22
Symoxds (Charters J.) a case of tubercular ulceration of septum of nose • 3
-a case of tubercular disease of septum • . .4
— ■ a case in which the left vocal cord was removed for cicatricial
stenosis . . . • . • .4
- further notes of two cases of disease of septum nasi • . 31
— introduction to discussion on foreign bodies in the upper air and
food passages • • . . . .58
1 - reply . . . . . .80
Syphilis (congenital) of palate and larynx (Leonard Roper) . . 2
- (tertiary) of larynx and nose (E. Formas Potter, M.D.) . ♦ 2
105
PAGE
Syphilis: pharyngeal tumour, probably syphilitic (H. Tilley, M.D.) . 70
- syphilitic endotracheitis (Felix Semon, M.D.) . . .9
-ulceration of trachea, pathological specimen (Percy
Kidd, M.D.) . . . . . .18
Thohson (StClair, M.D.), fibroma (? fibro-sarcoma) of the cartilaginous
septum ; case and microscopical specimen . . .48
- case of myxoma of vocal cord . . . .67
Thyroid gland: case of enlargement of thyroid gland in a boy, which
almost blocked lumen of pharynx (E. C. Stabb) . . .21
- case of thyroid disease after operation (E. C. Stabb) . * 30
-microscopical section of round-cell sarcoma of thyroid (F. W.
Bennett, M.D.) • . . . • .25
Thyrotomy for epithelioma of larynx (Felix Semon, M.D.) . . 85
-in case of tubercular laryngitis (J. W. Bond, M.D.) . . 87
Tilley (Herbert, M.D.), case of inter-arytaenoid pachydermia laryngis . 50
- laryngeal case for diagnosis . • . .50
- case of pharyngeal tumour, probably syphilitic . . 70
- discussion on foreign bodies in the upper air and food passages . 77
- case and specimen of cured polypi of frontal sinus . . 91
Tongue: pathological specimens of infiltration of pharynx and tongue
(E. Clifford Beale, M.B.) . • . . .25
Tonsil: carcinoma of tonsil and soft palate (David Newman, M.D.) . 45
- mycosis of tonsils and pharynx (Scanes Spicer, M.D.) . . 92
- (lingual): microscopic specimen of hmmorrhagic myxoma of lin¬
gual tonsil (in albuminuric patient) (A. Bronner, M.D.) . . 14
- (right): tubercular ulceration (Felix Semon, M.D.) . . 8
-(left): epithelioma of left tonsil, left posterior pillar, and uvula
(David Newman, M.D.) . . . . ,45
Trachea: syphilitic ulceration of trachea with cicatricial stenosis of both
main bronchi ; pathological specimen (Percy Kidd, M.D.) . . 18
-tubercular ulceration of trachea, larynx and pharynx: pathological
specimens (P. R. W. de Santi) . . . .26
-(inflammation) : see Endotracheitis.
Tracheotomy tube (new) (P. R. W. de Santi) . . .94
Tuberculosis: case for diagnosis—tubercle or cancer (E. Clifford Beale,
M.B.) . . . . # . . .21
-tubercular ulceration of soft palate, uvula, right tonsil, and larynx
(Felix Semon, M.D.) • . . . .8
-case of tubercle or cancer ? (E. Clifford Beale, M.B.) . . 65
■ . - two cases of tubercular laryngitis with complete recovery (David
Newman, M.D.) . . . . . .43
-tubercular laryngitis (J. W. Bond, M.D.) . 87
-healed tubercular disease of larynx (L. Lack) . . .89
„- 0 f nose (William Hill, M.D.) . . . .70
-tubercular ulceration of septum of nose (Charters J. Synionds) . 3
-— disease of septum (Charters J. Symonds) . . 4
-pathological specimens of tubercular infiltration of pharynx and
tongue (E. Clifford Beale, M.B.) • . . .25
- tubercular ulceration of trachea, larynx and pharynx; patho-
gical specimens (P. R. W. de Santi) • . . .26
Tumour (pharyngeal), probably syphilitic (H. Tilley, M.D.) . . 70
-of soft palate (E. C. Stabb) . . . .71
Turbinectomy: regeneration of tissue after turbinectomy (William Hill,
M.D.) . . . . . . .15
— - —microscopical section (William Hill, M.D.) . . 42
9 *
106
PAGE
Typhoid fever: specimen of necrosis and operation of tip of epiglottis
which occurred in course of typhoid fever (A* A. Kanthack, M.D.) . 7
-• stenosis of larynx doe to laryngitis complicating typhoid fever
(A. A. Bowlby) . . . . . .13
- typhoid ulcer of larynx (A. A. Kanthack, M.D.) . .15
- discussion on the nature of the laryngeal complications of typhoid
fever:
-introduction by A. A. Kanthack, M.D., and J. H. Drysdale,
M.B. . . . . . . .53
--remarks by P. Watson Williams, M.D. .55
-S. G. Shattock . . . .57
--W. Jobson Horne, M.B. . .57
- - - Felix Semon, M.D. . . . .57
-reply by A. A. Kanthack, M.D. . .57
Ulcer: typhoid ulcer of larynx (A. A. Kanthack, M.D.) . . 15
Ulceration : specimen of necrosis and ulceration of tip of epiglottis, which
occurred in the course of typhoid fever (A. A. Kanthack, M.D.) . 7
- (syphilitic) of trachea; pathological specimen (Percy Kidd, M.D.) 18
■- — (tubercular) of soft palate, uvula, right tonsil, and larynx (Felix
Semon, M.D.) . . . . . .8
-of septum of nose (Charters J. Symonds) . . 3
--of trachea, larynx and pharynx: pathological specimens
(P. It. W. de Santi). . . . . .20
Uvula: epithelioma of left tonsil, left posterior pillar, and uvula (David
Newman, M.D.) . . . . . .45
-tubercular ulceration (Felix Semon, M.D.) . . .8
Vocal cord: inspiratory spasm of the vocal cords (W. A. Wills, M.D.) . 32
— ■- early malignant disease of vocal cords; drawing (P. Watson Wil¬
liams, M.D.) • . . . . .96
-case of myxoma of vocal cord (StClair Thomson, M.D.) . 67
—— (left): warty growth of suspicious nature on left vocal cord in a
man aged fifty-four (Scanes Spicer, M.D.) . . 19,47
-growth on left vocal cord (J. B. Ball, M.D.) . . 24
-paralysis (J. B. Ball, M.D.) . . . .12
-removed for cicatricial stenosis (Charters J. Symonds) . 4
WAGGBTT (E. B.), case for diagnosis . . . .32
- discussion on foreign bodies in the upper air and food passages . 79
Warty growth of suspicious nature on left vocal cord in a man aged fifty-
four (Scanes Spicer, M.D.) . . . . 19,47
Web causing obstruction of larynx (Barclay J. Baron, M.B.) . . 84
Williams (P. Watson, M.D.), discussion on the nature of the laryngeal
complications of typhoid fever . . . .55
-a drawing of a case of extrinsic malignant disease of the
larynx . . . . . . .96
-a coloured drawing of a case of early malignant disease of
the vocal cords . . . • * .96
Wills (W. A, M.D.), case of inspiratory spasm of the vocal cords . 32
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