Full text of "Proceedings of the Laryngological Society of London 12.1905"

See other formats

Google

Uber dieses Buch

Dies ist ein digitales Exemplar eines Buches, das seit Generationen in den Regalen der Bibliotheken aufbewahrt wurde, bevor es von Google im
Rahmen eines Projekts, mit dem die Bucher dieser Welt online verffigbar gemacht werden sollen, sorgfaltig gescannt wurde.

Das Buch hat das Urheberrecht fiberdauert und kann nun offentlich zuganglich gemacht werden. Ein offentlich zugangliches Buch ist ein Buch,
das niemals Urheberrechten unterlag oder bei dem die Schutzfrist des Urheberrechts abgelaufen ist. Ob ein Buch offentlich zuganglich ist, kann
von Land zu Land unterschiedlich sein. Offentlich zugangliche Bucher sind unser Tor zur Vergangenheit und stellen ein geschichtliches, kulturelles
und wissenschaftliches Vermogen dar, das haufig nur schwierig zu entdecken ist.

Gebrauchsspuren, Anmerkungen und andere Randbemerkungen, die im Originalband enthalten sind, finden sich auch in dieser Datei - eine Erin-
nerung an die lange Reise, die das Buch vom Verleger zu einer Bibliothek und weiter zu Ihnen hinter sich gebracht hat.

Nutzungsrichtlinien

Google ist stolz, mit Bibliotheken in partnerschaftlicher Zusammenarbeit offentlich zugangliches Material zu digitalisieren und einer breiten Masse
zuganglich zu machen. Offentlich zugangliche Bucher gehoren der Offentlichkeit, und wir sind nur ihre Hiiter. Nichtsdestotrotz ist diese
Arbeit kostspielig. Um diese Ressource weiterhin zur Verffigung stellen zu konnen, haben wir Schritte unternommen, um den Missbrauch durch
kommerzielle Parteien zu verhindern. Dazu gehoren technische Einschrankungen fur automatisierte Abfragen.

Wir bitten Sie um Einhaltung folgender Richtlinien:

+ Nutzung der Dateien zu nichtkommerziellen Zwecken Wir haben Google Buchsuche flir Endanwender konzipiert und mochten, dass Sie diese
Dateien nur fur personliche, nichtkommerzielle Zwecke verwenden.

+ Keine automatisierten Abfragen Senden Sie keine automatisierten Abfragen irgendwelcher Art an das Google-System. Wenn Sie Recherchen
liber maschinelle Ubersetzung, optische Zeichenerkennung oder andere Bereiche durchffihren, in denen der Zugang zu Text in groBen Mengen
nfitzlich ist, wenden Sie sich bitte an uns. Wir fordern die Nutzung des offentlich zuganglichen Materials fur diese Zwecke und konnen Ihnen
unter Umstanden helfen.

+ Beibehaltung von Google-Markenelementen Das "Wasserzeichen" von Google, das Sie in jeder Datei finden, ist wichtig zur Information fiber
dieses Projekt und hilft den Anwendern weiteres Material fiber Google Buchsuche zu finden. Bitte entfemen Sie das Wasserzeichen nicht.

+ Bewegen Sie sich innerhalb der Legalitdt Unabhangig von Ihrem Verwendungszweck mfissen Sie sich Ihrer Verantwortung bewusst sein,
sicherzustellen, dass Ihre Nutzung legal ist. Gehen Sie nicht davon aus, dass ein Buch, das nach unserem Daffirhalten ffir Nutzer in den USA
offentlich zuganglich ist, auch ffir Nutzer in anderen Landem offentlich zuganglich ist. Ob ein Buch noch dem Urheberrecht unterliegt, ist
von Land zu Land verschieden. Wir konnen keine Beratung leisten, ob eine bestimmte Nutzung eines bestimmten Buches gesetzlich zulassig
ist. Gehen Sie nicht davon aus, dass das Erscheinen eines Buchs in Google Buchsuche bedeutet, dass es in jeder Form und fiberall auf der
Welt verwendet werden kann. Eine Urheberrechtsverletzung kann schwerwiegende Folgen haben.

Uber Google Buchsuche

Das Ziel von Google besteht darin, die weltweiten Informationen zu organisieren und allgemein nutzbar und zuganglich zu machen. Google
Buchsuche hilft Lesern dabei, die Bficher dieser We lt zu entdecken, und unterstfitzt Au toren und Verleger dabei, neue Zielgruppen zu erreichen.
Den gesamten Buchtext konnen Sie im Internet unter http : //books . google . com durchsuchen.

This is a reproduction of a library book that was digitized
by Google as part of an ongoing effort to preserve the
information in books and make it universally accessible.

Google" books

https://books.google.com

THE JOHN C5^BI^A3^
LIB3^A1RT 9 CHICAGO,

Digitized by

)

Digitized by LjOOQLe

Digitized by {jOOQie

PROCEEDINGS

" "• . • '■ . V > ■

OP TH/E ; ..... ,

'mRYNC&LOGICAL SOCIETY OF LONDON. ■

Ninety-second Ordinary Meeting, November 4, 1904'
P. McBride, M.D., F.R.C.P.Ed., President, in the Chair

E. Furniss Potter, M.D.,
P. de Santi, F.R.C.S.,

| Secretaries.

Present—40 members and 7 visitors. .

r''

The minutes of the previous meeting were read and confirmed.

The following cases and specimens*were shown :

Diagnostic Specimen from CEsophageal Stricture removed
by Killain’s Method.

Shown by Mr. E. B. Waggett. The specimen was shown to
emphasise the importance of examining strictures ^ bj[ Killian’s
tubes and thus making certain of the diagnosis ^•&.

The President asked why Mr. WaggSett spoke of the procedure as
“ Killian’s method.” His own impression was that Kussman was the
first to use the rigid tube for the oesophagus, and that Rosenheim and
others had elaborated it.

Mr. Waggett, in reply, said he called it Killian’s method because the
instruments employed were devised by Killian. He thought the subject
of oesophagoscopy ought to be taken up more largely in England than he
believed was the case at present. He had now done some fifteen cases by
that method, without difficulty, and there had been no danger to the
patient. About half the cases were done under cocaine, and the remainder
under a generST'Shmsth^tic; In every case he had assured himself, of the
presence of a stricture or of its absence. The tubes were valuable for
removing growths from children’s larynges, as he had found particularly
on three occasions. It was easy to see the exact position of the papillomata
in the larynx, and remove them with the tube forceps supplied in the case
of instruments. ^

first series—VOL. XII. 1

Digitized by

* ^ECJMENS ^OF 'CaRCIN6mA TN THE THROAT OF THE DOG AND THE CAT.

' * I » ft r * * t r r

; /: Jfrofessor Hobday, F.R.C.Y.S. (introduced by Mr. de

Santi). Professor Hobday demonstrated specimens from five cases
of true epithelioma of the throat of the dog and the cat, all of which
had been confirmed by microscopical examination either by Professor
McFadyean, of the Royal Veterinary College, or by Dr. Bashford and
Dr. Murray, of the Imperial Cancer Research Fund. All five cases
had been under the care of Professor Hobday, and had been met
with since January, and, in fact, four of them since June in this
year. He particularly drew attention to this fact because it used
to be thought, even until recently by some pathologists, that
carcinoma in the lower animals was exceedingly rare. He did not
think that it was as common as other tumours, but now that the
disease was particularly looked for, numbers of well-authenticated
cases had been found in the horse, the cow, the sheep, the dog, the
cat, and even the pig. Professor Hobday pointed out that one
must not forget thait cancer is a disease most frequently met with
in old age, and that in the varieties of animals used for food, oppor¬
tunities for the growth of such tumours are comparatively rare
because the host is killed before reaching even adult age.

Case 1 occurred in January, 1904, in a foxhound bitch, between
seven and eight years old. The tumour was situated on the
left side of the throat. The symptoms were those of lassitude and
emaciation. The growth at first was supposed to be an abscess.
She was sent to London for operation, and at the request of
Professor Hobday discretionary power was given to painlessly put
an end to her before recovering from chloroform if the growth
were found to be a cancer and inoperable.

Case 2 occurred in June, 1904, in a poodle, aged seven,
the right side being affected. Examination of the mouth
revealed an ulcerated jagged sore on the right side of the fauces,
just in front of the tonsil. The cervical glands were much
enlarged, the patient had difficulty in swallowing, salivated freely,
and was becoming emaciated. The growth had been observed
about four months, but latterly had become much enlarged.

Case 3 occurred in August, and was also a poodle which had
been treated for some four months for an ulcer of the mouth.
Dysphagia had been noticed for some months, and the enlargement
of the cervical glands had latterly much increased. Salivation
was profuse, the appetite capricious on account of the soreness of
the mouth, and the patient was perceptibly becoming emaciated.

Digitized by LjOOQle

Case 4, seen in September, was a Pembrokeshire terrier, eight
years old, of which a sketch and also the larynx was shown.
There was a jagged ulcerating wound on the fauces and the cervical
glands were enlarged. The owner had observed the patient to be
“ out of sorts ” for about five months, but during the last six
weeks had noticed considerable dysphagia, great lassitude, saliva¬
tion, and general emaciation.

Case 5, met with last month, was of particular clinical interest
on account of the situation of the growth. It was an epithelioma
of the oesophagus of a cat. The animal was eight years of age,
and was brought for advice on account of a continual gulping
movement when swallowing, a capricious appetite, and inability to
take solid food. An obstruction in the throat was suspected, and
when the probang was passed it could be distinctly felt to go over
some foreign body, and then to go on satisfactorily into the
stomach. As a repetition of the process always gave the same
result, and the obstruction could also be felt when the instrument
was withdrawn, a growth of some kind was diagnosed and, as the
owner did not (for sentimental reasons) wish for any cutting opera¬
tion, the patient was chloroformed to death.

All the specimens were proved to be of the squamous-celled
variety of epithelioma; in each dog the larynx, floor of the mouth,
and palate were affected, there being secondary infection of the
cervical glands. In none of the cases had the infection spread to
the lungs or digestive tract.

Professor Hobday remarked that there was a popular impression to
the effect that true carcinoma was not common in the animal kingdom,
though veterinary surgeons had for many years known of its occurrence,
as also had those who did work in comparative anatomy. But so much
attention had been drawn to the subject by the Imperial Cancer Research
Fund, that it was found to be comparatively common in animals. Still, he
frequently saw it stated in the medical papers that carcinoma was not
common in animals. If such an assertion was in the minds of those who
had facilities for expert work on the subject, certain analogies were drawn
which were incorrect. For instance, it was said that in the human subject
the irritation produced by a pipe and such things was a common precursor
of cancer; animals did not smoke, but irritants got across the mouth which
produced abrasions in the mucous membrane. In each of the laryngeal
cases exhibited the primary wound was apparently just where a bone
would get fixed across the back of the throat. That frequently happened
in the dog, and it was possible that some irritant there might have caused
the sore from which the carcinoma started. The horse and the cow had
long been known to suffer from cancer, and in all situations, and he had
other specimens. The five exhibited were shown because, being in the
larynx, he thought they would possess special interest for members of the
Society.

The President said the thanks of the Society were due to Professor

Hobday and Mr. de Santi for bringing forward such interesting matter.
He did not know that carcinoma was supposed to be so rare in dogs, of
which he had kept a fair number during his life, and among these he had
only two affected with cancer. The first case was one of carcinoma in
the mamma of a bitch, which he had had removed by a veterinary
surgeon, as he suggested malignancy. But the veterinary surgeon, in
the spirit of Professor Hobday’s statement, replied that cancer did not
occur in dogs. However, he (Dr. McBride) had it examined micro¬
scopically, when it was found to be typical carcinoma. The next was in
a favourite dog of his. He did not have it microscopically examined,
but it was undoubtedly typical epithelioma of the lip. He removed it
himself. Three months later a large gland was found, and he had to
have the dog destroyed because it could not swallow.

A Lesion op the Soft Palate for Diagnosis.

Shown by Mr. de Santi. The patient, a girl, aged twenty-two,
applied to Mr. de Santas Out-Patient Department, a week pre¬
viously, complaining of pain and discomfort in the throat, localised
to the left side. She said she had had discomfort in the throat
for some weeks.

On examination a bright red patch was observed on the left
side of the soft palate, about the size of a shilling; a similar
erythematous blush extended from this patch down to and over
the pillars of the fauces and tonsil on the left side. The appear¬
ance was simply that of erythema; the hyperasmic area presented
no signs of enlarged blood-vessels, and was in no sense a tumour.
The patient explained that she had seen the condition in her throat
for some seven months and that the patch had got larger during that
time. Application locally of cocaine and adrenalin solution pro¬
duced no diminution in the size or brightness of the blush.

The President said the case appeared to him to be one of angioma
of the pharynx, or at least a red tumour composed of minute vessels,
though he had never seen anything exactly like it before. He showed
before the Society some years ago a drawing of a case in which were very
large blood-vessels, in very much the same situation, and that un¬
doubtedly was angioma.

Mr. Cresswell Baber thought the condition was probably congenital.
It reminded him in an exaggerated degree of the blush met with some¬
times in sclerosis of the middle ear, which was, however, usually bilateral.

Mr. de Santi, in reply, regretted no suggestions had been offered as
to how the case should be dealt with.

A Case of Growth in the Aryteno-Aryepiglottic Region in a
Man, aged Sixty-Four (previously exhibited).

Shown by Dr. Furniss Potter. The case was shown at the
May Meeting. 1 Since then the swelling had steadily increased.

1 Vide Proceedings of the Laryngological Society of London , May, 1904, p. 168.

Digitized by LjOOQle

Anti-syphilitic remedies had been administered, but with no
appreciable result. There was no pain, and no enlarged glands
could be felt.

The case was shown with the view of obtaining expressions of
opinion as to diagnosis and treatment.

Mr. Butlin said he had not heard Dr. Potter’s remarks on the case,
and therefore did not know whether he proposed removal of the growth.
It appeared to him (Mr. Butlin) to possess all the characteristics of
malignant disease, and as Dr. Potter had watched it since October of last
year, its progress must have been very slow. Even now he could not
feel any enlarged glands, though probably there were some. If there
ever was a case in which excision should be practised for cancer of
extrinsic origin, the present instance seemed to be one.

Mr. de Santi said he remembered seeing the case when previously
exhibited, and from what he recollected about the case then and the
appearances now, he thought there could be no question about its
malignancy.

Dr. StClair Thomson said he supposed it might be a case of
malignant disease in a syphilitic larynx, but he would like to ask
Mr. Butlin whether it was not like a case which was seen by Mr,
Butlin, Sir Felix Semon, and himself, and in which the growth
entirely disappeared after tracheotomy. 1 Dr. Furniss Potter said the
present growth went down after tracheotomy, therefore it might be wise
to have a second tracheotomy performed, for if syphilitic it would sub¬
side much more quickly under appropriate treatment with a tube in the
trachea to give the larynx rest. For' was it not exceptional for extrinsic
malignant disease of the larynx to go so long without more distinct in¬
volvement of the glands P

Mr. Butlin, in reply to Dr. StClair Thomson’s question, said his point
was that it was an exceptionally slow case, but it was really so easily
within reach that he did not see why one should not be sure about it. A
sufficient piece could be removed with cutting forceps to enable the
diagnosis to be certainly made.

Dr. Furniss Potter, in reply, thanked members for their comments.
The tracheotomy tube was removed in less than a week; the man had
an acute attack of swelling, producing sufficient embarrassment to
necessitate tracheotomy. Immediately after the operation the swelling
rapidly subsided. He brought the case in order to get an expression of
opinion as to whether it was desirable to operate in the uncertain state
of the diagnosis. He intended following Mr. Butlin’s advice, namely, to
try to procure a piece of the growth and submit it to microscopical
examination before doing anything further.

A Specimen of Actinomycosis of the Tonsil.

Shown by Mr. Arthur Cheatle and Dr. W. D’Este Emery.
A girl, aged sixteen, living in the country, was seen on account
of deafness. The left tonsil was enlarged and had a rounded,
overlapping appearance. The glands on both sides of the neck

1 Proceedings of the Laryngological Society of London , vol. vii, December,
1899, p. 15.

Digitized by

Google

were enlarged. There was no suppurative lesion anywhere. The
tonsil was so curious in appearance that it was sent to Dr. Emery,
Clinical Pathologist to King's College Hospital, for examination.
This was the first case reported in which actinomycosis had been
found in the tonsil in this country. Dr. Wright, of New York, has
lately published a similar case.

Dr. Emery’s Report .—The tonsil was greatly enlarged, and on
section it was found to be hyperplastic, and on further examina¬
tion several “ tubercles” (using the word in the histological sense)
were found grouped around a crypt, the lower portion of which
was greatly dilated. This cyst-like cavity contained large numbers
of lymphocytes and of desquamated squamous epithelium, in
addition to which there were four colonies of an interesting form
of streptothrix. The smallest colony was similar in every way to
the colonies of actinomyces usually met with in human pus, and
showed a tangled mycelium, with a radial arrangement at the
periphery, and a few chain-spores in the middle. The larger
colonies showed more spore-formation at the centre, and at the
periphery the radial filaments showed a peculiar thickening, which
was thought to indicate a form of qonidium formation, and not the
presence of “ clubs.” ( The epithelial walls of the crypt were
thickened and showed signs of inflammation, being infiltrated with
leucocytes that were obviously making their way through into
the central cavity. In one place, however (where it was
touched by the mass of streptothrix), the epithelium had dis¬
appeared and the fungus impinged directly on an ulcerated surface.
Beneath the epithelium there was a narrow band of lymphoid
tissue, which was, in its turn, surrounded by a zone of well-formed
tubercles, in which, however, no tubercle bacilli could be detected.

It was pointed out that in this case (as in that described by
Wright, of New York) the masses of actinomyces were inside the
crypts— i.e. in a region which is physiologically outside the body.
In this situation they must have elaborated their toxins, which
attracted the leucocytes from the tissues, produced inflammation
of the epithelium and sub-epithelial tissues, and finally gave rise
to a hollow shell of tubercles at some distance from the mycelial
masses.

Dr. Herbert Tilley suggested, as such cases were so rare, that some
micro-photographs should be taken for publication in the Proceedings.

Mr. Butlin said a curious case was sent to him from Nottingham,
which was one of the noted centres for actinomycosis, several years ago.
The patient was a young gentleman, who was sent with a flat tumour of
the neck. The question was raised as to whether it was malignant
disease or not. He concluded that it was not a new growth, but one of
the infective tumours, though he had no idea which. It did not appear

Digitized by qjOOQle

to be syphilitic, and was not like ordinary tubercle. Then he was asked
—as the people from that district were well up in the subject—whether it
might be actinomycosis. He replied that he had not seen actinomycosis
in that early condition, but he did not know why it should not be. The
patient gave a very clear history of having, three or four months pre¬
viously, walked through a field of wheat, a head of which he had plucked
and began to chew. Presently one of the husks lodged in his tonsil,
making it bleed. He did not get rid of it for two or three days, but at
the end of that time his tonsil got well. Shortly afterwards he found
the tumour for which advice was sought. It was opened by Dr. Anderson
and found to be actinomycosis. There was a clear history of infection
through his tonsil, but the tonsil did not retain the actinomyces. He had
seen many cases of actinomycosis, but never one in the tonsil.

Mr. Cheatle, in reply, said he would gladly supply a plioto-lithograpli
for the Proceedings if Dr. Emery could do it. It was entirely due to
Dr. Emery that the case was detected at all.

A Case of Laryngeal Growth in a Boy aged Six.

Shown by Dr. W. H. Kelson. The patient had complained of
steadily increasing loss of voice, first noticed after measles, two
years previously; on examination a growth could be seen the size
of two peas at the anterior commissure. The growth was removed
with Mackenzie's forceps under chloroform, the patient being in
the sitting position. It was found on microscopical examination
to be a fibroma. On recovering from the anaesthetic the patient’s
voice was quite clear.

Dr. Herbert Tilley said that he could lay no claim to having
suggested the removal of papillomata of the larynx under general
anaesthesia. What he had frequently asserted was that in order for this
method to be successful it was necessary that the anaesthesia should be
deep—in fact, pushed so far that the laryngeal reflex was abolished. An
expert anaesthetist could, without much danger, provide such a deep
narcosis lasting from twenty to thirty seconds, and during those intervals
it was possible to remove the growths by means of suitable forceps, be¬
cause the operator was not hampered by the patient coughing or swallow¬
ing.

Dr. Furniss Potter asked Dr. Kelson in what position he placed
the patient when he removed the papilloma under a general anaesthetic.

Dr. Kelson, in reply, apologised to Dr. Scanes Spicer for not connect¬
ing his name with the operative procedure, but he mentioned Dr. Tilley’s
name because he had heard that gentleman, in the first instance some
years ago, speak about that method at some length. The child was sitting
on the matron’s lap in practically the upright posture. The anaesthetic
was chloroform and ether, and was pushed fairly deeply, so that there
was no probability of the child moving during the operation.

A Case of Pharyngeal Obstruction from a Diaphragm between
the Back of the Tongue and the Posterior Wall of the
Pharynx.

Shown by Mr. H. Betham Robinson. The following conditions
were observed in a female child aged ten: There was a central

Digitized by {jOOQie

destruction of the soft palate with loss of the uvula, and the faucial
pillars were dragged back to the posterior pharyngeal wall by firm
fibrous adhesions. On the left faucial pillar and tonsil there was
active ulceration when she was first seen by Mr. Robinson in
September last. From the posterior part of the tongue to the
posterior wall of the pharynx there was a horizontal membrane,
due to a contracted cicatrix; in the centre of this an oval opening,
longer from before backwards, through which just the tip of the
epiglottis projected. The left edge of the epiglottis was adherent
to the scar. Through the posterior part of the opening was seen
the glottic orifice and the very limited communication with the lower
pharynx. As to the cause, syphilis seemed to be the most probable,
but there was no other evidence to support it; there was no history
of it being the sequel of a specific fever like scarlet fever.
Dysphagia, which was very marked, had almost disappeared with
the use of bougies.

Mr. Cresswell Baber said the case was much like one which he
himself showed before the Society some years ago, and which was
described in Yol I of the Proceedings. In that case the diaphragm
contained a heart-shaped aperture which was about two inches across.
He thought it was situated rather lower down than in the present in¬
stance. He enlarged the opening by removing a small piece about the
size of half a sixpence from the posterior part, and dilating it with the
finger. There was some difficulty in swallowing, which was relieved, but
slight noise during sleep remained. There was no dyspnoea. The trouble
supervened upon scarlet fever.

Foreign Body removed by Direct Laryngoscopy from a Child
aged Twelve Months.

Shown by Dr. D. R. Paterson. The body was a metal collar-
stud, which had been impacted in the larynx for three months.
While playing with a stud, the child had a coughing fit, and it
was noticed directly afterwards that it made a crowing noise in
sleep. Two months later difficulty of breathing set in, and this
had increased latterly to well-marked stridor. Skiagraphs taken
showed the stud fixed in the larynx in an oblique position with its
head anteriorly. This was confirmed on examination by the direct
method, when considerable oedema of the entrance of the larynx
was made out. The stud was readily seized, by the head, but it
required firm traction to free it from the cedematous tissue around.
The breathing was at once relieved, but it was quite ten days
before all trace of stridor had vanished. The absence of inter¬
ference with respiration at first was no doubt due to the situation
of the body, which kept the glottis open, and the gradual onset
of oedema caused the block.

Digitized by CjOOQle

The President asked what instrument Dr. Paterson used for the
purpose. Was it the rohrenspatel of Killian ? It was most interesting
that that method should have been found useful in a child of that age.

Dr. Paterson, in reply, said he used the “ rohrenspatel ” of Killian
and the straight crocodile forceps which he showed at the June meeting
of the Society. The patient was under chloroform, with the head over
the table. By that means one avoided the nuisance of the mucus in the
throat. In two instances he had removed papillomata of the larynx
by that method, which possessed enormous advantages over the means he
formerly employed, viz. that introduced by Dr. Scanes Spicer. One was
also able to dispense with the number of assistants which the old
method required.

A Case of Incrustation in the Trachea, with, at times, well-

marked Stenosis.

Shown by Dr. Edward Law. The patient, aged eighteen,
had suffered from hoarseness during the last four years, par¬
ticularly in the winter ; this symptom had greatly increased
during the last three months and had been accompanied at
times by great difficulty in breathing. There had never been
any severe spasm except for two days, two months ago, when
she was several times afraid of suffocation. Ipecacuanha was
administered, and, after vomiting, the choking sensations were
greatly diminished. A disagreeable odour of the breath has been
noticed during the last four months. The general health had been
good, only breathlessness had troubled the patient on running,
going upstairs, or any exertion. The friends considered that the
hoarseness was due to living in a damp house.

A week ago the patient was seen for the first time on account
of difficulty in breathing; she was anaemic and the voice very hoarse
and breathy.

On examination, a little purulent secretion was seen over the
middle turbinates and over the remains of Luschka's tonsil, but no in¬
crustations nor dryness were present in the nostrils or naso-pharynx.
In the larynx a few black particles, looking like small pieces of
charcoal, were lying on the ventricular bands and vocal cords;
whilst, lower down, the trachea appeared to be almost occluded by
large, dry, black incrustations, which reduced the lumen of the
canal to the size of a quill. The patient tolerated an examinatioji
very well, and the peculiarly black incrustations could be followed
for a considerable distance down the windpipe. There was a very
foetid odour in the breath and some dyspnoea. The symptoms
appeared so urgent that the patient was advised to go into the
London Throat Hospital for observation. A nasal solution had
been employed, and the black incrustations in the trachea had

Digitized by {jOOQie

almost disappeared, small greenish-yellow crusts having taken the
place of the large black masses; these crusts were now smaller in
size and less in number.

The patient had never complained of cough or expectoration,
and had apparently swallowed the offensive crusts. This probably
accounted for her somewhat unhealthy appearance.

The President said the case was very interesting, and must have
been more so when first examined by Dr. Law. To his mind it was
certainly a case of laryngitis sicca, with crusting in the trachea. He had
seen many such cases where the nose was not affected, but only once a
case like that which Dr. Law described his case to be at the beginning.
In that case, too, there was immense crusting and obstruction of the
lumen, to such an extent as to cause very marked dyspnoea.

Dr. Milligan said that about two years ago he saw, in consultation
with Dr. Brooke, of Manchester, a similar case in a young girl, who had
typical ozsena, with the condition of the larynx and trachea which had
been described. Accessory sinus disease was examined for, but not found,
and she was put under routine treatment, without effect, for the crusts
continued to form in the larynx and trachea and the stenosis increased.
He then suggested that the treatment might be carried on by injecting
anti-diphtheritic serum, on the idea first mentioned by Belfonti and
della-Vedova, who suggested that those cases might be due to an atten¬
uated form of diphtheria. The patient was taken into a surgical home,
where she had the injections, which were continued for nearly two months.
The result was very marked improvement; indeed, he thought the con¬
dition had ceased altogether.

A Case of New Growths in the Larynx.

Shown by Dr. Dundas Grant. Louisa H—, aged seventeen, was
sent to the Central London Throat and Ear Hospital on August 25,
1904, on account of attacks of dyspnoea for several months so serious
as to place her life in danger. In the absence of Dr. Grant, Mr.
Stuart-Low examined her and found a growth covering the whole of
the upper part of the larynx of an appearance suggesting that of the
top of a toadstool. He performed a temporary laryngotomy and re¬
moved a large portion of the growth through the mouth. The dyspnoea
entirely disappeared. When seen three weeks after by Dr. Grant,
there remained a round growth of about the size of a small cherry,
which appeared to several observers to be growing larger, though
with no great rapidity. It was impossible by inspection to decide
as to its site of attachment, but from the way in which it could be
moved by the probe it appeared to arise from the upper margin of the
ary epiglottic fold, near its anterior part. Dr. Grant managed to
get a snare round it in such a way as to make it certain that its
attachment was well to the front. It proved to be so firm that
its removal was impossible without an anaesthetic, and gas was
administered while a snare was still in situ . Then, by the exercise

Digitized by

Google

of a considerable amount of force, the growth was dragged away
with a tag of mucous membrane hanging from it. The larynx was
then quite clear, although the aryepiglottic fold seemed somewhat
ragged and raw. The right vocal cord was fixed. The section
made of the first portion of the growth showed what Dr. Win grave
considered to be a spindle-celled sarcoma, but he stated that the
difficulty in the diagnosis of growths of mesoblastic tissue was
always one of immense difficulty. Another pathologist thought it
presented more the appearance of a fibroma. The second portion
was found to consist of a capsule and a core, and the neoplasm
seems to have been eradicated in toto. There is now a slight
degree of movement of the right vocal cord, and the raw surface
on the aryepiglottic fold has cicatrised. A microscopical section
was exhibited for the opinion of the members.

Mr. de Santi said he had carefully looked at the microscopic section,
and his feeling was that it was more like a sarcomatous growth than a
fibromatous one. Of course there was a certain amount of fibrous tissue
in the section, but he thought the sarcomatous elements predominated.

Dr. StClair Thomson asked whether Dr. Grant was still a supporter
of the use of the snare for operations on the larynx. Dr. Grant seemed
to have had an unhappy moment when the snare gripped that growth
and it would not come away, and the snare would not let go. When the
subject was discussed at Oxford there was, of course, a difference of
opinion, but many of those who then spoke condemned snares. He
wished to know whether the experience of the present case left Dr. Grant
a supporter of the snare.

Dr. Pegler suggested that as the specimen seemed to merit a very
careful examination, it should be submitted to the Morbid Growths
Committee to report upon.

Dr. Dundas Grant, in reply, said he would be pleased to place the
slide at the disposal of the Pathological Committee, whose report he
would await with interest. In any event he would bring the case before
the Society again at a future meeting. In answer to Dr. StClair
Thomson’s question concerning the snare, he did not believe in absolute
condemnation of one instrument. He thought there was room for the
snare, even though it was much more limited than some of its former
admirers thought. He regarded the present case as a very good one for
its application. There was no particular anxiety, and if there had been
he would simply have cut the wires and pulled the stem of the instru¬
ment away. Where there was a pedunculated growth which the snare
could be got round, it was the instrument to use. As he had said in his
description, the fact of getting the snare round it enabled him to decide
as to its origin, and as to the possibility of getting it away. He was more
or less probing with the snare.

Digitized by

Google

Digitized by LjOOQle

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Ninety-third Ordinary Meeting, December 2, 1904.
P. McBride, M.D., F.R.C.P.Ed., President, in the Chair.

E. Furniss Potter, M.D.,
P. de Santi, F.R.C.S.,

Secretaries.

Present—25 members and 2 visitors.

The minutes of the previous meeting were read and confirmed.

The following gentlemen were nominated for election as Ordinary
Members at the next meeting :

G. A. Garry Simpson, M.R.C.S., L.S.A., East Acton.

Joseph William Leech, M.D., F.R.C.S., Newcastle-on-Tyne.

The following cases and specimens were shown:

Case of Incrustations in the Trachea.

Shown at last meeting by Dr. Law.

Sir Felix Semon said he saw the case a little while ago, after his
return from America. Dr. Law brought the patient to him, and he saw
some crusts far down in the trachea. At that time Dr. Law said the
patient was better than when he demonstrated her before the Society.
He, Sir Felix, did not know anything of an examination of the case by
Killian’s tracheoscope having been suggested, and he recommended it;
but Dr. Law told him of the objection—which he had to admit was
justified—that by the introduction of the tube possibly crusts might be
torn off, pushed in front of the instrument, and cause dangerous
dyspnoea. It was Dr. Law’s intention to first try to make the crusts
softer by the inhalation of steam, and the patient was taken to the
hospital for the purpose. To day he found the stridor certainly greater
than when he saw her a week ago, and the crusts seemed more extensive.
Under those circumstances he submitted that it might be legitimate, if

FIRST SERIES—YOL. XII. 2

Digitized by LjOOQle

the obstruction should further increase, to perform tracheotomy, remove
the crusts, and see whether they re-formed.

Mr. Robinson said a better mode of treatment would perhaps be
to try a formalin spray before doing tracheotomy.

Crusts prom a Case of Dry Catarrh of the Nose and Naso¬
pharynx, TREATED BY FORMALIN SPRAY.

Shown by Dr. Bronner. Dr. Bronner (Bradford) showed a
specimen of large crust removed from the naso-pharynx of a
case of atrophic rhinitis. The girl, aged twenty-one, had had
nasal discharge for some years, and no less than three opera¬
tions had been performed on the nose under chloroform. The
nares were very large and full of crusts, and the naso-pharynx
completely filled with a large crust. This was removed with
forceps. There was frequent recurrence of the naso-pharyngeal
crust, which not only caused much discomfort, but also occa¬
sional oedema of the soft palate and uvula. The patient used
a formalin spray, and in a few weeks there was only slight
recurrence of the crusts. Dr. Bronner had shown the specimen
partly because of its unusual size and thickness, and also to
advocate the use of formalin in these cases. It not only pre¬
vented the recurrence of the crusts, but also at once removed the
offensive odour in cases of ozaena. He should like also to protest
against the common custom of scraping the nares in cases of
atrophic rhinitis and ozaena. This case had been scraped no less
than three times.

The President asked what strength of formalin Dr. Bronner used.
He thought he said up to 1 per cent.

Dr. Herbert Tilley asked what Dr. Bronner’s procedure was in
this case (or in an ordinary one of atrophic rhinitis) with regard to the
application of formalin. Did he wash the nose free from crusts and
then apply formalin ? Also, how did he apply the formalin—on a mop
or by spraying P And how much did he apply at a time ?

Dr. Bronner, in reply, said the strength of formalin he applied
varied from 1 in 500 to 1 in 100. When there were any large crusts he
removed them with forceps; then he applied formalin or trichloracetic
acid. The patient attended perhaps once a week as long as there was
recurrence of the crusts, and then less frequently. In some cases it was
necessary to use a syringe with weak formalin solution, 1 in 1000, in
order to remove the crusts.

Epithelioma of Larynx ; Thyrotomy ; Recurrence ; Removal of
Greater Part of Larynx; Recovery.

Shown by Sir Felix Semon. The patient, Mr. R. M., an Indian
barrister, was brought to me by Mr. Waggett on May 6 of the

Digitized by CjOOQle

present year on account of his laryngeal condition. He had had
syphilis twenty-five years ago, followed occasionally by secondary
symptoms. In 1902 he had an ulcer on the front part of the
right ventricular band, which yielded under the use of mercury
and iodide of potassium. Later on an ulcer appeared on the
opposite vocal process, which yielded to the same treatment.
Shortly after this a fresh ulcer appeared on the original spot on
the right ventricular band, and although resort was again had to
iodide of potassium in large and long-continued doses, and to mer¬
cury, gradual tumefaction of the ventricular band took place, with
correspondingly increasing hoarseness.

On May 6 there was very considerable tumefaction of the whole
right half of the larynx, with almost complete immobility. The
tumefaction involved the whole of the right ventricular band,
which was irregular, dusky red, rather mamillated, and the vocal
cord, of which only the front part could be seen, and on which
there was also a red irregular tumefaction. All this left practically
no doubt as to the disease being of the nature of a slowly growing
infiltrating epithelioma.

On May 16 I performed thyrotomy. The operation went off
without the slightest hitch, and the patient made an excellent
recovery. The microscopic examination made by *Mr. Shattock
confirmed the diagnosis of epithelioma. Mr. Shattock, however,
already then expressed a fear that recurrence would be likely to
take place on account of the great extent of the disease, and the
fact that the growth was apparently not far from the margin of the
wound. Unfortunately, his prediction came true, the growth
recurred rapidly, and on August 27 the patient, who had been at
St. Moritz, under the care of Dr. Yeraguth, returned to me.

Repeated slight haemorrhages from the throat having occurred,
Dr. Veraguth had made a laryngoscopic examination and had seen
a distinct tumour. It was button-shaped, smooth, but indentated,
the size of a bean, and situated in the middle of the scar, corres¬
ponding to where the border of the anterior and middle third of
the vocal cord had been. There vras no enlargement of glands
externally. I at once removed the greater part of the tumour
intra-laryngeally. The report of the microscopist was as follows :
“ The bulk of the specimen consists of granulations and fibro-cica-
tricial tissue. Within young lymphatic spaces in the latter are
seen aggregations of malignant epithelial cells.”

On August 30 a renewed and much more extensive operation
was undertaken. This consisted in reopening of the old wound (in
part rather difficult, as the landmarks were lost through cicatrisa-

Digitized by

Google

tion), insertion of Hahn’s tube and of sponges in the pharynx and
above the cannula, cocaine application, all as usual. On reopening
the larynx the front part of the left ala of thyroid and a little part
of the front part of the left vocal cord certainly looked rather
fishy. This portion was removed by oval-shaped resection of car¬
tilage, with its covering mucous membrane, and with the left vocal
cord. Not much of actual tumefaction seen in scar on right side,
but the right half of the thyroid cartilage was in parts cedematous,
in parts soft, easily breaking down, and discoloured. I thought that
very likely there was cancerous invasion of the cartilage. Nothing
wrong was detected outside the larynx; not a single enlarged
gland was to be seen. I removed the entire right wing of the
thyroid, and upper part of right side aspect of cricoid, until every¬
where glistening white cartilage was visible. Thus the only parts
left of the cartilaginous framework was the left ala of thyroid
cartilage and the greater part of the cricoid cartilage.

The patient recovered from this operation in the most pleasing
manner. The condition as noted on November 19th was as follows:

The patient looks as well as possible, has gained a good deal of
flesh since the last operation, breathes freely, though with a slight
stridulous noise, and speaks with an astonishingly loud voice. He
swallows with some care, because he has got a sensation of pressure
in the left side of his neck, due, no doubt, to cicatricial contraction
of the parts. On examination of the larynx it is astounding, in
view of the extent of the second operation, to see how little the
larynx is distorted in the laryngoscopic image. The epiglottis is
perfectly normal, and so is the mucous membrane over the ary¬
tenoid cartilages. The left half of the larynx, i.e. the ventricular
band, and the left arytenoid cartilage move freely towards the
middle line, and the left arytenoid cartilage completely joins the
right one, which is immovable. It is no doubt due to the free
action of the left ventricular band, which compensates for the left
vocal cord, that the astonishing loudness of the voice is produced.
In the interior of the larynx not the slightest trace of any recur¬
rence can be seen. Everything is covered either by normal mucous
membrane or by healthy-looking cicatricial tissue. There is no
enlarged gland anywhere in the neck. The external wound is
perfectly normal but somewhat tense.

It need not be said that there will still be anxiety as to further
recurrence, but the fact that the pieces of cartilage removed at the
last operation wer.e, on careful microscopic examination, found not
to have been invaded by the growth, and that the laryngeal con¬
dition, as well as that of the glands, is at the present time so

Digitized by LjOOQle

satisfactory, gives one reason to hope that the cure this time may
be lasting.

The President said he was sure members felt very much obliged to
Sir Felix Semon for bringing the case forward. It showed what could
be done, especially in the preservation of the voice. There did not seem
to be much room for criticism, only for congratulation.

Case of Hypertrophic Rhinitis with Sessile Outgrowth on the
Septum in a Male Patient aged Twenty-two, the Growth
of such a Size and Shape as at First Sight to Simulate the
Middle Turbinated Body.

Shown by Dr. Dundas Grant. A. W—, aged twenty-two, com¬
plained of stuffiness of the left nostril of three months* duration.
On the left side of the septum, at the level of the middle turbinated
body, is the outgrowth described, which simulates a middle tur¬
binated body adherent to the septum. A probe can, however, be
passed between the growth and the middle turbinated body. On
the right side there is also a hypertrophy in the same position, but
of much smaller size. There was no opacity on transillumination
and no tenderness in the region of either frontal sinus.

Dr. Pegler said that if the hypertrophy of the tubercle of the
septum were removed, the specimen would be almost precisely like the
one shown by Mr. Arthur Cheatle some years ago, of which a full-sized
plate appeared in the “ Proceedings.’'

Mr. Cresswell Baber thought such hypertrophies on the septum in
the region of the tubercle were not very uncommon. In the case of the
young woman there was a very anaemic mucous membrane, and the chief
feature seemed to be a deflected septum.

Case of Bony Tumour of the Nose.

Shown by Dr. Lambert Lack. The patient, a young girl, was
sent to me at the London Hospital by Dr. Keigwin. She was
suffering from complete nasal obstruction of some months* duration.
On examination a smooth mass was seen in the left nostril,
apparently continuous with the septum. It was covered with
mucous membrane, normal in colour. The septum was pushed
over so as to block completely the right nostril. On trans¬
illumination the left cheek was opaque. Under chloroform, a large
mass was found completely filling the left nostril, and projecting
posteriorly into the post-nasal space. The mass seemed to consist
of soft bone, and could easily be scraped away with a sharp spoon.
In this way the nose was cleared out. The tumour was apparently
growing from the ethmoid in the region of the middle turbinate.

Digitized by

Google

The septum was markedly deflected but otherwise intact. On
opening the antrum it was found to be filled with mucous contents.
Under the microscope the tumour is seen to consist of cellular
elements interspersed with bone.

So far as I know, the case is unique. It w r as certainly not an
ordinary osteoma, but might perhaps be an ossifying sarcoma.

The other point of interest is the condition of the antrum. I •
assume that the maxillary ostium was obstructed and that the
normal secretions accumulated; it was not empyema, but mucocele
of the antrum. I have found similar conditions of the antrum
before. This observation is interesting, as it is in direct opposition
to the views of Logan Turner, who, in a recently published paper
on the bony cysts or mucoceles of the nose, stated that in his
opinion mucocele of the antrum was unknown.

The patient was operated on in February, 1904, and there is so
far no sign of return of the growth, although the operation per¬
formed was obviously an incomplete one.

Dr. Pegler said the section seemed to be made up entirely of bone
and fibrous tissue. There was no evidence of malignant disease, but the
growth was very interesting.

Mr. Steward asked whether sections through other parts of the
growth showed anything further. The small piece shown looked rather
mysterious.

Dr. Lambert Lack, in reply, said the growth was uniform in structure
throughout. It was a solid mass without air-cells. The sections ex¬
hibited were from two different portions of the growth. The operation
was undertaken with a view to diagnosis; otherwise some better method
of removal might have been devised.

Case of Carcinoma of the Nose in a Man Aged Sixty.

Shown by Dr. Lambert Lack. The patient is at present under
my care in the London Hospital. For the past two months he has
been suffering from nasal obstruction on the left side with a con¬
siderable amount of purulent discharge and intermittent attacks
of rather severe neuralgic pain. When first seen the left nostril
was filled with what appeared to be ordinary mucous polypi
between which pus exuded. On transillumination the left cheek
was dark. The patient w’as admitted for the radical cure of the
polypi. Under a general anaesthetic the antrum was punctured from
the inferior meatus and thick curdy matter exuded. The ethmoidal
region was then thoroughly curetted. Extensive bone disease was
found and the orbital cavity was freely opened. The antrum was
opened both from the middle and inferior meatus. Whilst operat¬
ing it was noticed that the base of the polypi consisted of a tough
fleshy mass. This was scraped away with difficulty and prepared

Digitized by {jOOQie

for microscopic examination. Tlie sections show the ordinary
appearance of carcinoma of this region. A fortnight later a more
radical operation was undertaken. An incision was made all round
the inner wall of the orbit and the periosteum separated from the
remains of the orbital plate. Rouge's operation was then per¬
formed, and a large opening made into the antrum through the
anterior wall. The whole outer wall of the nose from the floor as
high up in the ethmoidal region as could be reached through the
orbital incision was cut away. The lining membrane of the antrum
was thickened and was completely scraped away. These two
incisions give free access to the outer wall of the nose and allow
every step of the operation to be seen without leaving any dis¬
figurement of the face.

Dr. Pegler regarded the section as one of epithelioma.

Dr. Herbert Tilley thought one should lay stress on the point
which Dr. Lack had remarked on in the diagnosis of the case, namely,
the associated pain. He believed that where a growth in the nose was
accompanied by a deep-seated boring pain, that symptom in itself was
sufficient to justify a serious view of the case. It was a sweeping asser¬
tion, but would be found to be true in a large number of malignant cases.
He remembered making a mistake in a case where there was a discharge
of pus from the antrum, which was also dark on transillumination, and
in which deep-seated lancinating pain existed. When he opened the
canine fossa, prepared to clear out the antrum, he found it was filled by
a malignant growth, which had otherwise not produced symptoms of
pressure.

Dr. Wyatt Wingrave said that squamous epitheliomata from the
nasal mucous membrane were of special interest, since they were not only
atypical of the normal epithelium covering the area from which they
grew, but they did not quite conform to the characters usually associated
with that class of growth. Dr. Lack’s specimen did not exhibit any solid
cylindrical masses or “nests”; he therefore classified it with the “diffuse”
or non-pearly variety, which in its deeper parts was strongly suggestive
of an endothelial origin. He had seen several similar specimens, one
forming part of a large polypus. He considered the specimen a squamous
epithelioma of the “diffuse ” or non-cylindrical type, originating in
modified surface epithelium.

Case of Tumour of Tonsil in Female aged Sixty-four.

Shown by Dr. Wyatt Wingrave. Mary W., aged sixty-four,
complains of enlarged tonsil and stoppage of nose of fourteen
months' duration. It commenced with cold and total deafness,
which continued till last July, when hearing returned, but right
tonsil rapidly enlarged, involving the corresponding nostril. The
swelling extends upwards into the naso-pharynx, downwards to the
glosso-epiglottic fossa, and inwards to middle line of soft palate.
Its surface is not ulcerated; it is firm to the touch and only slightly

Digitized by {jOOQie

tender. There are some enlarged glands at angle of mandible.
Both maxillary antra are somewhat symmetrically dull, the infra-
* ocular crescents being absent.

During the last six months she has lost much flesh ; now she has
some dyspnoea, excessive somnolence, great physical weakness, loss
of taste and smell, with hallucinations.

Married at fifty-eight. No specific history.

Treatment (16 days) : Pot. iodid. and Hyd. perchlor.

Case of Lymphosarcoma of Tonsil in which great benefit had

BEEN DERIVED FROM ARSENIC.

Shown by Dr. Herbert Tilley. A male patient aged nineteen,
in whom eighteen months ago some enlarged glands had been
removed on the right side of neck, and the scar along the anterior
border of the sterno-mastoid was still visible. When first seen by
Dr. Tilley in September, 1904, the patient had a very large, soft,
red, and superficially ulcerated right tonsil. It almost completely
blocked the fauces, so that the swallowing of liquid food was
becoming a difficulty, and breathing was difficult. There was a
large mass of glands on the right side of the neck which scarcely
stretched the afore-mentioned scar. The patient was put on rapidly
increasing doses of Liquor arsenicalis, until he was taking Nlxv three
times daily. He has recently gone back to tt\v thrice daily,
because the larger doses produced sickness and intestinal irrita¬
bility. The tonsillar swelling and the glands in the neck have
practically disappeared. Whether they will remain in abeyance is
doubtful, because the general history of these cases was that they
recurred, and then arsenic had no effect. The temporary effect of
the drug was, however, very extraordinary.

Dr. de Havilland Hall said the case looked like one of lympho¬
sarcoma, and in view of the success which had attended the employment
of arsenic in Dr. Tilley’s case, he would advise the administration of
large doses of that drug. In some cases of that nature arsenic had a
wonderful effect. In a case of his own the tonsil was cleared out entirely,
but, unfortunately, the patient afterwards developed diffuse lympho-
sarcomatosis, and died in a very miserable condition. He regretted to
say, also, that her misery during the last few months of life was much
accentuated by the arsenical neuritis from which she suffered, the pain
being most intense, and was not stopped by discontinuing the arsenic.
A curious point was that the arsenic in these cases seemed to have only
a limited power. In Dr. Tilley’s case he thought it was fortunate that
the glands had been removed before the arsenic was commenced, because
he (Dr. Hall) had seen, in some cases where there were large masses of
glands, arsenic have little effect; but if a mass of glands was removed,
the remaining ones would (dear up. So that it seemed as if the arsenic
had the power of clearing up a moderate amount of glandular enlarge-

Digitized by LjOOQle

ment only. Some years ago, at Westminster Hospital, lie had, with Mr.
Spencer, a case in which that surgeon removed many glands, and then
the remainder cleared up under arsenic.

The President thought Mr. Wingrave’s case looked like lympho¬
sarcoma, and asked whether a piece had been removed for examination.
He did not know whether it had been the experience of others that where
arsenic failed in such cases cacodylate of soda sometimes succeeded.
Cacodylate was supposed to be an inert substance, but he had in mind
one case in which a combination of cacodylate and iodoform produced a
wonderful effect. He knew two cases of lymphosarcoma which dis¬
appeared under arsenic, but in both cases the patients died within a few
months, of malignant disease in another part.

