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3HT0N AND SUSSEX 


Uavy^<^olo^jca.l Socie 


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VOL. V. 

1897-98. 


WITH 

LISTS OF OFFICERS, SUPPLEMENTARY LIST OF MEMBERS, ETC. 


LONDON: 

PRINTED BY ADLARD AND SON, 
BARTHOLOMEW CLOSE, E.C. 


1898. 







k\k.i a 

1 . 5 B 

v.s-7 

OFFICERS AND COUNCIL 

OF THE 

||arpgologitaI J&ffaetjj of $£onbott 

ELECTED AT 

THE ANNUAL GENERAL MEETING, 

JANUARY 12th, 1898. 


H. TRENTHAM BUTLIN, F.R.C.S. 

J. W. BOND, M.D. A. BRONNER, M.D. 

F. DE HAVILLAND HALL, M.D. SOANES SPICER, M.D. 

T. J. WALKER, M.D. 

1 > 

treasurer. 

W. J. WALSHAM, F.R.O.S. 
librarian. 

J. DUNDAS GRANT, M.D-, F.R.C.S. 

Stcreiatus. 

HERBERT TILLEY, M.D., F.R.O.S. WILLIAM HILL, M.D., B.Sc. 

(Kmnrnl. 

A. A. KANTHACK, M.D. W. R. H. STEWART, F.R.C.S. (Edin.). 
SIR F. SEMON, M.D. StCLAIR THOMSON, M.D. 

P. WATSON WILLIAMS, M.D. 



PRESIDENTS OF THE SOCIETY. 

(From its Formation.) 

ELECTED 

1893 Sir George Johnson, M.D., F.E.S. 

1894 Sir Felix Semon, M.D., F.E.C.F. 

1895 Sir Felix Semon, M.D., F.E.C.P. 

1896 Sir Felix Semon, M.D., F.E.C.P. 


1897 H. Trentham Butlin, F.E.C.S. 



^ar^ngoCogicaC tpociety of London. 

SUPPLEMENTARY LIST OF MEMBERS 
(To July, 1898). 


LONDON. 

Elected 

1898 Fallows, John, L.R.C.S.Edin., 2, Princes Mansions, 66, 
Victoria street, W. 

1898 Fergusson, Arnold, F.R.C.S.Edin., 34, Canfield gardens, 
Hampstead. 

1897 Lamplough, Charles, M.R.C.S.Eng., L.R.C.P.Lond., Chest 
Hospital, Victoria park. 

1897 McIlraith, Charles Hugh, M.A., M.D.Glas., 17, Stra- 
della road, Herne Hill, S.E. 

1897 Paget, Stephen, F.R.C.S.Eng., M.A.Oxon., 70, Harley 
street, W. 

1897 Ramsay, Herbert, F.R.C.S.Edin., 35a, Hertford street, 

Mavfair. 

•> 

1898 Robinson, Henry B., M.S.Lond., F.R.C.S.Eng., 1, Upper 

Wimpole street, W. 

1898 Steward, Francis J., M.S.Lond., F.R.C.S.Eng., 24, 
St. Thomas’s street, S.E. 

COUNTRY. 

Bean, Charles Edward, F.R.C.S.Edin., M.R.C.S. and 
L.R.C.P.Lond., 19, Lockyer street, Plymouth 
Burt, Albert H., M.R.C.S., L.R.C P.Eng., Throat Hos¬ 
pital, Brighton. 

Claremont, Claude C, M.D., B.S.Lond., 57, Elm grove, 
Southsea. 

Foxcroft, Frederick Walter, M.B , C.M.Edin., 32, Para¬ 
dise street, Birmingham. 

Frazer, William, M.R.C.S , L.R.C.P.Eng, Johannesburg. 
Hutchinson, Arthur, M.A., M B., C.M Glas., 225, Bath 
street, Glasgow. 


1897 

1898 
1898 

1897 

1898 
1898 




VI 


Elected 

1898 Kelly, Adam B, M.B., C.M., 26, Blythswood square, 
Glasgow. 

1898 Marsh, Frank, F.R.C.S.Eng., 34, Paradise street, Bir¬ 
mingham. 

1898 Scatliff, John E., M.D.Aberd., M.R.C.S.Eng., 11, Char¬ 
lotte street, Brighton. 

1897 Snell, Sydney, M.D., B.S.Lond., M.R.C.S.Eng., L.R.C.P. 
Lond., D.P.H., Shaftesbury House, Grays, Essex. 


PROCEEDINGS 

OP THE 

LARYNGOLOGICAL SOCIETY OF LONDON. 


Ordinary Meeting, November \0th, 1897. 


Henry T. Butlin, Esq., F.R.C.S., in the Chair. 


StClair Thomson, M/D., 1 
Herbert Tilley, M.D., ) 


Secretaries. 


Present—42 members and 6 visitors. 

The minutes of the previous meeting were read and confirmed. 

Mr. Stephen Paget, F.R.C.S.Eng., and Charles Mcllwraith, M.D. 
(Glasgow), were elected ordinary members of the Society. 

The following gentlemen were nominated for election at the next 
Ordinary Meeting of the Society : 

Charles Lamplough, M.R.C.S., L.R.C.P., Chest Hospital, Victoria 
Park. 

Sydney Snell, M.D., B.S. (Lond.), M.R.C.S., Grays, Essex. 

Charles Edward Bean, F.R.C.S. (Edin.),M.R.C.S. (Eng.), L.R.C.P. 
(Lond.), of Plymouth. 

Frederick Walter Foxcroft, M.B., C.M. (Edin.), of Birmingham. 
Herbert Ramsay, F.R.C.S. (Edin.), of London. 


New Tracheotomy Tube for Permanent Use. 

The designer, Mr. W. Heywood, a working jeweller, of 81, Davies 
Street, W., was introduced by Sir Felix Semon, and exhibited the 
instrument. 


FIRST SERIES-YOL. V„ 


1 


2 


The main tube is similar to that of an ordinary tracheotomy tube, 
but has a small, easily removable metal box, fitting into the proximal 
end of the tube. The anterior wall of the box is replaced by a 
narrow metal bar, and hanging from the upper surface of the box, a 
little way from its anterior extremity, is a light metal flap, so inclined 
that a current of inspired air easily passes through the box, but on 
expiration the metal flap is driven forward, and effectually acts as a 
“stop” to expiration through the tube. Hence the patient can 
(in this case suffering from abductor paralysis) phonate quite easily 
without placing his finger on the proximal end of the tube, as is 
necessary in the ordinary patterns. Moreover the little box is very 
easily detached and cleaned, and having a larger and freer lumen is 
much less liable to become obstructed by mucus than the common 
tracheotomy tubes. 

The inventor acknowledged that he derived the idea of the instru¬ 
ment from Mr. de Santi’s tube, but considered the new design pre¬ 
sented advantages over any previously invented tracheotomy tubes. 

Mr. de Santi remarked that the new tracheotomy tube for per¬ 
manent use shown by Sir F. Semon’s patient was practically a 
modification of his own shown some time ago at the Society’s meeting. 
He, however, considered that the present modification was a distinct 
gain, because it gave more breathing space and was far easier to clean 
than his own tube. He had two patients, however, who were wearing 
and were well satisfied with his tube, and his friend Mr. Bowlby also 
had a couple of patients wearing his tube with great satisfaction. 
He congratulated Sir F. Semon’s patient on the improvements he had 
made, and hoped he would get the patent he had applied for. 


Syringe for making Submucous Injections in Laryngeal 

Tuberculosis. 

Dr. Donelan showed a syringe for this purpose. His attention 
was recalled to this treatment by Dr. Chappell’s paper, read before 
the New York Laryngological Society in 1895, reporting a number of 
successes with this method. The exhibitor since that time tried the 
injections in seven cases of advanced laryngeal tuberculosis which 
had proved refractory to curetting and lactic acid, and was able 
to speak most favorably of the effect of the injections on the 
local condition. The syringe consists of a steel barrel and tube 
mounted on a modified “ pistol handle.” The tube has a rect- 



3 


angular laryngeal curve, and at the distal end a rather coarse thread, 
capable of carrying safely nozzles varying in length according 
to the depth at which it is desired to make the injections. Each 
nozzle terminates in a rounded shoulder from which a hollow needle 
projects £ inch, that being the depth of puncture found necessary to 
insure retention of the fluid. As it was found that the creasote 
speedily rendered the piston leathers useless, these were replaced in 
this syringe by a “ plunger ” fitting closely to the interior of the 
barrel and graduated in minims. The whole instrument and its case 
are therefore sterilisable. 

The syringe is filled by pouring guaiacol into the barrel until it is 
full, and the oil begins to drip from the needle. The plunger is 
replaced and compressed until only the desired dose is left in the 
barrel. The needle is then guided by the laryngoscope into the pre¬ 
viously cocainised larynx, and inserted in the site selected. Then the 
thumb is placed in the button of the plunger, which is driven quickly 
home. The needle should not be withdrawn if possible for a moment 
or two longer. 

In the cases referred to the injections were followed by remarkably 
little local reaction, which was always controlled by sucking ice. The 
most remarkable immediate effect of this treatment was the relief of 
dysphagia, especially after two to three injections. 

In another case an obstinate tubercular ulcer in the interarytsenoid 
fold was quite cured. The injections were made at intervals of from 
four days to a week. The dose was generally one minim of pure 
guaiacol, and never more than two minims in obstinate cases. 
Besides the injections the most important part of the treatment was 
the frequent cleansing of the larynx by antiseptic and other sprays, 
most frequently an oily solution of guaiacol. 


Case of Fibro-sarcoma of the Nasal Septum. 

Shown by Dr. J. B. Ball. Emily P—, set. 26, seen August 14th, 
1897, complaining of a stoppage of the nose. About three or four 
months previously she began to suffer from repeated attacks of 
epistaxis. The bleeding was from the left nostril at first, but subse¬ 
quently from both nostrils. During the last two or three months the 
nose gradually became more and more obstructed, first the left side, 



4 


then the right, but the bleeding was less frequent and severe than 
before. She had experienced no pain. 

Examination showed each passage to be almost completely ob¬ 
structed by a smooth pinkish mass presenting in the upper part of 
each vestibule. Its attachment was made out to be to the carti¬ 
laginous septum. The posterior choanae were found to be free, and 
the growth could not be felt with the finger passed into the posterior 
nares. 

A small portion of the tumour was removed with a snare from the 
left side for microscopical examination. Its removal was followed by 
brisk haemorrhage. The Clinical Research Association’s report was 
that the growth consisted of young connective tissue, and might be 
termed a fibro-sarcoma. 

On August 24th the growth was removed by Mr. Swinford Edwards. 
Eor this purpose the left ala nasi was detached and turned up, and 
the growth was easily removed together with a certain amount of the 
cartilaginous septum. The greater part of the cartilage had, however, 
been absorbed. The tumour was about the size of.a walnut, and 
presented a constriction towards the right side marking the point 
where it had grown through the septum. 

The patient was shown together with the tumour and microscopical 
specimen. 


Tumour of Tongue—Patient and Specimen. 

Shown by Mr. Morley Agar. The tumour was removed from the 
right posterior dorsum of tongue in a lad set. 15. It was readily 
enucleated, and followed by very little haemorrhage. The growth had 
apparently only taken one week to attain its size. 

Mr. BuTiiiN suggested that it was a fibroma or fibro-sarcoma, and 
noticed a thickening around the area of removal which was suspicious 
of its sarcomatous nature. At his suggestion the specimen was 
submitted to the Morbid Growths Committee for examination. 


Separation of Old-standing Adhesion of the Soft Palate to 

the Pharynx. 

Shown by Mr. W. G. Spencer. The patient, a middle-aged 
woman, had suffered severely from tertiary syphilis, and the soft 



5 


palate had become completely united to the back wall of the pharynx. 
As a result of this she had great pain in the ears and over the 
mastoid processes, as well as collections of muco-pus which she could 
not expel from the nose. Antisyphilitic remedies had ceased to give 
any relief, and so severe and continuous was the pain that her general 
health and spirits had become impaired. 

When she was anaesthetised, the mouth gagged open, and the 
tongue depressed, the respiration became bad or stopped. Therefore 
the operation had to be carried out with only a partially opened 
mouth. The head was hanging low. The line of union between the 
palate and pharyngeal wall was first incised by an angular cleft palate 
knife, when it was found that the whole of the naso-pharynx above the 
palate was filled by dense fibrous tissue. This was penetrated from 
the mouth by using cleft palate raspatories, and from the nose by 
thrusting in a strong pair of nasal dilators. The soft palate was after 
this drawn forwards and fixed by two silk sutures to the muco- 
periosteum of the hard palate. There was free venous haemorrhage 
during and after the operation, but the nose and naso-pharynx could 
not be plugged because the soft palate largely obstructed respiration 
through the mouth. The haemorrhage stopped the next day. The 
sutures holding the soft palate forwards cut out in about a week. 
The separation has since then been kept up by the patient passing 
full-sized nasal bougies, and by stretching at intervals of a fortnight 
the soft palate by using an aneurism needle under cocaine. The 
patient has lost the pain in the ears, and can breathe easily through 
and blow the nose. She is now in very good health, and is cheerful. 
The opening will admit two fingers when the palate is stretched; the 
latter is mobile. There is still a small muco-purulent discharge. 

It is generally held that the occurrence of these adhesions cannot 
be prevented by any of the contrivances which have been proposed, 
and that it is useless to separate them when formed, owing to the 
tendency to recurrence. This opinion is no doubt correct as a rule, 
and Mr. Spencer had not heard of a successful case. But this 
patient is brought forward to show that, granted sufficient indications, 
the operation may be undertaken with some hope of affording relief. 
It will doubtless be necessary to keep up the dilatation in the present 
case for some time. 

No better way of operating seems to have been proposed. 
Measures which entail the cutting or partial excision of the soft palate 



6 


would be likely to set up fresh trouble, owing to the passage of food 
into the nostrils. 

Mr. de Santi congratulated Mr. Spencer on his excellent result. 
He had a similar case under observation where the patient had severe 
pain in the ear and mastoid; he intended to try Mr. Spencer’s method 
of operation. 


Papilloma of the Tonsil. 

Dr. William Hill showed two tonsils, on the surface of each of 
which a papillary growth, about one third of an inch in diameter, was 
seen. They had been removed from a female and male, set. 21 and 22 
respectively, who were sufferers from chronic pharyngitis. Although 
these neoplasms were common enough on the palate and pillars of the 
fauces, little information appeared to be obtainable of papillary 
growths springing from the surface of the faucial tonsils. It was 
suggested that these cases might, up to now, have been considered too 
trivial to be worth recording. A papilloma on the tonsil in a middle- 
aged person, however, might in certain circumstances be of much 
clinical significance. 

Messrs. Wingrave and Waggett reported having met with cases 
similar to those described by Dr. Hill. In Mr. Wingrave’s case the 
papilloma seemed to be attached to the base of a follicle. 

Sir Felix Semon thought it would be of great interest if members 
would bring full reports of such cases, and expressed surprise that so 
many cases had been seen by members of the Society. Hitherto he 
had shared in the general belief that benign tumours of the tonsil 
were practically non-existent. 

Mr. Btjtlin recalled two cases of papilloma of the tonsil, and 
agreed that it would be well to obtain full reports of any such cases 
occurring in future. 

Dr. Jobson Horne remarked that he had met with these growths 
on the tonsils, and referred to notes of two cases. Case 1.—January 
25th, 1894. Edward C—, set. 17, with a history of a sore throat 
extending over six months. A papilloma of the size of a boot button, 
surface finely papillated, springing from the lower part of the left 
tonsil close to the junction of the anterior pillar with the base of the 
tongue. Both tonsils were hypertrophied and indurated. Case 2.— 
May 22nd, 1896. Sarah E—, set. 48, subject to sore throats for 
fifteen months. Follicular tonsillitis, follicles of right tonsil plugged ; 
projecting from behind anterior pillar on right side, and lying across 
the upper surface of the tonsil, was a smooth white polypoid growth 
attached to a stalk running behind tonsil. After removal of growth 



7 


the abnormal sensations and discomfort referred to the fauces 
disappeared. 

Mr. Macleod Yeabsley said that in 1894 he saw a patient, aged 
45, who presented a small polypoid growth about the size of a grape- 
stone at the upper part of the left tonsil, which was itself enlarged. 
It had only been noticed by her for about four weeks, and caused no 
symptom beyond a frequent desire to swallow. It was removed under 
cocaine and did not recur. On section it was found to consist of 
adenoid tissue with a covering of stratified epithelium. At one spot 
in the growth was a small haemorrhage. 


Lupus of the Larynx. 

Dr. William Hill showed a young girl, set. 13, who had been 
brought before the Society last winter, when she had lupus of the tip 
of the nose and palate. By persistent scraping and cauterisation (she 
had been under an anaesthetic nearly twenty times) the nose and palate 
had healed by August last, and the epiglottis showed no infiltration at 
that period, when she was sent to a convalescent home. Six weeks 
ago the patient presented herself again, complaining of cough; on 
examination the epiglottis was seen to be thickened and infiltrated 
and rather pale,—in fact, very suggestive of the ordinary form of 
tuberculosis ; now, however, it was red, irregular and granular on the 
surface, and conforming with the appearances of chronic tubercular 
lupus. The patient also had a patch of lupus on the face and on the 
left foot. 

Dr. Dundas Grant thought it a case of lupus of the larynx. 

Dr. Beale had seen many such cases, and found the surface of the 
epiglottis remained free from ulceration, and therefore he advised 
leaving the local condition alone. 

Dr. Hill, in reply, said he purposed trying a new form of tuber¬ 
culin. 


Cyst of Epiglottis. 

Shown by Dr. Jobson Horne. The patient, a man set. 36, com¬ 
plained of cough and wasting. Pnlmohary tuberculosis was diagnosed, 
and it was whilst looking for evidence of tubercle in the larynx that 
he met with this cyst on the epiglottis. 

The cyst had the appearance of a small grape ; it was tense, slightly 
translucent, and coursed by vessels. It was situated on the lingual 



8 


surface of the epiglottis, occupying the left half, and was attached by 
a broad base close to the free edge. 

The man had been suffering from dysphagia for six months; for some 
time he had been taking only food fairly chopped, but latterly had 
had to reject even fluid food. The dysphagia had been so gradual in 
developing that he regarded it as occasioned by his general ill-health. 

The cyst was removed with a hot snare, a faint linear scar indicating 
its situation. It contained a watery thin fluid. Since the removal 
of the cyst dysphagia had completely disappeared, the cough had been 
less, and the man’s health had considerably improved. 

Dr. Horne considered that in the interarytaenoid folds there was 
evidence of a deposition of tubercle. 

In both nostrils the mucous membrane of the turbinal borders was 
in a condition of true hypertrophy, and was causing partial obstruction. 

Mr. Cresswell Baber instanced a case of a child set. five 
months in whom there was a cyst, about the size of a marble (appa¬ 
rently congenital), to the right side of the epiglottis. It produced 
noisy respiration and occasional dyspnoea. The cyst was ruptured by 
means of forceps, and collapsed completely. The breathing was 
relieved. 

Dr. Bronner, Sir Felix Semon, and Dr. Dundas Grant reported 
similar cases in which large cysts had been present and given rise to 
well-marked symptoms. 


Case op Paralysis of Right Vocal Cord, Right Side of Soft 
Palate, and Right Side of Pharynx, probably due to 
Nerve Lesion high up in Neck. 

Shown by Dr. Scanes Spicer. J. W—, set. 72. Has been a 
smith. In good health until Christmas, 1896, when after a cold he 
became hoarse and had difficulty of swallowing; no difficulty of 
breathing even on exertion, though occasionally his breathing is 
noisy; when first ill could not lie on his left side. On examination 
the right vocal cord is seen to be immobile and in the middle line; 
the right arytsenoid cartilage jerks a little on commencing phonation 
there is no marked alteration in contour of the right crico-arytsenoid 
joint, and the left side of the larynx is normal. The right side of 
soft palate is paretic, the faucial arch being lower than the other and 
flatter, and the patient states he does not feel as well on right side of 
pharynx as on left when probed. The tongue, sterno-mastoid, and 



9 


trapezius are not paretic or wasted. These points were confirmed by 
Dr. Wilfrid Harris, who also examined the chest with a negative 
result. No evidence of pressure in neck. By process of exclusion it 
appears probable that some lesion has involved some of the roots of 
the spinal accessory and vagus, perhaps a peribulbar pachymenin¬ 
gitis, or possibly focal degeneration of bulbar or spinal nerve cells. 

The patient denies specific history, and there are no evidences of it. 
He has, however, been taking iodide of potassium, ten-grain doses 
thrice daily, for three months, without any marked change in condition 
three weeks ago. ' • 

Dr. Hall was inclined to view the local appearances as due to 
inflammatory mischief. 

Sir Felix Semon thought the appearances were almost within 
physiological limits, in which Mr. Btjtlin agreed; but Dr. Grant 
thought the palate paralysis was quite marked. 

Dr. StClair Thomson also confirmed Dr. Grant’s opinion, and 
observed that Dr. Hughlings Jackson laid stress on observing the 
soft palate in all cases of motor impairment, and to accept as 
distinctly typical of hemiparesis that condition in which on phona- 
tion one side of the palate remained lax, while the opposite showed a 
contraction dimple, and the median raphe was drawn towards the 
unaffected side. 

In reply, Dr. Scanes Spicer thought that the palate condition had 
altered since his last examination, and the faucial arches were now of 
equal height. 


Case of Chronic Lateral Hypertrophic Laryngitis simulating 

Malignant Disease. 

Shown by Dr. Herbert Tilley. Patient is a male set. 38. He 
had suffered from hoarseness for six months, but no pain or difficulty 
of swallowing, and has not lost weight to any appreciable degree. 

He is a confirmed asthmatic, and has to rise every night to smoke 
his “ powder.” 

On examination the right vocal cord is seen to be quite immobile 
on phonation. It is in parts of a pale milky colour. The thickening 
extends nearly the whole length of the cord, and some is seen in 
the anterior commissure. 

There is an enlarged gland in the right submaxillary triangle. 



10 


Sir Felix Semon said that it was only fair to say that the title of 
the case was really due to his suggestion made some week or two ago, 
when he saw the case in consultation with Dr. Herbert Tilley, who 
had brought the patient to him for confirmation as a case of malig¬ 
nant disease, and to discuss the advisability of operating. Appear¬ 
ances in the patient’s larynx had since altered, and now he felt 
inclined also to look upon it as malignant, but would not like to be 
positive in the matter. 

Dr. Bronner suggested removing a piece for microscopic examina¬ 
tion, and Dr. Dundas Grant asked that the sputa might be examined 
for tubercle bacilli. 

Dr. Herbert Tilley, in reply, stated that he thought there was 
no suggestion of tubercle in the case; the patient was a great sufferer 
from asthma, and asthma and phthisis were rarely found together. 
It would be difficult to examine his sputum, as it was impossible to 
obtain anything except small pellets of clear mucus, which he expecto¬ 
rated after burning his “ asthma powder.” He thought the case 
would turn out to be malignant. 


Thyro-hyoid Cyst. 

Shown by Mr. Wyatt Wingrave. A little girl, set. 5, when 
first seen complained of a “ running sore ” in her neck. Her history 
was that ever since a few months old a swelling had existed below her 
chin, which gradually grew to the size of a cobnut. Twelve months 
ago, becoming red and tender, it was “ cut ” by her doctor, and had 
discharged ever since. 

On examination the aperture of a fistula was seen in the middle 
line of the neck, superficial and apparently attached to the isthmus of 
the thyroid body, moving with deglutition and discharging pus-like 
matter, which was found to consist of epithelial cells undergoing fatty 
degeneration, suggestive of colostrum corpuscles. 

From its situation, anatomical relations, and history it was 
diagnosed as the vestige of a cystic thyro-hyoid duct. 

It was dissected out, and on microscopical examination presented an 
irregularly corrugated canal with diverticula, lined by spheroidal and 
ciliated “ palisade ” epithelium, resting on an ill-defined hyaline base¬ 
ment membrane, outside which were occasional clusters of small-cell 
tissue. The wall or capsules was composed of densely packed bundles 
of white fibrous tissue. 

These histological details exactly correspond with those occurring 

a perforation made two years ago from a case under the care of 



11 


Dr. Dundas Grant, and although such examples may not be of un¬ 
frequent occurrence clinically, in the absence of other microscopic 
records relating to this particular portion of the thyreo-glossal duct 
they may be of interest to the Society. 

Mr. Butlin had removed two or three of such cysts with their 
ducts, and had been obliged to follow the latter up to the base of the 
tongue by going in front of the hyoid bone. 

Mr. Walsh am and Mr. Stewart reported similar cases. 


Case of Necrosis of the Left Inferior Turbinal with a 
History of Traumatism. 

Shown by Dr. Pegler. Mrs. A—, seen July, 1897, complained 
of discharge from and obstruction in the left nostril. When a young 
woman she had struck her nose violently against a post. The organ 
was said to have been broken, and there was much epistaxis at the 
time. Since that time there had been some trouble connected with it, 
i.e. obstruction, offensive discharge, and more recently bleeding. 
Two pieces of dead bone are said to have been taken away some time 
ago. 

Externally there is now some deflection of nose to the right. 
There is a mucocele in the inner canthus of the left eye. A mass of 
granulation tissue blocks up the left meatus and is bathed in pus. 
With the probe a rough grating may be felt beneath the granulations 
like that of dead bone. Little has been done in treatment, owing to 
patient’s objection to an anaesthetic. 

Such cases are probably not rare, but have not received the 
attention they deserve, and the exhibitor would like the opinions 
and experiences of members of the Society in similar cases. 

Mr. Cresswell Baber thought the rough body in the left nasal 
cavity was either a piece of necrosed bone, a rhinolith, or a foreign 
body. He advised its removal with forceps after it had been, if 
necessary, broken up. 

Mr. Walsham said he thought the mass would easily come away. 

Dr. StClair Thomson thought that the history of injury dated 
rather far back, but that if trauma was actually the cause it was 
important to put such a case on record along with Mr. Walsham’s, 
for Tissier said that necrosis of a turbinal was so pathognomonic of 
syphilis, that whenever found it was superfluous to inquire for a 
specific history. 1 

1 * Wiener klin. Wochenschrift,’ No. 37,1897. 



12 


Dr. Pegler, in reply, stated that he had not regarded the case 
as syphilitic, because the appearances were entirely different from 
what he had seen of that disease. 

In reply to Dr. StClair Thomson, the history might be rather 
ancient, but the woman was very intelligent in the matter. There 
seemed to be a definite continuation of nose trouble, traceable directly 
back to the date of the accident. 

In reply to Dr. William Hill, there was no reason why the 
case should not be regarded as one of rhinolith with dead turbinate 
bone for a nucleus. 


Disease of the Right Yocal Band for Diagnosis. 

Shown by Dr. Pegler. E. C—, set. 56, complains of loss of 
voice. 

History .—The trouble commenced five or six years ago by a 
feeling as of always wanting to swallow; this was followed by a bad 
cough. Her voice gradually left her, and has never returned. The 
woman has had seven children born alive; the eighth pregnancy ter¬ 
minated in a miscarriage. There is no pain in the throat. 

Laryngoscopically the most conspicuous object is a deep red some¬ 
what conical growth occupying the upper surface of the anterior third 
of the right vocal band. The right vocal cord is entirely concealed, 
the left is intensely red. The arytsenoid cartilages move freely and 
equally on attempts at phonation, and there was no infiltration of the 
laryngeal structures. 

Mr. Butlin thought a piece of growth might be removed, in which 
Sir Felix Semon concurred. 

