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OF THB
LAETNGOLOGICAL SOCIETY
or
LONDON.
VOL. II.
1894-95.
♦ *
WITH
LISTS OF OFFICERS, MEMBERS, ETC.
LONDON:
PRINTED BY ADLARD AND SON,
BARTHOLOMEW CLOSE, E.C., AND 20, HANOVER SQUARE, W.
OFFICERS AND COUNCIL
OF THE
Hsrpgological ^otietg af
ELECTED AT
THE ANNUAL GENERAL MEETING,
JANUARY 9th, 1896.
FELIX SEMON, M.D., P.R.O.P.
0ia-^w8ib*«t8.
E. ORESSWELL BABER, M.B. CHARTERS SYMONDS, F.R.C.S.
H. T. BUTLIN, P.B.O.S.
Itibrsnan.
E. 0. BEALE, M.B., P.R.O.P.
^tcretams.
SOANES SPICER, M.D. W. R. H. STEWART, F.R.O.S.
d^onuctl.
P. W. BENNETT, M.D. I J. W. BOND, M.D.
A. BRONNER, M.D. 1 DUNDAS GRANT, M.D.
PERCY KIDD, M.D.
577630
1
PRESIDENTS OP THE SOCIETY.
{From it* Formation.)
SLECTXP
1893 Sib Geobob Johnson, M.D., F.K.S.
1894 Felix Semon, M.D., F.R.C.P.
1896
PROCEEDINGS
OP THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Obdinabt MEBTiNa, October \0th, 1894
Felix Semon, M.D., F.E.C.P., President, in the Chair.
E. Cliffobd Beale, M.B.,
ScAEEs Spiceb, M.D.,
Secretariea
Present—18 Members and 3 Visitors.
The minutes of the previous meeting were read and confirmed.
The following candidates were proposed for election:
Dr. J. M. Hunt, Liverpool.
Mr. A. E. Shaw, Wandsworth.
Mr. E. F. Potter, Kensington.
Adenoma of Tongue.
Clinical case exhibited by Mr. Ceesswbll Babee.— »E. W—, »t. 16,
came as out-patient to the Brighton Throat and Ear Hospital on July
2nd, 1894, with a history of difficulty in swallowing and thickness of
speech for nine months. A tumour was found at the base of the tongue
about the size of a small walnut, which hid the larynx from view. There
was no dyspnoea. On July 16th she was admitted into the hospital
as in-patient, and the following notes were made:—** The affection of
voice and deglutition began in September after a * sore throat,' Rud
for a week before she first applied she is said not to have been able
to eat anything. The tumour is globular, now about the size of a walnut,
in the median line of the tongue, attached by a large base just in front
of the epiglottis. It has a smooth surface, of a mottled red and white
colour, with numerous veins coursing over it. It is seen on depress¬
ing the tongue forcibly, and when retching is induced it starts up
filling the whole faucial space. The tumour, which presents the appear¬
ance of a cyst with thick walls, can be well seen in the laryngeal mirror.
It hides the epiglottis, and only the posterior half of the cords (which
FIRST SBBIES — VOL. II. 1
2
are clear and pale) can be seen when the patient phonates a high
On palpation the tnmonr also gives the impression of a cyst,
and below it the epiglottis can be indistinctly felt.” On Jnly 19th the
growth was seized with catch forceps which caused rather free venous
hsemorrhage. This was arrested with the galvanic cantery. The
tumour was then punctured in the centre with a galvanic cautery
point, and a probe passed in nearly one inch, but no contents escaped,
and the growth became only slightly, if at all, reduced in size. The
opening was kept patent with probe and cautery for a short time, but
as no appreciable diminution in size took place, the tumour was
removed on August 31st with the galvanic snare, which was adjusted
without any difficulty. There was no hsemorrhage of consequence,
and the growth came off on a level with the surface of the tongue. No
untoward symptoms occurred beyond slight hsemorrhage ten days
afterwards. Before she left the hospital on September 24th the sur¬
face had quite healed, but had become rather more raised into an irre¬
gular flat growth, which was reddish at its posterior part. It Mt firm to
the touch. The epiglottis, which was clearly seen, was so pendulous
that only a glimpse of the cords was obtainable. There was no pain
or difficulty in swallowing, but the voice remained about the same,
partly hoarse and partly nasal in character. There was no swelling
in the median line of the neck or enlargement of the thyroid gland.
On October 2nd the remains of the growth appeared rather flatter,
though still raised at the back part, and the epiglottis was somewhat
less pendulous.
RemarJcs .—This case closely resembles those described by Mr. Butlin
in the * Transactions of the Clinical Society of London ^ for 1890, vol.
xxiii, p. 118, under the head of ^'Glandular Tumours of the Tongue.”
Mr. Butlin could only find eight cases of this description, two of which
were under his own care. In one of the eight the tumour was
situated on the under surface of the tongue near the tip, in the re¬
mainder, as in this case, its position was on the back of the tongue
just in front of the epiglottis. As in Butlin^s first case, in the present
one the growth felt so elastic that it gave the impression of being
cystic. All the cases mentioned by Butlin occurred in females, whose
ages varied from extreme infancy to thirty-two years.
The microscopical examination was kindly made by Mr. H. H. Taylor,
who reported as follows:—The minute structure of the growth closely
resembles that described by Mr. Butlin in the ^Clinical Society's
3
Transactions/ vol. xxiii. Bound or oval spaces of small size^ lined by
a single layer of cubical epithelium, and containing in some cases
granular, in others hyaline material. The interstitial tissue is made
up of fine nucleated fibres. Towards the capsule the spaces are larger
and more irregular in outline. Here and there (but very few in
number) some of the spaces are elongated and flattened, somewhat re¬
sembling ducts, but 1 do not think they are of this nature. I cut
vertical and horizontal sections to see if ducts were present, but
failed, with the exception of the appearances mentioned above, to find
any.
" The growth closely resembles thyroid tissue, and may well be con¬
nected with some foetal remains of the lingual duct. There are no
cysts, nor does the tumour present any tubular structure.”
This case, therefore, seemed to support the theory advocated by
Bernays and Bland Sutton, that these tumours are of the nature of
accessory thyroid glands.
Mr. Lake mentioned a similar case.
The President, replying to Mr. Baber, advised that the growth
should be again removed by the snare, but no more radical operation
undertaken unless the symptoms became serious.
Immobility op the Left Vocal Cobd.
Dr. Bennett showed the case of Mrs. C — , mt. 47. Onset about
two years ago. Loss of voice had been progressive, but more rapid
since influenza some ten months ago.
First seen three months ago. There was no congestion, no
ulceration, and no symptoms which pointed to any other affection.
There were no certain signs of chest mischief either in the lungs or
in the vessels. There was no difficulty in swallowing. There was at
first a sensation of aching over the larynx, but this soon disappeared.
She took iodide of potassium for a short time but without any benefit.
There was no suspicion of syphilis.
Dr. Dundas G-bant thought it difficult to account for the immo<,
bility. There seemed to be no special cause within the larynx, and no
evidence of pressure upon the nerve-trunk unless by a deep-seated
gland. The further history of the case might explain it.
Dr. Tilley suggested that the spasms might be indicative of tabes.
He had seen a similar case in a male whose pupils had subsequently
been contracted and the knee-jerks lost.
4
. Pr. Spicer had noticed some fulness in the left pjriform fossa, and
thought that there might possibly be a local lesion.
The President could not tell the exact cause of the lesion in the
present case; fixation of one cord was often seen and was not incom*
patible with good health. Such cases ought to be carefully kept in
view, and ^post-mortem as well as clinical evidence recorded. Gou-
guenheim had suggested that some enlargement or inflammation of
one of the chain of glands accompanying the recurrent laryngeal
nerve might account for such cases. It was very desirable that the
whole course of the recurrent laryngeal and vagus should be closely
examined when opportunities occurred. The first case of paralysis
preceding tabes hM been shown in 1878, two years after the onset of
the paralysis. The patient lived for eight years afterwards. Many
cases had been reported since. He had examined many cases at
Queen Square Hospital and found some without paresis of any kind,
unilateral or bilateral. The relative frequency was diflScult to deter¬
mine. Li his first twelve cases he had found seven cases of paralysis
or paresis, but not another case in the next fifty or sixty cases of
tabes. Hence the discrepancy of frequency among different observers.
Cystic Fibroma op the Left Vocal Cord.
Dr. Adolph Bronner (Bradford) showed microscopical specimens
of a tumour removed from a clergyman aged 76. The veins were
very distended and numerous, and there were several large cavities
lined with endothelium.
Drawings of similar growths were shown as demonstrated by Pro¬
fessor Chiari in * Archiv fiir Laryngologie/ ii, 1.
The growths were situated on the upper surface of the cord, and
had been first noticed three years ago. Fibromata of the small cords
were rare in old age.
Epithelioma op the Epiglottis.
Dr. Bronner also showed a man of 78, suffering from a growth of
three years' duration. There were unmistakable symptoms of secon¬
dary affections of the liver and lungs. The growth was partly
removed by cutting forceps, and the patient could now eat and speak
without any difficulty. It was very rare indeed to find secondary
deposits in cases of epithelioma of the larynx.
Case of (?) Chronic Tuberculosis op the Larynx.
Dr. DE Havilland Hall showed the case of E. M. V — , set. 51.
The patient stated that he had had syphilis twenty-six years ago.
He first began to be troubled with his throat ten years ago.
5
but be was not mncb inconvenienced until five years ago. For the
last three years he had been under the care of Br. Valentin of Berne.
He first consulted Dr. de Havilland Hall on May 1894.
The epiglottis^ ary-epiglottic folds, and arytenoids were found to be
greatly tumefied, and the glottis was reduced to a mere chink, the
vocal cords not being visible. The mucous membrane of the posterior.
wall of the pharynx was replaced by cicatricial tissue. The septum
nasi was completely destroyed. At the apex of the left lung posteriorly
there was impaired resonance, with bronchial breathing and occasional
rfiles.
On making a forcible expiration with the mouth closed, two
tumours appeared on each side of the larynx. ? Dilated ventricles
of Morgagni. A distinct “ pop " accompanied the appearance of the
tumours.
As the symptoms of laryngeal stenosis steadily increased, the
patient was admitted into the Westminster Hospital, and tracheotomy
had to be performed rather suddenly on June 3rd by the house surgeon,
Mr. S. A. Bull.
At the present time the patient was taking carbonate of guaiacol
internal, and the galvano-cautery was being applied to the larynx.
The patient had gained weight and improved generally since the
tracheotomy, and the application of the galvano-cautery had been
followed by marked diminution of the swelling of the epiglottis, so
that the vocal cords were now visible.
Dr. de Havilland Hall regarded the case as having been of a
syphilitic nature at the commencement, but thought that the present
condition was due to chronic tuberculosis.
Dr. Beale referred to a somewhat similar case shown in 1893, in
which the laryngeal conditions had remained imaltered for a twelve-
month. The |»atient had taken iodide persistently, and believed that
it kept the disease in check. The passive, swelled, and congested
condition, occurring in association with tubercle and syphilis, as in
Dr. Hall’s case and his own, seemed to be due to the combined pro¬
cesses.
Dr. Bbonneb suggested the use of mercurial inunction.
Dr. Hall had found that the most relief was given to the dysphagia
by cauterisation of the swollen epiglottis, which was tough and
leathery.
Dr. Dubdas G-eant thought that in the combined cases of tubercle
and syphilis, there was generally ulceration. The dry appearance of
the larynx in the present case was very striking.
6
Tonsiliab Mycosis.
Mr. It. Lakb showed two cases of tonsillar mycosis, both females.
He wished to raise the question, whether there was any more rapid
method of dealing with these cases than that of galvano-cautery ?
One of these cases had been freely and carefully cauterised once a
week for three months, and was not yet cured ; the second had not
had more than one application.
Dr. Hall advised continued use of the cautery, as that treatment
gave relief at any rate.
The PuESiDENT thought that these cases might well be left alone
if they gave rise to no distress. He had quite given up the use of
the cautery to the disease on the base of the tongue, and had seen
disastrous results ensue where it had been used. Patients as a rule
only became aware of the disease by seeing the white patches in the
mirror, which they described as “ ulcers,” and often declared that
no discomfort was caused by them. To destroy the colonies of mycosis
on the surface was easy, but it did not cure the disease. Change of
air and general treatment gave better results than operation.
Mr. Obesswell Babeb thought it best to leave the milder cases
alone. When the growth was extensive he had seen good results from
the application of absolute alcohol.
Dr. Spiceb had used the galvano-cautery in such cases very fre¬
quently without permanent benefit. He preferred to cut away the
tonsillar tissue, and so to destroy every crypt that could harbour the
growth. At the base of the tongue he preferred to apply antiseptic
remedies.
Dr. Bennett advocated forcible syringing out of the crypts and
application of pure carbolic acid to the openings.
Dr. Dundas Grant pointed out that pharyngo-mycosis was very
distinct from pharyngitis with accretions, but the distinction was not
always recogpiised, and the condition was sometimes mistaken for
syphilis. He had used the galvano-cautery in each individual crypt,
but had found very good results from the daily use of a lotion of
tincture of iodine with fifteen grains of bicarbonate of soda. In
one case it had completely checked recurrence.
Mr. Lake, in reply, thought that patients generally complained of
subjective symptoms and sought reuef, without always being aware
of the white patches in the throat.
Lupus of the Nose treated by Thyroid Extract.
Mr. TiAEE also showed the two following cases:
The first, a boy of 11 years of age, had suffered for fourteen months.
The soft palate and posterior pillars of the fauces were also affected.
7
He had been taking 7^ grains of thyroid extract daily since July 14th,
and was very much improved.
The second case, that of a girl of 16 years, had been affected for
three years, and when put on thyroid treatment at the same time as
the boy, also had a patch of lupus below the right eye over the nasal
duct; this was now almost healed, and the nose was very much
improved; she was now taking 17^ grains daily. Mr. Lake wished
to show these cases to the Society in order that, if successfully cured
by this treatment, the result might subsequently be verified.
Dr. Dundas Gbakt expressed some doubt as to the nature of the
disease in the girl’s case. He pointed out that the thyroid extract
had not been the sole treatment.
Dr. Jessop related a case in which marked improvement had
followed the use of three hundred tablets in a case where the disease
had existed for thirty years.
Tonsillar New Growth.
Dr. Scares Spicer showed Thomas H—, set. 70, who had a
vascular tumour the size of a large walnut, spreading from the lower
part of the right tonsil on to the base of the tongue. Two years ago
thorough tonsillotomy was performed for growths which were too
large to He lateraUy in pharynx, so that one passed upwards, the
other downwards; the symptoms were dysphagia, dyspnoea, and
uninteUigible articulation. The reappearance on the right side had
been very gradual, and its growth was slow. Microscopically, it was
made up of closely packed round cells. Repetition of removal was
proposed, but suggestions were invited.
Dr. Bbonner referred to the value of arsenic in large doses in such
cases.
Dr. Tilley mentioned the case shown to the Society by Mr.
W. B. H. Stewart last session, in which arsenic had given very
marked relief for a time.
Dr. W. Hill thought that such cases showed varying degrees of
malignancy, but they all tended to spread if left alone. He would
not use the guillotine, but preferred enucleation.
Dr. Peoleb regarded the case as one of lympho-sarcoma and not
ordinary hypertrophy.
The Pbesident remarked that after the age of forty such cases
were generally lympho-sarcoma or adenoma.
Dr. Dundas Grant suggested that the tumour chould be enucleated
e
bj snipping tbrongb the mucous membrane and turning the growtii
out by means of the finger.
Mr. DE Sakti thought that such a growth might be removed by
external incision, and referred to two cases thus treated.
Dr. Spices replied.
Laryngeal Stenosis supervening on Typhoid Fever.
Dr. Soanes Spicer showed a young man set. 20, who was under
Dr. Gheadle in St. Mary’s Hospital six months ago for typhoid fever.
Acute stenosis of larynx supervened and tracheotomy was performed.
Some weeks afterwards he was sent to the throat department for
examination. The vocal cords were found to be adherent at anterior
fourth, and on attempting breathing with finger on trachea tube, a
red subglottic mass was seen to almost completely occlude lumen.
He could phonate, but a probe could not be put through stricture
after cocainising, nor was intubation, attempted with some force,
successful. The case was shown preliminary to division of stricture
under general anaesthesia by Whistler’s dilators and use of O’Dwyer’s
intubation tubes.
The President agreed that an attempt should be made to divid
the stricture and dilate it, but he was not sanguine as to the result in
such a case.
i
PEOCEEDINGS
OF THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Oedinaet Meetino, Novemher 14ith, 1894.
Felix Semon, M.D., F.E.C.P., President, in the Chair.
E. Cliffoed Beale, M.B.,
SCANES Spicee, M.D.,
Secretaries.
Present—30 Members and 6 Visitors.
The minutes of the previous meeting were read and confirmed.
The following candidates were balloted for and diily elected:
Mr. E. F. Potter. Mr. A. E. Shaw.
Dr. J. M. Hunt.
The following candidates were
members:
Dr. C. C. Cripps.
Mr. A. L. Roper.
Dr. George Mackern.
Dr. Henry Sharman.
proposed for election as ordinaiy
Mr. A. E. Hill-Wilson.
Dr. W. J. Home.
Mr. R^inald Poulter.
Swelling op Left Side of Laeynx, with Pakalysis and Atrophy
OP Left Half op Tongue and Soft Palate, and Peri¬
chondritis.
Mr. A. A. Bowlby showed this case. John T—, set. 52, a meat
porter, had had good health previous to December, 1893, when he
began to suffer from a painful lump about the size of a walnut on the left
side of the front of the neck. There were no other symptoms. Under
treatment he improved; the pain left him, but the lump remained.
When seen again, in August last, there was a large and ex¬
tremely indurated mass, nearly as large as an orange, in front of and
FIRST SERIES—VOL. II. 2
10
to the left of the larynx. There were pain, dysphagia, and blood¬
spitting. With fomentations the mass softened, and an incision let
out about an ounce of pus. He improved for a while. On October
2nd he again came under observation. Then there were inability to
swallow solids, constant cough with glairy expectoration but no
haemoptysis, and some loss of weight. There was still a hard mass,
softening near site of old scar. He was admitted to the hospital.
On October 10th some pus was discharged through the old scar, and
patient was relieved. There was also some haemoptysis. He then
came under observation in the Throat Department, and examination
found—
Externally, an old scar situated over and adherent to the thyroid
cartilage, discharging pus, but no tenderness on manipulation.
Beneath the left maxilla there was felt an enlarged stony hard gland,
with the superjacent skin intact. Some slight loss of facial symmetry
noticed. The tongue was protruded with difficulty and pushed over
to the left. The left half was in an advanced state of atrophy. The
left half of the soft palate was also atrophied, and hung lower than
right; it had but little movement, being only dragged up by right
half. Slight rigidity of soft palate noticed in attempting to raise it
up on back of a throat mirror. No scars on soft palate or tongue.
Larynx : epiglottis twisted out of the median line, so that the tip was
looking towards the left. Occupying the greater part of the left half
of the larynx there was a smooth reddish mass, obscuring the posterior
two thirds of the left cord and ventricular band. The right cord was
fixed and partly hidden by the overhanging ventricular band. No
ulceration or scar.
Since this examination the mass referred to had increased in size,
and now only part of right cord was to be seen.
Examination of chest yielded no definite morhid signs. No history
of syphilis.
Remarks .—Much of the swelling was evidently due to perichon¬
dritis j but the question was, whether this, in its turn, was due to a
malignant growth. In favour of this event was the extreme hardness
and fixity of the glandular swelling. It was, further, a very rare thing
for paralysis of nerves to be caused by any merely infiammatory
swelling. The atrophy of the tongue was probably due to pressure
on the hypoglossal by the mass of glands which lay just over its
course. On the other hand, the prolonged history, and the fact that
11
the patient had improved under treatment, seemed to point to peri¬
chondritis without new growth. The only operation which appeared
at all likely to be useful was one for exposing the thyroid cartilage
opposite the swelling, and seeing if there was any necrosed portion to
be removed.
The President thought that there was no evidence that the growth
was causing the paralysis. There were no other symptoms of dis¬
turbance of the vagus. It must be remembered that both centripetal
and centrifugal fibres had been demonstrated in the pneumogastric,
but in the recurrent laryngeals the existence of centripetal fibres had
never yet been shown, although many observers believed in their
existence. Unilateral pressure on the recurrent laryngeal did not
cause bilateral paralysis or spasm.
Tubercular Disease of Soft Palate, Larynx, Pharynx, and
Lungs.
Mr. A. A. Bowlby showed the case of P. E —, set. 22, a bootmaker,
seen first on October 24th, 1894, on account of a sore throat he had
had five weeks. When first seen, there was spreading over the soft palate
and uvula and on the pharynx, a greyish membranous-like deposit,
which at a glimpse was suggestive of diphtheritic membrane; but there
was no swelling nor oedema of the parts, the tonsils were eaten into and
excavated, and appearing through the secretion were a number of small
pin-head glistening nodules, which clustered thickly around the base
and tip of uvula. On cleaning the part a bleeding surface was left,
which was irregularly ulcerated. The pulse was quickened, and the
temperature raised between 101° and 102°.
The tongue was free from disease; by depressing it the tip of the
epiglottis could be seen thickened and reddened. The epiglottis was
turban-shaped, and on the tip one or two whitish pin-point nodules, but
no ulceration. The arytmnoids were somewhat reddened and enlarged,
the left more so than the right, but their surfaces intact. The cords
and ary-epiglottic folds were very slightly affected, and presented no
ulceration, the cords moving well and equally. No particular change in
voice.
There were well-marked signs of chronic but progressive disease in
the lungs.
November 9th.—Some scrapings from the soft palate, and also the
sputum, yielded tubercle bacilli.
12
Since the 24th of October, when he was first seen, there had been no
very appreciable increase in the extent of the ulceration of the soft palate,
but what there was had become deeper. The laryngoscope showed
farther epithelial changes along the tip of the epiglottis and on the
summit of the left arytsenoid.
In his general health the patient had improved, and the disease in
the lungs was not so active.
There was no history of syphilis, nor any family history of phthisis.
Mr. Bowlby observed that there seemed to be no doubt of the nature
of the affection in this case, and it did not appear that any radical treat*
ment of an operative nature could be undertaken, considering that the
disease was very widely spread. He had, however, seen one similar
case of even greater extent, which recover^ under the use of iodoform
locally and cod-liver oil internally, and he proposed to continue the
same lines of treatment in this case.
Pachydermia with Perichondritis.
Dr. Adolph Bronner (Bradford) showed a specimen of diffuse pachy¬
dermia of the larynx with perichondritis of the right arytsenoid cartilage.
The man, a brushmaker of J|^had been hoarse for ^ 2 iu:_years, and
there had been difficulty in breathing for three or four weeks. He
was admitted into the Bradford Infirmary; tracheotomy was performed
on the following day, but the patient died of broncho-pneumonia
in eight days. No tubercle bacilli could be found in the sputum or
lungs. There was a scar on the glans of the penis, probably specific.
The long duration of the h oarseness and loss of voice, and the short
duration of the dyspnoea, semed to point to ihe pacliydermia as the
primary condition, and that the perichondriti s was due to the pachy¬
dermia. It was possible, however, that the perichondritis had uaused
the pachydermia. The vocal cords were very thick, and showed several
small growths. The ventricular bands were also much enlarged, and
the mucou s membrane of the right ventricle was so enlarged as to
project to some extent.
Similar cases have been recorded by B. Eraenkel in the * Archiv fur
Laryngologie.^
Mr. Butlin observed that so-called perichondritis was frequently
neither more nor less than syphilis, and he thought that it was so in the
present case. It was always difficult to distinguish at first sight be¬
tween .pachydermia and flat epithelioma.
13
Dr. Milligan (Manchester) commented on the difficulty in deter*
mining whether perichondritis panLj/iormi'g ^as the primary con¬
dition when both WHl'U Ul'yUisurr
Case of Lymfhadbnoma with Obstbucted Breathing.