Dr. Lambert Lack said his view of Dr. Wingrave’s case differed from
that of the previous speakers. He did not consider the tonsil was
involved at all, but that the growth was in the post-nasal space and
pushed the soft palate and tonsil forward. Dr. Tilley’s case looked now
as if it would be possible to perform a radical operation, but perhaps it
would be better to continue with the arsenic, and operate, if need be,
later. The case rather suggested that it might be well to treat this
disease with arsenic before attempting to operate.

Mr. Robinson asked whether a digital examination of the naso¬
pharynx had been made in Dr. Wingrave’s case.

Dr. Wyatt Wingrave,ui reply, said he had not removed a fragment,
because there did not seem to be any portion sufficiently prominent. If
only a small paring were taken from the surface, possibly it would
only be a portion of tonsil, and therefore misleading. Lymphosarcoma
at the time of life of this patient was not so serious as in early life.
Digital examination afforded better evidence of its extensiveness than
vision. The growth apparently began in the tonsil, and extended
upwards, blocking the right choana, and also into the soft palate. It
seemed to extend almost beyond the middle line of the soft palate into
its substance.

Dr. Herbert Tilley, in reply, said his patient was doing so well
under, the arsenic that he felt inclined to continue with it until the limit
of improvement was reached before suggesting operation.

Case of Submucous Resection of Deflected Nasal Septum
(Killian's Method).

Shown by Dr. Herbert Tilley. Dr. Tilley showed a young
man aged nineteen, to whom this operation had been carried out
for the relief of almost complete obstruction of the right nasal
cavity. The operation took thirty minutes, but since he had done
more of them he thought that fifteen to twenty minutes would
give ample time. In this case he had been obliged to remove some
of the vomer and central plate of ethmoid because the obstruction
continued a long way posteriorly. The removal of the bony incisor
crest and the lower bony part of the obstruction was a most im¬
portant part of the operation.

Digitized by Google

Subacute Frontal Sinus Empyema following Scarlet Fever in

a Child.

Shown by Dr. Herbert Tilley. A lad, aged nine, had scarlet
fever during latter half of September. Three weeks after onset
he complained of headache and sickness, followed by swelling in
the region of the left frontal sinus and oedema of eyelid, which
quickly spread to the right lid and over the lower part of the fore¬
head. The appearance of an abscess over the forehead when seen
by exhibitor on November 4 was very similar to that of the caput
succedaneum of a new-born child. The ordinary radical operation
was carried out on the left frontal sinus, and it was found that the
anterior sinus wall had been perforated through its inner median
boundary. A free passage was made into the nose, and the sinus
was now practically well and obliterated by granulation tissue.
Dr. Tilley had never seen a case of the kind in so young a patient.

Case of Chronic Laryngitis in a Male aged Thirty-two.

Shown by Dr. Cathcart. For the last four years this patient
has been hoarse every winter for two or three months at a time.
This year the hoarseness did not come on till February. He came
to my clinic in May complaining of hoarseness and a constant
cough. On examination I found an enlarged Luschka's tonsil
secreting pus, large faucial tonsils with deep crypts and a very
long uvula. In the larynx there was thickening of the mucous
membrane of the ventricular bands, and also very slightly in the
interarytenoid space. There was likewise some subglottic thicken¬
ing, more especially on the right side. He was taken into hospital
and the uvula was snipped, the Luschka’s faucial tonsil removed.

After the operation the hoarseness got much less and the
patient ceased attending. In October he returned and said that
the fogs had made the hoarseness w’orse than it had ever been.
The laryngeal condition was also worse; besides an increase of
thickening there w’ere crusts in the larynx, although the nasal
condition still remained good after the operation.

I shall be very glad to receive any hints in the way of treat¬
ment, as I have tried everything, and nothing seems to do him the
slightest bit of good.

The President said the case looked to him excessively difficult to
diagnose ; but it was certainly more than chronic laryngitis. There was
loss of substance, and, he thought, the presence of some adventitious
substance. He would be sorry to say what form of infiltration was
present.

Digitized by LjOOQle

Dr. Dundas Grant thought the case was one of extreme pachy¬
dermia of the larynx, with a projection on one side fitting into a hollow
on the other. It seemed to approach the typical picture, though it was
rather an exaggerated one. He recommended that the silence-cure
should be tried for a time ; not that which people often tried—speaking
in a kind of husky voice—but speaking in a genuine whisper, or not
speaking at all. The effect of that was sometimes very remarkable.
This was quite apart from the question of the nose, which Dr. Cathcart
said was originally the seat of some suppuration, and which Dr. Grant
assumed was under treatment.

Mr. Atwood Thorne agreed that the case might be described as one
of pachydermia, and suggested spraying with formalin.

Dr. de Havilland Hall asked whether the case could be brought
again to a future meeting, as it was most interesting and important.

Dr. Cathcart, in reply, said a suggestion had been made that the
larynx should be sprayed with mucin, and he would like to hear from
any members who had tried it. He would bring the patient to the next
meeting.

Case of Lupus of Pharynx and Larynx.

Shown by Mr. H. W. Carson. Patient is a healtliy-looking
nursemaid, aged twenty-three, who has suffered from pain of a
burning character in the throat on swallowing for twelve months.
There is also some cough and hoarseness. Her elder brother died
of phthisis, and her father has had lupus of the face for twenty
years.

Present condition .—Many discrete nodules are present on the
uvula and posterior pillars of the fauces, particularly the left, the
uvula being much thickened and clubbed. There is no destruction
of tissue. The epiglottis is similarly affected, and its enlargement
prevents a clear view of the ventricular bands and cords, which
appear unaffected. There is no palpable enlargement of glands,
no lupus anywhere else in the body, no pulmonary affection, and
no tubercle bacilli have been discovered in the pharyngeal secre¬
tion. The case is shown as one of some interest, and particularly
to obtain the views of members of the Society on treatment and
for an expression of opinion on the possibility of transmissibility
as the patient is in charge of several young children.

The President said it seemed to be an interesting and typical case
of lupus, no doubt affecting the uvula and the epiglottis. His idea
would be to scrape and possibly remove the uvula and epiglottis with
Krause’s double curette, followed by the application of lactic acid.

Mr. Parker suggested that arsenic should be tried. It seemed to
act as well in lupus of the phaiynx as in lymphosarcoma of that region.

Dr. Lambert Lack recommended the internal administration of
arsenic in increasing doses. With a large experience of this affection he
had found that pharyngeal lupus almost invariably got well with arsenic,
and lupus in the larynx was cured in the great majority of cases. If

Digitized by {jOOQie

there were no tubercle bacilli in the sputum he should not consider the
disease dangerous from the point of view of contagion. Lupus of the
skin could rarely, if ever, be ascribed to direct infection.

Dr. Bennett said he had found more good result from multiple
puncture with the cautery than any other line of treatment for such
cases.

Dr. de Havilland Hall said Sir Felix Semon mentioned a case
many years ago which was cured after protracted treatment by multiple
puncture with the cautery.

Mr. Carson replied.

Case of Paralysis of Left Vocal Cord, caused by Localised
Tumour of the Thyroid Gland ? Malignant.

Shown by Mr. F. J. Steward. The patient, a woman aged
forty-six, stated that she had only noticed a swelling in her neck
for six weeks, and for about the same period her voice had been
altered. On examination of the larynx the left vocal cord was
seen to be completely paralysed. A localised tumour, about one
and a half inches in diameter, and oval in shape, is present in the
lower part of the left lobe of the thyroid gland. The tumour is
quite smooth, elastic in consistence, and is freely movable in all
directions.

Case of Hypertrophic Rhinitis involving both Inferior Tur¬
binated Bodies (recently Cauterised) and Fibro-Myxomatoid
Outgrowth on the Right Side opposite the Middle Turbinated
Body in a Female Patient aged twenty-two.

Shown by Dr. Dundas Grant. A probe can be passed between
the two structures; no bare cartilage can be felt on the septum.
There is a growth of papillomatous appearance on the middle of
the lower border of the left middle turbinal. The nasal stuffiness
has been perceived for between two and three years, but has got
worse of late.

Case of Ulcer of the Tongue in a Boy aged two and a half Years.

Shown by Dr. Dundas Grant. The patient was brought to the
hospital on account of a sore on the tongue of six months' dura¬
tion. On the middle of the dorsum of the tongue there is an
elongated shallow ulcer; the edges are irregular; it is slightly
increasing in size ; there is no pain. The father was the subject
of tuberculosis. Pending a bacteriological examination it was
thought probable that the ulcer might be tuberculous.

Mr. Robinson said his opinion was that it was a tuberculous ulcer.

Digitized by CjOOQle

A Case of Post-Pharyngeal Swelling, shown at the May Meeting.

Dr. Bennett reported that a section was made of a small piece
of the pharyngeal wall, but no evidence of tuberculosis was
detected. The patient was sent to the country for several weeks
and given iodide of mercury internally. The swelling gradually
diminished, and has now almost completely gone. There has been,
however, no reason to suspect any syphilitic process, and the
swelling was most probably a chronic inflammatory process.

Two Cases of Ethmoidal Necrosis.

Shown by Dr. W. Hill. Dr. Hill showed a brother and sister
suffering from ethmoidal necrosis due to hereditary syphilis.

Digitized by CjOOQle

Digitized by LjOOQLe

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Thirteenth Annual General Meeting, January 13, 1905.

Charters J. Symonds in the Chair in the absence of P. McBride,
‘M.D., F.R.C.P.Ed., President.

Present—The Honorary Officers and 33 members.

The minutes of the last Annual General Meeting were read and confirmed.

Dr. Donelan and Dr. Peters were appointed scrutineers of the ballot 1
and the following officers were appointed for the year:

President. —Charters J. Symonds, F.R.C.S.

Vice-Presidents —Wm. Milligan, M.D., F. Willcocks, M.D., J. B.
Ball, M.D., William Hill, M.D.

Hon. Treasurer —H. B. Robinson, F.R.C.S.

Hon. Librarian —StClair Thomson, M.D.

Hon. Secretaries —P. R. W. de Santi, F.R.C.S.; H. J. Davis, M.B.,
M.R.C.P.

Council —L. H. Pegler, M.D., J. Walker Downie, M.B., P. McBride,
M.D., W. R. H. Stewart, F.R.C.S.Ed., Felix Semon, C.V.O., M.D.,
E. Furniss Potter, M.D.

The Report of the Council was then read and unanimously
adopted:

Report of Council for Year Ending January 13th, 1905.

The Council have much pleasure in announcing that the past year has
been one of continued success. The supply of clinical material has been
abundant, and the meetings have been well attended, the average number
of those present being thirty-three.

During the year thirteen Ordinary members have been elected, and
two have resigned.

The Council record with regret the loss of one member by death—
Dr. J. Scatlrffe.

The Council look forward to celebrating the centenary of Senor
Manuel Garcia, the Society’s oldest honorary member, in March next,
and it is hoped that every member of the Society will co-operate with the
Council by doing all in his power to make the occasion a distinct success.
In March last a committee was formed, consisting of the office-bearers
and ex-Presidents of the Society, to organise the centenary celebration.

SECOND SCRIMS-—VOLv JJh 3

Digitized by LjOOQle

This Committee decided ;

1st.—To present Senor Garcia with his portrait, to be painted by Mr.
John Sargent, R.A.

2nd.—That addresses should be presented by laryngological societies
and musical bodies.

3rd.—To hold a festival dinner in honour of the event.

4th.—To hold a special meeting of the Society on March 17th—the
day of the centenary—instead of the ordinary meeting fixed for the 3rd
of the month.

The distinguished artist has completed the portrait, which is an ex¬
cellent likeness, and a masterpiece worthy to be ranked as one of the
finest examples of work emanating from Mr. Sargent’s brush.

The Librarian’s Report was then read and adopted :

The Honorary Lirarian’s Report.

It will be remembered that our books are now housed on the shelves of
the Royal Medical and Chirurgical Society’s library, in return for their
being made accessible to the Fellows of that Society.

During the past year this arrangement has continued to work quite
satisfactorily. The librarian of the latter Society reports that our books
have been fairly used by our own members, and by the Royal Medical and
Chirurgical Fellows, and have been found most useful.

We possess a complete card index, and any of our books can be taken
out by members applying to the librarian any day during the hours of
11 a.m. to 6.30 p.m.

Several of our exchanges have ceased to reach us—in spite of repeated
requests for a continuance, and of the fact that our own Proceedings
have been sent regularly. The delivery of the latter has been discon¬
tinued, and our exchange list, therefore, is now limited to the following:
The Laryngoscope , American Laryngological Association, Archiv. fur
Laryngologies Monatsschrift fur OhrenheilJcunde, Annales des Maladies de
V Oreille, Revue de Laryngologies Archives Internationales de Laryngologies
Archivii Italiani di Laryngology Archivio Italiano di Otologia , and
Bolletino delle Malattie del Orecchio t etc. Our thanks are due to Sir Felix
Semon for presenting the bound volume of the Centralblatt fur Laryngo-
logie for the year 1904, and to the editors fora similar gift of the Journal
op Laryngology.

At the beginning of the year we had forty-five names of colleges and
institutions on our Free List. The Council decided that thirty of these
should be discontinued, and a free copy of our Proceedings is now sent
only to the following: The British Museum, the Royal College of Physi¬
cians, the Royal College of Surgeons, British Medical Association, Royal
Medical and Chirurgical Society.

The omitted institutions and colleges were invited to subscribe for
our Proceedings at the moderate price of 4 s. per volume, but only one
body (the Birmingham Medical Institute) has taken up a subscription.
One member has bought a complete set of the eleven volumes of Pro -
ceeding8 y and several odd back numbers have been sold, and in this way
I have received £3 4 s. 4d.

By reducing our Free List we have been able to reduce the number of
our monthly edition from 250 to 200 copies. Of these about 150 go to
members, 10 to exchanges, 5 free, and 35 go to our stock of back numbers.
Five back numbers were out of stock, and during the year these have
been reprinted, so that we are now able to supply single back numbers

Digitized by

Google

or complete sets of Proceedings. The Council have decided that the
price be 6d. per copy for members, and Is. per copy for non-members.
These back numbers are now stored by Messrs. Adlard in a half-berth,
which we rent at 10s. per annum. This includes the return of an annual
stock-taking. We possess seven bound copies of Yol. I, and two bound
copies of Yols. I and II (together), and these we should be glad to sell.
We have also cases for binding at the cost price of 6d. each.

A complete bound set of our eleven volumes has been added to the
library. It will be valuable for reference, and can readily be consulted
at our meetings.

I regret to say that the library has not been enriched this year by
any gifts of books, though several reprints have been sent us.

It will be noticed that the Proceedings are now issued in a different
size and type. It is hoped that the arrangement by which this has been
effected, together with a large reduction of our Free List, and the curtail¬
ment of our monthly edition to 200 instead of 250 copies, will all bring
about considerable diminution in the expenses of the Society. It would
be a help if members possessing duplicate copies of back numbers would
kindly present them to our reserve stock, as certain editions are getting
rather low.

The following Report of the Treasurer was read and adopted :

The receipts this year have been £160 12s. 9 d. This, with £18 10s. 6d.,
the balance brought forward from 1903, and <£50 transferred from the
Deposit Account, gives a total of £229 3s. 3d. The expenses have been
£203 12s. 4 hd., thus leaving a balance of £25 10s. 10|d.

The sum of £158 11s. was received in subscriptions and entrance
fees. Of this amount £13 13s. are entrance fees and £3 3s. for 1905.
All subscriptions have been paid with the exception of those of two
gentlemen who live in South Africa.

BALANCE SHEET, 1904.

Income. i

Subscriptions, 1904 . . . .

141

„ 1905 ....

Entrance Fees.

Interest on Deposit....

Balance, 1903 .

Brought forward from Deposit

Account.

£229 3 3

Deposit at Bankers—£150.

Expenditure.

Adlard—Printing . . .

. 109

s .

Garcia Testimonial . .

. 25

Rent . ..

. 31

Reporting.

. 13

Annual Dinner ....

A. Clarke—Indexing . .

Baker—Microscopes . .

Christmas Boxes . . .

Pathological Committee

. 0

Hodgkinson, Preston and King 0

Pulman—Binding . . .

Electric lamps ....

Arthur—Tongue-cloths .

. 0

Mathew (Porter) . . .

Bank commission . . .

Librarian.

Secretaries' Petty Cash .

Treasurer „ „

Balance.

. 25

10 101

£229

Examined and found correct,

H. FITZGERALD POWELL,
W. H. KELSON,

Auditors.

January 9, 1905.

W. R. H. STEWART, Hon, Treasurer.

Digitized by {jOOQie

The Report of the Curator of the Morbid Growths Collection was
then read and adopted:

In presenting my annual statement, I have first to thank those gentle¬
men who have generously contributed to the Society’s collection since
. the last general meeting. We now possess in the cabinet a fairly repre¬
sentative proportion of our histological exhibits and a very valuable
series of specimens. The additions include some sections illustrative of
various records of past proceedings, and amongst recent exhibits of last
year’s date are some exquisite specimens of bleeding polypus of the
septum; endothelioma of the soft palate, antrum, and larynx; angio¬
fibroma of the naso-pharynx; actinomycosis of the tonsil; papilliferous
columnar-celled carcinoma of the nose, etc. Sir Felix Semon has allowed
his collection of epithelioma of the larynx, eighteen very beautiful
examples, to be catalogued. They are all operation cases, some of which
are referred to in the pages of our 44 Transactions.” The following is the
list, chronologically arranged, with the names of the contributors. Some
further additions have been promised. For the convenience of members
a copy of the complete catalogue is about to be placed in the Society’s
library.

* I. Nose and Accessory Cavities.

1. Sarcoma (small round-cell) of the Septum, November, 1896, vol. iv, p. 4, Dr.

J. W. Bond.

2. Papilloma of the Septum (cauliflower growth, 6-1 inches in circumference),

November, 1896, vol. iv, p. 21, Mr. Logan Turner.

3. Section of Middle Turbinal from a Case of Early Polypus, February 5th, 1904,

vol. xi, p. 107, Dr. Eugene Yonge.

4. Endothelioma of Maxillary Antrum, February, 1904, vol. xi, p. Ill, Dr.

Lambert Lack.

5. Angioma of Left Maxillary Antrum, May 6th, 1904, vol. xi, p. 164, Dr. Bronner.

6. New Growth from Chronic Antral and Ethmoidal Disease, May, 1904, vol. xi,

p. 165, Dr. Scanes Spicer.

7. Bleeding Polypus of the Septum, May, 1904, vol. xi, p. 165, Dr. Scanes Spicer.

8. Cystic Polypus from the Middle Meatus, June, 1904, vol. xi, p. 184, Dr.

McBride.

9. Papilliferous Columnar-Celled Carcinoma, June, 1904, vol. xi, p. 188, Sir Felix

Semon.

10. Primary Tubercular Growth of Septum, vol. xi, p. 184, Dr. Smurthwaite.

II. Naso-pharynx.

1. Angio-fibroma of Naso-pharynx, Nasal and Accessory Cavities, November 7th,
1902, vol. x, p. 19, Dr. Herbert Tilley.

III. Pharynx , Soft Palate, etc.

1. Section from Case of Rapid Ulceration of Nose and Face, December, 1896, vol*

iv, p. 18, Dr. McBride.

2. Lympho-Sarcoma of the Tonsil, April, 1899, vol. vi, p. 80, Dr. Lambert Lack.

3. Epithelioma of Soft Palate, May, 1904, vol. xi, p. 167, Dr. Scanes Spicer.

4. Tumour of the Soft Palate (Endothelial), June, 1904, vol. xi, pp. 172, 185, Dr.

James Donelan.

5. Actinomycosis of the Tonsil, November, 1904, vol. xii, p. 5, Mr. Arthur

Cheatle.

IV. Larynx.

1. Endothelioma of the Larynx in a Case of Syphilis, February 5th, 1904, vol. xi,

p. 110, Dr. Lambert Lack. *

2. Fibromatous (? Sarcomatous) New Growth of Right Aryepiglottic Fold,

November, 1904, vol. xii, p. 10, Dr. Dundas Grant.

3 to 19 (inclusive): Eighteen Characteristic Examples of Squamous Epithe¬
lioma, particulars of which will be found in the Catalogue, Sir Felix Semon.

Digitized by {jOOQie

Supplementary Catalogue.

1. Fibroma of the Nasal Septum, Dr. Dun das Grant.

2. Cartilaginous Tumour of Left Ventricular Band, Dr. Lambert Lack.

The following gentlemen constitute the Morbid Growths Com¬
mittee :

Mr. Walter Spencer (Chairman).

Dr. Wyatt Wingrave.

Dr. Lambert Lack.

Mr. Ernest Waggett (Hon. Sec.).

Dr. Pegler—Curator of Morbid Growths Collection.

It was proposed by Sir Felix Semon, and seconded by Dr. de
Havilland Hall, that :

“ The Laryngological Society of London re-affirms its resolution of
February, 1900, viz. that at all International Medical Congresses a full and
separate section should be formed for Laryngology and Otology, and that
Laryngology should not on these occasions be combined with Otology. It
views with deep regret the fact that, in spite of the wishes of both Laryn¬
gologists and Otologists having been clearly expressed at the International
Medical Congress of Paris in 1900, attempts have been made at Madrid
in 1903, and are now again renewed on the occasion of the forthcoming
International Medical Congress at Lisbon, to assign to Laryngology a
position inferior to that of other recognised specialities, and to combine it
with Otology in one sub-section.

“The Laryngological Society of London, in its corporate capacity,
declines to assent to any arrangement derogatory to the dignity of Laryn¬
gology and to the position held by it at all International Medical Con¬
gresses ever since 1881.”

This was carried unanimously.

The meeting then adjourned.

Ninety-Fourth Ordinary Meeting, January 13 th, 1905.
Charters J. Symonds, President, in the Chair.

P. R. W. de Santi, F.R.C.S.,

Henry J. Davis, M.B., M.R.C.P.,

> Secretaries.

Present—33 members, 5 visitors.

The minutes of the preceding meeting were read and confirmed.

W. Stuart Low, F.R.C.S., 45, Welbeck Street, W., was nomi¬
nated for election as an ordinary member at the next meeting.

The ballot was taken for the election of the following candidates,
who were elected as members of the Society :

G. A. Garry Simpson, M.R.C.S., L.S.A., East Acton.

Joseph William Leech, M.D., F.R.C.S.Ed., Newcastle-on-Tyne.

The Hon. Secretary (Mr. de Santi) read the following Report
of the Morbid Growths Committee :

3§

Digitized by {jOOQie

Report of Specimens.

1. Dr. Donelan’s Case of Malignant Disease under Schmidt’s Serum
Treatment. A section of epithelioma.

2. Mr. Hunter Tod’s Case of Tumour of the Nasal Septum. A sec¬
tion of vascular fibroma.

3. Mr. Waggett’s Case of Primary Tuberculoma of the Septum. A
section of tuberculous tissue.

4. Tumour of Larynx, Dr. Dundas Grant (Proceedings, November, 1904).
The histological appearances make a diagnosis between sarcoma and young
fibroma tissue impossible.

5. Tumour of Palate, Dr. Donelan ( Proceedings, May and June, 1904).
We believe this tumour to be an endothelioma. It is based upon the
growth of the endothelial cells, which are large in size, polygonal in shape,
and which contain an oval nucleus. In some places these cells are grouped
in uniform masses, in others they are tending to form fibrous tissue, while
elsewhere they are producing a homogeneous material, scattered through
which are vacuoles containing nuclei and which thus acquire the false
appearance of cartilage.

6. Nasal Cyst, Dr. McBride (June, 1904, p. 184). The histological
appearances give no clue to the origin of the cysts, that portion of the
wall which was examined being composed of cedematous fibrous tissue
containing some glands.

Report of Morbid Growths’ Committee.

1. Dr. Donelan’s Case of Malignant Disease of Larynx Undergoing
Schmidt’s Serum Treatment (Proceedings, December, 1903). The section
was one of epithelioma.

2. Mr Waggett’s Primary Tuberculosis of Septum Nasi. The section
was one of tuberculous tissue.

3. Dr. Scanes Spicer’s Bleeding Polypus of the Septum ( Proceedings,
May, 1904). The section was that of a fibro-angioma.

4. Dr. Scanes Spicer’s Tumour of the Antrum (Proceedings, May,
1904). The slide contained sections of two distinct structures. One of
these was blood-clot containing a number of mononucleated leucocytes.
The other had the usual characters of polypoid tissue found in cases
of chronic antral suppuration, gland tissue being present in parts. In
some of the fragment portions of polypi tissue ( ? necrotic) were seen
embedded in the blood-clot. There was no evidence of sarcoma or endo¬
thelioma.

The following cases, specimens, and instruments were then
shown:

During the discussion on the cases, in the absence of the
President, the chair was taken by Sir Felix Semon.

Epithelioma of Larynx : Laryngo-Fisstjre : No Recurrence after

Six Months.

Shown by Dr. StClair Thomson. Man, aged forty-nine, shown to
the Society on December 4th, 1903 {vide Proceedings , vol. xi, p. 68).
The previous history of this case, the history of the development

Digitized by {jOOQie

of the laryngeal neoplasm, and the progress of the convalescence
after operation, all present points of considerable interest.

In the year 1893 this man was treated with Koch's tuberculin in
the Victoria Park Chest Hospital by Dr. Heron. Dr. Clifford Beale
(vide Proceedings , vol. xi, December 1903) says that there was a good
deal of tuberculosis in his system at that time, there was a remark¬
able reaction, and the patient was exceedingly ill for a long time.
The result is eminently satisfactory, as for eleven years he has
carried on the unhygienic occupation of a baker, and at present
he shows no traces of tubercle beyond slight dulness over the left
front upper chest.

When shown to the Society in December of last year he had
been hoarse for fifteen months, and presented an infiltrating growth
of the anterior two thirds of the left cord. The surface of the growth
projected into the glottis and was dimpled in a peculiar way.
Members may recollect that the case was thought to resemble closely
one shown by Sir Felix Semon at the same meeting, and the general'
vieww as thatb oth of_ them were either tubercular or simply in¬
flammatory. But whereas in $ir Felix’s case—in which, however,
the surface was distinctly ulcerated—the condition spontaneously
disappeared {vide Proceedings , xi, pp. 51 and 187), in mine it slowly
became more marked. It was not, however, until July last—seven
months after we saw the patient here, nine months after I had first
examined the case, and nearly two years from the onset of hoarse¬
ness—that I was able to decide that the growth was malignant.
This opinion was founded on the steady though slow increase of the
growth, and the onset of mobility of the cord—evidently due to
infiltration and not to mere mechanical obstruction. The only sus¬
picion of an enlarged gland was below the right jaw— i.e . on the
opposite side.

Thyrotomy was performed on July 16th, 1904, in the presence
of Dr. Newcomb, of New York. I employed Mr. Waggett's thyroid
shears for the first time, and found them most satisfactory. The •
growth was seen by direct inspection to be very much like its reflec¬
tion in the laryngeal mirror. The dimple on it was found to be a
retracted depression and not an ulceration. The growth was
clipped off, the whole cord and a good margin being included. The
sketch that I hand round was made at once by a skilled artist. As
the piece removed appeared infiltrated up to its margin, a second
portion was clipped away, exposing the white inner surface of the
thyroid cartilage.

Unfortunately, there was some trouble with the Hahn's tube and

Digitized by {jOOQie

some blood was inspired during the operation. Consequently, the
patient developed a double pneumdnia and a temperature of
102°, respirations 40, and pulse 120. But I kept him sitting up in
bed between two widely open windows, and he made a good
recovery.

I would like to invite opinions as to the situation of the new,
cicatricial, cord. I have never tried to produce exact coaptation
of the two halves of the thyroid, but have contented myself with
letting them fall together and stitching over them the reflected
perichondrium. This is the first time I have noticed that the
cicatricial cord has not been quite vis-a-vis the healthy one.

When the larynx was inspected a fortnight after the operation
the arytenoid on the diseased side was quite mobile. As the new,
cicatricial, cord formed it became fixed. Could this have been
avoided, say, by allowing the patient to speak more ?

I propose showing the patient again, when his year of probation
is completed.

Tracheotomy for Laryngeal Stenosis. Marked Improvement.

Diagnosis: Tuberculosis, Lupus, or Congenital Syphilis?

Boy aged Fourteen.

Shown by Dr. St.Clair Thomson. This boy came under
notice in November, 1904. He reported that his adenoids had
been removed at St. Thomas’s Hospital seventeen months pre¬
viously, that three months afterwards he caught cold on his
chest and his throat became sore, and had remained so ever
since. Three months before coming under observation he had
lost his voic£, and for the last month his breathing had been
obstructed.

On admission there was long inspiratory and expiratory stridor,
no cyanosis. The epiglottis, ventricular bands, vocal cords, and
laryngeal surface of the aryepiglottic folds were infiltrated with
indolent nodules, ulcerated and catarrhal, just like a case of
chronic tubercular laryngitis. But the ulcerated vocal cords were
absolutely fixed in the middle line, leaving only a narrow slit for
respiration. The pillars of the fauces and both tonsillar fossae
were infiltrated with the pale, indolent nodules still visible. One
of these was microscoped, but showed only granulomatous inflam¬
matory tissue, without indication of syphilis or tubercle.

There were crepitations over the upper lobe, with slight dul-

Digitized by LjOOQle

ness; but the temperature was normal, the pulse 74, and there
were no tubercle bacilli in the abundant tenacious sputum.

He was watched for five nights, but with everything at hand
for tracheotomy. The stenosis was constant, and after coughing
he had attacks of dyspnoea, with cyanosis and retraction.

Tracheotomy was performed on November 10th, 1904, and in
three weeks the boy put on eleven pounds in weight. All chest
symptoms disappeared. As soon as a view of the larynx was ob¬
tained the cords were seen to be moving, and gradually the glottis
became fully open. It w^l be seen that the posterior two thirds of
the cords have entirely ulcerated away, showing a clear view of
the subglottic space. Much of the nodular infiltration has broken
down, and healing appears to be taking place. The boy can talk
easily with a hoarse voice, and breathes freely through the larynx,
but in view of the marked improvement the tracheotomy tube is
still worn. The fauces are in statu quo. Neither mercury, iodide,
or arsenic have been given. I am inclined to view the condition
as one of lupus, but the fixation of the cords is unusual and difficult
to explain.

A Case of Swelling in the Left Arytenoid Region in a Woman

AGED THIRTY-FIVE.

Shown by Mr. de Santi. The patient complains of pain in
swallowing, localised to the left side: this she has suffered from
for about three months.

On examination, some anaemia of the pharynx is noticeable.
Occupying the left arytenoid region is a large oedematous inflam¬
matory swelling reaching forwards along the aryepiglottic fold,
and downwards towards the cricoid cartilage. The whole swell¬
ing is covered with frothy muco-pus. The rest of the larynx is
normal.

The appearance of the disease is such as to point strongly to
tubercular mischief, but repeated examinations of the muco-pus,
sputa, and lungs for tubercle bacilli have been quite negative.
The patient, moreover, has no temperature, cough, or night-
sweats. There is no history or evidence of syphilis, Patient
has been treated with carbonate of guaiacol, but so far with no
good results.

There seems a considerable element of doubt about the case;
the trouble may be of a malignant nature (there are one or two

Digitized by LjOC e

enlarged glands in the left side of the neck), although it is un¬
common in women, and the age of the patient is only thirty-five.
The case is brought forward to elicit opinions as to diagnosis.

Dr. Watson Williams suggested that it was a ease of perichondritis
of the cricoid, though, of course, that was only a general statement. He
asked whether Mr. de Santi could exclude that.

Mr. W. G-. Spencer suggested the performance of thyrotomy with
the object of scraping probably a tuberculoma or possibly a chronic
abscess in connection with the cartilage.

Dr. FitzG-erald Powell thought this case ought to be dealt with
very carefully. He was of opinion that it was most probably of a malig¬
nant nature, possibly sarcoma. He would advise removing a portion
of the growth for microscopic examination to determine definitely its
character.

Dr. Smurthwaite suggested that a thorough examination of the
lungs should be made to see if there was any marked condition indicating
phthisis. If so, one would suppose the lesion in the larynx was tuber¬
cular. /

Mr. de Santi said the lungs were free, but there might be a very
small focus of inflammation in the lungs, centrally situated, making it
difficult of detection, of which the local laryngeal signs were the first
indication. He had seen cases of tubercular lesions in the larynx in
which at the time no objective tubercular lung signs were present, though
three or four months later well-marked and rapid disease in the lungs
developed, the laryngeal mischief, though in all probability of secondary
origin, being the first danger signal. Certainly, in this case, the left
crico-arytenoid joint was very much infiltrated, the infiltration extending
well down on to the cricoid ; in addition, the false cord showed signs of
implication. Again, the patient was flushed and seemed to be a phthi¬
sical subject.

Dr. St.Clair Thomson thought the diagnosis rested between tuber¬
culosis and malignant growth. It was possibly malignant, and he
suggested that examination with the finger would be a. help. If there
were any confirmatory signs of tuberculosis, he could not see what would
be gained by thyrotomy; it would only hasten the woman to an early
grave. It would be impossible to excise the tuberculous condition in the
larynx. The records of thyrotomy for tuberculous larynx with cures
were so few and far between, even in quite limited disease, that it did
not seem wise. In the present case the cartilage was distinctly involved,
and the crico-arytenoid joint fixed. If it proved to be malignant, he
would leave others to say whether any radical operation would be
possible; but he thought it was doubtful.

Sir Felix Semon (in the Chair) said that in his own mind the dia¬
gnosis in the case rested between tubercle and malignant disease. The mere
expression “ perichondritis ” did not convey much, and primary peri¬
chondritis was nowadays hardly believed in, other than traumatic.
Neither could he see that thyrotomy would be of any considerable service.
Surely the disease was not inside the larynx, but on the posterior surface
of the cricoid cartilage, so that thyrotomy would not be of much help.
The best suggestion seemed to be that digital examination should be made,
and that a small piece should be removed for microscopical investigation.
If the disease were tubercular, one might do good by scraping it from

Digitized by LjOOQle

within. His personal experience of thyrotomy in tubercular disease had
been uncommonly good, but it was limited to two cases, both of whom
ultimately recovered. In both, however, the wound became infected, and
a second and more extensive operation became necessary before a cure
was obtained. If the disease should prove to be malignant, he feared the
prospect would be very grave, and did not think that anything short of
total extirpation of the larynx, with removal of the lymphatics on the
corresponding side, would be of any use.

Mr. de Santi, in reply, expressed his intention of removing a piece of
the swelling and having it microscoped, so as to determine, if possible,
the nature of the disease. He had thought all along that it was tuber¬
cular, and he agreed with Dr. Smurthwaite that in some of these cases the
symptoms were masked and slight in the lungs. The lungs of the patient
had been carefully examined, and the sputum had been on two separate
occasions examined for tubercle bacilli; it was because the result was
negative that he brought the case forward. Whether it was malignant or
not could be ascertained partly by examining with the finger, and more
decidedly by extirpating a piece for microscopical investigation. He re¬
garded the case as of sufficient interest to justify a subsequent later report;
the sequelae of many cases shown were their chief interest.

Case of Tracheal Obstruction of Uncertain Origin and Nature.

Shown by Dr. Herbert Tilley. The patient was a young man,
aged twenty-eight, of exceptionally fine physique. His general
health had always been good, but there was considerable probability
of his having had syphilis some six years ago. He applied to hospital
on account of increasing difficulty in breathing and incessant
cough, which was peculiarly trying at night. Examination of the
larynx and trachea showed that about the level of the fifth ring
there was what appeared to be a diaphragm of a reddish colour,
the opening in which was eccentric and more towards the right
side; it would possibly admit an ordinary lead pencil.

Ordinary exertion caused the patient much distress, hence he
was admitted to hospital and rested in bed, while the house-surgeon
was prepared to insert a Konig's tracheotomy tube at a moment's
notice. Mercury inunctions were applied daily. The breathing
became less stridulous, and the obstruction in the trachea, which
was at first so easily visible, seemed to recede, so that now it could
only be seen with difficulty, and, apparently, almost as low as the
bifurcation. The general improvement under mercury seemed to
point to a syphilitic origin, but it was quite unlike the usual effects
of tertiary syphilis on the trachea.

Mr. C. A. Parker said he had had the opportunity of seeing the case
before, and one day examined it very carefully. He noticed some promin¬
ence of the left stemo-clavicular joint, with a little redness and oedema
over it. The man’s breath at that time was very offensive, and he thought

Digitized by

Google

that probably there were some suppurating bronchial glands causing
stenosis.

Dr. Scanes Spicer said he could not distinguish anything abnormal
in the trachea. The cords were reddened and a little bowed, and he did
not think they approximated perfectly on phonation. At one time the
patient’s inspiration was stridulous, at another free. As two or three
members had seen something abnormal in the trachea that, day, tracheal
polypus, pedunculated and movable, was a possible hypothesis, though he
himself had failed to make out anything positively in an examination which
was only cursory and with indifferent illumination.

Mr. Cresswell Baber asked whether there was any enlargement of
the thyroid in the case, causing pressure on the trachea.

Dr. H. FitzGerald Powell thought, from Dr. Tilley’s description
of the case, that it was very much like a syphilitic gumma, which had
become absorbed on account of the anti-syphilitic remedies which the
man had been taking. The diaphragm previously noticed by Dr. Tilley
was not now to be seen. Possibly it was a general swelling, extending
from above downwards, and as it was now said to be seen further down,
it might be due to the upper part having cleared up.

Dr. Edward Law said he believed the condition to be syphilitic. Both
the appearance of the swelling—which was on the left side, and more
prominent in front than behind—and the fact that there had been a
diminution after specific treatment, were in favour of that view.

Sir Felix Semon suggested that it would be well to continue the use
of iodide of potassium. If further improvement resulted under its admin¬
istration the syphilitic nature of the entire disease would be clear. If it
remained stationary or got worse, he thought Killian’s tracheoscopy would
be an excellent course to adopt.

Dr. Herbert Tilley, in reply to Mr. Baber, said there had been no
enlargement of the thyroid. He failed to grasp Dr. Spicer’s line of thought
in the matter, viz. that it might be a papilloma, because that would not
explain the marked shifting in the position of the swelling. To-day it
was difficult for even experts to see the obstruction at all. Dr. Law saw
it, but it seemed to be only possible to do so when the patient leaned
slightly forwards and sat up very straight. It had vastly improved under
anti-syphilitic treatment. He could not explain the curious cedematous
swelling over the left stemo-clavicular joint, with associated redness, which
Mr. Parker noted the first day the patient came to the hospital. A few
days after his admission there seemed to be some oedema over the right
sterno-clavicular joint also. The temperature was 101° on the first night
he was in hospital, 100° the next day, after which it became normal, and
had remained so ten days. Since he came in’with a bad cold, this slight
pyrexia did not seem to throw much light on the case.

Pharyngeal and Laryngeal Nystagmus in a Case of (?) Tumour

of the Pons.

Shown by Sir Felix Semon. The patient, C. C—, aged twenty-
seven, is at present an inmate of the National Hospital for Epilepsy
ahd Paralysis, Queen Square, under the care of my colleague, Dr.
Ormerod, to whom I am much obliged for permission to show him

Digitized by

Google

here, whilst I am equally indebted to our senior house-physiciail^
Dr. Gordon Holmes, for the following notes about the patients
general condition.

The patient was admitted on August 5,1904, with the following
history: He had a blow on the right side of bis head eight years
ago, and denies that he has ever had syphilis. His present disease
began suddenly two years ago, when he found his eyes turned and
his mouth pulled over to the left. Four hours later he began to
feel giddy, and his left hand felt numb. For the next ten days he
walked reeling to the left. From this attack he recovered, but
during the next few weeks had frequent diplopia. Seventeen
weeks later on he lost power in the right side of his face, and the
diplopia returned. He recovered again, after a few weeks, and
.again relapsed, losing all power on the right side of the face.
Subsequently he had two more relapses, accompanied by diplopia.
Ten weeks before admission there was weakness in the left arm
and left leg, and, for the first time, a change in the voice was
noted.

On December 8, 1904, Sir Felix Semon described the condition
of the pharynx and larynx as follows : “ Distinct irregular spasm
of soft palate and uvula in a vertical direction, uvula being ener¬
getically drawn upward about twenty-five times in ten seconds.
The spasm is, however, not absolutely rhythmical, a few quick
contractions following a series of slower ones. At the same time
mucous membrane of the posterior wall of the pharynx is moved
in a somewhat obliq'u^ direction from left and below to right and
above. These movements are synchronous to those of the uvula.
The tongue and mucoufc membrane of the cheek do not participate
in the spasm, neither whin at rest nor when the tongue is protruded,
nor are there any fibrillary twitchings of the tongue.

The larynx is, with exception of the epiglottis, affected by a
clonic spasm similar to the pharyngeal one, and perfectly synchro¬
nous with the latter. This can be well seen if one allows the tip of
the uvula to appear in the lower part of the laryngoscopic mirror.
The vocal cords and arytenoid cartilages are constantly carrying
out, quite independently of respiration, a series of adduction move¬
ments, which do not go to the extreme of complete adduction and
closure of the glottis, but are pendulous between the position of
ordinary respiration and that of the cadaveric position.”

December 12, 1904. Patient has again developed complete
paralysis of the third nerve.

Remarks .—Whilst the ultimate cause of pharyngeal and

Digitized by

Google

laryngeal nystagmus is as yet unexplained* it is remarkable that
this rare symptom has been comparatively often observed in
tumours of either the pons or the cerebellum. In the present
case* at one time, nystagmus of the diaphragm was believed to be
associated with the pharyngeal and laryngeal movements, but I
have not been able to satisfy myself as to its existence.

Dr. Bronner expressed the hope that when Sir Felix Semon published
the case it would include some description of the patient’s eye symptoms,
such as exact condition of eye-muscles, of the optic nerves fields of vision.

Dr. Pegler remarked upon the difficulty of drawing a line of demar¬
cation between severe cases of pharyngeal and laryngeal nystagmus in
which a tumour of the pons or cerebellum was suspected and the milder
cases in which no such focal centre of irritation was thought of. In the
latter cases possibly local sources of reflex irritation had been removed
without benefit. In Dr. Bond’s case (a male, vol. iii, p. 41) and Dr.
Lack’s (No. 38) the spasm was mild in degree and confined to the pharynx.
In Sir Felix Semon’s former case (vol. viii, p. 49) and his own two (vol. x,
pp. 105,106) the movements were more extensive and involved the larynx.
These three cases, therefore, shared more of the character of Mr. Steward’s
(vol. x, p. 84) and the present, in which tumour of the cerebellum and pons
were provisionally diagnosed respectively, and one was led to think that in
these mild or “ functional ” cases some undiscovered central lesion might
exist. He had reason to know that his own two cases—accompanied by
entotic tinnitus—remained as they were when exhibited for him in 1903.
The references to the Society’s previous cases were given to assist those
who might be interested in obtaining fuller details of them.

Dr. Herbert Tilley asked whether Dr. Pegler could refer the Society
to any account which recorded such cases as of functional origin. He
did not remember any, nor did the text-books describe the condition as
functional. He showed a ease before the Society about seven years ago,
in which a man had twitching of the pharyngeal wall, exactly similar to
that seen in the present case. He heard that that patient died about two
years ago of general paralysis. When shown before the Society he had
irregular pupils, but otherwise was in perfect health. Later on, his
speech became blurred, and other symptoms of general paralysis rapidly
supervened.

Mr. W. G-. Spencer thought the patient was already getting paralysis
of his vagus centre; his pulse was 120, and intermittent. He would
soon have further symptoms of general paralysis.

Mr. Cresswell Baber said that he had several times seen cases of
spasm of the palate in connection with objective tinnitus, but was not
aware that they afterwards went to the bad. He thought these sym¬
ptoms occurred in neurotic patients, but they might have an organic
origin.

Dr. St.Clair Thomson said one case was shown by Dr. Bond, but
most of them had been brought together by Dr. Lack in a paper which
he contributed to The Laryngoscope. The disease was extremely rare,
but some of the cases to be found in the above reference were in young
people at an age when organic disease of the nervous system was seldom
met witn.

Digitized by {jOOQie

Slide from a Case of Epithelioma of the Right Vocal Cord and
Neighbourhood, in a Gentleman aged Fifty.

Shown by Sir Felix Semon. The patient was sent to me by Sir
Francis Laking on November 21st, 1904, on account of hoarseness,
which had existed for many months. On laryngoscopic examina¬
tion the whole of the anterior three fourths of the right vocal cord
was seen to be occupied by an irregular mamillated pale growth,
which materially encroached upon the glottis, but was as yet not
ulcerated. The mobility of the right vocal cord was considerably
affected. There were no glands in the neck. Some months pre¬
viously a piece of the tumefaction had been intra-laryngeally
removed in Paris, and M. Cornil was stated to have pronounced it
an innocent growth. Nevertheless, the appearances were so
characteristic of malignancy that, without renewed intra-laryngeal
removal and microscopic examination of a piece, I felt practically
certain that it was malignant. Thyrotomy was performed on
December 17 th with the assistance of Mr. St abb, Mr. Tyrrell giving
the chloroform. The growth, with a zone of healthy tissue all
round it, was thoroughly removed. The wound was closed by
stitches above and below, an opening was left in the upper part of
the lower third for drainage, and this too was closed on the second
day, as there was very little secretion. The patient made an other¬
wise excellent recovery, but an abscess formed below the lower
part of the incision, and a small part of the wound had to be re¬
opened in this region to allow the matter to escape. Now this part
of the wound is also closed by granulations from the bottom of the
wound, but the duration of the after-treatment has in consequence
of the formation of this abscess been unnecessarily prolonged, and
one of the reasons why the case is put on record is that the ex¬
perience made enforces the lesson that the part of the wound to be
left open immediately after the operation should not be in the
middle, but in the lower part of the incision. Another reason for
its publication is the misleading result of the microscopic examina¬
tion of a small portion intra-laryngeally removed. This is, of course,
only a further illustration of an experience often made before. I
am recording the case in the Proceedings of the Society because
they have become associated with the results of thyrotomy in malig¬
nant disease of the larynx.

Epithelioma of Palate, Tonsil, Tongue, and Cheek.

Shown by Dr. FitzGerald Powell. Male, aged forty years, said
that twelve months ago he noticed a difficulty in swallowing^

Digitized by

Google

There was a sore at the base of the tongue, which had gradually
extended to the tonsil, palate, and cheek on left side. It interfered
with his swallowing, but did not cause much pain.

On examination a large red ulcerating surface with considerable
overgrowth was observed extending over the soft and hard palate,
the tonsil, and on to the cheek.

A portion of the growth was removed with the snare and
submitted to microscopical examination. It was found to be an
epithelioma.

Mr. de Santi thought the condition of the patient was so bad that it
would be best to leave him alone and not subject him to any form of
treatment, whether by rays or anything else.

Mr. Westmacott said he thought the experience of those who had
used X rays in those cases was one which would lead them to avoid that
method. He had had two similar cases which were sent for X-ray treat¬
ment; in both there was a very rapid enlargement of cervical glands,
though there had previously been but little enlargement. One was a case
of excision of the tongue for epithelioma, with some feeling of irritation
remaining in the scar, and the other was epithelioma of the fauces on the
right side. There had been no infiltration until about three weeks after
commencing the rays, and then the neck got into a very deplorable state.
He would be very careful about submitting a patient with epithelioma in
that region to X rays.

Dr. Watson Williams said there was a case which had been sent
up by Dr. de Havilland Hall, reported by Dr. Dobson as having been
treated by X rays—inoperable epithelioma of the larynx. The result as
reported was very different to what appeared to have been Dr. Westma-
cott’s experience. If the X rays were to be continued it would be worth
while looking up the facts of the case.

Dr. Bronner asked whether there was much pain, and whether ortho-
form had been used, and if so, with what result.

Sir Felix Semon said it was remarkable to notice how different were
the reports as to the effect of X rays on malignant disease of the pharynx
and larynx. With regard to the larynx, he confessed he could not
see how any good could be effected by X rays. So far as he knew, the
only good effect of the rays, universally admitted, had been upon places
where the disease was directly amenable to the action of the rays. He
knew, however, that a successful case of laryngeal cancer had been reported
by Scheppegrell. With regard to malignant disease of the mouth, tonsils,
etc., he had, on several occasions, by the urgent desire of the patients,
consented to the employment of X rays, but he had to join with those who
had never seen any lasting good result from it.

Mr. Westmacott said, in drawing conclusions from the result of treat¬
ment it was necessary to know who was administering the X rays, as
there were hardly two cases in which a similiar therapeutic effect was
obtained. In certain cases where there was much thickening the rays did
not penetrate deeply, but if scarification of the part were carried out before
raying, the effect was greater. In recording cases, one should state, as
far as possible, the therapeutic strength of the rays. That could not yet
be done exactly, but an instrument had recently come from Berlin which
was useful for the purpose.