In reply to the President, Dr. Pegler said he had not been able 
to decide between malignant disease and syphilis. Dr. Whistler had ex¬ 
amined the patient with him, and was inclined to regard it as syphilitic; 
he should try the effects of an antisyphilitic treatment in the first 
instance. 


Prolapse of Yentricle of Morgagni. 

Dr. Worthington, who showed the case for Dr. Percy Kidd, said 
that there was dyspnoea and stridor for three weeks before her admis¬ 
sion to hospital, and great dyspnoea on admission ; also great oedema 
of epiglottis, which subsided in a day or two, leaving the small tumour 
which is now seen. 



Dr. StClair Thomson reminded the Society that Koschier— 
Stoerk’s first assistant—had published a paper founded on the 
histological examination of nineteen cases, and demonstrating that 
there was no actual eversion of the sinus in the condition known as 
“ prolapse of the ventricle of Morgagni.” Such cases turned out to 
be solid tumours, cystic or fibromatous, taking their origin from the 
wall of the sinus; but the actual wall of the sinus remained in situ. 

Dr. Bond also made remarks on the case. 


Case op Early Tubercular Laryngitis. 

Shown by Dr. Lawrence. C. N—, set. 22, general servant. One 
sister of nine suffers from “ weak chest/’ Patient lost her voice two 
years ago, and at that time had atrophic rhinitis, pharyngitis, and 
laryngitis. She quite recovered from this under appropriate constitu¬ 
tional and local treatment. There is almost complete aphonia now, 
and pharynx is as before. Vocal cords do not move freely, and there 
is a small pinkish swelling in the interarytaenoid space. 

Examination of chest shows a flattening and impairment of the 
note at right apex, fine crepitations and cogwheel breathing under 
right clavicle. The exhibitor considered these latter symptoms with 
the swelling of the interarytaenoid space indicated early tubercular 
laryngitis. 

Dr. Beale thought there was no evidence of tubercle, but only 
chronic laryngitis, which was probably secondary to nasal disease,—an 
opinion in which Mr. de Santi agreed. 




PROCEEDINGS 


OP THE 

LARYNGOLOGICAL SOCIETY OF LONDON. 


Ordinary Meeting, December 8 th , 1897. 


Cresswell Baber, Esq., M.B., in the Chair. 

teTiu?" 1 “ rie3 - 


Present—33 members and 5 visitors. 


The minutes of the previous meeting were read and confirmed. 

The following gentlemen were elected as ordinary members of the 
Society : 

Charles Lamplough, M.R.C.S., L.R.C.P. 

Sydney Snell, M.D., B.S. (Bond.), M.R.C.S. 

Charles Edward Bean, F.R.C.S. (Edin.), M.R.C.S. (Eng.), L.R.C.P. 
Frederick Walter Foxcroft, M.B., C.M. (Edin.). 

Herbert Ramsay, F.R.C.S. (Edin.). 


The Position and Condition of the Yocal Lips in the 
Chest and Head Registers. 

Dr. Jobson Horne, on behalf of Dr. Musehold, of Berlin, showed 
a series of photographs of the larynx demonstrating the above con¬ 
ditions. Dr. Horne referred to the researches of Dr. Musehold, 
and drew attention to what he understood from Dr. Musehold to be 
the more important conclusions which had been arrived at with the 
help of the stroboscope, and which the photographs demonstrated. 

FIRST SERIES—VOL. V.. 2 



16 


In the chest register it was seen that the glottis is “ opened and 
shut, whereas in the head register it is “ widened and narrowed,” 
a difference still more demonstrated with the stroboscope. 

The cords themselves in the chest register, and more particularly 
in the production of loud chest-notes, showed a rounded or tumid 
form. This was accounted for by the expiratory current of air 
meeting with an increased resistance, and forcing the cords upwards ; 
and it was the analogy of this condition of the cords with the con¬ 
dition of the lips when applied to the mouth-piece of a trumpet in 
producing loud notes that suggested the term “ vocal lips ” in the 
present instance. 

The photographs further showed that the deposition of the mucus 
secreted on to the cords was along different lines in the two registers; 
this was attributed to a difference in the manner and intensity of the 
vibrations. 

For a more detailed description of the photographs and of the 
photographic apparatus and stroboscope used, Dr. Horne referred to 
Dr. Musehold’s paper which had recently appeared in the “ Archiv fur 
Laryngologie und Rhinologie.’ 


Defect of Speech resulting from Paresis of Soft Palate, 

OCCASIONED BY LYMPHOMATOUS TUMOURS PROJECTING POS¬ 
TERIORLY FROM EITHER SIDE OF THE SePI’UM. 

Shown by Dr. Pegler. The patient is a youth set. 23. The 
defect of speech precisely resembled that of cleft palate. 

There was complete nasal obstruction, depending upon hyper¬ 
trophies and moriform bodies attached to both middle and inferior 
turbinates, &c., in addition to the septal growths. A diffuse lymphoid 
mass presenting a well-marked Tornwaldt's bursa lined the roof of 
the nasopharynx, but there were no post-nasal adenoids. 

The appearances of the septal lymphomata and microscopical 
sections (here shown), displaying pure lymphoid tissue throughout, 
were described in two recent numbers of the * Journal of Laryngology * 
(9 and 12). The growths were exceedingly tough, and had been 
taken away by means of the turbinotome. The other sources of 
obstruction having also been removed, nasal respiration was quite 
free. A much thickened septum is exposed. 

The drawings handed round showed the post-rhinal image before 



17 


and after operation. Papilliform lymphoid hyperplasiae had been 
suspected to occur by Jonathan Wright and others, but these were the 
first that had been microscoped and recorded so far as Dr. Pegler was 
aware. The paresis of the palate was bilateral and reflex, and the 
defect of speech remained, but was improving. 


The Case of Apparent Necrosis of Left Inferior Turbinate 
following Injury shown at the Last Meeting by 
Dr. Pegler. 

The patient was brought up again to show the condition of the 
nasal fossa after the loose body had been removed, and also the 
fragments themselves. The granulating surface was entirely healed 
over. The two pieces handed round had all the appearance of necrosed 
inferior turbinate bone encrusted with lime. The precise date at 
which pieces of dead bone had been extracted after the original acci¬ 
dent had been ascertained. Dr. Pegler said he should be happy 
to have sections made if that were possible and report again. 


Papillomata of Paucial Tonsil. 

Shown by Mr. Wyatt Wingrave. The interest exhibited in Dr. 
Hill’s cases shown at the last meeting, and the suggestion made by the 
President and Sir P. Semon, induced the exhibitor to present two 
examples occurring in his own practice. 

1. Papilloma removed from the left tonsil of a man set. 44. 
Consisted for the most part of a fibro-vascular core covered with 
iimbrise of stratified squamous epithelium, with a few concentric 
bodies. Slight symptoms of irritation. Tonsils enlarged; with 
history of several quinsies. 

2. Fibro-vascular papilloma removed from the right tonsil. It 
looked like a red polypus hanging from the surface of the tonsil, 
but under cocaine became ansemic. It apparently grew from a 
dilated lamina, and was removed by snare, coming out like a tooth. 
It was about 2 cm. in length, and consisted of fibro-vascular and 
small-cell tissue covered with smooth stratified epithelium. Sore 
throat and history of quinsies. Reported in ‘ Journal of Laryngo¬ 
logy * as “ Polypus of Tonsil,” vol. viii, p. 358. 



18 


The papillomata generally grow from the surface, whilst the so-called 
polypi spring from the interior of lacunae. Their origin is suggested 
by examining sections of chronic lacunar tonsillitis, in which papillary 
excrescences will be found growing from the fundus and sides of 
dilated lacunae. An exaggeration of such a condition would readily 
form a papilloma or a polypus. 


Female on whom Tracheotomy had been performed, with 
Immobility of Left Cord and Partial Immobility of Bight. 

Shown by Dr. J. W. Bond. (No notes received.) 


Female with Tumour of the Epiglottis. 

Shown by Dr. Bond. (No notes received.) 

Mr. de Santi thought that the tumour was too soft and vascular- 
looking lor an epithelioma, and took the view that it was sarcomatous 
and considered the enlarged glands to be a contra-indication to any 
operation. 


Case of Paralysis of Left Vocal Cord and Dilator of Pupil, 
with Ptosis of the Same Side. 

Shown by Dr. Spicer. T. B—, aet. 59, a gardener, complains of 
hoarseness and swelling in the neck. 

Laryngoscopic examination shows the left vocal cord in the middle 
line, and immobile. There is no deformity in the larynx nor patho¬ 
logical changes. Left pupil contracted. Left upper eyelid in 
condition of ptosis. There is a mass of three or four enlarged glands 
under the left sterno-mastoid opposite the cricoid cartilage. PatieDt 
has taken iodide of potash for more than six weeks. No history of 
syphilis. 


? Mucous Patches on Fauces; Case for Diagnosis. 

Shown by Dr. Scanes Spicer. Charles D—, set. 3. About four 
months ago the mother noticed a white, ulcerated-looking surface on 





19 


the tonsils, uvula, and soft palate, which has never disappeared but 
varies in its extent of surface. There are enlarged cervical glands, 
and swallowing is easy. Patient had “ thrush,” which lasted three 
weeks, when he was a month old, followed by an ulcer on eye and in 
the groin. He has also had an hydrocele. There has been no 
contact with diphtheria. When the white patches are removed the 
surface bleeds. 

The diagnosis seemed to be between chronic diphtheria, mucous 
patches, lupus, tuberculosis, papillomata, and simple ulceration. 

Dr. Plimmer reports that there are diphtheritic organisms present. 

A cultivation of the ulcerated surface shows streptococci and 
sarcinae. 

The treatment had consisted of internal administration of chlorate 
of potash, but it had not altered during the past six weeks. 

Dr. Barclay Baron had seen a similar case, which was not 
syphilitic. 

Dr. Lambert Lack had a patient in whom a similar ulceration 
was combined with lupus, and he advised arsenic as an internal 
remedy. 


Rapidly Recurrent Tumour of Nasal Septum. 

Shown by Dr. Spicer. Albert H—, set. 35, sent to St. Mary's for 
epistaxis. On examination a spongy, very red and vascular growth 
is seen attached by a broadish base to right side of cartilage of nasal 
septum. A portion was at once removed with scissors, and felt hard 
on cutting through. It has grown again nearly to original size in a 
fortnight, and base is larger. 

Report by Dr. Plimmer .—Large amount of fibrous tissue; few 
sarcomatous cells; lymphoid tissue ; very few vessels; prognosis as to 
benignancy favorable. 

Dr. StClair Thomson was of opinion that the growth was simple 
in character, and was a fibro-angioma or bleeding polypus of the 
septum. He recalled a very similar case he had shown to the Society 
two years ago (‘ Proceedings,’ vol. iii, January, 1896). In that case the 
growth rapidly recurred soon after removal, and the sections of the 
growth were found by some membfers to be so suggestive of sarcoma, 
that they warmly recommended speedy and radical excision. How¬ 
ever, the recurrence was simply removed with the snare, the base 
curetted and then well seared with the galvano-cautery (without 



20 


perforating the septum). He had kept the patient under observation, 
and now, at the end of two years, there had been no recurrence. The 
growth was declared by the Morbid Growths Committee to be a fibro- 
angioma, and he suggested that the sections in the present case might 
be submitted to the same Committee. 

Mr. Winoeave suggested that the tendency to alveolation of the 
cells was in favour of its sarcomatous nature. 


Cases shown by Dr. Lambert Lack. 

A girl set. 6 and a boy set. 3, who have had congenital obstruction, 
to show the persistent malformation. 

The two cases are in most respects similar. Both came under the 
care of my colleague Dr. Sutherland and myself, when a few weeks 
old, presenting all the characteristic signs of the affection known 
variously as congenital laryngeal stridor , infantile respiratory spasm , 
&c. The signs of laryngeal obstruction increased for some months, 
and then gradually passed off until, at two years of age, they had 
practically disappeared. The true pathology of this affection, hitherto 
generally considered a form of laryngeal spasm, was demonstrated 
in a recent paper by Dr. Sutherland and myself (* Lancet/ September, 
1897). We found that the epiglottis is folded laterally so sharply 
that its lateral halves come very close together, or even into actual 
contact. The aryl sen o-epiglottic folds, thus approximated, flap inwards 
at each inspiration, reducing the upper aperture of the larynx to a 
narrow slit or even completely closing it. In these two cases the 
stridor and other signs of laryngeal obstruction have completely passed 
off, apparently because the upper aperture of the larynx is larger, and 
the tissues forming it less flaccid than in infancy. The malformation 
of the epiglottis, however, remains unaltered—in the girl the folds 
being very close, in the boy in actual contact. This persistence of the 
curved epiglottis seems to me very important as showing (1) that 
although, as above stated, constantly present in this affection, and 
playing an essential part in its pathogenesis, it is not the actual 
curve of the laryngeal obstruction, and (2) that this form of epiglottis 
is not the normal type in infancy, as Escat and others have stated. 
The latter point is further shown by the fact that I have never yet 
found the malformation in a large series of examinations of the larynx 
in babies during the past two years. 



421398 


21 

Dr. Hill and Dr. Grant had seen similar cases, and the former 
asked Dr. Lack if there was ever any subluxation of the crico-arytsenoid 
joints in such cases. 


Case op Tornwaldt's Disease. 

Shown by Mr. Bichard Lake. The patient, a young woman, had 
been troubled for ten years by the crust formation, which she used to 
expel every second or third day. A point of interest in this case lies 
in the fact that the patient went to a throat hospital three years ago, 
and was treated for this trouble by having her inferior turbinates re¬ 
moved, and she seems to believe she has sifice become somewhat 
worse. 

Mr. Cresswell Baber had found the galvanic cautery applied 
with the aid of the rhinoscopic mirror of considerable benefit in 
these cases in arresting both the discharge and haemorrhage. 


Large Tumour in the Neck. 


Dr. Don elan showed a man set. 56 with a large tumour occupy¬ 
ing the left side of his neck from the temporo-maxillary joint to the 
clavicle. In last April the patient first noticed a small swelling behind 
the jaw, which was painless but continued to grow until in September 
it was about the size of an ostrich egg. He then went to University 
College Hospital, where its removal was advised, but patient declined. 
Since then the growth had rapidly increased to its present size. There 
had been, however, no pain until within the last few weeks, when there 
was some neuralgia in the left side of head. 

The points of interest to the Society were the paresis of the tongue, 
the immense displacement of the larynx to the right with paresis of 


left vocal cord and swelling of; left Ejrytaengi^ 'body,.; iCh$.'latter ?s 
difficult to see from overlapping of ary ; epiglottic" tissues and* ventricu¬ 
lar band. There was entire absence of dyspnoea ind\dysphagia, and 
but little change in the voice. On seeing the patient for'the first time 


Dr. Donelan thought the case one of lymphiul'encn^/buthow believed 
it to be a malignant tumour, probably sarcomatous. It was doubtful 
if anything could now be done. 



22 


Mr. de Santi considered this case to be one of malignant disease; 
probably primary epithelioma of the cervical glands. The mass was 
fixed, extensive, and of stony hardness. He could not get a view of 
the larynx. An examination of the oesophagus should be made. The 
case was quite inoperable. 


Sketches and Specimen of Benign Tumour of the Tonsil. 
Shown by Mr. Waggett. 


Sketches and Specimen of Papillary Hypertrophy of the 

Tonsil. 

Shown by Mr. Waggett. This patient has complained for about 
six months of “ stoppage in the nose.” About two months ago he 
came to the London Hospital, and some polypi were removed from 
both nostrils. The posterior ends of both inferior turbinates were 
also removed, and he ceased attending for the time. The polypi were 
not examined microscopically, but gave rise to no suspicion of being 
anything beyond simple polypi. 

Patient returned again on December 8th, appearing very ill. No 
polypi were seen anteriorly. On digital examination a hard mass 
about the circumference of a shilling was felt on the posterior naso¬ 
pharyngeal wall, apparently growing from the first or second cervical 
vertebrae in the middle line. It was very tender to the touch, and 
bled slightly after examination. There was no impairment of move¬ 
ment of the cervical vertebrae. 

Dr. Herbert Tilley instanced a case recently seen by him in 
which it was almost impossible to get the finger into the naso-pharynx 
because of the prominence of the upper cervical vertebrae. The 
/ pa$iejiK was •well buil^ yrith «© obvious deformity in the neck. 

I Div DajJtDAS fsRANx' said he had referred in another Society to 
such a prominence eimu.lat.Hjg the presence of adenoids. 

Mr. GreVsV^l* ^ABEff Said he had not had an opportunity of 
making r a thorough examination in this case, but he had noticed 
considerably thickening ;of l the soft palate and prominence of the 
tubercle qf thje/atlas^:;,.; 



23 


Soft Swelling in the Neck. 

Shown by Dr. Pegler. Patient was a young female with a large 
swelling in the neck, apparently extending outwards and backwards 
from beneath the left sterno-mastoid. 

Dr. Herbert Tilley said that by getting a strong light behind it 
and examining it like a hydrocele, a small amount of light penetrated 
it, and from its feel he thought it was cystic. 

Mr. de Santi looked upon this case as one of cystic nature, 
probably cystic hygroma. Probably the fluid was thickish and the 
aspirating needle small, thus accounting for the negative result on 
puncturing. It might be a very soft fatty tumour; but its shape, 
situation, history, and non-adhesion of the skin and absence of lobula¬ 
tion were against this diagnosis. He advised an exploratory incision. 


Case of Persistent Branchial Cleft in Neck. 
Shown by Dr. Dundas Grant. (No-notes received.) 


Symmetrical Ulceration of Tonsils, Perforation of Nasal 

Septum, in a Young Boy. 

Shown by Mr. Atwood Thorne. A boy set. 13, under the care of 
Dr. William Hill (by whose permission the case was shown). 

On admission the boy had been ill for three weeks, complaining of 
a “ cold, sore throat, and running from the nose.” 

Examination showed symmetrical inflammation of both tonsils, 
spreading on to the soft palate, and with a well-defined margin. The 
right tonsil contained a cheesy mass, which was removed, and the 
cavity painted with chromic acid. The glands behind the sterno- 
mastoid were enlarged and hardened on both sides. 

There was a blood-stained discharge from both nostrils, and a per¬ 
foration of the bony septum, covered with scabs. Over the chest there 
was a well-marked macular rash. 

Mr. Thorne suggested as a provisional diagnosis "secondary, or 
early tertiary syphilis.” 

Mr. Cresswell Baber suggested that the case was one of congeni- 

2 * 



24 


tal syphilis, and considered that one of the teeth was somewhat sug¬ 
gestive of that disease. 

Dr. Hill concurred in this opinion. 

Dr. Atwood Thorne, in reply, said that the family history seemed 
to negative “ hereditary syphilis.” Both history and examination 
contra-indicated tubercle. 



PROCEEDINGS 


OP THE 

LARYNGOLOGICAL SOCIETY OF LONDON. 


Annual General Meeting, January 12th, 1898. 

Henry T. Butlin, Esq., F.R.C.S., President, in the Chair. 

StOlair Thomsoh Ml)., ) 

Herbert Tilley, M.D., ) 

Present—43 members and 3 visitors. 


The minutes of the Fifth Annual Meeting were read and confirmed. 

Dr. Jobson Horne and Mr. Atwood Thorne were appointed Scruti¬ 
neers of the ballot for the election of Officers and Council for the 
ensuing year; they reported the result of the ballot as follows : 

President. —H. Trentham Butlin, F.R.C.S. 

Vice-Presidents. —J. W. Bond, M.D.; A. Bronner, M.D.; F. de 
Havilland Hall, M.D.; Scanes Spicer, M.D.; T. J. Walker, M.D. 

Treasurer. —W. J. Walsham, F.R.C.S. 

Librarian. —J. Dundas Grant, M.D. 

Secretaries. —Herbert Tilley, M.D.; William Hill, M.D. 

Council. —A. A. Kanthack, M.D.; Sir F. Semon, M.D.; W. R. H. 
Stewart, F.R.C.S.; StClair Thomson, M.D.; P. Watson Williams, 
M.D. 


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

The Council has much pleasure in reporting the continued prosperity 
of the Society, both as regards the increase in the number of its 
FIRST SERIES — VOL. V.. 3 


26 


members and the sustained interest in the work of the Ordinary 
Meetings. 

The Society now numbers 119 ordinary members and 9 honorary 
members, 16 ordinary members having been elected during the past 
year. 

We have not lost any members through death, but Dr. Walton 
Browne of Belfast has resigned owing to distance from London, and 
Messrs. Ewen Stabb and Davis have severed their connection with 
the Society owing to other claims upon their time. 

The meetings of the Society have been well attended, the average 
attendance of ordinary members being 31, of visitors 5. This is a 
higher average than any formerly attained by the Society. 

The ordinary meeting held May 12th was given up to a discussion, 
introduced by Dr. Dundas Grant, on “ The Uses of Turbinotomy as 
applied to the Inferior Turbinate Bone.” The subject being one of 
much importance elicited some interesting experiences from many 
members who joined in the discussion which followed the reading of 
the paper. 

The Council have discussed, without coming to any definite conclu¬ 
sion, the advisability of limiting in some way the admission to the 
membership of the Society, in order to minimise the excessive exami¬ 
nation to which many patients are subjected at the Ordinary Meetings. 

The Council consider that the Society is to be heartily congratulated 
on the honour of knighthood which has been conferred during the 
past year upon its past President, Sir Felix Semon, M.D. 


The Treasurer's Annual Statement was then presented as follows: 

The actual receipts for the year ending December 31st, 1897, have 
amounted to £141 15s. 6d. This amount includes four subscriptions 
for 1898. 

There are still a few subscriptions for 1897 outstanding (£7 7 s.), 
all of which are good, and will appear in the balance-sheet for' 1898. 

The actual expenditure was £83 17s. 8 d., leaving a balance for the 
year of £57 17s. lOd. This, with the balance of £112 2s. 7d. brought 
forward from the 1896 balance-sheet, leaves in the Treasurer’s hands 
on December 31st, 1897, the total balance of £170 Os. 5 d. 



27 


BALANCE-SHEET, 1897. 


Income. 


£ 

112 


s. d. 
2 7 


Balance from 1896 . . . 

Subscriptions— 

100 members at 

£1 Is .105 

13 members at 

£2 2s .27 

1 member at 

£9 9s .9 

Excess on Edinburgh cheque 0 
Returned by Rogers (excess 

paid on cheque) .... 003 


0 0 
6 0 


0 

6 


Total 


£253 18 4 


£ s. 
31 10 

44 14 
2 15 


Expbnditubb. 

Rent and Electric Light (20, 
Hanover Square) . . . 

Adlard for Printing and 
Postage, October 8th, 1896, 
to June 3rd, 1897 . . . 

Mayer and Meltzer (specula, 

&c.). 

Petty Cash— 

Rogers (Carbolic Acid 
and Spirit). . . £014 6 

Secretarial Expenses: 

Dr. StClair 
Thomson .£150 
Dr. Tilley . 0 2 5 

-17 5 

Stamps.012 0 

Doughton, attend¬ 
ance .10 0 

Bank Charges: 

Scotch and Irish 
cheques . . . .016 

Indexing volume, 

1897 (Clarke) . .110 

- 4 16 

Deficit on foreign cheque ..02 
Balance in Treasurer’s hands 170 0 


d. 

0 

6 

0 


Total 


£253 18 4 


The income for the 
year is . . . £141 15 6 


The expenditure for 

the year is . . £83 17 8 


Audited and found correct, 
January 6,1898. 


r E. B. WAGGETT. 

< StCLAIR THOMSON. 
IE. CLIFFORD BEALE. 


The following embodies the Librarian’s Report, which was then 
read. 

The following works have been added to the Library during the 
past year: 

Laryngologische Gesellschaft zu Berlin Verhandlungen, Band vi, 1895. Ausgege- 
ben 1897. 

Gesellschaft der Ungarischen Obren- und Kehlkopfarzte, Jahrbucher, Band ii, 
1896. 

Brighton and Sussex Medico-Chirurgical Society. Proceedings and Annual Report, 
1896-7. 

Niederlandische Gesellschaft fur Hals, &c.. Burger’s Berichte, 1896. 

Moritz Schmidt, Krankheiten der oberen Luftwegen, 2nd edition. (Presented 
by the author.) 







28 


Photographic Album of Views of the Vanderbilt Clinic for Diseases of the 
Throat. (Presented by Dr. Lefferts.) 

Monographs and Reprints on Laryngological and Rhinological Subjects, by Dr. 
Hugo Bergeat. (Presented by the author.) 

Gouguenbeim, Dr. Monographs and Reprints. (Presented by the author.) 

Moure, Dr. .E. J. (Bordeaux). Monographs and Reprints. (Presented by the 
author.) 

Ardenne, Dr. Tumeurs benignes de l’Amygdale. (Travail de la Clinique de 
Moure, 1897.) 

Stirling, Dr. On Bony Growths invading the Tonsil; Chicago, 1896. (Presented 
by the author.) 

Monographs presented by Dr. de Havilland Hall: 

Cagney, J. On the Laryngeal Motor Anomalus, Abductor Tonus, and Abductor 
Proclivity, 1894. 

Donaldson, P. Gr. Paralysis of the Lateral Adductor Muscle of the Larynx, 
with Unique Case, New York Med. Journ., February 12th, 1887* 

Donaldson, F. Gr. Further Researches upon the Physiology of Recurrent Laryn¬ 
geal Nerve (Johns Hopkins University), New York Med. Journ., August 13th, 
1887. 

Sewill, H., and England, W. Empyema of the Antrum. 

American Laryngological, Rhinological, and Otological Society, Transactions of 
the Second Annual Meeting, 1896. 

The numbers of the newly added exchanges have duly arrived, and 
several will start in January, 1898. 

The following volumes have been bound: 

Archiv fur Laryngologie (Frankel), vols. iv, v, vi. 

Revue de Laryngologie, &c. (Moure), vols. 1894, 1895, and 1896. 

Revue Internationale (Natier), vol. 1896. 

Bolletino delle Malatbe, &c. (Grazzi), vol. 1896. 

Archivii Italiani (Massei), vol. 1896. 

The Librarian expects to present the volumes for 1897 at the next 
Annual Meeting. 


The Morbid Growths Committee for the ensuing year will be com¬ 
posed of the following gentlemen : 

Mr. Bowlby, Dr. Kanthack, Dr. Pegler, Mr. Spencer, Mr, Waggett, 
Dr. Tilley. 


The Thirty-seventh Ordinary Meeting of the Society was subse¬ 
quently held, the President being in the Chair. 

The minutes of the previous meeting were read and confirmed. 



29 


The following gentlemen were nominated for election at the next 
Ordinary Meeting: 

John Fallows, L.R.C.S.E. and L.S.A.(Lond.), 66, Victoria Street, 
S.W. 

William Frazer, L.R.C.P., M.R.C.S., Johannesburg. 


Two Pressure Pouches of the (Esophagus. 

Shown by Mr. Butlin (President). Removed from living subjects. 
The references are to be found in the ‘ Medico-Chirurgical Transac¬ 
tions/ vol. lxxvi, p. 269, 1893, and in the ‘ British Medical Journal/ 
1898, vol. i, p. 8. The attention of the members of the Society is 
particularly directed to the return of particles of undigested food 
many hours or even days after they have been swallowed, as the one 
constant symptom in the diagnosis. 


Nasal Hydrorrhcea—Analysis of Liquid. 