Dr. James Donelan showed a patient, J. B —, set. 43, first seen
at the Italian Hospital four weeks ago. His father died of cancer
of the throat.” His health has been always good, except a slight
tendency to bronchitis.
On November 9th, 1893, a discharge from right ear began almost
painlessly, and continued for two months. A swelling next appeared
on the right side of the neck, followed by a similar swelling on the
opposite side. Dyspnoea soon set in, and he was obliged to give up
his trade of baker. There was marked enlargement of the cervical
glands along both borders of the stemo-mastoids, with dulness over
the sternum. A small group of enlarged glands could also be felt
near the xiphoid appendix. There was bronchial catarrh and con¬
siderable venous congestion of the head, neck, arms, and hands, from
which gradual closure of the superior vena cava was to be inferred.
The spleen was moderately enlarged but painless; there was, however,
some pain over the liver. No microscopic examination of the blood
had yet been made, but there appeared to be little anaemia. Up to
the present the patient had been taking three minims of Liq. Arseni-
calis three times daily, but the stomach did not seem able to stand
any larger dose.
Mr. W. G. Spencer mentioned a case in which there had been
marked intolerance of arsenic until a portion of the adenomatous mass
was removed, after which the patient was able to take the Liquor
Arsenicalis Hydrochloricus with marked benefit.
Dr. DE Havilland Hall pointed out that where intolerance of
arsenic was present, it was advisable to change the form of adminis¬
tration, since patients could sometimes assimilate one preparation
while quite unable to bear another.
Papilloma Nasi with Eodent Ulcer in an Aged Patient.
Mr. P. DE Santi showed a patient, David P —, set. 82, who was
admitted to Westminster Hospital June 6th, 1894, with a growth in
left nostril. Five years previously he had noticed a small pimple on
the inner and upper part of the left nostril. It had gradually in-
14
creased in size^ and interfered with nasal breathing. It had never
been painfnl. About one year ago he noticed that he had a foetid
discharge occasionally from left nostril, perceptible to himself as well
as to others.
About one year ago he noticed a similar kind of pimple on the skin
over the right side of the nose. It increased very slowly in size, was
painless, but itched. He therefore scratched it, and it ulcerated
and then became covered with a scab.
On admission the left anterior naris was occupied by a pear-shaped
growth which occluded the passage, and protruded slightly from the
nostril. The part protruded was rather dry and blackish, but not
ulcerated. The part within the naris was of a pinkish colour, and a
pedicle could be easily traced op to the septum nasi at the junction of
bone and cartilage. The attachment of the pedicle was small, there
was no hardness or sense of infiltration at its base. No ulceration
anywhere. The growth resembled a small cauliflower, and was freely
moveable. The man^s general health was excellent. There had been
no loss of flesh, there were no enlarged glands; no history of syphilis.
The rodent ulcer was about the size of a Spanish nut, raised and hard,
its surface was covered with a scab; there was no attempt at
cicatrisation.
The growth in the nostril was removed with a pair of scissors, and
its base cauterised on June 19th; the rodent ulcer was excised on
July 10th.
Congenital Fistula op the Neck.
Mr. W. E. H. Stewart showed the case of C. G—set. 19. First
noticed a slight enlargement over the apple of the throat five years ago,
quite in the middle line. Was then taken to a general practitioner,
who pronounced it a goitre, and after some external treatment with no
result, consulted with another general practitioner, who agreed with the
diagnosis, and decided to remove the growth. The wound did not
heal, and when seen by Mr. Stewart, in November, 1893, there
was a veritable rabbit warren of sinuses running in every direction,
and the scar tissue was bound down to the thyroid cartilage. He slit
up the sinuses and thoroughly scraped them with a sharp spoon and
freed the larynx, but could not, with the finest probe, find any further
channel. The wound not healing he dissected out the whole scar
15
tissue, following it up as far as it went. The wound healed, but some
weeks afterwards broke out again. After trying remedies such as
nitrate of silver, chromic acid, and the galvano cautery without avail
he again operated, following the new track as far as the hyoid bone.
This was once more unsuccessful, except that the new sinus was much
shorter and straighter. He was now trying the injection of a 40 gr.
solution of chloride of zinc. The first injection went into the throat,
and created a large amount of inflammation there. The second did
not reach the throat, and now there was next to nothing in the way
of a discharge, and the probe would only go about a quarter
of an inch. There was a difficulty in obtaining a correct history of
the earlier stages of the trouble, but he looked upon this as one of
those cases of congenital branchial fistula which are very rarely met
with, and still more rarely cured.
Mr. Butlin thought that the fistula had probably begun as a cyst
in connection with the lower part of the thyro-lingual duct.
Mr. BowIjBy believed that as a general rule these cases were not
really benefited by operation. The difficulty of removing the whole
sinus, and the impossibility of keeping the parts at rest, led to alter¬
nate healing and breaking down, but not to cure.
Dr. Dundas Geant mentioned a recent case in which he had
obtained a successful result.
The Pbbsident would avoid operative treatment if possible.
The operation in itself seemed simple, but was sometimes very
troublesome and often incomplete.
Mr. Stewaet observed that the operation in the present case had
given marked relief.
Disease of Tongue (fob Diagnosis).
Clinical case exhibited by Mr. C. A. Parker. E. W—, set. 8, a
schoolboy.
History .—In August last the child began to be poorly, lost his
appetite, and was languid, but improved under treatment. About this
time the mother noticed a rash on the patient^s body and thighs, which
consisted of dull red spots ; the largest was about as big as a pin’s
head, and it only lasted three days. Shortly after its disappearance
the child began to complain of soreness of the tongue, the surface of
which looked rough and uneven. This trouble had got steadily worse
until the present date.
Family history .—Father and mother both alive and well. The
16
patient was the youngest but one of thirteen children, eight of whom are
alive. Scarlet fever, diphtheria, and measles had caused the five deaths.
After the third child mother had three miscarriages. No history of
syphihs could be obtained as occurring in either parent, and the
patient showed no signs of congenital syphilis about his teeth or eyes,
&c. There was no history of tuberculosis.
The patient^s previou* history was good.
Present condition .—The whole of the posterior two thirds of the
tongue was covered with large bosses, about the size of an elongated
sixpence, the surfaces of which were flattened, uneven, and rather paler
than the rest of the tongue. They were all firm to the touch. There
was no ulceration and no discharge, and no marked pain, but some
tenderness. On the soft palate there were one or two smaller patches
with an area of congestion around them, less raised than those on
the tongue. There were some enlarged, hard, and slightly tender
glands beneath the chin and in the neck. About the buttock a few
small pigmented spots, and a larger scaly spot behind the right knee.
These were said to be the result of boils.
The child was otherwise in good general health. He had all the
signs of post-nasal adenoid vegetation.
Mr. Butlin thought that the case was one of macroglossia. The
youth of the patient, the papillated appearance of the central lump
on the tongue, and the presence of enlarged glands all pointed to it.
He did not think that any treatment was advisable at present.
Mr. Spences regarded the growth as an abnormal extension of the
lingual tonsil. He suggested that it should be gradually destroyed
at several points.
? Angioma op Vocal Cord.
Mr. Ernest H. Crisp showed a patient set. 36, who had been
primarily inoculated with syphilis ten years ago. He was religiously
under treatment for two years, and the secondary symptoms, which
were mild in character, entirely disappeared.
Three years after discontinuing treatment, i. e. about five years from
the primary inoculation, he complained of pain in the larynx about the
level of the left vocal cord. He was again treated constitutionally
and rapidly recovered, and had no recurrence of symptoms until on
December 30th, 1892, i. e. ten years after origin of disease, he con¬
sulted Mr. Crisp.
17
On examination the pharynx and soft palate were in a red irri¬
table condition. There was subacute laryngitis, and both cords were
deeply congested. Treatment with large doses of iodide of potas¬
sium and green iodide of mercury rapidly reduced the more acute
inflammatory processes, but both vocal cords were left congested and
showed defective movement. The voice was husky, but there was no
particular pain. Under the influence of local application the con¬
gestion of right vocal cord entirely disappeared, but no treatment up
to the present had cured the red raised condition of the left vocal
cord.
The diagnosis lay between chronic congestion and angioma of the
cord. Could it be improved by means of the galvano-cautery ?
Mr. CbesswelIi Babes thought that the swelling was simply
syphilitic thickening, and that cauterisation was not called for.
Chsonic Goeoestion of Lasyex.
Dr. F. W. Beenett (Leicester) demonstrated the case of A. B—,
set. 47, saddler. He had always lived a temperate life. There was
no history of syphilis or of tuberculosis. He became slightly hoarse
about May last, and with slight variations this had been progressive. On
examination about six weeks ago there was a general congestion of
the larynx. The anterior extremity of the right cord was thickened
and red, and there was a slight thickening of the tissue below the
level of the cord. The movements were slightly tardy, but equally so
on the two sides. This redness did not subside with the treatment
adopted. The opinion of members of the Society was invited as to
the nature of the case, and especially as to whether this slight ful¬
ness was more than could be accounted for by a catarrhal process.
The PsEsiDEET thought that much of the impairment of move¬
ment was of a neurasthenic character. He suggested that the
patient should be taught to speak in a deeper tone than normal, a
mode of treatment often successful with boys at the period of
“ broken voice.” The congested condition was probably catarrhal.
Eaelt Epithelioma? of the Vocal Coed.
Mr. Chabters Stmoeds exhibited a man set. 48, who had com¬
plained of a little hoarseness at times during the last two months.
He had taught for some years in a board school, and now was an
2 *
18
inspector. In addition to this he used the voice a good deal on
Sunday. In July the larynx was examined by Dr. Warner of Wood¬
ford^ who saw nothing amiss, but in September observed the condi¬
tion now present. On the left cord at the processus vocalis was a
nodular elevation with a depressed summit. It resembled pachy¬
dermia laryngis closely, but seemed to differ somewhat from this
affection in its nodularity, ff'he colour on the whole was pale. The
cord moved freely and the voice was clear. The opposite cord was free.
The condition was either an early epithelioma or a stage of pachy¬
dermia, and Mr. Symonds had advised rest of the voice and further
observation, in the hope that it would prove to be pachydermia
laryngis, and not epithelioma. The special point in favour of the
latter diagnosis appeared to be the nodular character of the growth.
Dr. MiLLiaAK thought that the case was either pachydermia or
epithelioma. He thought that the latter was the correct diagnosis,
and would advise thyrotomy and removal of the cord.
Dr. Spiceb suggested endolaryngeal removal, and if that should
prove unsuccessful he would perform thyrotomy.
Dr. Hill observed that if the condition was pachydermia the
amount of swelling indicated long duration of the disease.
The Peesident felt absolutely certain that the case was simply
pachydermia. A malignant growth on the inner side of the ary-
tsenoid cartilage was not compatible with such free movement. The
patient was not suffering in any way, and there could be no need to
operate unless the condition got worse. He would simply advise rest
to the voice, and a course of iodide of potassium.
Mr. Sthoeds intended to pursue a waiting treatment, as he did not
regard the case as malignant.
Tuberculae Disease of the Lartnx.
Mr. Charters Stuonds also showed a man of 35, with exten¬
sive swelling of the left arytmnoid and ulceration extending down to
the cord. The noticeable features were the small amount of distress
and dysphagia, and in this particular the resemblance of the disease
to syphilis.
PKOCEBDINGS
OF THB
LARYNGOLOGICAL SOCIETY OF LONDON.
Obsinabt Mebtiko, December 1894
Felix Semon, M.D., F.B.O.P., President, in the Chair.
E. Clxpvobd Beale, M.B.,
ScAEEs Spiceb, M.D.,
Secretaries.
Present—28 Members and 4 Visitors.
The minutes of the previous meeting were read and confirmed.
The following gentlemen were elected members of the Society:
Charles Cooper Cripps, M.D., London.
A. L. Boper, M.B., Lewisham.
Henry Sharman, M.B., Hampstead.
George Mackem, M.D., Buenos Ayres.
William Jobson Home, M.B., London.
A. B. Hill-Wilson, London.
B^inald Poulter, London.
The following candidates were proposed for election:
Dr. Barclay J. Baron, Clifton.
Mr. Percy Warner, Woodford.
Dr. J. Walker Downie, Glasgow.
Double Abductob Pabaltsis of Unoebtain Obioin, associated
WITH Cystic Bbonchocele and Dyspncea ; Opebation ; Im-
PBOVEMENT.
Mr. A. A. Bowlby showed a patient, a man set. 60, who was
admitted into St. Bartholomew's Hospital on March 17th, 1894, on
account of dyspnoea and bronchocele.
He said that the enlargement of the thyroid gland had existed for
about two years; that for about three months he had suffered from
FIRST SEBIES—VOL. II. 8
20
some difficulty in swallowing, and for a month from difficulty in
breathing. He had had several attacks of sudden and urgent
dyspnoea.
Examination showed a very large thyroid cyst, situated on the left
side of the neck, and about as large as a cocoa-nut. The larynx and
trachea were a good deal displaced to the right of the middle line.
The thyroid gland was not itself hypertrophied to any appreciable
extent. Voice not affected, except that it was not strong; swallowing
decidedly difficult and slow. Laryngoscopic examination showed
double abductor paralysis, the cords not separating in respiration
more than one eighth of an inch.
On March 22nd the cyst was removed by operation without trouble,
and the wound healed throughout by first intention. The dyspnoea
and dysphagia were immediately relieved, and three weeks later the
patient was discharged. He had one slight attack of dyspnoea a few
days afterwards, but since then had had no return of such attacks.
His breathing was now quiet, but on exertion he was short of
breath.^' His voice was normal. There was no alteration in the
condition of the cord. During inspiration there was a lozenge-shaped
aperture between the anterior attachments of the cords and the vocal
processes, and a smaller and similar shaped aperture between the
vocal processes and the interarytsenoid mucous membrane.
There was no evident cause for the paralysis, and no sign of tabes
dorsalis or of any cerebral affection.
Akeubish of the Aortic Arch compressing the Left Pneumo-
GASTBIC AND HeCURRENT LaRYNGEAL NeRVES AND THE TrACHEA,
AND ASSOCIATED WITH AbDUCTOR PaRESIS OF THE BiGHT
Cord.
Mr. A. A. Bowlbt showed a specimen taken from a patient,
W. S—, set. 60, sent by Dr. Furber of Oxted on November 24th,
1893.
Patient had had some difficulty in breathing for a year, but it had
not prevented him from doing his work. Four weeks before he came
to the department for diseases of the throat at St. Bartholomew's Hos¬
pital he had partially lost his voice, and since that time he had con¬
tinued to be hoarse, and his difficulty in breathing had increased.
There had been no difficulty in swallowing.
21
The patient was a very large, heavily built man of about seventeen
stone in weight. His breathing was not hurried when he was sitting
still, but he said that he could not walk without suffering from shortness
of breath. There was slight stridor.
No swelling was visible in the region of the air-passages, and the
fauces and pharynx were natural. The left vocal cord was almost
fixed in the cadaveric position, neither abduction nor adduction being
complete. The right cord was but little affected, although it was
thought that abduction was sluggish. Otherwise the larynx appeared
quite normal. No cause for the paralysis, and no evidence of either
disease of the central nervous system or of any thoracic tumour or
aneurism could be detected. As respiration was not dangerously
interfered with, no operation was advised, and the patient was not seen
again until December 8th. He was then much worse, the breathing
being very laboured and stridor well marked, with a good deal of
cough and expectoration of a considerable quantity of mucus.
The left cord was found to be completely paralysed and fixed in the
cadaveric position, while the right cord was very imperfectly abducted,
the abduction movement failing to place the cord quite as far from
the mid-line as its paralysed fellow. The dyspnoea appeared more
than could be accounted for by the deficiency of space in the larynx,
but no evidence could be detected of any pressure on the trachea.
The patient was put to bed and kept on fluid diet, with steam
inhalation and expectorants, but without real relief to the dyspnoea.
Two days later he had several severe attacks of dyspnoea which were
transient, and on December 12th, after consultation with Mr. Butlin,
tracheotomy was performed without ansesthesia.
The operation gave but slight relief, however, but it was now con¬
cluded that there must be some intra-thoracic pressure, such as had
been suspected from the beginning. Two days later the patient had an
attack of syncope, and suffered from similar attacks on subsequent days.
Death occurred suddenly from cardiac syncope on December 17th.
The post-mortem examination was made by Mr. James Berry, to
whom he was indebted for the great care with which all the affected
parts have been removed and dissected. The abdominal viscera were
normal. The right lung was oedematous and congested. The whole
aorta was dilated, and just beyond the origin of the left subclavian
artery a sacculated aneurism commqpced, involving about 4 inches
of the length of the vessel. The sac itself was about 4 inches wide
22
by 2^ inches broad, and extended chieOy in a backward direction and
a little to the left side. It had slightly eroded the third and fourth
dorsal vertebrse, and had pushed its way between the trachea and
oesophagus, displacing the latter considerably to the left, and flattening
it. The trachea was compressed from a point about 2 inches below
the cricoid to the bifurcation of the bronchi, the seat of maximum
pressure being just behind the manubrium stemi, where the tracheal
walls were only a quarter of an inch apart.
The right pneumogastric and recurrent laryngeal nerves were found
to be quite free from all pressure, separated from the sac by an
interval of about three eighths of an inch; they lay in normal loose
connective tissue.
The left pneumogastric and recurrent laryngeal nerves lay stretched,
flattened, and adherent over the front of the sac. They had evidently
been subjected to very severe compression.
The interest of this case is mainly in the paresis of the right cord
as a sequel to pressure on the left pneumogastric nerve. The
dyspnoea was chiefly the result of tracheal compression, but the
laryngeal aperture was also certainly diminished. The aneurismal
sac did not touch any part of the thoracic parietes with the exception
of two vertebrsB, hence the absence of physical signs during life could
be easily understood.
Mr. nx Santi suggested that intubation might have been employed
with advantage in this case in lieu of tracheotomy.
The PsEBiDEKT observed that the case tar^ht several lessons.
Double paralysis caused by pressure upon one vagus was very rare,
but the course of events in this case had borne out the truth of the law
as to the earlier affection of the abductor fibres. Where the source
of pressure was within the chest it was advisable not to commit
oneself to a promise of relief by tracheotomy, owing to the possi¬
bility of mechanical pressure obstructing the trachea at a lower level.
Dr. Maceebn (Buenos Ayres) mentioned a case of double abductor
pai^ysis in a tubercular patient, which recovered completely under
iodide of potassium and electricity.
Chbonic liABTNOmS.
Mr. BuTLiif showed the case of James D—, set. 35, regimental
bandsman (wind instrument), first seen on Nov. 30th, 1894, suffering
from aphonia. The voice, preAriously strong, had begun to get weak
one year and nine months previously, but fifteen months ago it became
suddenly aphonic, and had so remained.
23
The patient had syphilis, primary and secondary, five years ago, but
without sore throat, and the skin showed definite signs of former
syphilitic lesions. In his throat he complained of occasional choking
sensations, and difficulty of breathing, coming on at night, about twice
a week. The disease affected the true cords, which were red and
thickened. There were several outgrowths on each cord, especially
towards the commissure. One of these which hung below the glottis
flapped up and down during inspiration.
The question of diagnosis lay between syphilis, of which there was
a past history, tubercle, of which there was no history and no other
symptom, and multiple papilloma.
Teachbotomt Tube woen poe Eleven Ybaes.
Mr. Eicuaed Lake exhibited a silver tracheotomy tube which had
been worn by a patient for eleven consecutive years. The outer tube
was much eroded.
Foeeign Bodies in the Aie- and Food-Passages.
The Pebsident showed several cases of foreign bodies removed or
expelled from the air- and food-passages. These were—
1. A piece of holly-wood removed from the nostril of a child of four.
2. A pin removed by forceps from the arytseno-epiglottidean fold
of a boy of thirteen, where it had stuck for many months.
3. A counterfeit earring which first was lodged underneath the left
vocal cord, and afterwards penetrated into a bronchus on the left side
of the chest, whence it was expelled by coughing.
4. A blade from a tooth-forceps removed after tracheotomy from
the right main bronchus of a young woman.
5. Two halfyennies removed from the glottis of small children who
had swallowed them. (A specimen was also shown illustrating the
results of coins remaining undetected in the oesophagus.)
6. A piece of meat, with a long sharp bone attached to it, removed
from the oesophagus of an adult.
The history of all these cases, some of which had previously been
reported, were detailed.
Mr. Butlin mentioned a case of pleuro-pneumonia, following the
impaction of a foreign body, which had recently ended fatally.
Dr. Bbonneb observed that the rule given in the text-books did not
§
24
seem to be justified. They generally adyised waiting until definite
symptoms appeared, but he thought there should be no delay after the
diagnosis was once made certain.
The Pbesidekt agreed that no foreign body ought to be allowed to-
remain in the air-passages, but it was sometimes better to try the
effect of complete inversion of the patient if the foreign body was
round and likely to be expelled by gravitation.
Fibkosis op thb Thtroid; Pabtial Thyboidectomt, Tbachbo-
TOMY, AND Dilatation op the Stenosbd Tbacuea.
Mr. Walteb G. Spenceb exhibited a patient, a pale, thin do¬
mestic servant who had always lived in London. More than seven
years ago her parents had noticed a soft swelling in the region of the
thyroid, which gradually got smaller and harder. With this decrease
difficulty in breathing came on.
Her mother had had for years a soft thyroid tumour at the junction
between the isthmus and the right lobe, which was either a flaccid cyst
or an adenoma. When she first attended as an out-patient at the
Westminster Hospital the thyroid gland appeared of normal shape
and size, but it was of stony hardness. The pulse was 130 to 14C1
per minute, but without exophthalmos. There was stridor, loudest in
the trachea at the level of the isthmus, but heard over the whole
chest. There were no^signs of phthisis. The stridor gradually increased,
cyanosis became marked, and the pulse was never less than 180.
The duration of the affection and the decrease in the size of the
thyroid supported the diagnosis of calcification of a formerly enlarged
bronchocele.
Oil April 11th, 1894, a median incision was made down to the
isthmus. The texture of the isthmus when cut into was that of the
hardest fibrous tumour, but there was no calcification. In spite of
careful attempts no line of demarcation could be made out between
the isthmus and the trachea; therefore the isthmus and the adjacent
parts of each lateral lobe were shaved off from the trachea, leaving a
portion of the gland on either side about as large as the end joint of
the thumb. The trachea thus exposed felt like a soft tube, and was
sucked in and blown out by inspiration and expiration. The carti¬
laginous rings had softened or disappeared. As the breathing was
none the better for the removal of the isthmus, the trachea was
opened immediately below the cricoid cartilage, where the rings were
natural. On retracting its sides the lumen was seen to be narrowed
25
to a chink below, and so the trachea was incised longitudinally down¬
wards through the part which had been in contact with the thyroid
until cartilaginous rings were again reached. The mucous membrane
appeared normal, being merely thrown into folds in the narrow part.
A Parker^s silver tracheotomy tube was inserted, and the breathing
became free. After the patient had worn the tube for a fortnight
she was gradually able to discard it, so that at the end of a month
from the operation the wound in the neck had entirely closed. Six
months after the operation the girl was in better health, although still
thin; her breathing caused her no trouble, but a little stridor could
be heard in the trachea. The remainder of the gland had not altered.
The pulse was still 120 per minute.
On examination of the tissue removed a part showed, under the
microscope, thyroid alveoli in no way dilated, and containing normal
colloid matter, but the alveoli were separated from one another by an
increased amount of fibrous tissue. In the rest of the material
removed all glandular structure had been replaced by dense fibrous
tissue without any sign of sarcomatous elements or of cysts, but
showing vessels with well-marked walls.
Between these two parts the thyroid alveoli were smaller in size
and filled with epithelial cells, or clumps of epithelial cells sur¬
rounded by small cells marked the position of a former alveolus, or
lastly groups of small round cells alone were visible. The fibrosis
seemed to have spread inwards from the capsule of the gland.