Digitized by

Google

Dr. FitzGerald Powell in reply, said the expression of opinion
seemed to be against the use of the rays. But such cases seemed so
utterly hopeless, that one grasped at any means which might cause bene¬
fit. He understood a number of such cases had been treated with the rays
at Middlesex Hospital. The patient had not had pain. He thanked the
members for their opinions.

Dr. Smurthwaite showed a beautiful series of paintings in oil
illustrating diseases of the throat and larynx :

The President said he was sure all the members greatly admired Dr.
Smurthwaite’s paintings, which were very beautiful.

Laryngeal Forceps for use in Direct Laryngoscopy.

Shown by Dr. Paterson. It is fashioned on the crocodile prin¬
ciple and terminates in a beak with cutting edges. From the bend
on the shank to the tip the length is nearly eight inches. It is
used through the “ rohrenspatel,” and is lightly built so as to in¬
terfere with the vein as little as possible. At the same time, it is
quite capable of dealing with fairly tough tissue. It was found
exceedingly useful in clearing the larynx in papillomata in children,
the pieces being picked off with great ease.

Dr. Paterson, in reply, said that he found the forceps very useful in the
way to which a member objected. The beak which lifted up just fitted into
the anterior commissure and got the papillomata out. He thought the
thorough way in which the anterior commissure could be cleared marked
a distinct advance on the old procedure by the indirect method.

Ulceration of Soft Palate for Diagnosis.

Mr. Westmacott showed a gentleman who exhibited a slow re¬
current ulceration of the oropharynx.

In March, 1903, he showed the left tonsil which he had removed
in January of that year, and which he believed to be the seat of
acute primary tuberculosis. The wound healed, but between two
and three months later the part around the upper end of the ton¬
sillar region began to ulcerate and spread to the soft palate, asso¬
ciated with great pain in the fauces on the left side, and extending
into the ear. The left nostril wa$ obstructed and the posterior end
of the inferior turbinate bone on the left side was hypertrophied
and pale. After six weeks the part began to heal under the gal-
vano-cau£ery and lactic acid, and the pain disappeared. It healed
entirely, but ulceration again appeared on the anterior pillar of the

Digitized by CjOOQle

left fauces, and a piece was examined, but no tubercular evidence
was present. In July, 1903, X rays were employed daily for several
weeks, and the pain was much relieved by the treatment, although
the ulceration spread very slowly. It healed perfectly, however—
recurring from time to time, always with great pain and loss of
weight due to eating being difficult, and often commencing during
spells of hot weather. When healing took place, no scarring was
visible, and the weight lost was recovered; during July, 1904, the
ulceration spread to the uvula and right faucial region, with con¬
siderable thickening of the parts, as well as pain in the affected
area. All the thickened tissue was removed by free excision and
scraping, and again perfect healing took place. Soon, however,
ulceration recurred again on the left side, and has fluctuated in ex¬
tent ever since under scrapings and applications of lactic acid and
formalin.

There is no history of syphilis, nor other evidence of it in him¬
self or wife and family. There is no history of tubercle. There
has never been any glandular enlargement at any time, nor any
chest symptoms indicative of phthisis. His health has been quite
good in other respects. The patient has been under well-tried
courses of mercury and of potassium iodide without the slightest
effect. Arsenic has been given without benefit. Strong applica¬
tions, as carbolic acid, lactic acid, and formalin and chromic acid,
relieve pain quickly, as does also scraping. The sputum has
never revealed [tubercle bacilli, and guinea-pigs inoculated have
remained healthy. Tissues removed from time to time have shown
inflammatory exudation only.

The appearance of the affected area is described by Sir Felix
Semon as follows: “ One sees extensive ulceration of the middle
part of the hard and soft palate of the naso-pharynx, and of both
palatal arches, particularly of the left one, whilst the disease does
not extend into the larynx. Within the area affected a sharp
whitish serpiginous line of demarcation, which is in part sur¬
rounded by a zone of congestion, separates the healthy from the
affected parts. Inside this whitish line of demarcation there are
spots in part deep, in part superficial ulceration, and in part snow-
white little nodules reminding one of either tuberculosis or lupus.
The ulceration at the base of the uvula has a distinctly lupoid
character, whilst in other parts it is perfectly nondesci’ipt.”

Dr. Pegler thought, in view of the fact that the section of tonsil
shown to the Society in 1903 presented no appearance of tubercle, and
despite that anti-syphilitic treatment at that time yielded negative results,

Digitized by LjOOQle

some form of syphilis seemed to be the inevitable diagnosis, perhaps
acquired, and a late manifestation.

Mr. G-. W. Spencer remarked that the original experiments of Dr.
Lingard, which he saw himself at the Brown Institute, showed that the
lupus cases took any time up to a year to affect the guinea-pig. At that
time the animals died of tuberculosis with enormous spleens. Lingard
likewise showed that glandular tuberculosis took something like six
months to affect the guinea-pig. He suggested adhering to the opinion
that the case was one of lupus, and that the open-air treatment or a sea
voyage should be tried.

Dr. FitzG-erald Powell thought the case was one of tubercle, and
suggested that it should be well curetted, lactic acid rubbed in, and
iodoform applied regularly and continuously. Should any recurrence be
seen, the curetting should be repeated. He had seen tuberculosis of the
palate which curetting had relieved; but it had broken down again,
and continuous curetting and painting with lactic acid had eventually
cured it.

Dr. StClair Thomson said he had forgotten whether, there was a
syphilitic history in the case, and whether there had been the experi¬
mental administration of anti-syphilitic remedies. He thought a few
inunctions of mercury, or a weekly injection of calomel into the buttock
would soon settle whether it was syphilitic. If not, it might be lupus,
in which case the galvano-cautery would be of great benefit, and it was
much cheaper and quicker than a sea voyage.

Dr. Watson Williams suggested that, for diagnosis purposes, in a
case presenting difficulties, injections of tuberculin might throw some light
on the matter.

Sir Felix Semon said that, having seen the case at a different
stage, he inclined more to the diagnosis of tuberculosis or lupus than
to any other, though he would not go so far as to say there could not
be much doubt about it, as it was the sort of case which was doubtful
both clinically and microscopically. He thought it was a good suggestion
to inject tuberculin; that might help where microscopical and bacterio¬
logical examination, and even inoculation, had failed. The case had
been treated antisyphilitically, but with negative results. As to the use
of the galvano-cautery, he thought one should not be certain about that;
at any rate, he would like to disabuse Dr. StClair Thomson’s mind of the
idea that it would be a very quick measure. He had once had a very
good and lasting result in obstinate lupus, but it was necessary to make
about 150 applications, and he would have given up the treatment long
before if the patient had not insisted upon it.

Mr. Westmacott, in reply, said his own opinion had always inclined
to lupus, but if so it must be of the kind which was analagous to some
skin cases—a very low form of ulceration and inflammation. Either the
bacilli were very few or very attenuated, as in Bazin’s disease, an ulcera¬
tion of the front of the leg to which no pathological lesion could be
definitely assigned. Possibly the present case was due to some form of
nerve lesion, because the patient had an immense amount of pain when
the ulceration started; or it might be due to some circulatory trouble,
though he could find no change in the arteries. The man was positive
he had not had syphilis; he understood what it was and said he would
have sought treatment if it had been so. He thought the prognosis was
favourable, but that the only treatment of use was scraping under an
anaesthetic, with a Volkmann’s spoon, applying lactic acid and formalin.

D i g i t i ze d o y Google

and painting over it a solution of ether, tinctiire of benzoin, and iodo¬
form. That, however, was not sufficient; it should be followed up
with the actual cautery at any spot which showed sign of recurrence.
Professor Lorraine Smith, at Victoria University, suggested that speci¬
mens should be obtained from all stages of the ulceration and from all
parts of the oro-pharynx for inoculation, and this was being done; he
would report later on the case.

Case of Thickening of the External Plates of the Thyroid
Cartilage and Infiltration of the Left Side of the Cartila¬
ginous Septum Nasi.

Shown by Mr. Charles Parker.. The patient, a woman aged
forty-two years, was first seen ten days ago, when she gave the his¬
tory of having noticed the swelling in the neck for four months and
nasal obstruction for two weeks. She complained of very little pain
or discomfort and no laryngeal dyspnoea.

On examination a very hard dense swelling was found over the
laryngeal cartilages, taking more or less the shape of the thyroid
cartilage, moving with it on deglutition and being inseparable from
it. On the left side of the anterior triangular cartilage of the nose
there was a diffuse swelling, being hard at its circumference, but
showing some signs of softening at its centre.

Mr. Parker considered the condition of the septum more sugges¬
tive of a diffuse gummatous infiltration than of anything else, and
therefore, on the chance that the condition of the thyroid was also of
a syphilitic nature, treated the patient with twenty grains of iodide of
potassium three times a day. When seen a week later somewhat to
his surprise the swelling over the thyroid cartilage was undoubtedly
very materially diminished in size, though there was very little, if
any, alteration of the septum nasi.

Mr. Parker brought the case forward for opinions as to the
nature of the swellings, as he did not think the fact that there
was improvement under iodide of potassium clinched the diagnosis.
He also thought the case a somewhat unusual one.

Mr. Cresswell Baber said he thought the case was probably syphi¬
litic.

Dr. Pegler thought the case was one of syphilis; the growth on the
septum was a gumma.

Inflammatory (Edema of Obscure Origin affecting the Posterior
Parts of the Larynx in a Man aged forty-seven.

Shown by Sir Felix Semon. The patient, a gentleman of inde¬
pendent means and leading a healthy outdoor life, began to suffer

Digitized by

Google

two or three months ago from slight huskiness and feeling of sore¬
ness in the throat. The sensations seem to be rather general, but
are perhaps a little more felt on the right side, and there is also
occasionally some pain shooting into the right ear. He has not
used his voice excessively, has so far as he knows not caught a chill,
has not been exposed to septic influences (drains, etc.) and the disease
has not begun in an acute form, with rigors, etc. Very many years
ago he had a chancre, but was treated with mercury, and has
never had any secondary symptoms. He has not taken any iodide
internally, and his general health has been very good.

When he came to consult me on Januury 9th localised but
marked oedema of the larynx was seen over the interarytenoid fold
and arytenoid cartilages, particularly the right. The oedematous
portions were vividly red-coloured. No ulceration and no new
growth could be seen anywhere. The movements of the vocal cords
were quite free. External handling of the larynx did not cause pain,
and there were no enlarged lymphatic glands. For the last two days
he has lived on cold and fluid food only, has sucked ice, and has had
ice-water compresses externally. No change, however, has taken
place in the appearances and in the sensations, and since yesterday
diarrhoea has made its appearance. The temperature this morning
was normal, the pulse 80.

One has, of course, to think of a new growth further down caus¬
ing the oedema, of syphilitic or tuberculous perichondritis, in addi¬
tion to the possibility of a septic infection, but no definite clue
could be obtained with regard to the existence of any of these
diseases, and opinions are solicited as to the cause of the oedema.

Mr. W. G. Spencer said he thought the condition was a deep ulcer
underneath oedematous overhanging edges. It was in an awkward region,
very much like Mr. Butlin’s case, which he spoke of early in the session.
If it proved to be malignant, it would be a very bad case, but might be
syphilitic.

Dr. Herbert Tilley asked what was the history in regard to syphilis,
and remarked that on the right side low down on the posterior pharyngeal
wall there was a ledge of ulcerated mucous membrane with a sharply-
defined congested border. If he had approached the ease with an un¬
biassed, mind, he would have regarded it as a tertiary syphilitic ulceration.

Sir Felix Semon replied that there was a history of syphilis twenty-
five years ago, but not of secondaries. He only saw the patient two days
ago, and hesitated to give him iodide of potassium because of the oedema.
He would now try antisyphilitic treatment, and report again to the
Society.

Digitized by

Google

Digitized by

PROCEEDINGS

OP THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Ninety-fifth Ordinary Meeting, February 3, 1905.
Charters J. Symonds, F.R.C.S., President, in the Chair.

P. E. W. DE Santi, F.R.C.S., ) Secretaries

Henby J. Davis, M.B., M.R.C.P. 5 s* 501 ^ 1168 -

Present— 34 members and 4 visitors.

The minutes of the preceding meeting were read and confirmed.

The ballot was taken for W. Stuart Low, F.B.C.S., London, who was
elected a member of the Society.

•aphs were then

On page 40 :t —

from the top. fir ’ •?

line 18, for *" X:- l£ ~

UULUU MG

AGED THIRTY-ONE,
ANCY, AND SINCE
FANCIES.

is first seen some
lie patient's fifth
osis of the right
ntum. This last
itely, no written
x^ v nx also showed
definite signs of tuberculous infection, the arytenoids being swollen,
pale, and oedematous, and superficial ulceration in the interary¬
tenoid space was present. The patient looked ill, was short of
breath, and wasting rapidly, and her whole condition suggested a
very acute infection. She was treated with increasing doses of
creosote internally and the application of lactic acid to the ulcerated
surface locally. Contrary to expectation, she improved very much.

Digitized by CjOOQle

Digitized by LjOOQLe

ERRATA.

On page 40 of the January ‘ Proceedings,’ line 16
from the top, for “ possibly ” read “ possible,” and on
line 18, for “ No. 38 ” read “ vol. v, p. 38.”

Digitized by LjOOQle

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Ninety-fifth Ordinary Meeting, February 3, 1905.

Charters J. Symonds, F.R.C.S., President, in the Chair.

P. R. W. de Santi, F.R.C.S.,
Henry J. Davis, M.B., M.R.C.P.

Secretaries.

Present—34 members and 4 visitors.

The minutes of the preceding meeting were read and confirmed.

The ballot was taken for W. Stuart Low, F.R.C.S., London, who was
elected a member of the Society.

The following cases, specimens, and photographs were then
shown:

Case of Tuberculosis of the Larynx in a Woman aged thirty-one,

WHICH COMMENCED DURING HER FlFTH PREGNANCY, AND SINCE
WHICH THERE HAVE BEEN FOUR SUBSEQUENT PREGNANCIES.

Shown by Mr. Charles Parker. This case was first seen some
five years ago, immediately after the birth of the patient's fifth
child. She then had early, but active, tuberculosis of the right
lung, and tubercle bacilli were found in the sputum. This last
statement was made from memory, as, unfortunately, no written
record of the fact could be found. The larynx also showed
definite signs of tuberculous infection, the arytenoids being swollen,
pale, and oedematous, and superficial ulceration in the interary¬
tenoid space was present. The patient looked ill, was short of
breath, and wasting rapidly, and her whole condition suggested a
very acute infection. She was treated with increasing doses of
creosote internally and the application of lactic acid to the ulcerated
surface locally. Contrary to expectation, she improved very much.

Digitized by LjOOQle

She was under observation about eighteen months, during which
time she again became pregnant and gave birth to a child, still
living. Neither the laryngeal or pulmonary condition seemed to
be materially affected, and before she ceased attending, the lung
disease appeared to have become quiescent and the laryngeal
ulceration had healed, though the infiltration and oedema of the
arytenoids persisted. The patient was then lost sight of until
three weeks ago, when she again sought advice, after nearly three
years* interval, on account of loss of voice. At the present time
there were no signs or symptoms of active lung disease, though
there were definite signs in the right apex of past trouble, and the
larynx, though greatly infiltrated and cedematous, did not suggest
any very active tuberculous process but rather a chronic tuber¬
culosis.

The interest of the case lay in its relation to the patient’s
pregnancies. It was extremely rare for patients to recover from
pulmonary tuberculosis, especially if the larynx was involved, con¬
tracted during or immediately after pregnancy. Such cases seemed
to be almost invariably rapidly fatal, and yet this woman had lived
to become pregnant on four subsequent occasions, having had two
living children and two miscarriages. She had in all been preg¬
nant nine times, affording an interesting record : No. 1, child living
and well, aged twelve; No. 2, miscarriage at fourth month; No. 3,
child died of meningitis when three months old; No. 4, child living,
aged six; No. 5 (during which the tuberculosis commenced), child
died of meningitis when one year old; No. 6, child living, aged
four; No. 7, child died of meningitis when two years old; No. 8,
miscarriage; No. 9, miscarriage.

Finally, the question of treatment seemed to be important.
Was it better to “ let sleeping dogs lie,” or to try and restore the
patient’s voice by surgical measures ? His own feeling was to let
well alone.

Mr. Steward asked whether there were any tubercle bacilli in the
sputum. Otherwise the case suggested pachydermia rather than tuber¬
culous disease.

Dr. J. W. Bond said he thought the patient looked tubercular. He
found that she was nearly always troubled with bloody diarrhoea, with
considerable pain, and he believed she had tubercle of the bowels at the
present time. He thought it was not uncommon, when there was an out¬
break of tubercle in one place, for the tubercle to be quiescent, or com¬
paratively quiescent, in another. He thought there was also present much
chronic laryngitis.

Dr. Herbert Tilley said the question raised by Mr. Parker as to the
influence of pregnancy on tubercular laryngitis had interested him, because

Digitized by {jOOQie

eight years ago he saw a patient who had very marked tubercular laryn¬
gitis, and who was then expecting to be confined in five weeks. Her larynx
was much swollen and ulcerated, she suffered much pain; and this, with
sleeplessness, led him to think that she would not get through her preg¬
nancy. The patient came under the care of Sir Felix Semon, who treated her
by local applications of lactic acid. He (the speaker) met the general prac¬
titioner connected with the case two years ago, when he reported she was
alive and in good health. Later, he heard that tubercle had reappeared
in her larynx and lungs, and that she had succumbed. Her pregnancy,
however, was got over without any trouble, and for a considerable time
the laryngeal troubles were quite in abeyance.

Dr. Soanes Spicer said he would have thought the term “ hypertrophic
laryngitis ” would have been more appropriate. The great hypersemia and
distribution of thickening of the posterior wall seemed to point to the
condition being non-specitic, perhaps some accidental chronic catarrh in
a tubercular subject.

Dr. Lambert Lack felt that he could support Mr. Parker’s views. He
saw the patient four or five years ago, and the appearances at that time
were very suggestive of an acute tubercular ulceration of the larynx. Now,
it was difficult to recognise the affection because the ulceration had healed,
and there was nothing but scarring and thickening left. With regard to
the influence of tubercle of the larynx on pregnancy, a paper was published
some years ago in the Archiv f ur Laryngologie in which all the recorded
cases had been collected. Not a single case had survived a year, and of
the babies, many were still-born, and a few only survived. Since reading
this paper he had had one case brought to him with active tubercular
disease in the lungs and*larynx after parturition. There was pyrexia, she
had great pain on swallowing, and was very weak. There was thickening
and ulceration of the epiglottis and arytenoids. He did not wish to operate,
but the patient was keen upon having her epiglottis removed, on account
of the pain. He, therefore, did it, but told her doctor that she would be
dead in three months. The patient was still well three years later. Although
the disease was worse, the patient was much better off than Mr. Parker’s
case, was in good circumstances and able to avail herself of the open-air
method. XJntil Dr. Tilley related his case to-night, Dr. Lack had looked
on his patient as the only case of the kind which had survived so long a
time.

Sir Felix Semon said he had unfortunately not looked at the patient,
and therefore could not express an opinion on the case. It was of the
very greatest importance. At the present time a lively discussion was in
progress on the Continent on the subject, having been initiated by one of
the gentlemen who would shortly be visiting us, Dr. A. Kuttner, of Berlin,
and he trusted Mr. Parker would be good enough to bring his case forward
again then. Dr. Kuttner had pursued an inquiry into the influence of
gravidity upon laryngeal tuberculosis. His results showed even more
disastrous figures than previous statistics, and the question which was
now being discussed on the Continent was whether the presence of laryn¬
geal tuberculosis in the mother should not be an indication for producing
artificial abortion. There might be one or two exceptions, but in most
cases the mother had died within a few months of having given birth to
the child.

Dr. Clifford Beale said the case reminded him of one he showed
before the Society ten years ago (v. Proceedings., February, 1894), in
which similar conditions prevailed, with a considerable amount of sub-

Digitized by LjOOQle

mucous infiltration, the patient having at that time fairly active tuber¬
cular disease of the lungs. There, as in the present case, there was no
breach of surface, there was a considerable fleshy prominence, and it was
rather hyperaemic. The case was under observation several years, and
the patient did not die until five years afterwards, and then from disease
of the lung. The laryngeal condition varied only slightly, and he thought
considerable improvement was caused by the periodic use of tannic acid.
He strongly advised against the removal of the bosses in his case, as they
did not interfere greatly with comfort or life, any more than those in the
present case.

Mr. Parker, in reply to Mr. Steward, said that no tubercle bacilli could
be found at the present time, but he was confident that they were present
five years ago, though the hospital paper containing the record was lost.
At that time also there were undoubtedly active signs of phthisis at her
right apex, whereas all that could now be found was a little patch of
dulness, and harsh breathing, showing that the process in the lungs had
become arrested. Anyone seeing the case now for the first time might
possibly doubt the existence of tubercle, but five years ago it was
absolutely typical; the arytenoids were oedematous and infiltrated, and
there was distinct ulceration in the interarytenoid region. This had
gradually improved during the eighteen months the patient was under
treatment. Since then it had passed, as Dr. Bond said, into a condition
in many ways resembling chronic laryngitis. With regard to the in¬
fluence of pregnancy on such cases, he did not understand from Dr.
Tilley whether in his case the pregnancy occurred in a patient with tuber¬
culosis, or whether the tuberculosis commenced during pregnancy. He
thought that made a good deal of difference. It was the cases starting
during pregnancy, or immediately after the birth, which were so often
fatal. He had asked Dr. Jane Walker about that point, and she stated
that at her sanatorium she had had several cases of childbirth in women
who had had tubercle for some time, and the pregnancy had not preju¬
dicially affected the course of the case. She did not refer to tubercle of the
larynx, but pulmonary tuberculosis. He agreed with Dr. Clifford Beale
that it was better to let the patient suffer loss of voice than run the risk
of re-awakening her quiescent condition. He would be pleased to bring
the case up again in March.

Notes of Dr. Frederick Spicer’s Case of “ Diffuse Papilloma
of the Vocal Cords/’

Shown by Mr. Clayton Fox. A. B— presented himself at the
Metropolitan Ear, Nose, and Throat Hospital last September, com¬
plaining of hoarseness of six months’ standing. He had wasted of
late, but the family history was good, and patient had not had
syphilis.

On examination of the larynx the anterior half of each cord
was the seat of red granulations jutting beyond the level of the
healthy portions of the cords, and arranged in such a manner that
there was a convexity on the right which fitted into a concavity on
the other side. There was some considerable nasal obstruction on

Digitized by CjOOQle

the right side, due to a defective septum. The chest was examined
with no definite results.

The following November Sir Hugh Beevor examined the chest,
and beyond some slight dulness at the left apex and a few crepita¬
tions nothing was found. The sputum was repeatedly examined
for tubercle bacilli with negative results.

Treatment .—Alkaline douches for nose, ZnCl 2 and lactic acid
applied to cords.

Recently the condition of the parts had undergone a marked
change; the trouble on the right cord had almost gone, and in
place of the granulations greyish-white glistening polypi now
occupied the anterior half of the left cord and commissure.

Dr. Bronner recommended the local application of formalin. He
thought it was an ordinary case of papilloma.

Dr. Dtjndas G-rant said he thought the galvano-cautery point would
be a very useful instrument for the condition. He had had several cases
of fibroma and papilloma near the anterior commissure which had done
extremely well under it, used, of course, with considerable discretion. He*
believed the present condition was papillomatous*.

Mr. Clayton Fox, on behalf of Dr. Frederick Spicer, said the chief
point of interest to Dr. Spicer was as to whether the laryngeal trouble
was tubercular or simple in origin. The condition of the cords had mark¬
edly improved since the patient first came under notice; in fact, all the
granulations and polypi had disappeared from the right one. As regards
the chest, there was some slight dulness over the left apex, but nothing
definite; possibly what physical signs existed could be attributed to an old
tubercular lesion. An examination of the sputum for tubercle bacilli gave
a negative result. The diseased parts of the cords had been treated by
rubbing in lactic acid, and at times by painting with chloride of zinc.
The nasal obstruction caused by a deflected septum and hypertrophic
rhinitis had been treated by hot saline detergent douching. Dr. Spicer
intended performing a Moure’s operation shortly, and hoped that all the
trouble would eventually clear up.

Dr. Scanes Spicer thought the surface appearance of the growths
might be that of tubercular tumours, but that the larynx was so free
from disease, except at the anterior commissure, the localisation of the
growths was against this being tubercular disease. If they were tuber¬
cular the laryngeal disease would be more generalised. Therefore he
inclined to regard them as papillomata.

Dr. StClair Thomson thought it seemed a case of simple papilloma.
The situation would be unusual for tubercle; but could not the diagnosis
be settled by removing a small piece of growth ? It could be done by Dr.
Lack’s or Dr. Powell’s beak-shaped modification of Mackenzie’s forceps,
and possibly a cure effected at the same time.

Sir Felix Semon said, with regard to the observations just made as
to the growth not being likely to be tubercular because it was localised in
the anterior commissure, that he had in three cases removed tumours from
the anterior commissure which, on subsequent microscopic examination,
turned out to be tuberculous.

Dr. Dundas Grant in reference to tuberculous tumours said he ex-

Digitized by

Google

hibited a case before the Society two years ago, the patient being an old
man who had, in the commissure, a large sprouting growth, which on
microscopical examination was found to be tuberculous.

Dr. Fitzgerald Powell thought there was no appearance of tuber¬
culosis about the larynx; it seemed to be a papilloma springing from
anterior commissures, possibly subglottic, and he would have it removed.
If tubercle bacilli were present, most probably they would be found in
the sputum. [Mr. Clayton Fox said the sputum had been examined, but
with negative results.]

The PREsiDENT remarked that if anything further arose in connection
with the case it would be an advantage for the Society to be advised.

Hoarseness, Cough, Pain, little Bloody Expectoration, Man aged
Sixty-nine, from whom the late Dr. Whistler removed a
Growth from the Right Vocal Cord Twenty-two Years ago.

Shown by Dr. Edward Law. The patient was examined by
Dr. Law several times between 1883 and 1896 whilst under the
late Dr. Whistler’s care, and the following extract from Dr.
Whistler’s case-book was interesting: i( February 10, 1883.—On
laryngoscopic examination I found a growth, the largest portion of
which was the size of a large pea, pear-shaped, and attached by a
pedicle to the inner and under surface of the right vocal cord
about the anterior and middle third. In appearance it was like a
reddened wart. The vocal cords were both broad and red. The
entire growth was removed with a pair of Durham’s forceps.
April 20, 1883.—Right vocal cord nearly white excepting at pos¬
terior third. No return of growth; edge smooth ; voice clear and
good.” This satisfactory condition remained, and permitted the
patient to perform the duties of a schoolmaster until 1896, when
he again complained of cough and expectoration, and received
remedies for a pharyngeal trouble. He continued his duties until
April, 1901, when he retired according to the regulations of the
Education Act and not on account of any throat affection. He did
not complain of hoarseness until a year ago.

The patierft came to see him again last May on account of
hoarseness, expectoration of mucus stained with blood, and slight
difficulty in breathing on exertion. No pain, no loss of weight, no
difficulty in swallowing.

On examination, both vocal cords were seen to be thickened,
irregular, hyperaemic, and freely movable, with a thickening below
both cords, causing slight tracheal stenosis, especially as the
mucous membrane, immediately below the cords, was covered with
dry blood-stained secretion. There was a small nodule with a

Digitized by

Google

bleeding point on the posterior laryngeal wall immediately above
the posterior insertion of the right vocal cord. Sir Felix Semon
kindly examined the patient and expressed the opinion that there
was no evidence of malignancy, but advised that he should be kept
under observation. Patient was next seen October 17, when he
complained of soreness at the root of* the tongue on swallowing,
and now and then a darting pain on the right side of the larynx,
and an occasional trace of blood in the expectoration.

January 18, 1905. Patient was better until a fortnight ago,
when he again complained of pain on the right side of the larynx,
occasionally shooting into the right ear, worse at night. On exami¬
nation, little change was noticeable in the larynx, except that the
right side moved very imperfectly. Patient was sent into hospital
under Dr. Waggett, who prescribed potassium iodide and Liquor.
Hydrarg. Perchlor.

Dr. Scanes Spicer thought that at present there was ulceration
below the vocal cord; it was an infra-glottic ulceration of a greyish yellow
colour on the red infiltrated thickened right side. Its appearance was
very suggestive of malignant disease. Also, on the opposite cord, below
the vocal process, he saw a fleshy mass turning round from underneath.
That could be accounted for by the swelling on the right side having dug
into the left side and irritated it. It seemed to be of a totally different
nature from the angry redness and ulceration below the cord on the right
side where the greyish ulceration was now seen, and the latter he thought
was malignant at the present time, whatever the original condition had
been.

Sir Felix Semon said he had seen the patient on several occasions,
and did not feel so certain about malignancy as Dr. Spicer did. He could
only say that there was some chronic inflammatory process, leading to
diminished mobility of the vocal cord, and would suggest keeping the
patient still under observation before resorting to operation.

Mr. Waggett (replying for Dr. Law) thought the case had been
somewhat spoiled by the exhibition of iodide of potassium. It looked
different five or six days ago, before the iodide was given—not so red and
angry. The mobility of the cord seemed to vary ; that day it was less
mobile than a week ago. He did not regard it as malignant.

Woman, aged Thirty-five, shown at last Meeting with Laryngeal
Swelling thought to be Tubercular and Microscopic Slide
showing undoubted Squamous-celled Carcinoma.

Shown by Mr. de Santi. The patient was brought before the
Society at the last meeting as a case of doubtful nature. From the
appearance of the swelling a month ago it was thought to be tuber¬
cular : no tubercle bacilli or tubercle in the lungs were, however,
discoverable, and the question of diagnosis rested between tubercle

Digitized by {jOOQie

and malignant disease. There was a general opinion in favour of
tubercle, but removal of a piece of the growth and examination
digitally were recommended. Mr. de Santi removed a piece of the
growth with endolaryngeal forceps, and microscopic examination
by Dr. Helb proved the disease to be undoubted squamous-celled
carcinoma. The slide was presented at the meeting for examination.

Since the last meeting the growth had increased considerably
and now presented unmistakable naked-eye appearances of malig¬
nant disease; the cricoid plate was completely invaded and the
growth extended well into the lateral pharyngeal region.

The point for discussion was as to operation ; personally Mr.
de Santi was of opinion that even total laryngectomy would fail to
remove the disease in toto, that the attempt to remove it might
prove disastrous, and that even if the patient recovered from the
operation she would not be rid of the disease.

It was a curious fact that carcinoma, uncommon in the larynx
in woman, if it did occur, frequently attacked the region of the
cricoid plate, and was met with in them at a comparatively early age.

The President said the patient was a woman with a hard irregular
mass behind the arytenoids. He thought it had been previously pointed
out how remarkable those cases were in occurring in women of about the
age of this patient. He looked upon the disease as a primary pharyngeal
growth invading the larynx from behind.

Dr. Scanes Spicer said the left cord in this case moved freely, in spite
of the extraordinary amount of overhanging growth. He did not see any
other course except that of total laryngectomy.

Dr. Fitzgerald Powell was sorry the diagnosis he made when he
saw the case previously—malignant disease—was confirmed. He thought
the disease was now too far advanced to justify much hope of success from
total extirpation.

Sir Felix Semon said the case interested him, particularly from the
point of view just mentioned, namely, How was it that, while laryngeal
cancer was so rare in women, it localised itself when they had it, in the
majority of cases, on the posterior surface of the cricoid cartilage ? He
believed he was the first to draw attention to it in 1894 in the Lancet ,
and he had often since seen the fact corroborated. With regard to the
question of operation, nothing short of total laryngectomy could be of
any use in this sad case.

Dr. Lambert Lack asked whether such cases should be called laryn¬
geal carcinoma at all. It seemed to him to be pharyngeal. This growth
probably started from the lateral wall of the pharynx. The growths
formed a ring round the pharynx, and though they might first come into
view just behind the arytenoid body, if an attempt were made to remove
them they were found to involve half or more of the pharynx. It was a
question of pharyngectomy rather than laryngectomy if removal was
attempted.

Dr. Bronner said he had two similiar cases to the present one oper¬
ated upon, and the disease was of far greater extent than at first appeared

Digitized by LjOOQle

When the surgeon cut down on the parts, he found that the growth ex¬
tended into the pharynx and it could not be removed.

Mr. Westmacott thought there was not much evidence of pharyngeal
implication at present. With a growth that size and duration there would
be some glandular infection on one side of the neck or the other. The
glands were very little, if at all, enlarged.

Mr. Steward corroborated Dr. Lack’s remarks. In Guy’s Hospital
Museum there were some eight or ten specimens of similar growths of the
pharynx, from young women who died of that disease. In each case
practically from the level of the arytenoid cartilages downwards the
whole pharynx was a solid mass of growth. He had also seen four
patients during life with the same condition. About eighteen months ago
he had a young woman in hospital who had almost complete stenosis of
the pharynx from a similar growth, and before death could not even be
fed by means of a tube. In the end he did a gastrostomy so as to feed
her, yet one could only see a small growth sprouting up above the aryte¬
noids. The whole pharynx was found full of growth at the post-mortem.

The President said he had seen a good many such cases in his ex¬
perience, and when one could see even a small grey edge—not one fourth
as large as in the present case—one could conclude that the disease was
fairly extensive below. Most of them had not required tracheotomy. He
once, some years ago, attempted operation on such a case, where the dis¬
ease was much more localised, but he found it impossible to complete it.
He agreed with Dr. Lack that the growth was usually extensive, running
so far round the pharynx that it precluded operation.

Mr. Waggett suggested that it had become almost a duty not to leave
the question of whether or no the oesophagus was involved to conjecture,
but to look and see if that was the case. This could easily be done by means
of Killian’s tubes. He did not think the specimen shown looked like
carcinoma, though no doubt the disease was such. It seemed like normal
epithelium cut on the flat.

Mr. de Santi, in reply, thanked the members for their opinions. He
looked upon it as extrinsic carcinoma. He had watched it six weeks, and
it started from the arytenoid region, extending from there to the pharynx
and down to the cricoid plate. It now involved a greater area than could
be seen by the mirror. He thought it was not originally of pharyngeal
origin. With regard to operation, he had spoken to the woman and told
her how very severe the operation would be. But as he had seen her twice
during the last ten days and observed how it had spread, he felt that no
operation could be undertaken for it with any safety. The glands were
much enlarged, the pharynx was involved, and the pharynx would have to
be operated on as well as the larynx, and he doubted if she would survive
it; even if she did, the result would be disastrous. He would put the
case fairly before her, but could not hold out hope of permanent success.

Sir Felix Semon asked if Mr. de Santi would bring the patient to the
next meeting, as Professor Gluck would be coming.

Mr. de Santi : Yes, if she is alive, and well enough.

Fixation of the Left Vocal Cord in a Man aged about

Forty.

Shown by Mr. Paget for diagnosis.

Dr. H. J. Davis said he thought the pulses on the two sides were un-

Digitized by LjOOQle

equal, and that he regarded the case as one of aneurysm. The left was
retarded and not so forcible as the right pulse.

Mr. Robinson agreed with the view expressed by Dr. Davis, and
suggested that a skiagram be taken of the chests

Dr. Soanes Spicer said there was a small local difference on the two
sides. There was more swelling about the left crico-arytenoid front than
on the other, and it might be a local condition of the larynx—a crico¬
arytenoid arthritis.

Dr. Furniss Potter said there was a distinct difference in the two
pulses, the right one being much more easily felt than the left.

Mr. Stephen Paget, in reply, said the pulse had not been examined
since two or three weeks ago, and then nothing in the nature of aneurysm
was discovered. He agreed with Dr. Davis that the left pulse seemed
weaker than the right.

Growth on the Right Vocal Cord in a Woman who had under¬
gone Operation Twelve Years previously for Papilloma of
the Larynx.

Shown by Mr. Paget for diagnosis.

Dr. Soanes Spicer agreed with Dr. William Hill that the condition
was probably hypertrophic laryngitis.

Recurrent Ulceration of the Tonsils associated with Lymph-
adenoma in a Woman aged Sixty-four.

Shown by Mr. F. J. Steward. The case was a very unusual
one, the outstanding feature being that several attacks of ulcera¬
tion of the tonsils accompanied the onset of lymphadenoma.

The history of the case was as follows :

He first saw the patient, a woman aged sixty-four, on
October 22, 1904. She then complained of sore throat on the
right side, of a fortnight's duration. The right tonsil was a little
enlarged and red, and there were several enlarged glands on the
right side of the neck. There were then no other enlarged glands
or other signs of disease.

After two weeks' treatment the tonsil was normal and the glands
had almost disappeared. On November 27 the patient returned,
complaining of soreness on the left side. The left tonsil was
swollen, and on its surface was a shallow grey ulcer; there was also
a considerable glandular enlargement on the left side of the neck.

A week later the ulceration of the left tonsil had disappeared,
but the glands were not much smaller, but had considerably im¬
proved at the end of the next week. The patient was not seen
again until January 7, 1905, when it was found that both tonsils
were enlarged, purple in colour, and on the surface of each was a

Digitized by CjOOQle

greyish ulcer. There were also many enlarged glands on both
sides of the neck.

Some improvement again took place, only to be followed by
another relapse.

At the present time, February 2, 1905, the condition was as
follows: The right tonsil had a small haemorrhagic patch on its
surface, but was otherwise normal. The left tonsil was consider¬
ably enlarged, purple in colour, soft to the touch, and on its
surface was an ulcer with small adherent greyish sloughs. There
were large masses of hard, painless glands on both sides of the
neck extending from mastoid process to clavicle; considerable
enlargement of the axillary glands was also present, and to a less
extent of those in the groins. The liver was enlarged, but the
spleen could not be felt.

Blood examination .—There was no evidence of leucocytosis;
the red corpuscles were slightly diminished in number, and the
haemoglobulin below normal.

Mr. Baber thought the case was one of lymphadenoma. The patient
had enlarged glands in the right groin, and he suggested treatment by
arsenic if that had not already been employed.

Mr. de Santi said it was unusual to find such ulceration of the tonsils
with lymphadenoma. He occasionally saw these cases, and the great point
of interest seemed to be the recurrent ulceration, on the nature of which
he could not form any opinion.

Dr. Lambert Lack asked whether it would have been possible, by
removing pieces in the earlier stages, to have made the diagnosis before
the case became inoperable. He had seen one case of relapsing ulceration
of the tonsils with enlarged glands in the neck, and he removed pieces for
microscopical examination. This proved to be a sarcoma, and operation
was performed. He thought if a portion were removed early in such
cases, operation might be undertaken with some prospect of success.

Mr. C. Baber said that some years ago he published a case of lymph¬
adenoma of the tonsils. At first they seemed to be simply enlarged tonsils,
and were removed once or twice. But they grew so much in the hospital
that as much as possible of the tonsil had to be removed with a curette in
order to prevent choking. Eventually the patient died. He did not see
how any operation, however early, could do much good in such a case.

The President said the peculiarity in the present case was the ulcera¬
tion beginning in the tonsil. Mr. Steward had referred to a case under
his (Mr. Symonds’) care brought before the Society, in which both sides
were involved; it was recognised as ulcerating sarcoma of the pharynx.

Dr. Herbert Tilley said the case he showed two meetings ago was
one in which there was extensive ulceration of the tonsil with enlarged
glands in the neck. The glands and the tonsil were so large that he was
going to insert a tracheotomy tube; but under the administration of xv 11\
of arsenic three times a day the whole condition had, at any rate tem¬
porarily, disappeared.

Dr. Atwood Thorne said he would like to hear if other members
had seen such cases ulcerate, clear up, and again ulcerate.

Digitized by

Google

Sir Felix Semon, replying to Dr. Atwood Thorne, said he had seen
several such cases clear up temporarily under arsenic.

Dr. Clifford Beale reminded the Society that at a discussion at the
Pathological Society (‘ Transactions,’ vol. liii, PI. IX) not many years
ago, it was fairly well established that the definite structure of lymphade-
noma could be recognised from the structures with which it was formerly
confused. He believed it was first clearly laid down by the late Professor
Kanthack, but Mr. Butlin brought the matter forward. Therefore, he
thought it would be well to examine whenever any suspicion existed, to
see if such structure was beginning to show itself in the tonsil.

Mr. Steward, in reply, said the peculiarity of the case was that the
ulceration occurred first on one side and then on the other, with complete
healing between attacks. The enlargement of the glands, and so forth,
he looked upon as signs of the general disease, rather than as being
secondary to local growth of any kind.

Photographs of a Malignant Growth of the Larynx.

Shown by Dr. Bennett. R—, aged forty-eight, a hotel keeper,
who had taken alcohol rather freely, consulted Dr. Bennett at the begin¬
ning of October, on account of hoarseness of three months’ duration.
There was some glandular enlargement on the left side, and a little
on the right. On laryngoscopic examination the left side of the
larynx was fixed, and there was a growth occupying the position of
the left arytenoid cartilage. It seemed to extend about half an
inch downwards into the larynx and oesophagus. There was little
dysphagia and very little pain. The chances of operation did not
seem very good, but after consultation with Mr. Bond, of Leicester,
it was decided that an attempt might be made to remove the
growth.

Two or three days later Mr. Bond removed the glands on the
left side. It was soon seen that the extent of the mischief was far
beyond what could be detected from external examination. The
glands were found to involve the common carotid artery, the vein,
and also the hypoglossal nerve. Part of these structures had to be
removed, and all gland enlargements seemed to have been success¬
fully removed. Some glands were then removed from the right
side. Tracheotomy was now performed, and the larynx opened.
The right half of the larynx was removed. The growth extended
for more than one inch down the gullet, and the oesophageal wall
had to be extensively removed. The trachea was now completely
divided from the larynx, and stitched to the skin.

The patient rallied from the severe operation, but suffered from
loss of memory, delirium, and excitement, which caused great
difficulty in nursing. He was fed through the gaping oesophageal

Digitized by ^.ooQle

wound. After about six weeks Mr. Bond removed the remaining
half of the larynx, and by utilising the laryngeal mucous membrane
he succeeded in largely closing the oesophageal wound. As far as
the operation was concerned, there seemed for some time to be a
good chance of recovery, but later, in December, there was pro¬
gressive mental failure following influenza, and the patient died
early in January, from exhaustion. At the post-mortem examination
some of the prevertebral glands were found affected.

No difficulty arose through the utilisation of the laryngeal
membrane for the closure of the oesophageal wound, but a marked
improvement in the patient's general condition followed, when he
could again take food through the mouth, although the quantity
was not greater than that taken through the wound in the neck
after the first operation. The mental condition was seriously
affected by the ligation of the carotid, and memory never thoroughly
returned. It was interesting to notice that during sleep, when the
cerebral tissues were presumably still more anaemic, the excitement
and delusions seemed most marked.

Man aged Sixty: Mass of Malignant Glands in the Neck,
Swelling of Larynx same side.

Shown by Mr. de Santi. The patient was referred to Mr. de
Santi by his colleague, Mr. Stonham, for an opinion as to the con¬
dition of the larynx. There was no history of hoarseness, pain,
dysphagia, or anything pointing to laryngeal or oesophageal trouble.

On examination of the larynx a large swelling was seen occupy¬
ing the right arytenoid and aryepiglottic region. The swelling
looked more like an oedema than a distinct tumour; it was
on the same side as the affected glands, hid the true and false vocal
cord on that side, and was fixed.

Mr. de Santi had no doubt that it was carcinoma and the cause
of the mass of enlarged glands in the neck. Sometimes a small
extrinsic malignant tumour would cause enormous glandular infil¬
tration ; in other cases, though usually intrinsic in origin, a large
growth would cause little, if any, glandular infection. The case
was quite inoperable.

Mr. Robinson said the impression from the feel of the glands
strongly suggested malignant disease, and one would imagine that it
started in the larynx, especially as the larynx was so markedly affected.

Dr. Bond thought there seemed to be some malignant growth about
the right arytenoid. There was also considerable thickening behind the
posterior pillar, extending into the naso-pharynx. Now and then one

Digitized by LjOOQle

found cases with enlarged glands in the neck, malignant, where it was
very difficult to find out the origin of the condition. Sometimes there
was a growth in the naso-pharynx which was first manifested by glands
in the neck. He would like to know whether the naso-pharynx had been
thoroughly examined with the finger.

Dr. Soanes Spicer pointed out that there was considerable thicken¬
ing on the right side of the larynx, and the cord was quite immobile. He
regarded it as malignant disease of the larynx.

Case of Primary Sore of Tongue.

Shown by Dr. Herbert Tilley. A man, aged forty, who
presented on the tip of 'the tongue, and slightly to the left side, a
dark-coloured, slightly raised ulcerated and painful swelling the
size of a sixpence. The tissues immediately around the sore were
livid, red, and much congested, and a well-marked induration passed
gradually away into the normal tissues of the tongue. There were
one or two small indurated glands under the left ramus of the
mandible. He saw the patient twenty-four hours ago and had
prescribed for him full doses of mercury and inunction by the
same drug.

Mr. C. Baber thought it was the kind of case to be shown again to
observe the result of treatment. It did not seem quite clear whether or
not the ulcer was a chancre. The patient appeared to have irritated it
with caustic applications many times a day. Moreover, there was a pro¬
minent tooth which might cause irritation.

Mr. Bobinson asked whether there were enlarged glands. He had seen
two or three tongue cases like that, but they were simple granulomata.

Mr. de Santi did not think the glands at all typical of hard chancre.
There was one smallish gland to be felt in the middle line, but it could
be accounted for by the septic condition of the irritant ulcer. In a case
of hard chancre of the tonsil, recently seen by him, there was a large
number of enlarged glands in the neck, hard, discrete, and shotty, and
in other cases of chancre of the lip he had invariably seen a similar
enlargement. He was doubtful about the case and would watch it
carefully.

Dr. Fitzgerald Powell thought it would be better not to put the
patient on antispecific remedies for the present, until some definite mani¬
festations of syphilis appeared, to enable one to be certain of the diagnosis.

Dr. Herbert Tilley, in reply to Mr. Baber, said some importance
had been attached to a prominent tooth, but this tooth was not rough or
jagged; it was simply a little behind the level of those on either side of
it. If the man had nothing the matter with the tongue he would not
have noticed the prominent tooth. Dr. Powell’s remark raised an ethical
point, and he (the speaker) thought that if one was fairly certain that
a patient was suffering from a primary syphilitic, lesion, it was the
bounden duty of the physician to apply remedial treatment at once, and
not to wait for secondary symptoms which might pass unnoticed by the
patient. The harm induced by even a prolonged course of mercury would
probably be far less harmful than allowing the specific virus to run un¬
checked for months.

Digitized by LjOOQle

Case op Pachydermia Laryngis—Tubercular (?).
Shown by Dr. Cathcart at previous meeting.

Combined Functional and Organic Paresis of Larynx in a
Singer aged Thirty-four.

Shown by Dr. Cathcart.

Mr. C. Baber said he thought the nasal obstruction on the left side
which was complained of was subjective; there seemed to be plenty of
room. Possibly crusts occasionally ; formed. If there existed want of
abduction in the right cord, it was very slight. There was a slight ful¬
ness of the left ventricular band.

Dr. Scanes Spicer said the nose was unusually patent, but the man
was a foreigner and did not express himself in English very well. When
asked whether it was not a feeling of pressure rather than obstruction he
said yes. He had some abnormal sensation there, which had an objective
explanation in the contact between the septum quite high up and the
outer wall of the nose.

Dr. Pegler said, as touching the nasal obstruction complained of, the
cavities were both roomy and somewhat atrophic. Taking into considera¬
tion the important symptom of hemianesthesia and the generally neurotic
aspect of the case, he should be inclined to regard it as on all fours with
the cases of so-called subjective nasal obstruction that he had shown to
the Society. In them the close rhinolalia was absolute, but even in Dr.
Cathcart’s case the patient admitted some degree of it at times. If his
view were correct, it was an interesting instance of functional contraction
of the elevators of the soft palate in the male.

Sir Felix Semon expressed doubt as to any organic element being
present in the case. He regarded it as wholly functional.

Dr. Dundas Grant felt no doubt that the man was suffering from
chronic laryngitis. He saw him some years ago, when his left antrum
contained a good deal of pus. There was an atrophic condition in the
left nasal cavity, and no doubt crusts formed, some of which might get
inhaled into the larynx. The patient was obviously a hysterical subject,
of which he had evidence some years ago.

Case of Extensive Ulceration of the Nasal Septum for

diagnosis.

Shown by Dr. Bennett. The patient was shown in March,
1902, when the trouble had existed for four years. It would be
seen that the septal cartilage was almost entirely destroyed. The
severe pain and the frequent haemorrhages had continued through¬
out the whole period of six years. No evidence of any sinus
suppuration had been obtained. Mercury and iodides had no
effect. Cauterisation of the surface had done little good. Packing
had been tried with little success. No evidence of tuberculosis had
been obtained.