Mr. Cresswell Baber read notes of this case, and brought forward 
the analysis of the liquid. Patient, a married lady set. 42. The 
right side of the nose only affected. Five years before, after eight 
months’ excessive watery discharge following influenza, she had had a 
polypus removed; the secretion then stopped, but returned again at 
Christmas, 1896, after another attack of influenza. A polypus was 
removed in May, 1897, and the galvanic cautery applied, but as the 
secretion still continued the case was referred to me. When I first 
saw her, on June 16th last, there was no obstruction, very little 
sneezing, no pain, only profuse non-fcetid watery discharge from the 
right side, which continued day and night. No headaches of conse¬ 
quence. Examination showed that the right nasal cavity was much 
narrowed by deflection of the septum, and the mucous membrane was 
sodden and catarrhal in appearance. No polypus, but a little irregu¬ 
larity on the middle turbinated body. Transillumination showed 
both infra-orbital regions light, and nothing came out of the right 
antrum on hanging down the head. The fundus was normal in both 
eyes. No loss of sensation could be detected in the right nasal 
cavity. Spirit and cocaine spray was tried, but without any effect; the 
dripping of watery liquid continued constant, and on one occasion 



30 


(July 17th) I collected 70 mm. in five minutes. On this date I 
began the constant current, applying eight cells externally to the nose. 
This stopped the secretion for a few minutes. Patient was ordered to 
use it for five minutes twice a day. In a week’s time (July 24th) 
she reported that the running was rather less in the mornings, but 
when I saw her it still continued. A small piece of projecting 
mucous membrane was snared from the middle turbinated body, but 
only proved to be hyperplasia of normal tissue. Ordered, in addition 
to the constant current, a 20 per cent, solution of menthol in 
paroleine for a nasal spray twice a day. I did not see the patient 
again till September 15th, when she reported that about a month 
previously the running began to diminish, and had got so much less 
that she only used two handkerchiefs daily instead of twelve. 
Character of the secretion as before. Treatment continued. October 
5th.—No watery discharge at all for the last four days. Examination 
shows that there is much less swelling of the mucous membrane in 
the nasal cavity. To use spray and galvanism once a day only for 
three weeks. November 3rd.—No discharge at all from the right side 
since the last visit. Omit all treatment. Letter received from 
patient dated January 3rd, 1898, reports that there has been no 
return of the nose trouble. About an ounce of the liquid was sent to 
the Clinical Research Association, and they report that its chemical 
composition is as follows: 

Per 100 c.c. 

Organic solids .... 0*160 gramme. 

Containing—Mucin . . . 0*060 „ 

Proteids . . . 0*025 „ 

Undetermined constituents . 0*075 „ 

0*160 

Inorganic solids , 

Containing—Sodium chloride 

Calcium phosphate, &c. 

0*880 

Microscopical examination showed the presence merely of a few 
squamous epithelium cells and a few leucocytes. They note that the 
greater proportion of the solid matter consists of sodium chloride, and 
that the proportion of this closely approximates to the “ normal 
saline ” fluid. 


. 0*880 gramme. 

. 0*770 
. 0*110 



31 


From the absence of head symptoms, and especially from the 
beneficial effect of the continuous current, I think we are justified in 
concluding that the liquid in this case is simply an excessive secretion 
from the nasal mucous membrane, and not an escape of cerebro¬ 
spinal fluid. It seems probable that many of the cases reported may 
be explained in a similar manner. 

Dr. StClair Thomson said that the analysis which had been made 
for Mr. Baber was unfortunately, so far as the question of cerebro¬ 
spinal fluid was concerned, most incomplete. Since he had shown 
his case to the Society, he had assisted at repeated analyses of 
cerebro-spinal fluid, and also of other fluids from the nose which 
were supposed to come from the subarachnoid space. In hopes that 
other members might come across similar cases, he would just 
recapitulate the chief points which were characteristic of cerebro¬ 
spinal fluid. It was perfectly colourless and limpid, feebly alkaline, 
varying in specific gravity from 1005 to 1010, contained no albumen, 
but traces of a proteid which was found to be globulin; it reduced 
Fehling’s solution, but it did not contain sugar, for it failed to give 
the fermentation test with yeast. This reducing body was pyro- 
catechin, which had a pungent taste, and formed particular crystals. 
The analysis of the present case gave no information on these points. 

Dr. DE Havilland Hall asked Mr. Baber if he thought that the 
menthol spray had any real effect on the issue; his experience was 
that it rather increased the discharge from the nasal mucous 
membrane. 

Mr. Baber thought it was the constant current rather than the 
menthol spray that had had the beneficial effect in this case. 


Radical Operation for Frontal Sinus Disease. 

Mr. Ernest Waggett showed a patient on whom he had per¬ 
formed Luc's operation five weeks previously for r'ght frontal sinus 
suppuration of many years' standing. The skin incision followed the 
line of the eyebrow, and the trephine hole was made immediately 
above the superciliary ridge. The sinus was completely cleared of 
all the mucous membrane, which was throughout polypoid and 
bathed with pus. Attention was drawn to the advantages of carefully 
suturing the periosteum over the trephine hole, and of removal of the 
anterior end of the middle turbinate. From the first the cavity was 
irrigated by passing a fine flexible tube up through the drain-tube. 
The latter was removed on the thirteenth day. No pus had been 
seen since the operation, symptoms were absent, no depression of the 
bone could be detected, and the skin scar was unnoticeable. 



32 


Dr. Herbert Tilley thought that the case was a good illustration 
of the value of the incision through the line of tbe eyebrow, for the 
resulting scar was scarcely noticeable. He mentioned this because one 
authority on frontal sinus disease had maintained that a median 
vertical incision should be made in every case, whether the symptoms 
were uni- or bi-lateral. Mr. Waggett’s case was at least the second 
or third which had been before the Society, and in which the value of 
the supra-orbital incision was very evident. 


New Instrument—Turbinotomy Cautery. 

Mr. Ernest Waggett showed a galvano-cautery point, practically 
of the same shape as Jones' turbinotome, a hot platinum wire taking 
the place of the cutting edge. He has used it to remove hyper¬ 
trophies of the mucous membrane of the turbinates, particularly 
moriform bodies. All haemorrhage is avoided, and the shrinkage 
caused by cocaine rather facilitates matters than otherwise. The 
copper wires should be thick, so as to avoid over-heating by the 
current. 


Trigeminal Neuralgia relieved by Turbinectomy. 

Shown by Walter G. Spencer. The patient was a carpenter, 
aet. 46, who had had good health, and had not suffered in any similar 
way before. In April, 1897, he was in bed for two days with in¬ 
fluenza. Some few days afterwards, at 9 a.m., he was suddenly 
seized with severe pains in his face. The pains first occurred in the 
lower lip and skin over the left side of the jaw, then on the cheek 
over the infra-orbital foramen, over the supra-orbital nerve at the 
back of the eye, and at the back of the nose. He became dazed, and 
cannot remember his journey home from work; he is said to have 
staggered up the street like a drunken man. His memory is also 
a blank for the next fortnight. He suffered from neuralgia involving 
all the branches of the fifth nerve, attended by most severe paroxysms 
of pain, for which his doctor had to give opium and morphine in 
increasing doses. My colleague. Dr. Allchin, was after three weeks 
called to a consultation, and he concurred in the treatment by opium 
and morphine in large doses. 



33 


The patient got somewhat better, but on account of the pain could 
not sleep well at night, nor concentrate his attention on any work. 
He was much depressed, and opium or morphine was required when 
the pain became severe. This was his condition in September, after 
he had been ill five months, and Dr. Allchin then consulted me with a 
view to some surgical measure. I could not insert a speculum into 
the left nostril, on account of hypersesthesia, until he had been given 
an injection of morphine. The interior of the left nostril showed no 
definite disease. On touching the interior with the end of a blunt 
probe, nothing occurred until I touched the anterior part of the left 
middle turbinal, when a severe paroxysm of pain and itching was set 
up of the kind from which the patient had been suffering. After the 
nostril had been treated with cocaine 20 per cent, the middle turbinal 
could be touched without exciting the above symptoms. 

No other lesion was found, in particular there were no signs of antral 
disease. Some teeth had been removed without affording any relief. 

I and Dr. Allchin agreed that, assuming the neuralgia to have originated 
from an attack of influenza, it was not unlikely that the neuralgia 
would in course of time pass off. Therefore we considered that there 
were then scarcely sufficient indications for surgical treatment of the 
three roots of the fifth nerve, or of the Gasserian ganglion. I pro¬ 
posed to try removal of the middle turbinal for much the same reason 
as a specially tender tooth is extracted in the hope that it may afford 
relief to trigeminal neuralgia. I therefore excised the middle turbinal, 
taking away also the anterior end of the inferior turbinal to obtain 
room. I found nothing abnormal in the tissue removed, and it was not . 
in contact with the septum. From the time of the removal the 
patient has never had any pain, and has not required any narcotic. 
He has slept well, recovered his spirits, and has been at his work for 
three months. He still has, however, at times, itching in the dis¬ 
tribution of the terminal ends of the fifth nerve on the face, also at the 
back of the eye and nose. This annoys him and tempts him to scratch, 
but does not prevent his work. It is worse in the day, and is quite 
relieved by lying down, whereas the old pain was worse when lying 
down. The interior of the left nostril is now hyperaesthetic, so that 
the patient is easily made to sneeze, but no pain or itching is excited 
by touching the interior. I have told the patient that this itching 
wiil pass off in time, but I shall be glad to learn of any means of 
hastening its disappearance. 



34 


Mr, Oresswbll Baber mentioned the use of common salt as a 
snuff in cases of facial neuralgia, and also suggested the use of the 
galvanic cautery where very sensitive spots on the nasal mucous 
membrane were detected. 

Dr. Spicer said that the patient's nasal passages were still de¬ 
ficient, and were producing an “ exhaustion rhinitis; ” he advised the 
use of dilators to alleviate the chronic rhinitis, and removal of a small 
spur which was present. 

Dr. StClair Thomson said that the present case confirmed what he 
had ventured to insist upon elsewhere,* viz. that every case of tri¬ 
geminal neuralgia should be submitted to a thorough exploration of 
the nose and accessory cavities before operative procedures were under¬ 
taken. He happened to know of cases where extensive, dangerous, and 
in some instances unsatisfactory operations on the Gasserian ganglion 
had been carried out, and where the idea of examining the nose had 
never been even entertained. Amongst other instances of trigeminal 
neuralgia relieved by intra-nasal medication, he instanced one where 
a medical man had placed himself under the care of a distinguished 
neurologist who had referred the case to Dr. Thomson, although the 
patient himself was perfectly convinced that he was suffering from 
“ brow ague,” having passed some years in the tropics, where he con¬ 
tracted malaria, he scouted the idea of the “ brow-ague ” being due 
to an empyema, and was only convinced when an exploratory puncture 
expelled a quantity of foul-smelling pus, and drainage at once cured 
his neuralgia. As to labelling the present a case of “ cure,” he thought 
we should be a little careful of using that term when the objective 
symptoms in the nose had been so slight. We all knew the beneficial 
effects of operation per se, and these were especially marked in the 
case of idiopathic trigeminal neuralgia. In Sir William Gowers’ well- 
known text-book on nervous diseases there was the record of a case 
which an American author had traced for some dozen or so years. 
During this period the one individual’s case had been published by 
something like fifteen different physicians, and each one claimed to 
have cured him. 


SlJBPHARYNGEAL CARTILAGE OF THE TONSIL. 

Mr. Wyatt Wingrave exhibited microscopic sections of tonsils 
showing small islands of hyaline cartilage representing the sub- 
pharyngeal cartilage, a rudiment of the third visceral arch. 

The cartilage was enclosed in the connective tissue of the bed of the 
tonsil, but according to MacAlister it is generally situated beneath the 
mucous membrane below the tonsil, and often attached to it. 

He had found three examples in about 200 cases examined. 

* * The Year-book of Treatment 9 for 1897. 



35 


Larynx of Patient shown at Meeting held November 10th, 

1897. 

Dr. Herbert Tilley stated that shortly after the November 
meeting the patient died after suffering for three or four days from 
fever, intense headache, and delirium. Only the larynx and the brain 
were available for examination. The base of the latter was thickly 
covered with lymph and other evidences of meningitis. 

The larynx exhibited extensive superficial ulceration of the right 
vocal cord and process, but the left side was healthy. A small track led 
through the mucous membrane of the right arytsenoid cartilage, the 
latter being felt bare at the end of the sinus. 

When seen during life the right cord was rigidly fixed during 
phonation ; there was an enlarged gland in the right submaxillary 
region, and what appeared to be a greyish mass was seen situated in 
the position of and hiding the right vocal cord. The almost unanimous 
opinion then was that it was a case of malignant disease, but the 
exhibitor thought that the recent history indicated tubefcular laryngitis, 
and at his suggestion the growth was referred to the Morbid Growths 
Committee for more detailed examination. 


Case of Malignant Disease of Larynx. 

Shown by Dr. Furniss Potter. A man set. 64, who came under 
observation complaining of hoarseness for nine weeks previously, but 
who in other respects was in good health. On examining the 
larynx the left side was seen to be occupied by an extensive infiltra¬ 
tion, involving the arytsenoid region, the ventricular band, and the 
aryepiglottic fold; the left vocal cord was invisible, and the crico- 
arytsenoid joint appeared to be fixed and immoveable. 

There was no history of syphilis, and no complaint of pain except a 
little occasionally shooting into the left ear; there was no dysphagia, 
but slight stridor occasionally. The patient had been put on 
potassium iodide in doses increasing to grs. xx three times a day, 
but as yet with no appreciable result. 



86 


Papillomata of Larynx. 

Dr. Bronner (Bradford) showed a large number of papillomata 
removed from the larynx of a man set. 48, on December 13th.’ On 
several previous occasions growths had been removed, the last time in 
March. Various local and internal remedies had been used. 

On December 13th patient had a violent attack of dyspnoea whilst 
in a railway carriage, and was unconscious for some time (?). 

Dr. Bronner wished to have the advice of the Society as to whether 
laryngotomy or tracheotomy should be performed, or if the growths 
should be periodically removed per os. 

Mr. Butlin and. Sir Felix Semon concurred in the view that 
thyro-chondrotomy would afford no guarantee against recurrence of 
the growth, and might induce other undesirable complications. 

Mr. Spencer suggested that a crico-tracheotomy might be useful 
in enabling the operator to more efficiently remove the growths. 


Complete Recurrent Paralysis. 

Mr. Symonds exhibited a man of 61 showing the left cord lying in 
the cadaveric position. The patient had a stricture of the oesophagus 
12£ inches from the teeth, and gave a history of nine months' 
dysphagia, with loss of voice for four months. When first seen two 
months ago the condition was identical with that now existing. 
The case was brought forward to illustrate paralysis of the lateralis 
muscle following upon that of the posticus, which was presumed to 
have preceded the present stage. The patient also exhibited well 
the inability to speak a sentence of more than a few words, and gave 
a good view of his larynx. 

Sir Felix Semon said that he could not agree to this being a case 
of adductor paralysis, and expressed a hope that his friend Mr. 
Symonds would see his way to change the title of his communication. 
Adductor paralysis clearly meant that a vocal cord could not be 
properly adduced on intended phonation, whilst on deep inspiration it 
freely went outwards. In the present case, however, the vocal cord 
stood motionless between the phonatory and ordinary cadaveric posi¬ 
tion, and there was no question of adductor paralysis. He made it a 
point to protest against the title because otherwise it would be almost 
certain to be made capital of. Of greater importance, however, than 
this individual case was another question he wished to submit to the 



37 


Society. Was it not time to altogether abolish the expressions 
“adductor” and “abductor” paralysis? No doubt they were con¬ 
venient enough, but somehow or other there seemed to be a sort of 
fatality about misprints with regard to these two expressions, which 
but too often absolutely spoilt the author’s meaning. He instanced 
several recent experiences of his own to that effect. In Germany, 
following an analogous proposition of Professor Moritz Schmidt, the 
two expressions had almost completely vanished. If the words “ glottis 
openers ” and “ glottis closers ” were considered to be too clumsy, 
why not simply speak of “ posticus,” “ lateralis,” “ externus,” &c. ? 

In his reply to remarks by Sir Felix Semon, Mr. Symonds recast 
the original title of the case from that of adductor paralysis. 


Removal of Half the Larynx. 

Shown by Mr. Symonds. Mr. S— was brought before the 
Society in February, 1897, with fixation of the right cord, and a 
diagnosis of early carcinoma. The general opinion at that time was 
in favour of tubercle. A gland made its appearance in the end of 
April, and was removed March 17th. It had grown with great 
rapidity, and was already softening. The right half of the larynx was 
removed April 20th. The man was brought forward again, not to 
show the result of the operation, but because it was thought 
members would be interested to recall the early appearances. At 
present the man does full work, and has a moderate voice. 


Subglottic Carcinoma ? 

Shown by Mr. Symonds. A man of 55 had been hoarse six 
months. He came under treatment at Guy’s Hospital in December 
with grave stenosis of the larynx. Both cords were fixed, and were 
visible ; the chink was in the centre, and was elliptical in shape; the 
left cord appeared then slightly pushed up. The arytaenoids were 
fixed. Tracheotomy was necessary on January 1st. The diagnosis 
lay between malignant disease and syphilitic perichondritis. There 
was no breach of surface, but there was an abundant foul expectora¬ 
tion. The man was then in low health. Mr. Symonds regarded the 
case as one of subglottic carcinoma, and asked for an expression of 
opinion. 

Note .—At the meeting Mr. Symonds reported that since his last 
examination of the patient three days ago, when the above report 



38 


was written, a marked change had taken place. The left side had 
become more prominent, and a whitish edge was visible along the left 
cord—appearances pointing to malignant disease. 

January 17th.—Mr. Symonds sends a note to say the whole 
interior of the larynx has become swollen, that a papillated whitish 
mass can be seen in the position of the left cord, leaving no doubt 
of the malignant nature of the case. The general health has greatly 
improved. 


Formative Osteitis (Leontiasis Ossiijm). 

Shown by Dr. Watson Williams (Bristol). A specimen of the 
septum nasi and a portion of the frontal bone and left malar bone 
from a male set. 46. There was no history of syphilis, and no known 
cause for the disease. 

Post-mortem examination .—The patient presented large, smooth, 
bony thickenings on either side of his nose, and a smaller boss on the 
left side of the forehead. 

On removing the cranium pus was found situated between the dura 
mater and the bone over the frontal lobe. This pus seemed to have 
originally started from the frontal sinus on the left side, which was 
full of pus. The frontal sinus on the right side was found to be 
obliterated by soft cancellous bone. The pituitary body was normal 
in size. 

Examination of the nose showed that the sphenoidal sinus and 
ethmoidal cells were entirely obliterated by cancellous bony growths. 
The cavity of the nose on the left side was almost entirely filled up by 
growth from the septum. Apparently also the antra of Highmore 
were completely filled up with cancellous bone formation. The bones 
in the face were found to be growing from the malar and upper part 
of the superior maxillary bones. There was nothing noteworthy about 
the other organs, and no deformity of bones elsewhere. 


Case of Clonic Spasm of Pharynx. 

Shown by Dr. Lambert Lack. The patient, a girl set. 19, came 
under observation at the Throat Hospital about two months ago, com¬ 
plaining of “ phlegm in the throat." On examining the pharynx, one 



39 


at once notices a twitching movement of the posterior pharyngeal 
wall, which seems to be sharply drawn to the left and then relaxed. 
The movement curiously resembles nystagmus. The palate sometimes 
seems to move slightly in association. The larynx is healthy, and 
there is no twitching of the laryngeal muscles. The patient has some 
chronic rhinitis, but otherwise is in robust health, and is not of a 
specially nervous disposition. This pharyngeal spasm has been con¬ 
stantly present every time the patient has been seen in the last two 
months, but its duration beyond that is doubtful, as it apparently 
gives rise to no symptoms. 

The case seems identical with that of a man shown by Dr. Bond 
during the last session of this Society, and is brought forward in the 
hope that other members of the Society will state their experience of 
this apparently rare affection, or give some information as to its 
aetiology or pathological associations. 




PROCEEDINGS 

OP THE 

LARYNGOLOGICAL SOCIETY OF LONDON. 


Ordinary Meeting, February 9th, 1898. 


Hen by T. Butlin, Esq., F.R.C.S., President, in the Chair. 

Herbert Tilley, M.D.,) „ , . 

William Hill, M.D., j Secretanes ' 

Present—32 members and 2 visitors. 


The minutes of the previous meeting were read and confirmed. 

The following gentlemen were elected ordinary members of the 
Society : 

0 

John Fallows, L.R.C.S.Ed., L.S.A., 2, Princes Mansions, Victoria 
Street, S.W. 

William Frazer, L.R.C.P., M.R.C.S.(Eng-), Johannesburg. 


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

Frank Marsh, F.R.C.S.(Eng.), 34, Paradise Street, Birmingham. 
John E. Scatliff, M.D. (Aberdeen), M.R.C.S.(Eng.), 11, Charlotte 
Street, Brighton. 

Henry B. Robinson, M.S., F.R.C.S.(Eng.), 1, Upper Wimpole 
Street, W. 

Adam B. Kelly, M.B., C.M.(Glasgow), Blythwood Square, Clifton. 
Arthur J. Hutchinson, M.B., C.M.(Glasgow), 225, Bath Street, 
Glasgow. 


FIRST SERIES—VOL. V. 


4 



42 


Report of Morbid Growths Committee. 

The following reports were drawn up : 

Slide L.S.L. (Laryngological Society of London), No. 11.—From 
case shown by Dr. Spicer as “ Rapidly Recurrent Tumour of the 
Nasal Septum” (‘Proceedings/ vol. v, p. 19, December, 1897). 
The committee finds that the growth is a fibro-angioma, and quite 
benign in character. 

Slide L.S.L. No. 12.—From case shown by Mr. Morley Agar as 
“ Tumour of Tongue ” (‘ Proceedings/ vol. v, p. 4, November, 1897). 
The specimen is composed in part of dense fibrous tissue, and in other 
parts of a looser connective-tissue with some connective tissue cells. 
There is no evidence of malignancy. The committee would call 
attention to the fact that such growths in the tongue without any 
admixture of lymphangiomatous tissue are rare. 

Slide L.S.L. No. 13.—From case shown by Dr. Bond as “ Recurrent 
Laryngeal Growth” (‘Proceedings/ vol. iv, p. 104, June, 1897). 
The patient was a female set. 27, and had had a growth removed 
from the larynx at least five times in two years. Growth was as 
large as a couple of small peas, and sprung from the very bottom and 
posterior part of the left ventricular band, and hung down between 
the cords. It did not look like a papilloma, and on section it seemed 
to be an epithelial growth of unusual character. The committee con¬ 
firms Dr. Bond’s observations, but as the members had only one 
section to examine, they desire to postpone a definite report until they 
have examined other sections. 

January §th, 1898. 


The SUFRA-TONSILLAR FOSSA. 

Dr. Paterson showed specimens and photographs of this space. 
His attention was drawn to its importance by a case which came 
under his care two years ago, and since that time he had accumulated 
a large number of observations on its variations and the affections 
to which it is subject. A search into the literature showed that it had 
been practically ignored by writers on diseases of the throat, and the 
index of the ‘ Centralblatt fur Laryngologie ’ contained no reference 



43 


to it. The space which is met with in the majority of individuals is 
situated behind the anterior palatal fold in its upper part, and has 
been erroneously looked upon as an enlarged tonsillar crypt. It has 
been described by His as an anatomical space, to which he gave the 
above name, and he regarded it as the remains of the second visceral 
cleft. The exhibitor, from the examination of a large number of 
specimens, both in the living and the dead subject, concluded that two 
main factors influenced the situation and relations of the space. 
(1) The disposition of the plica triangularis may affect the size and 
the outlet of the cavity. This structure is a triangular fold of mucous 
membrane found projecting from the anterior palatal arch between the 
fourth and fifth months of foetal life, and frequently persistent into 
adult life. (2) The development of the tonsillar adenoid tissue in 
the sinus tonsillaris varies considerably, and will modify the extent 
and even the position of the fossa; in some, indeed, its situation is 
not above the tonsil, and the designation “ palatal recess ” would 
perhaps be a more appropriate term. It extends in various directions, 
and comes into relation with the deeper parts. It is liable to certain 
affections ; in two cases the exhibitor observed it as the starting-point 
of malignant disease, and its importance is increased by the fact of it 
being frequently the seat of infection in certain forms of disease. 

Dr. Scjlnes Spicer was much interested in the definite anatomical 
and developmental facts concerning the supra-tonsillar fossa brought 
forward. He had long regarded the fossa as a morphological entity. 
Clinically the morbid conditions (retention cysts, grit, calculus, and 
suppuration) as common causes of chronic and recurrent discomforts 
referred to the tonsils were well known to most specialists, and person¬ 
ally he considered they usually demanded surgical interference. For¬ 
merly he had confounded these fossal conditions with lacunar disease; 
later he had regarded them as occurring in a cavity formed by abnormal 
adhesions; but for some years he had been convinced that we had in 
this supra-tonsillar recess a definite and regular anatomical structure. 
He had frequently known the adenoid mass of the faucial tonsil to 
hypertrophy into the fossa, from which it could be easily withdrawn. 

Dr. Hill expressed some surprise that Dr. Paterson had found 
no literature on the subject, as in the * Proceedings * of the Society a 
little while ago a case was brought forward in which a calculus was 
lodged in the fossa. 

Dr. StClair Thomson was also surprised to hear that there were so 
few references to the subject in leading text-books. He was under the 
impression that the supra-tonsillar fossa was recognised and frequently 
referred to in current German literature. Quite recently he had read 
an article by Griinwald in the ‘ Miinchener medizinische Wochen- 
srchrift ’ recommending that peritonsillar abscesses should be opened 



44 


through the supra-tonsillar fossa; and Killian (in the * Monat. fur 
Ohrenheilk.’) had pointed out that abscesses of the tonsil could be easily 
opened with a probe in the peritonsillar fossa. This region, which had 
been so fully investigated and well described by Dr. Paterson, was of 
clinical importance with regard to periton sillar collections of pus. For 
Dr. Thomson thought that most laryngologists opened the abscess 
cavity in this region, although they did not enter it, ,as Grunwald 
recommended, between the pillars of the fauces, but by puncturing 
the anterior pillar with a pair of sharp sinus forceps, which were then 
opened as they were withdrawn. 

In reply,Dr. Paterson wished to emphasise the important difference 
between this space and what it has usually been regarded as, viz. an 
enlarged tonsillar crypt. 


Papilloma of Tonsil. 

Shown by Dr. Paterson. The specimen was obtained from a boy 
set. 10, who came under notice for enlarged tonsils. These were 
excised, care being taken to bring away intact the little tumour. It 
was about the size of a hemp-seed, was provided with a well-marked 
stalk, and consisted microscopically of squamous epithelium. It gave 
rise to no symptoms. The object in showing the specimen was to 
point out that, although situated on the anterior and inner aspect 
of the tonsil, it did not grow from that gland, but sprung from the 
plica triangularis, which was well marked. The latter fold could be 
readily made out lying loosely over the tonsil and giving origin to the 
papilloma. From his observations the exhibitor concluded (1) that 
most of the so-called papillomata of the tonsil—which may either be 
little masses of lymphoid tissue covered to a varying extent with 
epithelium or true papillomata, as in the present specimen—spring 
from the plica, and do not grow from the tonsil; and (2) that they 
are frequently in relation to the outlet of the supra-tonsillar fossa, and 
may be induced by discharge from that cavity. Care is often neces¬ 
sary to distinguish the plica, which may be intimately adherent to the 
subjacent tonsil. 

A New Snare for Throat and Nose Work. 