The longitudinal division of the stenosed trachea might possibly
result in a persistence of the dilatation, as in the case of other stric-
tured tubes, and,the unaltered condition of the mucous membrane might
be considered as favorable to the maintenance of the dilatation. The
rapid pulse would seem to date from the time when an enlarged
bronchocele was present. It was remarkable that it should remain
26
rapid when so much of the gland had been put out of action. On the
other hand, no myxoedematous symptoms had supervened, for
doubtless there was some active thyroid tissue still left, and the stony
hardness of the gland differed widely from the soft and withered gland
in myxoedema.
The most important feature, from a surgical point of view, was the
fact that the trachea had become intimately included in the disease and
the cartilaginous rings softened, whereas the clinical and microscopical
features of the case presented no signs of malignancy.
Fibrosis or fibrous degeneration of the thyroid gland must be a very
rare disease, for no case of the kind appeared to have been yet put on
record. Ziegler alone simply mentioned the occurrence of the disease.
Fibro-sarcoma had been met with, e.g. by Mr. Bowlby (‘ Lancet,^ 1884,
ii, 1001), from which this case was distinguished by the clinical course
of the disease and by the microscopical appearances of the portion
removed.
Pakalvsis of Left Vocal Coed associated with Paealysis of
Soft Palate (? of Diphtheeitio Oeigin).
Dr. ScANES Spicee showed the case of C. fl—, set. 34, stableman,
who had complained of hoarseness and regurgitation of fluids through
nose on attempted swallowing since the middle of September, 1894.
Illness commenced with an ordinary cold.” There were no
patches or ulcers on the throat at the time, but little soreness and
pain on swallowing at first. The voice was distinctly nasal in
character, and patient had dyspnoea on exertion. Hand-grasp good
and equal on both sides. Knee-jerk, elbow reflex, and pupil reflexes
normal. Mechanical stimulation of palate felt, but no reflex con¬
traction. Laryngoscope showed left vocal cord in cadaveric position
almost entirely immobile. Nothing abnormal detected in chest. No
history of syphilis, influenza, or diphtheria to be obtained.
The patient was gradually improving under five drops of Liq.
Strychnise, large doses of iodide of potassium for some weeks having
had no effect.
Dr. Ball considered that the paralysis of the soft palate and left
vocal cord was probably diphtheritic in origin.
Dr. Hale White h^ seen somewhat similar conditions associated
with lead poisoning.
Dr. McBbide thought it possible that some changes might have
been set up in the muscles supplied by the spinal accessoiy nerve.
57
Aneurism of the Aortic Arch with Paralysis of the Bight
Yocal Cord.
Dr. Soanes Spicer showed a specimen obtained from a sailor, W.
S-o, mt. 48, who was under treatment at St. Mary's Hospital under
the charge of Dr. David B. Lees and the reporter, for severe attacks
of spasmodic dyspncea, hoarseness, and breast pain.
The laryngoscope disclosed paralysis of right vocal cord, while left
vocal cord remained freely moveable throughout the illness. Physical
examination of the chest showed undue prominence of right upper
chest hront, dnlness, and stridulous breathing.
Intubation, venesection, and injections of morphia and atropine gave
relief from time to time. The patient died from cardiac syncope of
gradual onset.
The specimen was a saccular aneurism of aortic arch involving the
second and third parts, and due to the yielding of the posterior wall
of the vessel. The U(ft recurrent nerve appeared stretched over the
back of the sac. The tumour had displaced the lower part of the
trachea backwards and to the right, in such a way that the convexity
of the deflected trachea pressed on ther^^^ recurrent and pnenmogastric
nerves. The tumour also bulged into the trachea and opened into
its lumen. The large vessels were not involved in the aneurism, as
their site of origin was anterior to that part of the wall forming the
tumour.
Ankylosis (?) of the Left Arytenoid Joint.
Mr. Symonds showed the case of Eliza P—, set. 56, seen at Guy's
Hospital for hoarseness in May, 1894. The condition had existed
more or less for a year, and when seen again in November it was
unchanged.
The whole of the left half of the larynx was flxed, the arytmnoid
and cord showing no movement on phonation. The cord lay in the
median line, and the right moved up to it. The right arytmnoid
moved up to, but did not cross the left. The line of the glottis where
the cords were in contact was oblique.
There was no evidence of destructive ulceration of the cord or
arytenoid, and no cause of pressure could be discovered in the neck or
elsewhere. The patient could swallow ordinary food with ease. A
bougie passed readily without encountering obstruction. There was
28
no sign of syphilis. The patient was stone deaf and of an excitable
temperament.
The diagnosis lay between paralysis and fixation of the arytsenoid,
and Mr. Symonds inclined to the latter view on account of the
position of the arytsenoid^ the oblique line of the glottis, and the fact
that the moving arytsenoid did not displace the immoveable one.
Dr. PsBCY Kidd had seen this case at an earlier stage, and thought
the fixation of the cord was mechanical rather than paralytic, due to
ankylosis of the crico-aryteenoid joint.
Tubercular Ulceration of the Epiglottis treated by
Curetting and Lactic Acid.
Mr. Symonds exhibited a patient, Mr. E. S—, set. 29, who com¬
plained in August, 1891, of some pain in swallowing, the expectora¬
tion of much frothy mucus, alteration of voice, and nocturnal cough.
On examination the epiglottis was thickened, red, and shiny, especially
on the right side ; mucus entirely concealed the laryngeal view. On
the posterior surface of the epiglottis was extensive ulceration, more
particularly on the right half and edge. The change of voice was due
to the presence of mucus only. He had lost two stone in two years,
but considered himself in good general health. There was no family
history of tubercle and no evidence of pulmonary disease.
The disease seemed so extensive that at first he was treated with
sedative powders and general remedies. In five weeks he had
improved a good deal, and had gained in weight. A better view
obtained showed that the left arytsenoid was involved and the ary-
epiglottic fold.
October 31st.—The epiglottis was freely curetted and lactic acid at
once applied.
November 24th.—The local condition was much improved; he
could swallow well and eat anything. He had been curetted four
times. All expectoration had disappeared. He had gained 9 lbs. in
the three months.
December 5th.—Some recurrence took place, giving rise to dys¬
phagia due to increased swelling of the ary-epiglottic fold. This was
scraped well and rubbed with lactic acid.
January 12th, 1892.—Both cords were well seen owing to the greater
mobility of the epiglottis, and were healthy. A small smooth swelling
29
remained in front of the left arytsenoid. The epiglottis looked irre¬
gular and nodular from cicatricial contraction.
November^ 1892.—A small grey surface appeared in the left side of
epiglottis. This was curetted off and lactic acid applied.
The treatment never interrupted the patient^s business engage¬
ments. Since the last date he had continued well.
Dr. Clifford Bbale referred to the occasional occurrence of
spontaneous healing of localised tubercle of the epiglottis without
any special treatment.
Mr. Butlin mentioned the case of a boy with destructive ulceration
of the epiglottis, which healed completely under the simple application
of iodoform.
Dr. McBbidb quoted a case of spontaneous cure, in which the
pharynx had been affected with a pale bluish oedema similar to that
seen in the larynx in tubercular cases. Lactic acid was applied, but
not very regularly, and the swelling disappeared. No bacilli were
found in the case.
Mr. Obesswell Babeb referred to a case of apparently tubercular
disease of the epiglottis, and commented on the great variety in the
course taken by laryngeal tubercle in different cases.
Mr. Symonds pointed out that in his case relief was rapid after the
conditions had remained unaltered for six weeks.
The Pbesidebt observed that without the presence of bacilli it was
not always possible to be sure of the tubercular nature of some cases.
Pachydermia Lartnois.
Mr. C. J. Symonds brought forward the patient shown at the last
meeting {vide ‘ Proceedings/ vol. ii^ p« 17). Some change had taken
place since the previous examination, but the condition was still
characteristic of pachydermia in the opinion of the President, Dr.
Kidd, Dr. McBride, and Dr. Ball.
Dr. Bbonneb and Dr. Spiceb advocated the removal of a small
piece of the projecting tissue for microscopic examination.
The President thought that the diagnosis was sufficiently clear
without the use of the microscope. Changes took place very rapidly
in these cases, and the results of microscopic examination were not
always positive, but sometimes brought confusion into a simple case.
Venous Angioma op Pharynx.
Dr. P. McBride showed a sketch taken from this case. The
patient, a young married woman with tendency to varicose veins,
noticed the tumonr accidentally one day on looking into her throat.
The angioma consisted of tolerably large veins, and occupied the
whole palatal margin from the nvnla indnsive of the left side.
Smaller separate patches were seen on the anterior and posterior
pillars of the fauces, while a bluish tinge was communicated to the
anterior portion of the soft palate of the corresponding side.
As the tumour produced no symptoms it was not intended to apply
any treatment.
PEOCEBDINGS
OP THE
LARYNGOLOGICAL SOCIETY OF LONDON.
AnnttaIi Genebaii MEETiNa, Ja/niia/ry 9th, 1895.
Felix Sekon, M.D., P.E.C.P., President, in the Chair.
E. Cliefobd Beale, M.B.,
ScANEs Sficeb, M.D.,
Secretaries.
Present—27 Members and 7 visitors.
The minutes of the last Annual Meeting were read and confirmed.
Dr. W. Law and Dr. George Mackern were appointed as Scruti¬
neers of the ballot for Officers and Council for the ensuing year, 1895.
The Eeport of the Council for the past year, 1894, was then read,
as follows:
During the past year, 1894, the Society has held the full number of
meetings, all of which have been well attended. Sixteen new members
have joined the Society, and the Council have only to report the loss
of one member by the lamented death of Dr, Ernest Jacob of Leeds.
In response to a request from the House Committee of the Royal
Medical and Chirurgical Society, the Council have entered into a new
and inclusive agreement as to rent, accommodation for the Society’s
Library, and supply of electric current through the lamps used in
the clinical examinations. An inclusive annual rent of .£31 10s. has
been agreed to.
It having been suggested by some of the country members of the
Society that a scale of compounding fees should be established in
lieu of annual subscriptions, the Council, having carefully considered
the matter, have to submit the following propositions for confirmation
by the Society;
1. That it is undesirable to establish a compounding fee for town
members at present.
2. That country members should be allowed to compound for the
sum of ten guineas (£10 lOs.) oh entrance, which sum should include
the entrance fee.
3. That country members who have not paid, five annual subscrip¬
tions should be allowed to compound for the sum of nine guineas
(£9 9a.).
4. That these fees should entitle the compounding members to
FIRST SERIES—VOL. II. 4
enjoy all the privileges at present accorded to ordinary members of
the Society.
It was then proposed, seconded, and carried unanimously—“ That
the Beport be received and adopted, and that the Recommendations
with respect to Compounding Fees be approved, and that the
Council empowered to alter Buie 10 of the Society’s Buies in
accordance therewith.”
The Treasurer’s Beport was then presented as follows:
THE LABTNGOLOaiCAL SOCIETT OF LONDON.
BALANCE-SHEET, 1894.
iKOom.
£ t. d.
By Balance in hand from
1893 . 15 13 4
,, Subscriptiona—
49 members at
£lls.. .£61 9 0
17 members at
£2 28. . . 35 14 0
- 87 3 0
The 17 subscriptions at
£2 2s. include 15
entrance fees and 2
snbscriptions for the
coming year, 1895.
Total . . £102 16 4
ExvaimiTuss.
£ «. d.
To Bent, 20, Hanover Square 20 0 0
„ Adlard for Printing and
Postage.36 13 10
„ Corbyn and Co., Spirit
Lamps, &c.1 18 0
„ Cheque-book,4«. 2d.; col¬
lecting two Cheques, 3d. 0 4 5
„ Petty Cash-
Dr. Spicer . £1 18 2
Dr. Beale . . 0 15 0
Attendant ..200
Waterlow —
Diploma of
Hon.Member-
ship ... 0 9 6
- 6 2 8
„ Balance in
Treasurer’s
hands, Jan. 1,
1895 . . 38 17 6
Total . . £102 16 4
Expenditure of
the year . £102 16 4
88 17 5
£68 18 11
Audited and found correct, WALTER G. SPENCER.
January 4,1895. RICHARD LAKE.
The Report was unanimously received and adopted.
The Beport of the Librarian was read as follows:
Numerous monographs, pamphlets, periodicals, and a few books
have been received during the year. Amongst the latter are 'Me¬
dical Essays and Lectures,’ and an ‘Essay on Asphyxia’ by Sir
George Johnson, presented by the Author. Additional accommoda-
83
tion has now been provided in the Library of the Boyal Medical and
Chinii^cal Society for the Society’s Library, and negotiations are in
progress which, it is hoped, will render the use of the Library more
available to the members of the Society.
The Beport was unanimously received and adopted.
The President then called attention to the first bound volume of the
Society’s * Proceedings/ to which a complete index had been added,
and stated that the Society's printers, Messrs. Adlard and Son, 20,
Hanover Square, were prepared to bind any sets of * Proceedings'
sent to them by the members, together with the new title-page and
index, in the same manner as the specimen volume exhibited.
The Scrutineers then presented the result of the ballot for Officers
and Council, as follows:
President. —Dr. Felix Semon, M.D., F.R.C.P.
Vice-Presidents .—Charters J. Symonds, M.S., F.B.C.S.; E. Cress-
well Baber, M.B.
Treaswrer. —H. T. Butlin, P.R.C.S.
Librarian. —E. Clifford Beale, M.B., P.E.C.P.
Secretaries .—Scanes Spicer, M.D.; W. E. H. Stewart, F.E.C.S.Ed.
Council. —J. Dundas Grant, M.D.; Adolph Bronner, M.D.; Percy
Eidd, M.D., F.E.C.P.; J. W. Bond, M.D.; F. W. Bennett, M.D.
The President briefly returned thanks for the election of himself and
the other members of the Council.
The following recommendation of the Council was then considered,
and after some discussion agreed to:
The Council propose that a Reception should be given to the
Foreign and Provincial Laryngologists attending the Ann ual Meet¬
ing of the British Medical Association in London in July, 1895.
They suggest that a Conversazione should be held in the rooms of
Messrs. Erard in Marlborough Street at 10 p.m. on the night of
July 29th, and that the expenses should be borne by voluntary con¬
tributions from the members, the amount of subscription not to be
limited.
It was agreed that a small Sub-Committee should be appointed at
a later date to make arrangements for the Conversazione.
Ordinabt Mebtikq.
The minutes of the last Ordinary Meeting were read and confirmed.
The following gentlemen were elected Members of the Society :
Mr. Percy Warner, Woodford.
Dr. Barclay Baron, Clifton.
Dr. J. Walker Downie, Glasgow.
34
Morifobm Growths sprikoing from the Posterior Border of
THE Nasal Septum.
Dr. William Hill showed this case.—C. H —, set. 40, presented
himself at St. Mary^s Hospital in July, 1894, suffering from slight
catarrh of the Eustachian tube and tympanum; he had a congenital
cleft in the hard and soft palate. On post-rhinoscopic examination
two elongated moriform tumours were observed, about the size of
broad beans, springing symmetrically from the posterior border of the
septum. As these were not large enough to cause obstruction it was
decided to watch their growth. Since that date the right one of the
two tumours had nearly doubled in size.
Growths in this situation must be comparatively rare, though the
exhibitor of this case had removed two such tumours, springing from
the same site, from a patient whose posterior nares were quite blocked
by them; their removal by snare, scissors, and knife had proved by
no means easy. As far as Dr. Hill was aware, the only recorded case
was the one shown some time since at this Society by Dr. Dundas
Grant, in which moriform tumours sprang from the same site.
Ulcbrativb Disease of the Left Nasal Fossa of Undoubted
Tubercular Nature followed by Lupoid Disease of the
Left Ala.
Dr. William Hill showed this case.—E. H—, set. 30, sought
advice in May, 1893, for a blocked and ulcerated condition of the left
nasal fossa. There was no evidence of syphilis. The patient had been
dismissed from the army four years previously for tubercular disease
of the lung with haemorrhage, but there had been no active pulmo¬
nary disease for three years.
Granulations and exposed bone were found on the middle fossa
in the region of the uncinate body. Dr. Semon saw the case in
consultation, and whilst advocating the administration of iodide of
potassium he concurred in the view that the disease was probably
tubercular, and required energetic local treatment as well. The dia¬
gnosis was eventually confirmed by bacteriological examination. The
granulations were frequently curetted, and applications of lactic acid,
chromic acid, sulphoricinate of phenol, and trichloracetic acid were
tried, the last apparently with most benefit ; a small sequestrum came
35
away, aiid after this the ulceration was found to be practically healed
at the end of two months, though the patient was recommended to
continue to medicate the nose daily with an alkaline douche.
When seen again on December 15th, 1894, there was an abundant
purulent discharge from the nostril and ulcers on the floor and on the
outer wall of the middle meatus, together with excoriation and
swelling of the upper lip near the anterior naris, and evidently ex¬
tending by continuity from the vestibule; in spite of appropriate
treatment the disease had extended to the ala, which at the present
time, presented a tuberculated appearance, and looked just like
lupus. The patient had recently been under the care of Mr.
Stanford Morton fur purulent ophthalmia, probably caused by the
irritating nasal discharge having been conveyed accidentally to the eye.
The case was of interest, inasmuch as an undoubted tubercular disease
of the nasal mucosa had been followed after nearly two years by ex¬
tension to the cutaneous covering of the ala, and this more recent
lesion would have been unhesitatingly diagnosed as ordinary lupus had
not the course of the disease and the continuity of the lesion been
known. Ichthyol ointment was now being applied locally, but it was
proposed to scrape the affected skin.
Dr. Eddowes thought that the disease was probably lupus. He
Suggested getting rid of infection by means of mercurial plasters and
ointment, and then attacking the diseased surface by the cautery,
using great care to keep the wound aseptic.
Dr. still regarded the case as tubercular.
Dr. Alexander Hodgkinson (Manchester) exhibited—
1. A throat mirror for laryngoscopic purposes in which quartz
was substituted for the glass of the ordinary mirror. It was thus
rendered far more durable.
2. A magnifying laryngoscope. This consisted of a magnifying
throat mirror and an ordinary frontal reflector to which were adapted
magnifying lenses. The throat mirror consisted of a plano-convex
lens mounted in the usual way, and having the convex surface silvered
so as to constitute a concave reflector when seen through the plane face.
The magnifying power was varied by having two such mirrors with
focal lengths of eight and eleven inches respectively. The frontal
mirror, of the ordinary size and form, was fitted with four double
convex lenses, two for each eye, and capable of being used separately
86
or together, so as to allow of farther varying the amplifying power.
The focal length of each of these lenses was twenty inches. When
properly constructed for varying width of eyes it was easy to use, and
gave excellent results.
Labtngsal Stenosis j Polypoid Growth prom Left Vocal Cord,
(?) Syphilitio.
This case was shown by Dr. Percy Kidd. —William I—, set. 44,
polisher, admitted into the Brompton Hospital December 15th, 1894,
on account of dyspnoea.
Patient bad syphilis sixteen years ago, followed by a rash, and was
treated at the Middlesex Hospital for eighteen months. His tongue
has been cracked and covered with whitish patches for thirteen or
fourteen years. Hoarseness began three years ago, and he ultimately
lost his voice. Por the last four months he had suffered from gradu¬
ally increasing dyspnoea with cough and slight expectoration, which
he found much difficulty in expelling. Slight haemoptysis (one
teaspoonful) occurred a fortnight ago. He stated that he had lost
much flesh.
On admission marked stridor and dyspnoea, mainly inspiratory.
Nutrition of body poor. Chest slightly hyperresonant ; breath-
sounds weak generally. Tongue showed leucoplakia and some scar¬
ring. Larynx moderately congested. Glottis represented by a mere
chink bounded by two motionless fleshy bands, which showed a kind
of fusiform swelling at their middle two thirds. Just below the
posterior third of the left band a pale pink, irregularly rounded, poly¬
poid outgrowth projected inwards, and almost touched the opposite
side of the larynx. The posterior wall was marked with numerous
coarse nodular elevations; no definite ulceration. Sputum examined
for tubercle bacilli with negative result.
The case was regarded as one of laryngeal syphilis, and was treated
with large doses of iodide and mercury.
The stridor and dyspnoea had diminished slightly, but there had
been no change in the larynx beyond a slight decrease in the nodular
appearance of the posterior wall.
The case resembled somewhat that of C. H —, shown at the March
meeting of the Society in 1894, which proved to be syphilitic.
37
Mr. W. G. Spbnoeb thought that thjrotomy should be performed,
as the laryox was very narrow.
Dr. Hall considered that the disease was undoubtedly syphilitic,
and that it would be best to perform tracheotomy, and to attack the
larynx with the forceps at a later stage.
The Pbesident thought that the possibility of malignant disease
should not be disregarded. There seemed to be an excessive out¬
growth for a simply syphilitic condition, but antisyphilitic treatment
should be tried.
Dr. Einn, in reply, stated that no attempts had yet been made to
remove the growths with the forceps. He had, at first, thought that
the disease was tubercular, but now regarded it as syphilitic. He
proposed to treat the case by tracheotomy, and subsequently to try
removal of the outgrowths with the forceps.
(Edematous Swellings of the Palate and Phaeyni.
Dr. Edward Law showed a patient, Mrs. S. B —, aged 62, widow,
first seen on November 20th, 1894, on account of the sudden occur¬
rence of great difficulty in respiration and deglutition, associated with
much discomfort and swelling at the back of the throat. The patient
had been under the care of Dr. Alfred Eddowes for nine months suf¬
fering from so-called Quincke^s disease or acute circumscribed oedema,
a malady which had been also described as urticaria tuberosa, nodosa,
or gigans.
Daring childhood she was said to have sufiered from one attack of
nettle-rash, and her father is reported to have been very gouty.
The patient had always enjoyed fairly good health with the ex¬
ception of occasional dyspepsia. Three years ago she lost her hus¬
band, and suffered from severe and lasting shock, but it was not until
eighteen months later that the disease began from which she now
suffered. Before the rash appeared she took chillies for indigestion,
but neither Dr. Eddowes nor the patient had been able to ascertain
that the ingestion of any particular condiment or food had any influence
in the causation of the eruption.
The patient was now practically never free from the disease. She
described the lesions as coming on with little hard isolated lumps under
the skin, which were about the size of a pea or bean and very irritable.
The redness and oedema appeared later, and were apparently accom¬
panied by a feeling of heat, tension, and smarting rather than of true
itching. No factitious urticaria could be produced by scratching.
38
although a little excessive congestion followed the irritation of the nail,
but no distinct urticarial wheals had been observed in her case, either
from the disease or from artificial excitement.
The appearance of a patch when the oedema was well established and
the redness at its height was somewhat similar to erythema nodosum,
but it differed from that affection in the history of the case and in
many other respects.
The size and shape of the patches varied greatly, sometimes involv¬
ing nearly the whole of a limb. They caused most distress when they
affected the mouth, throat, or face. Occasionally the eyelids had been
so swollen as to be completely closed for one or two days.
She had had previous attacks of a less urgent character in the
throat and mouth, with and without swelling of the lips and tongue.
The patient gave the following history on the occasion when first
seen by Dr. Law. She woke up suddenly in the early morning with
the feeling of a lamp at the back of the throat, which she was unable
to dislodge by coughing or swallowing. There was great discomfort
and uneasiness, but little or no pain. She noticed, by means of a
looking-glass, that her throat was so much swollen that the uvula
was in contact with the two sides of her mouth. The difficulty in
swallowing greatly increased, and the sense of suffocation became so
oppressive that the patient was very nervous and alarmed through the
fear of impending death. This critical condition lasted for two or
three hours, when the symptoms gradually subsided and the swelling
rapidly disappeared.
On examination a few hours later an oedematous swelling of the
uvula was found with slight serous infiltration of the left half of the
palate and of the left aryepiglottic fold. The left ventricular band
appeared to be more prominent and congested than the one on the
opposite side. The neighbouring parts of the pharynx were only
slightly hyperaemic, and a few enlarged follicles were visible upon the
posterior pharyngeal wall. There was increased redness of the epi¬
glottis and laryngeal mucous membrane, but the vocal cords moved
freely, and, with the exception of streaky redness, were normal in
appearance.
No active treatment was called for, as the urgent throat sym¬
ptoms had evidently already passed away. Dr. Eddowes stated
that the following internal and local remedies had been employed
with only questionable advantage:—arsenic, quinine, ichthyol, colchi-
89
cam, iron, citrate and chlorate of potash, bromide of potassium,
creoline, tinctare of iodine, and solntion of alum.