Digitized by LjOOQle

Mr. Robinson thought it was an old syphilitic case, in which there
had been destruction of the septum.

Dr. StClair Thomson said he remembered the case being shown
previously, when he thought it was due to sinus troubles; and that
opinion he still held. There was pus in the middle meatus, besides poly¬
poid hypertrophy, and he thought there was considerable ethmoiditis as
well. He added that if ever an abrasion occurred on the mucous mem¬
brane of the septum—probably traumatic in origin—in a case of nasal
suppuration, that ulceration would take place, remain septic, and easily
lead to perforation and extensive destruction of the septum.

Dr. Dundas Grant asked whether the disease had come to an end, or
was still active. It seemed to him as if it were an exhausted process,
probably some low form of tubercle which had led to the destruction of
cartilages and then stopped.

Mr. Waggett echoed Dr. StClair Thomson’s remarks; such a case
could properly be called one of ethmoiditis.

Dr. Bennett agreed that there had been ethmoidal trouble, but
believed it was coming to an end. The surface seemed to be smoothing
over, and was less angry. In the last fifteen months there was a change
for the better.

Growth on the Left Yocal Cord in a Man aged Forty-six,

WHO HAD NOTICED SLIGHT HOARSENESS OF THE VOICE FOR THE

last Fifteen Months.

Shown by Mr. Stephen Paget for diagnosis.

Mr. Waggett thought it was a large papilloma.

Mr. de Sant i suggested that a piece should be removed from the
growth for examination, as its nature seemed doubtful. He inclined to
the belief that the disease was malignant, though he hoped members
would not think he was always “ plumping ” for malignant disease.

Dr. StClair Thomson thought the growth looked suspiciously like
malignant disease, and he would be prepared to find it such. As it did
not extend up to the arytenoid, it might be examined by laryngo-fissure,
with a view to extirpation. If malignant, then, so far as could be judged
by the laryngoscope, it was a suitable case for thyrotomy.

Dr. Fitzgerald Powell thought that the overgrowth was papillo¬
matous ; he did not believe it was malignant; there was, in his opinion,
too free movement of the cords. It was usual in malignant cases in such
a state of advancement as this appeared to be to find considerable inter¬
ference with movement.

Digitized by

Google

Qr >Z)

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Ninety-sixth Ordinary Meeting, March 17, 1905.
Charters J. Symonds, F.R.C.S., President, in the Chair.

Philip R. W. de Santi, F.R.C.S.
Henry J. Davis, M.B., M.R.C.P. )

Secretaries.

Present—64 members and 27 visitors.

The meeting was a large one owing to the number of Continental
visitors who were paying an official visit to London on the occasion of
the Garcia Centenary Celebration.

The minutes of the preceding meeting were read and confirmed.

The President in his opening remarks called attention to the
special character of the meeting, in its relation to the Garcia Cele¬
bration. The cases had been all carefully selected by the secretaries,
the exhibition of specimens had been arranged by Dr. Pegler with
much care, and would be found instructive. The President also
directed the attention of the members to the improvements in the
lamps, to the glass bowls and holders, and the new spirit lamps,
these additions being the gift of one of the members—Mr. Waggett.
He was sure he might convey to the donor the best thanks of the
Society.

The President further welcomed the foreign visitors, especially
Dr. Frankel from Berlin, who had come as the bearer of the
decoration to Senor Garcia from the German Emperor; Professor
Chiari from Vienna; Professor Gluck from Berlin, who he would
remind the Society had arranged to give a demonstration of his
methods of removing the larynx the next day at 2 p.m.; also Dr.
Moure of Bordeaux; Dr. Botella and Dr. Tapia of Madrid; Professor
Landgraf and Dr. Kiittner from Berlin; Dr. Lermoyez and Professor
Koenig, Dr. Mahu, Dr. Texier, and Dr. Molinie from Paris, and

Digitized by ^.oosle

Dr. Molle, Dr. Goris, Dr. Lieven, and many others. He begged
all visitors to join in the discussion.

The following cases, specimens, and photographs were then
shown.

Case of Tuberculosis of the Larynx in a Woman aged Thirty-one.

Shown at the February meeting by Mr. Charles Parker. The
disease commenced during her fourth pregnancy, since which she
had been pregnant five times; on three occasions the child was
born alive, and on two occasions she had miscarriages.

Mr, Symonds said opinions would be particularly interesting, because
the case was shown to illustrate the bearing of gestation upon tuberculosis
of the larynx. At a recent meeting there was considerable discussion on
the point.

Six Patients upon whom Radical Operations had been performed
for the Cure of Chronic Empyemata of the Frontal and
other Nasal Accessory Sinuses.

Shown by Dr. Herbert Tilley.

(1) Mrs. C—, aged fifty. Radical operation upon left frontal and
maxillary sinuses, May 15, 1900.

(2) Miss H—, aged forty. Bilateral empyemata of frontal,
maxillary, and sphenoidal sinuses. Both frontal, ethmoid, and
sphenoidal sinuses were operated upon at one operation, and the
maxillary sinuses at another operation a fortnight later—January 21,

1903.

(3) Miss W—, aged twenty-one. Right frontal and maxillary
empyemata. Radical operation March, 1904.

(4) Mr. H—, aged twenty-one. Right frontal, ethmoidal, and
sphenoidal sinus with right maxillary. Operation March, 1904.

(5) Mrs. B—, aged thirty-three. Left frontal, ethmoidal, and
maxillary sinuses. Radical operation March, 1903.

(6) Miss B—, aged twenty-three. Left frontal, ethmoid, and
maxillary sinuses. Radical operation (modified Killian) September,

1904.

In none of these cases could any pus be found in the nasal
cavities nor any sign of recurrent disease.

By the term “ radical operation ” as used above was meant:

(A) Frontal sinus : complete removal of the anterior wall,
curetting away of all diseased mucous membrane, establishment of
free communication with the nose, in which process diseased
anterior ethmoidal cells were broken down. The removal of the

Digitized by LjOOQle

anterior half of the middle turbinal was the first step in operation.
The cavity was then lightly packed with gauze and dressed every
second day until the sinus was obliterated by granulation tissue.

(B) Maxillary antrum : a large opening in the canine fossa,
curettage, Removal of greater part of inner antral wall, suture of
bucco-antral mucous membrane. This sinus was not packed. The
anterior half of the inferior turbinal was removed as a pre¬
liminary step.

(G) Sphenoidal sinus : removal of middle turbinal, breaking down
of anterior wall of sinus by means of suitable hooks. The mucous
membrane was not curetted, but free drainage of the sinus secured,
and local medicaments could be applied during the after-treatment.

Mr. Cresswell Baber congratulated Dr. Tilley on the success of his
frontal sinus cases. The radical operation appeared to be a modification
of Kuhntz’s. He asked how long Dr. Tilley left the nasal tube in posi¬
tion. He suggested it was only necessary to keep the tube in the nose
for a short time, so as to allow the canal to granulate up as soon as
possible.

Professor Chiari (Vienna) expressed his admiration at the results
achieved by Dr. Tilley. He found the cicatrix everywhere without
deformity, either of the skin or face, a rare result in such cases. The
method used by Dr. Tilley was not quite new, but the results were so
excellent that he was glad of the opportunity of seeing the cases.

Dr. Herbert Tilley, in reply, said that the time the tube (extending
from the sinus via the fronto-nasal canal into the nasal cavity) remained
in position depended upon the size of the sinus and of the naso'-frontal
canal. If these were small, the tube could be removed even before the
external skin wound had completely healed, because the fronto-nasal canal
became obliterated and the sinus cavity could be treated as an ordinary
granulating wound. Generally speaking, the tube, which could constantly
be reduced in calibre during the after-treatment, was removed last of all,
i. e. when the whole sinus was obliterated by granulation tissue which
gripped the tube. The resulting fistula quickly healed. If the tube was
dispensed with too quickly, there was a tendency for the granulation in
the naso-frontal canal to become cedematous and infected by nasal dis¬
charges, with the result that the sinus itself became unhealthy again. He
did not claim any originality in the operation but selected for each particular
case what seemed best of the various operations which had been described
by Kiihntz, Killian, Luc, Ogston, Jansen, and others. The speaker thought
that whatever method of operation was selected, the final degree of excel¬
lence obtained would very largely depend on the degree of patience coupled
with attention to detail which the surgeon bestowed upon the case.

Woman, aged thirty-five, with Pharyngo-Laryngeal Epithelioma.

Shown by Mr. de Santi. The patient was
January, 1905, as doubtful tubercular disease, in

exhibited

February

5§

Digitized by {jOOQie

undoubted malignant disease, and condemned as inoperable. She
was now shown again for opinions as to operative interference.

Professor Moure (Bordeaux) expressed some doubt as to the diagnosis
of malignant disease being correct. Admittedly there were some small
glands in the neck, but they might not be malignant. He inclined to the
view that it was tertiary syphilitic perichondritis, and advised that before
any operation—which would have to be a radical one—were attempted,
an energetic course of antisyphilitic treatment should be tried.

Professor Gluck (Berlin) said he would be able to show on the
following day a specimen which he removed from a patient two
weeks since, which was a mixed tubercular and syphilitic affection, and
which he removed from a similar case to the one now shown. He extir¬
pated the larynx, and he hoped the pharynx would heal. If the tumour
in Mr. de Santi’s case were malignant, the case was operable, as he
himself had removed a more extensive growth than the present one.
He was of Professor Moure’s opinion, that the malignant nature of the
growth was not decided.

Professor Chiari (Vienna) recommended that a large piece of the
growth should be removed for examination by a pathologist, which would
do no harm, and would afford a satisfactory diagnosis. If it proved to
be cancer he would operate immediately. Of course, he would not operate
without knowing the nature of the condition.

Mr. de Santi, in reply, thanked especially those foreign visitors who
had expressed their opinion on the case, which was one of considerable
interest from the point of view of diagnosis. He had observed the patient
for three months, and members had seen her twice before, offering various
opinions as to diagnosis. At first he showed the case as possibly tuberculous,
the evidence, however, in regard to bacilli and chest mischief being nega¬
tive. Then the question of possible malignancy arose, and he was advised,
at one meeting, to remove a piece of the growth endolaryngeally and
submit it to the microscope, also that he should feel the growth with his
finger via the mouth. Both these were done. Though Dr. Moure was
correct as to some doubt having arisen as to the nature of the microscopic
section, this was the view of only one member, Mr. Waggett, who took the
specimen home and pronounced it doubtful. The sections were made by
an eminent pathologist, Dr. Hebb, who expressed the opinion that it was
undoubted epithelioma, and this was also his (Mr. de Santi’s) view. That
would answer Professor Chiari’s suggestion. He agreed with Dr. Moure
that there had been a large element of doubt about the case ; the small
amount of glandular infiltration was noteworthy for such an extensive
case. The general health of the patient struck him as extraordinary
each week he saw the patient. He thought the best course would
be to put the woman under a general anaesthetic, to tell her beforehand
that there was an element of doubt in the case, and perform ordinary
thyrotomy. If naked-eye inspection showed the disease to be malignant,
one should go further and do what was necessary, which, according to
Professor Gliick, would mean a very extensive operation. The woman
had been treated with iodide of potassium, but only for about ten days,
which was not long enough to determine whether it was specific or not.
But having shown her to the Society before and heard such definite
opinions expressed that it was malignant, he had not again put her upon
iodide of potassium. Ought he to put her upon a thorough course of
iodide of potassium, or to operate and see the nature of the disease? He

Digitized by {jOOQie

was in favour of an exploratory operation, and if necessary a much larger
piece of growth could be excised for examination ; subsequently the case
could b8 dealt with by a very extensive operation, namely, removal of the
whole larynx and pharnyx, part of oesophagus, and removal of glands on
both sides of the neck. As to such an operation and its effects, he had
come to the conclusion that the German subject must be “ tougher ” than
the English subject.

A Case of Unilateral Congenital Lesion of the Medulla and
Spinal Cord, with brief Notes of the Pathological Changes
in the Mouth, Throat, and Ear in a Man aged forty-one.

Photographs shown by Mr. de Santi and Dr. Purves Stewart.
For the following brief account of this most interesting and unique
case he (Mr. de Santi) was indebted to his colleague, Dr. Purves
Stewart, under whose care the patient remained until his death,
from pontine haemorrhage.

The case was brought to Mr. de Santas notice by Dr. Purves
Stewart, who asked him to examine the patient's throat, mouth,
and ear.

A complete description of the case had been published by Dr.
Purves Stewart in Brain, Spring number, 1904, Part CV, and he
had to thank Dr. Stewart for his courtesy in allowing him to bring
the case to the Society's notice, and for the following notes, ex¬
tracted from Dr. Purves Stewart's fully reported account.

The following was a brief account of the conditions found in
the mouth, throat, and ear : Lower jaw, right side, absence of any
molar teeth either of the first or second dentition. All the other
teeth erupted normally. General intelligence only moderate;
speech and articulation normal, but the voice was hoarse; smell
and taste normal both sides. Hearing dull both sides, but much
more so right side. Eight auditory meatus narrower than left and
on a higher plane. Right pinna much smaller than left. Right
mastoid process absent. Right arch of palate at rest was nearer
to mid line than the left, and on phonation the left side moved
alone, pulling the raphi upwards and to the left. Sensibility of
the mouth, pharynx and larynx was normal. Right vocal cord was
immobile in the middle line: the left cord moved freely. Right
omo-hyoid, stylo-hyoid, and posterior belly of digastric absent.
Right side of tongue smaller than the left, and the tongue on
protrusion pointed to the right. The right sterno-hyoid, sterno¬
thyroid, and thyro-hyoid muscles were absent. All the above-
mentioned muscles, which were clinically non-active, were non-
responsive to the strongest electric stimulation, faradic or galvanic.

Digitized by {jOOQie

On both sides of the tongue the reaction was normal. The
right sterno-mastoid muscle and part of the trapezius were absent,
and Dr. Purves Stewart concluded that the absence of these
muscles, together with the paralysis of the palate and vocal cord
on the same side, pointed to a congenital lesion of the spinal acces¬
sory and vagus nuclei on the right side. r

He further in his very complete published report of the case
{Brain, Spring number, 1904, Part CY) stated that the partial
hemiatrophy of the tongue indicated an implication of the hypo¬
glossal nucleus; the absence of the depressor muscles of the hyoid
bone and of the posterior belly of the digastric indicated that the
lesion extended down the anterior cornua of the spinal cord at
least as far as the third cervical segment.

The patient, whilst under Dr. Stewart’s care, suddenly died
from pontine haemorrhage, and thus a complete post-mortem ex¬
amination was obtainable.

The following points he had, with Dr. Stewart’s permission,
abstracted from his description of the autopsy : Total absence
of sterno-mastoid, sterno-hyoid, sterno-thyroid, thyro-hyoid, stylo¬
hyoid, digastric (posterior belly) and omo-hyoid muscles. Absence
of upper fibres of trapezius, middle fibres from seventh cervical to
fourth dorsal spine well developed, fibres below that level absent.
No signs of spinal accessory nerve discoverable. Right soft palate
thinner than left, and subsequent microscopic examination showed
on right side absence of levator palati and diminution in size of
azygos uvulae. Right side of tongue was smaller than the left.
The epiglottis was bent over towards the right side. '

Examination of larynx , post-mortem .—General atrophy of right
half. The thyroid cartilage with its pomum Adami was thrust
across to right side. The right middle constrictor of the pharynx
was very defective, and the styloid muscles hardly recognisable.
Right crico-thyroid entirely absent' also the right crico-aryte-
noidens posticus. Right crico-arytenoideus lateralis only a thin film
of functional pale muscle-fibres. Kerato-cricoid muscle was
present. Arytenoideus transversus and obliquus small. Right
thyro-arytenoideus feebly developed. Nerves —Absence of right
hypo-glossal nerve. Right superior laryngeal (internal laryngeal
branch) and right recurrent laryngeal nerve, although smaller
than on the left side, were recognised. Foramen caecum on
dorsum of tongue deeper than usual. Right external auditory
meatus shorter and narrower than left, but the tympanum and
auditory ossicles were normal.

Digitized by {jOOQie

Examination of the medulla oblongata showed marked abnor¬
mality. On the right side the hypoglossal nucleus and the adjacent
lower part of the accessorio-vagus nucleus were absent, whilst the
corresponding nuclei on the left side were well developed. The
spinal root of the trigeminus was much smaller on the right than
on the left side.

In the spinal cord the anterior median fissure was expanded into
a deep cleft extending from the lower part of the second cervical
to the upper part of the seventh cervical segment; the cleft
extended into the grey matter on the right side, causing much
distortion. Below the seventh cervical segment the cord showed
no abnormality.

Some conclusions arrived at by Dr. Stewart in connection with
the pathological changes in the parts referred to in this communi¬
cation : “The atrophy of the laryngeal muscles is due to the lesion of
the vagus, the lower part of whose nucleus was deficient, and whose
trunk was much diminished in size, especially its supra-laryngeal
and recurrent laryngeal branches.

“ The absence of the right levator palate and diminution in size of
right azygos uvulae and right middle constrictor of pharynx corre¬
sponds with remarkable accuracy to a lesion of that part of the
vagus formerly named the f bulbar part of the spinal accessory/

" The deformity of the temporal bone and lower jaw is probably
to be associated with the congenital smallness of the spinal root of
the trigeminus.”

A Case of Soft Fibroma of the Larynx and Neck removed by
External Operation without opening the Cavity of the
Larynx.

Shown by Sir Felix Semon. The case was previously demon- •
strated at the meeting of the Society on March 9, 1898, further
described to the Society on June 3, 1904, and in the British
Medical Journal of January 7, 1905. Besides the patient, the
tumour which had been removed and microscopical preparations
taken from sections of the growth were also shown.

Professor Chiari (Vienna) said the results were very satisfactory.
It was an extremely rare and interesting case, and though the operation
was not new, he believed this was only the second time it had been
performed. One could not imagine a better result. The patient could
breathe and speak very well. Perhaps a more energetic operator would
have extirpated half the larynx, and the patient would then have been
forced to always wear a cannula.

The President considered the result was excellent.

Digitized by LjOOQle

A Case of Complete Extirpation of the Larynx.

Shown by the President. William B-, aged fifty-two, was

admitted into G-uy’s Hospital July, 1904, under the care of
Mr. Symonds, for laryngeal obstruction. The larynx showed a
mass of new growth, nearly filling its interior, evidently growing
from the left side. On considering the case the larynx on the left
side appeared somewhat swollen externally, suggesting that exten¬
sion had already taken place through the cartilage, but no glands
could be felt. On opening the larynx the disease was seen to be
very extensive on the left side, while the anterior part of the right
cord was free. On separating the skin on the left half it was
found that the disease had penetrated the larynx and already
infiltrated the overlying muscles. It was, therefore, decided to
perform complete extirpation. In order to effect a more complete
removal the left lobe of the thyroid gland was included with all
the surrounding deep fascia so as to take up as far as possible the
lymphatic tract. The trachea was fastened to the skin, the pharynx
was closed with two rows of sutures, the muscles and skin left open,
and this cavity packed with gauze. The patient made a good
recovery, primary union taking place, except for one small spot.

The preparation showed the usual appearance of an epithelium
involving the left half of the larynx and extending across to the
right side. The extension to the muscles was not well seen, as
the preparation was imperfect. The left lobe of the thyroid body
would be seen.

Epithelioma of the Larynx in a Man aged forty-nine ; Laryngo-

FlSSURE EIGHT MONTHS AGO; NO RECURRENCE.

Shown by Dr. StClair Thomson. In this case pulmonary
tuberculosis had been arrested twelve years ago after injection of
tuberculin (vide Proceedings , vol. xi, p. 68; and vol. xii, p. 32).

Dr. Botella (Madrid) said he did not regard eight months as suffi¬
ciently long to determine whether epithelioma would recur after operation;
at least two years should elapse before regarding recurrence as unlikely.
In a very similar case in Spain recurrence occurred more than two years
after operation.

Professor Gluck (Berlin) said he had operated upon a patient aged
sixty-five, and eight and a half years after healing he had cancer in the
other side of his larynx. That and the glands were removed, and the
patient lived to the age of seventy-seven; so that operation prolonged the
man’s life eleven and a half years. Thus recurrence might take place
even eight years after the operation.

Digitized by LjOOQle

Professor Moure (Bordeaux) asked whether Dr. StClair Thomson
removed the cannula immediately after the operation and then closed the
whole wound.

Sir Felix Semon said he thought any period which might be
mentioned as constituting a “ cure ” of cancer of the larynx, whether one,
two, three, or even eight years, was purely arbitrary. There was no time
after which one could safely say the case was cured. He had had a very
considerable experience of that class of cases, as he had operated upon
about thirty cases in private practice, and had been able to follow
up their subsequent history. He would say that if operation were per¬
formed early, and the patient remained well one full year afterwards, the
chances of recurrence were extremely remote. Practically he had never
seen recurrence after one year of immunity. Still, he deprecated the use
of the word “ cure ” in such cases, because, as Professor G-liick had just
shown, recurrence might take place at any period. Moreover, Mr. Butlin
had a case of recurrence three and a half years after operation, and there
were other similar cases on record. Thus the three years’ limit was as
arbitrary as any other. Nothing which anyone else might say would
alter his opinion on this matter. Every patient would, of course, ask
whether there was a reasonable prospect of his remaining free, and he
could be conscientiously told that if he remained free one year, he might
reasonably expect to remain free always. All this, however, applied to
such cases only in which the disease was of the intrinsic variety, and in
which early and thorough operation was performed.

Professor Moure (Bordeaux) made some further remarks confirming
the opinions expressed by Sir Felix Semon.

Professor Gluck (Berlin) said he had operated on a physician aged
sixty-three and removed the right vocal cord and ventricular band. The
larynx healed perfectly, but three years afterwards he died from a cylin-
drical-celled growth, the previous tumour having been one of the flat-
celled variety. There must, therefore, have been two separate cancers in
one individual. Post mortem the larynx was removed, and was found to
be perfectly healed.

Dr. Walker Downie said he was very pleased to see the case, and
congratulated Dr. St.Clair Thomson on the result. On several occasions
he had performed thyrotomy for intra-laryngeal disease. One was in
1888, the patient being fifty-two years of age, and he had a small localised
epithelioma of the left cord. The cord was completely removed and
healed satisfactorily, and the man was still living, the cord having been
replaced by firm scar-tissue. The cicatricial band was not so marked as
in Dr. StClair Thomson’s case, but there was a fairly good voice, and
seventeen years had passed without recurrence.

Mr. de Santi agreed that the question as to a cure or not in any given
case of epithelioma of the larynx was a very difficult one, but those who
had spoken had referred to intrinsic carcinoma. He thought a distinction
must be made between intrinsic and extrinsic. His experience had been
that in extrinsic cases, if there were freedom from recurrence for a
year after operation, one could not say that in another year or so
the patient would not have a recurrence. Kecurrence was very apt
to take place in the extrinsic form. In the intrinsic form there was
a very fair chance of a long immunity if no recurrence appeared within a
year. But in all cases of cancer in any part of the body it was difficult
to tell a patient whether he could be definitely cured or not. He thought
the only way the case could fairly be put to the patient was to tell him

Digitized by

Google

that from the nature of the growth and the extent of the disease, there
was a fair chance of deriving what was called a cure, i. e. non-return for
some three years, or possibly longer. It was the same with cancer of
the breast; one’s experience was that a fairly early case might not recur
for three to five years after operation, but that it did so afterwards. The
only case of carcinoma of the body which had not recurred within his own
experience and reeollection was a carcinoma of the tongue in an old Irish¬
man, who came with a small growth on the tongue, which he removed,
taking away half the tongue and the glands in the neck. The patient
was very angry when he found that half the tongue had been removed,
but as he had not lost his Irish brogue, and he was eighty years old
when the operation was done and lived to be ninety-two and died of
bronchitis, there was good reason to be satisfied. Still, he might have
had recurrence if he had lived another year.

The Chair was here taken by Dr. Ball, Vice-President.

Dr. StClair Thomson, in reply, said he omitted to exhibit in the
adjoining room a pair of thyroid shears designed by Mr. Waggett. He
(Dr. Thomson) had only been able to use the instrument on one occasion,
but he had found it most effective, and a great improvement on cutting
through from the outside. Division could thus be made exactly in the
middle line of the larynx. In reply to Dr. Moure, he did not leave the
cannula in place. He sewed up the soft tissues over the larynx, but not
opposite to where the tube had been inserted. Dr. Moure suggested that it
was a precaution against pulmonary and other infections if the whole
wound were closed at once, but that was a view which he (Dr. Thomson)
did not think was shared in this country. There was no harm in leaving
an opening in the trachea, and it had been beneficial in the present case,
because the patient had some pneumonia from the blood inspired, and he
recovered more easily through being able to expectorate the muco-pus
through the tracheal wound. With regard to recurrence, in one of his
cases of epithelioma of the larynx, the larynx was apparently cured, hut
one year later the patient developed epithelioma of the base of the tongue
on the opposite side. He thought there was no connection between the
two, for the larynx was quite free from recurrence up to the time—three
years later-—when the patient died from cancer on the opposite side of
his tongue. His present case was especially interesting, as the man was
hoarse for a year before he was operated upon, and was shown at the
Society six months before the operation and no one would venture a
diagnosis. Finally the diagnosis was made by the fixation of the vocal
cord. The value of this symptom had been much discussed, and even
doubted by some Continental writers, but Sir Felix Semon had taught
laryngologists to lay great stress on it. The diagnosis was made without
any prior microscopical examination. The sections in the next room
showed that, as diagnosed clinically, it was undoubted epithelioma.

Primary Lupus of Larynx (quite healed) and Pharynx (nearly
healed) in a Woman aged twenty-two, with Drawings of
Original Condition.

Shown by Dr. StClair Thomson.

Digitized by

Google

A Case op Incrustations in the Trachea, with, at times, well-

marked Stenosis.

Shown by Dr. Edward Law. The patient, a young woman, had
been shown at a previous meeting.

Professor Chiari (Vienna) said Dr. Law showed him the patient that
morning, and he had just seen her again. He examined the nose and
naso-pharynx, but could not find much in the nose except chronic catarrh;
there was no stenosis of the posterior nares. He thought it was rhino-
scleroma, but did not know what the condition was in the trachea. In
the morning he saw yellow mucous crusts, but now there were white
crusts ; he had no idea where they came from.

Dr. Edward Law, in reply, said the tracheal symptoms had materially
improved since he showed the case two months ago. The patient had
been under the care of Dr. G-eorge Stoker in the Oxygen Hospital, and
had inhalations of oxygen and ozone for several hours daily, and had
been sleeping in a cubicle designed for such treatment. The first inch of
the trachea was now free from incrustations, and the patient was in a
better condition than three months ago, when she was having various
sprays and inhalations. If the present treatment did not cure her he
would try formalin later.

Series op Microphotographs.

A beautiful series of microphotographs was shown by Dr.
Milligan: (1) Angioma of left vocal cord; (2) lymphangioma of
vocal cord; (3) papilloma of uvula; (4) tubercular diseases of the
uvula; (5) laryngeal papilloma; (6) papilloma of tonsil; (7) sarcoma
of nasal septum; (8) angio-sarcoma of middle turbinated body; (9)
epithelioma of nasal mucosa.

Case of . Epithelioma of the Nose (shown at the January
Meeting, 1904) ; Patient, Macroscopic and Microscopic
Specimens and Photographs.

Shown by Mr. Atwood Thorne and Mr. J. R. Lunn. This was
the case of a man, aged seventy, first seen at the London Throat
Hospital in January, 1904. He had then complained of increasing
difficulty of breathing through the right nostril for a month or so.
The nose was a good deal enlarged, and the right nostril was
occupied by a granular mass arising from both the inner and outer
walls of the vestibule. A portion of the growth was removed, and
this both gave the patient a better breathing space and enabled ar
diagnosis of epithelioma to be made.

The condition about this time was well shown in the photographs.
At a previous meeting he (Dr. Atwood Thorne) asked if the nose

Digitized by

Google

should be removed, but opinions were on the whole unfavourable
to operation.

After the meeting the growth increased somewhat in size. No
bed being available at the London Throat Hospital, he was admitted
on February 2 to the Marylebone Infirmary.

When admitted there the patient’s nose was occupied by a large
everted ulcerating growth about the size of a small apple which
was breaking down, he had a tender gland in the neck on the right
side. The patient’s general condition was fairly good, except for
the inconvenience of the discharge from the growth into the nose.
He stated he had always had excellent health; he had been in the
habit of taking snuff for the last thirty-five years. No history of
syphilis or tuberculous disease could be obtained. Mr. Lunn
operated on February 4th, 1904; the sides and front of the large
mass occupying the nose was injected with half an ounce of a
sterlised solution of adrenalin 1—5,000. This made the nose quite
blanched and bloodless, and it was then excised, no bleeding took
place, and no vessels were tied. The nasal bones in front and the
vomer were cut away, the upper and lower edges of the wound were
brought together by catgut sutures. On February 9th the patient
was submitted to the X rays, and this treatment was continued
twice a week for some time, when he developed eczema, but no good
results apparently followed the application of the X rays. Mr. Lunn
also tried grafting the raw surface, but the grafts did not take
owing to the profuse discharge from the Schneiderian membrane.
After the removal of the growth,the gland in the neck disappeared.
Before he left the infirmary, the patient was given glasses for
distance and reading, and the false nose was fixed to the spectacle
frame.

Report of the specimen by the Clinical Research Association,
February 12^,1904.— Sections (1) showed some irregular masses of
epithelium which probably represented the outlying processes of an
epithelioma. (This specimen was taken from the centre of the
growth.) The other section (2) was removed from the outer, side of
the incernus to see if one had got clear of the growth ; it contained
many large sebaceous glands, and a few foci of inflammatory cells,
but no traces of epithelioma.

The patient was shown with his. nose as removed, and also
microscopic specimens (1) taken from tfye growth and showing dis¬
tinct epithelioma; and (2) a specimen taken at the completion of
the operation from the edges of the wound, containing many
sebaceous cysts and inflammatory cells, but no traces of epithelioma.

Digitized by OjOOQle

Cicatricial Diaphragm due to Inherited Syphilis passing from
the Posterior Third of the Tongue to the Posterior Wall
of the Pharynx.

Shown by Mr. H. Betham Robinson. The patient who exhibited'
the above condition was a female, aged twenty-two. The cicatricial
diaphragm passed backwards almost horizontally to the pharynx at
the junction of the upper third with the lower two thirds of the
epiglottis : the latter projected through the central opening and its
right margin at the point of crossing of the diaphragm was adherent
to it. Out of the left margin of the epiglottis was a notch due to
specific destruction, and the whole epiglottis was drawn down over
the larynx so as to put the median glosso-epiglottic fold upon the
stretch. Below the diaphragm the larynx could be seen quite
healthy, the view of the latter being particularly seen through the
deficiency in the left margin of the epiglottis. There was no
marked difficulty in swallowing. The soft palate was adherent to
the posterior pharyngeal wall, mainly on the left side, and its lower
edge was here eroded. There were evident specific changes in the
nose, and externally the bridge was depressed and broadened.

She had interstitial keratitis at seven years old. The teeth were
bad but showed nothing characteristic.

The syphilitic history was very complete. The mother at the
present time attended Mr. Robinson's department with necrosis of
the septum nasi, and the father had been in the hospital with a
syphilitic nerve lesion. The mother never had any miscarriages,
but had nine children, the last five of whom were born dead.

Case of Pharyngeal Diverticulum opening into the Pyriform
Fossa in a Woman aged fifty-one, with Rontgen Ray
Photograph showing the Pouch when filled with Bismuth.

Shown by Dr. Dundas Grant. The patient was a sparsely
built woman of small stature, aged fifty-one, who for about a year
had been conscious of a slight difficulty in swallowing. On exami¬
nation the right pyriform fossa was seen to be filled with frothy
fluid; the larynx was otherwise normal. An oesophageal bougie
passed without any difficulty. At first suspicions were entertained
that it might have been a case of early epithelioma in the pyriform
fossa, but after careful mopping no signs of epithelial sprouting
were found. To the right side of the thyroid cartilage was an
elongated swelling resembling a mass of enlarged lymphatic glands

Digitized by

Google

lying on the carotid artery, from which it received a communicated
pulsation. When this swelling was compressed the fluid in the
pyriform fossa exuded in increased quantity. On inquiry it was
elicited that small particles of food returned at intervals of several
hours after swallowing, and the condition was then believed to be
a diverticulum of the pharynx. Attempts were made to introduce
a' curved probe into the cavity, but without success. Rontgen ray
photographs were taken by Dr. Mackenzie Davidson before and
after the swallowing of bismuth by the patient; in the latter the
bismuth emulsion was seen to collect like ink at the level of the
swelling, and in the subsequent photograph there could be seen an
elongated area of opacity in the same region, which was not visible
in the previous one, and which could only be accounted for by the
bismuth (opaque to the Rontgen rays) having collected in the sac.
This appeared to confirm the diagnosis, and it was proposed to
remove the sac by an operation from outside.

Dr. Watson Williams asked whether the opening could be seen, and
whether food lodged in the pouch.

Dr. Dundas G-rant, in reply, said he could not see the opening, but
only frothy mucus exuding from the pyriform fossa on the right side.
That was increased by pressing the little swelling at the level of the
thyroid cartilage, and apparently it lay upon the carotid artery, from
which it received a slight pulsation. He showed a Rontgen ray picture
of the condition after the patient swallowed bismuth. Before doing so
the oval black mark was not visible. He proposed to operate on the case.
On no occasion had food remained in the pouch till the next day.

Fixation of Left Vocal Cord in a Man aged forty-nine, with
a Pulsating Thoracic Aneurysm.

Shown by Dr. H. J. Davis. The patient had been shown to
the Society in May, 1904, through the kindness of his colleague,
Mr. Stephen Paget, when no signs of aneurysm were present
either by examination or radiogram. When he first presented
himself at the hospital in January, 1904, he complained only of
intense weakness and regurgitation of fluids through the nose
There was paralysis of the right side of the palate, weakness and
wasting of the muscles of the right arm, a “ squeaky ” voice and
slight hoarseness. The left vocal cord was seen to be fixed and
the right cord swung across the middle line in phonation. The
pulses and pupils were unequal, the heart-beats were feeble, but
there was no evidence of hypertrophy or any other signs of
aneurysm. The patient was a hansom cab driver; formerly he

Digitized by CjOOQle

had served fifteen years in the United States Mercantile Marine.
There was a history of syphilis contracted on two occasions, and
the knee-jerks were exaggerated.

Dr. de Havilland Hall had then expressed the opinion that
the case was one of aneurysm.

The patient had since been treated with 15 grains of iodide of
potassium in a mixture containing a dram of Easton's syrup, and
he (Dr. Davis) had found this a useful prescription, as the Easton's
syrup acted as a good general “tonic" and markedly counteracted
the depressing effects which usually resulted when iodides were
taken for a long period. The mixture had to be well diluted.

All the symptoms of weakness, and regurgitation of food into
the nose, disappeared under iodides, but four months ago distinct
“ heaving" was noticeable to the left of the sternum. The patient
had constant pain in the chest, and on three occasiojis an attack
of Angina Pectoris.

The signs of aneurysm were now well marked. The constant
hacking cough had been markedly relieved by 3jss. of Syr.
Codeine, and this accounted for the fact that the pupils were now
symmetrical and both contracted.

The points of interest in the case were :

(1) That the voice was not hoarse or gruff, but high pitched and
“ squeaky."

(2) That the typical signs of aneurysm were so long delayed
after the patient's first appearance at the hospital for treatment.

(3) That the fixation of the left vocal cord co-existed with a
paralysis of the right half of the palate and paresis and wasting of
the right arm, which tended to mask the signs on which we relied
in diagnosing aneurysm, and pointed rather to a lesion of central
origin.

(4) That all the symptoms of central trouble had disappeared
under iodides.

(5) That the pulsating swelling was too far to the left of the
sternum, and too low down to have originated in the first or second
part of the arch, and that it was, therefore, a deep-seated aneurysm
which had reached the surface of the chest.

(6) That the patient had twice contracted syphilis, infected his
wife, and that she had now marked signs of tabes dorsalis, with
gastric crises and lightning pains.

He (Dr. Davis) had seen and heard of so many cases of fixation
of a left vocal cord attributed to early aneurysm, and where this
diagnosis had subsequently been proved to be incorrect, that he

Digitized by LjOOQle

thought it was of interest to see a case where an aneurysm really
existed, and was the undoubted cause of the lesion.

Dr. Permewan said he had come to the conclusion that the great
majority of cases of paralysis of the left vocal cord were due to aortic
aneurysm, where no particular cause could be found for it. He, and
probably others also, could think of cases in which no signs had shown
themselves for several years, but in which aortic aneurysm had eventually
been found. He believed fully nine tenths of such cases of paralysis of
the left cord were due to that cause.

Professor Poli (Italy) expressed the view that a paralysed left vocal
cord did not by any means prove the presence of aneurysm, though in the
main his experience confirmed what the previous speaker had stated. He
asked if any tracheal tugging was present.

Dr. FitzGerald Powell said he would be sorry for Dr. Permewan’s
statement to go forth as a dictum from the Society. Aneurysm of the
aorta occurred in many cases in one’s experience, but most of the cases of
paralysis of the cords were due to syphilitic and tubercular lesions. He
had shown a case in which the paralysis occurred as a result of the toxin
of influenza.

Dr. Jobson Horne concurred with Dr. Permewan that the vast
majority of the cases of paralysis of the left vocal cord without signs to
account for the fixation were due to aneurysm. Dr. Home added that he
would not regard the search for signs to be complete in such a case
without a radiograph of the thorax. Amongst the exceptions were these
cases in which the nerve had become implicated in enlarged lymphatic
glands or in a deep-seated new growth, and Dr. Horne referred to a case
he had shown to the Society some years ago in illustration of that point.

Dr. Ball (in the Chair) thought the duration also should be taken
into account. If one included cases in which a cord had been paralysed
for a long time without any symptoms appearing, he did not think that
in nine tenths of the cases it would turn out to be aneurysm. A very
large proportion of cases which had lasted not more than a year or two
turned out to be aneurysm: but he had met with cases in which a vocal
cord had been paralysed for an indefinite period, and no one could
account for it. It might happen with either cord.

Professor Koenig (Paris) said that if Professor Vemicker were
present he would tell the meeting of a case in his clinique aged forty or
forty-five, whom he showed frequently for several years, who had paralysis
of both posticus muscles. They moved only very slightly from the
middle line. The patient breathed fairly well, and no aneurysm was
found, nor anything to explain the condition. It was probably a case of
neuritis.

Dr. Watson Williams said that, having seen many similar cases as
a general physician, his experience certainly bore out Dr. Permewan’s
remarks that where there were no other symptoms or physical signs of
other lesions, nine tenths of the cases of paralysis of the left vocal cord
were due to aneurysm. On that assumption he had several times had
the diagnosis confirmed.

Dr. Dundas Grant said that, while agreeing in the main with what
had been said with regard to paralysis of the left vocal cord, there had
been two curious cases in his experience. One seemed to be attributable
to alcoholic poisoning, which got well when the patient corrected his
habits. The other was a case which he saw seven or eight years ago,

Digitized by {jOOQie

in a comparatively young woman, who had fixation of the left vocal cord,
but there was nothing discoverable to account for it. She was delicate,
but he could find no evidence of tuberculosis. He heard a day or two
ago that she died very recently of pulmonary tuberculosis. He believed
the left recurrent nerve was involved in a tuberculous gland.

Dr. Smurthwaite said he had seen three post mortems in which the
patients suffered from paresis of vocal cord, in two cases of the left cord
and in one of the right. In one there were no symptoms of aneurysm,
and no glands could be felt at the triangles. Post mortem a small gland
was found, in which the recurrent laryngeal nerve was tightly .embedded.
In one case the patient had haematemesis and haemoptysis, and it could
not be discovered whether she had carcinoma of the stomach or phthisis.
Post mortem it was found that a small old gland had ulcerated into the
trachea and oesophagus, involving at the same time the recurrent laryngeal
nerve. The third case—paresis of the right cord—was thought to have
aneurysm in the region of the subclavian. At the post mortem the
aneurysm was not pulling on the right subclavian, but there were ad¬
hesions where the nerve recurred around the subclavian and passed up on
to the trachea. The nerve was embedded in old adhesions.

Dr. Permewan said, in further explanation, that he was familiar with
right cord paralysis ; but in cases of paralysis of the left cord, lasting a
considerable time, where there was no local disease in the larynx itself,
and without any cause which one could be sure of, the vast majority
would be found to be due to aortic aneurysm.

Dr. Davis, in reply, said that there was no tracheal tugging and no
physical signs in the heart. The first part of the arch was certainly not
affected; he thought that the aneurysm had been deep-seated and had
now reached the surface of the chest; it could not be a mediastinal new
growth, as the swelling was expansile on pulsation.

Case 1. Epithelioma of Epiglottis and Base of Tongue removed
by Sub-Hyoid Pharyngotomy.

Shown by Dr. Lambert Lack. Previously exhibited to the
Society in January, 1904. The patient first came under his care
in May, 1903, suffering from epithelioma of the epiglottis, the
glosso-epiglottic fossa, and adjacent part of the tongue. There
were enlarged glands in both anterior triangles of the neck, especi¬
ally hard and fixed on the left side.

The skin incisions extended from near the tip of the mastoid
on either side of the neck along the anterior border of the sterno-
mastoid muscle to the level of the cricoid cartilage. Both anterior
triangles were completely dissected, all glands, fat and fascia being
removed, and the large vessels fully exposed. The lateral incisions
were then united by a transverse one passing across the front of
the neck immediately below the hyoid bpne. Laryngotomy was
performed and the pharynx opened by a transverse incision through
the thyro-hyoid membrane immediately above the upper border of
the thyroid cartilage. The epiglottis was thus cut through well

Digitized by CjOOQle

below the disease. It was drawn out of the wound, and thus the
growth was brought into full view and removed freely. The stump
of the tongue was then sutured to the thyroid cartilage and the
remains of the epiglottis. The opening in the pharynx was closed
by a series of closely set, fine, interrupted sutures passing through
mucous membrane only. The over-lying fascia, muscles, etc. were
then very carefully sutured to strengthen the union. Finally the
larger muscles were sutured and the skin incision closed. Drainage
tubes were inserted in both sides of the neck.

The patient .made an uninterrupted but slow recovery. There
was some suppuration of both sides of the wound, and for three
weeks the patient was unable to swallow without coughing.
During this time he was fed through a tube.

He regarded the complete closure of the wound in the pharynx
with several layers of interrupted sutures the most important part
of the operation.

Now (nearly two years later) the patient remained well, free
from recurrence, and in excellent health. He was able to swallow
well and speak well. Microscopical examination showed typical
squamous epithelioma.

Case 2. Epithelioma of Right Arytenoid and Adjacent Parts,
Removed ry Lateral Pharyngotomy.

Shown by Dr. Lambert Lack. The patient, a man aged fifty-six,
was seen in association with Mr. Peake and Dr. Watson Williams,
both of whom kindly assisted at the operation.

The glands in the neck were first noticed in January, 1904.
On February 18 there was oedema and ulceration of the right ary¬
tenoid. Iodide of potassium, 60 grains a day, was given for a
month without improvement. On March 18 the disease was ob¬
viously malignant, and the case was referred to me. At this time
there was an irregular cedematous swelling of the right arytenoid,
complete fixation of the right side of the larynx, and no enlarged
glands could be felt in the right anterior triangle of the neck.
Although the growth was attached to the posterior surface of the
arytenoid, Dr. Lack advised its removal, believing it to be strictly
circumscribed, and both his colleagues agreeing, operation was
performed on April 3.

A skin incision was made in the median line from the hyoid
bone to within a finger's breadth of the sternum, and a second
curved incision was made from the upper end of this cut outwards

Digitized by {jOOQie

along the lower border of the hyoid bone to the anterior border of
the sterno-mastoid, and upwards to end just below the mastoid
process. The large triangular flap thus marked out was dissected
up and turned outwards. The object of this incision was to render
it possible to remove half the larynx, or even the whole larynx, if
it should be found impossible to excise the growth otherwise. The
anterior triangle was first cleared out, one large and several small
glands being removed. Then the trachea was opened and a Hahn's
cannula inserted. The pharynx was opened by a vertical incision
just behind the posterior border of the thyroid cartilage. This in¬
cision was found to be just beyond the growth, which was exposed
and clipped out with scissors together with a half-inch margin of
surrounding healthy mucous membrane. The excised parts con¬
sisted of the whole of the right arytenoid, the right aryepiglottic
fold, and a small portion of the pharyngeal wall. The opening in
the pharynx was then closed by three layers of closely applied
sutures. The first layer united the mucous membrane of the
arytenoid and of the interior of the larynx to that of the lateral
pharyngeal wall. The skin wound was then stitched up and a
drainage-tube inserted. The Hahn's cannula was retained for
about a week, and the patient during this time was fed with a
tube, although he was able to swallow a little. He made an un¬
interrupted recovery, and was quite well in a month.

At the present, time he was in good health and free from all
signs of recurrence. He could swallow naturally, but his voice
was rather hoarse and weak. The left cord swung across the
middle line in phonation to meet the right.

These two cases were exhibited to draw attention to the fact
that growths in the pharynx, even growths affecting both pharynx
and larynx, the most unfavourable situation of all, could be re¬
moved if seen early enough, without in any way impairing any
important function, and with fair prospect of complete success.
Too many of such cases were considered to be inoperable merely
because the parts affected by these growths were considered
inaccessible to the surgeon.

Dr. Herbert Tilley congratulated Dr. Lack on the excellence of the
results which he had obtained in these cases which had been considered
inoperable. He had had the pleasure of seeing Dr. Lack operate upon
some of these extensive cases and thought the level of excellence obtained
in these cases was equal to that which had been reported from other
countries.

Dr. Watson Williams remarked that Dr. Lack’s second case had

Digitized by

Google

come under his (Dr. Williams’) care, and considering the patient’s age and
the extent of the disease, he thought it was not a favourable case for
operation. However, he had the pleasure of assisting Dr. Lack at the
operation, and the result he felt sure would call forth the congratulation
of members, as it certainly did his own.

Two Cases of Tubercular Laryngitis, healed under Treatment.

Shown by Mr. H. Barwell. C. R-, a man aged thirty-three,

came under Mr. Barwell’s care on November 17, 1904, suffering
from hoarseness and dysphagia of moderate severity for seven
months. There were signs of early phthisis at both apices; both
testicles had been removed for tuberculosis a year before; the
general health was fairly good.

On examination, both arytenoids were much swollen, the left
especially; there were interarytenoid granulations; the left ventri¬
cular band was enlarged, and the left cord thickened, red, and
granular.

Altogether eleven large pieces were removed from the arytenoid
region with Lake’s punch-forceps, and applications of a solution of
lactic acid, formalin, and carbolic acid used daily.

Treatment was discontinued on January 31, 1905, and the con¬
dition had not changed. There were now no laryngeal symptoms
present, but some enlargement of the false cord remained and a
little thickening on the anterior aspect of the arytenoid region,
but the parts were entirely covered with sound epithelium.

A microscope slide from one of the pieces removed was shown,
and the section was typical of tuberculosis.

A. W-, a woman aged thirty-one, came under Mr. Barwell’s

care in November, 1903, having suffered from hoarseness and
almost constant aphonia for three years. There was consolidation
at the left apex.

The larynx showed diffuse red infiltration of the left cord, with
an ulcer at its centre and numerous small interarytenoid granula¬
tions. She was treated as an out-patient throughout, with weekly
frictions of the lactic acid, formalin, and phenol solution. In June,

1904, the ulcer was healed, but the infiltration of the cord remained
as also the interarytenoid outgrowths, and aphonia persisted. In
August the voice returned and became steadily stronger; and in
October the left cord was only slightly thickened in front, and the
interarytenoid outgrowths had disappeared, leaving a slight uniform
thickening; phonation was good. Treatment was then discon¬
tinued, and at the present time the larynx remained soundly healed.

Digitized by {jOOQie

Case op Cerebro-spinal Rhinorrhcea which had apparently
Recovered Spontaneously.

Shown by Dr. Watson Williams. S. C -, female, aged forty-

three. She was shown in the Laryngological Section at the Annual
Meeting of the British Medical Association at Cheltenham in 1901,
and the case was reported in the British Medical Journal for 1901,
vol. ii, in association with Dr. Stocker. She had been in good
health till March, 1901, when she had a febrile attack resembling
influenza, but with the constant dripping of cerebro-spinal fluid
from the right nostril. She lost a pint of fluid daily during the
waking hours and a good deal more which ran down the throat
posteriorly during the night. The tests applied to identify the
escaping fluid were described in the original report. Professor
Osier had then suggested the desirability of trying continuous
lumbar puncture, and in this way Dr. Stocker had endeavoured to
give relief, but without avail. The escape of fluid persisted with¬
out alternation till about three months ago, when it began to lessen,
and after decreasing steadily it ceased to flow a month ago. She
was subject to very severe frontal headaches about once every
month or six weeks, but these were not different in character or
frequency to the headaches from which she had suffered for many
years, nor were they appreciably modified during the four years
she had the nasal flow. The patient seemed now fairly normal,
and nothing abnormal has ever been detected in her nasal passages
except the flow of fluid.