Shown by Dr. Lambert Lack. The chief advantage claimed for 
this snare is that the wire loop having been adjusted round a growth 
can be rapidly drawn tight so as to seize the growth firmly, and that 



45 


then, if required, the loop can be further tightened by a screw. By 
this latter movement sufficient force is obtained to cut through the 
firmest growths ; at the same time the division is slowly effected and all 
bleeding arrested. The instrument is strong in all its parts, the 
mechanism simple, and it has nothing to get out of order. The 
instrument is entirely of metal, and easily takes to pieces for cleaning, 
&c. The wire can be easily and quickly attached, and is very firmly 
fixed. It may be of any size, and the loop may be over six inches 
long. The snare works noiselessly ; the clicking of some instruments 
is very distressing to sensitive patients. The instrument has three 
ends a thick barrel for very tough growths, a fine end for aural and 
nasal polypi, and a curved end for use in the larynx or post-nasal space. 

The instrument requires the use of two hands to work the screw; 
but the growth having been already firmly seized, I do not think this 
can be considered a disadvantage. 

I am greatly indebted to my friend Mr. Bingham (an engineer) 
for much help, and for suggesting the method by which the screw is 
brought into action; and to Messrs. Mayer and Meltzer, who have 
made the instrument for me. 


Radical Cure op Long-standing Antral Empyema. 

Mr. Waggett showed a middle-aged woman with an eight years’ 
history of left antral empyema, during which time she had practised 
daily irrigation through a tube in the alveolus. He performed Luc’s 
operation, making a large opening through the canine fossa, removing 
entirely the polypi and the thick purple papillated lining of the 
cavity, which was cleared until the white bone was laid bare through¬ 
out. The bony structure was exceedingly soft and yielding, and in 
inserting a drain-tube held in a pair of fine sinus forceps through 
the hole drilled into the inferior meatus, the hard palate was wounded. 
The latter fortunately healed in the course of a few days; never¬ 
theless to avoid such accidents it would seem advisable to puncture 
and insert the tube from the nasal side rather than the antral. The 
muco-periosteum was sutured over the canine fossa wound, which 
healed firmly. The drain-tube into the bone was removed on the 
third day, and in the speaker’s opinion might well be dispensed with 
altogether. 

§ 



46 


No reaction followed the operation. From the day of operation, 
five weeks ago, no pus has been secreted in the cavity; injections 
made through the inferior meatus opening at intervals of eight days 
returning perfectly clear, while the nose has been entirely free from 
discharge. 

Dr. William Hill and Mr. Lake demurred to the credit of this 
operation being given to Luc, as Dr. Spicer had reported and shown a 
case of this particular operative procedure before Luc had written his 
paper on the subject. Senn has also independently described an 
osteoplastic resection of the anterior wall with a nasal opening. 

Dr. StClair Thomson asked if a piece of the bony wall was 
detached and replaced in making the opening through the canine 
fossa, and how long the drainage-tube from the antrum into the 
inferior meatus was left in situ. 

Dr. Scanes Spicer was surprised at Dr. Waggett’s referring to the 
method as a new one. Dr. Luc (‘ Bull, et Mem. de la Soc. Fran^ d’Oto- 
logie, Laryng., et de Rhinol.,’ 1897) had, indeed, claimed it as a “ new 
operative method for the radical and rapid cure of chronic empyema of 
maxillary sinus. He specially claims (ibid., p. 81) as the original 
feature of his operation the “ creation of an artificial opening which 
serves to drain the sinus cavity by the corresponding nasal fossa.” 
He also gives as the date of his first operation case February 16th, 
1897 (ibid., p. 84). Both Dr. Waggett and Dr. Luc have overlooked 
the numerous references which have appeared in the English medical 
press during the last four or five years detailing a method differing in 
no essential detail from that now put forward (vide * Brit. Med. 
Joum.,’ December 15th, 1897, ‘Journ. of Laryng.,’ * Proc. Laryng. 
Soc. Lond.,’ &c.). Moreover, a formal discussion on chronic antral 
empyema was held by the Laryngological Society of London, one of 
the ieading features of which was the general condemnation of the 
method advocated by the speaker on that occasion as unnecessarily 
severe, leading to facial deformity and falling in of cheek, rendering 
patient unable to smoke his pipe, and leaving a permanent bucco- 
antral fissure. Further experience has confirmed the speaker that 
these objections were visionary and theoretical; and, in fact, not one 
of these sequelae ever followed. Many others besides Dr. Luc were 
now using the method with success. What he wished to emphasise 
was that this large canine fossa opening, curettement, no buccal 
drainage-tube, free counter-opening into inferior meatus of nose for 
drainage, had been practised largely by British rhinologists for about 
five years, and numerous references to the results are to be found. 
He congratulated Dr. Waggett on his result in this case, and, speaking 
from a large experience, could assure the Society that in uncompli¬ 
cated chronic antral empyema they would find the method radical 
and certain, and not followed by any one of the dreadful results 
predicted for it. 

Mr. Waggett, replying to Dr. Thomson, said that with the exception 
of some white fibrous tissue underlying the infra-orbital nerve, all the 
«oft structures were removed. He did not for a moment dispute 



47 


Dr. Spicer’s claim to originality in the method, and would give him 
all credit for it; and with reference to the latter’s opinion that where 
the floor of the antrum was on a lower level than that of the nose, it 
was advisable to leave the canine fossa opening patent for purposes 
of drainage, Mr. Waggett thought it better to avoid the necessity of 
prolonged drainage altogether by removing the glandular lining of 
the cavity. 


Immobility of Right Cord. 

Shown by Dr. Willcocks. Henry O’B—, set. 70. He first 
came under observation about five months ago, when he had loss of 
voice and considerable swelling, affecting chiefly the right side of the 
glottis and the interarytsenoid space. The swelling gradually subsided 
under the influence of soothing inhalations and iodide of potassium, 
and was for a time confined only to the posterior end of the right 
cord. 

Present condition .—The right vocal cord is immobile and somewhat 
congested. There is no evidence of intra-thoracic pressure of any 
kind. 

Sir Felix Semon thought the case one of mechanical immobility, 
both from the history and the improvement under potassium iodide. 
There was a particularly “ clean ” appearance about the larynx, 
which he thought was indicative of its non-malignant nature. 

Mr. Btttlin inclined somewhat to the malignant nature of the case 
on account of the, presence of enlarged glands and the bad health of 
the patient. 


Early Epithelioma of Cord. 

Shown by Dr. Herbert Tilley. Fred. W—, set. 49. Patient 
complained of loss of voice for two months, but there was no pain 
or difficulty of swallowing. At the anterior end of the left vocal 
cord is a whitish patch; the posterior part of the cord congested, and 
more so than the corresponding part of the right one. There is 
slight loss of movement on phonation. 

The President and Sir Felix Semon both agreed it was an 
excellent case for operation, but suggested the advisability of remov¬ 
ing a small portion of the growth lor examination previous to the 
radical operation. 



48 


Case of Primary Epithelioma of the Uvula. Two Coloured 
Drawings of the Parts and Microscopic Sections of the 
New Growth. 

Shown by Dr. Walker Downie. The patient, a man set. 56, 
came under observation in July, 1897. He complained of having 
had sore throat for fully two months, and that within the past few 
days he had had some difficulty in swallowing, along with considerable 
discomfort in breathing while asleep. 

On examination the uvula was represented by a large fleshy body; 
the greater portion of its surface anteriorly and to the right was 
ulcerated, the mucous membrane in the middle line and to the left 
side being alone intact. The tip, which rested on the dorsum of the 
tongue, was also raw. The whole structure was found to be hard and 
firm on palpation, and manipulation caused the surface to bleed. 
The faucial pillars were unaffected. 

It was diagnosed epithelioma, and without delay the whole of the 
uvula was removed under cocaine, the incisions going well into the 
soft palate. The surface was practically healed in four days; and 
now, at the end of six months, the man is in perfect health, and 
there are no evidences of recurrence. 


Interarytasnoid Growths. 

Shown by Mr. Lake. Patient was a female. The growth occupied 
the upper portion of the interarytaenoid region, and was a pale pink 
colour, but no breach of surface. No subjective symptoms except 
loss of voice. 

The pieces shown were removed on February 3rd, 1898. Since 
then the patient has improved very much in her general condition. 

Dr. Clifford Beale asked Mr. Lake to keep the patient under 
observation if possible, and to report the result of the operation after 
an interval of three months. He thought it very desirable that the 
limits of operation on this class of case should be defined. The inter¬ 
arytaenoid tumours were well recognised since Professor Stoerk first 
drew attention to them; and, as a rule, they did not give rise to suffi¬ 
cient trouble to warrant any operation. The resulting wound was apt 
to remain unhealed, and to become the starting-point of a further 
tubercular infiltration. In Mr. Lake’s case the voice had been im¬ 
proved, but there remained a large ragged sore in the interarytaenoid 
space, and it would be desirable to watch its progress. 



49 


Carcinomatous Tumour of the Epiglottis and Base of the 

Tongue. 

Mr. Spencer showed a tumour which had occupied the upper 
epiglottis and superficially the base of the tongue. It was about the 
size and shape of a Tangerine orange, with a nodular surface, and 
appeared firm and white on section. Under the microscope the 
growth was found to be a carcinoma. Columns of epithelial cells 
projected downwards from the surface epithelium to mingle with the 
main structure of the tumour, which consists of polyhedral oval and 
spindle cells, and soft connective-tissue stroma. In the lymphatic 
gland, which was enlarged in the neck, the structure at first sight 
appeared like an oval and spindle-celled sarcoma with a stroma between 
the individual cells. There are a few nest-cells in the primary growth, 
about one in each section, but none have been met within the glands. 
A distinct alveolar arrangement is absent both from the primary and 
secondary growth ; but there can be little doubt that the growth 
originated in the epithelium, in the fold between the epiglottis and 
tongue. 

The tumour was taken from a man over 70, who complained 
of increasing difficulty in swallowing. He had suffered for three 
or four months, and had become reduced to soft substances like 
well-masticated bread and butter. He was further troubled by the 
constant rising up into the mouth of ropy mucus, and a tense swell¬ 
ing in the neck had formed, which gave him pain. He had lost flesh 
and felt weaker since the swallowing had become difficult. His 
breathing had not troubled him, but his voice had become somewhat 
muffled. On examination the lower part of the pharynx appeared to 
be completely filled by the tumour, which could be touched by the 
finger; but neither the opening of the larynx nor that of the cesophagus 
were visible. There was an enlarged superficial gland in the neck, 
which was breaking down, and was tense. When the administration 
of the anaesthetic was commenced the patient became dyspnoeic, and 
preliminary tracheotomy was at once done. The pharynx was then 
more thoroughly explored by the finger. The larynx was found to be 
drawn up behind the tumour, and the arytaeno-epiglottic folds were 
stretched over its posterior surface. Transverse subhyoid pharyngo- 
tomy was therefore done, the base of the epiglottis cut across, and the 



50 


arytaeno-epiglottidean folds divided. A pedicle was thus made, and the 
tumour was quickly removed by the galvano ecraseur. The wound in 
the pharynx was completely sewn up, the tracheotomy tube removed, 
and the broken-down gland in the neck incised, wiped out with a 
strong antiseptic, and the skin united. The previously weak patient 
stood this palliative operation well, could swallow easily, and felt 
relief from the tension in the neck. Unfortunately on the fifth day 
there was a bad fog, some bronchitis then started, and the patient 
died a week after the operation. There were no signs of pneumonia, 
neither during life nor post mortem. The pharyngeal wound and 
the cut made into the broken-down gland were firmly stuck together, 
and the tracheotomy wound was filling up by granulations. The primary 
tumour had been completely removed, but there were some small 
nodules, apparently in the lymphatics of the pharyngeal wall, also the 
secondary gland in the neck, but nothing else abnormal. 

It does not appear that the tumour could have been satisfactorily 
removed by an ecraseur through the mouth, even at an early stage, for 
there was no pedicle until the base of the epiglottis and the arytaeno- 
epiglottidean folds had been cut through ; and if these latter had been 
included in the snare, oedema glottidis or other complications might 
have ensued. 

Mr. Waggett suggested that the Morbid Growths Committee should 
investigate the nature of the growth. 

Sir Felix Semon commented on the curious fatality which attended 
subhyoid pharyngotomy, and yet the post-mortem evidences gave no ex¬ 
planation of the matter. He could recall no case which had recovered. 

Mr. Btjtlin’s experience was much the same, and he instanced a 
case in which jaundice and acute mania preceded death. 


Epithelioma op Left Vocal Cord. 

Shown by Mr. Stephen Paget. D. R—, male set. 43, had 
suffered from hoarseness for six months, and now experienced some 
pain on swallowing. 

The left vocal cord was ulcerated and thickened, the ulceration 
extending to the interarytsenoid space. It was quite immobile on 
phonation. An enlarged gland was present in the left submaxillary 
region. 



51 


Sir Felix Semon advised operation without delay, and said that he 
feared the disease would be found more advanced than the laryngo- 
scopic appearances suggested. 

Mr. Butlin agreed, and also stated that there was an enlarged 
submaxillary gland, and that a partial laryngectomy might be neces¬ 
sary as well as removal of the gland. 

Ebbatum. 

‘ Proceedings,’ December 8th, 1897, p. 22, line 9, read “ shown by 
Mr. Morley Agar (by kind permission of Mr. Mark Hovell).” 




PROCEEDINGS 


OF THE 

LARYNGOLOGICAL SOCIETY OF LONDON. 


Ordinary Meeting, March 9th, 1898. 


Henry T. Btjtlin, Esq., F.R.C.S., President, in the Chair. 


Herbert Tilley, M.D., | 
William Hill, M.D., j 


Secretaries. 


Present—38 members and 2 visitors. 


The minutes of the previous meeting were read and confirmed. 

The following gentlemen were elected ordinary members of the 
Society : 

Henry Betham Robinson, M.S.(Lond.), F.R.C.S.(Eng.), 1, Upper 
Wimpole Street, W. 

Arthur J. Hutchinson,M.A., M.B., C.M.(Glasgow), 225, Bath Street, 
Glasgow. 

Adam Brown Kelly, M.B., C.M., B.Sc.(Glasgow),Blythwood Square, 
Glasgow. 

Frank Marsh, F.R.C.S.(Eng.), 34, Paradise Street, Birmingham. 
John Scatliff, M.D.(Aberdeen), M.R.C.S.(Eng.), 11, Charlotte 
Street, Brighton. 


Report op Morbid Growths Committee. 

Slide L.S.L. No. 14.—From larynx of case shown by Dr. Herbert 
Tilleyat the November meeting, 1897. The Committee report, "Along 
the border of the section in the subepithelial lymphoid layer are 
several typical giant-cells, in some of which nuclei can be distinguished, 
FIRST SERIES — VOL. V, 5 



54 


and mostly surrounded by an abundance of small-cell infiltration. 
Tubercle bacilli were also found in the section. Lower down is to be 
seen a large tubercle in a state of caseous degeneration. We consider 
that the case was, therefore, one of tubercle of the larynx.” 

Slide L.S.L. No. 15.—From specimen shown by Mr. W. G. 
Spencer on February 9th, 1898, as “ carcinomatous tumour at the base 
of tongue and epiglottis.” The Committee report that “ the tumour 
is of malignant type, and is composed of epithelial cells. The cells 
are arranged in masses without intercellular substance, and are partly 
spheroidal and partly squamous, and cell-nests were not found in the 
depth of the tissue, but only in the superficial layer of epithelium. 
The growth is a carcinoma, but whether it originated from the squamous 
epithelium is not certainly shown by the specimen; it is, however, 
probable that such is the case. Considering the situation, it is pro¬ 
bable that it originated from the surface epithelium.” 

Slide L.S.L. No. 16.—The gland shows collections of exactly 
similar cells, and here also without cell-nests. In neither growth is 
there any evidence of keratinous change. 


Lepra Tuberosa op thb Larynx, Mouth, and Nose, with Re¬ 
marks upon the Origin and Nature op “Globi” and 
“Giant- cells.” 

For Dr. Paul Bergengrun (Riga), communicated by Prof. A. A. 
Kanthack. Prof. Kanthack demonstrated for Dr. Bergengrun a 
complete series of photographs and coloured drawings illustrating the 
macroscopic and microscopic appearances of leprous lesions of the 
larynx, tongue, fauces, and nose ; and a number of coloured sketches 
of the laryngoscopic images obtained in lepra tuberosa laryngis. 

Larynx .—Indurative and ulcerative processes are well marked ; 
ulceration along or below the vocal cords or in false cords is common ; 
ulceration may be extensive, and the whole epiglottis may be destroyed. 
Thickening and infiltration of epiglottis, in some cases amounting to 
lepromata, is remarkable. Favourite seats of infection are the epi¬ 
glottis, and especially its petiolus, the region just above and below the 
anterior commissure of the vocal cords. The ary-epiglottic folds are 
thickly infiltrated and often nodular. The epiglottis is often curved 
upon itself, and may be so thickened that the interior of the larynx 



55 


cannot be seen. The cords may be normal, although there is extensive 
disease. The mucosa over the aryteenoid cartilages often becomes 
swollen, in the shape of thick globular masses. The ventricular bands 
are almost always diseased, either infiltrated, nodular, or ulcerated. 

Tongue .—The tongue frequently becomes irregular and nodular; 
the nodules may be large and numerous; they may be arranged sym¬ 
metrically on either side of middle line, separated by a deep groove. 
Occasionally the “silver tongue” of Leloir may be observed, when 
there are flat, low, silvery, disc-like swellings on the tongue, with a 
finely granular surface, and also broader silvery streaks. 

Uvula .—Frequently diseased; may be converted into a coarse 
nodular mass or into a pyriform swelling with granular, nodular, or 
ulcerated surface; may become fibrous and cicatrised or completely 
slough away. 



Leprous larynx seen from behind. 



56 


Fauces .— While the anterior fauces remain intact, the posterior 
become nodular or ulcerated. 

Palate and Gums .—Hard and soft palate may be infiltrated with 
small lepromatous nodules, extending backwards in the middle line as 
far as the uvula, and forwards through the incisors as far as the 
gums. Ulcers on the gums and palate are also observed. 



Leprous larynx seen from behind 


Nose. —Dr. Bergengriin lays special stress on the trilobed external 
appearance. Local cicatrisation may occur to such an extent that the 
rima oris becomes reduced to a small opening, through which only 
one or two teeth can be seen. 

Histological observations. —Prof. Kauthack also demonstrated beau- 



57 


tiful microscopical specimens and coloured drawings prepared by Dr. 
Bergengriin, which clearly proved two points : (a) that the so-called 
ct globi ” are bacillary thrombi lying in the dilated lymphatics; and 
(6) that the lepra giant-cell develops from the lymphatic endothelium. 
As to the globi, in longitudinal section, they appear as sausage- or 
chain-like narrow strands or bands, which run through the connective 
tissue as parallel streaks. These are curved and tortuous, short and 
long, broad and narrow, and often lie in spaces lined by a typical 
endothelium. The formation of the lepra giant-cells is explained as 
follows:—The bacillary thrombi in the lymphatic vessels act like foreign 
bodies, and irritate the endothelium lining the lymphatics, so that here 
and there endothelial cells divide and proliferate. The diseased cell 
protoplasm cannot keep pace with the nuclear division, and the proto¬ 
plasm of different cells fuses into a plasmodial mass. Thus a giant¬ 
cell forms around the bacillary thrombus, gradually wrapping itself 
around the latter. The microscopic specimens left no doubt as to the 
correctness of this interpretation. 

Dr. Bergengriin has once and for all settled the old controversy re¬ 
garding the distribution of the leprosy bacilli, by thus showing that 
the intra-cellular distribution is almost insignificant when compared 
with their endolymphatic distribution. This has recently also been 
confirmed by Dohi, Herman, and others. 


Case of Oz^ena following Removal of Inferior Turbinate. 

Shown by Mr. Stewart. P. S—, a female. For some years she 
had suffered from the usual discharge and symptoms consequent on 
hypertrophy of the nasal mucous membrane. Turbinotomy was per¬ 
formed in 1893 for deafness and discharge from right ear. Since ope¬ 
ration crusts have formed in the throat and back of nose, with a 
considerable amount of foetor. 

Dr. Spicer thought that the history of the case scarcely proved the 
post et propter aspect of the operation. The patient had a dis¬ 
tinct history of nasal suppuration since a child, and it was possible 
that the operation only accentuated the intra-nasal drying of the dis¬ 
charge. The shape of the nose is also that seen in atrophic rhinitis, 
a condition which could scarcely have developed since the operation. 

Mr. Waggett said the patient had distinctly told him that there 
were no crusts before the operation. 

Mr. Stewart in reply stated that he brought forward the case for 



58 


what it was worth. They could not, however, get over the facts that 
the patient stated that, previous to the operation, the discharge from 
the nose was what one usually finds in hypertrophic conditions of the 
mucous membrane, and that since the operation there had been 
crust formation, and both objective and subjective fcetor, and that 
when first seen at the hospital the nose and throat were thickly 
coated with very offensive crusts. 


Case for Diagnosis—Laryngeal Swelling. 

Shown by Mr. Edward Roughton. J. P—, an iron moulder 
set. 52, has suffered from hoarseness for one year and eight months, and 
from pain on speaking and swallowing and dyspnoea for six months. 
Attributes his condition to inhaling fumes of sulphur. Both false 
cords are swollen ; they overlap on phonation; some swelling of ary- 
tsenoids and ary-epiglottic folds; true cords remain almost immobile 
during respiration, and adduct with difficulty on phonation, the left 
moves more than the right. There is also some subglottic thickening. 
(Esophageal bougie passed without encountering obstruction. 

Lungs .—Chronic bronchitis and emphysema. No evidence of 
phthisis. 

No history of syphilis; gonorrhoea many years ago. Has been 
taking Pot. Iodid. for a month ; no improvement. 

Dr. Clifford Beale regarded the case as tubercular, and called 
attention to the excessive amount of sputum, which might, if exa¬ 
mined, show the presence of bacilli. 

Dr. StClair Thomson entirely agreed with Dr. Beale’s suggestion. 

Mr. Symonds thought that it was possibly a case of malignant 
disease, and pointed out the enlarged submaxillary glands in support 
of this view. 


Lupus of Pace, Nose, and Mouth. 

Mr. Houghton also showed a young woman suffering from lupus of 
face, nose, palate, tongue, and epiglottis. 


Mechanical Fixation of Vocal Cords. 

Shown by Dr. Herbert Tilley. Patient is a man set. 43, who 
two years ago applied to hospital for hoarseness and pain on swallow- 



59 


ing of three weeks* duration. There was also slight stridor, which 
much increased in the course of the next few days. Examination of 
the larynx showed marked oedema over the arytsenoids and sluggish 
action of the cords. There were no physical signs in the chest, nor 
evidence of nerve lesions of any kind. The stridor increased so 
rapidly that tracheotomy was performed, and the man has worn the 
tube ever since. He is in perfect health, and can produce a fairly 
good voice with expiration. Inspiration is impossible without the 
tube. The history of sudden onset with a cold, pain on swallowing, 
and oedema over the arytaenoid region suggest implication of the 
crico-arytsenoid joints, with subsequent fixation of the cords in their 
present adducted position. 


Double Abductor Paralysis without Apparent Cause. 

Shown by Dr. Herbert Tilley. Patient is a man set. 49, who 
seven years ago applied to hospital for difficulty of breathing, 
especially marked on exertion. He was otherwise a very healthy man, 
with no abnormal physical signs in his chest and no evidence of com¬ 
mencing tabes. The vocal cords were seen to be adducted, but were 
otherwise healthy in appearance, as also the rest of the larynx. 
Tracheotomy was performed at once and without ansesthesia. After 
the skin incision the patient complained of very little pain. 

Patient is now a particularly healthy-looking man; he still has to 
wear his tube, and, as in the last patient, his voice is very good. 

The knee-jerks and pupils have normal reactions. The question 
arises whether such a condition might not be a form of peripheral 
neuritis, and whether many of the laryngeal paralyses which are seen 
where there is no evidence of pressure on the recurrent laryngeal may 
not be due to a similar cause. 


Fluctuating Swelling over the Left Ala of Thyroid 

Cartilage. 

Shown by Dr. Herbert Tilley. Patient is a lad set. 10, with a 
swelling as described. It has been noticed only three weeks, and no 
reason can be assigned for its presence. It extends slightly across the 
middle line, fluctuates, and is rather painful on pressure. The left 



60 


side of the larynx (internally) is distinctly more swollen than the 
right, especially the left vocal process. 

Mr. Butlin thought it was a thyro-lingual duct tumour, which 
are occasionally situated to one side of the median line. 

Original Drawing and Description by Sir Robert Christison 
of a Method for Removal of a Double Fish-hook from 
the Gullet (date 1819). 

Shown by Dr. StClair Thomson for Dr. Walker (Peterborough). 



[COPY.] 

Edine. ; 

Septr. 24th, 1819. 

Dear Sir, 

The rude sketch given above will communicate a pretty 
good idea of the mode in which the hook was extracted from the 
hoy's throat at our hospital here about a fortnight ago. The hook 
was double (one division being less than the other), and had fixed 
itself across the gullet from before backwards, though not so far down 
as I have represented it. The wire attached to it hung out of the 




61 


mouth. A hole was drilled through the Ivory ball of a Probang, but 
not in its centre, the reason of which is evident when it is considered 
that the two divisions of the hook were unequal. The boy was able 
to give a tolerably accurate description of its size and form, so that it 
fortunately happened that the ball suited it exactly ; both barbs were 
covered by the ball, and the whole was easily removed after being 
first slightly pushed down in order to loosen the attachments of the 
barbs. The extraction was considerably facilitated, in the opinion of 
the surgeon, by previous suppuration. Though it had remained 
about twelve days the boy recovered without a bad symptom. 

1 remain, yours most sincerely, 

B. Christison. 


Epithelioma op the Larynx from a Case exhibited on 

January 12th. 

Mr. Symonds reported that the patient, aet. 55, he exhibited at 
the January meeting improved so much in general health, owing to 
local treatment, that he was able to remove the larynx on January 
24th. The oesophagus and pharynx were closed anteriorly, and the 
muscle and skin united. The severed trachea was attached to the 
skin just above the sternum. Primary union took place in the greater 
part of the wound, and the man was able to swallow after twenty-four 
hours, and made an excellent recovery. 

Mr. Symonds exhibited the patient, who showed great improvement 
in general health. 

The disease proved extensive, as the specimen showed. The right 
ala was penetrated by growth and the left partly destroyed. There 
was also considerable extension to the pharynx, a further inch having 
to be removed after separation of the larynx. The specimen showed 
extensive disease of the whole interior of the larynx, the cords being 
destroyed. The starting-point was probably in front below the left 
cord, but as both sides were almost equally involved, it must have 
really spread to the right. 

Though rapid extension took place after the man was exhibited on 
January 12th, the pharyngeal growth must have existed at that time. 
No enlarged glands were found at the operation. 

§ 



62 


The microscopic characters were those of a squamous-celled epi¬ 
thelioma. 


Microscopic Specimen op Early Epithelioma op Vocal Cokd 
from Dr. Tilley's Case shown at February Meeting. 

Shown by Mr. Ernest Waggett. The correctness of the diagnosis 
was abundantly proved by the nature of the specimen. 


Post-mortem Specimen of Epitheliomatous Larynx which had 

BEEN TWICE OPERATED UPON. 

Dr. David Newman showed the larynx removed post mortem from 
a man who had thyrotomy performed twice for epithelioma. 

The patient was first operated on for epithelioma on the anterior 
third of the left vocal cord in 1890 by thyrotomy,* and no recurrence 
took place till 1893, when a small growth the size of a barleycorn 
was discovered close to the anterior commissure, and on removal 
proved to be an epithelioma. From 1893 till 1897 no appearance of 
recurrence, although patient was examined regularly every two months. 
In March, 1897, symptoms of slight laryngeal obstruction and evidence 
of (edematous swelling in larynx, which prevented a complete view of 
larynx being obtained. Laryngeal symptoms were accompanied by 
symptoms and physical signs of chronic parenchymatous nephritis. 
Patient died suddenly from laryngeal oedema, and post mortem the 
larynx was found to be occupied by an epitheliomatous ulcer. 