Brocq, Biehl, Unna, Crocker, Pringle, and others had reported
similar cases in which the tongue or mucous surfaces of the eye,
throat, or stomach were affected by the disease. Striibing had also
probably described the same disease as an angioneurotic oedema.
The Pbbsident observed that these cases were excessively rare.
He had been watching a case for some time, but bad never been able
to see it while the local swellings were visible. In that case the
swellings came on without warning on the soft palate, and lasted for a
few minutes or sometimes for an hour. The condition had been well
described by Strubing as angioneurotic oedema.
Dr. Hali. suggest^ that 10 or 20 per cent, solution of cocaine
might afford temporary relief if applied to the swellings directly they
appeared.
Mr. BuTLin objected to the term ** Quincke’s disease ” as being
altogether unknown. These temporary oedematous swellings, when
causing obstruction to the respiration, might very well be overcome by
means of intubation.
Mr. Bopbb mentioned a case in which oedematous swellings of
the lips, tongue, soft palate, arms and back occurred to an old
lady of seventy-five without any warning. The swellings were of
short duration, and seemed to c^l for no treatment.
Dr. Law, in reply, had not been able to find any reference to
Quincke’s disease ” as such in any text-book, but a case was reported
in the ‘ Archiv fur Laiyngologie.’
Lupus of Pharinx and Larynx.
The President showed the little girl affected with lupus of the
pharynx and larynx whom he had demonstrated at the April meeting
1894 (* Proceedings,* p. 103). The treatment then proposed, viz.
curetting and application of lactic acid locally with the internal
administration of cod-liver oil and arsenic, had been carried out
methodically in such a way that the local applications had been
limited to the pharynx, and the larynx had not been treated at all
locally. Nevertheless a very general improvement had taken place,
also in the condition of the larynx. The patches of lupus from the
gums, palate, and pharynx had entirely disappeared; the larynx was
much less ulcerated, though still swollen, and the previously aphonic
voice was now loud and strong. The case offered a fresh illustration
of the fact that certain cases of lupus will get better or even tempo¬
rarily well under almost any medication.
40
Db. Hbnnio’s Oil Studies of Lartnoeal and Nasal Disease.
The President also demonstrated Dr. Arthur Hennig's (of Konigs*
berg) admirable studies in oil for teaching purposes of normal and
diseased conditions of the upper air-passages. These studies represented
forty illustrations very considerably enlarged from nature. It was
mentioned that the artist greatly wished that these paintings should
be reproduced for teaching purposes, but that the great cost of such
reproductions stood in the way, and that it would only be possible to
take the matter into serious consideration if a large number, at least
300 subscribers were found.
Dr. ScANBS Spicer proposed a vote of thanks to Dr. Arthur
Hennig for the trouble he had taken to bring the pictures to the
notice of the Society, and expressed the opinion that they should be
reproduced if possible for teaching purposes.
Mr. Cbesswell Baber seconded the resolution, which was carried
by acclamation.
At the invitation of the President, several members offered criticisms
on the drawings.
Mr. Cresswell Baber, whilst complimenting Dr. Hennig on some
of his excellent paintings, thought that the representations of the nasal
cavities as seen from the front were not satisfactory, owing to their not
showing the parts in perspective. In the drawings made and published
by him some years ago this point was specially attended to, and
therefore, in his opinion, they gave a true idea of what was actually
seen. Dr. Hennig’s drawings also did not show the neck of the middle
turbinated body.
Dr. Ball did not think that the reproduction of some of the com¬
moner affections would be worth while, especially as they were by no
means typical.
Dr. Hill pointed out that in these pictures, as in many of the text¬
books, the post-rhinoscopic inn^e was represented in the ideal manner,
but not as it was actually seen. The upper turbinal was, as a rule,
quite invisible, while the position of the middle turbinal was quite
inaccurate.
Dr. Bronnbr observed that for teaching pui'poses a good set of
typical conditions was required.
The President undertook to convey these criticisms to the artist.
The method of reproduction proposed was chromo-lithography, but the
cost as at present estimated was almost prohibitive. It was intended by
the artist that the pictures should be made useful for teaching pur¬
poses by means of pieces of frosted glass which could be laid over the
pictures, and variations sketched upon the glass by means of coloured
chalks.
41
Radical Cobb of Obstinate Suppuration op the Antrum op
Highmore, combined with Intra-nasal and Intra-antral
Polypi.
Dr.^ScANBS Spicer showed P. H—, lawyer^s clerk, set. 80. Sent
by Dr. J. Q. Bown in aatnma, 1890, for foetid suppuration in the
right nasal cavity. On examination polypi were seen in region of
ostium maxillare, and were removed. Suppuration continued, and
antral empyema was diaguosed, and confirmed by transillumination.
On December 27th, 1890, the antrum was tapped through the socket
of a tooth which had been previously removed, and a gold tube fitted
to a plate by Mr. Boyd Wallis. Irrigation was practised, and there
was temporarily much improvement. After some months the tube
caused pain and irritation, and had to be several times altered, and
finally removed altogether, and purulent nasal discharge became worse
than ever. In May, 1892, patient desired to have something more
done, and he was operated on in St. Mary^s Hospital by a large
opening made with chisel and mallet through the canine fossa into the
antrum, and its cavity was well curetted, much^thickened granulation
tissue being removed. Subsequently drainage apparatus was used,
lead spigots, vulcanite plugs, rubber drainage-tubes, and Ellises tube.
All these from time to time caused local pain, and the suppuration,
though at first less, finally relapsed to its former condition. In April,
1893, the drainage of the antrum being still deficient, patient was
advised to have a further operation, in which an attempt should be
made to render drainage better. With this view the opening in the
anterior wall was opened up and enlarged, the cavity again curetted,
and a large naso-antral opening made from inferior meatus (well behind
entrance of nasal duct) into antrum with a Krause's trocar, the index
finger being introduced into antrum through anterior opening to act as a
guard. The antrum was flushed out with boracic lotion, and was then
tightly packed with creolin gauze, and especially so as to distend the
bucco-aiitral opening. After forty-eight hours the gauze was removed,
and from that time irrigation practised thrice daily. No drainage appa¬
ratus was used. The patient was directed to blow frequently from nose
through antrum to mouth, and vice versa, so as to move on any secre¬
tions tending to loiter in antral recess, and also to force boracic
lotion from mouth through antrum into nose. The result of this was
that the discharge gradually subsided, and soon ceased entirely. The
42
patient had now seen no pus for eighteen months, and at the present
time the nasal cavity looked healthy, and he could blow air through
the antrum from mouth to nose or vice versa.
Dr. Scanes Spicer also showed the debris which he had curetted
from other cases of chronic maxillary empyema, and which were.seen
to consist of fungous granulation tissue, mucus polypi, cholesteatoma*
tons cysts, and in one case a portion of necrosed ethmoid.
He advocated the adoption of the double opening into the antrum
in chronic cases in which there was reason to suspect the above
complications, in which drainage was defective, and in which drainage
apparatus caused irritation, or in which there was marked intra^nasal
disease, under which category all his cases heretofore had come, for
none of them had yielded to the simple method of alveolar puncture
and drainage-tube.
Mr. Bvtlin had had several such cases. He generally scraped the
antrum, but called attention to the necessity for making the opening
in the floor and not at the side of that cavity in order to ensure
perfect drainage.
Dr. Bves doubted whether such operations were necessary in every
case. They caused considerable deformity, and many cases could be
simply relieved by removal of a tooth. The large openings were
often an annoyance to patients who were smokers.
Dr. Dundas Grant had been able to cure a few cases without
operation. He thought that the extent of the operation must depend
upon the condition of the lining membrane of tbe antrum. He had
obtained good results in patients who possessed a good set of front
teeth by the use of Krause’s trocar.
Dr. Spicbb had not tried dry treatment in these cases. In the
present case all simpler methods had ’already been tried and found
unsuccessful.
Eecderent^’ Tdmouk at the Back of the Tongue ; Operation,
June, 1889.
Mr. Butlin showed this patient, whose case is described in the
f Clinical Transactions^ for 1889.
The tumour stood up in front of the epiglottis; it was cut off with
a galvano-cautery loop in June, 1889. Its structure was similar to
that of the thyroid gland.
At present there was. a prominent lump far back in the left half of
the tongue.
43
Hoauseness confined to the Loweb Beoistee of the Voice.
Dr, Dundas Grant showed a patient^ Miss D—, set. 30, a
school teacher, who had for about three years been the subject of
hoarseness characterised by a “bleating” or "croaking” vibration
accompanying her ordinary speaking voice and her singing in the
lower part of its range. This entirely disappeared above the note
^ where, when she sang softly, the change of register occurred,
and the tones became perfectly clear. On laryngoscopic examination
the vocal cords were seen to approximate imperfectly in their posterior
thirds during the utterance of the lower notes. (On subsequent more
close observation the inner portions of the cords were seen to be
thrown into loose visible vibrations.) During the emission of the
higher notes the cords appeared to act normally. Dr. Grant attri¬
buted the condition to inactivity of a portion of the internal thyro¬
arytenoid muscle. The chest was normal, and the patient, though
spare, was fairly muscular. He had recommended instruction in the
use of the breath under Mrs. Emil Behnke.
The Fbesident pointed out that the condition was one of diplo-
phonia. So long as all the elastic fibres in the cords were acting they
might act unequally, and an imperfect tone was produced; but if only
certain bundles of fibres were acting they might, within their own
range, produce a clear tone as in Dr. Grant’s case. He advised rest
to the voice, electric stimulation both inside and outside the larynx,
and a course of strychnia.
PiXA'i'ioN OP Righi' Cord.
Dr. WiLLCOCKS showed a patient, B. M—, a boatman, who had
had a severe blow on nose about thirteen weeks ago, and felt as if
his backbone was broken in pieces. Eight weeks after he woke up
one night complaining of his throat. On speaking he noticed his
voice was hoarse. Since then he had got no better and no worse.
Present condition .—Bight cord somewhat oblique and immoveable.
Bight arytsenoid cartilage prominent. No evidence of intra-thoracic
tumour. No history of syphilis.
44
Dr. Bsoknes and Mr. Stewart expressed the opinion that the case
was one of perichondritis, causing mechanical interference with the
movement of the cord.
The Annual Dinner of the Sociefy was held after the meeting at the
Cafd Royale. The President occupied the Chair, and was supported
by Sir Bussell Beynolds, President of the Boyal College of Physicians,
the President of the Pathological Society, Sir George Johnson, Senor
Manuel Garcia, Sir W. McCormac, Dr. Ord, and a large gathering of
members and guests.
PEOCEBDINGS
or THB
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinaet Meeting, February \Zth, 1896.
Felix Semon, M.D., P.E.C.P., President, in the Chair.
ScANES Spicbb, M.D., ■) Secretaries
W. R. H. Stewart, F.E.C.S., J secretaries.
Present—23 Members and 8 visitors.
The minutes of the previous meeting were read and confirmed.
Before the usual business of the meeting, the President referred in
feeling terms to the loss laryngology had sustained by the death of
Professor Gottstein of Breslau.
Mr. Arthur Reginald Poulter, M.R.C.S., L.E.C.P., was called to
the table, and admitted a member of the Society by the President.
The following candidates were proposed for election :
George C. Cathcart, M.B., C.M., London.
Alec H. Gordon, M.B., B.C., London.
Bruce Hamilton, M.R.C.S., L.E.C.P., London.
Percy Jakins, M.E.C.S., London.
T. E. Foster Macgeagh, M.D., M.R.C.S., London.
G. Calwall Stephen, M.D., L.E.C.P., London.
The following gentlemen were nominated as a committee to carry
out the arrangements for the entertainment of the Laryngological
Section of the British Medical Association in July:—^The President,
the Secretaries, Dr. St. Clair Thomson, Dr. Hill.
The President stated that the subject for discussion at the next
Ordinary Meeting was the diagnosis and treatment of empyema of the
maxillary sinus, and that an invitation would be sent to the members
of the Odontological Society, asking them to be present and to join
in the discussion.
first series—VOL. II.
5
46
A Case tor Diagnosis, whether Tuberculous, Malignant, or
Syphilitic.
The President asked the opiniou of the members on the following
case. J. E—, set. 55, a porter, came to the Throat Department of
St. Thomas's Hospital on September 28th, 1894, complaining of
hoarseness, which commenced fourteen days previously, a slight
cough which came on after the hoarseness, with dryness, and a tickling
sensation in the throat, causing frequent ** hawking; expectoration
scanty; no blood; complains of drawing pain at left apex. Family
history good. Past history good. No history of syphilis.
Examination.—Fauces and pharynx congested. Posterior pharyn¬
geal wall granular, with distended veins and adherent secretion.
Larynx: considerable congestion of larynx, and some swelling of
ventricular bands.
November 9th.—Ventricular bands more swollen, some ulceration
of both vocal cords. Was put on iodide of potassium, grs. v, three
times a day.
December 21st.—More ulceration spreading to interarytsenoid
commissure. Patient says he feels as if he were going to be choked.
Complains of pain on swallowing.
February 8th.—^Voice slightly improved; has been taking Pot.
lodidi three months. Cough worse, and has pain in right side in
region of hyoid bone on deglutition. Larynx: ventricular bands
irregularly swollen; ulceration on posterior end on the right side.
Vocal cords: posterior end of right side considerably thickened; left
side similar, though in a less degree. Movements free both sides.
Distinct superficial ulceration in the considerably tumefied inter-
arytsnoid fold. Chest at first normal, but on February 8th was in
the following condition. Eesonance slightly impaired, but equal.
Breath-sounds, right apex, harsh, with a few rllles; left apex, the
r&les more numerous; breath-sounds almost inaudible over rest of
lung. No loss of flesh. No night sweats. No hemoptysis. Spfutum:
no tubercle bacilli found after repeated examination.
Dr. Cbbsswell Baber thought it was a case of syphilis, and
inquired if large doses of iodide of potassium had been given.
Dr. Dundas Gbant thought it was a case of tubercle of the dry
warty kind. Had seen a case of this sort, in which there were no
47
physical chest signs during life, but post mortem pulmonary tubercle
had been discovered. He thought there was too much movement for
epithelioma. Suggested curetting and lactic acid applications.
Dr. Percy Kidd had seen two or three cases where the disease was
situated in the angle formed by the vocal cords and arytmnoids, which
had proved to be tubercle.
Mr. Charters Stmonds had one in which the vocal cords were
fringed with growths in a tuberculous case.
Dr. Hill asked if the use of tuberculin was justifiable in such a
case for the purpose of diagnosis.
The President, in reply, stated that he had used large doses of
iodide of potassium with no result. He had given up the use of
tuberculin, but considered it quite justifiable for the purpose of dia¬
gnosis, and also the removal of a portion of the growth for micro¬
scopic investigation.
Pathological Specimen of Adenoid Growths and one op
Perforation op the Nasal Septum.
Dr. Kanthack showed these specimens, and pointed out that the
growths were not in the position usually depicted in books, but were
situated on the walls of the naso-pbarynx and around Luschka’s tonsil.
The President in the name of the Society expressed their indebted¬
ness to Dr. Kanthack for bringing before them such excellent patho¬
logical specimens.
Drs. Cresswell Baber and Dundas Grant suggested that if Dr.
Kanthack was able to obtain another specimen of adenoid growths,
the anterior wall should be removed so as to give a view from the
front.
Dr. Ball thought the perforation in the nasal septum was a case
of simple perforating ulcer, as the voice was not affected.
Dr. Dundas Grant suggested that frequent epistaxis was dia¬
gnostic of simple ulcer.
Dr. Tilley quoted a case where a perforation occurred without local
symptoms during an attack of typhoid fever.
Dr. Law had a case of perforation caused by the removal of a cai'ti-
laginous spur by means of the galvano-cautery.
Dr. Cresswell Baber frequently removed cartilaginous spurs by the
galvano-cautery, and had never seen a perforation follow; he always
attacked the apex of the spur.
Dr. ScANES Spicer had never seen perforation follow the applica¬
tion of the galvano-cautery to the spur; he thought Dr. Kanthack’s
case was one of simple ulcer from the shape.
48
Case illustrating Various Morbid Conditions op the Nose
AND Ears.
Dr. E. Law sliowed this case. A patient, set. 26, came to the London
Throat Hospital complaining of deafness. Had suffered from ear and
eye troubles during childhood, and had contracted syphilis four years
ago. Examination showed general catarrhal conditions of the upper
air-passages—deflected nasal septum—a papillomatous-looking growth
from the anterior third of the left inferior turbinate bone, extensive
polypoid proliferation of the left middle turbinate, enlarged Luschka^s
tonsil, sequelae of otitis media superior (perforation cicatrices, &c.},
hyperostosis of external auditory meatus, eczema of both auricles, and
various affections of the eyes. Dr. Law asked if the papillomatous-
looking growth was a true papilloma, or a simple enlargement of the
anterior extremity of the turbinate.
Dr. Peoleb considered this a case of papilloma.
Mr. Stewabt and Dr. Cbesswell Babbb thought it was a simple
hypertrophic condition.
Mr. Santi, Dr. Hill, and Dr. Scakes Spicer also thought it was not
papillomatous.
Dr. Law, in reply, stated that he would remove a portion and have
it microscopically examined.
Laryngeal Stenosis, probably Lupus.
Case shown by Mr. Parker. M. D—, a girl set. 16, first suffered
from hoarseness and loss of voice a year and eight months ago, was
treated by Dr. Macdonald at the Throat Hospital, Golden Square,
and soon got quite well for the time, but has since then lost her voice
off and on. Present attack followed influenza eight weeks ago, became
steadily worse, causing complete aphonia and much dyspnoea until
February 11th. The aphonia and dyspnoea were now very marked,
there was loss of flesh and general debility.
Examination .—Distinct scars on the soft palate, and considerable loss
of substance of the epiglottis were found ; the aryepiglottidean folds
were much distorted, and covered by a number of small pale irregular
nodules. The arytaenoids, seen with great difficulty, were swollen and
oedematous. Cords and ventricular bands could not be made out; base
49
of tongue was covered with small nodules. On account of the scars on
soft palate was put on iodide of potassium; has been taking it for one
monthingr. vdoses,but the condition of the partshas remained unaltered.
Family history good. No suggestion of tuberculosis or syphilis,
congenital or acquired. Lungs normal.
Mr. Santi thought the case more like syphilis than lupus.
Mr. Milsom Bees considered it a case of lupus, and very like some
cases he had seen treated with tuberculin.
Mr. Parker, in reply, said he would try lactic acid applications.
The President suggested that arsenic should he given internally.
Anterior Nasal Stenosis from Cicatricial Contraction after
Ulceration, with Consecutive Chronic Laryngitis.
Dr. ScANES Spicer showed a patient, Mrs. I. K —, set. 52, a
monthly nurse, who contracted "blood-poisoning^’ two years ago
while attending a case. She had suffered from glandular en¬
largements, rash, frontal headaches, and showed scars on arms and
legs resembling those left by rnpial sores, and ulceration about
anterior nares and vestibula narium. These latter had healed, but had
been followed by such narrowing as to give rise to subjective dis¬
tress. Mouth breathing and obstinate laryngitis with thickening of
the posterior wall of the larynx. Suggestions were invited as to the
treatment of the cicatricial stenosis, which did not appear to the ex¬
hibitor to be capable of material improvement.
Mr. Stewart referred to a case he had shown at a previous meet¬
ing, where the alse of the nose were completely drawn in and the throat
was secondarily affected; had tried all sorts of forms of dilatation with¬
out success, but the patient was kept fairly comfortable by the use of
menthol. Thought Dr. Spicer’s case was one of syphilis, did not
think any operation would be successful.
Dr. MiiiSOM Bees and Mr. Stmonds thought Dr. Spicer’s case was
syphilitic, as she had nodes on legs and arms.
The President suggested iodide of potassium and mercurial in¬
unction ; he thought an operation might be successful if the stenosis
was incised, pyoktanin applied, and the wound stuffed with slips of
iodoform gauze. He drew attention to the fact that in cases of
syphilis of the upper air-passages it was peculiar that the disease
attacked intensely one part and passed quite over another.
In reply, Dr. Soanes Spicer thought that the laryngitis presented no
syphilitic characters, but was of that form seen in simple catarrbal
conditions.
50
Paralisis op the Left Vocal Coed.
This was shown by Mr. Charters Stmonds. J. C—> set. 40, a
butcher sent to Guy's Hospital by Dr. Dodwell, complaining of altera*
tion in his voice. Up to October, 1894, resided in California; at the
commencement of that month, while still there, he caught a cold”
and had a severe chill,” but does not seem to have had any cough or
even nasal catarrh. Woke up one morning with altered voice as it
is now. Had no previous hoarseness. No joint pains, though says
he has had rheumatism. No history of injury or debauch.
Family history excellent. Married with healthy family. Declares
he never had a day's illness in his life, and now feels perfectly well.
He is a strong-looking, healthy man. Voice exactly the same as when
first noticed to be different from the normal. No dysphagia, but he
cannot drink large gulps of anything—all his fluid he is obliged to
sip. Eyesight good, pupil reflexes normal; knee-jerks normal. Can
stand perfectly with eyes shut. Chest normal. No dulness. No
dyspnoea. When first seen, on January 25tb, mucous membrane of
larynx healthy. No swelling anywhere. The left cord fixed and
moveable, quite on the middle line. The cord itself appeared quite
healthy. The right moved well, and was in all respects normal.
The voice is somewhat gruff, but is loud and fairly strong. There
is no evidence of perichondritis nor of intra-thoracic disease.
The case seems to be one of paralysis of the cord without a
discoverable cause. May it be an early stage of some central disease ?
Dr. Milsom Bees thought the case was one of simple rheumatic
paralysis from cold.
Dr. ScANEs Spicer considered the paralysis due to intra-thoracic
trouble, as there was no abnormality in the larynx.
Mr. Symonds, in reply, stated that he had not examined the chest
himself, but would do so. It had been examined by his clinical
assistant and pronounced normal.
Paralysis op Left Vocal Cord after Injury.
This case was shown by Mr. Symonds. L. H—, set. 56, came to
Guy's Hospital, January 11th, 1895. One week before was looking
after a steam elevator, which was above him. As he was speaking to
some one below it came down, crushing him severely about the upper
61
part of the chest. Does not think his neck was hurt. Immediately on
recovering he found his voice had disappeared. I^o haemorrhage. No
pain. No dysphagia. No history of syphilis, phthisis, or rheuma¬
tism.
Examination .—Left cord red and fixed on phonation, not quite in
middle line, nearer adduction than abduction. The arytsenoid did not
move at all. Nothing found in chest to account for symptoms. No
sign of external injury. Bight cord normal. On January 25th the
left cord has approached the middle line and occupied a mid position ;
is immoveable. Some dysphagia the last ten days.
Eebruary 8th.—Larynx remains the same. A full-sized bougie
passed is caught at the cricoid, evidently from muscular spasm.
The man speaks in a whisper, but can copy a low laryngeal note;
the aphonia is presumed to be nervous. No sign of aneurism or
malignant disease.
Mr. Stmokds was disposed to think that the paralysis may have
existed before the injury.
The Pebsidbnt said it was difficult to say if it was caused by the
injury, but as the position of the cord had altered at different times
he would say yes. He considered the aphonia to be neurotic.
Pachydermia Labyngis.
Mr. Symohds again showed the case of Mr. H—. The swelling on
the left cord was still present. It has gradually diminished in size;
the nodular character has nearly all disappeared. At the present time
the swelling is more marked posteriorly, where it is abrupt and
elevated while in front it is flatter and smoother. The cord itself is
fairly normal, and the opposite side is free. The cord moves freely.
The voice is strong and clear for the most part, but at times is gruff.
The patient at first took iodide of potassium, but has for some weeks
taken mercury. No local treatment beyond rest has been employed.
Drawings illustrating the various stages, which had been made by
Dr. Waggett, were shown.
Dr. Wabkeb said this case had more or less redness of the throat
for some time, but this had increased considerably two days ago.