Case op Sphenoidal and Posterior Ethmoidal Sinusitis, Cured.

Shown by Dr. Watson Williams. This patient, a male, had for
fourteen years complained of a bad taste in the mouth, with sym¬
ptoms of gastric catarrh. He had had treatment for the gastric
symptoms, and finally daily washing out of the stomach without
any marked or permanent benefit. Since coming under Dr. Watson
Williams* care, the posterior ethmoidal cells and sphenoidal sinus
on the right side had been laid open, and the cessation of nasal
purulent discharge had been followed by very marked relief to the
gastric symptoms, while the patient's general health and weight
had shown marked advance. Inspection through the nose anteriorly
allowed a view of the opened sphenoidal sinus.

Digitized by LjOOQle

A fine collection of naked-eye and microscopical preparations,
selected and arranged by Dr. Pegler, Curator to the Society,
were on view during the day. The following is a list of the
catalogued exhibits :

Section A. NAKED-EYE SPECIMENS.

I. Larynx.

1. Inflammatory (Edema of the Larynx ceasing below at the ventri¬

cular bands. University College Hospital Museum.

2. Pachydermia of the Larynx. Guy’s Hospital Museum.

3. Pachydermia of the Larynx in a man aet. 34. Glottis much

stenosed and completely closed in one situation. Mr. R. Lake.

Royal College of Surgeons’ Museum.

4. Diffuse Pachydermia of the Larynx in a case of suspected syphi¬

lis. St. Bartholomew’s Hospital Museum.

4a. Lymphoma of the Larynx, involving the Epiglottis, Ventricular
Band, and Arytenoid Cartilage, etc., of the left side. ‘Lancet,’
Oct. 15th, 1887. Dr. Clifford Beale.

Great Northern Hospital Museum.

5. Papilloma of the Larynx. St. George’s Hospital Museum.

6. Diffuse Papilloma of the Larynx in a child two years old. Aditus

completely filled by a densely papillomatous growth.

St. Bartholomew’s Hospital Museum.

7. Simple Tumour of the Larynx. A papillated cauliflower excres¬

cence attached to each vocal cord and below anteriorly in the
middle line ; young woman set. 17. (Death from suffocation.)

University College Hospital Museum.

8. Large lobulated Lipoma of the Larynx growing from the right

aryepiglottic fold; removed from a man set. 24, who could
eject it into the mouth at will.

St. Thomas’s Hospital Museum.

9. Fibro-lipoma of the Larynx. The growth could be protruded

into the mouth. (Death from suffocation.)

Westminster Hospital Museum.

10. Tuberculosis of the Larynx. Deep ulcer of the left vocal cord

causing longitudinal fission in a man set. 49.

Brompton Hospital Museum.

11. Tuberculosis of the Larynx. Both vocal cords are split, and the

arytenoid cartilages laid bare by ulceration.

Brompton Hospital Museum.

12. Leprosy of the Larynx. Swelling and ulceration.

St. George’s Hospital Museum.

13. Leprosy of the Larynx; later stage ; cicatricial contraction. From

Leper Asylum, Trinidad. St. George’s Hospital Museum.

14. Glanders of the Larynx affecting the epiglottideal region.

St. George’s Hospital Museum.

Digitized by LjOOQle

15. Laryngeal Ulcer with necrosis of Cricoid and one Arytenoid

Cartilage in Typhoid. St. Bartholomew’s Hospital Museum.

16. Diphtheria of the Larynx and Trachea in a case of Tuberculosis

of the Lung. St. George’s Hospital Museum.

17. Foreign Body in the Larynx. Aditus completely obstructed by a

piece of meat. ‘ Proc. Laryng. Soc. of London,’ vol. iii.

St. Bartholomew’s Hospital Museum

18. Artificial dilatation of the Pyriform Fossa of the Larynx into a

Pouch : produced by Indian native for secreting rupees; also
leaden disc used for the purpose.

St. Bartholomew’s Hospital Museum.

19. Larynx from a case of Aortic Aneurysm which complicated the

left recurrent Laryngeal Nerve. Atrophy of the left crico-
arytenoideus posticus, and crico-arytenoideus lateralis.

St. Thomas’s Hospital Museum.

20. Fasciculated Sarcoma of the Larynx (spindle-cell sarcoma).

St. George’s Hospital Museum.

21. Carcinoma of the Larynx in a Woman aet. 35. Papillomata had

been removed intra-laryngeally from the glottis four years before
death. Squamous-cell epithelioma. Sir Felix Semon.

Royal College of Surgeons’ Museum.

22. Carcinoma of the Larynx (squamous cell). Sagittal section through

tongue, larynx, trachea, pharynx, and oesophagus, man jet. 42
‘ Proc. Laryng. Soc. of London,’ vol. iii.

St. Bartholomew’s Hospital Museum.

23. Carcinoma of the Larynx. Complete extirpation. Mr. Charters

Symonds. Guy’s Hospital Museum.

24. Carcinoma of the Larynx. Partial excision for squamous-cell

carcinoma of the ventricle of Morgagni (the case of the late Mr.
Montague Williams). Sir Felix Semon.

St. Thomas’s Hospital Museum.

25. Carcinoma of the Larynx. Partial excision of the true and false

vocal cords for carcinoma on the under surface of the vocal
cord in a gentleman set. 50. Mr. Butlin.

St. Bartholomew’s Hospital Museum

II. Nose and Accessory Cavities.

26. Fragments of deviated Septum Nasi with spur removed by

complete submucous resection, ‘ Proc. Laryng. Soc. of London,
vol. xi. Dr. StClair Thomson.

27. Papilloma of the Septum Nasi, removed from a man set. 89; no

recurrence. Mr. P. de Santi. Westminster Hospital Museum.

28. Large polypi attached to the inferior and middle turbinals; a

smaller polypus seen in the frontal sinus.

St. Bartholomew’s Hospital Museum.

29. Right side of a child’s head in which the nasal passages are

blocked by a fibrous tabulated polypoid growth from the mucous
membrane. Rapid growth ; death from suffocation.

St. Bartholomew’s Hospital Museum.

Digitized by LjOOQle

30. Carcinoma of the Antrum (spheroidal-cell). A large firm growth

extending upwards from the antrum into the orbit, and inwards
filling the nostril on the right side. Woman set. 64. Death from
epistaxis. St. Bartholomew’s Hospital Museum.

III. Naso-Pharynx.

31. Naso-pharyngeal fibroma attached to the base of the skull and
internal pterygoid plate in a boy set. 12. Removed through the
nares. Dr. Dundas Grant.

32. Two halves of a large naso-pharyngeal polypus removed from a
man get. 17, by splitting the palate and removal of the upper
jaw. Angeio-fibroma. St. Bartholomew’s Hospital Museum.

33. Two large Polypoid Masses removed by operation from the Naso¬

pharynx of a boy get. 14. Angeio-fibroma.

St. Bartholomew’s Hospital Museum.

34. Right Superior Maxilla removed from this case.

35. Large Naso-pharyngeal Polypus attached to the base of the

skull in a boy get. 14 ; removed through an opening in the roof
of the mouth. St. Bartholomew’s Hospital Museum.

IV. Pharynx and (Esophagus.

36. Pharyngeal tumour, commencing from left tonsil, extending
upwards to the naso-pharynx, and ultimately protruding through
the left external auditory meatus.

University College Hospital Museum.

37. An (Esophageal Diverticulum removed by operation from a

gentleman get. 50. Mr. Butlin.

St. Bartholomew’s Hospital Museum.

38. An (Esophageal Pressure Pouch which opened from the junction

of the Pharynx and (Esophagus. Removed from a lady get. 50.

Mr. Butlin. St. Bartholomew’s Hospital Museum.

39. Epithelioma of the (Esophagus. Specimen showing an epithelio-

matous stricture, with a Symonds’ tube in situ. Mr. Charters
Symonds. Guy’s Hospital Museum.

40. An (Esophageal Pouch, the size of a pigeon’s egg, projecting from
the anterior wall on a level with the bifurcation of the trachea.

Guy’s Hospital Museum.

The thanks of the Society are due to the Curators and Museum Authorities
of the respective Hospitals who have kindly lent the above Specimens for this
occasion .

Section B. MICROSCOPICAL PREPARATIONS.

I. Larynx.

1. Section of Epithelioma of the Right Vocal Cord from a case of
Thyrotomy ; gentleman get. 50. ‘ Proc. Laryng. Soc.,’ vol. xii,

p. 41. Sir Felix Semon.

Digitized by LjOOQLe

A collection of nineteen other microscopical preparations (by
Mr. S. G. Shattock), of malignant'disease operated on by thyro-
tomy or partial extirpation by Sir Felix Semon, is also exhibited.

2. Section of Endothelioma of the Larynx in a Case of Tertiary

Syphilis; woman set. 50. ‘ Proc. Laryng. Soc./ vol. xi. Dr.

Lambert Lack.

3. Section of Sarcoma of Interior of Larynx and Thyroid Gland.

‘ Proc. Laryng. Soc./ vol. vii. (Specimen shown.) Dr. Dundas
Grant.

4. Section of Soft Fibroma from the Aryepiglottic Fold; young

woman aet. 17. ‘ Proc. Laryng. Soc.’ vol. xii. (Specimen shown.)
Dr. Dundas Grant.

II. Nose and Accessory Cavities.

5. Section of Polypoid Growth of Septum showing Localised Psoro¬

spermosis. Also a description of the new organism “ Rhino-
sporidium Kinealyi ” by Prof. Minchin, and a drawing from life.

‘ Proc. Laryng. Soc.,’ vol. x. Major F. O’Kinealy, I.M.S.

6. Section of Papilloma of the Septum from a specimen measuring

six and a half inches in circumference. ‘Proc. Laryng. Soc./
vol. iv. Mr. Logan,Turner.

7. Section from a case of Rhino-scleroma; woman aet. 26. ‘Proc.

Laryng. Soc., vol. vii. Dr. Dundas Grant.

(Drawings of other cases will be shown, kindly lent by Mr.
* Shattock, Royal College of Surgeons.)

8. Section of Bleeding Polypus of the Septum. Type of granuloma;

a recrudescence after six weeks ; woman aet. 38. ‘ Proc. Laryng.

Soc./ vol. xi. (Drawings shown.) Dr. Scanes Spicer.

9. Section of Bleeding Polypus of the Septum. Type of granuloma

exhibiting fibromatous and cavernomatous development; woman
aet. 33 (a coloured drawing also shown). ‘Proc. Laryng. Soc./
vol. x. Mr. Hunter Tod.

10. Section of Bleeding Polypus of the Septum. Type of fibroma

with marked endothelial proliferation ; man aet. 29 (a coloured
drawing shown). ‘ Laryng. Soc. of Lond./ vol. iii. Dr. StClair
Thomson.

11. Section of Bleeding Pplypus of the Septum. Type of telangiec-

toma. ‘Proc. Laryng. Soc./ vol x.; (a drawing also shown.)
Dr. A. Brown Kelly.

12. Section of bilateral lymphoid tumour of Septum (lymphoid tissue

rich in follicles) growing from close to the posterior choanae;
man aet. 19. ‘Proc. Laryng. Soc./ vol. v. Dr. Pegler.

13. Section of Cystic Tumour depending from roof of Left Nasal

Cavity; man aet. 29. ‘Proc. Laryng. Soc./ vol. ix (with
drawing). Dr. Pegler.

14. Section of large Fibroma of Nasal Septum which extended into

the naso pharynx and formed a rounded hollow in the base of the
skull (drawing and specimen shown). ‘Proc. Laryng. Soc./
vol. iii. Mr. W. R, H. Stewart.

Digitized by

Google

1$: Section of Papillary Columnar-cell Carcinoma of nasal cavity
removed by radical operation; man set. 24. ‘ Proc. Laryng.

Soc./ vol. xi. Sir Felix Semon.

16. Section of oedematous Angeio-fibroma from the maxillary antrum
occluding left nostril; woman set. 60. ‘Proc. Laryng. Soc./
vol. xi. Dr. Adolph Bronner.

• 17. Section of Granulomatous New Growth from the Antrum and

Ethmoidal Cells. ‘ Proc. Laryng. Soc./ vol. xi. Dr. Scanes
Spicer.

18. Section of Endothelioma of the Antrum; man set. 50. ‘Proc.

Laryng. Soc./ vol. xi. Dr. Lambert Lack.

III. Naso-pharynx.

19. Section of Angeio-fibroma (of hard consistence) of naso-pharynx

with additional attachments to the Ethmoidal and Antral
Cavities. ‘ Proc. Laryng. Soc.,’ vol. x (specimen shown). Dr.
Herbert Tilley.

20. Section of CEdematous Angeio-fibroma (of soft consistence)

of naso-pharynx and nasal cavities, attached to the Base of the
SphenoicL ‘ Proc. Laryng. Soc./ vol. vii. Dr. Pegler.

IV. Pharynx.

21. Section of Polypoid Growth of lymphoid character springing

from the right supra-tonsillar fossa. ‘ Proc. Laryng Soc./ vol. vi.
(with coloured drawing). Mr. Arthur Cheatle.

22. Section of Tonsil showing colonies of Actinomycosis, girl set. 16.

‘Proc. Laryng. Soc./ vol. xii, p. 65. Mr. Arthur Cheatle
and Dr. Emery.

Digitized by LjOOQle

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Ninety-seventh Ordinary Meeting, April 7 , 1905 .

Charters J. Symonds, F.R.C.S., President, in the Chair.

Philip R. W. de Santi, P.R.C.S. •) Secret aries
Henry J. Davis, M.B., M.R.C.P. j becretanes -

Present —30 members and 1 visitor.

The minutes of the preceding meeting were read and confirmed.

William Douglas Harmer, M.C.Cantab., F.R.C.S., London, was
nominated for election at the next meeting.

The following cases, photographs, and specimens were then
shown:

The President announced that Professor Onodi, of Buda-Pesth,
had presented to the Society a number of valuable plates illus¬
trating the anatomy of the frontal and other sinuses. Professor
Onodi attended the Oxford meeting and exhibited these plates.
He had written a letter specially thanking the Society for its
courtesy. The drawings would be placed in the library, where
they could be accessible to members. The Secretary had been
requested by the Council to acknowledge the gift, conveying the
best thanks of the Society to Professor Onodi.

The President, on behalf of the Secretaries, requested members
to alter the shorthand reporter's notes as little as possible. In
some instances the alterations were so extensive as to change the
complexion of what had been said at the time, and even to alter the
sequence of the debate. The editorial work was greatly increased
on this account, and he would therefore request the members to
confine their alterations to the verbal changes necessary to make
the matter clear, and in all instances to return the numbered notes
of the reporter.

Digitized by ejOOQie

Traumatic (?) Perforation of the Septum in a Boy aged seventeen.

Shown by Dr. H. J. Davis. The patient was engaged in the
flour mills of a saccharine manufactory, and was working in a
very dusty atmosphere. He first attended the West London
Hospital two months ago for attacks of epistaxis. A perforation
of the septal cartilage was plainly visible, and at its upper border
there was a small blood-clot of recent formation. When this was
disturbed haemorrhage returned. The boy seemed in excellent
health, but he stated that he was perpetually “ scratching his nose,
as it was always itching when he was at work.” Ulceration had
evidently resulted, with consequent perforation of the septum and
haemorrhage. He was advised to find other occupation, was treated
with quinine and iron, ordered to sniff hydrogen peroxide into
the nostrils, and to syringe the nose with a solution of tannic acid
(gr. x, ad 3 j)- The perforation was now in the process of repair,
and had diminished considerably in size during treatment. He
(Dr. Davis) would like to know if there was any possibility of the
perforation closing, and whether members had ever seen a case
where a similar perforation of the septum had become totally
occluded.

Mr. Robinson, in answer to Dr. Davis’ question, expressed the opinion
that the perforation would never close up.

Dr. Ball also thought the perforation would not close up, but perhaps
Dr. Davis meant would the edge heal ?

Dr. Davis explained that he meant to ask whether it would com¬
pletely close. It was now about half the size it was two months pre¬
viously.

Dr. Ball said that such perforations were not uncommon, but his
experience was that in some cases it was very difficult even to get the
edges to heal; they would continue to form crusts month after month,
and unless cauterisation and curetting were performed, they would not
heal. He gathered that Dr. Davis attributed the condition to the boy’s
occupation. One would scarcely accept that idea unless one knew that
people in that occupation were specially subject to the complaint, and
he did not know whether that was the case. Probably dust had some¬
thing to do with it, but others were exposed to the effects of dust. Had
they not all seen erosions on one or other side of the septum, sometimes on
both sides, and been unable to get them to heal ? yet they went on for
months or even years without perforating. He did not know exactly
what happened when they perforated, but the process was rapid when it
occurred.

Dr. Waggett thought the most important element in the treatment of
that kind of case was to make the patient go to bed with a thick pair of
woollen gloves on the hands in order to prevent the unconscious use of
the finger-nails.

Dr. Westmacott remarked that the perforation was over a spot in

Digitized by {jOOQie

the cartilaginous part of the septum where there was a poor blood supply
(Zuckerkandel’s area). If the artery passing over it became injured,
ulceration occurred on the one side and necrosis followed sooner or later,
leaving a perforation, circular, with regular border and limited to cartilage.
Probably, as Dr. Davis suggested, dust caused crusts to form after the
first haemorrhage, and those being removed by the finger from time to
time caused the perforation. He considered that the perforation was
healed at the edges, with the exception of a small spot on the posterior
lower edge, at which there was a little brown incrustation, and under
which healing had perhaps not occurred. He thought the perforation was
best left alone.

Dr. Dundas G-rant said it was not merely a dusty occupation which
brought about the condition, but the character of the dust had some
bearing on the point. The dust might be either a chemical irritant, such
as the bichromates, or a mechanical one, such as irregular particles from
breaking stones. But another necessary condition seemed to be a septum
so shaped that there was a receptacle for the dust to lodge in. In the
present patient there was a concavity in the left side of the septum in the
innermost part of which the dust appeared to be caught. In cases in
which a perforation of traumatic origin was not so evident there might
be some loss of nutrition from probable thrombosis of the artery, which
he believed was named after Kieselbach (?). There was then a wasting of
the very thin tissue between the two layers of the mucous membrane
followed by a tissue necrosis.

Dr. Vinnace suggested that the primary treatment in such a case
should be directed towards the patient’s general health. He believed the
perforation was due to some constitutional cause; either it was tubercular,
or due to some extreme debility brought on by a previous illness, such as
typhoid, or one of the zymotic diseases. To him it was very unlikely that
in a patient of anything like normal health the mere irritation of flour,
aided by picking the nose, would cause a perforation through the septum.
He had never seen such a case.

A Piece of Blue Chalk half an inch in length Impacted for
Three Weeks in the Respiratory Passages of a Boy aged
ten.

Shown by Dr. H. J. Davis. Dyspnoea and bronchitis super¬
vened. The chalk was eventually dislodged and swallowed during a
laryngoscopic examination. It was subsequently passed per rectum..
The boy was at school when the accident happened; “he was sucking
at the chalk, when he was abruptly spoken to by the teacher, and
it slipped into his throat. He could not bring it up or swallow
it. He then began to cough and made a noise in breathing.”

Dr. Davis said that he had been asked by Dr. Law whether he would
not have expected to find some indications of the action of the digestive
juices on the surface of the chalk. This point had, however, occurred to
him also, and he had immersed the chalk into a test-tube containing
saliva. Although the chalk had been exposed to the influence of the

“ 6 §

Digitized by

Google

juice for four days, yet no alteration in the surface was apparent, and the
saliva was not even discoloured. He thought that the foreign body had
lodged between the tongue and epiglottis, or in one of the fossae, and
that when the tongue was drawn out for laryngoscopy and a mirror
inserted, the chalk was dislodged and had slipped down the gullet.
The boy stated that he had swallowed it. His mothor gave him a
dose of castor oil, and the chalk was passed intact through the bowel.
From that time the symptoms of dyspnoea ceased.

A Case of Carcinoma of the Larynx.

Shown by Dr. Jobson Horne. The patient, a smith, aged
fifty-eight, had experienced discomfort in the left half of the
larynx since Christmas, 1904 , and throat synlptoms for some time
previously. Syphilis was contracted some forty years ago. The
left half of the larynx was involved; the right half appeared to be
free. Dr. Horne said that he had definitely stated to the patient
that the disease was cancer and could be removed by an operation.
Dr. Horne trusted that no member would be prejudiced by that
expression of opinion.

Mr. de Santi said the case was undoubtedly one of malignant disease,
and he thought it was a fairly suitable case for the operation of extirpa¬
tion in the hands of a competent surgeon. It must, however, be done by a
man who was accustomed to do big operations, as it was by no means a
niggling procedure.

The President said the case seemed to him to be largely epiglottic as
a primary disease, extending down the ary-epiglottic fold. The right
vocal cord and arytenoid seemed to him to be free from disease, sufficiently
free and sufficiently far away to raise the question of the possibility of re¬
lieving that portion of the larynx in any operative interference. The
glands were not extensively enlarged, but there was one on the left side.
He agreed with Mr.'de Santi that the man’s prospects were much better
with operation than without.

Dr. Dundas G-rant said that the doubtful point seemed to be as to
whether the disease had not extended to the side of. the pharynx, and it
seemed difficult to decide that merely by laryngoscopic examination.
Possibly by palpation under an anaesthetic that might be made out. If
that were so it would, of course, greatly alter the prognosis in reference to
operation. On the other hand, the comparatively insignificant enlarge¬
ment of the glands would suggest that it was rather approaching the
intrinsic than the extrinsic form of cancer.

Sir Felix Semon thought that it was a case for suprahyoid pharyngo-
tomy. The parts would be easily accessible, and should the disease prove
to be more extensive than now appeared laryngoscopically, it would not
interfere with the prospects of total laryngectomy.

The President asked whether Dr. Home had examined the parts
with the finger. He had not himself done so, but suggested that in this

Digitized by LjOOQle

way a fair estimate of the amount of the pharynx involved could be
ascertained.

Dr. Jobson Horne, in reply, said he had not palpated the parts. He
thanked those who had spoken for the opinions they had expressed, and
which had coincided with his own and the operative measures he con¬
templated carrying out.

A Case of Lingual growth in a Man aged sixty.

Shown by Dr. Kelson. The patient complained of dryness in
the throat and difficulty in swallowing of four months’ duration.
On examination, a rounded swelling was observed about the size of
a cherry on the dorsum of the tongue in the region of the foramen
caecum; it felt elastic and was pedunculated. It was thought prob¬
ably to be connected with the remains of the thyro-lingual duct.
Opinions were requested as to its nature and treatment.

Dr. Davis considered it was a thyro-lingual cyst, and if pricked that
it would probably collapse; if not it could be removed with a snare.

Mr. Robinson thought it looked rather solid. It had a pedicle, and
its appearance suggested a relation to the little papillomatous growths
seen in the supra-tonsillar fossa. It was growing from the margin of the
foramen caecum in relation with the lymphoid structures in the neighbour¬
hood of the circumvallate papillae.

Mr. de Santi remarked that the growth had a pedicle, and he believed
that if ligatured and cut off it would be got rid of entirely.

The President suggested that perhaps Dr. Kelson would report on
the case later, after operative procedures had been carried out. This Dr.
Kelson agreed to do, and to exhibit the specimen.

Case of High-arched Palate and Crowding of Teeth due to
Nasal Obstruction, Showing the Factors producing the
Deformity.

Shown by Dr. Lambert Lack. The patient, a boy, aged
twelve and a half, attended the London Hospital for nasal
obstruction. He had had left-sided facial paralysis since two
years of age. The mouth was drawn over to the right side, the
tension of the tissues on the right side of the mouth was much
greater than on the left. The eyes closed almost equally well;
the right side of the face was normal.

The palate was seen to be highly arched, and the teeth on the
right side were irregular. He was indebted to Mr. J. (x. Turner
for pointing out the exact deformities of the teeth, and for making
the casts of the jaws which were now exhibited.

Digitized by {jOOQie

The right central incisor was rotated so that its posterior surface
looked inwards; its axis also sloped inwards. The right lateral
incisor was on a posterior plane to the central teeth ; that is, it
retained its foetal position. The right, canine was a temporary
tooth, the permanent canine not having yet erupted. The arch on
the left side was slightly flattened, owing to the loss of a second
bicuspid, but not nearly so much so as on the right side, and the
teeth were regular. The lower jaw showed the same deformity in
less degree. On the sound side there was flattening of the dental
arch from the canine back to the second molar (exclusive of the
latter). On the other, the paralysed side, there was pushing in of
the dental arch from the central incisor to the first molar (exclusive
of the latter) due to the same cause as in the case of the maxillary
dental arch of that side, i. e. loss of a bicuspid, which allowed
tissue-tension to contract the arch (J. G. Turner).

Most observers were probably agreed that the nasal obstruction,
and the consequent mouth-breathing, was the primary cause of this
deformity of the jaws and teeth, but various views were held as to
the factors by which these developmental irregularities were pro¬
duced. He had always accepted the theory which ascribed the
chief influence to the tension of the soft parts of the cheeks. These
tissues were put on the stretch when the mouth was kept open, and
caused a lateral flattening of the jaws, more especially of the upper
jaw. The most common deformity—lateral approximation of the
alveolar borders with high-arched palate and V-shaped alveolus—
was exactly what one would expect to be produced by this lateral
compression of the cheeks. This case went far to prove this view.
On one side (the paralysed) the tissues of the cheeks were flaccid,
and there was little or no deformity of the jaws; on the other side,
the normal one, the tissues were tense and the deformity was well
marked. The differences in the tension on the two sides was well
shown in the photograph handed to the meeting, and might be
tested by applying the finger to the corner of the boy’s mouth. Of
course, one case was insufficient to prove a theory, the more so that
unilateral deformity was occasionally found; still, the coincidence,
if it be one, was very striking.

Dr. Ball thought the case an extremely interesting one. He had
never had much belief in the theory of the pressure of the cheek from the
open month, though he, among others, had mentioned it. In the present
case there was certainly a difference between the two sides, and here, at
any rate, the pressure of the cheek on one side had an effect which was
not seen on the other. Dr. Lack would no doubt admit that in the de¬
velopment of high palate and narrow alveolar arch, the pressure of the

Digitized by {jOOQie

cheek was not the only factor. Of course there were plenty of adenoid
cases with open mouths which did not develop a high narrow arch, so
that there was some other element, such as undue softness of bones. It
was curious that this high and narrow arch was peculiar to a certain type
of head and face, which in its turn was almost always associated with
adenoids, and undoubtedly heredity played a great part in the production
of the deformity.

Mr. Robinson thought it could scarcely be said that facial paralysis
was present, therefore that could be dismissed from the case. If that
were put out of court, would not a defective bite lead to that condition of
jaw ?

Mr. Westmacott thought the case illustrated very well the effect of
even such a slight pressure as that induced by the muscles of the cheek
on any alteration in the shape of the teeth and the conformation of the
arch. There was certainly some change on that side. But what he was
not satisfied about in the case, and in all others of so-called high-arched
palate, was that there was any increase in the height of the arch. With
Mr. Campion, a dentist in Manchester, he had examined many skulls and
the models and mouths of a large number of children at the Children’s
Hospital, with a very ingenious instrument which Mr. Campion devised
for measuring the height of the palate; and the result was that very little
increase in the height was discovered. Apparently the two alveoli were
pressed closely together, and there was no great increase in height. In
all the cases in which he had taken measurements inside the nose he found
that the floor of the nasal space was not higher than it would be in a
normal case—i. e. that in the arching of the palate there was no corre¬
sponding convexity in the floor of the nose, that the floor was perfectly
fiat. Seven years ago he read a paper in which he tried to show that there
was some arrest of development in the nasal septum, owing to intra-nasal
pressure, with an arrest of blood-flow down the nasal septal arteries, and
a corresponding venous and lymphatic congestion, and in the result the
nasal septum, and more especially the vertical plate of the ethmoid, did
not get sufficiently nourished to keep pace with the growth of the facial
bones. However, in view of the later experiments, he had come more
round to the theory that there was some actual pressure of the buccina¬
tors on the alveolar arch.

The President said l«e understood Dr. Lack to call special attention
to the bulging of the alveolar margin towards the median line. If that
was a point in the case, he would like to refer to an instance in a man with
complete congenital atresia stenosis of both clioanse. The peculiarity of
his mouth was, that both alveolar arches were enormously thickened, and
were almost in contact in the middle line. There was merely a cleft with
vertical sides running antero-posteriorly along the middle line. His own
explanation at the time was, that it was due to the absence of any respira¬
tion through the nose; but the anterior part of the nose was fully de¬
veloped, and was quite capacious, a point against this view. Possibly the
case might help to support the view held by Dr. Lack.

Sir Felix Semon said he had seen and described a case of bilateral
congenital stenosis of both nostrils. It was described many years ago, in
the German edition of Morell Mackenzie’s book, 1884 , vol. ii. He was
certain that in that case there was no abnormality of the palate.

Dr. Kelson remarked that if the irregularity was due to pressure on
one side by the buccinator and not on the other, why was it that in the
lower jaw the same irregularity was not seen ? Of course the lower jaw

Digitized by CjOOQle

was more mobile than the upper, but it was held in position by powerful
muscles, such as the masseters and pterygoids, and on the hypothesis which
had been advanced one would expect irregularity in the lower jaw as well as
in the upper.

Dr. Lambert. Lack, in reply, said that there was deformity in the
lower jaw, which Mr. Turner would be willing to describe. In answer to
Dr. Ball, he thought the deformity of the upper jaw could not be expected
unless nasal obstruction persisted for many years during childhood. He
admitted there were a few inexplicable cases, like that quoted by Sir Felix
Semon, in which complete nasal obstruction had given rise to no de¬
formity of the jaw. Such cases were extremely rare, and the one related
by the President was a much more typical case. In answer to Mr. Robin¬
son he said there could be no possible doubt about the facial paralysis.
The lower part of the face was chiefly affected. Dr. Lack was very in¬
terested in Mr. Westmacott’s remarks. He considered that in many cases
there was one reason for supposing the roof of the palate was raised,
namely, its frequent association with deflection of the septum. This
pointed to the fact that the floor of the nose was raised, sq that there was
no room for the vertical development of the septum. The facial paralysis
dated from two years old.

Mr. J. Gh Turner (visitor) said the lower jaw showed flattening on
the affected side from the region of the canine back to the second molar.
On the other side there was an arch from the region of the first incisor to
the second molar. On that side from the region of the canine it went
straight back. That was produced by the same tension of constantly
using the mouth, which flattened the maxilla. In the ordinary adenoid
case the lower jaw, pari passu with the upper jaw, became flattened and
moulded forward. One always looked for a deformity of the lower as
well as upper jaw, and it made one think they both owned a common
cause. The tension of the tissues in the mouth-breather seemed to be
the one common cause. Another cause, as far as the upper jaw was
concerned, he would take to be a more pronounced want of growth than
was found in other parts of the body.

Case of Broadening and Disfigurement of the External Nose

Caused by Tense, Bilateral, . Non-Vascular Swellings

ATTACHED TO THE ANTERIOR THIRD OF THE CARTILAGINOUS

Septum. Nasal Obstruction Complete.

Shown by Dr. L. F. Pegler. The patient, a man aged fifty-
seven, had been attending Dr. Pegler’s clinic about three weeks and
was at present taking potassium iodide with a view to the swellings
being gummatous. No operation had yet been undertaken. The
tension was already diminished and the swelling on the left side of
the growths had subsided a little, but the great thickening of the
external nasal walls was not so far affected by the iodide. The
man denied syphilis, but a transverse cicatricial band along the
junction of the hand with the soft palate, favoured this diagnosis.

Mr. Robinson thought it was an abscess of the septum of some dura-

Digitized by

Google

tion, and that the insertion of a scalpel would let out pus. But the nose
would not be so beautiful afterwards, as a depression would be left.

Dr. Dundas Grant supported Dr. Pegler’s idea that the swellings
were gummata, which would subside under well-carried-out antisyphilitic
treatment. Probably the man had been a little casual about it.

Dr. Jobson Horne said he gathered that there was a history of
traumatism, and he would regard it as a haem atom a which had not
cleared up.

Mr. de Santi concluded that it was a bilateral haematoma. The general
condition of the nose outside, the swelling, and so forth, was unlike a
gummatous deposit. The appearance was much more suggestive of double
suppurative hsematoma, and he thought a scalpel should be put into each
swelling and the case would then probably clear up. If it proved to be t
gummatous, the use of the scalpel would do no harm.

Dr. Davis said he also thought it was haematoma.

The President said the haematoma view was. interesting, and he
would like to elicit from those who mentioned it whether they meant that
blood actually existed at present, or that it consisted of blood which had
undergone some change. He was familiar with permanent, thickening of
the septum after injury, in which a haematoma left a permanent thickening
of the character of a perichondritis. ‘

Dr. Pegler, in reply, said he had suspected the case to be syphilitic
from the condition of the pharynx, to which perhaps he had not drawn
sufficient attention. There was no history of an injury to favour a diag¬
nosis of haematoma; on the other hand, the appearance recalled to his
mind an extensive gummatous tumour of the septum of which he had
shown sections to the Society in June, 1903 . Photographs of this case
had been taken, since which the effects of the iodide were very noticeable.
The man gave no intelligible history of his condition, but said the swellings
were considerably greater at one time than another. Dr. Pegler proposed
to deal surgically with the case and report the result.

Case of Obstinate Headache accompanied by Crusting and Muco-
JPus Formation in a Man aged forty in which the Maxillary,
Sphenoidal, and Frontal Sinuses had been explored without
TANGIBLE RESULTS ; FOR DIAGNOSIS.

Shown by Dr. L. H. Pegler. The man was an engine-tender
who pursued his occupation in South Africa, but periodically visited
his home in Sunderland, whence he had been sent to him by Dr.
Rowstron.

On admission the walls of the naso- and oro-pharynx were
crusted with sticky muco-pus which seemed to escape chiefly from
the left sphenoidal opening and, to a less extent/from the right.
The walls of both nasal cavities were smeared with the same adhesive
material; the middle turbinals were spongy, red, and vascular, but
there was no general atrophic condition of the mucosa nor fcetor.
Persistent headache, causing insomnia, was complained of, chiefly at
the root of the nose. After removal of the crusts the pharyngeal

Digitized by {jOOQie

100

mucosa was intensely red and beefy. Both middle turbinals were
removed under chloroform soon after admission, and the stumps
were now satisfactorily healed over. After this both sphenoidal
sinuses were explored, the openings being easily reached, but with
negative results. Later, Dr. Tilley, who kindly expressed a wish to
see the case, confirmed this observation, and the sphenoidal sinuses
were again explored and washed out. The right antrum was ex¬
plored at the same time and two or three flakes of coagulated non-
foetid pus removed by the syringe. The left maxillary antrum was
washed through by an alveolar opening but contained nothing; the
frontal sinuses were easily entered by a sound from the nose, but
no pus escaped. The case was still under treatment, but the head¬
aches were so'far but little relieved.

Dr. Waggett thought the work in the case was only just beginning.
Dr. Pegler now had to gain access to some of the posterior ethmoidal
cells, and on the left side the bulla ethmoidalis was suppurating. On
the right side the posterior attachment of the middle turbinated was
not yet completely removed, and there was pus coming from its neigh¬
bourhood. A couple of months’ hard work yet remained to be done on
the case.

Mr. Westmacott thought it was the bulla that was seen on the right
side. The middle turbinal seemed to have been removed. It would be
interesting to have a bacteriological examination of the discharge. There
seemed to be such a general affection of the whole of the nasal cavity
that it hardly seemed to come from any particular sinus; it was appar¬
ently more of a general disease than the manifestation of a local em¬
pyema.

Sir Felix Semon thought it would be a pity if the discussion on that
very interesting case were curtailed, because he was convinced that every¬
thing was not yet known about nasal suppuration. There were some
cases in which, without any tangible lesion of any of the accessory cavities,
there was a general tendency to the formation of crusts. He had, by
chance, at present two such cases under his care, and he had been unable
to find evidence of disease of any of the accessory cavities. For years,
without the usual symptoms of accessory sinus disease, there had been a
muco-purulent secretion in the naso-pharvnx of a troublesome nature.
He had not found out what was the real cause, but from a therapeutic
point of view—and he was a great sceptic on therapeutics in such a
connection—very decided effects were produced by applications of fluid
vaseline by means of an atoniser, with a suitable receptacle, which he first
saw in the practice of Dr. G-oldstein at St. Louis. He had found it very
useful to make daily applications to the interior of the nose similar to
placing a liniment on an exterior surface, though he could not yet speak
of a “ cure.”

Dr. Herbert Tilley said his experience of such cases as shown by
Dr. Pegler was practically identical with that mentioned by Sir Felix
Semon. He had the advantage of seeing the present case with Dr. Pegler
some weeks ago, and on transillumination it was found that the right
antrum was darker than the left. The right antrum was washed out,
and what came away was not the ordinary purulent discharge which one

Digitized by Google

101

expected in an ordinary case of empyema, but purulent debris , which
might have been pus at one time, but had since become disorganised and
desiccated. The frontal sinuses were carefully explored, and both
sphenoidal sinuses were washed out, the ethmoidal cells were likewise
investigated, but he was bound to say that at the conclusion of the
examination he was in doubt as to what was the causal condition under¬
lying the symptoms. These cases were unlike the ordinary empyemata
of the accessory cavities, in which one found liquid yellow pus, which re¬
appeared shortly after it was removed from any one sinus opening. He
was reminded by Dr. Pegler’s case of one recently shown by Dr. Bennett,
of Leicester, which exhibited an identical condition of things, but in which
the whole inside of the nose was covered by a thin veneer of what looked
more like dry muco-pus than pus, and the mucous membrane was in a
thin red-glazed condition. He felt certain that no curetting of the
ethmoidal cells or any radical operation upon this patient would produce
a good result, and he thought some method of treating the mucous mem¬
brane rather than accessory cavities should be adopted.

Dr. StClair Thomson agreed with Dr. Pegler’s diagnosis, viz. that
he had eliminated all the accessory sinuses except the posterior ethmoidal
cells. He saw the patient before the meeting, when pus was exuding
from what must have been posterior ethmoidal cells. In those cases of
purulent rhinitis where the pus did not come out of the large accessory
cavities there was much difficulty. He sent a case for inspection to Dr.
Tilley’s clinique six months ago, in which he had located the posterior
ethmoidal cells. That patient suffered so much from headache, as well
as from the crusts, that he (Dr. Thomson) did his best to open up the
cells. He confessed that though she was greatly relieved of her head¬
aches, and though he had gone in as far as it was safe to go, she still had
a great deal of the secretion. He thought the pictures of Dr. Onodi
would show how large the posterior ethmoidal cells could be; some could
be as large as the sphenoidal sinus, and would admit the end of his little
finger. He . gave Dr, Pegler credit for saying he had removed the
middle turbinals, but he thought the muco-pus on the left was coming
from a posterior ethmoidal cell.

Dr. Dundas Grant said an appliance had recently been published
which might help the diagnosis, and perhaps also the treatment, of such
cases. One wanted to relieve the patient of his uncomfortable symptoms
and to ease his mind, as well as to radically open the sinus. The present
patient did not seem to have an immense amount of discharge, and many
people would not complain if their trouble was no greater than his
appeared to be. The appliance he referred to was a suction apparatus
invented by Dr. Sondermann. There was one form for use in the nose
and another for the ear. It was like a miniature anaesthetist’s face-piece,
fitting over the nose, with pneumatic cushions to make it fit tightly.
Attached to it was a compressible india-rubber bottle, which acted only
in the direction of suction. When in position the patient uttered the
sound e, which shut off the naso-pharvnx by means of the soft palate.
By the suction a little mucus might be drawn from the frontal or any of
the ethmoidal sinuses, and relief given in that way. He had seen relief
produced by that instrument where there seemed to be little more than a
slight catarrh of the frontal sinus. In the present case the suction might
help the diagnosis by bringing out the fluid and enabling one to judge
where it came from. He had found it give relief in the ear when there
seemed to be pus 1 or muco-pus lying in the deeper accessory cavities of

Digitized by LjOOQle

102

the tympanum. He would be happy to bring the instrument to the next
meeting, but Messrs. Meyer and Meltzer had procured it on his recom¬
mendation.

Dr. Pegler said he was much obliged for the valuable opinions that
had been offered in relation to this case. In reply to Mr. Waggett, he
thought he had removed both middle turbinals sufficiently, but was aware
that the anterior lip of the meatus (formed by the uncinate process) still
projected a little on the right side. He, however, quite agreed with the
suggestion to open the ethmoidal cells and carry the treatment further in
that direction. He attached great importance to the point alluded to by
Dr. Tilley, viz. the absence of fluidity and creaminess in the discharge,
the sticky irritating character of which, as Dr. Tilley said, visibly affected
the lining membrane everywhere, including the walls of the septum. This
fact suggested relationship to those cases of crusting often associated with
atrophic conditions, which had been a bone of contention amongst rhino-
logists, and which G-riinwald maintained depended upon accessory sinus
suppuration. The idea of a bacteriological examination of the material
had occurred to him, but he did not hope for any tangible assistance
towards treatment in this direction.

[The patient left the hospital the day after this consultation with
view to returning to South Africa, as his leave of absence had expired
but he hoped to come back later.]

Soft Fibroma on Left Vocal Cord.

Shown by Mr. H. Betham Robinson. The patient, a man aged
sixty-five, came to St. Thomas's for stuffiness in the nose, and in a
routine examination the tumour was detected on the vocal cord*
He had no laryngeal symptoms except slight liuskiness at times*
On the left vocal cord, at the junction of its anterior with the
middle thirds, was a small tumour the size of a split-pea, involving
only the mucous and submucous layers : on plionation it fitted
into a depression on the opposite cord. Its surface was rather
vascular, from impact only, and there was no sign of any loss of
tissue. It was an undoubted soft fibroma, but from the appearance
on its surface it was just a question whether it should be con¬
sidered an angiofibroma.

Dr. Jobson Horne said he had had the opportunity of seeing a pre¬
cisely similar growth, and also of removing it and afterwards of observing
it under the microscope. It did not contain much angiomatous tissue.
He believed the present growth to be more fibrous than angiomatous.

Dr. StClair Thomson thought the word “ angio ” was unnecessary.
Though, such cases looked red and purplish in the mirror, when removed
and placed under the microscope they were found to be vascular fibromata.

Mr. Robinson, in reply, said he thought it was only a soft fibroma.

Angioma of Larynx.

Shown by the President. Mr. R—, aged thirty, consulted Mr.
Symonds in November, 1904 . He stated that he suffered from recur-

Digitized by

Google

103

rent colds followed by hoarseness. With the present attack he had,
for the first time, a sensation as of a lump in the larynx, and on the
right side. Ten years before he had syphilis and to this the
hoarseness had been attributed. He took iodide of potassium
himself and got better. The appearance presented was that of a
purple vascular, though hard, lobulated swelling on the right side.
It overhung but did not seem to involve the cord. The ventricular
band was lost in the swelling. The anterior end of the vocal cord
was just; visible on phonation and the movement was free. The
appearances suggested the existence of a growth for some time—a
growth not in any way syphilitic—and that, for the most part giving
rise to no trouble, it swelled under the effect of a simple catarrh
and gave rise to symptoms. Seen on several occasions, no material
change was observed except that at times the cord was lost to view
The voice returned to what he considered its normal condition and
to what his friends recognised as natural to him, but the swelling
remained unaltered.

The opinion he had formed of the case was that there had been
an angioma in existence for some years—probably from birth and
that the increased hoarseness and the recent sensation of swelling
are due to aggravation of the catarrhal affection. At the present
time (March 31 st, 1905 ) the whole of the vocal cord can be seen ; the
movements are good. The growth was divided into two parts by
a deep falcus, the lower division projected as a somewhat lobulated
mass above the cord, and of a somewhat purple colour. The upper
and smaller part is distinctly vascular and is at times blue as from
enlarged veins.

Sir Felix Semon said he had now seen the patient three times, and
he was certain the President’s diagnosis of genuine angioma was correct.
The tumour varied so much in size and appearance that nothing short of
a real blood tumour could explain those variations. It was an extremely
rare condition, and he did not remember having seen anything exactly
like it. As it did not cause much trouble to the man he counselled
leaving it alone for the present.

Dr. StClair Thomson said he would show the members some day a
beautiful colour drawing (made by a lady artist) of an angioma in a
patient who had been frequenting Golden Square, off and on, for between
20 and 30 years. The patient had been seen by Morel Mackenzie, and
later by Dr. Walfenden, and Dr. Bond had also seen him. Others had
made attempts to treat him by the galvano-cautery, but with unfortunate
results. The man appeared to suffer from no haemorrhage or trouble,
except when he was treated 1 Though Mr. Symonds’ case was not so
typical, yet there was a blueish infiltration under the ventricular band
which was characteristic.

Mr. Atwood Thorne asked whether the President would have a
colour drawing made of the condition and publish it in the Transactions.

Digitized by LjOOQle

104

Dr. Pegler said this exceedingly interesting case would seem from
the appearance of the growth to be one of genuine capillary or cavernous
angeiomaof the larynx, such as Bland-Sutton described in his work on
tumours as occurring, though very rarely, in that region. He remarked
that he had no microscopical preparation in the Society’s collection that
corresponded to this; on the other hand, of “ fibro-angeiomas ” he had
several. These were more or less related to the case Mr. Robinson was
showing that day as a probable angeio-fibroma, and were actually
granulomata with some dilated capillaries, and more or less admixture of
fibrous tissue.

Dr. Spicer said his idea was that it was a venous telangiectasis, such
as Dr. Pegler described, rather than angioma in the histological sense of
that term.

The President, in reply, said he would be glad to have a drawing of
the case made for the Transactions. . He had intended doing so, but was
in a difficulty as to the artist. He would ask Dr. StClair Thomson to
advise him on this point. He was glad his diagnosis had been confirmed,
as it would enable him to assure the patient he could safely undertake
the journey round the world which he had projected.

Subglottic Hyperplasia, producing Tracheal Stenosis, probably
op Syphilitic Origin.

Shown by Dr. Herbert Tilley. Patient was a female, aged
thirty-one, who sought advice for difficulty in breathing, which
became very marked if she hurried or exerted herself in any way.
She stated that eight years ago she suffered from a bad attack of
“ laryngitis and bronchitis ” which caused such difficulty in breath¬
ing that it was thought probable a tube would have to be inserted
into the trachea. This was followed in a few days by a rash on the
chest and limbs like measles. Shortly afterwards the bridge of the
nose began to sink in, and some five or six months later she had
another attack of difficulty in breathing, coupled with some pain
in the nose and jaw, and accompanied by a temperature, of 103 °.
Six years ago complete loss of voice ensued, and she went to reside
in the South of England, where during a six months’ stay the voice
gradually returned. During this period she often coughed up
“crusts and matter.” Laryngoscopic examination revealed marked
subglottic hyperplasia and imperfect mobility of the cords, the
latter being much thickened. There was no crust formation nor
signs of active ulceration. The patient had been taking iodide of
potash and mercury internally for five weeks, and externally using
mercurial inunctions, but up to the present without beneficial
effects.

Mr. Robinson said he had a woman under care at the present time
with subglottic hyperplasia, and she had tracheotomy done three months

Digitized by CjOOQle

105

ago, but it had not diminished the trouble. At the same time she had
been under anti-syphilitic treatment.

Dr. Herbert Tilley explained that towards the end of the sitting
the patient became more tolerant of examination, and several members
had obtained a view of the larynx. He wished to ask members if they
had ever found that the performance of tracheotomy, thus inducing rest
of the larynx for, say, a couple of months, had had any effect in removing
these subglottic hyperplastic conditions.

Unilateral Right Abductor Paralysis associated with Paralyses
of Right Half of Soft Palate and Pharynx, Right Sterno-
mastoid, Upper Fibkes of Right Trapezius, Ptoses of Right
Upper Eyelid and Contracted Pupil.

Shown by Dr. Tilley. Patient was a man of sixty-one, who
sought advice for difficulty in swallowing and slight hoarseness.
The symptoms developed some two months ago after an attack of
“ spasm of breathing ” associated with temporary loss of conscious¬
ness, ascribed by his medical man to a “ minor attack of epilepsy.”