Naso-pharyngeal Papilloma. 

Dr. David Newman also showed a very large papilloma removed 
from the naso-pharynx of a young man. The growth was the size of 
a hen's egg. 


# See Newman, * Malignant Diseases of the Throat and Nose/ p. 93. 



63 


Adhesion op Soft Palate to Posterior Pharyngeal Wall. 

Shown by Dr. Willcocks. Mrs. R—, set. 43. This patient had 
always enjoyed good health until eleven years ago, when at about a 
month after her confinement (the fourth) she had an ulcerated throat. 
She is the mother of five children, all living and healthy, and has had 
no miscarriage. 

Present condition .—The soft palate is adherent to the posterior 
pharyngeal wall, and the only communication with the naso-pharynx 
is a small slit in the median line of the soft palate. 

The vocal cords are normal, but the edge of the epiglottis is some¬ 
what nodular. 

For the last two months she has been taking a mixture containing 
Liquor Hydrargyri Perchloridi and iodide of potassium. 

Mr. Symonds thought as there was an opening into the nose, the 
patient had better be left alone. A small aperture permitted 
respiration and descent of mucus, and prevented the cleft-palate 
voice. 

Mr. Spencer said that with regard to the operation for the separa¬ 
tion of the soft palate from the pharynx, he had never done nor 
recommended it except for the relief of distinct complication, 
Eustachian obstruction with pain in the ear, persistent laryngitis from 
breathing through the mouth, and so forth. 


Case op Syphilitic Pharyngeal Stenosis. 

Shown by Mr. Walsham. Patient is a middle-aged man in whom 
the soft palate is drawn into contact with the posterior wall of the 
pharynx as the result of cicatrisation following tertiary syphilitic 
ulceration. There is also destruction of the septum and falling in of 
the bridge of the nose. 


A Case op Rhinitis, Pharyngitis, and Laryngitis Sicca. 

Shown by Sir Felix Sehon, M.D. . The patient is a gentleman 
set. 48, sent by Dr. Rattray of Upper Holloway, who began to suffer 
from a discharge from the right nostril without any definite cause being 
known. Crusts were formed in the right nostril, and also often 



64 




evacuated through the mouth, whilst the throat became dry and the 
voice gradually hoarse. There has never been any dyspnoea. The 
patient has not lost the sense of smell, and is not aware that the 
discharge has ever been very foetid. On examination the right nostril 
is found to be abnormally wide, with considerable atrophy of the 
lower and middle right turbinated bones, but without any evidence 
of actual disease of the bony framework of the nose or of any of the 
accessory sinuses. Further, there is considerable dry naso-pharyngeal 
and pharyngeal catarrh, with formation of crusts, after removal of 
which the mucous membrane looks wrinkled and shining. In the 
larynx on the first examination both vocal cords were completely 
covered with green dry crusts, after removal of which the cords 
appeared red and dry, whilst the ventricular bands were considerably 
swollen and equally dry. The patient having been treated for a week 
with benzoin inhalations aud the use of salt water injections into the 
nose by means of a Higginson’s syringe, all the conditions described 
appeared to be considerably improved on the occasion of his second 
visit, but as soon as these simple cleansing measures are neglected 
the previous conditions return. 

The case is shown, first, on account of the one-sidedness of the 
atrophic rhinitis, which in the observer’s experience is comparatively 
rare unless due to a distinctly local process, such as impaction of a 
foreign body, or disease of the accessory cavities, or again to a syphilitic 
process, of all of which contingencies there is not the least evidence in 
the present case. 

The second remarkable feature consists in the persistence of the 
process. In the observer’s experience ordinary ozsena usually exhausts 
itself about the age of forty or thereabouts, but it is remarkable that in 
a man of forty-eight like the patient it should still be so active. 

The third remarkable fact is the extension of the process into the' 
larynx, which in this country at least is very rare. It is seen with 
slightly greater frequency on the Continent. 


Case of very Uncommon Laryngeal Tumour. 

Shown by Sir Felix Semon, M.D. The patient, set. 40, is a 
married lady who formerly lived in North-west Canada, and up to 
about ten years ago enjoyed good health, apart from the fact 
that she sometimes suffered from slight “spasms in the throat.” 



65 


Tea years ago she first observed a swelling in the left submaxillary 
region, which gradually grew until it attained its present size, that of 
an average walnut. At first it gave no discomfort, and particularly 
caused no difficulty in breathing, or, so far as she knows, in the voice. 
In spring and autumn it used to swell, but always returned to its previous 
size. Gradually it became tender on pressure, and her breath became 
permanently short, whilst the previous attacks of spasms in the throat 
increased in severity. She went to Montreal and consulted Dr. Major, 
who found not only the external growth as described, but also a growth 
in the larynx. He is stated to have attempted to puncture the latter, 
but without striking fluid. He also tried, according to the patient’s 
statements, to snare the laryngeal growth, but the snare broke. Dr. 
Major then recommended the patient to go to England and to take 
further advice; he had never seen a similar growth. The patient 
went to London and was treated in a special hospital. This was seven 
years ago. Her medical attendant is stated to have attempted to snare 
the intra-laryngeal growth off with the galvano-caustic snare, but to 
have brought up a very small piece of growth only, whilst during the 
attempt the throat and the tongue were severely burnt. Three weeks 
afterwards her difficulty in breathing had increased to such a degree 
that tracheotomy had to be performed. This was followed by immediate 
relief of the breathing and very great improvement in general health, 
the patient previously, according to her description, having wasted 
away to a skeleton. The little piece of growth removed was stated by 
her attendant to have been of a malignant nature,—indeed, of a can¬ 
cerous character. No further attempts were made to interfere with 
the intra-laryngeal growth. The external swelling has never been 
explored. Two years ago the external swelling in the spring again 
became so much increased and gave the patient so much discomfort 
that she returned to her medical attendant, who is said to have thought 
that there was fluid in it, but he did not want to perform any further 
operation unless it was absolutely necessary. No further steps were 
then taken. Recently there has been again some external swelling, 
which has now subsided, with a good deal of shooting pain in the 
throat extending to the jaws and to both ears. All this is again 
better now. The patient has not recently lost flesh, and has never 
had any dysphagia. Her voice is so surprisingly clear and strong, 
although she still wears a tracheal cannula, that the history, as given 
above, was listened to with a certain amount of incredulity. The 



66 


result of the objective examination, however, was very surprising. 
Externally the small tumour in the left submaxillary region was 
tender to the touch, and any pressure on it, unless extremely gentle, 
each time caused immediate retching and cough. It was, however, 
ascertained that it was not adherent to the skin, and somewhat mobile 
in various directions, although it seemed to be fixed to something very 
low down. No enlargement of lymphatic glands in its neighbour¬ 
hood. On laryngoscopic examination a very surprising condition was 
seen. Whilst from the almost normal voice one would have expected 
a corresponding normal aspect of the larynx, it is seen that almost 
the whole laryngoscopic image is filled out by an enormous tumefac¬ 
tion of the left half of the larynx, which above extends to nearly the 
free border of the epiglottis and below to the left arytaenoid cartilage. 
All the constituent parts of the larynx within that distance have 
perished, as it were, in the smooth round tumefaction, covered by 
apparently normal mucous membrane. Of the epiglottis itself not 
much more than the free border can be seen, which is twisted so that 
the epiglottis is looking towards the right. From this small remnant 
both on the dorsal and on the ventral aspect the tumefaction of the 
left side begins, which involves the ventricular band, the arytaeno- 
epiglottideau fold, and the arytaenoid cartilage. To the right of this 
tumefaction a small chink remains, which is bordered on the right by 
the right ventricular band. Neither of the vocal cords can be seen, 
and it can only be concluded from the integrity of the voice that the 
left vocal cord cannot be involved in the process. The right 
arytaenoid cartilage moves well, the left half of the larynx is almost 
immoveable. On touching the tumefaction with the probe a feeling 
of an elastic resistance is encountered, similar to that experienced on 
pressing the external tumour. 

The observer wished to have the opinion of the Society on this 
most uncommon condition, the like of which he did not remember 
having ever seen. 

Dr. Newman regretted not having heard the history of the case, 
and judging merely from the clinical appearances he thought it 
looked like a sarcoma; the long history, however, was somewhat 
against this suggestion, and he should suggest it was a fibrous or 
fibro-cystic growth. 

Dr. Spicer thought the tumour encapsuled, and that if the mucous 
membrane were divided it would shell out. 

Mr. Symonds found difficulty in deciding what was the relation of 




Sir Felix Semon’s Case. 


A r : 


I * 



67 


the outside to the inside tumour. He thought the case might be sur¬ 
gically attacked, and without any great danger. 

Mr. de Santi remarked that though very uncertain as to the 
nature of the tumour, he inclined to the opinion that it was a slowly 
growing fibro-sarcoma. With reference to Dr. Newman’s remarks he 
would point out that the history of eight years’ duration was not 
incompatible with a diagnosis of sarcoma. Recently he had had 
under his care a girl of twenty, who for eighteen years had had ex¬ 
tensive tumours of the neck and scalp. Six years ago one of the 
largest was removed by one of his colleagues, and Dr. Hebb, a well- 
known pathologist, reported it to be a fibro-sarcoma. Four and a 
half years ago another was removed, and also reported to be a fibro¬ 
sarcoma. Last summer Mr. de Santi made a clean sweep of all the 
tumours, some thirty or forty, and those, microscoped by Dr. Hebb, 
showed almost pure fibrous structure The girl got quite well, but 
some ten months after died with supposed secondary growths in the 
lungs. He hoped to hear soon from the medical man who did the 
post-mortem whether there were definitely secondary growths or not. 
At any rate the case showed the very slow malignity of some of these 
cases of sarcomata. 

Mr. Butlin thought that possibly the tumour was glandular in 
nature, and might be an extension or outgrowth of the thyroid gland, 
and pointed out that the external tumour moved with the hyoid on 
swallowing. He thought that an operation for removal might be 
attempted, and with prospects of success. 

Sir Felix Semon was glad to hear the suggestions which had been 
made relative to active interference with the tumour, but he could not 
yet make up his mind as to whether he should advise the patient to 
undergo the risks of such a severe operation as the case would 
necessarily entail. At present the patient is comfortable, her voice is 
good, she has no trouble with the tracheotomy tube, and the tumour 
is obviously a very slowly growing one. On the other hand, an 
operation, the extent and limits of which we cannot foretell, has been 
suggested for a tumour of whose nature we are ignorant, and which is 
probably closely connected with the vagus, an operation which, there¬ 
fore, is necessarily of a very serious nature. At present he thought 
he would watch the case a little longer, and report later to the Society 
as to what course, if any, had been adopted, and its results. The 
Society is indebted to Mr. Ernest Waggett for the accompanying 
sketch of the tumour. 


Localised Thickening of Interaryt.®noid Fold of Tubercular 

Origin. 

Dr. Bronner (Bradford) showed a microscopic specimen of hyper¬ 
trophy of the mucous membrane of the interarytsenoid fold of 
eleven years’ duration. The patient, set. 34, was first seen in 
November, 1894. She complained of hoarseness and occasional loss 



68 


of voice for over seven years. The symptoms were not increasing in 
severity. There was the well-known thickening of the interarytsenoid 
fold. Sprays, insufflations were tried. The parts were then removed 
with cutting forceps several times ; they always grew again. The use 
of the galvano-cautery was equally ineffectual. The patient was 
under treatment for nearly two years. The present appearance of the 
parts was just the same now as it had been four years ago. The 
Clinical Research Association had reported, “ There are several dis¬ 
tinct tubercles having a nodular outline, and large giant-cells. Other 
pieces consist of ulcerated mucous membrane, the raw surface being 
covered with granulation tissue. The evidence points to the existence 
of tuberculous laryngitis.” 

The mother of the patient had died of phthisis, and patient had 
nursed her for some months. There were no other symptoms of 
tuberculosis. 

Dr. Bronner wished to have the opinion of the meeting—(1) if 
many cases of chronic thickening of the interarytsenoid fold, without 
any apparent cause, were of tubercular origin ; (2) if there was any 
danger of the disease spreading. 

Dr. Herbert Tilley referred to a case which he had shown the 
Society nearly twelve months ago. He pointed out that there were 
two distinct forms of thickening found on the anterior face of the 
arytaenoid commissure. (1) Tubercular granulation tissue such as was 
shown at the last meeting by Mr. Lake. The granulations were soft, 
easily removeable, and tended to recur rapidly. Associated with this 
condition one found signs of tubercle in the lung or iu the larynx. 
(2) That form which is found in cases of chronic laryngitis, especially 
in alcoholics, and not in any way associated with tubercle. The 
growth is a tough, fibrous hyperplasia covered with epithelium 
natural to the part. Often there is a vertical fissure in it, and then 
there is usually sharp pain on swallowing. He did not know what 
was the best treatment for such a condition, though galvano-cautery, 
lactic acid, and removal of pieces by forceps (cutting) only seem to 
give temporary relief, and he was inclined to believe that such cases 
did best when left alone. 

Mr. Spencer also thought that such a condition would not increase 
if it was left alone. 

Dr. Jobson Horne observed that the section of the part removed 
showed, under the microscope, an increase in the breadth of the 
epithelium, with papillae passing into the subepithelial layer. Accom¬ 
panying this hyperplasia there was a metaplasia of the cells con¬ 
stituting the condition of pachydermia. He attributed the condition 
to the chronic irritation caused by the subjacent tubercle. 



69 


• Extensive Syphilitic Adhesions of Soft Palate. 

Mr. de Santi showed a woman on whom he had operated for 
extensive syphilitic adhesions of the soft palate to the posterior wall 
of the pharynx. The patient’s mother had suffered from syphilis, the 
woman herself had inherited the disease, yet after marriage she 
contracted the disease again, and her child had congenital syphilis. 
The whole of the naso-pharynx was cut off from the oropharynx by 
the dense adhesions, and recently patient had had intense pain in the 
right mastoid and ear. There were old perforations of both drums, 
and the patient was deaf to both air and bone conduction. The pain 
in the ear and mastoid always started from the throat. Mr. de Santi 
operated by thoroughly separating all the dense adhesions with scissors 
and knife as close to the pharynx as possible. There was but little 
bleeding ; on the left side no soft structure could be detached, but on 
the right side a fair amount of tissue was separated and then stitched 
forwards to the muco-periosteum of the hard palate, according to 
Mr. Spencer’s method. The case did very well, re-adhesion did not 
take place, and the patient became entirely free from the mastoid and 
ear pain. She also now is able to speak better, and all post-nasal 
discharges pass down the normal way. She is able to blow her nose 
and breathe with her mouth shut. 


Ivory Exostosis of Frontal Sinus causing Pressure Symptoms. 

Mr. de Santi also showed a case of a man suffering from an ivory 
exostosis involving the right frontal sinus, and which had by pressure 
caused a suppurating mucocele. The man had had the exostosis for 
over five years, but beyond the disfigurement had not troubled about 
it until within the last ten days, when the whole of the parts at the 
inner can thus of the eye began to swell and cause pain. The exostosis 
was a very hard, large, and sessile one, and Mr. de Santi dealt with 
the abscess only by incision and scraping, and proposed to operate on 
the exostosis a little later. If left alone it would probably destroy 
the right eye. 



70 


Syphilitic Periostitis op Forehead. • 

Mr. de Santi also showed a case of a man with a syphilitic periosteal 
swelling in the mid-frontal region of the head, just above the articu¬ 
lation of the frontal bone with the nasal bones. It was of interest 
because the patient two years ago had been shown by his colleague, 
Mr. Spencer, for symmetrical enlargement of both parotid glands. 
Some of the members of the Society, notably Dr. Lack, had considered 
the case to be syphilitic parotitis. At any rate, under iodide of 
potassium both parotids soon resumed their normal size. It was, 
however, of interest to note that concomitant with the diminution in 
size of each parotid gland there was a yellow discharge from each ear. 
This discharge did not last long, and there is no sign of perforation 
recent or old to be seen in the membranae tympani. Nor at the time 
of the enlargement of the parotids was there any “ dry mouth ” or 
symptom of obstruction of the parotid ducts. 


Tumour of Lower Lip. 

Mr. Lawrence showed a case of tumour in middle line of lower 
lip in a man set. 61. Disease of a warty character, and hard and 
ulcerated. No history of previous disease and no loss of flesh. 
There was little doubt but that it was malignant. 


Enlargement op Tonsils after Tonsillotomy. 

Mr. Lawrence showed a young woman set. 22, who had been 
(< troubled with her throat ” for twelve years. Tonsils were removed 
last November. Since then they have grown considerably, and there 
are masses of large glands behind and below the angles of the jaw. 

Mr. Butlin and Sir Felix Sem:on thought the case was one of 
syphilis occurring in a tubercular subject, an opinion generally con¬ 
curred in by other members. 

Mr. Spencer thought it was possibly a slow diphtheritic growth, 
and suggested that a bacteriological investigation should be made. 



71 


Cutting Laryngeal Forceps. 

Mr. R. Lake showed a pair of punch forceps for use in double 
curetting of the larynx in tubercular laryngitis. 


Gumma and Perichondritis of Nose. 
Shown by Mr. Atwood Thorne. 


Bilateral Abductor Paresis op Vocal Cords—for Diagnosis. 
Shown by Mr. Atwood Thorne. 


Case of Phthisis and Healed Laryngeal Tuberculosis. 

Shown by Dr. Lambert Lack. The patient, a girl set. 19, came 
under his care in July, 1896, complaining of hoarseness and cough. 
The symptoms pointed to an acute but early phthisis, the lung signs 
being most marked at the right apex. The sputum was crowded with 
tubercle bacilli, there was a history of night sweats, cough, &c., for 
three months, but not much interference with the general nutrition. 
On laryngeal examination the right ventricular band was seen to be 
much swollen, and in its anterior two-thirds covered with pale fleshy 
granulations. The anterior third of the left ventricular band and the 
intervening area of the anterior part of the larynx were similarly 
affected. The vocal cords were congested, but the rest of the larynx 
appeared normal. The whole of the apparent tubercular tissue in the 
larynx was removed with the cutting curette in some three or four 
sittings; on each occasion chromic acid fused on a probe was applied 
to the resulting raw surface. This somewhat extensive surface healed 
readily, lactic acid being occasionally applied to stimulate it. After 
about two months' treatment the larynx was entirely healed, and the 
patient’s general condition had considerably improved. Now for 
more than eighteen months the patient has had no further treatment, 
the disease in the chest has quieted down, and the general health 
remains fairly good, although the patient has unavoidably continued 
work as a waitress in London. 



72 


The larynx remains healed, the absence of the right ventricular 
band disclosing a large part of the upper surface of the right vocal 
cord. 

Dr. Clifford Beale agreed that healing had taken place in this 
case, but pointed out that there was still a good deal of difference on the 
two sides. The patient’s throat showed none of the characteristic 
anaemia of tubercular disease, the mucous membrane looking particu¬ 
larly well nourished—au important point in the selection of cases for 
operation. He thought that surgical wounds of the ventricular bands 
were more likely to heal than those made in the interarytaenoid space, 
as being less likely to become infected by secretions from above or 
below. He congratulated Dr. Lack on the results obtained. The 
successful removal of foci of active disease from the larynx showed a 
distinct advance in treatment. 


Erratum. 

In the report of the discussion of Mr. Spencer’s case of “ Carcino¬ 
matous Tumour of the Epiglottis,” the statement is ascribed to 
Sir Felix Semon (‘ Proceedings,’ February 9th, 1898, p. 50, line 26) 
that he could recall no case which had recovered after subhyoid 
pharyngotomy. This statement is due to an error on the part of the 
reporter. What Sir Felix Semon said was that, according to Sendziak, 
in more than 50 per cent, of the cases of laryngeal cancer, in which 
subhyoid pharyngotomy had been performed, death had ensued. 



PROCEEDINGS 


OF THE 

LARYNGOLOGICAL SOCIETY OF LONDON. 


Ordinary Meeting, April 13 th, 1898. 


Henby T. Butlin, Esq., F.R.C.S., President, in the Chair. 

Hebbebt Tilley, M.D.,) „ , . 

Williah Hill, M.D., j Secretanes ' 


Present—26 members and 1 visitor. 

The minutes of the previous meeting were read and confirmed. 

The following gentleman was nominated for election at the next 
meeting: 

Arnold Fergusson, F.R.C.S.E., 34, Canfield Gardens, Hampstead. 


Cyst op the Epiglottis. 

Shown by Mr. Wyatt Wingrave. Girl set. 13 complained of 
sore throat and occasional deafness for six years, on and off, following 
scarlet fever. Her tonsils were removed four years ago, when nothing 
wrong with her throat was noticed. 

On examination a mass is seen attached to the left half of the 
laryngeal aspect of the epiglottis, resembling a small white-heart 
cherry in size and colour. The only symptom is occasional pain 
on swallowing, her singing and speaking voice being normal. 

FIRST SERIES-VOL. V. 6 



74 


Dr. Law said that he had often noticed these cases following exci¬ 
sion of the tonsils for chronic hypertrophy, and questioned whether 
a traumatism might account for them. 


Case of Chronic Pharyngitis. 

Shown by Mr. Wyatt Wingrave. Man set. 26 has been under 
treatment for chronic suppurative middle ear disease for six years. 

Suspecting adenoids, his pharynx on examination showed a sym¬ 
metrical flesh like thickening, which commenced behind the posterior 
pillars and met in the middle line above the level of the soft palate, 
extending upwards into the naso-pharynx. This tissue proved tough 
on attempting to scrape with finger-nail. 

There is a doubtful history of hereditary syphilis. 

Is the condition due to asymmetrical hypertrophy of the lymphoid 
tissue ? or is it of inflammatory origin ? 

Dr. Spicer called attention to the adhesion in this case between the 
salpingo-pharyngeal fold and the pharyngeal wall, as had been ob¬ 
served in connection with Tornwaldt’s disease. 

Dr. Grant ascribed the condition to hyperplasia of the salpingo¬ 
pharyngeal folds, which had become adherent to each other at a lower 
level than the choanae. 

Mr. Spencer advised removal of the bands on account of deafness. 

Dr. Hill suggested that it was a case of adhesion of the lower 
portion of the hypertrophied salpingo-pharyngeal fold to the posterior 
pillar of the fauces. 

Dr. Edward Law thought it resembled a gummatous condition of 
the lateral pharyngeal wall. 

Dr. StClair Thomson suggested that the condition might be an 
hypertrophy left by a syphilitic process. He had seen a gumma in 
the region of Luschka’s tonsil break down in the upper part, but 
leave a thickening across the pharyngeal wall—at the level of the 
soft palate,—and uniting with a hypertrophic lateral pharyngitis of 
both sides. This condition had remained unaffected by autisyphilitic 
remedies. In the present case some further help might be obtained 
by the microscopical examination of a portion, which could easily be 
i*emoved for that purpose. 

Mr. Wingrave in reply said that on digital examination the finger 
simply passed between the soft palate and the deposit, upwards to a 
free and well-defined vault. The deposit did not hang in front of 
the posterior pharyngeal wall, but was flush with it. There was a 
doubtful history of congenital syphilis which suggested a possible 
pre- or post-natal inflammatory process. 



75 


Modification of Baratoux' Electrical Laryngo-phantom. 

Shown by Dr. Dundas Grant. In the original instrument there 
is a model of the larynx, with a number of metallic points at definite 
positions. Each of these points has, in communication with it, a 
flexible wire and a pin, to which a numbered label is attached. In 
front of a machine is a tracing of the larynx, on which the correspond¬ 
ing points are numbered. 

When the student wishes to exercise himself in touching with the 
laryngeal probe any given point in the larynx, the pin correspond¬ 
ing to that point has to be selected by its numbered label (the number 
having been discovered by examination of the aforesaid tracing), and 
is then fixed in a screw connection. When this is done, and the probe 
is made to touch the correct spot—and no other spot—a loud electric 
bell rings. A considerable time is spent in seeking out the proper 
number, label, and pin, and the present modification has been devised 
by Dr. Grant to minimise this trouble. 

The pins and labels are removed, and in the place of them there are 
small pieces of brass tubing. These are inserted in the appropriate 
places in another tracing of the larynx on an ebony plate. All that 
is then necessary is to insert the single pin into the appropriate hole 
on this tracing, and the necessary connection is at once complete. 

(The instrument in this form was tested by many of those present 
at the meeting, and was highly approved by them. The original in¬ 
strument is manufactured by Gaiffe, of Paris, and the modification 
has been effected by Mr. Trood, of London.) 


A Case of Empyema of the Frontal Sinus cured by the 

Ogston-Luc Operation. 

Shown by Dr. Dundas Grant. The patient was a man set. 40, 
who had suffered from foetid purulent discharge from his left nostril, 
accompanied by pain in the left frontal region, which he alleges to 
have been only of six months' duration. The discharge was traced to 
the middle meatus, but by transillumination and exploratory irriga¬ 
tion, disease of the antrum was excluded. On transillumination of 
the frontal sinus there was found to be distinct comparative opacity 



76 


on the left side. The anterior extremity of the middle turbinated 
body was considerably swollen. 

Belief was afforded by cocainisation of the middle turbinal, followed 
by the use of Politzer’s bag to the left nostril, while the opposite one 
was closed with the finger; both ears were stopped up, and the patient 
uttered the sound “ ee.” As a palliative measure this process was 
carried out for some time by his family attendant, and an alkaline 
antiseptic douche was employed to wash away the pus as it collected. 
The patient was laid up with an attack of gout, so that he disappeared 
for some time, but his nasal condition remained comparatively un¬ 
changed, and he came into hospital for operation by Luc’s method— 
a free opening, thorough curettement, the insertion of an india-rubber 
drainage-tube through the infundibulum, and immediate closure of the 
operation wound by suture of the periosteum, and then of the super¬ 
ficial parts. The patient was kept in bed, and unfortunately had 
almost immediately a recurrence of his gouty or rheumatic joint 
affection, which involved his right wrist-joint. The wound in the 
eyebrow healed almost entirely by first intention, although there was 
on one occasion a slight temporary superficial oozing from the inner 
extremity, which, however, was not visible when Dr. Grant inspected 
it. The drainage-tube was extracted on the tenth day. A glass 
syringe was applied to the extremity of the drainage-tube which pro¬ 
truded from the nostril, and an extremely minute quantity of pus was 
withdrawn. This was repeated daily, and at the end of a week a fine 
intra-tympanic tube was pushed up through the drain, and the sinus 
was washed out with boracic acid, pressure being exercised over the 
wound during the process, a precaution also adopted whenever the 
patient wished to blow his nose. This was repeated on three successive 
days. By that time the patient’s arthritis had disappeared, and he 
was allowed to return home. He is now free from pain and from 
discharge, there is no disfigurement, and the middle meatus of the 
nose is quite dry. 


Microscopical Section of Tissue from Frontal Sinus. 

(Dr. Dundas Grant’s Collection.) 

Shown by Mr. Wyatt Win grave. This consisted of small-cell 
or lymphoid tissue, containing nodules similar to ordinary adenoid 
growth. 



77 


Dr. StClair Thomson directed attention to the fact that at that 
meeting there was a demonstration of the presence of adenoid tissue 
in the lining of the frontal sinus, and in the hypertrophies of the 
arytenoid bodies, while it was well known that adenoid tissue could 
be found in the hypertrophies of the inferior turbinals. He would 
like to ask pathologists—especially those whose practice was not 
limited to the upper air-passages—what their views were as to this 
distribution. 