Some years ago he suffered from granular pharyngitis.
Dr. Waggett suggested absolute silence as treatment, and men¬
tioned a case he had seen in conjunction with the President which
under this treatment had greatly improved; Leiter’s tubes and iodide
52
of potassium had also been used. He thought in Dr. Sjmonds* case
the vocal cords had become much redder, and over an increased area.
Pachydermia Laryngis.
This case was shown by Dr. Tilley. Mrs. S —, set. 52, came to
the London Throat Hospital complaining of a feeling of suffocation
in the throat, more especially at night, occasional darting pain in left
ear, and hoarseness. Complaint came on twenty years ago, six months
before a confinement, and some sixteen years after coming to Eng¬
land—was horn in Germany. Has been twice married ; first husband
died of cancer, second husband had sufl'ered for five years from ulcers
on the legs. Has drunk beer freely since childhood, and latterly has
taken in addition a half quartern of rum when the suffocating feelings
come on, which is pretty frequently. Had tonsils removed at Middlesex
Hospital two years ago. At London Throat Hospital some varicose
veins at the base of the tongue were burnt, and gave great relief for
two or three months.
Hzamination. —Vocal cord congested and thickened; outward move¬
ments limited. Shreds of dry adherent mucus in various parts of larynx.
In interarytsenoid fold is a large and well-marked swelling of somewhat
triangular outline; traversing this mass in a direction from above down¬
wards is a fissure, The points of interest are the rarity of the affection
in women ; the important setiological factor of alcohol; the position
of the disease in the interarytsenoid fold; the fissure through the
growth, which probably accounted for the pain; and the slight immo¬
bility of the vocal cords, probably due to chronic inflammation.
Dr. Waggbtt had seen the case at the London Throat Hospital,
had painted it regularly with perchloride of iron, and the voice was
quite recovered for three weeks.
The President said these cases were extremely rare here, but very
common in Vienna, and in answer to Dr. Law attributed this fre¬
quency to beer-drinking-
Mr. Him. supposed that attrition must be present in pachydermia.
PB0CEBDING8
OV THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Ordinary Meeting, March 13th, 1895.
Felix Sbmon, M.D., F.E.C.P., President, in the Chair.
Soanes Spicer, M.D., ) c a •
W. E. H. Stewart, F.E.O.S., ) Secretaries.
Present—19 Members and 10 visitors.
The minutes of the previous meeting were read and confirmed.
The following gentlemen were elected members of the Society:
George 0. Cathcart, M.B., C.M., London.
Alex. H, Gordon, M.B., B.C., London.
Bruce Hamilton, M.E.O.S., L.E.C.P., London.
Percy Jakins, M.E,C.S., London.
T. E, Poster Macgeagh, M.D., M.E.C.S., London.
G. Calwall Stephen, M.D., L.E.C.P., London.
The following candidate was proposed for election:
Arthur Sandford, M.D., M.Oh., Cork, Ireland.
Discussion on the Diagnosis and Treatment op Empyema of
THE Antrum of Highmore.
The President in the name of the Society offered a cordial welcome
to the members of the Odontological Society present, and stated that,
although the diagnosis and treatment of empyema of the antrum had
of late years been frequently discussed, yet at a recent meeting of the
Laryngological Society such a difference of experience with r^ard
to the results of treatment and to the methods employed had become
apparent, that the Council of the Society had considered it desirable to
choose this subject for general discussion. What was required was not
any academic discussion of the whole subject of empyema of the
maxillary sinus, but brief and practical statements as to the methods
employed by various observers, and as to the final results they had
first series—^YOL. II. 6
54
obtained, together with such points of diagnostic importance as
they bad found of particular value. He invited remarks to be made
in this spirit.
Dr. Adolfh Beonnbe thought that one ought to distii^ish be¬
tween the mild and severe cases. The former were mostly due to
nasal disease, and could be cured by treatment through the middle or
inferior meatus, as suggested by ^kulicz. If syringing with boric
acid did not effect a cure, the insufflation of powder was to be recom¬
mended. At first boric acid and iodoform should be used, and then the
iodoform should be discontinued and aristol be used. Iodoform often
caused abnormal growth of granulation tissue. If a diseased tooth
were found, this should be removed, and the antrum opened through
the alveolus. The patient could syringe or blow in powder through a
small eustachian catheter. In cases where there was a polypus or much
granulation tissue the canine fossa should be opened and the finger
introduced, and if necessary the antrum scraped with a sharp spoon.
It was not always necessary to introduce through and keep a tube in
the alveolar process when this was opened. In answer to the President
he stated that 40 per cent, of his cases were cured, the length of time
taken being under five or six months. In answer to Dr. Spicer, he
stated that the deformities caused by a large opening in the canine
fossa were a falling in of the face, which tWs did not present
a symmetrical appearance, and the growth in a wrong direction of
the teeth.
Dr. Gebvillb MacDonald maintained that it was the custom to
trust for diagnosis too implicitly on the replacement of pus in the
middle meatus on bending forward the head. He had seen at least a
dozen cases, some of them associated with antrum disease, others not,
where suppuration in the frontal sinus produced the same phenomenon.
He likened the condition of the latter case to a narrow-necked bottle,
which, held in an inverted position, would not allow its contents to
escape without ocaasionally being placed on its side to allow the air to
enter. As far as treatment was concerned, and his remarks did not
refer to cases with co-existent nose disease, he believed that the explo¬
ratory opening through the alveolar border, and drainage with the
smallest size drainage-tube, were sufflcient for the cure of recent cases,
i. e. of not more than six months’ duration. In those of longer exist¬
ence he had occasionally found it necessary to make the large opening
for the insertion of the finger, and after scraping away granulations, &c.,
he had always secured a cure. But in speaking of cure he would have
it undertsood that he did not mean more than the cessation of suppu¬
ration, believing that chronic catarrh frequently remained in spite of
all endeavours; and he maintained that such a catarrh would often
make it desirable that some form of drainage should be permanently
secured.
A letter was read from Dr. Ceesswbll Babbe, who stated that in
his opinion transillumination was a valuable aid in the dia^osis .of
empyema of the antrum. He attached special importance to the
illumination of the outer half of the infra-orbital region, this being
the part least accessible to rays transmitted through the nose
and not through the antral cavity. Certainty of diagnosis could
55
only be arrived at by flushing out the antrum through the socket
of a tooth or other opening, or aspirating through the inferior nasal
meatus after the method of Moritz Schmidt. With regard to treatment,
he always tried the alveolar method,first allowing the patient to syringe
out himself with an antiseptic solution through a metallic eustachian
catheter attached to a Higginson’s syringe; and only when this method
failed to arrest discharge did he resort to a larger opening in the same
position or though the canine fossa for the purpose of exploration, and
if necessary scraping and packing the cavity.
Dr. William Hill read part of a letter from his colleague, Mr.
Ernest Lane, who had been associated with him in the treatment of
several cases of antral disease at St. Mary’s Hospital, and who was
.unavoidably prevented from taking part in the discussion. Mr. Lane
wrote, “ From the experience gained, and on reviewing our cases, 1
am led to the conclusion that the most appropriate and rational
method of treatment is that of opening the antrum above the alveolar
process through the canine fossa, and thoroughly clearing out the
cavity with Yolckmann’s spoon or other appropriate instrument.
Bearing in mind the fact that in the majority of our cases—six out
of seven—the walls of the maxillary antrum were covered with either
soft and polypoid granulations or with genuine polypi, in addition to
caseous debris, it seems to me to be an essential point in the treat¬
ment that the antrum should be thoroughly inspected, digitally
explored, and radically treated by an adequate opening at a dependent
part of the cavity, through which efficient drainage can afterwards be
carried out.” Dr. Hill, whilst endorsing Mr. Lane’s remarks,
explained that in the cases referred to the ordinary method of
drainage and syringing, by a hole drilled through the socket a
tooth, had been first carried out for many months, and in one case for
two years, with most unsatisfactory results. He felt certain that the
morbid contents of the antral cavities in these cases could never have
been cured by the application of any lotions or powders at present in
surgical use. It was as futile to expect such a result in the case of
antral polypi and granulomata as in the case of similar disease
in the nose and ear. Instrumental removal was the only rational
treatment. If a case with obvious antral disease associated
with nasal polypi, granulations about the uncinate body, came
under his care, and was unrelieved after two months’ treatment
by the ordinary alveolar method, he would have no hesitation in
recommending the thorough exploration of the antrum through a
large opening in the canine fossa. He believed an additional opening
in the nasal cavity, as recommended by Dr. Spicer, was often useful,
especially when the ostium maxillare was blocked by an hypertrophied
granular condition of the uncinate process. The radical operation he
advocated was devoid of danger; be had never seen, any deformity
result. The oedema and pain in the cheek occasionally observed rarely
lasted more than a week or two; certainly in one patient, an early case,
the nasal duct had been slightly injured, either by a too vigorous
curetting of the nasal wall of the antrum, or else from the counter
opening into the nose having been made too far forward.
In answer to a question from the President as to the proportion
56
of cases in wMch the canine fossa operation had been resorted to.
Dr. Hill admitted that his experience had not been large, but that
the seven cases operated on radically had been very marked ones,
and due to nasal dmease; in three others he had been content with the
alveolar method, but inasmuch as they had not long remained under
observation he could only say they were relieved. Perhaps it was
accidental that he had seen so large a proportion of cases in which the
antrum was choked by growths, and which therefore could only be
treated by a large opening; but it might be that he had failed to
attach much importance, and even failed to diagnose the milder cases
which had been described by members of the Society as yielding so
readily to applications syringed into the cavity through a small hole.
Mr. Walsham said he considered that in empyema of the antrum,
as elsewhere, the only absolute sign was the actual detection of pus
on exploration. He, however, held that transillumination was of
much value, and had practised it as a matter of routine in all cases in
which pus in the antrum was suspected. In some cases in which pus
had been detected, there had been merely a shadow below the eyelid
of the affected side, the rest of the face lighting up. In two or three
instances of what turned out subsequently to 1^ empyema of the
antrum no pus could be discovered in the nose, the only symptom
calling attention to the affection having been intermittent fcetor, and
this in one instance was only evident to the patient himseli A
marked dulness to percussion on the affected side has been observed
in a few cases. He had practised exploration through the inferior
meatus, an empty alveolus, and the canine fossa. The first method
he considered a useful one in nervous patients, since the puncture
could be made under cocaine. As he was accustomed, however, to
drain either through an alveolus or canine fossa, he preferred as a
rule to puncture at one of these situations under gas, as the one
operation then sufficed. Of the two last methods, he only punctured
through an alveolus when a tooth was absent or carious. He would
on no account remove a sound tooth for the purpose. He generally
succeeded b^ merely washing out, leaving the small spiral tube in$itu
during the intervals. In exceptional cases he had had to make a
larger opening through the canine fossa, introduce his finger, and scrape
out the cavity. In answer to Dr. Hill, he said the material removed
was granulation-like matter. He had not had to remove anything
like true polypi from the cavity. He had met with an instance in his
own practice where the large opening thus made had not closed, but
remained as a discharging sinus, and he had seen another case in
which such an opening had been made by a distinguished rhinologist
several years previouslv, which had also remained open and continued
to discharge. He wisned to know the experience of others on the
subject. He had not found patients had been troubled, where the
spiral tube had been used either in an alveolus or in the canine fossa,
by food passing into the antrum. Dr. Hill said that so far from
having to complain of the hole in the canine fossa remaining patent,
the difficulty in his experience had been to prevent it healing too soon.
Dr. Clreville Macdonald, on the other hand, stated that in his ex¬
perience the wound never healed.
57
Dr. Dttkdas G-bant a^eed with Dr. Greville Macdonald that the
presence of muco-pus in the middle meatus was in itself quite insuffi¬
cient evidence on which to found a diagnosis of empyema of the antrum.
He considered transillumination of the greatest value; by its means
we could sometimes eliminate antrum empyema absolutely from
the presence of translucency, and thus prevent unnecessary operative
interference. Opacity was not of equally positive significance. He
relied chiefiiy on the exploratory puncture and irrigation of the
antrum by the introduction of Lichtwitz’s fine trocar and cannula
through the outer wall of the inferior meatus. The revelation of
pus by this method was very convincing to the patient, the temporary
comfort obtained inducing greater readiness to undergo further re¬
medial treatment. He had not found irrigation through the
natural orifice, as Garel had described, at all easy, even when he
employed a cannula of Garel’s own pattern. He thought it of great
importance to diagnose the cause if possible. He attributed the
disease to nasal causes in the absence of the characteristic dental
foBtor, and of obvious dental disease, especially if the affection ap¬
peared to ordinate in a well-marked coryza, or there were some
other intra-nasal cause, such as a frontal sinusitis. (He had a case
of frontal sinus suppuration without at first any antral disease.
The nasal suppuration persisted in Spite of the apparent cure of the
frontal condition. On re-investigating the antrum a secondary sup¬
puration of that cavity was detected, which yielded readily to
intemasal treatment by means of Krause’s trocar.) In presence
of a diseased tooth in the appropriate position, or with a history of
dental pain preceding the nasal dischage, he would ascribe the
antral empyema to dental disease. His cases had, as a rule, been
treated by the alveolar method, but some by means of a small per¬
foration in the canine fossa. Those cases seemed to have done
best in which a tube was carefully fitted by the dentist, and in which
peroxide of hydrogen was the antiseptic employed. He thought it
possible the alveolar puncture was too exclusively employed, for
althoi^h the opening was in the lowest position it was not used
for drainage, but as an orifice of entrance for the irrigating
fluid. It was a possible source of infection of the antrum by
some of the numerous bacteria inhabiting the mouth; and in those
cases in which pus did not appear at the time of the puncture, but
later on, he thought that in some instances at least this process of
infection would account for it. Alveolar puncture was not always
easy, as the antrum was sometimes very small and situated far
inwards, while the alveolar process extended far outwards. Under
such circumstances it was easily possible to miss the antrum, and he
had seen even in the hands of an experienced operator the puncture
so made that the fluid used for irrigation was extravasated into the
tissues over the antrum, causing a large painful swelling of the
cheek. The ^eat facility with wUch the patient could practise irri¬
gation for himself was the crowning advantage of the alveolar
operation. He had, however, seen several cases in which, after long-
continued alveolar irrigation, a degree of improvement was obtained
which remained stationary. Bapid advance took place when there
58
was superadded the method of treatment bj means of Krause’s
trocar, and still more as soon as the alveolar opening was got
to close. JDr. Grant had by latter method of treatment effected
cures in two cases in a few weeks. The irrigations were practised
thrice, then only twice a week. After each irrigation, air was
blown in to dry out the cavity, and europhen or iodoform insuf¬
flated. He recommended the adoption of this method in cases in
which (1) there was no evidence of dental origin or the presence of
diseased teeth, (2) when the patient could easily attend for irriga¬
tion by skilled hands, or (3) in which the alveolar opening had
been maintained for a long time and the disease had reached a
stationary stage, before resorting to the more extensive operation
through the outer wall of the antrum. In cases where alveolar
puncture was badly borne or unsatisfactory the nasal operation
was certainly advisable.
Dr. ScAiTES Sficeb said that transillumination was in many cases
of decided value and clinched the diagnosis. Belative opacity of one
side combined with positive rhinoscopic and symptomatic evidence
afforded the strongest presumption of antral empyema, and justified ex¬
ploratory puncture. Taken alone, however, transillumination was not
conclusive, since the bones may not be bilaterally symmetrical in
thickness, or the antra in size, shape, and partitioning—circumstances
which must affect the transmission of light through the face. He
attributed more value to the comparison of the areas below the lower
lids than to the lighting up or not of the pupils, which latter phe¬
nomenon appeared to be much less common normally than the former.
On the other hand, bilaterally symmetrical opacity of cheek tissues and
non-iUumination of pupils do not indicate double antral empyema,
nor do they exclude empyema of one or both cavities. In a large
number of healthy subjects such opacity is found. With reference
to the subjective perception of light on transillumination, a dull red
glow may be felt on the healthy side to contrast strongly with the
absence of such on the side of the empyema. This observation was made
for the first time, it is believed, by a former colleague when the latter
was transilluminated four years ago for antral empyema. He had not had
a single cure on treating chronic antral empyema by the usual openings
through the alveolar ridge. He had, with the co-operation of skilled
dentists, for some time made these openings, and had had adapted to
them gold tubes fitted to artificial palates, or to small plates attached
to adjacent teeth. Such tubes (and plates), in his experience, always
caused, sooner or later, irritation, pain, and perpetuated suppuration,
The cases went on washing out for many months or years, and were
not followed by cure. He had treated all his earlier cases in this
way. It is true they were chronic cases, and had well-marked intra-
=nasal disease, polypi, granulations, necrosis, or foetid purulent rhinor-
rhcea. He had therefore been led to look about for some method of
shortening the period of treatment, and that of Dr. Kobertson appeared
to meet some of the indications, in removing the membrane secreting
the pus and in providing freer drainage; but it had the disadvantage
of requiring a mechanical drain. He had therefore conceived the idea
of adding to the canine fossa opening a large one from the inferior
59
nasal meatus, well'behind nasal duct, opening into the antrum with
a Krause’s trocar and cannula, so that the patient could keep the
antrum clear, after curettement, by blowing air from nose through
antrum to mouth and vice versd constantly, and also washing antrum
out frequently by forcing antiseptic washes through from mouth.
This addition largely diminishes the tendency of the bucco-antral
opening to close, though should it do so the passage is easily restored
after cocainisation by incision and dilating forceps, and renders
abolition of drainage apparatus practicable. After curettement
suppuration diminishes jpari paem with contraction of bucco-antral
opening, and often entirely ceases, leaving a small permanent potential
bucco-antral nasal fistula which gives rise to no symptoms, and is
rather to be treasured as an emergency exit for antral secretions, or
safety-valve through which the antrum can be blown out. The objec¬
tions which bad teen raised against this operation were its severity,
that deformily was caused, that chronic toothache followed, and that
smokers could not draw their pipes properly. As to the severity, the
temperature frequently never rose at all, and patients need not usually
be confined to their room more than a few days. In all the cases in
which he had operated by this method (now about twenty) he had
never on any occasion found any approach to either of the other objec¬
tions which had been raised, and he could only regard them as
theoretical as applied to the operation he had described. The real
objections to the operation lay in the time and patience requisite to
effect it thoroughly and without injury to nasal duct, infra-orbital
nerve, or dental nerves, and the impossibility of guaranteeing in
every case that the bucco-antral opening would not require incision
and dilation owing to growing over of soft parts too soon. These
appeared to him small inconveniences compared with the positive
advantages of measuring the period of cure of antral empyema by
weeks instead of by months or years, which was what he claimed
for it.
Dr. Ball considered the important practical point was whether any
very radical treatment should be employed at the outset, or whether
this should be deferred until simple means had failed. His own
opinion was that simple means should be tried first. An openii^
should be made in the alveolar border whenever this was possible;
otherwise in the canine fossa, and irrigation of the cavity should be
practised in the usual manner. He had followed this plan in sixteen
cases. In all these cases the opening was made in the alveolar
process. Of these sixteen cases, six had got well after a varying
number of months, and had remained well after removal of the tube
and closure of the orifice. Of the remaining ten cases, three were
abroad, and one had been lost sight of, and he could not say what
their condition was. Three declined any further interference, as they
were satisfied to keep themselves comfortable by washing out the
antrum daily. In three cases he had enlarged the alveolar opening
sufficiently to pack the cavity with iodoform gauze, and had kept it
packed for a week or two, changing the gauze daily, until the opening
had contracted so much that it was no longer easy to pack the cavity.
After that the cavity was washed out daily. Two of these cases got
60
well, the third was not in any way benefited. He therefore quite
agreed that there would always he a residuum of cases which would
require very radical treatment, and probably in these cases Dr. Spicer’s
method would prove the most effectual.
Mr. Waltsb Spewcbb mentioned three cases of puS in the antrum
which differed widely from those upon which the discussion had taken
place, since the pus was formed in connection with acute necrosis of
the jaw. In one case he removed the alveolar process of the superior
marilla, which had become necrosed, thus taking away the floor of the
antrum. The case was shown some time ago at the Clinical Society,
when the whole dome of the antrum could be easily seen. Another
case had been previously treated by an incision through the cheek,
and several attempts had been made to remove portions of the
maxilla. When first seen by Mr. Spencer, a most ugly puckering of
the cheek had been produced without any relief to the suppuration.
A wide alveolar opening was made, and the case soon got well. A
third case seen post mortem had died of septicsemia from acute
necrosis of the maxilla, and pus was found in the antrum and in the
spheno-maxillary fossa. All three cases were considered to be syphilitic
in origin.
The Fbesidekt observed that the discussion had clearly shown how
widely the experiences and opinions of various members differed in
this question, and how impossible it was as yet to draw from it any
f eneral lessons. He must range himself decidedly by the side of
>r. Ball in believing that the more heroic measures ought only to be
adopted after the failure of the milder means. He may perhaps have
been fortunate in his own results, but, having treated in conjunction
with Mr. England between twenty and twenty-five cases in private
practice during the last few years, in the overwhelming majority of
cases the alveolar method, witn subsequent insertion of a golden tube
and washing out the antrum through that tube by means of a
Christopher Heath’s apparatus, had answered admirably. He wished,
however, to lay particular stress upon the necessity of giving most
minute directions to the patients as to the after-treatment which they
had to carry out themselves. One always was between the Scylla ana
Oharybdis of their doing either too little, and thereby allowing pus to
decompose in the antrum itself, or of their overdoing the washing out,
and thereby never allowing the mucous membrane to come to a con¬
dition of rest. The rules which he had adopted were as follows:—
The operation having been performed, and the tube having been
inserted, he saw the patients once again after the operation. On that
occasion he prescribed for them a weak solution of some astringent,
usually sulphate of zinc, not stronger than ten grains to the ounce, of
which solution one teaspoonful was to be added to a tumblerful of
tepid water for each injection. The patient was to sit before a mirror,
so as to be able to see the fluid come out from his nose. As soon as
the patient observed that the fluid returned clean from the nostril,
{. e. neither being turbid nor having flecks of pus mixed with the
water, he was to stop injecting immediately. This proceeding was to
be adopted at first twice daily; later on, as soon as the pus diminished,
once daily. When, after the lapse of twenty-four hours, hardly any
61
pus was evacuated on syringing, the washing out was only to be per¬
formed on alternate days; on further diminution occurring every third
day, and so on, until finally a week’s interval was reached. When,
after the lapse of a full week, on injection no pus was evacuated, the
patient was directed to' make an appointment with him (the speaker)
a week afterwards, and meanwhile to leave the part quite alone. On
the occasion of the interview he (the speaker himself) washed the
antrum out, and if then no pus came out, the time had come for re¬
moving the tube. In this manner he had not merely succeeded in
curing the great majority of his patients, although amongst them
cases had been in which the disease had in all probability existed for
a great many years, but he had been able to convince himself of the
actual fact that the cure had been obtained, and he therefore warmly
recommended this method. Should it fail, as no doubt occasionally
it must if there were either necrosed bone or formation of granula¬
tions or polypi, &c., in the antrum, more enei^etic measures were of
course indicate. But he regrett^ to say that in the few cases in
which he had been compelled to^resort to a broad opening through the
canine fossa, with scraping out of the cavity and subsequent packing
with dry iodoform gauze, <&c., his results had not been very satisfactory.
Mr. Englaud showed the tube he always made for these cases fitted
to a cast of the mouth. It consisted of a plain straight gold tube,
attached to a plate which fitted to the alveolus and round the teeth
on either side. The mouth of the tube was closed with a split plug,
which could be removed easily by the patient.
Erraium.
Dr. Peoles desires to correct an error appearing under his name
in the last report of ‘ Proceedings ’ with reference to Dr. Law’s case
of nasal obstruction. He intended to imply at the time that he
disapproved of the term papilloma as applied to anterior hypertro¬
phies of the inferior turbinal, since after making a number of micro¬
scopical sections of such growths he had never succeeded in tracing
any analc^y between that structure and that of a true papilloma.
6 *
THE
JOHN GK-IRAH
lisrary
PEOCBEDINGS
01? THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Oedinaey Meeting, April lOth , 1895.