In addition to the above symptoms, largngoscopic examination
revealed a large collection of saliva in the right pyriform sinus.
A full-size oesophageal bougie could be passed quite easily into
the stomach. Beneath the right mandible was a hard, well-defined
swelling as large as a pigeon’s egg, and situated in the position of
the submaxillary gland. This swelling could easily be felt through
the right floor of the mouth, and it was freely movable. Behind
the right ascending ramus of jaw, between it and the auterior
border of the sterno-mastoid and extending upwards to the base of
the skull, a distinct but ill-defined thickening could be felt, and it
was a question whether the lesions indicated were not due to some
involvement of the nerve-trunks in this situation as they emerged
from the base of the skull. There was no history of syphilis, neither
were any clinical evidences of the disease to be found in other
parts of the body :

Dr. Dundas Grant said the case seemed to be of a complicated
nature. It was difficult to see how the swelling in the submaxillary
region could compress at the same time the sympathetic there and the
pneumogastric at the part where the pharyngeal branch came off, because
he took it that that was where the innervation of the half of the palate
was derived. He thought the lesion which caused that hemi-paresis of
the palate, as well as the paralysis of the left vocal cord, must be situated
at a considerable height, perhaps close up to the foramen lacerum
posterius. The relation of the growth in the neighbourhood of the sub¬
maxillary gland to the nervous lesion was very doubtful. He thought
there must be some change close to the foramen to account for this,
especially as the tumour behind the maxilla had apparently lasted many

Digitized by

Google

106

years, whereas he believed the other lesion was not of very long dura¬
tion.

Mr. Robinson thought that whatever the cause of the nerve lesion
was one must put out of court the submaxillary swelling, as he did not
think it had any relation to the other part. It suggested a mixed tumour
of the submaxillary gland, or possibly an old calculus.

The President said he thought Dr. Tilley pointed out that above the
old swelling, behind the jaw, there was another gland, and the question
was whether that did not throw some light on the cause of the paralysis;
there might be some primary growth at the base of the skull. The old
swelling seemed to resemble a calcareous formation. Possibly it was
some caseation followed by calcification in an old tuberculous mass.

Dr. Herbert Tilley, in reply, said he saw the case three weeks ago,
and thought the gland under the jaw had nothing to do with the paralysis.
There was distinct thickening behind the ramus of the jaw, which was
possibly the cause of the lesions, and very likely of a syphilitic nature.
He wished to ask Sir Felix Semon whether he had ever seen a case of this
type—which was not very uncommon—benefited by any form of treat¬
ment.

Sir Felix Semon answered Dr. Tilley’s question in the negative.
Even in cases where there was a syphilitic history he had not seen improve¬
ment. He had not meant to speak to the case, but in reference to Dr.
Dundas Grant’s observation, he was strongly of opinion that its cause
was peripheral, not central.

The President agreed with Sir Felix Semon’s view, and hoped an
opportunity would be afforded of seeing it later.

Case of Double Frontal Sinus Suppuration, in Young Man, cured
by Radical Operation.

Shown by Mr. Waggett. There were two points of interest in
the case. ( 1 ) The external operation enabled the operator to
examine the right frontal sinus, the lower supra-orbital portion of
which had been completely cured by syringing through the nasal
route, carried out by the patient himself for some months. It was
interesting to observe that the mucous membrane was thin, and
perfectly healthy in appearance, although there was no doubt that
some months previously large quantities of pus were daily washed
out of this portion of the sinus by the use of the cannula. The
upper mesial portion, partly separated from the rest of the sinus
by an incomplete partition, remained in a state of suppuration
owing to the presence of a pathological perforation (carious edges)
of the septum between the two sinuses. This portion discharged
into the left sinus. ( 2 ) On the left side a modified Killian’s opera¬
tion was performed, a considerable portion of the roof and inner
wall of the orbit being removed, a bridge being left as usual. On
the right side the orbital roof and inner wall were left, intact for
the reason that the lower part of the sinus and the frontal ethmoidal

Digitized by CjOOQle

107

cells had already been successfully dealt with through the nasal
route.

Now, five months after complete healing of the wound, there
was no noticeable deformity upon either side; that is to say, the
removal of the orbital wall had, at all events in this case, in no way
affected the cosmetic result, which was equally good upon the two
sides of the head. On both sides the inner angles of the stem
wound were kept open for a fortnight, granulation taking place
around small drainage-tubes, two directed upwards and one down¬
wards on each side.

The President thought all would agree that it was a very satisfactory
result.

Papilloma op the Larynx.

Shown by the President. A man, aged thirty-seven, came
into Guy’s Hospital for hoarseness of twelve months’ duration. On
examination, there was to be seen attached to the left vocal chord
in its anterior part a lobulated purple movable swelling. Its upper
surface was grey in patches, a condition probably due to injury
during mobility, for the swelling moved freely in phonation. The'
movement of the left cord, though not quite so rapid as that of the
right, was sufficiently so to practically exclude infiltration. The
anterior attachment of the growth was difficult to see. He sub¬
mitted it as an example of a simple papilloma of the left vocal cord.

Dr. Dundas Grant said the most remarkable point about the case
seemed to be the absence of symptoms arising from so considerable a
growth.

A Case Seven Years after Complete Extirpation of the Larynx.

Shown by the President. The patient, a lady, was now aged
sixty-four. When she came under his care, a tracheotomy tube
had been worn since the summer of 1895 . There was complete
laryngeal obstruction; the interior could be seen filled with a soft
pale growth. The larynx was somewhat broadened; no glands
could be felt. The larynx was removed in January, 1898 . The
trachea was attached to the skin just above the sternum, and the
pharynx sutured. Glands were found under both lobes of the
thyroid gland. The entire thyroid gland was removed, together
with the lymphatics. The recovery was slow, owing to incomplete
closure of the pharynx. The piece of growth removed before
operation showed typical carcinoma. Traumatic myxoedema

Digitized by LjOOQle

108

occurred, but was relieved, by thyroid extract and it was still
necessary to take this remedy.

He attributed the absence of recurrence, in the case to the
free removal of the thyroid gland, and underlying glands and
lymphatics.

The patient could make herself understood fairly well, and had
been able to superintend the management of a hotel.

Note .—The tracheotomy referred to was performed by Sir Felix
Semon in 1895, under whose care the patient was at that time.
Sir Felix had been good enough to give him the early notes in
writing, and permission to add them to this report, thus making
the record complete.

The following are Sir Felix Semon’s notes on the case:

“ In compliance \yith my promise, I have looked up my notes of
Mrs. G—. She was sent to me in June, 1895. I found great
narrowing of the glottis, the left vocal cord was almost invisible,
the right only slightly moved outwards. Both cords were swollen
and the rest of the larynx was congested and relaxed. In the
narrow slit remaining between the cords a whitish projection was
seen. More than this could not be made out.

"I was not certain about the nature of the whitish growth, and,
whilst naturally thinking of malignancy, was doubtful on this
point on account of the very long duration of the symptoms. She
had suffered from aphonia for a period of more than ten years;
there was no broadening of the larynx, and no enlargement of
cervical lymphatic glands in the neck, nor was there any evidence
of perichondritis. After the performance of tracheotomy, which
was necessitated by the dyspnoea, I found on October 8 of the
same year very considerable improvement generally and locally.
The condition of the larynx had considerably changed, the front
part of the vocal cords was better visible, and although they
appeared to be somewhat adherent in front, and still much swollen
and congested, the glottis opening was larger than it had been.
It could then be seen that the anterior part of the cricoid carti¬
lage was enormously swollen. I recommended continuation of her
wearing the tube, and the administration of iodide of potassium
from time to time.”

The President said that Sir Felix Semon had found it necessary to
perform tracheotomy one and a half years before he (Mr. Symonds)
removed the larynx. That fact would indicate the severity of the obstruc¬
tion. When he saw her there was a large growth filling the whole upper
opening of the larynx, so that a large piece was easily removed for ex-

Digitized by LjOOQle

109

animation. He had the larynx, and would try to complete the case some
day by showing it.

Sir Felix Semon heartily congratulated the President on the result;
it was the most happy-looking case of total extirpation of the larynx he
had ever seen.

Mr. Atwood Thorne asked whether it was not most unusual after
such an operation for the voice to be as good as the present patient’s, and
wished to know if Mr. Symonds could in any way account for the excellent
voice in this case.

The President replied that it was a question of practice on the part
of the patient. It was seven years since the operation, and she managed
the kitchen in a hotel. He also exhibited the case to show the effect of
total removal of the thyroid gland. She had been kept well by thyroid
extract.

Dr. StClair Thomson asked whether the patient was able to make
exertions. It was said that those who had gone through that operation were
handicapped, that they could not strain at stool, and that they could not
earn their own living, especially when there were weights to lift, etc.
The voice, in the present case, was the most remarkable he had himself
heard after laryngectomy; and it would be important to know whether
she could lead a free and vigorous life and keep free from tracheitis and
bronchitis.

Dr. Vinrace asked for what disease the larynx was removed.

The President, in further reply, said he would inquire as to the
points raised by Dr. StClair Thomson. She was an active woman, but
was not called upon to make any great effort The larynx was removed
for extensive carcinoma, and there were secondary glands under both
lobes of the thyroid gland. He had microscopical sections.

Man aged thirty-nine with Lateral Ulceration of the Larynx:
Hoarseness about Two Months.

Shown by Dr. Donelan for diagnosis.

Dr. Davis was of opinion that the case was one of syphilis.

Digitized by CjOOQle

Digitized by LjOOQle

///

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Ninety-eighth Ordinary Meeting, May 5, 1905.

Charters J. Symonds, F.R.C.S., President, in the Chair.

Philip E. W. de Santi, F.E.C.S. ] gecretaries
Henry J. Davis, M.B., M.E.C.P. j becretaries -

Present—23 members and 3 visitors.

The minutes of the preceding meeting were read and confirmed.

Election of Ordinary Member.

The ballot was taken for—

William Douglas Harmer, F.R.C.S., M.C.Cantab.,,
who was elected a Member of the Society.

The following cases, specimens, and apparatus were then shown :

A Case of almost Complete Bony Occlusion of the Left Nostril,

THE RESULT OF TRAUMA AND SEPTAL DEFORMITY IN A Man AGED
TWENTY-FIVE.

Shown by Dr. Donelan.

Mr. Waggett thought it would be well to deal with the case by re¬
jection, making use of the chisel.

Dr. Herbert Tilley agreed with Mr. Waggett that it would be an
admirable case for resection of the deviated septum. Dr. Donelan,
during the speaker’s inspection of the patient, suggested. that difficulty
would arise on account of adherence of the septum to the anterior end of
the inferior turbinal by cicatricial adhesions originating from some former
traumatism. But if one occluded the patient’s right nostril he could blow
down the left, and bubbles of mucus could be seen issuing from the whole
length of the cleft between the deviation and the anterior end of the
turbinal, and hence he thought it was probably only an apparent junction
of the two. Even if there was a real adhesion it would still be an
excellent case for resection of the deviation.

The President referred to a recent case of his own, in which there
was real bony fusion between the septum and the outer wall, but the

Digitized by CjOOQle

112

appearances were different from those in the present case, which looked
more like a simple deviation, with perhaps some adhesion, such as might
result from the attrition of two mucous surfaces. In his own case he was
obliged to saw through the attachment, and by submucous section to
remove a considerable portion of the bony septum. But that scarcely
applied to the case under present discussion.

Dr. Dundas G-rant said that although this was not an ideal case for
submucous resection, yet he thought the operation feasible. Even if it
did not eventuate in an ideal way, and a perforation resulted, the condition
of the patient would be much better than at present. He recommended
that procedure; *

Dr. Pegler said he had recently operated in private upon an extreme
deviation in which the septal curvature was such that it created consider¬
able external deformity by pushing outwards the superior lateral cartilage,
causing the patient to seek advice on that account, quite disregarding the
complete unilateral obstruction. If Dr. Donelan did not care to do a
“ fenster resection ” in the present case, he assured him that if he tried a
modified Moure’s operation he would be very pleased with the result. By
this means he had had an excellent result, both as regards the deformity
and the obstruction, in the case to which he referred. If the incisions
were made sufficiently freely above and below, ample room would be
obtained for breathing, and even if an absolutely straight-looking septum
were not obtained, the obstruction would be sufficiently cured and the
nasal functions restored. Two incisions would suffice, though it might
be advisable afterwards to shave off some of the redundant cartilage in
order to reduce the convexity.

Dr. Scanes Spicer doubted if complete relief would be given in this
case by submucous resection. He thought it would be necessary to
operate with the saw and straighten, and of the two evils, incomplete
relief or perforation, he would not bother much about the probability of
perforation.

Dr. Donelan, in reply, pointed out that he did not suggest that
obstruction was complete, and in reply to Dr. Tilley he stated that the
patient had been under chloroform, and considerable force had been used
in endeavouring to separate the adhesions. He had attempted to force
a flat director with a stout handle through the obstruction, but without
success, and through an incision which he made he had examined with a
probe, and altogether he thought the union must be bony. He thanked
members for their suggestions.

Laryngeal Case for Diagnosis.

Shown by Mr. de Santi. The patient, a female aged fifty-six,
came to Mr. de Santas clinic complaining of cough, hoarseness, and
pain in the throat of four months' duration. Examination revealed
paralysis of the right vocal cord and thickening of the right crico¬
arytenoid joint; there was also some limitation of movement in
the left vocal cord. There were no glands or swelling in the
neck, no history of syphilis, nothing in the chest showing intra-
thoracic pressure or disease of the lungs; there was evidence

Digitized by

Google

113

of organic heart disease. The case was brought forward for
diagnosis.

Dr. Scanes Spicee asked whether the thorax had been examined with
X-rays. He had at present under treatment a case which appeared exactly
similar, and in which the X-rays revealed a marked aneurysm. In another
apparently similar case he could not find anything wrong with the chest.
In the absence of pressure in the chest he should regard Mr. de Santi’s
as probably due to an intrinsic nerve condition.

Sir Felix Semon was not so sure whether there was paralysis or
mechanical fixation. There was considerable thickening about the base
of the right arytenoid cartilage. Possibly the immobility of the right
vocal cord might be due to congenital ankylosis, or ankylosis acquired a
long time ago, to which attention had been only directed by accident in
consequence of some intercurrent acute laryngeal affection. The difference
between the two arytenoids was very striking, and the mechanical possi¬
bility as the cause should be kept in view.

Dr. Dundas Grant recalled the attention of members to a case in
which he was led into error—and, he thought, justifiable error—where
the appearances were somewhat similar to those in the present one. The
woman was about forty years of age, and had fixation of the right vocal
cord. There was slightly more infiltration than in the present instance,
and he was disposed to attribute it to syphlitic perichondritis. Mr.
Symonds suggested at the time that an oesophageal bougie should be
passed. When that was done some obstruction was found, and there was
soon some sprouting in the pyriform fossa, the case eventuating as one
of epithelioma. The appearances in this case When it was exhibited before
the Society were somewhat similar to those in Mr. de Santi’s, although
there seemed more activity. There was, in the present case, a gland in
the neighbourhood on that side, enlarged and hardened.

Dr. Jobson Horne thought the appearances in the larynx were sufficient
to account for the fixation, although, as Sir Felix Semon had suggested,
it might be of longer standing than was known. He gathered that there
was a history of tuberculosis in the family, if not in the patient herself,
and he thought that before taking any other view, a very thorough ex¬
amination of the chest should be made, and a radiograph obtained, with
the idea of excluding any pleural adhesions and enlarged glands which
would account for the fixation of the cord.

Mr. Atwood Thorne remarked that no one had referred to the swelling
on the left side, above the left vocal cord. He did not know what its
exact nature was, but it suggested that the disease was intrinsic rather
than extrinsic.

Dr. Robert Woods said the left vocal cord was distinctly limited with
regard to its movement. And there was not much difference in the two
sides. He believed the affection to be local, and not due to any intra-
thoracic involvement.

Mr. Barwell said the left vocal cord was not only swollen, but it
showed the longitudinal groove which was sometimes described as cleft
cord. He regarded the case as one of fixation rather than of paralysis,
because of the local lesions in the larynx, and the base of the arytenoid
was decidedly swollen. On phonation, the right arytenoid was not seen
to be pushed away by the left. He regarded it as a case of ankylosis.

Mr. de Santi, in reply, said he had been interested in the various
diagnoses advanced. The first time he saw the woman he noticed a con-

Digitized by

Google

114

ditionvery similar to that mentioned by Dr. Woods on the opposite side.
He observed this two or three times, and found subsequently that there
was more movement on the left side. He believed there was still limita¬
tion there ; he did not regard the case as malignant. In answer to Dr.
Home, he mentioned in describing the case that the chest had been care¬
fully examined by a physician, but nothing had been found except some
dilatation of the right ventricle and mitral regurgitation. There was
nothing wrong with the lungs or sputum, though the latter was examined
as a routine procedure, as the patient had a cough. He had seen three
or four cases of paralysis of the same kind in which the diagnosis had
been cleared up by th^ radiograph showing an aneurysm. He did not
think much could be done for the patient, but he would watch the case.

Bleeding Polypus of Septum in a Boy aged nine.

Shown by Mr. Waggett. Each of the anterior nares was blocked
by a growth resembling a raspberry in colour and appearance. Each
lobulated growth was attached by a broad base to the septum, just
within the muco-cutaneous boundary line, and posteriorly it shaded
off into the normal mucous membrane. Bleeding was frequent.
The growth on the right side was noticed two years ago, while the
left nostril was believed to be quite clear a year ago. Some inter¬
stitial corneal opacity was to be seen. There was no evidence of
past or present ulceration of the septum.

Dr. Pegler remarked that if this were a fibro-angioma (bleeding
polypus) of the septum, it was in the youngest patient but one on record.
The youngest previously was exhibited by Norval H. Pearce, who described
two cases, one was a patient aged fifteen, and the other aged five. The
growth seemed to be absolutely sessile, and he did not think one could
decide positively as to its true nature until it had been removed and
examined microscopically. Although it was lobulated on the surface, yet
it did not appear to be very vascular. - There was also a smaller growth
on the opposite side, but a bilateral “ bleeding polypus,’* or one making
its way through the cartilage of the septum had not yet been described.
The nearest approach to this was the case described by Vemeuil, in which
a pulsating erectile angioma appeared first on one side of the septum,
then disappeared, an exactly similar one appearing on the opposite side.
There were true angiomata elsewhere on the patient’s body, including
the palate, as in Dr. Lack’s case.

Dr. Dundas Grant thought there were grounds for suspecting it to
be tuberculous.

Mr. de Santi asked whether Mr. Waggett had found any evidence
of perforation in the septum, and whether the condition seen might not
be excessive granulation tissue in connection with perforation through
the septum. That might go with the history of interstitial keratitis and
congenital syphilis, but as Mr. Waggett had examined the case thoroughly
he could inform them as to that point.

Dr. Woods said he had operated upon two cases which, clinically,
were similar in appearance to the present one. They both turned out tQ

Digitized by

Google

115

be tuberculosis of the septum. There was no tubercle anywhere else in
the body.

Dr. Jobson Horne thought the growth was absolutely innocent. He
had seen a good many such growths, and had occasion to examine them,
and to follow out the subsequent history. In the majority of cases they
were thought to be sarcoma, but they generally proved to be innocent
growths, and after they were thoroughly removed nothing further was
heard of them. With regard to the diagnosis of tubercle in those cases,
it was as well to resort to animal experiment; the histological structure
was at times misleading. After the removal of the growth, a portion
might be reserved for the inoculation of a guinea-pig, and the remainder
placed in a preservative fluid for microscopic examination. He asked
Dr. Woods whether, in his cases, the diagnosis of tubercle was made on
the presence of bacilli, or merely upon the presence of giant-cells,
because the latter were not in themselves conclusive evidence of tubercle.

Dr. Woods, in reply to Dr. Horne, said the diagnosis in his cases was
made from the general microscopic appearance. Tubercle bacilli were not
found.

Dr. Pegler said further that he joined with those members who were
inclined to regard the case as one of lupus of the septum.

Mr. Waggett, in reply, thought the history was against it being
tubercle or lupus. It had been stationary on the right side for two years,
while it had been present on the left side one year. He thought it was
an ordinary vascular soft fibroma, which had very likely pierced the
septum. There was no perforation, and the upper inner edge of the
growths shaded off into the mucous membrane. He would report the
progress of the case later.

Atomizer for Spraying Medicated Fluid Vaseline.

Sir Felix Semon showed an atomizer for the application of
fluid vaseline to the mucous membranes of the upper respiratory
tract. The application consists in the interpolation of a cylindrical
nickel-plated metal tube, about 1£ inches in height and a little
more than 2 inches in diameter, with a removable lid, into the air-
conducting tube of a De Vilbiss atomizer. After screwing off the
lid a small quantity of vaseline is put into the tube, which may be
medicated by the addition of thymol, cinnamic aldehyde, etc.,
dissolved in paroleine or adepsine. The lid is screwed on again,
and the tube heated over an ordinary spirit lamp until the vaseline
becomes fluid, when the solution may be sprayed on to the mucous
membranes in the ordinary way by a hand-ball, or from a com¬
pressed air cylinder. The parts are thus covered with a thin film
of medicated fluid vaseline, which is very effectual in preventing
the formation of crusts in atrophic conditions of the mucous mem¬
brane and gives the patient considerable relief. As to the curative
effects of this application, the demonstrator did not wish to express
as yet any opinion.

Digitized by LjOOQle

116

Dr. Donelan thought the apparatus would be greatly improved if it
had a pistol handle, as it seemed difficult to hold it when it was hot.

A new Inhaler designed by Dr. Heryng, of Warsaw.

Exhibited by Dr. Pinkus. Dr. Pink us, in the absence of Dr.
Heryng, gave an interesting demonstration on the principles and
working of a new inhaler, which he claimed was capable of spray¬
ing medicated vapours, in which the molecules were reduced to
such a minute state of subdivision that, when inhaled, the drugs
or ingredients employed penetrated into the smallest interstices of
the lung.

He exhibited drawings of the lung of a cat, in which 'post¬
mortem section, after only thirty inspirations, showed staining of
the entire lung from apex to base.

The ingredient employed in the inhaler for the experiment had
been a solution of methylene blue, 1 in 1000.

The President thought the members would accord a vote of thanks
to Dr. Pinkus for exhibiting the apparatus at great trouble to himself.
It seemed to fulfil all the conditions claimed for it.

Dr. Pinkus (Warsaw) explained that the spray really represented a
mixture of fully saturated and partially over-saturated vapours or atomised
fluid. They were bubbles containing terebene, or turpentine, or thymol,
or creasote. There was full saturation with different localised points of
condensation, represented by droplets of mm - * n diameter. Such a
fine spray, no doubt, penetrated into the lungs. He exhibited drawings
of the lung of a cat which was killed immediately after 30 inhala¬
tions of a solution of methylene blue 1 in 1000. On dissection the
lung showed staining commencing at the apex. Sodium iodide inhaled
in that way would appear in the urine fifteen minutes later, whereas if
taken by the mouth it would not be found in the urine in less than two
or three hours. On the other hand, its appearance in the urine lasted
much longer—some twenty hours. Dr. Heryng would come over in the
winter and speak on the matter himself. When pyramidon, 1 gramme,
was inhaled, the patient’s temperature being 39° R., it fell to 375°, and
remained so for sixteen hours. Administration by the mouth lowered
the temperature only by for a shorter time. He regretted that he had
not been able to demonstrate another apparatus for a cold spray, which
was similar to a Richardson’s atomiser, with a pear-shaped bulb.

A Case of Atrophic Rhinitis and Pharyngitis with Visible Pulsa¬
tion of the Carotids in a Man aged thirty-six.

Shown by Dr. Donelan.

Digitized by LjOOQle

117

Case of Angioma of the Palate.

Shown by Dr. Lambert Lack. The patient was a girl aged
twenty-one. For about a year she had noticed a red discoloured
patch on the soft palate ; this had gradually increased in size during
the last two months. For the last three weeks it had bled frequently.
The slightest touch, even the passage of food, brought on the bleed¬
ing, and the patient complained that all her food tasted of blood.

On examination, a swelling about the circumference of a shilling
was seen on the left side of the soft palate, extending outwards
almost to the cheek, and upwards to the hard palate. It was soft
and but slightly raised, the surface was covered with dilated
venules which bled readily when touched. At one part near the
lower edge the surface seemed slightly harder and inclined to be
papillary.

The case was considered to be one of angioma. It had been
suggested that because of its rapid growth, it might have under¬
gone a malignant transformation, and might prove to be a sarcoma.

The case was shown on account of its rarity, and to elicit
opinions as to diagnosis and treatment.

The President remarked that, from the history, it did not appear to
be congenital. He thought the question was rather whether it was
sarcoma, and what method of treatment would be best.

Mr. de Santi thought, from the appearance of the swelling and its
history—though such cases were very rare—that it had a sarcomatous
element in it. The case should not be left, but should be subjected to
some form of treatment. He did not see why, under ordinary care, a
piece should not be cut out and subjected to microscopical examination.
Of course, it would bleed freely, but with adrenalin and the usual
appliances for checking haemorrhage, such as Paquelin’s cautery, it was
justifiable to remove a piece and deal with the disease accordingly.
Sections could be cut at the time of the operation, and then the operation
proceeded with. ’He thought it should not be left, as there was rapid
growth, and the age of the patient and the appearance of the tumour
were very suggestive of malignant disease.

Mr. Waggett thought the diagnosis of sarcoma made from inspection
of hastily prepared microscopical specimens in the operating theatre was
not very reliable. He thought it would be unwise to cut out a portion
for diagnostic purposes, but considered it would be better to remove the
whole growth by an operation, planned on a liberal scale.

The President said he at first thought, from the description, that it
was congenital, but obviously it was not. Naevi in that position did give
trouble, but the operation was not insuperable. He was struck with its
great solidity, and agreed it would be best to excise it. He did not
think very much haemorrhage would result if one kept free from the
tissue itself. That was the great principle in operating upon naevi. The
haemorrhage was very small if one kept well beyond the disease. He

Digitized by LjOOQle

118

thought that the tumour could be excised with very little risk indeed.
The bleeding on handling was chiefly from the surface ; it was probably
a papillomatous growth, which might have a sarcomatous basis.

Case of Pharyngeal Diverticulum opening into the Pyriform
Fossa in a Woman aged fifty-one.

Shown by Dr. Dundas Grant. The patient was a sparely built
woman of small stature, aged fifty-one, who for about a year had
been conscious of a slight difficulty in swallowing. On examination,
the right pyriform fossa was seen to be filled with a frothy fluid;
the larynx was otherwise normal. An oesophageal bougie passed
without any difficult}'. At first, suspicions were entertained that
it might be a case of commencing epithelioma in the pyriform
fossa, but after careful mopping no signs of epithelial sprouting
were found. To the right side of the thyroid cartilage was an
elongated swelling resetubling a mass of enlarged lymphatic glands
lying on the carotid artfery from which it received a communicated
pulsation. When this swelling was compressed the fluid in the
pyriform fossa exuded in increased quantity. On inquiry, it was
elicited that small particles of food returned at intervals of several
hours after swallowing, and the condition was then believed to be
a diverticulum of the pharynx. Attempts were made to introduce
a curved probe into the cavity, but without success. Kbntgen ray
photographs were taken by Dr. Mackenzie Davidson before and
after the swallowing of bismuth by the patient; in the latter the
bismuth emulsion was seen to collect like ink at the level of the
swelling, and in the subsequent photograph there could be seen an
elongated area of opacity in the same region, which was not visible
in the previous one, and which could only be accounted for by the
bismuth (opaque to the Rontgen rays) having collected in the sac.
This appeared to confirm the diagnosis, and it was proposed to
remove the sac by an external operation.

Mr. de Santi said he thought there seemed to be a swelling on the
other side and that it was a bilateral swelling, larger on the right than
on the left side. Did Dr. Grant think the* swelling on the left side some¬
thing separate ?

Mr. Waggett asked whether Dr. Grant thought he could get a more
complete knowledge of its anatomy by means of the short Killian’s tube.

Dr. Dundas Grant, in reply, said he had tried to insert a bent probe
into the orifice, but had not succeeded with such force as he felt justified
in using without damaging the tissues. He did not think anything re¬
mained but removal. The patient said she could not get any “ satis¬
factory ” food down ; she could only take milk and slops, and very soft

Digitized by LjOOQle

119

Bolide ; she could not eat meat with any comfort. He could not say she
was wasting to any extent, but she was suffering.

Case of Left Facial Paralysis (one week); Ulceration of Oro-

AND NaSO-PhARYNX (FIVE WEEKS) IN A Man AGED FORTY-SEVEN.

Shown by Dr. H. J. Davis. The patient attended the West
London Hospital two days before the meeting complaining of a sore
throat and inability to close the left eye. He stated that the throat
had been sore for about five weeks, but that the trouble in the eye
had only originated seven days ago. “ It did not inconvenience him
much, but, as he was a football referee, he found it difficult to blow
his whistle properly,” and this impeded him in the exercise of his
duties on the field. He thought, but was not sure, that the face
trouble came on very gradually after a night journey to Plymouth.
There was complete facial palsy on the left side, and tears were run¬
ning down the cheek, but the muscles still responded to faradism,
though feebly. There was also well-marked ulceration at the back
of the pharynx, more plainly visible when the palate was raised.
Examination by the finger detected extension of the ulceration high
up into the naso-pharynx chiefly on the right side ; no glands
were found enlarged, and there was a vague history of specific
disease about twenty-five years ago. There was no nasal disease.
He (Dr. Davis) thought that the ulceration was undoubtedly specific;
that the facial paralysis was a true Bell's palsy, and the associa¬
tion of the two diseases in this patient a mere coincidence. But he
w r ould like the opinions of members on the case, which he thought
a very interesting one.

Dr. H. J. Davis explained that he showed the case to ascertain whether
members thought the facial paralysis was specific, or whether it was
simply a coincidence in the case. The only reason that be had for thinking
that it was not a pure facial palsy was that the onset was gradual. As a
rule, peripheral neuritis due to cold came on abruptly. The patient
stated that the lower eyelid gradually drooped, and that he could not
breathe properly through the left nostril unless he drew his cheek to one
side, and this was evidently due to paralysis and collapse of the muscles
around the nostril as a result of the palsy. He believed it to be purely
Bell’s palsy, associated with a gumma of the palate; but he could not state
that there was not some pressure in the bony canal where the facial nerve
emerged. At the hospital there was difference of opinion as to the con¬
dition and the proper treatment to adopt, and he would like the opinion
of members as to diagnosis.

Sir Felix Semon though no one could answer the question which Dr.
Davis desired, but considering that gummata were so frequently multiple,
he thought before believing in a mere coincidence, which was one of the

Digitized by {jOOQie

120

well-known refuges, he would give iodide of potassium and mercurial
inunctions, and see what the result would be. The palsy also might be
the better thereby. He himself considered it more likely that the para¬
lysis was of syphilitic origin.

Dr. Dundas Grant asked if there was any defect of taste, and on
being answered by Dr. Davis in the negative, said that it looked as if the
cause were peripheral rather than in the part of the facial nerve above its
junction with the chorda tympani, and below where the great superficial
petrosal came off. He suggested it would be more helpful for diagnosis
to avoid for a time giving antisyphilitic remedies, as Bell’s paralysis
sometimes passed off quickly ; there was a so-called “ rheumatic ” facial
paralysis which resulted from exposure to cold, and was sometimes very
rapid in its departure. He only mentioned that in regard to diagnosis,
as, of course, in the patient’s interest, iodide of potassium was required.

Dr. Davis, in reply, said he believed that the lesion could not be above
the nucleus, because, if so, only the lower part, of the face would be
affected. The orbicularis was evidently paralysed, and the patient could
not raise or depress his eyebrows. If the lesion were in the cortex, or in
the nuclear fibres, the lower part of the face would only be affected, and
the upper part would escape, but this was not the case. The paresis
certainly involved the whole trunk of the nerve, and, therefore, he
thought it must be of peripheral origin, and very unlikely, therefore, to
be due to tertiary syphilis.

Case of Excavated Ulcer of the Pharynx presenting the

PuNCHED-OUT APPEARANCE OF A TERTIARY LESION, BUT WITH A

Degree of Induration Characteristic of Epithelioma, in a

Male Subject aged sixty.

Shown by Dr. Dundas Grant. The disease was of three months’
duration,, and there was remarkable absence of pain or of enlarge¬
ment of lymphatic glands.

Dr. Dundas Grant remarked that it looked like syphilis, and felt
like carcinoma.

Sir Felix Semon said he would go further and say it did not look
like syphilis. Although the ulcer itself looked very clean, as if it were a
broken-down gumma, he thought the margins of it, particularly in its
lower aspect, were much too big for a mere syphilitic ulcer. There was
distinct new growth in this ; it was not merely ulcer. Surely it was a
case in which removal of a small piece for microscopical examination
would be justified.

The President said he took the opportunity of feeling the growth,
and it had all the characters of malignancy, especially in its lower part.

Mr. de Santi said the growth looked malignant, and was so; prob¬
ably there were some enlarged retro-pharyngeal glands, which could not
be felt. Of course it was inoperable.

Dr. Dundas Grant, in reply, said his own opinion was that it was
malignant, but in view of the possibility of doubt he had given iodide of
potassium and mercury. He only saw the patient on the preceding day,
and therefore had no opportunity of observing the course of the complaint.

Digitized by LjOOQle

121

Subacute Osteomyelitis of Frontal Bone with Empyema of
Right Frontal Sinus.

Dr. Scanes Spicer showed Henry W. H—, aged thirty-five,
a shop-assistant, who had been referred to him at St. Mary's
Hospital on January 10, 1905, by Dr. Campbell Pope for empyema
of frontal sinus.

The patient first noticed aching over the right eyebrow and '
swelling of the eyelid on January 6. The next day the pain
became a severe neuralgia, the eyelid cedematous and closed over
the right eye, which was painful and injected.

This was the condition on January 10, when there was much
thickening and tenderness of the supra-orbital ridge and the frontal
bone above and below. It conveyed the impression of a greatly
distended frontal sinus reaching well to the outer margin of the
orbit. On transillumination there was intense blackness of the
whole brow when the lamp was placed under inner edge of orbit,
as compared with the opposite side. There was no discharge what¬
ever from the nose, but the middle turbinated was enlarged and
red, and no probe could be insinuated into the infundibulum.
The temperature was normal. The provisional diagnosis was
retention of fluid in a distended frontal sinus, with inflam¬
mation of the frontal bone supervening. Owing to the brief
duration of symptoms it was regarded as an acute inflammatory
condition, and ice-bags were applied to the forehead, and hot
alkaline nasal washes, and mentholised steam inhalations ordered,
a purge of calomel and colocynth and potassium iodide. After
four days the condition remaining unchanged, the front end of
the middle turbinated was amputated, two polypi were found in
subjacent ethmoidal cells. An attempt was made to probe the
frontal sinus without success; the same treatment was continued.

After another week with no alteration, it was decided to
explore the sinus from the outside. On the removal of the crown
of bone, at the junction of the supra-orbital ridge with the median
line, red cancellous tissue was seen filled with marrow-like sub¬
stance. The cells were lined with thin white delicate membrane,
and exuded sanguineous fluid. Quite an inch of this was gone
through before reaching a small cavity downwards and inwards,
the size of a small almond, filled with glairy yellow pus. On
enlarging the passage from frontal sinus into nose, small polypoid-
looking masses were brought away. The same red cancellous

Digitized by

Google

122

tissue with no trace of pus extended outwards over the orbital
plate and was freely curetted away. The operation was completed
in the usual way, and uninterrupted recovery ensued.

The points of interest appeared to be the extensive affection of
the frontal bone, and the small size of the cavity representing the
frontal sinus, in spite of the very marked and extensive opacity on
transillumination and the absence of nasal discharge. Syphilis
was denied, but there had been tonsillar and pharyngeal trouble
in the past, and chronic eczema, which did not present specific
characters. No evidence of tuberculosis. The term “ osteo¬
myelitis ” is applied to the case because the inflammation of the
marrow of the cancellous tissue appeared to be the most prominent
feature, though there was also periostitis and osteitis of the outer
table, as well as an empyema of the small frontal sinus.

Dr. Jobson Horne asked whether any examination of the material
removed had been carried out, with the view of ascertaining the nature
(if the disease.

Mr. Chichele Nourse asked whether there was any traumatism.
Two years ago he operated upon a case of chronic frontal sinusitis, in
which he noticed beforehand that there was considerable bulging of the
bone over the site of the sinus. During the operation he found that it
was due to the thickening of the bone, which was reddened and softened
over the frontal sinus, but this was not so marked as in Dr. Spicer’s case.
The disease had come on slowly, and the degree of osteitis was not
advanced.

The President said it was a rare case, and it led him to a case be
was called upon to handle three or four years ago at Guy’s Hospital.
A man came with signs of cerebral abscess, but he had never been
operated upon. There was a purulent discharge from the nose and
osteomyelitis of the whole frontal bone, extending back and involving the
temporal bone. On removing the bone a quantity of pus was found
lying over the dura mater. The patient practically died from encephalitis.
Dr. Scanes Spicer had his case in an early stage and removed the disease.
In support of that gentleman s view, he had found in operating on the
mastoid of little children aged fourteen months a distinct osteomyelitis,
while the mastoid antrum was quite healthy, and there was softening of
the bone for some distance backwards, covering over the lateral sinus.

Dr. H. J. Davis asked whether the osteomyelitis extended beyond the
cavity, or whether it was simply limited to the shell of bone surrounding
the frontal sinus.

Dr. Scanes Spicer, in reply, said on lifting the crown of bone of the
external table there was spongy cancellous tissue, softer than natural, and
the pulp of which was unduly red and engorged with sanguineous serum,
a greyish-white membrane lining. The bony cells could be distinguished.
One inch of such material was encountered before coming to what he
considered the frontal sinus itself, which was the size of a small almond,
and filled with pus. He thought the osteomyelitis might have started
from the retained frontal sinus empyema.

The President said it might have represented the stage when

Digitized by Google

123

suppuration was extending through the bone and was about to perforate
in front.

Dr. Dundas Grant suggested that the term osteitis would more
correctly describe the condition, as there was no constitutional disturbance
such as was present in osteomyelitis. Dr. Spicer said that the lining of
the cavity, when he opened it, was perfectly smooth. It was an unusual
case, though apparently of longer duration than the three days mentioned
in the description.

Dr. Scanes Spicer, in further reply, agreed that possibly osteitis
might be a better term than osteomyelitis, because the outer table was
involved as well as the cancellous tissue, but the most striking feature of
the case was the inflammatory condition of the marrow of the diploe.

[Mr. Maynard Smith, Surgical Kegistrar to St. Mary’s Hospital, has
since reported that the material removed from the frontal sinus itself was
of myxomatous nature, and similar in every way to the usual structure of
the polypi removed in accessory sinus disease. The material removed from
the enlarged cancellous spaces in the diploe of the frontal bone, above the
frontal sinus, had the naked-eye appearance of granulation tissue. The
microscopical examination showed the presence of granulation tissue. No
pus was present. No tubercles were present. There were no signs of
caseation. Bacteriological examination was not made. He looked upon
the condition as one of sub-acute septic osteomyelitis.]

A Case of Total Extirpation of the Larynx in a Man.
Shown by the President.

Digitized by

Google

Digitized by

GoogI

/>^r

PROCEEDINGS

^ OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Ninety-ninth Ordinary Meeting, June 2, 1905.

Charters J. Symonds, F.E.C.S., President, in the Chair.

Philip E. W. de Santi, F.E.C.S.">
Henry J. Davis, M.B., M.E.C.P. )

Secretaries.

Present—21 members and 2 visitors.

The minutes of the preceding meeting were read and confirmed.

Nomination of Ordinary Member.

Ernest Playfair, M.B., M.E.C.P.Bond., was nominated for election
at the next meeting.

The following specimens and cases were shown :

Case of Nasal Tuberculosis.

Shown by Mr. H. Barwell. The patient was a woman, aged
twenty-nine and unmarried. She came under Mr. BarwelFs care
in March, 1905, with signs of phthisis in an early stage. There
was an ulcer of characteristic tuberculous appearance on the left
anterior part of the septum, with pale “ speckly ” base, ill-defined
edges, and an irregular mass of sproutirt^ granulations; there was
occasional slight bleeding from the nose but no pain. A piece
removed for examination showed typical giant cells. She did not
attend regularly, and by May 18 a smaller ulcer had appeared on
the outer wall, as well as a soft granular patch on the left middle
turbinal, which Med readily when probed. These cases were rare
and not uncommonly primary in the nose. The usual position of
the ulcer on the front of the septum pointed to direct infection,
with the finger as the cause!

Digitized by {jOOQie

126

Mr. Barwell said he specially desired the opinions of members on
the prognosis of the case. He regarded it as favourable under suitable
treatment.

Dr. H. Smurthwaite said he had a case of tuberculosis of the nasal
septum, and showed the specimen before the Society a year ago. The
septum was perforated, and there had been stenosis for three years. The
patient had then no symptom of lung trouble, but he had heard a month
ago that she was dying of acute phthisis. Earlier in the case the sputum
was examined, with negative results. In r^Ly to the President, he said
the nasal condition progressed. He thoroughly scraped it, and reported
on the condition at the time.

The President said he supposed the prognosis in the present case
would be modified by the presence or absence of phthisis at the moment.
In his own cases of tuberculosis of the nasal septum and of the inferior
turbinal, the only parts of the nose in which he had seen tuberculosis as
a primary affection, the patients had done well and healed. But in the
presence of active phthisis the prognosis would not be good.

Mr. Barwell, in reply, said the patient had phthisis now, but only in
an early stage, and the physicians regarded it as a suitable case for open-
air treatment. He thought many of the cases of nasal tuberculosis were
primary. Some years ago Francis Steward collected 100 cases, of which
some 58 were found to be primary. Many, he thought, were confused
with lupus. In a primary case it was difficult to differentiate lupus in
the nose from tuberculosis. Lupus cases might be expected to do well,
but the tuberculosis cases were less favourable.

Case of Lupus of the Larynx and Uvula.

Shown by Mr. Barwell. The patient, a girl aged fifteen,
came under Mr. BarwelPs care last March. She had suffered
from hoarseness for six or seven months; there was no aphonia
and no pain. The disease was, as usual, most marked on the
epiglottis, and extended along the right aryteno-epiglottidean fold;
the cords were extensively infiltrated and showed ulceration. The
uvula was also affected. He proposed to treat the case with
frictions of lactic acid and formalin and excision of part of the
epiglottis should this be necessary.

Case of Curious Multiple Growths in the Epiglottic Region in a
Man, aged forty-three.

Shown by Dr. G. C. Cathcart for diagnosis.

Dr. H. J. Davis said that he regarded them as growths or hyper¬
trophies from the lingual tonsil. He had examined them with his finger,
and he thought that they were undoubtedly connected with the lingual
tonsils.

Mr. Atwood Thorne said he agreed with Dr. Davis, and suggested
that the growths should be removed and examined.

Dr. Scanes Spicer asked if the opinion of Dr. Davis and Dr. Atwood
Thorne were correct, what the central mass was, as there was no tonsil
substance in the median line.

Digitized by {jOOQie

127

The President said he had not been able to obtain a good view of
the larynx, largely on account of the condition of the mirror. The case
had previously been shown, in January, 1892, and this was important.

A Case of New Growth in the Right Maxillary Antrum in a Boy,

AGED TEN.

Shown by Dr. Cathcart.

Mr. Barwell remarked that there seemed to be no expansion of the
antrum in any direction, except on the facial surface; it did not expand
into the nose, nor press down the palate, nor expand upwards into the
orbit. The notes did not indicate that it extended back into the naso¬
pharynx. Those points were against malignant disease of the antrum.
It was very hard and firm, and was probably a tumour connected with
one of the teeth—a dentigerous cyst, or an odontome in the upper jaw.

The President pointed out that the eye was somewhat raised, but
the condition seemed more like bony growths or, as Dr. Barwell sug¬
gested, a dentigerous cyst. The question could only be settled by
opening the tumour up, which, he considered, would be the best course
to adopt.

Slides from a Case of Malignant Disease of the Pharyngo-

Larynx.

Shown by Mr. P. de Santi. The patient, a woman, had been
shown at previous meetings.

The President said the slides certainly showed the disease to be
carcinoma.

A Specimen of a Lingual Growth.

Shown by Dr. W. H. Kelson. The growth was removed from
a man shown at the April meeting; it was the size of a cherry,
pedunculated, and proved to be a fibroma.

Case of Faucial Eruption.

Shown by Dr. W. H. Kelson. A woman, aged forty-seven, with
eruption on the fauces, consisting of whitish patches on a red
inflamed base affecting the tonsils and palate, and first noticed five
months previously.

The case was shown as another of a series of cases shown in
1903 and 1904 {vide “ Transactions of the Laryngological Society”)
and having the following characteristics in common:

(1) The affection is more or less symmetrical, and closely re¬
sembles in appearance the earliest stage of secondary syphilis of
fauces.

Digitized by LjOOQle

128

(2) Antisyphilitic remedies have no effect, and there is no history
or other sign of syphilis to be found after careful search.

(3) The disease runs a chronic course and is of long duration,
generally over a year; it is superficial, and leaves no cicatrices.
It is never vesicular.

(4) It is accompanied by a good deal of burning pain, and some¬
times almost disappears and then relapses.

Dr. F. de Havilland Hall thought it was probably a herpetic con¬
dition. He understood there had been no vesicles. One knew how
rapidly vesicles disappeared from the mouth, and he thought the con¬
dition might be herpes of the pharynx.

Dr. Lambert Lack suggested that before excluding syphilis a much
more complete examination should be made than was possible in the
adjoining room. The appearance of the fauces was very suggestive of
secondary syphilis. The glands in the sub-occipital region were -char¬
acteristically hard and other glands in the neck were enlarged. It was
impossible always to discover how the infection occurred, but this diffi¬
culty should not be allowed to exclude the diagnosis.

, The President said he did not see the case, but the description
seemed to suggest pemphigus.

Dr. Kelson, in reply, said he had always been on the look-out for
vesicles. He knew what herpes and pemphigus looked like, but regarded
the present case as of a different nature. Certainly it bore a great
resemblance to syphilis, and he quite understood Dr. Lack’s remark on
the point. But in the other cases the condition did not alter for a year,
although mercury and iodide of potassium had been used. He thought
he could bring a case up which two years ago presented exactly the same
appearance, and which alternated a good deal. He showed that case in
19 °3.

Sir Felix Semon said it was very desirable to see the case referred to
by Dr. Kelson, together with the one now shown.

The President said the eruptions of herpes and pemphigus closely
resembled that of secondary syphilis. He had now two patients under
his care, one of them a medical ijian, in both of whom the fauces were
occupied by superficial white patches looking like secondary syphilis.
But there was no syphilis in either of them, and the condition lasted for
many weeks. He hoped Dr. Kelson would exhibit the case to which he
had referred, as it was desirable to clear the matter up.

Epithelioma of Larynx in a Man aged fifty-one.

Shown by Dr. Smurthwaite. The patient was sent to Dr.
Smurthwaite complaining of cough and hoarseness of some five
years* duration—worse the last year. There was no history of
syphilis. The patient was temperate in his habits and had not
to use his voice much. Examination revealed thickening and
irregularity of right vocal cord, which was difficult to differentiate
from false cord, the latter being also infiltrated, especially at its
anterior part. The left cord at its upper middle third showed

Digitized by LjOOQle

129

signs of some implication. Three weeks ago Dr. Smurthwaite
removed a piece of growth from the right cord and had it
examined. The report was squamous epithelioma.

The case was brought before the Society for an expression of
opinion as to whether one could have reasonable hope by operative
measures of eradicating the disease.

Mr. de Santi thought the general appearance that of malignant
disease, but as there was some doubt about it he suggested that Dr.
Smurthwaite should try the diagnostic methods which had recently been
advocated by Dr. Moore, of Liverpool, and of the results of which he
(Mr. de Santi) had some experience. Any patient suspected of suffering
from malignant disease was given a test meal, consisting of three quarters
of a pint of tea, without sugar or milk, and a round of dry toast; then the
contents of the stomach were drawn off one and a half to two hours later,
and were tested for free hydrochloric acid. The paper appeared in the
Lancet in April, 1905, and was brought before the Royal Society in March.
It described seventeen cases of malignant disease in various parts of the
body, including the tongue, cheek, and breast, and in two thirds of the
cases there was no trace whatever of free hydrochloric acid in the fluid
yielded by the stomach after the giving of the test meal. In the remainder
of the cases there was only a very small trace of the free acid, with the
exception of one case in which a quantity under one fifth of the normal
was found. In over 90 per cent, of the cases of carcinoma of the stomach
no free hydrochloric acid was found. The absence of free hydrochloric
acid in the stomach in cases of malignant disease was a somewhat recent
discovery, but four or five cases had been tested in that way at West¬
minster Hospital, and in the main corroborated the published results,
and it seemed to be a very valuable diagnostic measure. If it were true
it would hit the microscopist a good deal, and provide an excellent method
of detecting malignant disease.