Mr. Spencer remarked on the development of lymphadenomatous 
tissue after chronic irritation, and considered the tissue in the frontal 
sinus to have been antecedent to the suppuration. He also referred 
to the difficulty of distinguishing diffuse forms of tubercular forma¬ 
tion from lymphadenomatous tissue. In some cases histological 
examination did not solve the question, and the only thing would be 
the inoculation into animals. 

Dr. Pegler thought the presence of normal lymphoid tissue in the 
section very remarkable. In sections made from a case of Dr. Tilley’s 
the polypoid growths consisted entirely of granulated tissue, such as 
one finds in analogous growths from the antrum. 

Mr. Stmonds suggested that it might not be out of place to men¬ 
tion the possible dependence of the adenoid tissue in this case upon 
tubercle. He referred to one instance of persistent suppuration of 
the frontal sinuses, which resisted curetting and the use of iodoform, 
and subsequently died of pulmouary tubercle. 

Mr. Wingrave in reply said he considered that it was not of a 
tuberculous nature, owing to the strong resemblance which it bore 
to ordinary pharyngeal tonsil tissue, and the regularity of the group¬ 
ing of the lymphoid nodules. 


(Edematous Hypertrophy of Arytenoids. 

Shown by Mr. W. G. Spencer. More than a year ago Dr. de 
Havilland Hall showed the patient, a man set. 47, to the Society. It 
was difficult to get a good view of the laryngeal condition, and the 
case was considered to be an unusual one of chronic laryngeal oedema. 
The history of the affection was mainly negative, merely a gradually 
increasing hoarseness and difficulty in breathing. After this Dr. Hall 
tried to remove some of the swelling by intra-laryngeal forceps under 
cocaine. But before he could do anything the patient had a bad 
fainting attack. 

As dyspnoea was increasing the extra-laryngeal method became 
necessary. On retracting the alse of the thyroid cartilages I found that 
each arytsenoid had become a tumour of the size of the thumb, with a 
perfectly smooth surface, and that there was but very little change in the 



78 


size of the larynx. Each tumour was seized with a volsella, and cut 
off with scissors, the line of division being through the apex of the 
cartilage. There was no important haemorrhage. Healing occurred, 
and the patient has remained well for a year, except for an occasional 
catarrh. On examining the larynx now there is not much deviation 
from the normal, except that the arvtaenoids appear flat-topped. 

Under the microscope the tumour is seen to be a soft oedematous 
fibroma, covered by normal stratified epithelium, and containing 
normal arteries, veins, and nerves, also groups of mucous glands 
embedded in it. 

The peculiarity of the case lies in the situation of the affection, as 
it is evidently the same as the common hypertrophy of the inferior 
turbinal. It was clearly of inflammatory origin, not liable to recur. 


Papilloma op the Septum Nasi. 

Shown by Mr. Yeaesley. E. B—, aet. 20, complained of pain in 
the right nostril, lasting three months. There was occasional slight 
bleeding on rubbing, picking, or blowing the nose. Latterly she had 
found some difficulty in breathing through the right side of the nose. 
On inspection the condition was as shown in the photograph, kindly 
taken for me by Dr. Fallows. The growth was situated upon the 
cartilaginous septum, about three quarters of an inch inside the 
vestibule. There was also some hypertrophic rhinitis and a small 
spur on the right side. 

The growth was easily removed under cocaine with a cold snare, 
the haemorrhage being very trifling. 

The specimen shown under the microscope passes through the 
delicate fimbriae, and shows the growth to be a papilloma. 

Dr. Logan Turner showed one specimen before this Society on 
December 9th, 1896.* Another, in a man aged 82, was reported by 
Mr. De Santi in the Lancet. + A third case (that of a Roumanian 
woman aged 28) was brought before the American Laryngological 
Congress of 1895 by Wright. To Wright’s and De Santi’s papers I 
would refer members for other published cases. 

* * Proceedings of Laryngological Society of London/ vol. iv, p. 21, 
f December 8th, 1894, 



79 


Case of Laryngeal Stridor and Nasal Obstruction. 

Shown by Dr. Lambert Lace. The patient is a weakly child aged 
five months. Within a few hours of its birth it was noticed that 
respiration was accompanied by a crowing noise, and this has con¬ 
tinued more or less since. The infant has almost complete nasal 
obstruction, and snuffles and snores a great deal. Also at the end of 
inspiration there is a higher pitched, much louder sound, which, as 
far as the ear can judge, is true laryngeal stridor. When the child is 
awake and breathing through the open mouth this stridor is very 
slight or quite inaudible, but it at once becomes marked if the 
mouth be closed as in suckling. Also in sleep the stridor is intensified, 
and sometimes the patient's rest is disturbed by severe suffocative 
attacks. There is recession of the chest walls on inspiration, appa¬ 
rently constant but varying in amount. The child is wasting, and 
seems to be much enfeebled. The case seems to be one of laryngeal 
spasm, probably due to adenoids. It is proposed to give an anaesthetic, 
to examine the throat thoroughly, and remove the adenoids or other 
cause of nasal obstruction. 

Dr. Hill asked if Dr. Lack would accept the explanation that in 
this case the cause of the stridor was that the tongue in certain posi¬ 
tions alluded to fell back on the pharynx, pushing with it also the 
epiglottis, and so causing partial collapse of the vestibule of the 
larynx. 

Dr. Spicer thought the obstruction was intra-nasal rather than 
post-nasal, and recommended treatment iu that direction. 

Mr. Symonds called attention to the emaciation of the child and 
the appearances of general illness, and suggested that the difficulty 
of breathing when the mouth was shut might be due to the child 
not inspiring sufficient air into a diseased lung. He did not ques¬ 
tion the fact of post-nasal obstruction. He suggested a post-pharyn¬ 
geal abscess as a cause of the child’s illuess, or possibly pulmonary 
tubercle. 

In reply to questions, Dr. Lack said that there was no malforma¬ 
tion of the upper aperture of the larynx iu this case. Judging purely 
from the characters of the sound he thought the stridor was pro¬ 
duced in the larynx, probably by the vocal cords, but there was no 
•direct evidence of this. The air entered the chest badly, and there 
was probably some collapse of the bases of the lungs, but this was 
the usual condition in all cases of congenital laryngeal obstruction. 




PROCEEDINGS 


OF THU 

LARYNGOLOGICAL SOCIETY OF LONDON. 


Ordinary Meeting, May llta, 1898. 


Henry T. Btjtlin, Esq., F.R.C.S., President, in the Chair. 

Herbert Tilley, M.D.,) a , . 

William Hill, M.D.. j Secretaries. 


Present—38 members and 4 visitors. 

The minutes of the previous meeting were read and confirmed. 

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

Arnold Fergusson, F.R.C.S.E., 34, Canfield Gardens, Hampstead. 
Claude C. Claremont, M.D., B.S. (Lond.), 57, Elm Grove, Southsea. 
Francis J. Steward, M.S. (Lond.), F.R.C.S. (Eng.), 24, St. 
Thomas’s Street, S.E. 

Albert H. Burt, M.R.C.S. (Eng.), L.R.C.P. (Lond.), Throat and Ear 
Hospital, Brighton. 


A Case of Carcinoma of Larynx subsequent to Laryngeal 

Tuberculosis. 

Shown by Mr. H. Betham Robinson. E. D—, a single woman set. 
36. The first sign of any throat trouble was in 1878, when she was 
hoarse, and at times aphonic. She had no pain or difficulty in swallow¬ 
ing until August, 1882, after an attack of tonsillitis. In December, 
1885, she saw Sir Felix Semon, who ordered daily treatment. This 
first series—VOL. v. 7 



82 


she did for three months, and then ceased attendance. After some 
months she returned with chronic laryngitis. She attended the 
hospital for some years with varying laryngeal symptoms, but since 
the beginning of 1893 she has been unable to speak above a whisper. 
In July, 1896, when she complained of weakness, shortness of breath, 
loss of appetite, and wasting. Sir Felix Semon said it was tuberculous 
laryngitis, and she had lactic acid applied twice a week. She gradu¬ 
ally got worse, and in March, 1897, the extreme dyspnoea required 
tracheotomy done. Her condition improved, gaining flesh and speak¬ 
ing fairly up to November, since which time she has been only able to 
whisper. In December last the swelling on the right side of the neck 
was first manifest, and about the same time the margins of the tracheo¬ 
tomy wound were becoming prominent. Laryngeal examination 
showed that the subglottic space was completely filled with growth. 
Since this time it has extended, so that now the right pyriform sinus 
has become invaded and filled up, and both cords are almost completely 
obscured. The sprouting about the tracheotomy wound has increased. 
The growth on the right side of the neck has softened, so that a carci-. 
nomatous cyst has formed. During this time, however, her health has 
remained very good, and she has not lost flesh appreciably. 

There is a history of consumption on both sides of the family, 
father and one sister in particular succumbing; there is also a history 
of cancer, both mother and grandmother dying of cancer of the womb. 

The chest gives signs of excavation at both apices, especially on the 
right side, but the disease is now quiescent. 

On microscopical examination of portions of the growth it proves to 
be a non-cornifying epithelioma, such as might arise from the glands 
of the laryngeal ventricle. 

A Case op almost Fixed Cords prom Syphilis simulating 
Bilateral Abductor Paralysis. 

Shown by Mr. H. Betham Robinson. E. J—, a married woman 
set. 50, has enjoyed good health except on occasions during the past few 
years. She has had five children, all healthy. 

In October, 1886, she first attended St. Thomas’s for laryngeal 
tumour, and the diagnosis was secondary syphilis. She complained then 
of sore throat, loss of voice for a few weeks at a time, and bronchitis. 
In May, 1887, she returned with similar symptoms, and was treated for 



83 


a while. Five years ago she again sought advice for similar symptoms, 
which have continued since. 

In February of this year she had influenza, followed by increased 
shortness of breath. 

Early in April there was great dyspnoea, and on examination of 
larynx the present local condition was seen. 

Present condition .—On inspiration the cords are seen almost meet¬ 
ing in the median line except in the interarytmnoid region, the left 
cord being on a plane slightly superficial to the right ; on expiration 
they recoil about to their normal position,-—in fact, the appearance pro¬ 
duced is suggestive of delayed innervation. On phonation the cords 
are adducted normally. There is no definite swelling of soft parts, but 
some appearance of thickening in the arytaenoid region. The left cord 
is still injected. 

The chest is normal, no swelling in the neck, and no signs of any 
bulbar or nerve affection. Her pupils and knee-jerks are normal. 

The question in this case seems to be whether the local laryngeal 
signs are dependent on nerve lesion or on an old syphilitic infiltration 
causing some hampering of the movements at the crico-arytsenoid 
joints and muscular degeneration. There has probably also been 
some perichondritis in addition in posterior part. 

The muscular wasting and altered tension of the cords fully explain 
the appearance produced on inspiration. 

With the disappearance of the catarrh her voice and dyspnoea have 
nearly gone. 

For general treatment she has had iodide of potassium, but owing to 
the great discomfort produced this has been given up. 


Kibstein's Autoscope. 

Mr. Cresswell Baber showed the latest form of instrument used by 
Dr. Kirstein, which consists of a strong rectangular metal tongue de¬ 
pressor. The blade of the instrument measures about 11 centimetres by 
51 millimetres, and is 3 millimetres thick. For a distance of 5 centi¬ 
metres from the tip the blade is curved, forming a segment of a circle 
of 13‘5 centimetres radius. The end lias a slight depression to 
receive the middle glosso-epiglottic ligament, and the edges are 
carefully rounded. For illumination the ordinary forehead mirror or 
Kirstein’s electric frontal lamp may be employed. This is all that is 



84 


required for examination; for demonstration the electric autoscope is 
used. 

The method of using the instrument was explained, and the 
opinion expressed that direct inspection of the larynx and trachea as 
employed by Xirstein was worth practising by laryngologists for use 
in suitable cases, as a supplementary means of examination, not as a 
substitute for laryngoscopy. 


Case op Malignant Disease op the Laryngo-cesophageal 

Region. 

Shown by Dr. Peglek. It. D—, ®t. 37, married, complained of 
swelling in the throat and difficulty, but not pain, in swallowing. 

Examination showed extensive thickening and ulceration of the 
oesophageal aspect of the arytenoid region and interspace, and ary- 
epiglottic folds, A broad-based neoplasm projected towards the 
middle line from the left arytenoid, and obstructed the view of the 
larynx. It was ulcerated on the surface. A mass of hypertrophied 
glands, the uppermost of which was breaking down, and on the point 
of discharging through the thinned epidermis, was conspicuous on the 
left side of the neck. Others were commencing to enlarge on the 
right side. The throat trouble dated from about a year. From the 
laryngoscopical appearance and history there seemed at first some 
chance of the disease being syphilitic, or at all events of its being a 
mixed case, but sections of the neoplasm, part of which had been 
removed with a snare for the purpose, displayed every characteristic 
of epithelioma, and scrapings from the broken-down gland cavity 
yielded epithelial squames only, and no tubercle bacilli. The interior 
of the larynx was healthy so far as could be seen after removal of the 
growth. 

Constant spitting of an abundant watery secretion was the chief 
trouble besides the dysphagia, and it was very desirable that some 
means should be found to relieve this. 

Dr. Bond stated the same patient had attended his clinique at Golden 
Square for some weeks. She bad then an enlarged gland externally 
and ulcerating growth on left side of pharynx, extending behind 
arytenoids. Although there was some slight improvement under 
iodide at first, the malady afterwards steadily progressed, and was 



85 


thought to be malignant. Dr. Bond recommended palpation of the 
growth in such cases as an aid in diagnosis. 

Mr. Spencer suggested the use of atropine pills to check the 
excessive salivation. 

Dr. Pegler inquired whether the high palate he observed in this 
as well as in some of his own cases might have anything to do with 
the speech disability. Removal of the nasal obstruction, primarily 
responsible for the paresis of the soft palate, did not improve matters 
much, as more air passed through the nose than before. When this 
patient’s nostrils were closed she pronounced the “s” in “kiss” very 
fairly. He thought the elongated uvula in this case rather aggravated 
the paresis. 


A Case op Recurrent Multiple Papillomata of the Larynx. 

Shown by Dr. Dundas Grant. The patient, a female set. 20, 
whom he first saw in February, 1895, had then several large papillo¬ 
mata in the larynx. These were removed by means of the forceps, 
but recurred repeatedly. Various chemicals were applied, among 
others chloride of zinc, absolute of alcohol, tincture of thuja, and 
perchloride of iron, but none had any effect until in October, 1896, 
salicylic acid dissolved in alcohol was applied daily by means of a fine 
laryngeal probe coated with cotton wool, in strength gradually from 
1 up to 10 per cent. Under this treatment the stumps shrivelled up 
and the recurrence was permanently stopped. 


Nodal Agmination of Secretion on the Vocal Cords of a 
Singer. ? Incipient Nodules. 

Shown by Dr. Dundas Grant. The patient, a female set. 21, a 
student of singing, complained of want of timbre in the voice. There 
was a frequent accumulation of white secretion at the junction of the 
anterior and middle thirds of both vocal cords, the seat of election 
of “singer’s nodules.” On the removal of the secretion a tiny 
acuminate projection could be seen at the spot, but this was so small 
that it w-as doubtful whether it amounted to a morbid condition at 
all, or whether it was the earliest stage of a nodule. There had been 
considerable nasal obstruction, which had been removed by treatment, 
and since then the secretion on the vocal cords had very greatly 
diminished. 


§ 



86 


Dr. Bennett said he could only see a trace of a nodule, and thought 
the patient might resume her studies without any risk of permanent 
damage to the larynx. 


Case op Sigmatic Dyslalia. 

Dr. Dundas Grant brought forward the case of a female set. 30, 
who complained of stuffiness in the nostrils, and a defect of speech 
resembling that produced by cleft of the palate. In particular, there 
was absolute inability to produce the hissing of the letter “ s,” for 
which was substituted the guttural “k.” The palate was somewhat 
paretic, and the turbinated bodies hypertrophied. On contraction of 
the latter by means of cocaine the feeling of discomfort in the nose 
was removed, and utterance of the letter “s,” in spite of the increase 
of nasal freedom, became more easy. When the nostrils were com¬ 
pressed hissing became easier still. The turbinated bodies were 
cauterised, and the patient instructed in the method of exercising her¬ 
self in the utterance of the hissing sound. 

Note .—Since the exhibition of the case Dr. Dundas Grant has 
found that the letter “ s ” is more easily produced when the patient 
projects the lower jaw forwards, and she is exercising herself in this 
movement. 


Sessile Papilloma op the Left Tonsil associated with Pe¬ 
dunculated Papilloma of the Left Posterior Faucial 
Pillar. 

Shown by Dr. Sharman. F. H—, a boy of 15, came to the 
hospital on April 25th, 1898, complaining of difficulty in swallowing 
and in breathing through the nose of about one year’s duration. He 
was found to have chronic enlargement of both tonsils, a central pad 
of post-nasal growth, some enlargement of both inferior turbinates, and 
some slight chronic laryngitis. On the surface of the left tonsil is an 
apparently sessile papilloma, the size of half a small split pea ; and 
behind the tonsil, growing from the left posterior pillar of the fauces, 
is a small pedunculated papilloma rather larger in size. Dr. Sharman 
thought the case worth showing in view of previous remarks at the 
Society this session on the subject of the rarity of benign growths of 



87 


the tonsil, and also in view of Dr. Rose Paterson’s theory that such 
papillomata really grow not from the tonsil proper, but from the plica 
triangularis. The tonsil will probably be removed, but the boy’s 
throat up to the present has not been subjected to any surgical inter¬ 
ference whatever. 


Patient with Laryngeal Paralysis (previously shown at 
March meeting) who has recently had several Epilepti¬ 
form and Vertiginous Attacks associated with Laryngeal 
Spasm and Irritation. 

Shown by Mr. Atwood Thorne for Dr. Hill. The case, a man 
set. 38, was shown at the March meeting of the Society as a case of 
paresis of both vocal cords of doubtful origin, but no definite opinion 
of its cause was expressed at that meeting. At that time it was not 
known that he had had any attacks of giddiness. 

On April 7th, while assisting in loading a barge, he felt queer in his 
head, gave a cough, and fell head over heels into the barge, striking 
his head in falling. He remained unconscious for an hour and a quarter. 
(Probably the length of unconsciousness was due to the blow received 
while falling.) 

He has had in all six attacks of unconsciousness, each immediately 
preceded by a feeling of constriction in the throat, with inspiratory 
whoops and deep coughs. He has remained unconscious (except when 
he struck his head) for two to six minutes each time. 

At different times the abduction of the cords has been very feeble, 
and he has suffered from marked stridor, and the question of tracheo¬ 
tomy has been discussed. At the meeting, however, the cords moved 
fairly well. 

There are no signs or symptoms of locomotor ataxy, and examina¬ 
tion of the chest gives no hint as to the cause of the paresis. 

Dr. Beale questioned whether the infantile shape of the epiglottis, 
to which attention has recently been drawn in cases of infantile 
laryngeal spasm, had anything to do with the stridorous attacks. 

Drs. Hill, Spicer, and Thomson also briefly discussed the case. 



88 


Case op Pharyngo-mycosis. 

Shown by Dr. Edwapd Law. The patient was first seen December 
13th, 1897. She complained of her throat aching, and of the 
sensation of crumbs and roughness in swallowing, which sometimes 
produced a feeling of sickness; occasionally of a disagreeable taste 
in the mouth, but never of an offensive smell. She had never used 
her voice excessively, and her teeth were in a most satisfactory 
condition. She considered her general health to be good. 

In September she lost her voice for a few days after bicyling a long 
distance, and a week later noticed throat irritation with numerous 
white patches and excrescences upon the nostril, which she attributed 
to having eaten bad oysters. Her doctor, who scraped the tonsillar 
crypts, applied various antiseptic remedies, and prescribed suitable 
gargles and tonics. The outgrowths quickly returned after removal. 
On examination the tonsils were found to be large and covered with 
numerous white patches, which varied considerably in size and shape. 
With the laryngeal mirror, numerous excrescences could be seen 
between the tonsils and anterior pillars to pass to the side of the 
tongue, and resembling in appearance rows of small incisor teeth. 
The lingual tonsil was largely developed, and studded all over with 
white elongated projections, especially at the sides. A few very small 
isolated points could be recognised in Rosenmiiller’s fossa, on the 
posterior lip of the left Eustachian tube, and three or four white dots 
were also visible on the posterior pharyngeal wall. 

The galvano-cautery was very freely applied on several occasions to 
both tonsils after curetting away the soft but firmly adherent masses; 
various antiseptic pigments and gargles were employed, and iron and 
arsenic given internally. No improvement was noticed from the local 
and constitutional remedies, so the patient was sent to Margate for 
ten weeks in order to get away from a damp bedroom, and to be 
placed under the best climatic surroundings. 

She returned in excellent health, but with only slight improvement 
in her throat symptoms. 

Since her return to London the local trouble has greatly improved, 
although absolutely no treatment has been employed. 

Dr. Waggetthas very kindly made the drawings which were handed 
round, but these sketches unfortunately only represent the condition 
after great improvement had taken place. 



89 


The case is interesting on account of the great number and extent 
of the excrescences, and as showing the inefficacy of the treatment 
employed. 

Dr. Herbert Tilley strongly recommended, a solution of salicylic 
acid in absolute alcohol (salicylic acid one part, absolute alcohol four 
parts) for these cases. He had recently tried it in two cases in which 
other remedies had entirely failed, and in which the general health 
was good, and from the rapid improvement noticed he concluded that 
the latter was due to the application, and not to a natural cessation of 
the disease. The preparation is a strong one, and should be used 
cautiously; it whitens the surface to which it is applied, producing an 
appearance similar to that of the galvano-cautery. Small surfaces 
should be dealt with at a time, and the comparison of such a surface 
with that which has not been treated would, he thought, quite convince 
members of the efficacy of the application. Where possible a probe 
tightly wrapped round with wool and dipped into the solution should 
be screwed into the crypts from which the white masses protrude. 

Dr. Grant said that such applications were also useful in pachy¬ 
dermia of the larynx. 

Dr. William Hill said that, considering the nature of the disease, 
we might a priori expect salicylic acid to be useful, as in keratinous 
growths in other parts of the body, e. g. corns, warts, &c. 

In reply Dr. Law stated that he had only read Dr. Kelly’s very 
valuable paper on keratosis pharyngis after cauterising the tonsils, 
otherwise he would have had sections made in order to examine the 
coruification of the epithelium of the crypts. Remembering the use¬ 
fulness of boric acid in alcohol in cases of otomycosis, he tried it in 
this case, but without success. He would try salicylic acid in absolute 
alcohol, but would hesitate to rub into the lingual tonsil such a strong 
solution as 1 in 8. 

The following report has been received of a small piece which was 
recently punched out of the tonsil:—“ The sections show sufficient to 
confirm the statement that the crypts in the mucous membrane are 
filled with keratinised epithelium. The adjacent submucous tissue is 
unduly vascular, and shows round-celled infiltration.” 


Syphilitic Ulceration with Perichondritis op the Larynx. 

Shown by Mr. Symonds. The patient is a man set. 35. The 
disease was confined to the left side, and appeared chiefly as a 
thickening with an outgrowth about the site of the ventricular band. 
There was a four months’ history of hoarseness, and a well-marked 
syphilitic scar on the neck and chest. 



90 


Case op Sessile Fibroma of Yocal Cord. 
Shown by Mr. Symonds. 


Frontal Sinus Disease. 

Shown by Mr. Morley Agar. Patient was a man set. 27, who for a 
year had suffered from pains and a “ cold sensation ” over the lower and 
middle part of the frontal region. There were no objective symptoms 
beyond some hypertrophic rhinitis. This had been treated several times 
with slight relief. However, there still remained some nasal obstruction 
on both sides. Iodide and mercury had been thoroughly tried on the 
suspicion that the frontal symptoms were due to a syphilitic periostitis, 
but without result. Phenacetin or antipyrin did not give even tem¬ 
porary relief. The case was shown to obtain the opinion of members 
as to “ the justifiability of exploring for an exostosis,” or as to “ the 
propriety of treating the hypertrophic rhinitis more energetically, on 
the supposition that the symptoms were due to exhaustion sinusitis.” 
The patient suffered so much distress that he was anxious for something 
to be done. 

Mr. Cresswell Baber did not think that there were any distinct 
signs in this case of abscess in the frontal sinus. 

Dr. Hill thought it was a case of exhaustion sinusitis, and that 
there was no indication for opening the frontal sinus. 


Section op Tubercular Epiglottis removed by the Galvano- 

cautery Snare. 

Shown by Mr. It. Lake. The epiglottis in this case was removed 
in the manner indicated in the title for two reasons,—its extreme 
vascularity, and on account of its very horizontal position. It healed 
well, there was neither primary nor subsequent haemorrhage, there was 
immediate relief to dysphagia, and one was able to see definitely the 
extent of the diseased surfaces, and apply treatment with better 
prospect of success. Tubercle bacilli are scarce in the sections, and 
not to be found in all. The sections were cut by Dr. Cobbledick. 



91 


In reply to Mr. Butlin, the piece was about a third of an inch 
in thickness at its base, but was all cut up and destroyed in section 
cutting. 


Case of Subglottic Swelling. 

Shown by Mr. Laurence for Mr. Butlin. C. M—, set. 55, has 
had “ throat trouble since Christmas, 1896. Some ill-defined attack 
of dyspnoea in July, 1897. Since then more or less hoarseness of 
voice and noisy respiration. 

Condition in January last, 1898 : both vocal cords white, the 
right cord very limited in motion. A pinkish subglottic swelling on 
each side, greatly narrowing the opening into the trachea. Some pain 
radiating to the right ear, and also involving the left side of the chest. 

This condition has continued with very little variation to the present 
time. The patient is not losing flesh or strength, and she was shown 
with a view to diagnosis. 

Mr. Spencer said it was a case of malignant disease, and that some 
glands in the neck were becoming infected. As in his case, there was 
no ulceration of the subglottic swelling, but soft, breaking-down glands 
were found over the jugular vein. The appearances in the two cases 
were almost identical. 

Sir Felix Semon and the President said that they could not con¬ 
vince themselves of a tumour being present, and thought that possibly 
some chronic perichondritis with chronic laryngeal inflammation 
would account for the appearances. Iodide of potash and Leiter’s coil 
were recommended. 


Paresis of the Right Divergents of the Larynx. 

Shown by Dr. Bennett. Mr. J—, set. 45, complained at the end 
of 1895 of a feeling of weakness in the larynx after any use of the 
voice. He attended a few times at a London hospital, but no weak¬ 
ness of the muscles was noted at that period. In May, 1896,1 found 
the right half of the larynx irregular in its movements; one moment 
it would remain stationary during inspiration, and the next it would 
move, but more sluggishly than the left half. Faint sibilant rhonchi 
were occasionally noticed at the right apex, but nothing else abnormal. 
In June the right half remained completely stationary. 

Although there was no history of syphilis iodides were given for 



92 


some time. Before the end of 1896 the movements had again become 
complete, though somewhat sluggish. During this period of recovery 
it was interesting to note that marked changes occurred in the course 
of an examination, as if the nerve could only permit the stronger im¬ 
pulses to pass, whilst the ordinary inspiratory efforts were not sufficient 
to affect the contraction of the muscles. During 1897 he felt per¬ 
fectly well, and called to see me recently to say that he was quite 
better. I found the right half of the larynx again stationary, but this 
condition is now once more passing off. No intra-thoracic growth can 
be detected. 



PROCEEDINGS 


OP THE 

LA.RYNGOLOGICAL SOCIETY OF LONDON. 


Ordinary Meeting, June 8th, 1898. 


Henry T. Butlin, Esq., F.R.C.S., President, in the Chair. 