Feme Semon, M.D., P.R.C.P., President, in the Chair.
Soanes Spicee, M.D., I „
W. E. H. Stewaet, F.E.O.S.,)
Present—29 members and 4 visitors.
The minutes of the previous meeting were read and confirmed.
The following gentleman was elected a member of the Society:
Arthur Sandford, M.D., M.Ch., Cork, Ireland.
The following candidate was proposed for election:
David Moore Lindsay, L.E.O.P., L.E.C.S.I., Salt Lake City, U.S.A.
Dr. Foster Macgeagh and Dr. A. Khyvett Gordon were called to
the table, and having signed the Eegister were admitted members of
the Society by the President.
Papilloma of t-hb Nose.
Mr. Cebsswbll Baber showed this case. Eev. —> set. 86, first
noticed a growth in his left nostril two years ago. In August, 1894,
it was removed by another surgeon, and pronounced after micro¬
scopic examination to be a papilloma. It grew from the floor of the
nose, and was entirely removed, the left ala being slit up for the
purpose. Two months after the operation it appeared again as a
small papilla on the floor of the nose. Condition when seen on March
7th, 1895, was as follows;—In the left nasal cavity there is a firm
mammillated growth, like a small mulberry, projecting into the ves¬
tibule, and extending backwards about three quarters of an inch,
PIBST SERIES—VOL. II. 7
64
It is attached by a broad base to the floor of the nasal cavity and to
the septum. Just behind the tumour is a deflectiou of the septum,
through which there is a clear-cut perforation about one eighth of
an inch in diameter. Bight nasal cavity normal except that it shows
the concavity of the deflection and the perforation. By posterior
rhinoscopy (with palate hook) the parts are found normal excepting
a slight swelling on the left side of the septum, probably unconnected
with the growth. There are no enlarged glands. There is no history
of syphilis. A small piece from the upper part of the growth was
removed for microscopical examination with the cold snare, but it
proved so firm that the screw of the snare had to be brought into
requisition. The microscopic examination showed only hyperplasia
of structure, and no malignant elements. The patient has a flat wart
on his head, which he is in the habit of picking, and it has been sug¬
gested that the nasal cavity may have been directly inoculated by
means of the finger.
Mr. Baber wished to have the opinion of the members with regard
to the nature of a further operation.
Mr. Bxttlin advised the free excision of the growth, and the de¬
struction of the remains with the galvano-cautery. He considered
the growth extremely active for an innocent one.
Case or Lupus op the Throat and Nose.
This case was shown by Dr. J. B. Ball. Emma K—, set. 14, was
admitted to the West London Hospital on March 6th, 1895, suffering
from hoarseness and laryngeal dyspnoea. She first complained of
her throat about eighteen months previously, and had attended at a
London hospital for some months, when she was told that she was
suffering from lupus of the palate. Has had no treatment during
the last nine months. Has suffered from obstruction and crusting in
the nose for some months. Two months previous to admission had a
sore patch on the left side of the neck. The hoarseness commenced
about the end of December, 1894, and for two or three weeks pre¬
vious to admission the breathing had been noisy, especially at night.
Patient was a fairly healthy-looking girl, though rather thin. No
history of phthisis. The voice was husky, and there was well-marked
laryngeal stridor and slight cough; no pain or dysphagia. There was
some enlargement of the glands under the angles of the jaw, especially
66
on the right side. On the left side of the neck, a little below the ear,
was a patch of lupoid ulceration about the size of a florin, covered
with crust. The gums were normal. The whole of the anterior
aspect of the soft palate presented a coarsely granular surface, with
here and there some fine cicatricial striae. The granular appearance
extended forward on to the hard palate for a little distance. The
pillars of the fauces, especially the right, were thickened, and studded
with fine granules. Epiglottis appeared to be partially eaten away ;
it was thickened, and its free edge presented some large pale nodules.
The aryepiglottic folds and arytaenoids were swollen and pale. The
ventricular bands thickened, slightly nodular, especially the left, and
the edges of the cords, which were just visible, seemed uneven. On
deep respiration the cords were not freely abducted. Both nostrils
were blocked with crusts. On removal of these an ulcerated surface
was exposed, occupying both sides of the septum nasi, extending from
a little above the columna for about three quarters of an inch, and
involving the floor of the nose and the fore-part of the inferior tur¬
binated body on each side. About half an inch above the columna
there was a small perforation through the septum. Chest normal.
Patient has been in the hospital since March 5th, and has taken cod-
liver oil and arsenic. The ulcerated patch on the neck has been
scraped, and has cicatrised. The nose has also been scraped, and is
much improved. The laryngeal dyspnoea has quite disappeared,
apparently owing to a diminution of the nodular thickening of the
ventricular bands, and there is a freer mobility of the vocal cords.
The general condition of the throat is improved.
In view of the apparent improvement, and of good results obtained
in a similar case recently exhibited by the President, under the admin¬
istration of cod-liver oil and arsenic, it is intended for the present
not to apply any active local treatment to the throat.
Mr. 0. Stmonds inquired if thyroid extract had been given, as he had
seen cases in which remarkable results had followed its administra¬
tion.
In reply, Dr. Ball stated that he had not yet used the extract, as
the case was. doing so well without it.
66
A Case ok Nasal Defobmitt of Tbaumatic Obigin.
Shown bj Dr. J. B. Ball. May M—, set. 16, a healthy'looking
girl, came to the West London Hospital with a view to having an
operation done to improve the appearance of her nose. When
four and a half years old she had received a violent blow on the
nose with the fist. The nose bled very much, the under part was
severed from the face, and it was a long time before the parts
were healed. At present the nose is broad and flattened, the nasal
bones being depressed and spread out. There is a transverse groove
across the nose at the line of junction of the nasal bones and lateral
cartilages. The plane of the anterior nares is directed somewhat
forwards. The anterior part of the septal cartilage is destroyed, as
well as a portion of the columna, only, a stump of the latter remaining
in front and behind. There is a communication running from the
anterior part of the floor of the nose into the mouth, between the
upper lip and the alveolar process.
The general appearance of the parts rather suggests some destructive
disease, such as syphilis, as the cause, but the history of a traumatic
origin is very definite, and there is nothing in the family or personal
history to indicate syphilis. My colleague, Mr. Keetley, proposes to
operate, and the case is shown partly on account of the peculiar defor¬
mity of traumatic origin, and partly with a view of eliciting sugges*
ticns as to the best means of remedying the deformity.
Mr. Knyvett Gobdon showed—
1. A section of a middle turbinate body with polypus formation.
Though there was no dead bone to be seen or felt in the nose, and
no operation bad been performed n that situation, yet there was,
microscopically, well-marked caries of the bone, as shown by the
destruction of tissue with well-marked small-celled infiltration and
numerous osteoclasts.
Dr. Hiiiii thought the specimen was exactly like that described by
Woakes.
Mr. Stmonds asked how the specimen differed from normal bone.
He could see some change at the edge of the specimen, but none in
the bone itself.
Dr. S. Spicer said that clinically this was a case of ordinary polypus;
was he to infer that ordinary polypi lead to absorption of bone ?
Mr. Gordon, in reply to Dr. William Hill, stated that he was in¬
clined to regard cases such as this as an early stage of Dr. Woakes’s
" cleavage.”
67
In reply to Mr. Charters Symonds, he said that the presence and
position of the osteoclasts with the small-celled infiltration had led
him to the diagnosis of caries.
2. Sections of masses curetted from the antrum maxillare in cases
of empyema, by Dr. Scanes Spicer.
These showed marked proliferation of the mucous glands in the
lining membrane, the epithelium of which was in a state of active
secretion. The proliferation was so great as almost to justify him in
describing the growth as an adenoma.
Empyema, of Antrum entirely cured by Treatment by means
OP Krause’s Trocar.
Shown by Dr. Dundas Grant. Diagnosis was made by means of
transillumination and Lichtwitz’s exploratory irrigation in June, 1894,
while under care of Dr. Wallis Ord for epileptic fits. The nasal dis¬
charge and obstruction had existed for some years.
A perforation was made through alveolus on July 9th, when fluid
came through the nose, but pain and swelling occurred in the cheek.
It was later determined to try intra-nasal treatment only.
Krause’s trocar was used in September, and through it the antrum
was washed out twice or thrice a week with sanitas lotion. In a few
weeks the discharge had completely stopped, and has not since
returned. Since the improvement in the condition of his nose the
epileptic fits have almost entirely disappeared, though of course he has
not left off his regular bromide.
Empyema op the Antrum op Highmore, complicated with
Suppuration op (probably) the Frontal Sinus.
Shown by Dr. Dundas Grant. A young Scotchman, who for
about two and a half years had a foetid nasal discharge on the left side,
and had suffered a good deal of treatment at various hands, came to
me in October last.
Empyema of the antrum was diagnosed by means of trtinsillumina-
tion and Lichtwitz’s trocar. Krause’s trocar treatment was instituted
and some relief afforded, but still more when the alveolar perforation
68
was made and daily irrigation practised. The discharge fluctuated in
amount to an unusual degree^ and it was observed that after washing out
the antrum with apparent completeness a return of discharge occurred
within a few minutes. On inspection this could be seen to spring
from the upper part of the semilunar hiatus^ and more could be
washed out by means of Hartraann^s frontal sinus tube. Puncture of
the bulla ethmoidalis revealed no ethmoidal pus. 1 have recommended
external opening of the left frontal sinus, but the patient is unwilling
to submit to it.
Case op Empyema op the Antrum under Treatment by means
OP Krause’s Trocar.
Shown by Dr. Dundas Grant. A young married woman, suffer¬
ing from nasal suppuration of old standing.
Her antrum was opened through the alveolus of an extracted tooth
two years ago, and she practised irrigation with soda solution, followed
by the injection of a little peroxide of hydrogen. Irrigation was to
be practised twice or thrice a week, and in seven months she seemed
well, the condition remaining apparently stationary till five months
ago. She returned to me about two months ago.
Krause’s trocar was ntroduced about five weeks ago; the antrum
was freely washed out and inflated, so as to blow out the remaining
moisture, and europhen was insufflated through the cannula.
Great diminution in the amount of discharge has taken place, and
she can get on comfortably with much less, frequent irrigation, though
at present she is unable to go for a week without it.
Case op Empyema op the Antrum greatly benepited by the Use
OP Krause’s Trocar and Cannula, and Closure op the
Alveolar Perforation.
Shown by Dr. Dundas Grant. A gentleman set. 55, who first
suffered from nasal discharge about 1884, Numerous polypoid growths
were removed from time to time down to 1894.
Antral empyema was diagnosed in February, 1894, and alveolar
irrigation was carried on up till the last two months, when no further
improvement seemed to accrue.
69
In October, 1894, Krause’s trocar was used, and irrigation followed
by drying and insufflation of antiseptic powders (of which europhen
was found to be the best) was continued at gradually increasing
intervals. Alveolar irrigation was gradually left off, and the dis¬
charge diminished. The alveolar opening was allowed to close in
February of this year, and still greater improvement took place.
He left town five weeks ago, and omitted all treatment, the nasal
condition causing hardly any inconvenience. He has just returned,
but on irrigation fetid muco-pus could be evacuated.
Empyema of the Antrum secondary to Suppuration in the
Frontal Sinus treated by means op Krause’s Trocar with
Good Kbsult.
Shown by Dr. Dundas Grant. Referred to him by Dr. Graham
Grant in July, 1892, on account of pain in left front region and dis¬
charge of fetid pus from the left nostril. Antral disease was excluded
by means of transillumination and Lichtwitz’s puncture.
A small external opening was made in February, 1893, and pus
revealed. Drainage and irrigation were practised with very slight
improvement. The anterior part of middle turbinal was removed, but
even then the discharge persisted in spite of apparent improvement of
the condition of the frontal sinus.
The sinus was widely opened by means of gouge-forceps in June,
1894, and the granulating lining was thoroughly scraped. The
nasal discharge continuing, the antrum was again examined, and proved
to be the seat of an empyema. In a few weeks the suppuration
entirely disappeared under treatment by means of Krause’s trocar.
A Case op Tubercular Laryngitis.
Previously shown at an early meeting of the Society by Dr.
Dundas Grant. The ulceration was on the former occasion almost
entirely confined to the region of the right vocal process, and
may he remembered as presenting, on a mass of pale granulations at
that point, a white spot where the galvano-cautery had been applied.
Since that time the patient has been residing in Jersey, his voice has
got more hoarse again, and his cough more frequent. Tubercle
70
bacilli have been detected (though formerly absent) but no pulmonary
lesion can be demonstrated. The granulations in the region specified
have become more exuberant, and there has developed a shallow longi¬
tudinal fissure just below the edge of the opposite (left) vocal cord.
The laryngeal symptoms are diminishing, and the local signs
becoming less marked under almost daily application of pure lactic
acid.
The Pbesident said he had been asked how long his cases treated
by the simple methods lasted. He would say, taking them in the
broadest sense, an average of three or four months. He had a letter
for Dr. Brady about one case which had gone to Australia, and which
had lasted between one and two months.
Dr. HaiiL suggested that in this case the pure air of the sea voyage
had operated beneficially.
Mr. C. Symonds said that as it was presumed the good effect in
these cases was due to drainage, he did not see that the meatal
opening was superior to the alveolar.
Dr. Ball thought the advantages of Krause’s trocar depended on
whether it was better to use the dry treatment with powder once a
week, or fluid daily.
Dr. Law asked if europben was more efficacious than iodoform.
Dr. Geant, in reply, said he had been led to try the meatal plan on a
patient who had a beautiful set of teeth, and would not agree to the
alveolar operation. Also many cases operated on by the alveolar
method became stationary, and one case improved greatly when the
alveolar opening closed. He also thought it was possible for infection
to spread through the opening. He would suggest it, too, as an
alternative method of treatment. He had not given iodoform such a
trial %>s he had europhen, but it was niiuch better than any of the
substitutes for iodoform, and had not the distinctive odour.
A Case op Mycosis Pungoidbs.
Shown by Dr. db Havilland Hall. A man set. 52, suffering from
mycosis fungoides. The disease had existed for about two years and
a half. There are numerous tumours all over the body and limbs.
In October, 1894, he complained of sore throat, and has had more
or less pain in the throat since, but the speech has not been affected.
On the posterior and lateral walls of the pharynx there are small oval
tumours; and on the left arytsenoid cartilage there is a tumour about
the size of a hazel-nut'j the surface is superficially ulcerated. This is
thought to be the first case in which the larynx has been attacked by
mycosis fungoides.
Dr.de Havilland Hall: Case oe Mycosis Fungoides.
(See page 70.)
THE
^ ’GMRAR
V ^ARY
71
The President suggested, and. it was agreed, to by the Society, that
as Dr. Hall’s case was unique, a drawing of it should be made for
insertion in the ‘Proceedings,’ and Dr. Waggett was asked to
make it.
Disease op the Frontal, Ethmoidal, and Maxillary Sinuses in
Association with Nasal Polypi.
Dr. William Hill showed a patient, A. K—, set. 34, who
recently sought his advice at St. Mary’s Hospital for pain in the nose
and chronic headache. Nasal polypi had been removed fifteen years
before. She sufifered from a profuse purulent discharge, and the left
nostril was blocked with mucous polypi ; these were removed, and pus
was then seen issuing from under the anterior extremity of the left
middle turhinal, which was enlarged and bulbous; this end of the
turhinal was cut off, and an ounce and a half of pus immediately came
away, giving the patient instant relief. Granulations could then be
seen and diseased bone felt in the neighbourhood of the ethmoidal
cells. The left frontal sinus was tender on percussion, and the skin
over it was red, and at times puffy; the left maxillary sinus was dark
when tested by transillumination.
Whilst the amount of discharge in the neighbourhood of the hiAtus
semilunaris was not now abundant, a profuse flow of matter was con*
stantly to be seen coming down between the middle turhinal and
septum from the superior meatus, presumably from the posterior
ethmoidal cells. The middle turhinal was very enlarged, but not
cystic, and Dr. Hill thought that nothing short of removal of
this bone would relieve the ethmoidal disease which was the prominent
factor in the case. He was also prepared to open the frontal sinus by
a vertical incision, and the antrum through the canine fossa. He
hoped to show the patient again later.
Epithelioma of the Pharynx.
Dr. William Hill also showed a man, set. 44, who consulted'him
at St. Mary’s Hospital a week previously complaining of pain in the
throat rendering swallowing difficult, and a shooting pain in the ear.
On laryngoscopic examination an ulcer was seen in the right glosso-
72
epiglottic fossa, extending into the pyriform fossa; the right pos¬
terior pillar and the right side of the epiglottis were oedematous, the
edges of the ulcer were hard and prominent to the touch; there were
some tender and slightly enlarged glands on the right side of the
neck at the level of the hyoid bone. There was no history or
indication of syphilis. The patient had the day before been digit¬
ally examined by students at the College examinations, and the
pharynx was much swollen and oedematous in consequence, and less
typical in appearance. It was proposed to perform pharyngotomy, and
endeavour to remove the growth and the enlarged glands. Mr.
Pepper has recommended and offered to carry out this treatment.
Microscopical Specimens illustrating Case of Multiple
Papillomata op Larynx.
Shown by Dr. Hunt. C. W — , ®t. 12, was operated on by Mr.
Paul at the Liverpool Royal Infirmary on September 28th, 1893,
when a large growth, which had so completely obstructed the larynx
as to demand tracheotomy two months previously, was removed by
thyrotomy (see Liverpool ‘Med.-Chir. Journal,’ January, 1894).
This growth was described by Mr. Paul as having "all the micro¬
scopic characters which point to the least malignant form of spindle-
celled sarcoma, without allowing any question that it is a genuine
sarcoma, and not a simple benign growth.”
Six months afterwards I made a laryngoscopic examination of the
patient, as his breathing was again becoming difficult, and recurrence
was feared. I then found the cavity of the larynx filled by two pale
warty-looking growths, springing from the left ventricular band, evi¬
dently pedunculated, and freely moveable with the breath current. A
third growth of a similar character was situated on the posterior
surface of the left aryteenoid. These growths were easily removed by
means of Schroetter’s forceps, and on microscopic examination were
found to present the characters of simple papilloma.
During the past year I have on many occasions removed similar
growths from this patient’s larynx, originating from the vocal cords,
the ventricular bands, and the aryepiglottic folds, but so far there
has been no recurrence of the original growth which sprung from the
under surface of the left cord.
73
The President asked if anyone had seen a similar case in which
the usual order of events had been transposed, and papillomata had
followed sarcoma.
Mr. Butlin had never seen such a case.
Dr. Hunt, in reply, stated that there was no real recurrence, and that
the papillomata were situated on a different site though close to the
former scar.
Laryngeal Stenosis ; Polypoid Growth prom Left Vocal
Cord.
Case shown at the January meeting, 1895, by Dr. Percy Kidd.
After tracheotomy had been performed, the growth on the left side
and portions of the fleshy swollen vocal cords were removed with
Mackenzie’s cutting forceps. Much increase of the glottic space was
obtained, the tracheotomy wound was allowed to close, and, for a
time, the patient experienced considerable relief.
Microscopical examination of the tumour revealed a well-marked
papillomatous structure, with slight, small-celled infiltration of the
submucosa, but no appearances of tuberculosis.
Early in March the patient’s general condition began to deteriorate,
the chief symptoms being progressive weakness, loss of flesh, moderate
remittent pyrexia, and pain on swallowing.
The laryngoscope now showed swelling over both arytsenoid carti¬
lages, with some ulceration over the right. Examination of the chest
gave no constant results. The sputum was examined seven times
with a negative result, but a week ago tubercle bacilli were detected
on two occasions. The physical signs now indicate infiltration of the
apices of both lungs.
Present condition of the larynx:—Epiglottis swollen on right side.
Much pale tumefaction over both arytsenoid cartilages, with sloughy
ulceration of the superior and laryngeal surface of the right. Both
vocal cor^s of pale pink colour, and irregularly thickened. At the
posterior end of the right cord is a small sessile reddish outgrowth
Vocal cords motionless, lying close together and causing considerable
stenosis of the glottis.
74
Case op Empyema op the Anteum of Highmoee.
Dr. ScANBS Spicee showed this case.
The Peesident congratulated Dr. Spicer on the improved condition
of the patient, he having since the operation fourteen days previously
gained 11 lbs. The result of treatment in these cases by the members 1
of the Society was most gratifying.
A Case ih which a very Laegb and Haed Fibro-papili.oma op
THE Larynx has caused Indentation op the Opposite
Vocal Cord.
Shown by The President. The patient is a man aged about
40, who two years ago began to suffer from hoarseness, soon followed
by dyspnoea and complete loss of voice. The difficulty of breathing
became so great that tracheotomy had to be performed. Laryugo-
scopic examination showed an enormous tumour growing from the
left side of the larynx, the exact origin of which could at that time not
be made out, and completely filling the vocal organ. A fear was ex¬
pressed that this might be malignant, and external operation had
already been contemplated, when Dr. Johnson Smith, of Greenwich,
sent the patient to Dr. Semon. The intra-laryngeal removal and sub¬
sequent microscopic examination (Mr. Shattock) of some fragments,
however, showed that the tumour was of benign character, and it has
in the course of several sittings been reduced to its present size, which
is about that of a large bean. The interesting feature of the case is
the fact that the right vocal cord is deeply eroded, corresponding to
the pressure which the growth in its original size exercised upon it.
Mr. Stmonds asked whether the opposing vocal cord in this case
was absorbed or eroded.
The President stated that be could not say at present, as the time
since the growth was removed was too short. It was quite possible,
however, that absorption had taken place.
Suppuration op Frontal Sinus.
Mr. Symonds showed this case. Eev. J. E— consulted me on
November 1st, 1892, for a foul discharge from the left nostril of seven
years^ duration. The left upper first molar had been removed just
75
after the discharge began. For six years he had been under treat¬
ment for what was described to him as '' necrosing ethmoiditis/^ and
had been cauterised regularly, but without relief. Three years ago a
little discharge appeared on the right side, and this was also cauterised.
The case was obviously one of empyema of the antrum, probably
bilateral. Through the alveolus the left antrum was perforated, and
much thick, foul pus forced through the nose. The nasal opening
of the antrum was evidently small, and, on examining the nose, the
middle turbinated was adherent to the outer wall, and the whole
middle meatus blocked with adhesions, the result of the cautery.
After removing the anterior end of the middle turbinated the stream
came freely. Granulations still remained in the nose, and some
pus escaped. In February, 1893, the right antrum was drained through
the incisor fossa ; much foul pus was found. In May this side
was well, and the tube removed. Though little if any pus came
through the nose when the antrum was syringed, pus, sometimes
blood-stained, was always visible high up. In December, 1894, bare
bone could be felt amongst easily bleeding granulations. These were
curetted. The diagnosis now was suppuration in the ethmoidal or
frontal sinuses, or both.
January 21st, 1895, he called with swelling in the centre of the fore¬
head, evidently suppuration. A week later (January 28th) I incised
in the median line over the centre of the fluctuating area, and let out
a good deal of foul pus. A large opening in the frontal bone to the
left of the median line led into the frontal sinus. All nasal discharge
had ceased while the pus was collecting; a curved probe was easily
passed into the nose. A piece of gum-elastic bougie was passed into
the nose and retained. Later, a small silver cannula of a length to just
enter the sinus was inserted, and through this the bougie was passed.
The sinus was daily irrigated with boric acid, and later sanitas.
When shown to the Society rather less than three months from the
opening of the abscess the discharge was mucus only, no pus escaped
from the nose, no granulations were visible, and the bare bone felt by
a probe passed through the nose into the sinus no longer existed.
The left antrum for a long time gave no pus, the tube being retained
as a precaution only.
Bemarhs ,—The site at which the spontaneous opening formed seems
the best at which to open the sinus, i. e. just to the left of the median
line, and half an inch above the level of the eyebrow. From here a
drain can easily be passed into the nose, and retained by means of a
projecting lip. This, covered with a piece of plaster, is by no means
disfiguring. 1 think it much superior to the opening at the inner
jcorner of the eye, through which it is difficult to pass a probe or
drain into the nose, and 1 would suggest this site as the appropriate
one for making the external opening. When both sides are involved,
a median opening, either a long one or with a flap, will be best. The
long period covered by treatment in this case was partly due to
the neglect of the irrigation of the left antrum. The rigid tube at
first employed gave much pain when introduced, but so soon as the
wire one was substituted this inconvenience disappeared, and the
antrum rapidly became healthy.