Mr. de Santi, in answer to Dr. Pegler, said his patient had recently
been operated on and was not in a condition to have a stomach-tube
passed at present or to take a meal such as was necessary for testing
purposes.

Sir Felix Semon said he would not have had any doubt about the
malignancy of the case, but he had a conversation with a distinguished
member of the Society who was as astonished at the idea of malignant
disease as Sir Felix was that anyone should regard it as other than malig¬
nant. He was convinced it was an epithelioma, and, at the same time,
probably one of the rare instances of auto-inoculation of the opposite
vocal cord, such as Mr. Shattock and he had described years ago before
the Pathological Society. He thought the larynx should be opened with¬
out delay and the right cord removed ; then one would be able to judge
whether there was malignant disease in the middle of the left vocal cord,
and whether merely that part could be removed with a margin of healthy
tissue or whether the whole of the left cord would have to be removed.
The sooner that were done the better for the man’s life and the chance
of preserving some amount of voice.

Dr. StClair Thomson said he concluded clinically that it was
epithelioma of one vocal cord. He had watched the opposite side care¬
fully, and the lesion there seemed to come and go a little, as if there was
a good deal of mucus on it. After removing a singer’s nodule on one

Digitized by

Google

130

side, one often saw that the nodule which one expected to have to remove
on the opposite side disappeared. In cases where laryngo fissure was
advised it had often been mentioned at these meetings that certain things
could then be more easily seen. But in some which he had done the
direct appearance was not so different from that seen reflected in the
mirror. He had therefore mentioned to Dr. Smurthwaite the advantage
of feeling with the finger the suspicious cord after laryngo-fissure had
been performed. This would frequently reveal the extent of the infiltra¬
tion, and one could tell by touch whether it was a secondary infiltration
opposite. The case seemed a most suitable one for operation.

Dr. Lambert Lack said that he had examined the patient carefully,
and in his opinion the disease was not malignant. There was a growth
on the right vocal cord which fitted into a corresponding depression in
the left. There was certainly considerable swelling far back on the left
cord, but both cords moved equally and freely, and he thought if the
patient were left alone and told to rest his voice he would improve con¬
siderably. (Dr. Lack was not present when Dr. Smurthwaite first
stated that a portion of the growth had been removed, examined, and
reported to be malignant.)

Dr. Smurthwaite, in reply, thanked members who had expressed
their opinion on the case, though the different ideas left him in doubt as
to what should be done. A good piece had been removed from the right
cord, which would account for the depression spoken of by Dr. Lack.
The piece had been microscoped, and the report was squamous epithelioma,
as he remarked at the commencement of the meeting. Still, even then
one sometimes felt uncertain about malignancy. That was why he
brought the case up, for a clinical opinion. He would send the slide up
to the Society, and he regretted he did not bring it with him. He would
be glad of a report by the Morbid Growths Committee.

Dr. StClair Thomson suggested that the Morbid Growths Committee
should have a special sitting in reference to this specimen.

Sir Felix Semon, in further remarks, said Dr. Lack.spoke of a
“depression” on the opposite side. He (Sir Felix) had not seen any
depression. Pachydermia was not so remote an idea that one would not
think of it, but the part from which Dr. Smurthwaite had removed a
projecting piece of growth extended much further forward than one would
expect pachydermia to go.

Drawing of Angeioma of Larynx.

Dr. StClair Thomson showed a coloured drawing of a very
marked case of angeioma of the larynx. It illustrated, not a local
tumour, but a form of telangeiectasis, beneath the mucous membrane,
involving the right vallecula, both ventricular bands, the left sub¬
glottic region, and the right aryepiglottic fold. He was sorry
that he had no further note of the case beyond the fact that the
man was aged thirty, and had been under his observation at the
Throat Hospital in Golden Square in 1900. Dr. Thomson believed
that the man had at other times been under the observation of
some of his colleagues, and had even been a patient in the time of

Digitized by

Google

131

Sir Morell Mackenzie. He believed that the man had not suffered
from haemorrhage.

Thie President expressed the Society’s appreciation of the beautiful
drawing, and asked whether it had yet been published.

Dr. Pegler mentioned, for the information of members who were
interested in angeioma of the larynx, that Dr. Percy Kidd had sent him
a valuable specimen of telangeiectoma of the larynx, which that gentle¬
man described in the British Medical Journal in 1888.

Dr. StClair Thomson, in reply, said the drawing had not been
published. Dr. Bond said the patient was under his care at one time.
It was understood he had been shown before the Society, under Dr. Bond’s
name.

Girl, aged seventeen. Complete Paralysis op the Left Vocal
Cord, associated with Dilatation of the Left Pupil, Mitral
Stenosis, and Enlargement of the Left Auricle.

Shown by Mr. Atwood Thorne. D. S-, a dressmaker, aged

seventeen, came to the London Throat Hospital on May 13th, 1905,
complaining of hoarseness of three or four months’ duration. On
examination the left vocal cord was found to be in the cadaveric
position and immobile. The left pupil was dilated, but responded
sluggishly both to- light and to accommodation. There was no
localised sweating or other sign of involvement of the sympathetic
nerve. The upper eyelid did not droop. The radial pulses were
apparently synchronous and equal. There was a history of rheu¬
matic fever about four years ago, and there was great dyspnoea on
exertion. On examination of the chest there was no indication of
aneurysm, but evidence of marked mitral stenosis. He considered
that the laryngeal paralysis was probably due to the enlarged left
auricle, and remembering a somewhat similar case which was shown
some two years ago at the Harveian Society by Dr. Wilfred Harris,
he asked him to see the case. He reported as follows :

“ In my opinion the palsy of the left vocal cord is due to her
heart condition. She has advanced mitral stenosis, with very little
presystolic murmur left. There is a marked slapping diastolic shock
over the pulmonary artery, with an intensely loud pulmonary
second sound and reduplication of the second sound to be heard
all down the left side of the sternum. I examined the patient by
the screen with the X rays, and there is no sign of any mediastinal
growth, but the shadow of the base of the heart is unduly large to
the left, no doubt due to the enlarged auricle, as it is faintly
pulsatile.”

Although Mr. Thorne knew that the condition was a very rare

Digitized by

Google

132

one, he considered that th£ paralysis of the cord was due to
pressure on the recurrent laryngeal nerve by the enlarged left
auricle, and that the dilatation of the left pupil was due to irrita¬
tion of the sympathetic from the same cause. He would be much
obliged if members would give their opinion on the cause of the
paralysis.

Dr. de Havilland Ha.ll said it was a most interesting case, and he
had always been on the look-out for the condition, i. e., a sufficient
dilatation of the left auricle to involve the recurrent laryngeal. He did
not see why such should not occur, but had not seen a case. The girl
did not appear to be suffering severely from heart disease, but he under¬
stood there were marked physical signs—it was not possible then to
examine for them. Failing any other explanation, it was probably due to
pressure of the hypertrophied left auricle. Such cases had been
described before.

Mr. Atwood Thorne, in reply, said the X-rays revealed no evidence
of aneurysm.

Microscopic Section of Angeioma of Palate removed from a
Patient shown at the last Meeting.

Shown by Dr. Lambert Lack. The patient was a girl, aged
twenty-one, with a tumour on the left side of the soft palate, the
size of a shilling. It had grown rapidly during the past three
months, and some doubt was expressed at the last meeting as to
whether it was not a sarcoma.

Two days after the meeting the growth was excised. Deep
incisions were made round the tumour about one quarter of an
inch from its margin. The growth was then easily shelled out
with the finger. The somewhat free haemorrhage was arrested by
sponge pressure, and one artery which spurted freely was sealed
with Paquelin’s cautery.

Sections through the piece removed showed that the growth
consisted of a simple angeioma, and that a considerable margin of
healthy tissue had been removed all round. The deeper portion
of the tissue consisted of fat and glands. . There was no trace of
anything resembling malignant disease. Some of the cavernous
sinuses came up close to the surface of the growth, separated only
by two or three layers of epithelium. This accounted for the
readiness with which the slightest touch caused bleeding.

The President said it seemed to be a very clear and definite case of
angeioma.

Dr. Pegler remarked that this case had maintained its interest to

Digitized by

Google

1B3

the last. The microscopic specimen was as interesting and unique as the
growth itself. It was not a capillary naevus, but a pure cavernous
angeioma.

Specimen of Post-nasal Adenoids removed from a Man, aged

FIFTY-NINE.

Shown by Dr. Lambert Lack. The patient, a healthy country¬
man, complained of deafness, dating from an attack of influenza
three months ago. The patient also complained of a dry throat
and of nasal obstruction, which had commenced at the same time.

On examination, the deafness was found to be due to Eustachian
obstruction; both membranes were indrawn, and the hearing greatly
improved on inflation. On examining the post-nasal space, a lar^e
mass of adenoids was seen. There was no other cause of nasal
obstruction. The adenoids were removed under nitrous oxide
anaesthesia, and the hearing greatly improved immediately after
the operation, as was usual in adenoid deafness.

The mass removed seemed to be ordinary adenoid tissue, and
was of considerable size ; on post-rhinoscopic examination it was
sufficient to conceal half the septum.

This was the oldest subject with adenoids he had ever seen, the
previous oldest case being forty-four years of age. The latter also
had typical adenoid symptoms, including Eustachian catarrh, and
was of recent origin. Immediate and permanent relief followed
operation.

He should be glad to hear if any other members had met with
similar cases of apparently recent development of adenoids in old
people.

The President said it seemed a very exceptional case. He had not
seen such extensive disease in so old a subject. He asked whether the
growths were removed by Grottstein’s curette, and whether there was any
associated disease, such as lymphadenoma.

Mr. de Santi asked whether the microscope showed the mass removed
to be the same as ordinary adenoid tissue. It looked more like a new
growth—possibly adenoma.

Dr. StClair Thomson said he had had a case of adenoids over fifty.
His patient was deaf, and he gave a Politzer inflation, which greatly
improved her. When he told her she had adenoids she was most indig¬
nant at his suggesting such a childish complaint. He told her she would
probably be deaf unless they were removed, but he did not remove them.
He met her in society several years later, when she heard perfectly well,
but said she had never had her adenoids touched.

Dr. Furniss Potter said he had removed adenoids from a woman,
aged forty-seven, who suffered from deafness. Considerable improvement

Digitized by

Google

in hearing resulted. The tissue was examined microscopically and reported
to be “ adenoid.”

Woman, aged forty-five, with Inspiratory Dyspncea : History of
Syphilis, for Diagnosis.

Shown by Mr. de Santi. The patient attended Mr. de Santi’s
clinic for hoarseness and dry throat of some months* duration.
There was a history of syphilis sixteen years previously. Examina¬
tion revealed some atrophic rhinitis, pharyngitis sicca, chronic
laryngitis, and an enlarged thyroid gland. The patient only
attended two -or three times; later she came under the care of one of
the Physicians of the hospital, who found her to be suffering from
inspiratory dyspnoea; he reported the breath sounds as being much
more feeble on the left than the right side of the chest, and made
a provisional diagnosis of stenosis of trachea or left bronchus.

The patient was referred back to Mr. de Santi, who could find
no infra-glottic thickening. The question of diagnosis of the in¬
spiratory dyspnoea was the reason for bringing the case before
the meeting. In Mr. de Santi*s opinion the enlarged thyroid was
considered to be the probable cause of the trouble.

The patient had been on iodide of potassium, but was none the
better for it.

Dr. de Havilland Hall was of opinion that it was a case of per¬
verted action of the vocal cords. On getting the patient to phonate
steadily for some time, the cords became worn out, and then there was a
momentary widening of the cords to the full inspiratory position. It
reminded him of the first case he saw, when he was indebted to Sir Felix
Semon for the diagnosis. Sir Felix told him the trick by which the action
of the vocal cords could be overcome, namely, by prolonged phonation.
That woman had a good deal of laryngeal catarrh, sticky mucus about
the larynx, and he took her into Westminster Hospital, where she was
under observation some weeks and the laryngitis was cured, and by various
remedies directed to her hysterical condition she got-rid of the perverted
action. When he first saw her he thought she was suffering from bilateral
abductor paralysis, but the prolonged phonation settled the diagnosis, and
it was a very valuable means of distinction.

Sir Felix Semon said he believed he was the first to describe the con¬
dition to which Dr. Hall had referred and which was present in his case
in the G-erman edition of Mackenzie’s book, in 1880, under the name of
“ Perverse Action of the Vocal Cords.” He had seen several instances of
it in hysterical patients, and accidentally had learned the trick which
answered perfectly in Mr. de Santi’s case. After prolonged phonation,
when there came the necessity for respiration, the cords all of a sudden
separated normally. One case he had cured by electricity, and another
by an unexpected cold water douche.

Dr. StClair Thomson said the patient had no stenosis of the larynx;

Digitized by {jOOQie

135

he saw the cords at one moment gaping widely open, so if she had any
inspiratory dyspnoea it must be lower down, in the trachea or still lower.
The thyroid did not appear to be in the position which generally caused
pressure on the trachea. Of course, syphilitic stridor in the trachea or
bronchi was difficult to diagnose, and very unsatisfactory to treat; still, in
some of those cases which had not improved with iodide of potassium, he
found they did well with muscular injections of mercury. So far as the
laryngeal condition was concerned, it was functional.

Mr. Atwood Thorne said that mostly during inspiration the cords
were close together, and he thought it was double abductor paralysis. He
regarded the case as laryngeal.

Dr. Furniss Potter said that he had succeeded in making the
patient separate the cords several times in succession, during which she
had breathed freely. He had accomplished this by directing her to
phonate the word “hay” repeatedly with forcible aspiration. Whilst
doing this she appeared to experience no difficulty.

Mr. Atwood Thorne said that perhaps Dr. Potter saw the patient
after others had tried the experiment. (Dr. Potter replied that he had.)

Mr. de Santi, in reply, said he would give her a cold douche if he
could. The patient had marked inspiratory dyspnoea, but whether that
condition could be accounted for by what Sir Felix Semon and Dr. de
Havilland Hall had described as perverted action seemed doubtful,
Mr. de Santi, having had the opportunity of seeing the patient more than
once, was confident there was no abductor paralysis, as he had seen the
cords on more than one occasion widely abducted, but the condition of
“ perverted action ” of the cords he had missed altogether.

Intrinsic Laryngeal Neoplasm of Left Vocal Cord in a Man, aged

SEVENTY-THREE.

Shown by Dr. Scanes Spicer. There had been hoarseness of
nine months’ duration, but the cord moved normally. The mass
appeared to have a broad base of attachment and to invade the
deeper tissues of the laryngeal wall, and resembled a mass of
Iceland spar. It was removed at one cut with Mackenzie's laryn¬
geal forceps, and on examination presented innocent characters
only. The voice returned at once. The appearance of the growth
and age of the patient suggested malignancy, and the limitation of
the growth pointed to its favourable nature for laryngo-fissure,
but in face of the definite nature of the histological report, no inter¬
ference could be recommended and a watching policy was pursued.

Report on the growth hy Mr. Maynard Smith .—“ The section shows a
papilloma (squamous-celled). At one point the tissue lying at the base
of the growth is cut through. This has been somewhat damaged in
removal, but shows clearly the absence of any invasion with new growth;
the tissue is, in fact (apart from some round-celled infiltration), quite
normal.”

Sir Felix Semon said he would still be suspicious about the growth.

Digitized by LjOOQle

136

He did not deny that a man aged seventy-three might have an innocent
growth, but although under the microscope there might be no evidence of
malignancy, he would keep the patient a considerable time under observa¬
tion. The projections of the growth were very sharply pointed, which he
did not like to see.

Ulceration of Tonsil and Palate in a Man, aged forty-five.

Shown by Dr. Kelson. The patient had a large ulcer on the
left tonsil and palate, with warty indurated edges. It was said to
be of four months* duration. The lymphatic glands in the corre¬
sponding sub-maxillary region were enlarged, and the disease was
believed to be cancer.

Mr. de Santi said there could be no question about it being
epithelioma; there was a large mass of fixed glands.

The President asked whether it was the general opinion that any¬
thing could be done for him. It would be very difficult to remove. He
had operated upon a man who had malignant disease involving the whole
of the left side of the lower jaw, the pharynx, and part of the tongue,
etc. There was no particular trouble about it, but he thought he had
invasion of the opposite side, in the glands and lymphatics. It was of
no use operating unless the jaw were removed. The present patient was
not a very good subject, but it was possible to operate, as the disease
did not reach the aryepiglottic fold, and therefore one could not decline.

Case of Extensive Infiltration of the Pharynx, with slight
Ulceration ; for Diagnosis.

Shown by Mr. Charles Parker. The patient, a man, aged
thirty-seven, had suffered from sore throat and mouth, and a
sensation of something rising in the throat for three months. He
was otherwise in good health, and was able to carry on his work
as a gardener. On examination of the pharynx great swelling of
the tonsils, posterior pillars of the fauces, and the lateral bands of
the pharynx were seen, more marked on the left side. Studded
over the swollen parts were small yellow deposits about the size of
a split millet-seed. These also extended along the free border of
the soft palate and on to the uvula. At the junction of the soft
and hard palate there was distinct superficial ulceration. On
examination of the larynx there was seen to be very considerable
oedema of the left arytenoid and slight oedema of the right. On
the anterior surface of the right one a small tag of mucous mem¬
brane or granulation tissue could with difficulty be observed. The
patient also suffered from deafness of a month's duration. The
teeth were carious and in a filthy condition. There was a possi-

Digitized by LjOOQle

bility of syphilitic infection nine months previously, but the history
given and the results of examination were too indefinite to draw
any conclusions from them.

Dr. Pegler suggested it was a case of tuberculosis.

Dr. Scanes Spicer thought the condition was syphilitic.

Dr. Smurthwaite thought from the general appearance that it was
syphilitic. If it were tuberculous, bethought there would be redness of
the cords, whereas the cords appeared to be white, except at the base. If
it had been tuberculosis in the pharynx, one would have expected the
patient to be worse than he was at present, and there would have been
pain on swallowing. He advocated putting the patient upon a course of
antisyphilitic treatment first.

Sir Felix Semon said that if the patient had come to him privately
he would not have committed himself to a definite opinion after one single
examination.

Mr. Bar well said it was difficult to believe it was tuberculosis. That
disease was not only very uncommon in the pharynx and fauces, but it
usually only occurred at a late stage of phthisis. No report of the condi¬
tion of the chest had been mentioned. The patient was usually very ill,
and dysphagia was severe ; therefore it seemed improbable that the ulcera¬
tion of the fauces could be tuberculous. The oedema of the arytenoids
was asymmetrical, and a very translucent bluish-red, the remainder of the
larynx being unaffected. It did not give him the impression of tuber¬
cular laryngitis, but of an inflammation of the posterior surface, which he
regarded as probably syphilitic.

Dr. StClair Thomson said he did not think Mr. Parker suggested it
was tubercular, but that the diagnosis lay between chronic infection of the
pharynx and syphilis. One had never seen a tuberculous pharynx like that
without much more local and general reaction. The pseudo-oedema of the
arytenoids in this case was more characteristic of syphilis than of tubercle.
Recently he saw a case in his clinique in which the arytenoid flapped
about and looked as if it were fluid, but when taking hold of it and try¬
ing to get it off it was very tough. A similar case was brought to the
hospital during his absence, and it was looked upon as oedema of the
larynx, because it appeared translucent. Post-mortem examination showed
it to be an extremely fibrous syphilitic infiltration.

Mr. Parker said, in reply, that he would have been glad to hear from
those who thought it was syphilitic what they considered the exact lesion
was. He thought that with such extensive infiltration of the lateral walls
of the pharynx it could hardly be of a purely secondary nature, and yet, if
it was tertiary, it was very unusual for such extensive gummata in the
pharynx to persist for three months without breaking down.

Digitized by ^.oosle

Digitized by

INDEX.

PAGE

Abductor paralysis (unilateral right) associated with paralyses of right
half of soft palate and pharynx, right sterno-mastoid, upper fibres of
right trapezius, ptosis of right upper eyelid and contracted pupil
(H. Tillejr) . ...... 105

Actinomycosis of tonsil: specimen (A. H. Cheatle and W. d’Este Emery) 5
Adenoids (post-nasal) removed from man aged fifty-nine (H. Lambert

Lack) ....... 133

Anatomical plates presented to Society by Professor Onodi . .91

Aneurysm (thoracic, pulsating), with fixation of left vocal cord (H. J.

Davis) . . . . . .78

Angeioma of larynx (C. J. Symonds) .... 102

- - drawing of (StClair Thomson) . . . 130

- of palate (H. Lambert Lack) . . . .117

-*-microscopic section (H. Lambert Lack) . . 132

Annual General Meeting, January 13tli, 1905 . .25

-re-affirmed resolution carried that Laryngology

should be separate section from Otology at International Medical
Congresses. . . . . . .31

Antrum, right maxillary, new growth in (G. C. Cathcart) . . 127

Arsenic in treatment of lymphosarcoma of tonsil: great benefit resulting

(H< Tilley) . . . . .20

Aryteno-aryepiglottic region, growth in (E. Furniss Potter) . . 4

Arytenoid (right), epithelioma of right arytenoid and adjacent parts

removed by lateral pharyngotomy (H. Lambert Lack) . . 82

Arytenoid region (left), swelling in (P. R. W. de Santi) . . 35

-case subsequently proved to be carcinoma

(P. R. W. de Santi) . . . . .55

Atomizer for spraying medicated fluid vaseline (Sir F. Semon) . 115

Auricle (left) enlargement, with mitral stenosis, associated with complete

paralysis of left vocal cord (A. Thome). . . .131

Baber (E. Cresswell), discussion on lesion of soft palate . . 4

-discussion on case of pharyngeal obstruction from

diaphragm. . . .8

-discussion on case of hypertrophic rhinitis with sessile

outgrowth on septum . . .17

-discussion on case of tracheal obstruction . . 38

-discussion on case of pharyngeal and laryngeal nystagmus 40

-discussion on case of thickening of external plates of

thyroid cartilage and infiltration of left side of cartilaginous septum
of nose . . . . . .46

-- discussion on recurrent ulceration of tonsils, associated

with lymphadenoma. . . . .58

-discussion on case of primary sore of tongue . . 62

VOL. XII 9

Digitized by LjOOQLe

140

PAGE

Baber (E. Cresswell), discussion on combined functional and organic

paresis of larynx in singer .■ . . . .63

-discussion on cases of chronic empyemata of nasal

accessory sinuses treated by radical operations . . .67

Balance Sheet, 1904 . . . .29

Ball (J. B.), discussion on case of fixation of left vocal cord, with

pulsating thoracic aneurysm . . . .80

-discussion on traumatic ? perforation of septum . 92

-discussion on high-arched palate and crowding of teeth,

due to nasal obstruction . . . . .96

Barwell (Harold S.), two cases of tubercular laryngitis, healed under

treatment . . . . . . .84

- case of nasal tuberculosis . . . . .125

Discussion (p. 126'. Dr. Smurthwaite, The President (Mr. C. J.
Symonds), Mr. Barwell (reply).

- case of lupus of larynx and uvula .... 126

- discussion on laryngeal case for diagnosis . . .113

- discussion on new growth in right maxillary antrum . . 127

- discussion on case of extensive infiltration of pharynx . . 137

Beale (E. Clifford), discussion on tuberculosis of larynx commencing

during pregnancy . . . .51

- discussion on recurrent ulceration of tonsils, associated with

lymphadenoma . . . . . .60

Bennett (F. W.). photographs of a malignant growth of the larynx . 60

- case of extensive ulceration of the nasal septum for diagnosis . 63

Discussion (p. 64). Mr. Robinson, Dr. StClair Thomson, Dr.
Dundas Grant, Mr. Waggett, Dr. Bennett (reply).

- discussion on case of lupus of pharynx and larynx . . 24

- a case of post-pharyngeal swelling, shown at the May meeting . 25

Bond (J. W.), discussion on tuberculosis of larynx commencing during

pregnancy . . . . . .50

—- discussion on case of malignant glands in neck . . 61

Bony tumour of nose (H. Lambert Lack) . . . .17

Botella (Dr.), discussion on case of epithelioma of larynx 72

Brain: see Pons.

Bronner (Adolph), crusts from a case of dry catarrh of the nose and

naso-pharynx treated by formalin spray . . .14

Discussion (p. 14). The President (Dr. P. McBride), Dr. Tilley,

Dr. Bronner (reply).

- discussion on case of pharyngeal and laryngeal nystagmus 40

- discussion on case of epithelioma of palate, tonsil, tongue, and

cheek . . . . . .42

- discussion on case of diffuse papilloma of vocal cords . . 53

- discussion on case of laryngeal swelling first shown at meeting

of January 13, 1905, subsequently proved to be carcinoma . 56

Butlin (H. T.), discussion on growth in aryteno-arycpiglottic region . 5
- discussion on actinomycosis of tonsil . . .6

Carcinoma of larynx (W. Jobson Home) . . .94

- of nose (H. Lambert Lack) . . . .18

- in throat of dog and cat (F. Hobday) . . .2

- swelling in left arytenoid region; case subsequently proved to be

carcinoma (P. R. W. de Santi) . . . .55

Carotids, pulsation of, visible in case of atrophic rhinitis and pharyngitis

(J. Donelan) ...... 116

Carson (H. W.), case of lupus of pharynx and larynx . . 23

Discussion (p. 23). The President (Dr. P. McBride), Mr. Parker,

Dr. Lambert Lack, Dr. Bennett, Dr. de Havilland Hall, Mr. Carson
(reply).

Cartilage (thyroid): see Thyroid cartilage.

Digitized by LjOOQLe

141

PAGE

Cat: carcinoma in throat of (F. Hobday) . . .2

Catarrh (dry) of nose and naso-pharynx treated by formalin spray;

crusts exhibited (A. Bronner) . . .14

Cathcart (G. C.), case of chronic laryngitis in a male aged thirty-two 22
Discussion, pp. 22-23. The President (Dr. P. McBride), Dr.
Dundas Grant, Mr. Atwood Thorne, Dr. de Havilland Hall, Dr.
Cathcart (reply).

- combined functional and organic paresis of larynx in a singer

aged thirty-four . . . . .63

Discussion, p. 63. Mr. C. Baber, Dr. Scanes Spicer, Dr. Pegler,

Sir F. Semon, Dr. Dundas Grant.

-case of pachydermia laryngis, tubercular ? . . .63

-curious multiple growths in epiglottic region in a man aged

forty-three . . . . 126

Discussion, p. 126. Dr. H. J. Davis, Mr. Atwood Thome, Dr.
Scanes Spicer, The President (Mr. C. J. Symonds).

- new growth in right, maxillary antrum in a boy aged ten . 127

Discussion, p. 127. Mr. Barwell, The President (Mr. C. J.
Symonds).

Cerebro-spinal rhinorrhoea : see Rhinorrhcea (cerebro-spinal).

Chalk (piece of blue) impacted in respiratory passages (H. J. Davis) . 93

Cheatle (Arthur H.), and Emery (W. d’Este), a specimen of actino¬
mycosis of the tonsil. . . . .5

Discussion (p. 6). Dr. Herbert Tilley, Mr. Butlin, Mr. Cheatle
(reply).

Cheek: epithelioma of palate, tonsil, tongue and cheek (H. FitzGerald

Powell) . . . . .41

Chiari (Professor), discussion on cases of chronic empyemata of nasal

accessory sinuses treated by radical operations . . .67

- discussion on case of pharyngo-laryngeal epithelioma . . 68

- discussion on case of soft fibroma of larynx and neck removed

by external operation . . .71

- discussion on case of incrustations in trachea. . .75

Congresses (International Medical): see International Medical Congresses.
Council: Report for year ending January 13, 1905 . .27

Davis (H. J.), fixation of left vocal cord in a man, aged forty-nine, with

a pulsating thoracic aneurysm . . .78

Discussion (pp. 80, 81). Dr. Permewan, Professor Poli, Dr.
FitzGerald Powell, Dr. Jobson Home, Dr. Ball, Professor Koenig,

Dr. Watson Williams, Dr. Dundas Grant, Dr. Smurthwaite, Dr.
Davis (reply).

- traumatic (?) perforation of the septum in a boy, aged seventeen 92

Discussion (p. 92). Mr. Robinson, Dr. Ball, Mr. Waggett, Dr.
Westmacott, Dr. Dundas Grant, Dr. Vinrace.

- a piece of blue chalk, half an inch in length, impacted for three

weeks in the respiratory passages of a boy, aged ten . . 93

- case of left racial paralysis (one week); ulceration of oro- and

naso-pharynx (five weeks) in a man, aged forty-seven . .119

Discussion, p. 119. Sir F. Semon, Dr. Dundas Grant, Dr. Davis
(reply).

- discussion on case of fixation of left vocal cord . . 57

- discussion on case of lingual growth . . . ' 95

-discussion on case of broadening and disfigurement of external

nose . . . . . .99

- discussion on case of lateral ulceration of larynx . . 109

- discussion on subacute osteomyelitis of frontal bone with em¬
pyema of right frontal sinus ..... 122

Diagnosis, cases for: fixation of left vocal cord (S. Paget) . . 57

-growth on left vocal cord (S. Paget) . ,64

Digitized by LjOOQLe

142

PAGE

Diagnosis, cases for : growth on right vocal cord; operation twelve years

previously for papilloma of larynx (S. Paget) . . .58

-headache (obstinate), accompanied by crusting and muco-

pus formation: maxillary, sphenoidal, and frontal sinuses explored
without tangible results (L. H. Pegler). . . .99

-infiltration (extensive) of pharynx, with slight ulceration

(C. A. Parker) . . . . . 136

-inspiratory dyspnoea; history of syphilis (P. R. W. De

Santi) ....... 134

-laryngeal case (P. R. W. De Santi) . . . 112

-laryngeal stenosis (tuberculosis, lupus, or congenital

syphilis?) (StC. Thomson) . . . . .34

-lateral ulceration of larynx (J. Donelan) . . 109

-lesion of soft palate (P. R. W. De Santi) . . 4

-ulceration (extensive) of nasal septum (F. W. Bennett) . 63

-ulceration of soft palate (F. H. Westmacott) . . 43

Diaphragm between back of tongue and posterior wall of pharynx

causing pharyngeal obstruction (H. Betham Robinson) . 7

- (cicatricial) due to inherited syphilis passing from posterior third

of tongue to posterior wall of pharynx (H. Betham Robinson) . 77

Discussions: request from President to members to limit alterations in

notes of discussions as reported . . .91

Diverticulum (pharyngeal) opening into pyriform fossa (J. Dundas

Grant) ...... 77, 118

Dog: carcinoma in'throat of (F. Hobday) . . . .2

Donelan (James), man, aged thirty-nine, with lateral ulceration of the

larynx: hoarseness about two months .... 109

Discussion (p. 109). Dr. Davis.

-a case of almost complete bony occlusion of the left nostril, the

result of trauma and septal deformity in a man, aged twenty-five . Ill
Discussion (p. 111). Mr. Waggett, Dr. Tilley, Mr. Symonds, Dr.
Dundas Grant, Dr. Pegler, Dr. Scanes Spicer, Dr. Donelan (reply).

- a case of atrophic rhinitis and pharyngitis, with visible pulsation

of the carotids, in a man, aged thirty-six . . .116

- discussion on atomiser for spraying medicated fluid vaseline . 116

Downie (J. Walker), discussion on case of epithelioma of larynx . 73

Dyspnoea (inspiratory), case, with history of syphilis for diagnosis

(P. R. W. de Santi) ...... 134

Ear: pathological changes in ear in case of unilateral congenital lesion

of medulla and spinal cord (P. R. W. de Santi and P. Stewart) . 69

Emery (W. d’Este) and Cheatle (Arthur H.), a specimen of actinomy¬
cosis of the tonsil . . . .5

Discussion (p. 6). Dr. Herbert Tilley, Mr. Butlin, Mr. Cheatle
(reply).

Empyema of frontal sinus (subacute) following scarlet fever (H. Tilley) . 22

-— of light frontal sinus, with subacute osteomyelitis of frontal bone

(R. H. Scanes Spicer) ..... 121

- (chronic) of nasal accessory sinuses, radical operations performed

for (H. Tilley) . . . . . .66

Epiglottis: epithelioma of epiglottis and base of tongue removed by

sub-hyoid pharyngotomy (H. Lambert Lack) . . .81

- growths (multiple) in epiglottic region (G. C. Cathcart) . 126

Epithelioma: excavated ulcer of pharynx, with induration characteristic

of (J. Dundas Grant) ..... 120

- of right arytenoid and adjacent parts removed by lateral pharyn¬
gotomy (H. Lambert Lack) . . . . .82

- of epiglottis and base of tongue removed by subhyoid pharyn¬
gotomy (H. Lambert Lack) . . . . .81

- of larynx (H. Smurthwaite) , 128

Digitized by LjOOQLe

143

PAGE

Epithelioma of larynx treated by laryngo-fissure (StClair Thomson) . 32

--eight months previously; no recurrence

(StClair Thomson) . . . 72

-treated by thyrotomy; recurrence; removal of greater

part of larynx ; recovery (Sir F. Semon) . . .14

- of nose (A. Thorne and J. R. Lunn) .75

- of palate, tonsil, tongue, and cheek (H. FitzGerald Powell) . 41

- of pharynx and larynx (P. R. W. de Santi) . . .68

- of right vocal cord ; slide from case shown (Sir F. Semon) 41

Eruption (faucial) (W. H. Kelson). .... 127

Ethmoid, necrosis of, two cases (G. William Hill) . . .25

Exhibition of collection of naked-eye and microscopical preparations,
selected and arranged by Dr. Pegler, Curator to the Society, during
day of meeting held on occasion of Garcia Celebration . 86-90

Section A. Naked-eye specimens.

I. Larynx . .86

II. Nose and accessory cavities . .87

III. Naso-pharynx . . .88

IY. Pharynx and (esophagus . . .88

Section B. Microscopical preparations.

I. Larynx . . . .88

H. Nose and accessory cavities .89

III. Naso-pharynx .90

IY. Pharynx . .90

Extirpation (total) of larynx (C. J. Symonds) . 123

Eyelid: ptosis of right upper eyelid and contracted pupil, associated

with unilateral right abductor paralysis (H. Tilley) . 105

Fauces, eruption on (W. H. Kelson) . 127

Fibroma of larynx (case of laryngeal growth in a boy aged six) (W.

H. Kelson) . .7

-and neck (soft), removed by external operation without

opening cavity of larynx (Sir F. Semon) . .71

- (soft) on left vocal cord (H. Betham Robinson) 102

Fibro-myxomatoid outgrowth on right side opposite middle turbinated

body (J. Dundas Grant) . . .24

Fixation of left vocal cord (S. Paget) . . .57

- of left vocal cord with pulsating thoracic aneurysm (H. J. Davis) 78

Forceps (laryngeal) for use in direct laryngoscopy (D. R. Paterson) . 43

Foreign body removed by direct laryngoscopy from a child aged twelve

months (D. R. Paterson) . . .8

Formalin spray in treatment of dry catarrh of nose and naso-pharynx

(A. Bronner) . . . .14

Fox (Clayton) demonstration of, and discussion on, Dr. Frederick Spicer’s

case of diffuse papilloma of the vocal cords . . .53

Frontal bone, osteomyelitis of (R. H. Scanes Spicer) . . 121

Garcia Celebration, meeting of Society on occasion of . .65

-collection of naked-eye and microscopical

preparations exhibited during day . . . 86-90

-foreign visitors present . . 65

Gluck (Professor), discussion on case of pharyngo-laryngeal epithelioma 68

- discussion on case of epithelioma of laiynx . . 72, 73

Grant (J. Dundas), a case of new growths in the larynx . 10

Discussion (p. 11). Mr. de Santi, Dr. StClair Thomson, Dr.
Pegler, Dr. Dundas Grant (reply).

_ T_L__ii.1. _ 1 _J.1. _

septum in a male patient aged twenty-two, the growth of such a
size and shape as at first sight to simulate the middle turbinated
body . . . . . .17

Discussion (p. 17). Dr. Pegler, Mr. Cresswell Baber.

Digitized by LjOOQle

144

PAGE

Grant (J. Dundas), case of hypertrophic rhinitis involving both inferior
turbinated bodies (recently cauterised) and fibro-myxomatoid out¬
growth on the right side opposite the middle turbinated body in
a female patient aged twenty-two . . . .24

- case of ulcer of the tongue in a boy aged two and a half . 24

-— case of pharyngeal diverticulum opening into the pyriform fossa

in a woman aged fifty-one, with Rontgen-ray photograph showing
the pouch when filled with bismuth . . . .77

-j— case of pharyngeal diverticulum opening into the pyriform fossa

in a woman ...... 118

Discussion (p. 118). Mr. de Santi, Mr. Waggett, Dr. Dundas
Grant (reply).

-case of excavated ulcer of the pharynx presenting the punched-

out appearance of a tertiary lesion, but with a degree of induration
characteristic of epithelioma, in a male subject aged sixty . 120

Discussion (p. 120). Sir Felix Semon, The President (Mr. Charters
Symonds), Mr. de Santi, Dr. Dundas Grant (reply).

- discussion on case of chronic laryngitis . . .23

- discussion on case of diffuse papilloma of vocal cords . . 53

- discussion on combined functional and organic paresis of larynx

in singer . . . . . . .63

- discussion on case of extensive ulceration of nasal septum . 64

- discussion on case of fixation of left vocal cord, with pulsating

thoracic aneurysm . . . . . .80

- discussion on traumatic (?) perforation of septum . . 93

- discussion on carcinoma-of larynx . . . .94

- discussion on case of broadening and disfigurement of external

nose . . . . . .99

- discussion on case of obstinate headache accompanied by crusting

and muco-pus formation ..... 107
- discussion on case of unilateral right abductor paralysis associ¬
ated with other paralyses ..... 105

- discussion on case of papilloma of larynx . . . 107

- discussion on trauma and septal deformity, causing bony occlu¬
sion of left nostril . . . . .112

- discussion on laryngeal case for diagnosis . . . 113

- discussion on bleeding polypus of septum . . 114

-discussion on left facial paralysis and ulceration of oro- and naso¬
pharynx ....... 120

- discussion on subacute osteomyelitis of frontal bone, with

empyema of right frontal sinus .... 123
Growth in aryteno-aryepiglottic region (E. Fumiss Potter) . . 4

-on left vocal cord; slight hoarseness for past fifteen months (S.

Paget) . . . . . . .64

- removed twenty years ago from right vocal cord by the late Dr.

Whistler; present condition of patient (E. Law) . . .54

- (lingual), case of (W. H. Kelson) . . . .95

- -specimen of (W. H. Kelson) ... 127

- (new) in right maxillary antrum (G. C. Cathcart) . 127

Growths (multiple) in epiglottic region (G. C. Cathcart) . . 126

- (new) in larynx (J. Dundas Grant) . . . .10

Hall (F. de Havilland), discussion on case of lymphosarcoma of tonsil

treated by arsenic ..... . 20

- discussion on case of chronic laryngitis . . .23

- discussion on case of lupus of pharynx and larynx . . 24

- seconder of re-affirmed resolution that Laryngology should be

separate section from Otology at all International Medical Con¬
gresses . . . . . . .31

-discussion on faucial eruption .... 128

Digitized by LjOOQLe

145

PAGE

Hall (F. de Haviiland), discussion on case of complete paralysis of

left vocal cord associated with mitral stenosis and enlargement of
left auricle. . . 132

- discussion on case of inspiratory dyspnoea . . . 134

Headache (obstinate) accompanied by crusting and muco-pus formation

(L. H. Pegler) . . .99

Heryng (Dr.), a new inhaler designed by Dr. Heryng, exhibited by Dr.

Pinkus . ... . 116

Discussion (p. 116). Mr. Charters Symonds, Dr. Pinkus.

Hill (G. William), two cases of ethmoidal necrosis . . .25

Hobday (F.) (introduced by P. R. W. de Santi), specimens of carcinoma

in the throat of the dog and the cat . . .2

Discussion (p. 3). The President (Dr. P. McBride).

Horne (W. Jobson), a case of carcinoma of the larynx . 94

Discussion (p. 94). Mr. de Santi, The President (Mr. Charters
Symonds), Dr. Dundas Grant, Sir Felix Semon, Dr. Horne (reply).

- discussion on case of fixation of left vocal cord, with pulsating

thoracic aneurysm . . . . .80

.- discussion on case of broadening and disfigurement of external

nose . .99

- discussion on case of soft fibroma on left vocal cord . 102

- discussion on laryngeal case for diagnosis . 113

- discussion on bleeding polypus of septum • 115

- discussion on subacute osteomyelitis of frontal bone, with

empyema of right frontal sinus .... 122

Hyperplasia (subglottic) producing tracheal stenosis, probably of

syphilitic origin (H. Tilley) ..... 104

Incrustation in case of dry catarrh of nose and naso-pharynx, treated by

formalin spray (A. Bronner) . . . . .14

- in trachea, with at times well-marked stenosis (E. Law) 9, 13, 75

- obstinate headache accompanied by crusting and muco-pus

formation (L. H. Pegler) . . . .99

Infiltration of pharynx (extensive), with slight ulceration (C. A. Parker) 136
Inflammatory oedema of obscure origin affecting posterior parts of larynx

(Sir F. Semon) . . .... .46

Inhaler (new) designed by Dr. Heryng, of Warsaw, exhibited by Dr.

Pinkus ....... 116

Inspiratory dyspnoea; history of syphilis ; case for diagnosis (P. R. W.

de Santi) ....... 134

International Medical Congresses : re-affirmed resolution that Laryn¬
gology should be separate section from Otology at International
Medical Congresses carried at Annual Genei*al Meeting, 1905 31

Kelson (W. H.), a case of laryngeal growth in a boy aged six. 7

Discussion (p. 7). Dr. Herbert Tilley, Dr. Furniss Potter, Dr.
Kelson (reply).

- a case of lingual growth in a man aged sixty . .95

Discussion (p. 95). Dr. Davis, Mr. Robinson, Mr. de Santi, the
President (Mr. Symonds).

-a specimen of a lingual growth .... 127

- case of faucial eruption ..... 127

Discussion (p. 128). Dr. de Haviiland Hall, Dr. Lack, the Presi¬
dent (Mr. C. J. Symonds), Sir F. Semon, Dr. Kelson (reply).

- ulceration of tonsil and palate in a man aged forty-five. 136

Discussion (p. 136). Mr. de Santi, the President (Mr. Symonds)

- discussion on high-arched palate and crowding of teeth due to

nasal obstruction . * .97

Digitized by LjOOQLe

146

PAGE

Killian’s method in removal of stricture of oesophagus (E. B. Waggett) . 1

-of submucous resection in case of deflected septum

(H. Tilley). . .21

Koenig (Professor), discussion on case of fixation of left vocal cord, with

pulsating thoracic aneurysm . . . . .80

Lack (H. Lambert), case of bony tumour of the nose . . 17

Discussion (p. 18). Dr. Pegler, Mr. Steward.

- case of carcinoma of the nose in a man aged sixty .18

Discussion (p. 19). Dr. Pegler, Dr. Herbert Tilley, Dr. Wyatt
Wingrave.

- Case 1. Epithelioma of epiglottis and base of tongue removed by

sub-hyoid pharyngotomy . . . .81

- Case 2. Epithelioma of right arytenoid and adjacent parts,

removed by lateral pharyngotomy . . . .82

Discussion (p. 83). Dr. Tilley, Dr. Watson Williams.

- case of high-arched palate and crowding of teeth due to nasal

obstruction, showing the factors producing the deformity . . 95

Discussion (pp. 96-98). Dr. Ball, Mr. Robinson, Mr. Westmacott,
the President (Mr. Symonds), Sir Felix Semon, Dr. Kelson, Mr.

J. G. Turner (visitor), Dr. Lack (reply).

- case of angeioma of palate . . .111

Discussion (p. 117). The President (Mr. Symonds), Mr.

De Santi, Mr. Waggett.

- microscopic section of angeioma of palate removed from a patient,

shown at the last meeting (May 5th) . . . .132

Discussion (p. 133). Dr. Pegler.

- specimen of post-nasal adenoids removed from a man aged fifty-

nine ....... 133

Discussion (p. 133). The President (Mr. Symonds), Mr. de Santi,

Dr. StClair Thomson, Dr. Furniss Potter.

- discussion on case of lymphosarcoma of tonsil treated by arsenic 21

- discussion on case of lupus of pharynx and larynx . . 23

- discussion on tuberculosis of larynx commencing during preg¬
nancy . . . . . .51

- discussion on case of laryngeal swelling first shown at meeting

of January 13th, 1904, subsequently proved to be carcinoma. . 56

- discussion on recurrent ulceration of tonsils, associated with

lymphadenoma . . . . .59

-discussion on faucial eruption .... 128

- discussion on case of epithelioma of larynx . . . 130

Laryngitis (chronic), case of (G. C. Cathcart) . . .22

- tubercular, two cases, healed under treatment (H. S. Barwell) . 84

Laryngo-fissure, in treatment of epithelioma of larynx (StC. Thomson) . 32

-no recurrence after eight months (StC. Thomson) . 72

Laryngology: re-affirmed resolution that Laryngology should be separate
section from Otology at International Medical Congresses, carried
at Annual General Meeting, 1905 . . . .31

Laryngoscopy (direct), in removal of foreign body from child aged twelve

months (D. R. Paterson) . . . . .8

-laryngeal forceps for use in (D. R. Paterson) . . 43

Larynx, angeioma (C. J. Symonds) . . . 103

- - drawing of (StC. Thomson) .... 130

- carcinoma of (W. Jobson Home) . . . .94

- (diseases), demonstration of paintings in oil illustrating (H.

Smurthwaite) . . . . . .43

- epithelioma of (H. Smurthwaite) .... 128

-thyrotomy; recurrence; removal of greater part of larynx;

recovery (Sir F. Semon) . . . . .14

-treated by laryngo-fissure (StC. Thomson) . . 32

Digitized by LjOOQLe

147

PAGE

Larynx, epithelioma of, treated eight months previously ; no recurrence

(StC. Thomson) . . . . .72

-of pharynx and larynx (P. R. W. de Santi) . . 68

- extirpation (total) (C. J. Symonds) . . . 72, 123

-- case seven years after (C. J. Symonds) . . 107

- fibroma (case of laryngeal growth in boy, aged six) (W. H. Kelson) 7

-:- (soft) of larynx and neck removed by external operation

without opening cavity of larynx (Sir F. Semon). . .71

- inflammatory oedema of obscure origin affecting posterior parts

(Sir F. Semon) . . . . .46

- intrinsic laryngeal neoplasm of left vocal cord (R. H. Scanes

Spicer) . . . . . .135

- laryngeal case for diagnosis (P. R. W. de Santi) . . 112

-lupus of larynx and uvula (H. S. Barwell) . . . 126

-pharynx and larynx (H. W. Carson) . . .23

-(primary) of larynx and pharynx (StC. Thomson) . 74

-naked-eye specimens and microscopical preparations exhibited

during day of Garcia Celebration . . . 86,88

-new growths in (J. Dundas Grant) . . . .10

- nystagmus of pharynx and larynx in case of (?) tumour of pons

(Sir F. Semon) . . . .38

- pachydermia laryngis (? tubercular) (G. C. Cathcart) . . 63

-papifloma (C. J. Symonds) .... 107

-operation for, followed at twelve years’ interval by growth

on right vocal cord (S. Paget) . . . .58

- paresis (combined functional and organic) in singer (G. C.

Cathcart) . . . . . . .63

- stenosis; tracheotomy with improvement (tuberculosis, lupus, or

congenital syphilis ?) (StC. Thomson) . . .34

- swelling same side as malignant glands in neck (P. R. W. de Santi) 61

- tuberculosis, case commencing during pregnancy (C. A. Parker) 49,66

- ulceration, lateral (J. Donelan) .... 109

- see Forceps (laryngeal).

Law (Edward), a case of incrustation in the trachea, with, at times, well-

marked stenosis . . . . . 9,13,75

Discussion (p. 10). The President (Dr. P. McBride), Dr. Milligan
(p. 13). Sir Felix Semon, Mr. H. B. Robinson (p. 75). Professor
Chiari.

-hoarseness, cough, pain, little bloody expectoration, man

aged sixty-nine, from whom the late Dr. Whistler removed a growth
from the right vocal cord twenty years ago . . .54

Discussion (p. 55). Dr. Scanes Spicer, Sir F. Semon, Mr. Waggett
(reply)

-discussion on case of tracheal obstruction . . 38

Librarian (Honorary), report for 1904 . . . .28

Lingual growth: see Tongue

Lunn (J. R.) and Thorne (Atwood), case of epithelioma of the nose
(shown at the January meeting, 1904); patient, macroscopic and
microscopic specimens and photographs . . .75

Lupus : laryngeal stenosis (StC. Thomson) . . . .34

-larynx and uvula (H. S. Barwell) .... 126

- (primary) of larynx (quite healed) and of pharynx (nearly healed)

(StC. Thomson) . . . . .74

- of pharynx and larynx (H. W. Carson) . . .23

Lymphadenoma, associated with recurrent ulceration of tonsils (F. J.