Herbert Tilley, M.D.,) a . . 

William Hill. M.D.. f S<!Cretarie8 ' 


Present—33 members and 1 visitor. 


The minutes of the previous meeting were read and confirmed. 

Albert H. Burt, M.R.C.S. (Eng.), L.R.C.P. (Lond.) ; 

Claude C. Claremont, M.D., B.S. (Lond.), M.R.C.S. (Eng.), South- 
sea; 

Arnold Pergusson, F.R.C.S. (Ed.), Hampstead ; 

Francis J. Steward, M.S. (Lond.), F.R.C.S. (Eng.), of London, 
were elected ordinary members of the Society. 

The following gentlemen were nominated for election at the next 
ordinary meeting: 

A. J. Dixon, M.B., B.C. (Cantab.), Welbeck Street, W. 

Frederick Spicer, M.D. (Durham), Devonshire Street, W. 


(Esophageal Tumour removed by Subhyoid Pharyngotomy. 

Dr. Permewan showed a tumour removed from the oesophagus by 
the above operation. The tumour was of a benign character, and was 
very easily shelled out and removed. The patient, however, died on 
the tenth day from septic pneumonia, three days after the removal of 
FIRST 8KRIES—VOL. V. 8 



94 


the tracheotomy tube. Dr. Permewan raised the question of the 
liability of a fatal issue in these cases, and suggested that they should 
be treated on the principles advocated by Mr. Butlin in thyrotomy, viz. 
that the wound should be left open. He compared the wound made 
in this operation with that in an ordinary cut throat, in which septic 
symptoms very rarely developed, and believed that the favorable 
course of the latter case was due to the fact that they usually healed 
by granulation. 

Mr. Symonds said that with regard to the fatality of these opera¬ 
tions, which was well known, he attributed the result to infection of 
the connective-tissue planes. He had successfully removed the 
epiglottis by this operation. He advised that after suture of the 
mucous membrane the wound should be packed for two days with 
iodoform gauze, as the best meaus of excluding this danger. 


Case op Tubercular Ulcer of the Nasal Septum. 

Shown by Mr. Lake. Patient, a man set. 28, suffers with pulmonary 
tuberculosis of about four years’ duration, and has had several attacks 
of haemoptysis. The nose began to bleed about twelve months ago 
from the right side. 

The ulcer on the septum was scraped and treated with lactic acid on 
May 24th, since when the acid has been applied eleven times, and 
insufflations of iodoform employed constantly. 

Dr. StClair Thomson thought it was open to question if the 
ulcer in this case was not a simple traumatic ulcer, produced by the 
patient picking his nose. It had not the thickened, indolent margin 
of the tuberculous ulcer, and the haemorrhagic and slightly inflamed 
base was more suggestive of traumatism. 

Dr. Bond asked if members had ever noticed the marked super¬ 
vention of general tubercular symptoms after removing small 
tubercular growths. 

Mr. Lake stated that the subject had been investigated by Clark, 
who concluded that such a complication was not usual—an experience 
which was corroborated by Dr. Watson Williams, who thought 
these cases generally improved after operation. 


Case of Tuberculoma on the Bight Yocal Cord. 

Shown by Mr. Lake. This was a small tumour on the right vocal 
process, which had been present about two weeks. It has been treated 
with lactic acid applications, and is now very much smaller than when 
he first saw the case. 



95 


Cured Case of Laryngeal Tuberculosis. 

Shown by Mr. Lake. The patient, a man set. 35, was under treat¬ 
ment the early part of 1897, and was discharged cured on May 8th, 
1897. When first seen he had redness and congestion of both cords, 
an ulcer on each towards the anterior extremity, and an irregular ulcer 
on the anterior part of the cricoid cartilage. The treatment consisted 
of daily intra-tracheal injections of a solution of naphthalene, 3 per 
cent., oil of cinnamon £ per cent., in parolene. 


Epithelioma of the Epiglottis. 

Mr. Symonds showed a man (set. 65) with epithelioma of the base 
of the epiglottis, also involving the tongue. The man came to the 
out-patient department at Guy's Hospital for the lump in his neck. 
The case was beyond operation on many grounds, and was exhibited to 
illustrate the large glandular infection in these cases; the patient has 
only recently complained of dysphagia, and noticed the glandular 
swelling two months before the dysphagia began. 

Dr. Bond drew attention to the comparative frequency with which 
patients sought relief for glands in the neck secondary to malignant 
disease in the larynx before complaining of inconvenience due to the 
primary growth. 

Mr. Waggett poiuted out the value of orthoform ” in relieving 
the pain in advanced ulceration of the larynx, due to malignant 
disease. 

Dr. Herbert Tilley had had similar experiences in the application 
of this remedy to relieve the dysphagia of tubercular ulceration of the 
pharynx and larynx. In a very advanced case in which be had 
recently used it, where the patient was literally starving to death, the 
insufflation of ten grains of orthoform enabled him to eat solid food 
with comfort, and the effect of one insufflation lasted nearly twenty- 
four hours. He had not met with any toxic effects, and compared 
with the drawbacks of morphia and the temporary anaesthesia of 
cocaine he thought the remedy was of very great value. 

Dr. MacGeagh had found it very valuable in relieving the pain of 
an ulcer of the leg, and Mr. Lake pointed out that in order to obtain 
its good effect a breach of surface was necessary. 



Case of Removal of Small Fibroma of Vocal Cord with 

EXTREMELY PENDULOUS EPIGLOTTIS. 

Shown by Dr. Dundas Grant. The patient, a young man, had 
been hoarse for about fifteen months, the epiglottis was extremely 
pendulous, and the cords could only be seen with great difficulty. A 
small growth could be detected at the junction of the anterior and 
middle third of the right vocal cord, and Dr. Dundas Grant’s endo- 
laryngeal forceps were introduced a Vaveugle. On the first occasion 
a small piece of the mucous membrane of the ventricular band was cut 
off, leaving a superficial sore which speedily healed. On the next 
occasion the growth was alone removed in its entirety. The exhibitor 
thought it would have been almost impossible to remove the growth 
with an unguarded instrument. 

Dr. Herbert Tilley gave details of au identical case at present 
under his treatment. The patient was a clergyman with a soft 
fibroma on the anterior third of the left vocal cord. It was impossible 
to get any view of the larynx without cocainising the posterior surface 
of the epiglottis, and then holding it forwards whilst the other hand 
held the laryngoscope. The patient himself could only exhibit the 
aryteenoids when phonating au e. The speaker had successfully 
removed nearly all the growth by means of Grant’s forceps, and like 
that operator had been obliged to introduce them “ in the dark,” so 
to say. He raised the question as to whether in these particular 
cases, where one has to adopt such a method and it fails to remove 
the growth, one is justified in advising external operation, e. g. splitting 
of the thyroid. He was aware there was the difficulty of getting 
accurate apposition of the cords after the operation, but thought 
it not an insurmountable one. A tracheotomy would scarcely be 
necessary. He asked if members had had any experience of the 
operation; he himself had none. In cases of tubercular ulceration of 
larynx in suitable early cases he thought the operation was advisable, 
and should perform it when opportunity offered itself, but of course 
these cases were on a different footing from those of simple growth. 

Dr. Bond cited two cases of tubercular laryngitis in which he had 
performed laryngo-fissure, one of which was successful. 

Dr. StClair Thomson observed that the last remarks were in 
reference to laryngeal conditions which could not be reached per vias 
naturale8. With regard to simple tumours of the larynx, he believed 
that in the last four years, at least, no case had presented itself in 
the clinic of any member of the staff of the Throat Hospital, Golden 
Square, which had not been successfully dealt with through the 
mouth. As to the question of laryngo-fissure for such cases, be 
quoted the publications of Professor Massei of Naples, who had had 
an extensive experience, and had recently published the statistics of 



97 


his 500 cases of laryngeal neoplasms. Dr. Massei protested strongly 
against external operation for simple growths, as being never quite 
free from danger, and often productive of damage to the voice. 

Mr. Sympnds said he would hesitate to advise the external opera¬ 
tion where he had failed to secure a growth by forceps without ashing 
the assistance of some colleague whose dexterity might be greater 
than his own. In two cases recently he was happy to see the patients 
relieved in this way. We were not all equally gifted with the 
manual dexterity requisite for such operations. With regard to the 
accuracy with which the cords can be adapted after thyrotomy, he 
would point out that perfect adaptation of the divided edges of the 
thyroid cartilage does not necessarily include complete restoration of 
the position of the cords. He pointed out that even in the most 
careful hands it was not always possible to make the section exactly 
between the cords, and he had seen a cord divided in very experienced 
hands. Therefore he would strongly oppose external operation in 
simple growths until the most skilled help at disposal had failed. 
He had known a case recently of complete recovery after external 
operation had been proposed by another operator who had failed to 
remove intra-laryngeally. In tubercle he had operated in two cases, 
only to make the patient much worse. In the early stages, where 
inaccessible to forceps, it might be advisable. 

Mr. Waggett thought that in discussing this question considera¬ 
tion should also be taken of the formation of granulations on the 
posterior aspect of the wound. Such formations might cause as 
much functional disturbance, and give as much trouble in their 
treatment, as the original growth. 

Dr. Permewan could not see the justifiability of thyrotomy in 
these cases of innocent growths. Loss of voice was the only incon¬ 
venience, and owing to the difficulty of exactly hitting the middle 
line in splitting the thyroid, and to the formation of granulations 
and cicatrices m healing, the voice was very unlikely to be improved 
by the operation. But in tubercular disease he thought thyrotomy 
had a future before it, and he personally would not hesitate to do the 
operation in a suitable case. But, as a matter of fact, so much could 
be done by intra-laryngeal surgery that there was seldom any 
necessity or indication to do more. 

Dr. Dundas Grant, in replying, contended for patience in the use 
of endolaryngeal instruments in cases of non-malignant disease, and 
protested against the too ready performance of thyrotomy for the 
relief of conditions which impaired the voice without threatening life. 
In malignant disease, on the other hand, the justifiability and necessity 
for early thyrotomy were unquestionable. , .• i ; ; 



98 


Microscopic Preparations of a Growth within the Ventricle 
of a Larynx: its nature considered with reference to the 

CONDITION OF “ HERNIA ” OR “ PROLAPSE M OF THE VENTRICLE. 

Dr. Jobson Horne showed the right half of a larynx cut into a 
series of microscopic sections to demonstrate the topography and 
nature of a tongue-like growth dependent from the roof of the ven¬ 
tricle. 

Dr. Horne considered that the specimen perhaps threw light upon 
the histology of some of those tumours variously described as pro¬ 



lapsus, procidentia, or hernia ventriculi, or fibroma ventriculi; and if 
seen during life it would probably have been described under one or 
other of these terms. 

The growth was more fully developed in the middle third of the 
ventricle, and a microphotograph of a section in this region that was 
shown is reproduced. Under the microscope the tongue-like excrescence 
was seen to be very similar in structure to the adjacent ventricular 
band. It was covered from root to tip with a columnar epithelium, 
which at points of pressure had been worn away, but had undergone 




99 


no metaplasia. Immediately subjacent to these points of detrition 
there was some small-cell proliferation, and this, in the absence of 
any specific irritant, Dr. Horne was inclined to attribute to traumatism, 
occasioned by compression of the growth within the sacculus. The 
growth, taken as a whole, suggested a duplication of the ventricular 
band. 

In reply, Dr. Horne regretted he was unable to say what clinical 
symptoms, if any, the condition described had given rise to during 
life. For the larynx he was indebted to Professor Kanthack. 
Sections were cut on account of some plication of the epithelium about 
the vocal processes, and the growth was then met with. Such a 
growth he thought might readily become the site of tubercular disease 
in a predisposed subject. From the ventricles of larynges removed 
from persons that had died of pulmonary tuberculosis, but which 
presented no macroscopic evidence of laryngeal tuberculosis, he had 
frequently been able to obtain tubercle bacilli; and in sections cut 
from such larynges he had found the disease commencing in the 
posterior and inferior parts of the ventricular band. Minor spurs 
and excrescences springing from the roof of the ventricle he had met 
with, but not with such a growth as the one here described. 


Laryngeal Forceps. 

Dr. Watson Williams showed a pair of laryngeal forceps which 
had been made from his design. By means of two finger openings in 
the lower handle, greater steadiness in manipulation is obtainable than 
in many of the ordinary patterns in use. 

Papilloma op Uvula. 

Mr. Lawrence showed a case of papilloma springing from the 
juncture of the uvula and soft palate on the left side, in a boy set. 15. 
There was no history of its duration. It caused no symptoms, and 
was noticed in treating the patient for other throat trouble. 


Cask of Dislocation op the Triangular Cartilage op the 

Septum. 

Shown by Dr. Pkgler. H. J—, set. 27, received a blow on the 
nose from a cricket ball last September. The impact occurred from 
below. The patient entered a provincial hospital, and after the swell- 



100 


ing bad subsided some operation was deemed advisable, as the scar of 
an incision is now visible on the dorsum just below the nasal pro¬ 
minence. This disfigurement, together with that resulting from the 
sunken cartilage, induced the patient to seek further advice. A 
secondary source of trouble is obstruction to breathing through the 
nose. On introducing the index fingers into the nasal cavities a 
sensation as of splitting of the triangular cartilage is felt above at the 
osseo-cartilaginous juncture. The two lateral halves seeming to sepa¬ 
rate again when the pressure is taken off, the nasal obstruction is 
caused by a prominent acuminated cartilaginous spur in the left fossa, 
and a smaller basal spur in the right one. 

Dr. StClair Thomson was not sure that the cartilages seen in each 
nostril were the displaced lateral cartilages. He was of opinion that 
what was seen was the broken and dislocated triangular cartilage, for 
on placing a finger in each nostril it was easily felt that there was no 
cartilage in the ordinary position, the anterior part of the nostrils 
being only separated by a septum of mucous membrane. With regard 
to treatment he advised avoidance of interference in such cases for 
merely cosmetic reasons. In numbers of these affections of the nose 
the cause of the collapse of the bridge was not simply the absence of 
the support of the septum, but the retraction of scar tissue. Surgical 
interference in this case would possibly only lead to more cicatrisation, 
and therefore a more saddle-backed nose. He had recently operated 
on a case where he had been successful in restoring a perfectly upright 
septum, but the external disfigurement remained. In the present case 
he suggested that the patient might always wear at night, and possibly 
by day, the hollow vulcanite splint used in Asch’s operation. It would 
prevent further collapse. 

Dr. Dundas Grant had been unable to follow Roe’s description of 
his operations for relief of deformity in similar cases. He thought 
improvement could be effected by making a median incision and re¬ 
moving the more prominent portion of the nasal bones. In reply to 
Dr. StClair Thomson, Dr. Dundas Grant pointed out that it was in 
syphilitic disease that cicatricial contraction was especially accountable 
for deformity, but that in a traumatic case like the present the same 
principle was not so applicable. 

Dr. Permewan could not see any great need for any surgical inter¬ 
ference in this case, and would limit himself to cutting off the pro¬ 
jecting pieces of cartilage without regard to their exact anatomical 
position. Like Dr. Grant, he had found it rather difficult to follow 
Dr. Roe’s methods of subcutaneous operation, though he had been 
much struck by his excellent results, as shown at Montreal last year. 

Dr. PegIiER said he gathered that the consensus of opinion was in 
favour of letting the case alone. He would, however, restore the ob¬ 
structed breathing way, think over the suggestions that had been made 
for curing the deformity, and report the result if any operation were 
undertaken. 



101 


Case of Tubercular Laryngitis. 

Shown by Dr. Snell. Patient is a married woman 21 years of 
age. Hoarseness commenced about twelve months previously, shortly 
before confinement, and has continued to the present time, while 
some dysphagia and much irritable cough are now present. There is 
some tubercular taint on her mother's side. There are dry cavities at 
the apex of right lung. General health is fairly good. 

In the interarytaenoid region there is a papillomatous-looking mass, 
probably a tuberculoma, and this was at first almost the only lesion 
observable, but recently some thickening of the arytseno-epiglottidean 
folds has appeared, and they are of a dark red colour. There is also 
some swelling of the false cords. A shallow ulcer is present on the 
surface of the right cord. 

The chief interest in the case is the initial interarytsenoid swelling, 
without other pathological appearances usually characteristic of early 
tubercular laryngitis. 

Dr. StClaib Thomson pointed out that the anaemic condition of 
the larynx, the situation of the hypertrophy in the interarylaenoid 
region, and especially the marked subglottic thickening, all pointed to 
the case being undoubtedly tubercular. He would not recommend 
active local treatment. 


Tumour of Right Vocal Cord—Cask for Diagnosis. 

Shown by Mr. H. Betham Robinson. E. G—, set. 38, complained 
of hoarseness in 1892, when a growth on the first vocal cord was dia¬ 
gnosed by his medical attendants. Not improving under treatment he 
applied to St. Thomas's Hospital early in 1893, where the presence of 
a growth was corroborated and it was painted with acid, which resulted 
in his getting quite well. He remained quite well till early in May, 
1898, when the hoarseness returned, and on June 2nd he again became 
a patient at St. Thomas’s under Mr. Robinson. Examination showed 
a small sessile swelling a little in front of the middle of the right cord. 
Its size is about that of a split pea, and it springs from the margin 
of the cord; it is white in colour, convex on the surface, and evidently 
is affected by compression on approximation of the cords. The tissues 
around its base are infiltrated, but the rest of the cord and larynx 



102 


appear healthy. There is no pain or cough, but there is a family 
history of tuberculosis, and the patient himself shows old cicatrices in 
the neck, but his chest is normal. There is no history of syphilis. 

Dr. StClair Thomson thought the growth might be taken as a 
fibroma, but strongly suspicious of malignancy. In support of the 
latter was the situation of the growth iti the middle of the cord 
(too far backward for speaker’s nodule, and too far forward for 
pachydermia), its white appearance, and the way in which it seemed 
to infiltrate the cord, although the latter moved freely. Still, it would 
be easy to remove a good portion with the forceps, and obtain a satis* 
factory microscopic specimen. 

Dr. Jobson Hobne also considered that the position of the growth 
was not that typical of pachydermia verrucosa laryngis. 

Mr. Symonds suggested that this might be a case of pachydermia 
because of the pyramidal shape, the white summit, and the way in which 
it was reduced by the pressure of the opposite cord in phonation. The 
short history of hoarseness, he thought, also supported this view. It 
was not typical, but resembled pachydermia more than any other for¬ 
mation. He would suggest that the case be watched without any 
active interference. 

Dr. Dundas Grant thought the site was unusual, being neither at 
the junction of the anterior and middle thirds nor at the vocal 
process. He recommended removal by means of a suitable instrument 
—for example, his own endolaryngeal forceps,—and the subsequent 
application of salicylic acid. The surface of the growth suggested that 
it was of a warty nature. 


Difficulty of Swallowing in an Infant. 

Shown by Dr. Bond. Patient, a female infant of 10 months, has 
always had a great difficulty in swallowing fluids. The child chokes 
on trying to swallow, makes an attempt many times, and finally swallows 
a little fluid, generally with a crowing inspiration. Occasionally some 
of the fluid gets into the nose. There is no history of diphtheria. 


Tuberculosis of Larynx and Pauces. 

Dr. Jobson Horne showed a case of tuberculosis extensively in¬ 
volving the larynx, soft palate, and left tonsil, occurring in a young 
man set. 21, who had sought relief for dysphagia and aphonia. 

The patient dated the onset of the disease from an attack of haemo¬ 
ptysis some eighteen months previously, whilst in his usual health, and 
free, as he thought, from any lung affection. Hoarseness quickly 



103 


followed the haemoptysis. When the man came under treatment some 
three months ago the epiglottis was considerably thickened and turban¬ 
shaped, and the free border along the right side was ulcerating. The 
dysphagia was intense. The laryngeal mucosa was universally infil¬ 
trated, and in places ulcerating. The disease had also attacked the 
soft palate about the base of the uvula and the palatine arches. 

The apices of both upper lobes of the lungs were infiltrated. The 
epiglottis was curetted and the larynx treated with lactic acid. The 
dysphagia was considerably relieved, and the patient went to the sea¬ 
side for a while, where he materially improved. He had now returned 
with the disease spreading about the left palate and left tonsil, which 
was excavated, and Dr. Horne was desirous of receiving suggestions as 
regards further treatment. Although no tubercle bacilli had been 
detected in the tissue removed from the epiglottis, it was undoubtedly 
of a tubercular nature. 


Correction. 

In * Proceedings ’ of May lltb, p. 85, Dr. Pegler’s remarks should 
follow Dr. Grant’s case of “ Sigmatic Dyslalia,” p. 86. 




INDEX. 


PAGE 

Abductor paralysis (double) without apparent cause (Herbert Tilley, M.D.) 59 

-paresis (bilateral) of vocal cords (Atwood Thorne) . . 71 

Adhesion (old-standing) of soft palate to pharynx; separation (W. G. 

Spencer) . . . . . . .4 

-(syphilitic) of soft palate (Philip de Santi) . . .69 

Agab (Morley), tumour of tongue, patient and specimen . . 4 

-case of frontal sinus disease . . . .90 

Agmination (nodal) of secretion on vocal cords of singer (J. Dundas 

Grant, M.D.) . . . . . • 85 

Analysis of liquid in case of nasal hydrorrhoea . . .29 

Antrum (empyema): radical cure of long-standing antral empyema 

(E. B. Waggett) . . . . . .45 

Arytmnoid: oedematous hypertrophy of arytaenoids (W. G. Spencer) . 77 

-interarytmnoid growths (Richard Lake) . . .48 

-localised thickening of interarytaenoid fold of tubercular origin 

(Adolph Bronner, M.D.) . . . . .67 

Autoscope, Kirstein’s (E. Cresswell Baber) . . . .83 

Babb& (E, Cresswell), nasal hydrorrhoea—analysis of liquid . . 29 

- on Kirstein’s autoscope . . . . .83 

Balance sheet, 1897 . . . . . .27 

Ball (J. B., M.D.), case of fibro-sarcoma of the nasal septum . . 3 

Baratoux’s electric laryngo-phantom; modification (J. Dundas Grant, M.D.) 75 

Bennett (F. W., M.D.), paresis of the right divergents of the larynx . 91 

Bebgengbun (Paul), lepra tuberosa of the larynx, mouth and nose, with 
remarks upon the origin and nature of “globi” and “giant-cells” 
(demonstrated by Prof. A. A. Kanthack, M.D.) . . .54 

Bond (J. W., M.D.), difficulty of swallowing in an infant . . 102 

-female on whom tracheotomy had been performed, with immo¬ 
bility of left cord, and partial immobility of right . . 18 

-female with tumour of the epiglottis . . .18 

Branchial cleft in neck persistent (J. Dundas Grant, M.D.) . . 23 

Bbonneb (Adolph, M.D.), localised thickening of interarytaenoid fold 

of tubercular origin. . . . . .67 

-papillomata of larynx . . . . .36 

Butlin (H. T.), two pressure pouches of the oesophagus . . 29 

-case of aubglottic swelling, shown by Mr. L. A. Lawrence . 91 

Carcinoma: carcinomatous tumour of epiglottis and base of tongue 

(Walter G. Spencer) . . . . .49 

-of larynx subsequent to laryngeal tuberculosis (H. Betham 

Robinson) . . . . . .81 

-(subglottic) ? (Charters J. Symonds) . . 37, 61 

FIRST SEKIES—VOL. V . 


9 




106 


PAGE 


Cartilage (subpliaryngeal) of tonsil (Wyatt Wingrave) . . 34 

- (thyroid) : fluctuating swelling over left ala of thyroid cartilage 

(Herbert Tilley, M.D.) . . . . .59 

-(triangular) of septum, dislocation (L. H. Pegler, M.D.) . 99 

Cautery for turbinotomy—new instrument (E. B. Waggett) . . 32 

Chest and head registers, position and condition of vocal lips in (W. Jobson 

Horne, M.B.) . . . . . .15 

Chbistison (Sir Robert), his original drawing and description of a method 
for removal of a double fish-hook from the gullet, shown for Dr. 
Walker by Dr. StClair Thomson . . . .63 

Clonic spasm of pharynx (H. Lambert Lack) . . .38 

Council: report of Council, 1897 . . . . . 25 

-list of Officers and Council, 1898 . . . .25 

Cyst of epiglottis (W. Jobson Horne, M.B.) . . . .7 

-(Wyatt Wingrave). . . . .73 

-thyro-hyoid (Wyatt Wingrave) . . . .10 


Diagnosis: cases for ? mucous patches on fauces (Scanes Spicer, M.D.) . 

-laryngeal swelling (E. W. Roughton) . 

-disease of right vocal band (L. H. Pegler, M.D.) 

-bilateral abductor paresis of vocal cords (Atwood Thorne) . 

-tumour of right vocal cord (H. Betham Robinson) 

Dislocation of triangular cartilage of septum (L. H. Pegler, M.D.) 
Divergents (right) of larynx: paresis (P. W. Bennett, M.D.) 

Donblan (James, M.B.), syringe for making submucous injections in 
laryngeal tuberculosis ..... 

-large tumour in the neck ..... 

Downie ( J. Walker, M.B.), case of primary epithelioma of the uvula. Two 
coloured drawings of the parts and microscopic sections of the new 
growth ....».* 
Dyslalia, sigmatic (J. Dundas Grant, M.D.) • 


18 

58 

12 

71 

101 

99 

91 

2 

21 


48 

86 


Empyema: radical cure of long-standing antral empyema (E. B. Waggett) 

-of frontal sinus cured by Ogston-Luc operation (J. Dundas 

Grant, M.D.) ...... 

Epiglottis: extremely pendulous in case of small fibroma of vocal cord 
(J. Dundas Grant, M.D.) . 

-carcinomatous tumour of epiglottis and base of tongue (Walter G. 

Spencer) ....... 

-cyst (W. Jobson Home, M.B.) . . . . 

-(Wyatt Wingrave)..... 

-epithelioma (Charters J. Symonds) . 

-malformation (H. Lambert Lack) . 

-section of tubercular epiglottis removed by galvano-cautery snare, 

(Richard Lake) ...... 

-tumour (J. W. Bond, M.D.) . . . . 

Epilepsy: patient with laryngeal paralysis, who had recently had several 
epileptiform and vertiginous attacks, associated with laryngeal spasm 
and irritation (Atwood Thorne and William Hill, M.D.) 

Epithelioma of the epiglottis (Charters J. Symonds) . 

-of larynx (Charters J. Symonds) .... 

-■ post-mortem specimen of epitheliomatous larynx which had 

twice been operated upon (David Newman, M.D.). 

-of uvula, primary (J. Walker Downie, M.B.) . 

-of left vocal cord (Stephen Paget) .... 

-(early) of vocal cord (Herbert Tilley, M.D.) 


45 

75 


96 

49 

7 

73 

95 

20 

90 

18 


87 

95 

61 

62 

48 

50 

47 









107 


PAGE 

Epithelioma (early) microscopical specimen (E. B. Waggett) (Dr. Tilley's 

case) . . . . . . .62 

Errata and corrections . . . . .61, 72, 103 

Exostosis: ivory exostosis of frontal sinus causing pressure symptoms 

(Philip de Santi) . . . . . .69 

Eye: paralysis of dilator of pupil with ptosis of same side in case of 

paralysis of left vocal cord (Scanes Spicer, M.D.) . . .18 


Face : lupus of face, nose, and mouth (E. W. Rougliton) . . 58 

Fauces (?) : mucous patches on fauces; case for diagnosis (Scanes Spicer, 

M.D.) . . . . . . .18 

-sessile papilloma of left tonsil associated with pedunculated papil¬ 
loma of left posterior faucial pillar (Henry Sharman, M.D.) . 86 

-tuberculosis (W. Jobson Horne, M.B.) . . . 102 

Fibroma of vocal cord : removal (J. Dundas Grant, M.D.) . . 96 

-sessile, of vocal cord (Charters J. Symonds) . . .90 

Fibro-sarcoma of the nasal septum (J. B. Ball, M.D.) . . .3 

Fish-hook : original drawing and description by Sir Robert Christison of a 

method for removal of a double fish-hook from the gullet (1819) . 60 

Fixation (mechanical) of vocal cords (Herbert Tilley, M.D.) . . 58 

Forceps, laryngeal (P. Watson Williams, M.D.) . . .99 

-cutting laryngeal forceps (Richard Lake) . . .71 

Forehead: syphilitic periostitis (Philip de Santi) . . .70 

Fossa, supra-tonsillar (D. R. Paterson, M.D.) . . .42 

Frontal sinus : See Sinus . 