PROCEEDINGS
OP THE
LARYNGOLOGICAL SOCIETY OF LONDON.
Oedinabt Meeting, May Sfh, 1895.
Felix Semon, M.D., F.E.O.P., President, in the Chair.
Soanes Spicer, M.D.,
W. B. H. Stewabt, F.E.O.S.,
I
Secretaries.
Present—31 members and 3 visitors.
The minates of the previous meeting were read and confirmed.
The following gentleman was elected a member of the Society;
Mr. David Moore Lindsay, L.E.O.P. and L.E.C.S.I., Salt Lake
City, TJ.S.A.
The following candidate was proposed for election:
Mr. deorge Vincent Ponrquemin, London.
Dr. C. Couper Cripps, Dr. d. Caldwell Stephen, and Mr. Bruce
Hamilton were called to the table, and having signed the Eegister,
were admitted members of the Society by the President.
Occlusion op Eight Posterior Naris.
Shown by Dr. J. B. Ball. F. H—, set. 31, has had obstruction
of the right nasal passage as long as she can remember. She has
always been troubled with frequent discharge of mucus from right
nostril. A probe passed through the right nostril is arrested at the
region of the posterior cavity by a hard, resisting structure apparently
bony. There is no passage whatever for air through the right nostril,
either with inspiratory or expiratory effort. By anterior rhinoscopy the
right nasal passage is seen to contain a quantity of clear, viscid mucus.
There is a slight deviation to the left of the anterior part of the
septum near the floor. By posterior rhinoscopy the left choana
FIRST series-VOL. II. 8
78
appears larger than normal, the distance of the posterior margin of
the septum from the left Eustachian tube being greater than from the
right tube. The right choana is completely occluded by a smooth
reddish structure which joins the septum, not at its posterior margin
but a little anterior to this, there being a distinct depression along
the line of junction. To the finger the occluding structure feels firm
and resisting. This patient was seen by me some six and a half years
ago, when the condition and appearances were the same as now. The
occlusion is no doubt congenital. Operative treatment was declined
on the former occasion, but the patient is now inclined to have some¬
thing done.
Mr. Cbesswell Babeb thought this was a case of congenital occlu¬
sion like a case he had shown to the Society. He had pushed through
the obstruction and dilated under an aneesthetic; no tube was worn
afterwards.
Dr. Dukdas Obant had a case he had treated by perforating with a
trocar and introducing a vulcanite tube, which, in answer to Mr, C.
Symonds, he stated the patient had to wear from time to time.
Mr. C. Stmoitds had a case in which the edge of the septum touched
the outer wall. He had sawn out a portion with a Bosworth’s saw.
Paralysis of Bight Vocal Coed.
Shown by Dr. J. B. Ball. M. A—, ®t 18, came under ob¬
servation at the West London Hospital in October, 1894. He com¬
plained of some weakness of the voice which had existed for about
three months. On laryngoscopic examination the right vocal cord
was found to be fixed in the position of complete paralysis, although
there was some slight movement of the right arytsenoid on phonation.
He had no cough, and repeated examination of the chest at this time
failed to discover any definite physical signs, and there was nothing
in the case to point to the cause of the paralysis. He was next seen
towards the end of December, when he had some cough, and then
there was found to be some impairment in the percussion note at the
right apex, front and back, and some crackling r&les in the same
region. His cough has left him for the last two months and he has
gained in weight, but the breath-sounds are weak at the right apex
and there is some dulness on the right supraspinous fossa together
with some crepitant rdles in deep inspiration. The diseased process at
79
the right apex, which is probably tubercular, gives a clue to the cause
of the paralysis of the right recurrent laryngeal nerve, but the para¬
lysis of the right vocal cord was in this case the first sign of disease
to be discovered.
Dr. CiiiFFOBD Beale had some doubt whether the paralysis could
fairly be put down to the presence of apical disease. Oases of uni¬
lateral paralysis of one cord were by no means uncommon where no
pleural or pulmonary disease existed, and as no pathological cause
could be found for them they were generally classed as “ functional.”
Cases of adhesion of the pleura at the right apex were, on the other
hand, exceedingly common, but seldom produced paralysis.
Case op Laegb Mass op Malignant Glands in the Neck, with
Paralysis op the Corresponding Sympathetic Nerve, and
Immobility OP the same side op the Larynx.
Shown by Mr. Butlin. An engine driver, 66 years old, who four
months ago had noticed a lump on the left side of the neck. About
the same time he had begun to experience slight difficulty in
At the present time he had a large mass of apparently malignant
glands in the neck, extending from the clavicle up to the level of the
hyoid bone. His voice was very hoarse, and he could only swallow
solids with difficulty. The left side of the larynx was completely
fixed, but healthy in appearance.
There were typical signs of paralysis of the cervical sympathetic,
narrowing of the palpebral fissure, contraction of the pupil, absence of
sweating on the corresponding side of the head and face. There was
no reddening of the left side of the face and ear, which were a little
paler generally than the corresponding parts on the right side.
Mr. Butlin believed the primary affection to be malignant disease
of the left side of the oesophagus very high up, and not producing so
much stricture as it does when the disease is lower down. He had
reported an almost precisely similar case in the * St. Bartholomew’s
Hospital Eeports,’ vol. xxix, p. 103, 1893. In that case there was
scarcely any suspicion of malignant disease of the oesophagus until it
was found after death. Yet there was a very large mass of glands in
the neck, which had produced paralysis of the cervical sympathetic
nerve, and immobility of the same side of the larynx.
Mr. C. Stmonds stated that he had asked Mr. Butlin whether it was
not a case of malignant disease of the thyroid, as there was a large
nodule on the right side, and Mr. Butlin bad replied that he had a
80
similar case previously, which he thought had been disease of the
thyroid, but that, post-mortem, carcinoma of the oesophagus was
found.
Casb op Paralysis of the Eight Vocal Cord of Uncertain
Origin.
Shown by Mr. Bdtlin. A woman, 28 years of age, a cook, who
was suffering from chronic enlargement of the tonsils, and complete
paralysis of the right vocal cord, which was in a position midway be¬
tween adduction and abduction.
In the middle of January of the present year she had been attacked
suddenly by a very severe cough. In March the cough ceased, and
she lost her voice quite suddenly.
The exhibitor had expected, from the history of the case, to find
* functional aphonia,* and was surprised to discover immobility of the
vocal cord. The cause of the condition had been diligently sought for,
but thus far without success. There was no history or appearance of
catarrh (the larynx was perfectly healthy in appearance). No sym¬
ptoms of disease of the brain or spinal cord. No tubercular or specific
history. No history of injury.
No improvement took place during her stay in the hospital, except
that her voice improved, and became almost of normal strength.
Dr. S. Spicer jc^^idered that as the paralysis was unilateral, func¬
tional paresis was^cluded.
A
Case of Laryngeal Stenosis.
Shown by Dr. Ddndas Grant. P. P—, set. 28, was admitted on
the 31st January, 1895, complaining of inability to breathe, except
through the tracheotomy tube he was wearing in September, 1894.
He had been sitting up ten days convalescent from typhoid fever,
when he complained of a sore throat. Difficulty of breathing set in
three or four days later, and tracheotomy was performed.
Condition of the larynx on admienon.—Vocal cords considerably
obscured by the swelling existing around each arytcsnoid were swollen
and red. The cartilages were more or less fixed and immobile, the
right one completely so. There was a rounded inflammatory swelling
at the posterior part of the right vocal cord, merging into the inter-
81
arjtsenoid fold, which was much swollen. Perichondritis was pro¬
visionally diagnosed. A later examination showed granulations at the
posterior extremities of the vocal cords, and evidence of web formation
in the anterior commissure.
On the 4th February, after removing some valve-like portions
of tissue projecting into the tracheotomy wound, dilatation of the
stenosed glottis was attempted by introducing an india-rubber conical
dilator through a special tube introduced upwards into the wound.
On February 7th a laminaria tent was introduced from the tracheo¬
tomy wound, and left for some hours in the glottis.
By these means the breathing aperture was enlarged, so that by
the 11th February some amount of breathing could he performed
through it.
On the 11th March, after recovery from an attack of influenza,
complicated with pneumonia, the web formation was divided with a
Whistler^s knife, and the smallest intubation tube passed in. The next
day a larger one was used; the breathing was distinctly improved, but
the effect was not sufficient to justify the postponement of operation.
On the 17th the larynx was opened. The tracheotomy wound was
enlarged three inches upwards in the middle line. All the soft parts
over the thyroid cartilage were found to be matted together, and the
latter was with difficulty exposed. Some granulation tissue was scraped
away from the posterior wall of the larynx and bare cartilage was felt,
but whether cricoid or left arytsenoid was uncertain. The original
opening in the trachea was also enlarged, granulations were scraped
away, and the finger introduced in both directions found plenty of room.
The breathing was much improved. The parts were then transfixed
with silver wire and brought together.
A tracheotomy tube with an upward limb was introduced, but the
patient could not tolerate it.
On April 8th, the glottic chink was so much more patent that the
tube was taken out during the daytime, and the hole plastered over.
May 6 th, introduced a dilator. Patient has passed a whole night
with wound closed, but still wears tube during a portion of the day.
§
82
Case op Syphilitic Perichondeitis op the Larynx.
Shown by Dr. William Hill. A female, set. 34, who had applied
at St. Mary’s Hospital a week before, suflfering from sore throat and
loss of voice. There was a clear history of syphilis, and on exami¬
nation the swollen and congested ventricular bands were seen to meet
on the middle line, except for a short distance posteriorly, where a little
of the right cord could be observed fixed and ulcerated; the right
arytsenoid region was swollen, and pus could be seen issuing from an
ulcerated surface on the pharyngeal aspect of this region; the larynx
was distinctly tender on pressure. Under iodide of potassium the
local condition had slightly improved.
Specimen of Pachydermia Syphilitica Dipfusa.
Shown by Drs. A. A. Kanthack and W. Jobson Horne. The
larynx with portions of tongue and trachea attached was sent by
Dr. Engelbach to the Pathological Department at St. Bartholomew’s
Hospital, with a note that it had been removed from a woman,
aged 20 (married—one child—no miscarriage), who kept a brothel,
and who for two years and a half had suffered from a very bad throat.
In December of 1894 she had extreme dyspnoea, and died suddenly
before tracheotomy could be performed.
The glottis was much narrowed. The epiglottis was entirely de¬
stroyed. The surface of the root of the tongue and of the interior of
the larynx and trachea was studded with closely-set papillomatous-like
excrescences.
Vertical sections were made through the anterior end of the right
ventricular band, through the posterior parts of the aryepiglottic
folds, and horizontal sections were made through the trachea.
Under the microscope there was found no loss of substance, nor
destruction of epithelium, but the sections showed a thickening and
heaping up of the epithelium together with a metaplasia of the cells
from the cylindrical to the squamous variety, even in the trachea.
Immediately beneath the epithelium there was an abundant small
round cell proliferation, which extended into the deeper parts, and
cells were found scattered between the muscle fibres. In places where
83
the cells were more closely packed^ retrogressive changes had com¬
menced.
Dr. Cliffoed Beale observed that confusion was likely to arise
if such cases were to be indiscriminately classed as “ pachydermia,”
as the lesions both in form and situation differed absolutely from
that which was usually described under that name.
Mr. C. Stmonds thought the case looked more like diffuse syphilitic
ulceration rather than pachydermia.
Case op Tubercular Ulceration op Nose and Pharynx.
Shown by Mr. C. A. Parker. F. McC— came to the hospital
about February 7th, 1894, complaining of stoppage in nose of two
to three years* duration, and was found to have hypertrophy of his
inferior turbinate bone, which was removed on the right side with
the cold snare.
Two or three days afterwards there was some epistaxis. About two
weeks after the operation, ulceration was found to be present over the
turbinate bone. This was at first treated by simple means, but it
spread steadily and made its appearance on the pharynx.
Some, little time later it was curetted, and painted with lactic acid
frequently, and was improving rapidly towards the end of the year, at
which time—^in October—he went into the country. After his return,
he attended at the Brompton Hospital for Diseases of the Chest.
In March, 1895, his weight was 8 st. 8| lbs.; on May 7th, 8 st. 3 lbs.
Examination of Chest .—In April, 1894, marked flattening of left
apex anteriorly with diminished movement and impaired percussion
note. Vocal resonance and fremitus were both +. Bronchial
breathing with numerous moist crepitations.
Night sweats occurred, but not much expectoration.
May 4th, 1895, examined again. But slight impairment of note.
Kespiration jerky ; expiration prolonged, with tendency to hollowness.
No crepitations could be heard. Vocal resonance and fremitus
slightly +.
Dr. Clifford Beale commented on the comparative rarity of
tubercular lesions in the nose and the importance of their early recog¬
nition and treatment by lactic acid. The corresponding lesions on the
tongue and soft palate were more often recognised in their early stages,
and were quite amenable to such treatment.
84
Microscopical Sections Tlldstratino the Histology op
Turbinal Hyperplasias.
Shown by Dr. Peglbr. The sections largely corroborated the
views put forth by Wingrave, in a paper read before the last meeting
of the British Medical Association at Bristol. Dr. Pegler had, how>
ever, been led to take a somewhat simpler view of the morbid changes,
so far as his observation had gone, since, in every speciipen examined,
he had found mucoid degeneration in greater or less degree, and in no
instance a true hypertrophic condition of the sinus walls. This applied
to growths taken from any point along the free border of the inferior
turbinate, from the middle turbinate, and from the septum. Special
attention was directed in section (1)—(normal inferior turbinate)—to
the walls of the sinuses, constituted by strands of visceral muscle-fibre
crossing in all directions, and interlaced with bands of the wavy areolar
tissue of the part. No. 2 was taken from a typical anterior hyper¬
trophy ” of the inferior turbinate, the external contour of which was
deeply convoluted, showing long finger-like processes in the section.
This character was probably answerable for the fact of “ papilloma **
being commonly applied to such growths, but instead of a dense
coating of stratified epithelium (altered by irritation ?) with a thin line
of vessels included, we had here a primary vascular outgrowth in a
mucoid matrix, put forth apparently from the main body, and bordered
by delicate ciliated epithelium. Attention was next called to the
mucoid degeneration of areolar tissue, conspicuous in the lymphoid
and general submucous area of the growth. Comparing carefully
with the normal, it would be seen that this change had conspicuously
attacked the walls of the venous sinuses, the mucoid thinning out of
the areolar element throwing into prominence the muscular constituent,
and creating an appearance of actual muscular hypertrophy. Sections
3 and 4 showed what were probably later stages of the pathological
process (apparently progressive in character), the muscular trabeculae
themselves disappearing, till a mere rim surrounding some of the spaces
remained. Wingrave believed that dilatation followed this atrophic
stage, and proposed the term turbinal varix to designate it, but he also
recognised a hypertrophic condition of the sinus walls in other cases.
The remaining sections were from polypoid hypertrophies of the middle
85
turbinate, and wall of the septum. The septal growths were mucoid,
and (edematous in the dependent portions, but contained numerous
glands and sinuses towards the pedicle. This was evidently the struc¬
ture of most septal proliferations, true papillomata being quite rare.
Mr. Chastbbs Stuokds had not sufScient experience in these
cases to criticise.
Dr. Bbonnes considered them most interesting.
Dr. S. Sficeb thought we ought to get rid of the name hypertrophic
rhinitis, and call the condition by some more suitable one.
Dr. Pegleb in reply stated that his observations were strictly
limited to the sections he had shown, and though he had not as yet
met with what appeared to him to constitute true tissue proliferation
or hypertrophy of the sinus walls, he did not deny the existence of
those conditions. He might have to alter his views; there were many
sources of fallacy, and much still remained to be worked out.
Case op Eistula in the Neck.
Shown by Mr. W. E. H. Stewaet. C. G —, set. 19, was shown at
the January meeting of the Society. He had been operated on several
times, and when shown the sinus was nearly healed. It was quite
healed a few days afterwards. Owing to adverse criticism as to whether
an operation in this case was justifiable, Mr. Stewart brought the
case again forward to show that it was possible to cure these cases by
operation. In answer to Dr. Hill, Mr. Stewart stated that the dissec¬
tion was carried back to the foramen caecum.
Specimens op Polypi pbom the Antbuh.
Mr. Symonds showed several polypoid masses, some of them three-
quarters and half mch long, which he had removed from the right
maxillary sinus. The patient, a woman set. 25, had the right second
bicuspid extracted for pain. There was no discharge from the nose.
Soon after this a swelling projected through the socket, and was re¬
moved ; a second soon followed. When first seen by Mr. Symonds,'
two pear-shaped gelatinous masses projected from the socket for¬
merly occupied by the tooth. That these were not connected with
the gum was shown by the fact that a probe could be passed all
round them, and entered the antrum. The anterior wall of the
86
antrum was removed, and the polypi which were attached to the inner
and posterior wall were removed by a sharp spoon. The largest measured
about seven eighths of an inch in length. They were all attached about
the same site and projected downwards. The aperture in the alveolus
was much enlarged, and the polypi which projected through the opening
were paler in colour and had a denser covering.
Large Nasal Polypus from a patient aged eighty-seven.
Shown by Mr. G. Syhonds. This was a large mass with a portion
of the middle turbinated, that had been removed by the cold snare.
It is composed of many pendulous masses, and when removed was in
outline as large as the palm of the hand. The walls of the nasal cavity
had been much absorbed.
A Post-nasal Sarcoma.
Shown by Mr, C. Symonds.
Case of Pachydermia Laryngis.
Shown by Mr. C. Symonds. This case was that of Mr. H —, exhi¬
bited on several previous occasions.
The mass had nearly disappeared, so that the original view of the
case has been confirmed. For three weeks the patient has resumed
his duties as a schoolmaster, and during this time the greatest change
has taken place for the better.
Case of Laryngeal Disease.
Shown by Dr. Herbert Tilley. S. E—male set. 49. "Com¬
plains of hoarseness and sore throat.^^ Patient had syphilis about ten
years ago, and was treated for it. About eighteen months after con¬
tracting the disease, he began to complain of his throat. It has been
getting worse and worse, and he applied to the hospital early in
February last, when he was at once put on anti-syphilitic treatment.
At first he improved, complained of less pain and easier breathing,
but recently he has remained in statu yio.
87
There is no history of phthisis in family. There is a history of
hfemoptysis when he was eighteen years of age. Eecently he has been
getting weaker. Altogether the history of phthisis is very indefinite,
and the only physical signs in the lungs are those pointing to slight
consolidation in the left apex.
There is a prominent granulation in the arytmnoid space on left side.
Left processus vocalis swollen. Over position of right vocal cord is a
swollen mass of tissue which looks something like a large granu¬
lation, There is no fixation of the vocal processes beyond that due
to infiammatory thickening. There is considerable laryngeal stenosis.
Dr. TiiiIiET was inclined to consider it a case of syphilis.
Dr. Spicbb and Mr. Stewabt considered it a case of tubercle.
Dr. Bbueeeb thought it was syphilitic, and recommended mercurial
inunctions.
Dr. Tillet stated that Mr. Butlin had suggested that it might
possibly be malignant.
INDEX
PAGE
Abductor paralysis (double) of uncertain origin (A. A. Bowlby) . . 19
-paresis: aneurism of the aortic arch compressing the left pneumo-
gastric and recurrent laryngeal nerves and the trachea, associated with
abductor paresis of the right cord (A. A. Bowlby) . . 20
Adenoid growths: pathological specimen (A. A. Kanthack, M.D.) • 47
Adenoma of tongue (E. Cresswell Baber) . . . .1
Air-passages: foreign bodies in air-passages (Felix Semon, M.I>.) . 23
Ala: see Nose.
Aneurism of the aortic arch compressing the left pneuraogastric and recur¬
rent laryngeal nerves and the trachea (A. A. Bowlby) . . 20
-with paralysis of right vocal cord (Scanes Spicer,
M.D.) . . . . . . .27
Angioma: ? angioma of vocal cord (Ernest H, Crisp) . . .16
-- (venous) of pharynx (P. McBride, M.D.) . . .29
Ankylosis (?) of the left arytaenoid joint (Charters J. Symonds) • . 27
Annual General Meeting, Jan, 9th, 1895 . . . .31
Antrum: radical cure of obstinate suppuration of antrum of Highmore
(Scanes Spicer, M.D.) .....
discussion on the diagnosis and treatment of empyema of the
41
antrum of Highmore
-remarks by Felix Semon, M.D.
-Adolph Bronner, M.D.
Greville MacDonald, M.D.
communication from E. Cresswell Baber
-J. Ernest Lane
remarks by William Hill, M.D.
-W. J. Walsham
-J. Dundas Grant, M.D.
-Scanes Spicer, M.D. .
-J, B. Ball, M.D.
W. G. Spencer
-exhibition of tube by W. J. England .
— sections of masses curetted from antrum maxillare in cases of em¬
pyema (Knyvett Gordon) ....
empyema of antrum under treatment by means of Krause’s trocar
53-^61
53,60
54
54
54
55
55
56
57
58
59
60
61
67
(J. Dundas Grant) . . . . . 67,68,69
-and cannula (J. Dundas Grant, M.D.) . . 68
-empyema of antrum of Highmore (Scanes Spicer, M.D.) , 74
-specimens of polypi from antrum (Charters J. Symonds) . 85
FIRST SERIES-VOL. II. 9
90
Aorta: aneurism of the aortic arch compressing the left pneumogastric
and recurrent laryngeal nerves and the trachea (A. A. Bowlby)
- --with paralysis of the right vocal cord (Scanes
Spicer, M.D.)
Arytssnoid joint: ankylosis (?) of left arytonoid joint (Charters J.
Symonds) •••••.
Babbb (£. Cresswell), adenoma of tongue ....
-communication (in absence) to discussion on the diagnosis and
treatment of empyema of the antrum of Higiimore
-papilloma of the nose
Balance-sheet, 1894 ......
BaIiL (J. B., M.D.), discussion on the diagnosis and treatment of empyema
of the antrum of Highmore .....
-case of lupus of the throat and nose . . . .
-a case of nasal deformity of traumatic origin .
-occlusion of right ik>8terior naris ....
-paralysis of right vocal cord ....
Bbnnbtt (P. W.), immobility of the left vocal cord .
-chronic congestion of larynx ....
Bowlby (A. A.), swelling of left side of larynx, with paralysis and
atrophy of left half of tongue and soft palate, and perichondritis
-tubercular disease of soft palate, larynx, pharynx, and lungs
-double abductor paralysis of uncertain origin, associated with
cystic bronchocele and dyspnoea; operation; improvement.
-aneurism of the aortic arch compressing the left pneumogastric
and recurrent laryngeal nerves and the trachea, and associated with
abductor paresis of the right cord ....
Breathing: case of lymphadenoma with obstructed breathing (James
13onelan, U.B.) ••..«.
Bronchocele: cystic bronchocele and dyspnoea associated with double
abductor paralysis of uncertain origin (A. A. Bowlby)
Bbonkeb (Adolph, M.D.), cystic fibroma of the left vocal cord .
-epithelioma of the epiglottis . . . .
-pachydermia with perichondritis ....
-discussion on the diagnosis and treatment of empyema of the
antrum of Highmore . . . . .
Butlik (Henry T.), chronic laryngitis ....
-recurrent” tumour at the back of the tongue; operation, June,
X889 .......
-case of large mass of malignant glands in the neck, with paralysis
of the corresponding sympathetic nerve and immobility of the same
side of the larynx ......
-case of paralysis of the right vocal cord of uncertain origin
Cannula: Krause’s cannula in treatment of empyema of antrum (J. Dundas
Grant, M.D.) ......
Council: report of Council, 1894 .....
-list of Officers and Council.....
Cbisp (Ernest H.), ? angioma of vocal cord ....