Steward) . . . . . . .58

Lymphosarcoma of tonsil; great benefit from arsenic (H. Tilley) . 20

Malignant disease of pharyngo-larynx (P. R. W. de Santi) . . 127

- glands in neck (P. R. W. ae Santi) . . . .61

9 §

Digitized by LjOOQLe

148

PAGE

Malignant growth of larynx, photographs (F. W. Bennett) . . 60

- (?) tumour of thyroid gland (localised), causing paralysis of left

vocal cord (F. J. Steward) . . . . .24

McBride (Peter), discussion on diagnostic specimen from oesophageal

structure removed by Killian’s method. . . . .1

- discussion on carcinoma in throat of dog and cat . . 3, 4

-discussion on lesion of soft palate . . . .4

- discussion on foreign body removed by direct laryngoscopy from

child, aged twelve months . . . . .9

- discussion on case of incrustation in trachea . . .10

- discussion on case of dry catarrh of nose and naso-pharynx

treated by formalin spray . . . . .14

- discussion on case of epithelioma of larynx . . .17

- discussion on case of lymphosarcoma of tonsil treated by arsenic 21

- discussion on case of chronic laryngitis . . .22

- discussion on case of lupus of pharynx and larynx . . 23

Medical Congresses (International): see International Medical Congresses.
Medulla: congenital lesion (unilateral) of medulla and spinal cord

(P. R. W. de Santi and P. Stewart) . . . .69

Microphotographs, demonstration of series of (W. Milligan) . . 75

Milligan (W.), demonstration of series of microphotographs . . 75

- discussion on case of stenosis of trachea . . .10

Mitral stenosis with enlargement of left auricle associated with complete

paralysis of left vocal cord (A. Thorne) . . . 131

Morbid Growths Collection: report of Curator . . .30

Morbid Growths Committee, members of . . .31

-Report of. . . . . 31, 32

Moure (Professor E. J.), discussion on case of pharypgo-laryngeal

epithelioma . . . . . .68

- discussion on case of epithelioma of larynx . . .73

Mouth : pathological changes in mouth in case of unilateral congenital

lesion of medulla and spinal cord (P. R. W. de Santi and P. Stewart) 69
Muco-pu8 formation and crusting accompanying case of obstinate head¬
ache (L. H. Pegler) . . . . .99

Naso-pharynx: catarrh (dry) treated by formalin spray (A. Bronner) . 14

- naked-eye specimens and microscopical preparations exhibited

during day of Garcia Celebration ... 88,90

- ulceration of oro- and naso-pharynx (H. J. Davis) . .119

Neck : fibroma (soft) of larynx and neck (Sir F. Semon) . . 71

- malignant glands in (P. R. W. de Santi) . . .61

Necrosis of ethmoid, two cases (G. William Hill) . . .25

Neoplasm: intrinsic laryngeal neoplasm of left vocal cord (R. H. Scanes

Spicer) . . . . . . 135

Nose: accessory sinuses: chronic empyemata treated by radical

operations (H. Tilley) . . . . .66

-naked-eye specimens and microscopical prepa¬
rations exhibited during day of Garcia Celebration . 87 ,89

-presentation to Society of plates illustrating anatomy

of frontal and other sinuses, by Professor Onodi . . 91

- bony tumour of (H. Lambert Lack) . . . .17

- carcinoma of (H. Lambert Lack) . . . .18

-— catarrh (dry) treated by formalin spray (A. Bronner) . . 14

-epithelioma (A. Thome and J. R. Lunn) . . .75

- (external) broadened and disfigured by tense bilateral, non-

vascular swellings, attached to the anterior third of the cartila¬
ginous septum. Nasal obstruction complete (L. H. Pegler) . 98

-naked-eye specimens and microscopical preparations exhibited

during day of Garcia Celebration , , , 87,89

Digitized by t^oosle

149

PAGE

Nose: obstruction, causing high-arched palate and crowding of teeth

(H. Lambert Lack) . . . . . .95

- (septum) bleeding polypus (E. B. Waggett) . . . 114

-deflected: submucous resection (Killian’s method) (H.

Tilley) . . . . . . .21

- : -infiltration of left side of cartilaginous septum nasi (C.

A. Parker). . . .46

-sessile outgrowth on septum in case of hypertrophic

rhinitis simulating middle turbinated body (J. Dundas Grant) . 17

-traumatic (P) perforation of (H. J. Davis) . . 92

-— ulceration, extensive, case for diagnosis (F. W. Bennett) 63

- tuberculosis of (H. S. Barwell) .... 125

- see Post-nasal space.

Nostril (left) bony occlusion, almost complete; result of trauma and septal

deformity (J. Donelan) . .111

Nourse (Chichele) discussion on subacute osteomyelitis of frontal bone,

with empyema of right frontal sinus .... 122

Nystagmus of pharynx and larynx in case of tumour ? of pons (Sir Felix

Semon) . . . . . . .38

Occlusion (bony, almost complete) of left nostril, result of trauma and

septal deformity (J. Donelan)..... Ill
(Edema (inflammatory) of obscure origin affecting posterior parts of

larynx (Sir F. Semon) . .46

(Esophagus, naked-eye specimens, exhibited during day of Garcia

Celebration . . . . . .88

- stricture; diagnostic specimen removed by Killian’s method

(E. B. Waggett) 1

Onodi (Professor), presentation to Society of plates illustrating anatomy

of frontal and other sinuses . . . .91

Oro-pharynx, ulceration of oro- and naso-pharynx (H. J. Davis^ 119

Osteomyelitis (sub-acute) of frontal bone with empyema of right frontal

sinus (R. H. Scanes Spicer) ..... 121

Otology: re-affirmed resolution that Laryngology should be separate
section from Otology at International Medical Congresses earned at
Annual General Meeting, 1905 3

Pachydermia laryngis, tubercular P (G. C. Cathcart) . .63

Paget (Stephen), fixation of the left vocal cord in a man aged about 40

(shown for diagnosis) . . . . .57

Discussion (pp. 57,58). Dr. H. J. Davis, Mr. Robinson, Dr. Scanes
Spicer, Dr. Fumiss Potter, Mr. Paget (reply).

- growth on the right vocal cord in a woman who had undergone

operation twelve years previously for papilloma of the larynx (case
shown for diagnosis) . . .58

-growth on the left vocal cord in a man aged forty-six, who had

noticed slight hoarseness of the voice for the last fifteen months . 64

Discussion (p. 64). Mr. Waggett, Mr. de Santi, Dr. StClair
Thomson, Dr. Fitzgerald Powell.

Palate, angeioma of (H. Lambert Lack) . .117

- microscopic section (H. Lambert Lack) . . 132

- epithelioma of palate, tonsil, tongue, and cheek (H. Fitzgerald

Powell) . . . .41

- (high-arched) and crowding of teeth due to nasal obstruction

(H. Lambert Lack) . . .95

- ulceration of tonsil and palate (W. H. Kelson) 136

- (soft) lesion of: case for diagnosis (P. R. W. de Santi) . . 4

-, paralysis of right half of soft palate and pharynx, of

right sterno-mastoid, and of upper fibres of right trapezius,
associated with unilateral right abductor paralysis (H. Tilley) . 105

Digitized by LjOOQLe

150

PAGE

Palate (soft), ulceration of : case for diagnosis (F. H. Westmacott) . 43

Papilloma of larynx (C. J. Symonds) .... 107

-operation for, followed at twelve years’ interval by

growth on right vocal cord (S. Paget) . . . .58

- of vocal cords (diffuse) (F. Spicer) . . . .52

Paralysis (abductor, unilateral right), associated with paralysis of right
half of soft palate and pharynx, right stemo-mastoid, upper fibres of
right trapezius, ptosis of right upper eyelid and contracted pupil
(H. Tilley) . . . . .105

- (left facial), ulceration of oro- and naso-pharynx (H. J. Davis) . 119

- of left vocal cord, associated with dilatation of left pupil, mitral

stenosis, and enlargement of left auricle (A. Thome) * . 131

-caused by localised tumour of thyroid gland (malignant ?)

(F. J. Steward) . . . . . .24

Paresis of larynx (combined functional and organic) in singer (G. C.

Cathcart) . . . . . . .63

Parker (Charles A.), case of thickening of the external plates of the
thyroid cartilage and infiltration of the left side of the cartilaginous
septum nasi . . . . . .46

Discussion (p. 46). Mr. Cresswell Baber, Dr. Pegler.

- case of tuberculosis of the larynx in a woman, aged thirty-one,

which commenced during her fifth pregnancy, and since which there
have been four subsequent pregnancies . . 49, 66

Discussion (pp. 50-52). Mr. Steward, Dr. J. W. Bond, Dr. Herbert
Tilley, Dr. Scanes Spicer, Dr. Lambert Lack, Sir Felix Semon, Dr.
Clifford Beale, Mr. Parker (reply).

Discussion (p. 66). The President (Mr. C. J. Symonds).

- case of extensive infiltration of the pharynx, with slight ulcera¬
tion ; for diagnosis ...... 136

Discussion (p. 137). Dr. Pegler, Dr. Scanes Spicer, Dr. Smur-
thwaite, Sir F. Semon, Mr. Barwell, Dr. StClair Thomson, Mr.
Parker (reply).

- discussion on case of lupus of pharynx and larynx . . 23

-discussion on case of tracheal obstruction . . .37

Paterson (D. R.), foreign body removed by direct laryngoscopy from

a child aged twelve months . . . . . 8

Discussion (p. 9). The President (Dr. MacBride), Dr. Paterson

(reply)-

- laryngeal forceps for use in direct laryngoscopy . . 43

Pegler, (L. Hemington), collection of naked-eye and microscopical
preparations, selected and arranged by Dr. Pegler, Curator to the
Society, exhibited during day of meeting held on occasion of Garcia
Celebration ..... 86-90

-case of broadening and disfigurement of the external nose, caused

by tense, bilateral, non-vascular swellings, attached to the anterior
third of the cartilaginous septum. Nasal obstruction complete . 98

Discussion (pp. 98, 99). Mr. Robinson, Dr. Dundas Grant, Dr.
Jobson Home, Mr. de Santi, Dr. Davis, the President (Mr.
Symonds).

- case of obstinate headache, accompanied by crusting and muco-

pus formation in a man, aged forty, in which the maxillary,
sphenoidal, and frontal sinuses had been explored without tangible

results; for diagnosis . . . . .99

Discussion (pp. 100-102). Mr. Waggett, Mr. Westmacott, Sir
Felix Semon, Dr. Herbert Tilley, Dr. StClair Thomson, Dr. Dundas
Grant, Dr. Pegler (reply).

- discussion on case of new growths in the larynx . . 11

- discussion on case of hypertrophic rhinitis with sessile outgrowth

on septum . . . . . . .17

-— discussion on case of bony tumour of nose . . .18

Digitized by LjOOQLe

151

PAGE

Pegler (L. Hemington), discussion on case of carcinoma of nose . 19

-discussion on case of pharyngeal and laryngeal nystagmus . 40

- discussion on case of ulceration of soft palate . .44

- discussion on case of thickening of external plates of thyroid

cartilage and infiltration of left side of cartilaginous septum nasi . 46

- discussion on combined functional and organic paresis of

larynx in singer . . . . . .63

- discussion on case of angeioma of larynx . . . 104

- discussion on trauma and septal deformity, causing bony occlu¬
sion of left nostril . . . .112

- discussion on bleeding polypus of septum . . 114, 115

- discussion on angeioma of larynx .... 131

- discussion on case of angeioma of palate . . . 133

- discussion on case of extensive infiltration of pharynx . . 137

Perforation (traumatic P) of septum (H. J. Davis) . . .92

Permewan (W.), discussion on case of fixation of left vocal cord, with

a pulsating thoracic aneurysm . . . 80, 81

Pharyngitis and atrophic rhinitis, with visible pulsation of the carotids

(J. Donelan) ...... 116

Pharyngo-larynx, malignant disease of (P. R. W. de Santi) . . 127

Pharyngotomy (lateral) in removal of epithelioma of right arytenoid and

adjacent parts (H. Lambert Lack) . .82

- (sub-hyoid) in removal of epithelioma of epiglottis and base of

tongue (H. Lamberf Lack) . . . .81

Pharynx: cicatricial diaphragm passing from posterior third of tongue

to posterior wall of pharynx (H. Betham Robinson) . . 77

- epithelioma of pharynx and larynx (P. R. W. de Santi) . 68

- infiltration (extensive), with slight ulceration (C. A. Parker) . 136

- lupus of pharynx and larynx (H. W. Carson). . .23

-(primary) of larynx and pharynx (StC. Thomson) . 74

- naked-eye specimens and microscopical preparations exhibited .

during day of Garcia Celebration . . 88, 90

- nystagmus of pharynx and larynx in. case of tumour P of pons

(Sir F. Semon) . . . . .38

- obstruction of, due to diaphragm between back of tongue and

posterior wall of pharynx (H. Bet bam Robinson) . . 7.

- paralyses of right half of soft palate and pharynx, of right

8terno-mastoid, and of upper fibres of right trapezius, associated with
unilateral right abductor paralysis (H. Tilley) . . . 105

- ulcer of, with punched-out appearance of tertiary lesion, and

induration characteristic of epithelioma (J. Dundas Grant) . 120

- See Diverticulum (pharyngeal).

Pinkus (Dr.): a new inhaler designed by Dr. Heryng of Warsaw,

exhibited by Dr. Pinkus ..... 116

Poli (Professor): discussion on case of fixation of left vocal cord, with

pulsating thoracic aneurysm . . . . .80

Polypus (bleeding) of septum (E. B. Waggett) . . . 114

Pons : tumour of pons causing pharyngeal and laryngeal nystagmus (Sir

F. Semon) . . . . . .38

Post-nasal space, adenoids in: removal from man aged fifty-nine (H.

Lambert Lack) ...... 133

Post-pharyngeal swelling, case previously shown (F. W. Bennett) . 25

Potter (E. Furniss): a case of growth in the aryteno-aryepiglottic

region in a man aged sixty-four (previously exhibited) . . 4

Discussion (p. 5). Mr. Butlin, Mr. de Santi, Dr. StClair Thomson,

Dr. Fumiss Potter (reply).

- discussion on laryngeal growth in boy aged six . .7

- discussion on case of fixation of left vocal cord . . 58

-discussion on case of post-nasal adenoids in man aged fifty-

nine . . . . . 133

Digitized by LjOOQLe

152

PAGE

Potter (E. Fumiss), discussion on case of inspiratory dyspnoea . 135

Powell (H. Fitzgerald): epithelioma of palate, tonsil, tongue, and cheek 41
Discussion (p. 42). Mr. de Santi, Mr. Westmacott, Dr. Watson
Williams, Dr. Bronner, Sir Felix Semon, Dr. Fitzgerald Powell
(reply).

- discussion on case of swelling in left arytenoid region . . 36

- discussion on case of tracheal obstruction . . .38

- discussion on case of ulceration of soft palate . . 45

- discussion on case of diffuse papilloma of vocal cords . . 54

- discussion 6n case of laryngeal swelling first shown at meeting

of January 13th, 1905, subsequently proved to be carcinoma . 56

- discussion on case of primary sore of tongue . . .62

- discussion on case of growth on left vocal cord . . 64

- discussion on case of fixation of left vocal cord, with pulsating

thoracic aneurysm . . . . . .80

Pregnancy : tuberculosis of larynx commencing during (C. A. Parker) . 50

Ptosis of right upper eyelid and contracted pupil associated with uni¬
lateral right abductor paralysis (H. Tilley) . . . 105

Pupil (contracted) : ptoses of right upper eyelid and contracted pupil

associated with unilateral right abductor paralysis (H. Tilley) . 105

- (left): dilatation of left pupil, mitral stenosis, and enlargement

of left auricle associated with complete paralysis of left vocal cord
(A. Thome) ...... 131

Pyriform fossa: pharyngeal diverticulum opening into (J. Dundas

Grant) . . . . . . 77,118

Resection (submucous) of deflected nasal septum (Killian’s method)

(H. Tilley). .21

Respiratory passages, piece of blue chalk impacted in (H. J. Davis) . 93

Rhinitis (atrophic) and pharyngitis, with visible pulsation of carotids

(J. Donelan) . . . . . 116

- (hypertrophic) involving both inferior turbinated bodies (J.

Dundas Grant) . . . . .24

-with sessile outgrowth on septum (J. Dundas Grant) . 17

Rhinorrhoea (cerebro-spinal), case recovering spontaneously (P. Watson

Williams) . . . . . .85

Robinson (H. Betham) : a case of pharyngeal obstruction from a
diaphragm between the back of the tongue and the posterior wall
of the pharynx . . . .17

Discussion (p. 8). Mr. Cresswell Baber.

- cicatricial diaphragm due to inherited syphilis passing from the

posterior third of the tongue to the posterior wall of the pharynx . 77

- soft fibroma on left vocal cord .... 102

Discussion (p. 102). Dr. Jobson Home, Dr. StClair Thomson,

Mr. Robinson (reply).

- discussion on case of incrustation in trachea . . .14

- discussion on case of lymphosarcoma of tonsil treated by arsenic 21

- discussion on case of fixation of left vocal cord . . 58

- discussion on case of malignant glands in neck . . 61

- discussion on case of primary sore of tongue . . .62

- discussion on case of extensive ulceration of nasal septum 64

- discussion on traumatic (?) perforation of septum . . 92

- discussion on case of lingual growth . . .95

- discussion on high-arched palate and crowding of teeth, due to

nasal obstruction . . . . . .97

- discussion on case of broadening and disfigurement of external nose 98

- discussion on subglottic hyperplasia, producing tracheal stenosis,

probably of syphilitic oiigin ..... 104

- discussion on case of unilateral right abductor paralysis, associated

with other paralyses . . . . 106

Digitized by Google

153

PAGE

Rontgen-ray photograph, showing pharyngeal diverticulum when filled

with bismuth (J. Dundas Grant) . . . .77

de Santi (Philip R. W.), a lesion of the soft palate for diagnosis . 4

Discussion (p. 4). The President (Dr. McBride), Mr. Cresswell
Baber, Mr. de Santi (reply)

- a case of swelling in the left arytenoid region in a woman aged

thirty-five . . . . . .35

Discussion (p. 36). Dr. Watson Williams, Mr. W. G. Spencer, Dr.
Fitzgerald Powell, Dr. Smurthwaite, Dr. StClair Thomson, Sir
Felix Semon, Mr. de Santi (reply).

-- woman, aged thirty-five, shown at last meeting with laryngeal

swelling, thought to be tubercular, and microscopic slide showing
undoubted squamous-celled carcinoma . . . .55

Discussion (pp. 56, 57). The President (Mr. C. J. Symonds), Dr.
Scanes Spicer, Dr. Fitzgerald Powell, Sir Felix Semon, Dr. Lambert
Lack, Dr. Bronner, Mr. Westmacott, Mr. Steward, Mr. de Santi
(reply).

- man, aged sixty, mass of malignant glands in the neck, swelling

of larynx same side . . . . . .61

Discussion (pp. 61, 62). Mr. Robinson, Dr. Bond, Dr. Scanes
Spicer.

- woman, aged thirty-five, with pharyngo-laryngeal epithelioma . 67

Discussion (p. 68). Professor Moure, Professor Gluck, Professor
Chiari, Mr. de Santi (reply)

- laryngeal case for diagnosis .... 112

Discussion (p. 113). Dr. Scanes Spicer, Sir Felix Semon, Dr.
Dundas Grant, Dr. Jobson Horne, Mr. Atwood Thorne, Dr. Robert
Woods, Mr. Barwell, Mr. de Santi (reply) •

- malignant disease of pharyngo-larynx . . . 127

Discussion (p. 127). The President (Mr. C. J. Symonds).

- woman, aged forty-five, with inspiratory dyspnoea; history of

syphilis, for diagnosis ..... 134

Discussion (pp. 134, 135). Dr. deHavilland Hall, Sir Felix Semon,
Dr. StClair Thomson, Mr. Atwood Thorne, Dr. Fumiss Potter,
Mr. de Santi (reply)

- specimens of carcinoma in the throat of the dog and the cat,

shown by F. Hobday, introduced by Philip R. W. de Santi . 2

-discussion on growth in aryteno-aryepiglottic region . . 5

- discussion on case of new growths in the larynx . .11

- discussion on case of epithelioma of palate, tonsil, tongue and

cheek . . . . . . .42

- discussion on recurrent ulceration of tonsils, associated with

lymphadenoma . . . . . .59

- discussion on case of primary sore of tongue . . .62

- discussion on case of growth on left vocal cord . 64

- discussion on case of epithelioma of larynx . .73

- discussion on carcinoma of larynx . . .94

-discussion on case of lingual growth . . .95

- discussion on case of broadening and disfigurement of external

nose . . . . . .99

- discussion on bleeding polypus of septum . . .114

- discussion on angeioma of palate . . . .117

- discussion on pharyngeal diverticulum opening into pyriform

fossa ....... 118

- discussion on excavated ulcer of pharynx, with appearance of

tertiary lesion, but characteristic of epithelioma . . . 120

- discussion on case of epithelioma of larynx . . 129

-discussion on case of post-nasal adenoids in man aged fifty-nine 133

- discussion on case of ulceration of tonsil and palate 136

Digitized by LjOOQLe

154

PAGE

de Santi (Philip R. W.), and Stewart (Purves), a case of unilateral
congenital lesion of the medulla and spinal cord, with brief notes
of the pathological changes in the mouth, throat, and ear in a man
aged forty-one . . . . . .69

Scarlet fever, followed by subacute frontal sinus empyema (H. Tilley) . 22

Semon (Sir Felix, C.Y.O.), epithelioma of larynx; thyrotomy; recur¬
rence ; removal of greater part of larynx; recovery . . 14

Discussion (p. 17). The President (Dr. McBride).

- pharyngeal and laryngeal nystagmus in a case of tumour ? of

the pons . . . . . . .38

Discussion (p. 40). Dr. Bronner, Dr. Pegler, Dr. Herbert Tilley,

Mr. W. G. Spencer, Mr. Cresswell Baber, Dr. StClair Thomson.

-slide from a case of epithelioma of the right vocal cord and

neighbourhood, in a gentleman aged fifty . . .41

- inflammatory oedema of obscure origin affecting the posterior

parts of the larynx in a man aged forty-seven . . .46

Discussion (p. 47). Mr. W. G. Spencer, Dr. Herbert Tilley, Sir
Felix Semon (reply).

- a case of soft fibroma of the larynx and neck removed by external

operation, without opening the cavity of the larynx . . 71

Discussion (p. 71). Professor Chiari.

- atomiser for spraying medicated fluid vaseline . . 115

Discussion (p. 116). Dr. Donelan.

- mover of re-affirmed resolution that Laryngology should be

separate section from Otology at all International Medical Con¬
gresses . . . . . . .31

- discussion on case of incrustation in trachea . . .13

- discussion on case of swelling in left arytenoid region . 36

-discussion on case of tracheal obstruction . . .38

-discussion on case of epithelioma of palate, tonsil, tongue, and

cheek . . . . . . .42

-— discussion on case of ulceration of soft palate . . 45

- discussion on tuberculosis of larynx commencing during preg¬
nancy . . . . . .51

- discussion on case of diffuse papilloma of vocal cords . . 53

- discussion on present condition of patient in whom the late Dr.

Whistler removed growth from right vocal cord twenty years ago . 55

- discussion on case of laryngeal swelling first shown at meeting of

January 13th, 1905, subsequently proved to be carcinoma . 56, 57

- discussion on recurrent ulceration of tonsils, associated with

lymphadenoma . . . . . .60

- discussion on combined functional and organic paresis of larynx

in singer . . . . . . .63

- discussion on case of epithelioma of larynx . . .73

- discussion on carcinoma of larynx . . . .94

- discussion on high-arched palate and crowding of teeth, due to

nasal obstruction . . . . . .97

- discussion on case of obstinate headache accompanied by crusting

and muco-pus formation ..... 100

- discussion on case of angeioma of larynx . . . 103

- discussion on case of unilateral right abductor paralysis asso¬
ciated with other paralyses . . . . . 106

- discussion on case of complete extirpation of larynx, exhibited

seven years after ...... 109

-discussion on laryngeal case for diagnosis . . .113

- discussion on left facial paralysis and ulceration of oro- and

naso-pharynx ...... 119

- discussion on excavated ulcer of pharynx, with appearance of

tertiary lesion, but characteristic of epithelioma . .120

- discussion on faucial eruption . . .128

Digitized by LjOOQLe

155

PAGE

Semon (Sir Felix, C.V.O.), discussion on case of epithelioma of larynx . 129

- discussion on case of inspiratory dyspnoea . . . 134

- discussion on case of intrinsic laryngeal neoplasm of left vocal

cord . . . . .135

- discussion on case of extensive infiltration of pharynx . . 137

Singer: combined functional and organic paresis of larynx in (G. C.

Cathcart) . . . . . . .63

Sinus (frontal) empyema, subacute, following scarlet fever (H. Tilley) . 22

- (right frontal) empyema of, in subacute osteomyelitis of frontal

bone (Scanes Spicer). ..... 121

Sinuses (frontal): suppuration of both frontal sinuses cured by operation

(E. B. Waggett) . 106

- (maxillary, sphenoidal, and frontal) explored without tangible

results in case oi obstinate headache, accompanied by crusting and
muco-pus formation (L. H. Pegler) . . . .99

Sinusitis, sphenoidal and posterior ethmoidal: cured case (P. Watson

Williams) . . .85

Smith (Maynard), microscopical report on subacute osteomyelitis of

frontal bone, with empyema of right frontal sinus . .123

- microscopical report on Dr. Scanes Spicer’s case of intrinsic

laryngeal neoplasm of left vocal cord .... 135

Smurthwaite (Hugh), demonstration of series of paintings in oil

illustrating diseases of the throat and larynx . .43

- epithelioma of larynx in a man aged fifty-one. . 128

Discussion (p. 129). Mr. de Santi, Sir F. Semon, Dr. StClair
Thomson, Dr. Lack, Dr. Smurthwaite (reply).

- discussion on case of swelling in left arytenoid region . . 36

- discussion on case of fixation of left vocal cord, with pulsating

thoracic aneuiysm . . . . .81

- discussion on nasal-tuberculosis .... 126

- discussion on case of extensive infiltration of pharynx . . 137

Spencer (Walter G.), discussion on case of swelling in left arytenoid

region . . . . . .36

- discussion on case of pharyngeal and laryngeal nystagmus . 40

- discussion on case of ulceration of soft palate. . . 45

- discussion on case of inflammatory oedema of obscure origin

affecting posterior parts of larynx . . .47

Spicer (Frederick), notes of Dr. Frederick Spicer's case of “Diffuse

papilloma of the vocal cords ” (shown by Mr. Clayton Fox) . 52

Discussion (pp. 53, 54). Dr. Bronner, Dr. Dundas Grant, Mr.
Clayton Fox, Dr. Scanes Spicer, Dr. StClair Thomson, Sir Felix
Semon, Dr. FitzGerald Powell.

Spicer (R. H. Scanes); subacute osteomyelitis of frontal bone, with

empyema of right frontal Binus .... 121

Discussion (p. 122). Dr. Jobson Home, Mr. Chichele Nourse, the
President (Mr. Charters Symonds), Dr. H. J. Davis, Dr. Dundas
Grant, Mr. Maynard Smith, Dr. Scanes Spicer (reply).

- intrinsic laryngeal neoplasm of left vocal cord in a man aged

seventy-three (with report on growth by Mr. Maynard Smith) . 135
Discussion (p. 136). Sir F. Semon. ✓

- discussion on case of tracheal obstruction . . .38

- discussion on tuberculosis of larynx commencing during

pregnancy . . . . . . .51

- discussion on case of diffuse papilloma of vocal cords . . 53

- discussion on present condition of patient in whom the late Dr.

Whistler removed growth from right vocal cord twenty years ago . 55

- discussion on case of laryngeal swelling first shown at meeting of

January 13th, 1905, subsequently proved to be carcinoma . . 56

- discussion on case of fixation of left vocal cord . . 58

- discussion on case of malignant glands in neck . . 62

Digitized by LjOOQLe

156

PAGE

Spicer (R. R. Scanes), discussion on combined functional and organic

paresis of larynx in singer . . . . .63

- discussion on case of angeioma of larynx . . . 104

- discussion on case of trauma and septal deformity, causing bony

occlusion of left nostril ..... 112

- discussion on laryngeal case for diagnosis . . .113

—-- discussion on case of extensive infiltration of pharynx . . 137

Spinal cord: congenital lesion (unilateral) of medulla and spinal cord

(P. R. W. de Santi and P. Stewart) . . .69

Spirit lamp presented to Society by Mr. E. B. Waggett . . 65

Stenosis of trachea, produced by subglottic hyperplasia, probably of

syphilitic origin (H. Tilley) ..... 104

- well-marked, at times, in case of incrustation in trachea (E. Law) 9,13,75

Stemo-mastoid (right) : paralysis of right half of soft palate and
pharynx, of right stemo-mastoid, and of upper fibres of right
trapezius, associated with unilateral right abductor paralysis (H.
Tilley) . . . . . .105

Steward (Francis J.) : case of paralysis of left vocal cord caused by

localised tumour of the thyroid gland malignant (P) . . 24

- recurrent ulceration of tonsils, associated with lymphadenoma,

in a woman aged sixty-four . . . . 58

Discussion (p. 59). Mr. Baber, Mr. de Santi, Dr. Lambert Lack,
the President (Mr. Symonds), Dr. Tilley, Dr. Atwood Thome,

Sir F. Semon, Dr. Clifford Beale.

- discussion on case of bony tumour of nose . . .18

- discussion on tuberculosis of larynx, commencing during preg¬
nancy . . . . . .50

- discussion on case of laryngeal swelling, first shown at Meeting

of January 13th, 1905, subsequently proved to be carcinoma . 57

Stewart (Purves) and de Santi (Philip R. W.), a case of unilateral
congenital lesion of the medulla and spinal cord, with brief notes of
the pathological changes in the mouth, throat, and ear of a man
aged forty-one . . . . .69

Suppuration of both frontal sinuses cured by radical operation (E. B.

Waggett) ....... 106

Swelling in left arytenoid region (P. R. W. de Santi) . . .35

-case subsequently proved to be carcinoma (P. R. W.

de Santi) . . . . . . .55

- of larynx, same side as mass of malignant glands in neck

(P. R. W. de Santi) . . .61

- post-pharyngeal, case already shown (F. W. Bennett) . 25

Swellings (tense, bilateral, non-vascular) attached to anterior third of
cartilaginous septum, causing broadening and disfigurement of
external nose, with complete nasal obstruction (L. H. Pegler) . 98

Symonds (C. J.), a case of complete extirpation of the larynx . . 72

- angeioma of larynx ..... 102

Discussion (pp. 103, 104). Sir F. Semon, Dr. StClair Thomson,

Mr. Atwood Thome, Dr. Pegler, Dr. Spicer, Mr. Symonds (reply).

- a case seven years after complete extirpation of the larynx . 107

Discussion (pp. 108, 109). Sir F. Semon, Mr. Atwood Thome,

Dr. StClair Thomson, Dr. Vinrace, Mr. Symonds (reply).

- papilloma of the larynx .... 107

Discussion (p. 107). Dr. Dundas Grant.

-a case of total extirpation of the larynx in a man . . 123

- discussion on case of laryngeal swelling first shown at meeting

of January 13th, 1905, subsequently proved to be carcinoma 56, 57

- discussion on recurrent ulceration of tonsils, associated with

lymphademona . . . . .59

-extends welcome to foreign visitors at meeting of the Society

held on occasion of Garcia Celebration . . . .65

Digitized by t^oosle

157

PAGE

Symonds (C. J.), remarks at meeting of the Society on occasion of Garcia

Celebration . . . . . .65

- discussion on tuberculosis of larynx commencing during pregnancy 66

-announcement of gift of anatomical plates from Professor Onodi

to the Society . . . . . .91

-request from Chair to members to limit alterations in notes of

discussion as reported . . . .91

- discussion on carcinoma of larynx . . . .94

- discussion on case of lingual growth . .95

- discussion on high-arched palate and crowding of teeth, due to

nasal obstruction . . . . . .97

- discussion on case of broadening and disfigurement of external

nose . . . . . . 99

- discussion on case of unilateral right abductor paralysis, asso¬
ciated with other paralyses ..... 106

- discussion on trauma and septal deformity, causing bony occlu¬
sion of left nostril . . . . Ill

- discussion on new inhaler designed by Dr. Heryng, of Warsaw . 116

- discussion on angeioma of palate . . . .117

-discussion on excavated ulcer of pharynx, with appearance of

tertiary lesion, but characteristic of epithelioma . . . 120

—- discussion on subacute osteomyelitis of frontal bone with

empyema of right frontal sinus .... 122

- discussion on nasal tuberculosis .... 126

- discussion on malignant disease of pharyngo-larynx . . 127

- discussion on new growth in light maxillary antrum . 127

- discussion on faucial eruption .... 128

- discussion on angeioma of larynx .... 131

- discussion 6n case of post-nasal adenoids in man aged fifty-nine 133

- discussion on case of ulceration of tonsil and palate . . 136

Syphilis (congenital): laryngeal stenosis congenital syphilis (?) (StC.

Thomson) . . . . .34

-causing cicatricial diaphragm passing from posterior third

of tongue to posterior wall of pharynx (H. Betham Robinson . 77

- history in case of inspiratory dyspnoea (P. R. W. de Santi) . 134

- (primary), case of primary sore of tongue (H. Tilley) . . 62

- subglottic hyperplasia, producing tracheal stenosis, probably of

syphilitic origin (H. Tilley) ..... 104

- (tertiary), punched-out appearance of tertiary lesion in excavated

ulcer of pharynx, and induration characteristic of epithelioma
(J. Dundas Grant) ...... 120

Teeth (crowding) and high-arched palate, due to nasal obstruction (H.

Lambert Lack) . . . . . .95

Thomson (StClair), epithelioma of larynx; laryngo-fissure; no recur¬
rence after six months . . . .32

-tracheotomy for laryngeal stenosis. Marked improvement.

Diagnosis: tuberculosis, lupus, or congenital syphilis ? Boy aged
fourteen . . . . . .34

-epithelioma of the larynx in a man aged forty-nine; laryngo-

fissure eight months ago; no recurrence . . .72

Discussion (pp. 72—74). Dr. Botella, Professor Gluck, Professor
Moure, Sir F. Semon, Dr. Walker Downie, Mr. de Santi, Dr. StClair
Thomson (reply).

- primary lupus of larynx (quite healed) and pharynx (nearly

healed) in a woman aged twenty-two, with drawings of original
condition . . . . .74

- drawing of angeioma of larynx .... 130

Discussion (p. 131). The President (Mr. Symonds), Dr. Pegler,

Dr. Thomson (reply).

Digitized by LjOOQLe

158

PAGE

Thomson (StClair), discussion on growth in aryteno-aryepiglottic

region . . . .5

- discussion on case of new growths in the larynx . .11

- discussion on case of pharyngeal and laryngeal nystagmus . 40

- discussion on case of ulceration of soft palate . . 45

- discussion on case of diffuse papilloma of vocal cords . . 53

- discussion on case of extensive ulceration of nasal septum . 64

- discussion on case of growth on left vocal cord . . 64

- discussion on case of obstinate headache, accompanied by crust¬
ing and muco-pus formation ..... 101

- discussion on case of fibroma on left vocal cord . . 102

- discussion on case of angeioma of larynx . . . 103

- discussion on case of complete extirpation of larynx, exhibited

seven years after ...... 109

- discussion on case of epithelioma of larynx . . .129

- discussion on case of post-nasal adenoids in man aged fifty-

nine . . . - 133

- discussion on case of inspiratory dyspnoea . . 134

- discussion on case of extensive infiltration of pharynx . . 137

Thorax : see Aneurysm (thoracic).

Thorne (Atwood), girl aged seventeen, complete paralysis of left vocal
cord, associated with dilatation of left pupil, mitral stenosis, and
enlargement of left auricle ..... 131
Discussion (p. 132). Dr. de Havilland Hall, Mr. Thome (reply).

- discussion on case of chronic laryngitis . . .23

- discussion on recurrent ulceration of tonsils, associated with

lymphadenoma . .59

- discussion on case of angeioma of larynx . . .103

- discussion on case of complete extirpation of larynx, exhibited

seven years after ...... 109

- discussion on laryngeal case for diagnosis . . . 113

- discussion on case of inspiratory dyspnoea . . . 135

- and Lunn (J. R.), case of epithelioma of the nose (shown at the

January meeting, 1904); patient, macroscopic and microscopic
specimens and photographs . . . .75

Throat; carcinoma in throat of dog and cat (F. Hobday) . . 2

- (diseases), demonstration of paintings in oil illustrating (H.

Smurth waite) . .43

- pathological changes in throat in case of unilateral congenital

lesion of medulla and spinal cord (P. R. W. de Santi and P.
Stewart) . . . . . . .69

Thyroid cartilage: thickening of external plates (C. A. Parker) . 46

Thyroid gland: tumour (localised) malignant ? causing paralysis of left

vocal cord (F. J. Steward) . . . . .24

Thyrotomy for epithelioma of larynx (Sir F. Semon) . . .14

Tilley (Herbert), case of lymphosarcoma of tonsil, in which great

benefit had been derived from arsenic . . .20

Discussion (pp. 20, 21). Dr. de Havilland Hall, the President
(Dr. McBride), Dr. Lambert Lack, Mr. Robinson, Dr. Wyatt
Wingrave, Dr. H. Tilley (reply).

- case of submucous resection of deflected nasal septum (Killian’s

method) . . . . .21

- subacute frontal sinus empyema following scarlet fever in a child 22

- case of tracheal obstmction of uncertain origin and nature . 37

Discussion (pp. 37, 38). Mr. 0. A. Parker, Dr. Scanes Spicer,

Mr. Cresswell Baber, Dr. H. FitzGerald Powell, Dr. Law, Sir Felix
Semon, Dr. Herbert Tilley (reply).

- case of primary sore of tongue . . . .62

Discussion (p. 62). Mr. C. Baber, Mr. Robinson, Mr. de Santi,

Dr. FitzGerald Powell, Dr. Herbert Tilley (reply).

Digitized by {jOOQie

159

PAGE

Tilley (Herbert), six patients upon whom radical operations had been
performed for the cure of chronic empyemata of the frontal and
other nasal accessory sinuses. . . . 66

Discussion (p. 67). Mr. Cresswell Baber, Professor Chiari, Dr.
Tilley.

-subglottic hyperplasia, producing tracheal stenosis, probably of

syphilitic origin . . 104

Discussion (p. 104). Mr. Robinson, Dr. Tilley (reply).

- unilateral right abductor paralysis, associated with paralysis of

right half of soft palate and pharynx, right sterno* mastoid, upper
fibres of right trapezius, ptoses of right upper eyelid, and contracted
pupil • . . . . . 105

Discussion (p. 105). Dr. Dimdas Grant, Mr. Robinson, the Presi¬
dent (Mr. Symonds), Sir F. Semon, Dr. Tilley (reply).

- discussion on actinomycosis of tonsil . . .6

- discussion on laryngeal growth in boy aged six . .7

- discussion on case of dry catarrh of nose and naso-pharynx

treated by formalin spray . . . .14

- discussion on case of carcinoma of nose 19

- discussion on case of inflammatory oedema of obscure origin

affecting posterior parts of larynx . .47

- discussion on tuberculosis of larynx commencing during preg¬
nancy . . .50

- discussion on recurrent ulceration of tonsils, associated with

lymphadenoma . . .59

- discussion on cases of epithelioma of epiglottis and of right

arytenoid . . .83

- discussion on case of obstinate headache, accompanied by crust¬
ing and muco-pus formation ..... 100

- discussion on trauma and septal deformity, causing bony occlu¬
sion of left nostril .... . . Ill

Tongue: cicatricial diaphragm passing from posterior third of tongue to

posterior wall of pharynx (H. Betham Robinson) . 77

- diaphragm between back of tongue and posterior wall of pharynx,

causing pharyngeal obstruction (H. Betham Robinson) . . 7

- epithelioma of epiglottis and base of tongue removed by sub-;

hyoid pharyngotomy (H. Lambert Lack) . .81

-epithelioma of palate, tonsil, tongue, and cheek (H. FitzGerald

Powell) . . . . . .41

- lingual growth, case of (W. H. Kelson) . .95

-specimen (W. H. Kelson) . . . 127

-primary sore of (H. Tilley) . . . .62

-ulcer of, in boy aged two months and a half (J. Dundas Grant) . 24

Tonsil: actinomycosis ; specimen (A. H. Cheatle and W. d’Este Emery) 5

- epithelioma of palate, tonsil, tongue, and cheek (H. FitzGerald

Powell) . . . . . .41

-lymphosarcoma of, great benefit from arsenic (H. Tilley) . 20

- tumour of (V. Wyatt Wingrave) . . . .19

- (left) ulceration of tonsil and palate (W. H. Kelson) . . 136

Tonsils, ulceration (recurrent) associated with lymphadenoma (F. J.

Steward) . . . . . .58

Trachea: incrustation in trachea, with at times well-marked stenosis

(E. Law) . . . 9, 13, 75

- obstruction in; origin and nature uncertain (H. Tilley) . 37

- stenosis, produced by subglottic hyperplasia, probably of

syphilitic origin (H. Tilley) . . . . . 104

Tracheotomy for laryngeal stenosis; improvement (StClair Thomson) . 34

Trapezius (right): paralyses of right half of soft palate and pharynx,
of right stemo-mastoid, and of upper fibres of right trapezius,
associated with unilateral right abductor paralysis (H. Tilley) . 105

Digitized by LjOOQLe

160

PAGE

Trauma and septal deformity, causing almost complete bony occlusion

of left nostril (J. Donelan) . • . .111

Traumatic (?) perforation of the septum (H. J. Davis) . 92

Treasurer, Report for 1904 . .29

Tubercular (?) pachydermia laryngis (G. C. Cathcart) . . 63

Tuberculosis : laryngeal stenosis, tuberculosis ? (StC. Thomson) . 34

- of larynx commencing during pregnancy (C. A. Parker) 49, 66

- of nose (H. S. Barwell) ..... 125

Tumour (bony) of nose (H. Lambert Lack) . . . . .17

Tumour ? of pons causing pharyngeal and laryngeal nystagmus (Sir F.

- Semon) . . . . . . .38

Tumour of thyroid gland (localised), malignant, ? causing paralysis of

left vocal cord (F. J. Steward) . .24

- of tonsil (Y. Wyatt Wingrave) . . . .19

Turbinated body (inferior), both inferior turbinated bodies involved in

case of hypertrophic rhinitis (J. Dundas Grant) . .24

- (middle) simulated by sessile outgrowth on septum in case of

hypertrophic rhinitis (J. Dundas Grant) . . .17

Turner (J. G.), discussion on high-arched palate and crowding of teeth,

due to nasal obstruction . .98

lesion, and induration characteristic of epithelioma (J. Dundas
Grant) . . . . . .120

-of tongue in boy aged two and a half (J. Dundas Grant) . 24

Ulceration of larynx (lateral) (J. Donelan) .... 109

- of nasal septum (extensive): case for diagnosis (F. W. Bennett). 63

-of oro- and naso-pharynx (H. J. Davis) . . 119

-of soft palate for diagnosis (F. H. Westmacott) . 43

-of tonsil and palate (W. H. Kelson) . . . 136

- of. tonsils (recurrent) associated with lymphadenoma (F. J.

Steward) . . . . . .58

- (slight) accompanying extensive infiltration of pharynx (C. A.

Parker) ....... 136

Uvula: lupus of larynx and uvula (H. S. Barwell) . . . 126

Yaseline (medicated fluid): atomiser for spraying (Sir F. Semon) . 115

Yinrace (Dennis W.): discussion on traumatic (?) perforation of

septum . . . . . .93

- discussion on case of complete extirpation of larynx, exhibited

seven years after . . . . . 109

Visitors (foreign) at meeting on occasion of Garcia Celebration . 65

-welcomed by the President . . .65

Vocal cord (left) fibroma (soft) on (H. Betham Robinson) . . 102

- fixation (S. Paget) . . . . .57

-with pulsating thoracic aneurysm (H. J. Davis) . 78

- growth on; slight hoarseness for past fifteen months (S. Paget) . 64

- intrinsic laryngeal neoplasm (R. H. Scanes Spicer) . . 135

- paralysis, associated with dilatation of left pupil, mitral stenosis

^ and enlargement of left auricle (A. Thorne) . . . 131

-caused by localised tumour of thyroid gland malignant (?)

(F. J. Steward) . . . . . .24

- (right) epithelioma; slide from case shown (Sir F. Semon) . 41

-growth on, operation twelve years previously for papilloma of

larynx (S. Paget) . . . . . .58

- growth removed twenty years ago by the late Dr. Whistler;

present condition of patient (E. Law) . .54

Vocal cords, papilloma (diffuse) (F. Spicer) . . .52

Digitized by LjOOQLe

161

PAGE

Waggett (E. B.), a diagnostic specimen from oesophageal stricture

removed by Killian’s method . . . .1

Discussion (p. 1). The President (Dr. McBride), Mr. Waggett
(reply).

- case of double frontal sinus suppuration in young man, cured by

radical operation ...... 106

- bleeding polypus of septum in a boy, aged nine . .114

Discussion (p. 114). Dr. Pegler, Dr. Dundas Grant, Mr. de Santi,

Dr. Woods, Dr. Jobson Home, Mr. Waggett (reply).

- discussion on present condition of patient in whom the late Dr.

Whistler removed growth from right vocal cord twenty years ago . 55

- discussion on case of laryngeal swelling first shown at meeting

of January 13th, 1905, subsequently proved to be carcinoma . 57

- discussion on case of extensive ulceration of nasal septum . 64

-discussion on case of growth on left vocal cord . . 64

- gift of new spirit lamps to the Society . .65

-discussion on traumatic (P) perforation of septum . . 92

- discussion on case of obstinate headache, accompanied by crust¬
ing and muco-pus formation ..... 100
- discussion on trauma and septal deformity, causing bony occlu¬
sion of left nostril ...... Ill

- discussion on angeioma of palate . . . .117

- discussion on pharyngeal diverticulum opening into pyriform

fossa ....... 118

Westmacott (F. H.), ulceration of soft palate for diagnosis . . 43

Discussion (pp. 41-46). Dr. Pegler, Mr. W. G. Spencer, Dr.
FitzGerald Powell, Dr. SfcClair Thompson, Dr. Watson Williams,

Sir F. Semon, Mr. Westmacott (reply).

- discussion on case of epithelioma of palate, tonsil, tongue, and

cheek . . . . . .42

-discussion on case of laryngeal swelling first shown at meeting

of January 13, 1905, subsequently proved to be carcinoma . 57

- discussion on traumatic (?) perforation of septum . . 92

- discussion on high-arched palate and crowding of teeth, due

to nasal obstruction . . . .97

- discussion on case of obstinate headache accompanied by crusting

and muco-pus formation .... 100

Whistler (W. Macneill), present condition of patient from whom the
late Dr. Whistler removed a growth from the right vocal cord twenty
yfears ago (E. Law) . . . . . .54

Williams (P. Watson), case of cerebro-spinal rhinorrhoea, which had

apparently recovered spontaneously . . . .85

- case of sphenoidal and posterior ethmoidal sinusitis, cured . 85

- discussion on case of swelling in left arytenoid region. . 36

-discussion on case of epithelioma of palate, tonsil, tongue, and

cheek . . . / . . . .42

- discussion on case of ulceration of soft palate. . .45

- discussion on case of fixation of left vocal cord, with pulsating

thoracic aneurysm . . .80

- discussion on cases of epithelioma of epiglottis and of right

arytenoid . . . . . . .83

W ingrave (V. Wyatt), case of tumour of tonsil in female aged sixty-

four . . . . . . .19

- discussion on case of carcinoma of nose . . .19

- discussion on case of lymphosarcoma of tonsil treated by arsenic 21

Woods (Robert), discussion on laryngeal case for diagnosis . . 113

- discussion on bleeding polypus of septum . . 114, 115

PRINTED BY ADLARD AND SON, LONDON AND DORKING.

Digitized by LjOOQLe

Digitized by LjOOQle

Digitized by

Internet Archive Audio

Featured

Top

Images

Featured

Top

Software

Featured

Top

Books

Featured

Top

Video

Featured

Top

Mobile Apps

Browser Extensions

Archive-It Subscription

Save Page Now

Full text of "Proceedings of the Laryngological Society of London 12.1905"

See other formats