Curetting and lactic acid in treatment of tubercular ulceration of epiglottis
(Charters J. Symonds) .....
PAGE
20
27
27
1
54
63
32
59
64
66
77
78
3
17
9
11
19
20
13
19
4
4
12
54
22
42
79
80
68
31
33
16
28
91
PAGE
Diphtheria: supposed diphtheritic origin of paralysis of left vocal cord
associated with paralysis of soft palate (Scanes Spicer^ M.D.) . 26
DoneIiAN (James^ case of lymphadenoina with obstructed breathing 13
Dyspnoea: double abductor paralysis of uncertain origin associated with
cystic bronchocele and dyspnoea (A. A. Bowlby) . . .19
Ears: morbid conditions (B. Law, M.D.) . • . .48
Empyema: discussion on diagnosis and treatment of empyema of antrum
of Highmore ..... 53—61
--remarks by Felix Semon, M.D. . . 53, 60
-Adolph Bronner, M.D. . . .54
-Qreville MacDonald, M.D. . . .54
---communication from E. Cresswell Baber . . 54
---J. Ernest Lane . . . .55
-remarks by William Hill, M.D. . . .55
-W. J. Walsham . . . .56
-J. Dundas Grant, M.D. . . .57
-Scanes Spicer, M.D. . . .58
-J. B. Ball, M.D. . . . .59
--W. G. Spencer . . . .60
■ ■ - -exhibition of tube by W. J. England . . .61
- sections of masses curetted from antrum maxillare in cases of
empyema (Knyvett Gordon) . . . . .67
-of antrum, under treatment by means of Krause’s trocar (J.
Dundas Grant, M.D.) .... 67,68,69
-- and cannula (J. Dundas Grant, M.D.) . . 68
-- of antrum of Highmore (Scanes Spicer, M.D.). , .74
-radical cure (Scanes Spicer, M.D.) . . 41
-complicated with suppuration of (probably) the
frontal sinus (J. Dundas Grant, M.D.) . . . .67
England (W. J.), exhibition of gold tube attached to plate used in treat¬
ment of cases of empyema of the antrum of Highmore . . 61
Epiglottis: epithelioma of the epiglottis (Adolph Bronner, M.D.) . 4
- tubercular ulceration of epiglottis treated by curetting and lactic
acid (Charters J. Symonds) . . . . .28
Epithelioma of the epiglottis (Adolph Bronner, M.D.) . . 4
-of the pharynx (William Hill, M.D.) . . .71
- early epithelioma ? of the vocal cord (Charters J. Symonds) . 17
Fibroma: cystic fibroma of the left vocal cord (Adolph Bronner, M.D.) . 4
Fibro-papilloma of larynx causing indentation of opposite vocal cord (Felix
Semon, M.D.) . . . , . .74
Fibrosis of the thyroid (Walter G. Spencer) . . .24
Fistula in the neck (W. B. H. Stewart) . . . .85
-congenital (W. R. H. Stewart) . . .14
Fixation of right vocal cord (P. Willcocks, M.D.) . . .43
Food-passages: foreign bodies in food-passages (Felix Semon, M.D.) . 23
Foreign bodies in air- and food^passages (Felix Semon, M.D.) . . 23
Glands: large mass of malignant glands in the neck (Henry T. Butlin) . 79
Gordon (Knyvett), a section of a middle turbinate body with polypus
formation . . . . , .66
-sections of masses curetted from the antrum maxillare in cases of
empyema by Dr. Scanes Spicer
67
92
PAGE
Grant (J. Dundas, M.D.), hoarseness confined to the lower register of the
voice . . . . . . .43
-discussion on the diagnosis and treatment of empyema of the
antrum of Highmore . . . • .57
■■ empyema of antrum entirely cured by treatment by means of
Krause’s trocar . . . . . . G7
-of the antrum of Highmore complicated with suppuration
of (probably) the frontal sinus . . . .67
-case of empyema of the antrum under treatment by means of
Krause’s trocar . . . . . .68
-of the antrum greatly benefited by the use of Krause’s
trocar and cannula and closure of the alveolar perforation . . 68
-empyema of the antrum secondary to suppuration in the frontal
sinus, treated by means of Krause’s trocar with good result . 69
-a case of tubercular laryngitis . . . .69
case of laryngeal stenosis . . . . .80
Hall (F. de Havilland, M.D.), case of (?) chronic tuberculosis of the
larynx . . . . . .4
-a case of mycosis fungoides . . . .70
Hennig (Dr. Arthur), his oil studies of laryngeal and nasal disease demon¬
strated by Felix Semon, M.D. . . . .40
Hill (William, M.D.), moriform growths springing from the posterior
border of the nasal septum . . . . . 31
-ulcerative disease of the left nasal fossa of undoubted tubercular
nature, followed by lupoid disease of the left ala . . .34
-discussion on the diagnosis and treatment of empyema of the
antrum of Highmore . . . . .55
-disease of the frontal, ethmoidal and maxillary sinuses in associa¬
tion with nasal polypi . . . . .71
-epithelioma of the pharynx , . . .71
-case of syphilitic perichondritis of the larynx . . .82
Histology of turbinal hyperplasias (L. H. Pegler, M.D.) . . 84
Hoarseness confined to lower register of the voice (J. Dundas Grant, M.D.) 43
Hodgeinson (Alexander), exhibit of (1) quartz throat mirror for laryngo-
scopic purposes; (2) a magnifying laryngoscope. . . .35
Horns (W. Jobson) and Kanthage (A, A., M.D.), specimen of pachy¬
dermia syphilitica diffusa . . . « .82
Hunt (C.), microscopical specimens illustrating case of multiple papillomata
of larynx . . . . . .72
Hyperplasias (turbinal) : histology (L. H. Pegler, M.D.) . . 84
Immobility of the left vocal cord (F. W. Bennett) . . .3
Injury causing paralysis of left vocal cord (Charters J. Syraonds) . 50
Kanthage (A. A., M.D.), pathological specimen'of adenoid growths and
one of perforation of the nasal septum . . , .47
-and Horne (W. Jobson), specimen of pachydermia syphilitica
diffusa . • • • • • .82
Kidd (Percy, M.D.), laryngeal stenosis; polypoid growth from left vocal
cord, (?) syphilitic . . . . . .36
--laryngeal stenosis ; polypoid growth from left vocal cord , 73
93
PAGE
Krause’s trocar in treatment of empyema of antrum (J. Dundas Grants
. . . .67.68,69
-aod cannula in treatment of empyema of antrum (J,
Dundas Grant, M.D.) . . , . .68
Lactic acid (after curetting) in treatment of tubercular ulceration of epi¬
glottis (Charters J. Symonds) . . . .28
Lake (Richard), tonsillar mycosis. . , . .6
-lupus of the nose treated by thyroid extract , . .6
—tracheotomy tube worn for eleven years , , , 23
Laee (J. Ernest), communication (in absence) to discussion on the diagnosis
and treatment of empyema of the antrum of Highmore . . 55
Laryngitis (chronic) (H. T. Butlin) . . . .22
- 7 -— with anterior nasal stenosis, from cicatricial contraction
after ulceration (Scanes Spicer, M.D.) , . 40
-(tubercular) (J. Dundas Grant, M.D.) . * * 59
Larygoscope exhibited by Dr. A. Hodgkinson . . .35
Larynx: chronic congestion (P. W. Bennett) . . I 7
-oil studies of laryngeal disease by Dr. Arthur Hennig ! * 40
-case of laryngeal disease (Herbert Tilley, M.D.) . ’ gg
large and hard fibro-papillouaa of larynx, causing indentation of
opposite vocal cord (Felix Semon, M.D.) . . .74
imnaobility of left side of larynx in case of large mass of maliir*
nant glands in neck (Henry T. Butlin) . . • * 79
-lupus of pharynx and larynx (Felix Semon, M.D.) .* ‘ 39
-pachydermia laiyngis (Charters J. Symonds) . 29 Kl Rfi
-(Herbert Tilley, M.D.) . ' ’ ’ 52
-^ laijnx (°C‘Hlint/*"'”®”® illustrating case of multiple papillomata
-syphilitic perichondritis (William Hill, M.D.) ! i * 82
In'TYrnopaal afarirkovo / TTSJ J HiT Tx \ ^
36,73
. 80
8
48
— laryngeal stenosis (Percy Kidd, M.D.)
-(J• Dundas Grant, M.D.)
-supervening on typhoid fever (Scanes Spicer, M.D.)
-probably lupus (C. A. Parker) ’ '
swelling of left side of larynx, with paralysis and atrophy of left
hall of tongue and soft palate with perichondritis (A. A. Bowlbv)
- tubercular disease (Charters J. Symonds) . . ‘
TT palate, larynx, pharynx, and lungs (A. A. Bowlbv) "
? chronic tuberculosis of larynx (F. de Havilland Hall, M.D.) .
Lxw (Edward, M.D ), cedematons swellings of the palate and pharynx
case illustrating various morbid conditions of the nose and ears !
Librarian : report of Librarian ...
.nd'h-g, (A.'
Lupus of the nose treated by thyroid extract (Richard Lake)
- - lupoid disease of left ala, following ulcerative disease of
fossa of undoubted tubercular nature (William HilL M D )
-of pharynx and larynx (Felix Semon, M.D.) *
-l^yngeal stenosis, probably lupus (C. A. Parker)
-of the throat and nose (J. B. Ball, M.D.)
left nasal
- ——« xxwox? ytf, AX, uuil, JU.Lf.l
Lymphadenoma with obstructed breathing (James Donelan, M.B.)
McBbisx (P., M.D.), venous angioma of pharynx
MacDonaid (Greville, M.D.), discussion on the diagnosis and'treatment
of empyema of the antrum of Highmore . weatment
9
18
11
4
37
48
32
11
•6
34
39
48
64
13
29
54
94
PAGE
Malignant disease : case for diagnosis, whether tuberculous, malignant, or
syphilitic (Felix Seinon, M.D.) • , . .40
- glands in the neck (Henry T. Butlin) . . .79
Mirrot: quartz throat mirror exhibited by Dr. A. Hodgkinson . . 35
Moriform growths springing from the posterior border of nasal septum
(William Hill, M D.) . . . . ,34
Mycosis : tonsillar mycosis (Richard Lake) . . . .6
- fungoides (P. de Havilland Hall, M.D.) . . .70
Naris; occlusion of right posterior naris (J. B. Ball, M.D.) . . 77
Neck : congenital fistula of neck (W. R. H. Stewart) . 14, 85
Nerve (cervical sympathetic) ; paralysis in case of large mass of malignant
glands in neck (Henry T. Butlin) . . , .79
Nose: nasal deformity of traumatic origin (J. B. Ball, M.D.) . • GO
' oil studies of nasal disease by Dr. Arthur Hennig . . 40
—. . ■ lupus of nose treated by thyroid extract (Richard Lake) . 0
■■ - of the throat and nose (J. B. Ball, M.D.) . . 64
—- ' ■ morbid conditions (E. Law, M.D.) . . . .48
-moriform growths springing from posterior border of nasal septum
(William Hill, M.D.) . . . . .34
-papilloma (E. Cress well Baber) . . . .0:1
-papilloma nasi with rodent ulcer in an aged patient (P. de Santi) . 13
. . pathological specimen of perforation of nasal septum (A. A.
Kanthack, M.D.) . . . . . .47
-section of a middle turbinate body with polypus formation (Knyvett
Gordon) . . . . . . .66
-disease of frontal, ethmoidal and maxillary sinuses in association
with nasal polypi (William Hill, M.D.) . . .71
large nasal polypus from a patient aged eighty-seven (Charters J.
Symonds) . . . . . .86
-post-nasal sarcoma (Charters J. Symonds) . . .86
-anterior nasal stenosis from cicatricial contraction after ulceration
(Scanes Spicer, M.D.) . . . . .49
-ulcerative disease of left nasal fossa of undoubted tubercular nature
followed by lupoid disease of left ala (William Hill, M.D.) . .31
-tubercular ulceration of nose and pharynx (C. A. Parker) . 83
Nostril: see Naris,
Occlusion of right posterior naris (J. B, Ball, M.D.) . . .77
(Edema: oedematous swellings of the palate and pharynx (Edward Law,
M.D.) . . . . . . .37
Officers: list of Officers and Council • . . .33
Pachydermia with perichondritis (Adolph Bronner, M.D.) . . 12
-: laryngis (Charters J. Symonds) . . . 29, 51,86
--(Herbert Tilley, M.D.) . . . .52
—-syphilitica diffusa (A. A. Kanthack, M.D., and W. Jobson Horne) 82
Palate: oedematous swellings of palate and pharynx (Edward Law, M.D.) 37
-(soft) : paralysis and atrophy of left half of soft palate in case of
swelling of left side of larynx (A. A. Bowlby) . . .9
-paralysis of left vocal cord, associated with paralysis of soft
palate (? of diphtheritic origin) (Scanes Spicer, M.D.) . . 26
-tubercular disease of soft palate, larynx, pharynx, and lungs
(A. A. Bowlby) . . . . . .11
Papilloma: microscopical specimens illustrating case of multiple papillo
mala of larynx (C. Hunt) ....
72
95
Papilloma of nose (E. Cresswell Baber) . . . ,63
-nasi with rodent ulcer in an aged patient (P. de Santi) . . 13
-see also Fihro-jpapilloma,
Paralysis: double abductor paralysis of uncertain origin (A. A, Bowlby) . 19
-of corresponding sympathetic nerve in case of large mass of
malignant glands in the neck (Henry T. Butliu) . . .79
-of right vocal cord (J. B. Ball, M.B.) . , .78
-in case of aneurism of aortic arch (Scanes Spicer, M.D.) . 27
-of uncertain origin (Henry T. Butlin) . . 80
-of left vocal cord (Charters J. Symonds) . . .50
-associated with paralysis of soft palate (? of diphtheritic
origin) (Scanes Spicer, M.D.) . . . . .26
-after injury (Charters J. Symonds) . • .50
Paresis (abductor): aneurism of the aortic arch compressing the left
pneumogastric and recurrent laryngeal nerves and the trachea asso¬
ciated with abductor paresis of the right cord (A. A. Bowlby) . 20
Pabkee (C. A.), disease of tongue (for diagnosis) . . ,15
-laryngeal stenosis, probably lupus . . . .48
—^-case of tubercular ulceration of nose and pharynx . . 83
PjBttLKE (L. H., M.D.), microscopical sections illustrating the histology of
turbinal hyperplasias . . . • .84
Perichondritis in case of swelling of left side of larynx (A. A, Bowlby) . 9
-pachydermia with perichondritis (Adolph Bronner, M.D.) . 12
--(syphilitic) of larynx (William Hill, M.D.) . . .82
Pharynx : venous angioma of pharynx (P. McBride, M.D.) . . 29
-epithelioma (William Hill, M.D.) . . . .71
-lupus of pharynx and larynx (Felix Semon, M.D.) . . 39
-oedematous swellings of palate and pharynx (Edward Law, M.D.) . 37
-tubercular disease of soft palate, larynx, pharynx, and lungs (A. A.
Bowlby) . . • • • • .11
-tubercular ulceration of nose and pharynx (C. A. Parker) . 83
Polypus : specimens of polypi from the antrum (Charters J. Symonds) • 85
>■ nasal polypi associated with disease of frontal, ethmoidal, and
maxillary sinuses (William Hill, M.D.) . . . .71
-large nasal polypus from a patient aged eighty-seven (Charters J.
Symonds) . . • . /. , . ‘ , -86
-polypoid growth from left vocal cord (? syphilitic) in case of laryn- ^
geal stenosis (Percy Kidd, M.D.) . . • 36, /3
Quartz substituted for glass in throat mirror for laryngoscopic purposes,
exhibited by Dr. A. Hodgkinson . . • .35
Bespiration, see Breathing.
Santi (P. de), papilloma nasi with rodent ulcer in an aged patient . 13
Sarcoma (post-nasal) (Charters J. Symonds) . . . .86
Semon (Felix, M.D.), foreign bodies in the air- and food-passages . 23
-lupus of pharynx and larynx . • • •
_ . - demonstration of Dr. Arthur Hennig’s oil studies of laryngeal and
nasal disease . • • ^
_a case for diagnosis, whether tuberculous, malignant, or syphilitic 4b
_discussion on the diagnosis and treatment of empyema of the
antrum of Highmore . • • • 53,60
_a case in which a very large and hard fibro-papiUoma of the larynx
has caused indentation of the opposite vocal cord . • 74
96
PAGE
Septum (nasal). See Nose.
Sinus: empyema of antrum of Highmore complicated with suppuration of
(probably) the frontal sinus (J. Dundas Grant, M.D.) . . 67
-empyema of antrum secondary to suppuration of frontal sinus
(J. Dundas Grant, M.D.) . . . . . 69
disease of the frontal, ethmoidal and maxillary sinuses in association
with nasal polypi (William Hill, M.D.) . . .71
- - ■ suppuration of frontal sinus (J. Dundas Grant, M.D.) . 67, 69
■ -(Charters J. Symouds) . . . .74
Spbkcbb (Walter G.), fibrosis of the thyroid; partial thyroidectomy, tracheo¬
tomy and dilatation of the stenosed trachea
■ ■ discussion on the diagnosis and treatment of empyema of the antrum
of Highmore ......
Sficbb (Scanes, M.D.), tonsillar new growth
-laryngeal stenosis supervening on typhoid fever
. paralysis of left vocal cord associated with paralysis of soft palate
(? of diphtheritic origin) .....
-aneurism of the aortic arch with paralysis of right vocal cord
' radical cure of obstinate suppuration of the antrum of Highmore,
combined with intra-nasal and intra-antral polypi
■ " ■ ■ anterior nasal stenosis from cicatricial contraction after ulceration,
with consecutive chronic laryngitis ....
- — — discussion on the diagnosis and treatment of empyema of the
antrum of Highmore .....
- case of empyema of the antrum of Highmore .
Stenosis of larynx (Percy Kidd, M.D.) ... 36,
- -Dundas Grant, M.D.) ....
-supervening on typhoid fever (Scanes Spicer, M.D.)
- -probably lupus (C. A. Parker)
— ■' anterior nasal stenosis from cicatricial contraction after ulceration
(Scanes Spicer, M.D.) . ^ . . .
24
60
7
8
26
27
41
49
58
74
73
80
8
48
49
Stbwabt (W. R. H.), congenital fistula of the neck . . .14
-case of fistula in the neck . . . . .85
Suppuration of frontal sinus (J. Dundas Grant, M.D.) . 67, 69
-(Charters J. Symouds) . . . .74
- - (obstinate) of antrum of Highmore; radical cure (Scanes Spicer,
M.D.) . . . . . . .41
Symonds (Charters J.), early epithelioma ? of the vocal cord . . 17
-tubercular disease of the larynx . . . .18
—ankylosis (?) of the left arytaenoid joint . . .27
-tubercular ulceration of the epiglottis treated by curetting and
lactic acid • • . • . .28
" pachydermia laryngis . . . .29,61, 86
-paralysis of the left vocal cord . . . .50
- - --after injury . . .50
-suppuration of frontal sinus . . . .74
- ■■ specimens of polypi from the antrum . . .85
-large nasal polypus from a patient aged eighty-seven . . 86
-a post-nasal sarcoma . . . . .86
Syphilis : polypoid growth from left vocal cord (? syphilitic) (Percy Kidd,
M.D.) . . . . . . .36
-case for diagnosis, whether tuberculous, malignant, or syphilitic
(Felix Semon, M.D.) . . . . . 46
-pachydermia syphiliti^ji diffusa (A. A. Kanthack, M.D., and W.
Jobson Horne) • . . . . .82
-syphilitic perichondritis of larynx (William Hill, M.D.) . . 82
97
PAGE
Throat: lupus of throat and nose (J. B. Ball, M.D.) . . .64
Thyroid extract in treatment of lupus of nose (Richard Lake) • . 6
-: fibrosis of the thyroid (Walter Q. Spencer) . • .24
Thyroidectomy (partial) in case of fibrosis of thyroid (Walter G. Spencer) 24
Tilley (Herbert, M.D.), pachydermia laryngis . . .52
-case of laryngeal disease . . . . .86
Tongue : disease of tongue (for diagnosis) (C. A. Parker) . . 15
-adenoma of tongue (E. Cresswell Baber) . . .1
-paralysis and atrophy of left half of tongue in case of swelling of
left side of larynx (A. A. Bowlby) . . . .9
-recurrent tumour at back of tongue; operation, June, 1889 (Henry
T. Butlin) . . . . . .42
Tonsils: tonsillar mycosis (Richard Lake) . . . .6
-tonsillar new growth (Scanes Spicer, M.D.) . . .7
Trachea: dilatation of stenosed trachea in case of fibrosis of thyroid
(Walter G. Spencer) . . . . .24
Tracheotomy in case of fibrosis of thyroid (Walter G. Spencer) . . 24
-tube worn for eleven years (Richard Lake) . . .23
Traumatic origin of case of nasal deformity (J. B. Ball, M.D.) . . 66
Trocar: Krause^s trocar in treatment of empyema of antrum (J. Dundas
Grant, M.D.) . . . . . 67,68,69
Tuberculosis : case for diagnosis, whether tuberculous, malignant, or
syphilitic (Felix Semon, M.D.) . . , .46
-tubercular ulceration of epiglottis treated by curetting and lactic
acid (Charters J. Symonds) . . . . .28
— tubercular disease of the larynx (Charters J. Symonds) . . 18
- case of tubercular laryngitis (J. Dundas Grant, M.D.) . . 69
- ? chronic tuberculosis of larynx (F. de Havilland Hall, M.D.) . 4
-ulcerative disease of left nasal fossa of undoubted tubercular nature
(William Hill, M.D.) . . . . .34
-tubercular ulceration of nose and pharynx (C. A. Parker) . 83
-tubercular disease of soft palate, larynx, pharynx, and lungs (A. A.
Bowlby) . . . . . ,11
Tumour: recurrent tumour at back of tongue; operation, June, 1889
(Henry T. Butlin) . , . . . .42
Turbinal hyperplasias : histology (L. H. l^egler, M.D.) . , 84
Turbinate body, see Nose,
Typhoid fever followed by laryngeal stenosis (Scanes Spicer, M.D.) . 8
Ulcer; rodent ulcer on nose (P. de Santi) . . , .13
Ulceration : tubercular ulceration of nose and pharynx (C. A. Parker) . 83
Venous angioma of pharynx (P. McBride, M.D.) . .29
Vocal cord: ? angioma of vocal cord (Ernest H. Crisp) . . 16
-early epithelioma ? of the vocal cord (Charters J. Symonds) . 17
- (right) aneurism of the aortic arch, compressing the left pneumo-
gastric and recurrent laryngeal nerves and the trachea, associated
with abductor paresis of the right cord (A. A* Bowlby) . . 20
--large and hard fibro-papilloma of larynx causing indenta¬
tion of opposite vocal cord (Felix Semon, M.D.) . . .74
-fixation (P. Willcocks, M.D.) . . .43
FIRST SERIES—VOL. II. 10
98
Vocal cord (right): paralysis (J. B. Ball, M.B.) . . . TO
of uncertain origin (Henry T. Butlin) . * 80
^ -case of aneurism of aortic arch (Scenes Spicer,
-(left) cystic 6 broma of the left vocal’cord (Adolph Bronner, M.D i ^4
-immobility of left vocal cord (F. W. Bennett) . - 8
-paralysis (Charters J. Symonds) . . ! 50
after injury (Charters J. Symonds) . * 50
~7 - -.T V ' associated with paralysis of soft palate (? of diph^
thentic origin) (Scancs Spicer, M.D.) . , . ^ 26
-T ,-polypoid growth from left vocal cord (? syphilitic) in case
of laryngeal stenosis (Percy Kidd, M.D.) . . 36,73
Voice: hoarseness confined to lower register of voice (J. Dundas Grant.
' ' ■ • • . . .43
W.^SHAU (W. J.), discussion on the diagnosis and treatment of empyema
of the antrum of Highmore . . . . ^ .
WliioocKS (P., M.D.), fixation of right cord
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BARTHOLOMEW CLOSE, E.C., AND 20, HANOYBR SQUARE, W.
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