Galvano-cautery snare used to remove section of tubercular epiglottis 

(Richard Lake) . . . . . .90 

“ Giant-cells 99 in lepra tuberosa of larynx, mouth, and nose: origin and 

nature (Dr. Paul Bergengriin and Prof. A. A. Kanthack, M.D.) . 54 

“ Globi ” in lepra tuberosa of larynx, mouth, and nose : origin and nature 

(Dr. Paul Bergengriin and Prof. A. A. Kanthack, M.D.). . 54 

Grant (J. Dundas, M.D.), case of persistent branchial cleft in neck . 23 

-case of empyema of the frontal sinus cured by the Ogston-Luc 

operation . . . . . . .75 

-modification of Baratoux' electrical laryngo-phantom . . 75 

-microscopical section of tissue of froutal sinus from case, p. 75, 

shown by Mr. Wyatt Wingrave . . . .76 

-case of recurrent multiple papillomata of the larynx . . 85 

-nodal agmination of secretion on the vocal cords of a singer, 

? incipient nodules . . . . . .85 

-case of sigmatic dy si alia . . . . .86 

-case of removal of small fibroma of vocal cord with extremely 

pendulous epiglottis. . . . .96 

Gullet. See Oesophagus. 

Gumma and perichondritis of nose (Atwood Thorne) . . .71 

Head and chest registers, position and condition of vocal lips in (W. 

Jobson Horne, M.B.) . . . . .15 

“ Hernia 99 or “ prolapse ” of ventricle of larynx (W. Jobson Horne, M.B.) 98 

Hill (G. William, M.D.), papilloma of the tonsil . . .6 

- lupus of the larynx . . . . .7 

-case of laryngeal paralysis, shown by Mr. Atwood Thorne . 87 



108 


PAGE 

Hobne (W. Jobson, M.B.), cyst of epiglottis . . .7 

* the position and condition of the vocal lips in the chest and head 
registers . . . . . • .15 

-microscopic preparations of a growth within the ventricle of a 

larynx; its nature considered with reference to the condition of 
<( hernia 99 or “ prolapse ” of the ventricle . . .98 

-tuberculosis of larynx and fauces .... 102 

Hypertrophy (oedematous) of arytsenoids (W. G. Spencer) . .77 

-(papillary) of tonsil: sketches and specimen (E. B. Waggett) . 22 

Immobility of right vocal cord (F. W. Willcocks, M.D.) . 47 

Infant: difficulty of swallowing in an infant (J. W. Bond, M.D.) . 102 

Instrument (new) : turbinotomy cautery (E. B. Waggett) . . 32 

Interarytaenoid fold: localised thickening of tubercular origin (Adolph 

Bronner, M.D.) . . . . . .67 

-growths (Richard Lake) . . . . .48 

Ivory exostosis of frontal sinus causing pressure symptoms (Philip 

de Santi) . , . . . . .69 

Kanthack (Prof. A. A., M.D.), lepra tuberosa of the larynx, mouth, and 
nose, with remarks upon the origin and nature of u globi 99 and 
“ giant-cells 99 (demonstrated for Dr. Paul Bergengriin) . . 54 

Kidd (Percy, M.D.), case of prolapse of ventricle of Morgagni, shown by 

Dr. Worthington . . . . . .12 

Kirstein’s autoscope (E. Cresswell Baber) . . . .83 


Lack (H. Lambert), cases of malformation of epiglottis with congenital 


obstruction of larynx . . . . .20 

-a new snare for throat and nose work . . .44 

-case of clonic spasm of pharynx . . . .38 

-phthisis and healed laryngeal tuberculosis . . 71 

-laryngeal stridor and nasal obstruction . . 79 

Lake (Richard), case of Tornwaldt’s disease . . .21 

-interarytaenoid growths . . . . .48 

-cutting laryngeal forceps . . . . .71 

-section of tubercular epiglottis removed by gal vano-cautery snare . 90 

-case of tuberculoma on the right vocal cord . . .94 

-case of tubercular ulcer of the nasal septum . . .94 

-cured case of laryngeal tuberculosis . . . .95 

Laryngitis: chronic, lateral, hypertrophic, simulating malignant disease 

(Herbert Tilley, M.D.) . . . . .9,35 

-sicca: case of rhinitis, pharyngitis, and laryngitis sicca (Sir Felix 

Semon, M.D.) . . . . . .63 

-tubercular (L. A. Lawrence) . . . .13 

■ - (Sydney Snell, M.D.) .... 101 

Laryngo-phantom, see Larynx . 

Larynx, photographs of larynx shown by Dr. Jobson Horne on behalf of 
Dr. Musehold, demonstrating position and condition of vocal lips in 
chest and head registers . . . . .15 

-laryngeal forceps (P. Watson Williams, M.D.) . . .99 

- cutting laryngeal forceps (Richard Lake) . . .71 

-modification of Baratoux’ electrical laryngo-phantom (J. Dundas 

Grant, M.D.) ...... 


75 




109 


• wis 

Larynx (ventricle) : microscopic preparations of growth within ventricle of 
larynx, in reference to “ hernia ” or “ prolapse ” of ventricle (W. Jobson 
Horne, M.B.) . . . . . .98 

-removal of half the larynx (Charters J. Symonds) . . 37 

-carcinoma of larynx subsequent to laryngeal tuberculosis (H. 

Betham Robinson) . . . . , .81 

-— subglottic carcinoma (Charters J. Symonds) . . 37,61 

-epithelioma (Charters J. Symonds) . . . ,61 

- - post-mortem specimen of epithelioraatous larynx which had 

twice been operated upon (David Newman, M.D.). . .62 

-lepra tuberosa (Dr. Paul Bergengrun and Professor A. A. Kantliack, 

M.D.) , . , . . . .54 

-lupus (William Hill, M.D.) . . . 7 

-malignant disease (E. Furniss Potter, M.D.) . . .35 

-of the lary ngo-oesophageal region (L. H. Pegler, 

* . * . . . , 84 

-— congenital obstruction (H. Lambert Lack) . . .20 

-papillomata (Adolph Bronner, M.D.) . . . 36 

-recurrent multiple papillomata (J. Dundas Grant, M.D.) . 85 

-laryngeal paralysis in patient who had recently had several epilepti¬ 
form and vertiginous attacks associated with laryngeal spasm and 
irritation (Atwood Thorne and William Hill, M.D.) . .87 

-paresis of right divergents of larynx (E. W. Bennett, M.D.) ! 91 

-case of laryngeal stridor and nasal obstruction (H. Lambert Lack). 79 

-laryngeal swelling (E. W. Roughton) . . .58 

-syphilitic ulceration with perichondritis of the larynx (Charters J. 

Symonds). . . . . . .89 

-tuberculosis (W. Jobson Horne, M.B.) . . , 102 

-cured case (Richard Lake) . . . .95 

--healed, in case of phthisis (H. Lambert Lack) . . 71 

- —-syringe for making submucous injections in laryngeal 

tuberculosis (James Donelan, M.B.) . . . .2 

-— (tumour) case of very uncommon laryngeal tumour (Sir Felix 

Semon, M.D.) . . . . . . 64 

Liw '(Edward, M.D.), case of pharyngomycosis . . .88 

Lawrence (L. A.), case of early tubercular laryngitis . . 13 

-enlargement of tonsils after tonsillotomy . . .70 

-tumour of lower lip . . . 1 70 

-(for Mr. H. T. Butlin), case of subglottic swelling . . 91 

-— papilloma of uvula . . . . .99 

Leontiasis ossium (formative osteitis) (P. Watson Williams, M.D.) . 88 

Lepra tuberosa of the larynx, mouth, and nose (Dr. Paul Bergeneriin and 

Prof. A. A. Kanthack, M.D.) . . . . .54 

Librarian: report of Librarian . . . . .27 

Lip (lower) tumour (L. A. Lawrence) . . . ! 70 

position and condition of vocal lips in chest and head registers 
(W. Jobson Horne, M.B.) . . . . .15 

Lupus of face, nose, and mouth (E. W. Roughton) . . 58 

-of larynx (William Hill, M.D.) . . . ‘7 

Lymphomatous tumours, projecting posteriorly from either side of septum, 

causing paresis of soft palate (L. H. Pegler, M.D.) . . 16 


Malformation of epiglottis (H. Lambert Lack) . . .20 

Malignant disease of laryngo-cesophageal region (L. H. Pegler, M.D.) . 84 
-of larynx (K. Furniss Potter, M.D.) . . . 35 

-simulated in case of chronic lateral hypertrophic larvmritis 

(Herbert Tilley, M.D.) . . .. . 9j 35 

§ 



110 


PAGE 

Morbid Growths Committee for 1898 . . . * 28 

---reports . . , . 42,53 

Morgagni (ventricle of) : prolapse of ventricle of Morgagni (Dr. Worth¬ 
ington and Percy Kidd, M.D.) . . . .12 

Mouth, lepra tuberosa (Dr. Paul Bergengriin and Prof. A. A. Kan- 

thack, M.D.) # . . . . .54 

-lupus of mouth, face, and nose (E. W. Roughton) . . 58 

? Mucous patches on fauces : case for diagnosis (Scanes Spicer, M.D.) . 18 

Musbhold (Dr.), photographs of larynx demonstrating position and con¬ 
dition of vocal lips in chest and head registers . . .15 

Mycosis: case of pliaryngo-mycosis (Edward Law, M.D.) . . 88 

Neck, persistent branchial cleft in (J. Dundas Grant, M.D.) . . 23 

-nerve lesion high up in the neck, probably causing paralysis of right 

Yocal cord, right side of soft palate, and right side of pharynx (Scanes 
Spicer, M.D.) . . . . . .8 

-soft swelling in (L. H. Pegler, M.D.) . . .23 

-— large tumour in neck (James Donelan, M.B.) . . .21 

Necrosis of left inferior turbinal, with history of traumatism (L. H. Pegler, 

M D.) . . . . . . 11, 17 

Nerve lesion high up in neck, probably causing paralysis of right vocal cord, 
right side of soft palate, and right side of pharynx (Scanes Spicer, 

M.D.) . . . . . . .8 

Neuralgia (trigeminal) relieved by turbinectomy (Walter G. Spencer) . 32 

Newman (David, M.D.), naso-pliaryngeal papilloma . . .62 

-post-mortem specimen of epitheliomatous larynx which had twice 

been operated upon . . . . . .62 

Nodules (incipient) possible in case of nodal agmination of secretion on 

vocal cords of singer (J. Dundas Grant, M.D.) . . .85 

Nose: new snare for throat and nose work (H. Lambert Lack) . . 44 

-dislocation of triangular cartilage of septum (L. H. Pegler, M.D.) . 99 

-fibro-sarcoma of nasal septum (J. B. Ball, M.D.) . . 3 

-gumma and perichondritis (Atwood Thorne) . . .71 

-nasal hydrorrhcea (E. Cress well Baber) . • .29 

■■■ lepra tuberosa (Dr. Paul Bergengriin and Prof. A. A. Kantlmck, 

M.D.) . . . . . . .54 

- ■ lupus of nose, face, and mouth (E. W. Roughton) . . 58 

-case of laryngeal stridor and nasal obstruction (H. Lambert Lack) . 79 

-naso-pharyngeal papilloma (David Newman, M.D.) . . 62 

-papilloma of septum nasi (P. Macleod Yearsley) . . 78 

-perforation of nasal septum (Atwood Thorne) . . .23 

-lymphomatous tumours projecting posteriorly from either side of 

septum, causing paresis of soft palate (L. H. Pegler, M.D.) . 16 

-- rapidly recurrent tumour of nasal septum (Scanes Spicer, M.D.) . 19 

-tubercular ulcer of nasal septum (Richard Lake) . . 94 

Obstruction (nasal) with laryngeal stridor, (H. Lambert Lack) . . 79 

--(congenital) of larynx (H. Lambert Lack) . . .20 

(Edema : oedematous hypertrophy of arytsenoids (W. G. Spencer) . 77 

(Esophagus: original drawing and description by Sir Robert Christison, 

of a method for removal of a double fish-hook from the gullet (1819) 60 

-- malignant disease of the laryngo-cesophageal region (L. H. 

Pegler, M.D.) . . . . . .84 

-pressure pouches (H. T. Butlin) . . . .29 

•- tumour removed by subhyoid pliaryngotomy (W. Permewan, 

M.D.) 


93 





Ill 


PAGE 


Ogston-Luc operation in cure of empyema of frontal sinus (Dundas Grant, 

M.D.) . . . . , . .75 

Osteitis, formative (leontiasis ossium) (P. Watson Williams, M.D.) . 38 

Ozsena following removal of inferior turbinate (W. R. H. Stewart) . 57 

Paget (Stephen), epithelioma of left vocal cord . . ,50 

Palate (soft) : separation of old-standing adhesion of soft palate to pharynx 

(W. G. Spencer) . . . . . .4 

-adhesion to posterior pharyngeal wall (F.W.Wilicocks, M.D.) G3 

---extensive syphilitic adhesions (Philip de Santi) . . 69 

-paralysis of right side of soft palate, probably due to nerve 

lesion high up in neck (Scanes Spicer, M.D.) . . .8 

-paresis causing defect of speech (L. H. Pegler, M.D.) . 16 

Papilloma: papillomata of larynx (Adolph Bronner, M.D.) . . 36 

-recurrent multiple papillomata of larynx (J. Dundas Grant, M.D.). 85 

-— naso-pharyngeal (David Newman, M.D.) . . .62 

-of septum nasi (P. Macleod Yearsley) . . .78 

-of tonsil (William Hill, M.D.) . . . .6 

-(D. R. Paterson, M.D.) . . . .44 

-papillomata of faucial tonsil (Wyatt Wingrave) . . 17 

-(sessile) of left tonsil, associated with pedunculated papilloma of 

left posterior faucial pillar (Henry Sharman, M.D.) . . 86 

-of uvula (L. A. Lawrence) . . . . .99 

Paralysis, laryngeal, of patient who had recently had several epileptiform 
and vertiginous attacks associated with laryngeal spasm and irritation 
(Atwood Thorne and William Hill, M.D.) . . .87 

-(bilateral abductor) simulated by almost fixed cords from syphilis 

(H. Betham Robinson) . . . . .82 

-(double abductor) without apparent cause (Herbert Tilley, M.D.) . 59 

-of right vocal cord, right side of soft palate, and right side of 

pharynx, probably due to nerve lesion high up in neck (Scanes 
Spicer, M.D.) . . . . . .8 

-of left vocal cord, complete recurrent (Charters J. Symonds) . 36 

----and dilator of pupil (Scanes Spicer, M.D.) . 18 

Paresis (bilateral abductor) of vocal (ords (Atwood Thorne) . . 71 

-of right divergents of larynx (F. W. Bennett, M.D.) . . 91 

Paterson (D. R., M.D.), the supra-tonsillar fossa . . .42 

-papilloma of tonsil . . . . .44 

Pegler (L. H., M.D.), case of necrosis of the left inferior turbinal with 

a history of traumatism . . . . 11, 17 

-disease of the right vocal band for diagnosis . . .12 

-defect of speech resulting from paresis of soft palate occasioned by 

lympliomatous tumours projecting posteriorly from either side of the 
septum . . . . . . .16 

-soft swelling in the neck . . . . .23 

-- case of malignant disease of laryngo-cesophageal region . . 84 

-.-dislocation of the triangular cartilage of the septum . 99 

Perforation of nasal septum (Atwood Thorne) . . .23 

Perichondritis of larynx with syphilitic ulceration (Charters J. Symonds) . 89 

-and gumma of nose (Atwood Thorne) . . .71 

Periostitis (syphilitic) of forehead (Philip de Santi) . . .70 

Permewan (W., M.D.), oesophageal tumour removed by subhyoid pharyn- 

gotomy ; ; . . . . * . 93 

Pharyngitis: case of rhinitis, pharyngitis, and laryngitis sicca (Sir Felix 

Semon, M.D.) ....... 63 

-(chronic) (Wyatt Wingrave) . . . .74 

Pharyngomycosis (Edward Law, M.D.) . . . .88 






112 


PAGE 


Pharyngotomy (subhyoid) to remove oesophageal tumour (W. Permewan, 

M.D.) . . . . . .93 

Pharynx, separation of old-standing adhesion of soft palate to pharynx 

(W. G. Spencer) . . . . . .4 

-adhesion of soft palate to posterior pharyngeal wall (F. W. 

Willcocks, M.D.) . . . . . .63 

-clonic spasm (H. Lambert Lack) . . . .38 

- naso-pharyngeal papilloma (David Newman, M.D.) . . 62 

-paralysis of right side of pharynx, probably due to nerve lesion 

high up in neck (Scanes Spicer, M.D.) . . . .8 

-stenosis, syphilitic (W. J. Walsliam) . . .63 

Phthisis: case of phthisis and healed laryngeal tuberculosis (H. Lambert 

Lack) . . . . . . .71 

Pillar (faucial) : sessile papilloma of left tonsil associated with pedun¬ 
culated papilloma of left posterior faucial pillar (Henry Sharman, 

M.D.) . • • . . . .86 

Potter (E. Furniss, M.D.), case of malignant disease of larynx . . 35 

Pouches: pressure pouches of (esophagus (H. T. Butlin) . . 29 

Pressure pouches of oesophagus (H. T. Butlin) . . .29 

- symptoms caused by ivory exostosis of frontal sinus (Philip 

de Santi) . . . . . . .69 

“ Prolapse” or “hernia 99 of ventricle of larynx (W. Jobson Horne, M.B.) 98 

-of ventricle of Morgagni (Dr. Worthington and Percy Kidd, M.D.) 12 

Ptosis of left upper eyelid with paralysis of dilator of pupil in case of 

paralysis of left vocal cord (Scanes Spicer, M.D.) . . .18 


Rhinitis : case of rhinitis, pharyngitis, and laryngitis sicca (Sir Felix Semon, 
M.D.) .... ... 

Robinson (H. Betham), a case of carcinoma of larynx subsequent to laryn¬ 
geal tuberculosis ...... 

-case of almost fixed cords from syphilis, simulating bilateral abductor 

paralysis ....... 

-tumour of right vocal cord; case for diagnosis . 

Roughton (E. W.), case for diagnosis—laryngeal swelling 
-lupus of face, nose, and mouth .... 

de Santi (Philip): extensive syphilitic adhesions of soft palate . 

-ivory exostosis of frontal sinus, causing pressure symptoms 

- syphilitic periostitis of forehead . 

Sarcoma: see Fibro sarcoma. 

Secretion : nodal agmination of secretion on vocal cords of singer (J. Dundas 
Grant, M.D.) ...... 

Semon (Sir Felix, M.D.), a case of rhinitis, pharyngitip, and laryngitis 
sicca ... .... 

-case of very uncommon laryngeal tumour 

Septum, nasal: see Nose. 

Shabman (Henry, M.D.), sessile papilloma of the left tonsil, associated 
with pedunculated papilloma of the left posterior faucial pillar 
Sigraatic dyslalia (J. Duudas Grant, M.D.) . 

Singing: position and condition of vocal lips in chest and head registers 
(W. Jobson Horne, M.B.) ..... 

-nodal agmination of secretion on vocal cords of singer (J. Dundas 

Grant, M.D.) ...... 

Sinus, frontal: microscopical section of tissue from frontal sinus (Dr. 
Dundas Grant’s collection, Wyatt Wingrave) 


63 


81 

82 

101 

58 

58 

69 

69 

70 


85 


63 

64 


86 

86 

15 


85 


76 





113 


PAGE 

Sinus, frontal, disease of (Morley Agar) . . # .90 

-- ■ radical operation for frontal sinus disease (E. B. Waggett) 31 

-case of empyema of frontal sinus cured by Ogston-Luc opera¬ 
tion (J. Dundas Grant, M.D.) . . . .75 

-ivory exostosis of frontal sinus causing pressure symptoms 

(Philip de Santi) . . . . . .69 

Snare (new), for throat and nose work (H. Lambert Lack) . . 44 

-galvano-cautery: section of tubercular epiglottis removed by galvano- 

cautery snare (Richard Lake) . ... . .90 

Snell (Sydney, M.D.), case qf tubercular laryngitis . . . 101 

Spasm (clonic) of pharynx (H. Lambert Lack) . . .38 

-laryngeal, associated with epileptiform and vertiginous attacks, 

(Atwood Thorne and William Hill, M.D.) . . .87 

Speech : defect of speech resulting from paresis of soft palate (L. H. Pegler, 

M.D.) . . . . . . .16 

Spences (Walter G.), separation of old-standing adhesion of soft palate to 

the pharynx . . . . . .4 

-trigeminal neuralgia relieved by turbinectomy. . .32 

-carcinomatous tumour of the epiglottis and base of the tongue . 49 

-oedeinatous hypertrophy of arytronoids . . .77 

Spices (Scanes, M.D.), case of paralysis of right vocal cord, right side of 
soft palate, and right side of pharynx, probably due to nerve lesion high 
up in neck . . . . . .8 

-case of paralysis of left vocal cord and dilator of pupil, with ptosis 

of the same side . . . . . .18 

-? mucous patches on fauces; case for diagnosis . . .18 

-rapidly recurrent tumour of nasal septum . . .19 

Stenosis: pharyngeal, syphilitic (W. J. Walsham) . . .63 

Stewabt (W. R. H.), case of ozsena following removal of inferior turbinate 57 
Stridor (laryngeal) with nasal obstruction (H. Lambert Lack) . . 79 

Subglottic carcinoma ? (Charters J. Symonds) . . 37, 61 

-swelling (L. A. Lawrence and H. T. Butlin) . . .91 

Subhyoid pharyngotomy in removal of oesophageal tumour (W. Perraewan, 

M.D.) . . . . . . .93 

Submucous injections: syringe for making submucous injections in 

laryngeal tuberculosis (James Donelan, M.B.) . . .2 

Subpharyngeal cartilage of tonsil (Wyatt Wingrave) . . .34 

Supra-tonsillar fossa (D. R. Paterson, M.D.) . . .42 

Swallowing: difficulty of swallowing in an infant (J. W. Bond, M.D.) . 102 

Swelling (laryngeal) case for diagnosis (E. W. Roughton) . . 58 

-(soft) in the neck (L. H. Pegler, M.D.) . . .23 

-(fluctuating) over left ala of thyroid cartilage (Herbert Tilley, M.D.) 59 

Symonds (Charters J.), removal of half the larynx . . .37 

-subglottic carcinoma ? . . . 37,61 

-epithelioma of the larynx from a case exhibited on January 12th . 61 

-case of syphilitic ulceration with perichondritis of the larynx . 89 

-sessile fibroma of vocal cord . . . .90 

-epithelioma of the epiglottis . . . .95 

Syphilis : extensive syphilitic adhesions of soft palate (Philip de Santi) . 69 

- syphilitic periostitis of forehead (Philip de Santi) . . 70 

-pharyngeal stenosis (W. J. Walsham) . . .63 

-ulceration with perichondritis of larynx (Charters J. 

Symonds) . . . . . . .89 

-almost fixed cords from syphilis simulating bilateral abductor 

paralysis (H. Betham Robinson) • . . .82 



114 


I 


Syringe for making submucous injections in laryngeal tuberculosis (James 
Donelan, M.B.) ...... 

Thomson (StClair, M.D.), original drawing and description by Sir Robert 
Christisou of a method for removal of a double fish-hook from the 
gullet (date 1819) (shown for Dr. Walker) . 

Thobne (Atwood), symmetrical ulceration of tonsils, perforation of nasal 
septum, in a young boy ..... 

-bilateral abductor paresis of vocal cords—for diagnosis . 

- - gumma and perichondritis of nose .... 

-(for Dr. William Hill) patieut with laryngeal paralysis who has 

recently had several epileptiform and vertiginous attacks associated 
with laryngeal spasm and irritation 

Throat: new snare for throat and nose work (H. Lambert Lack) 
Thyro-hyoid cyst (Wyatt Wingrave) 

Thyroid cartilage: fluctuating swelling over left ala of thyroid cartilage 
(Herbert Tilley, M.D.) .... 

Tilley (Herbert, M.D.), case of chronic lateral hypertrophic laryngitis 
simulating malignant disease . . • 

-early epithelioma of cord .... 

-microscopical specimen shown by Mr. E. B. Waggett 

-mechanical fixation of vocal cords 

-double abductor paralysis without apparent cause 

-fluctuating swelling over the left ala of thyroid cartilage 

Tongue: tumour of tongue, patient and specimen (Morley Agar) 

-car( inomatous tumours of epiglottis and base of tongue (Walter G 

Spencer ...... 

Tonsil: supra-tonsillar fossa (D. R. Paterson, M.D.) . 

-subpharyngeal cartilage (Wyatt Wingrave) 

-enlargement after tonsillotomy . . 

-papillary hypertrophy; sketches and specimen (E. B. Waggett) 

-papilloma (William Hill, M.D.) . . . 

-(D. R. Paterson, M.D.) 

-of left tonsil associated with pedunculated papilloma 


PAGE 


of 


left posterior faucial pillar (Henry Sharman, M.D.) 

— papillomata of faucial tonsil (Wyatt Wingrave) 

— benign tumour; sketches and specimen (E. B. Waggett). 
symmetrical ulceration of tonsils (Atwood Thorne) 


Tornwaldt's disease (Richard Lake) 

Tracheotomy: immobility of left cord and partial immQbility of right after 
tracheotomy (J. W. Bond, M.D.) 

-tube, new, for permanent use 

Traumatism, history of traumatism in case of necrosis of left inferior 
turbinal (L. H. Pegler, M.D.). - . . 11, 

Tuberculoma on the right vocal cord (Richard Lake) . 

Tuberculosis: localised thickening of interarytaenoid fold of tubercular 
origin (Adolph Bronner, M.D.) .... 

-section of tubercular epiglottis removed by galvano-cautery snare 

(Richard Lake) ...... 

-tubercular laryngitis (Sydney Snell, M.D.) 

-case of early tubercular laryngitis (L. A. Lawrence) 

-of larynx; cured case (Richard Lake) 

-and fauces (W. Jobson Horne, M.B.) . 

case of phthisis and healed laryngeal tuberculosis (H. Lambert 


60 

23 
71 
71 

87 

44 

10 

59 

9, 35 
47 
62 

58 

59 
59 

4 

49 

42 

34 

70 

22 

6 

44 

86 

17 

22 

23 

21 


Lack) 


case of carcinoma of larynx subsequent to laryngeal tuberculosis 


(H. Betham Robinson) 


18 

1 

17 

94 

67 

90 

101 

13 

95 
102 

71 

81 




115 


PAGE 

Tuberculosis of larynx: syringe for making submucous injections in 


laryngeal tuberculosis (James Donelan, M.B.) . . ,2 

-tubercular ulcer of nasal septum (Richard Lake) . . 94 

Tumour of the epiglottis (J. W. Bond, M.D.) . . .18 

-carcinomatous tumour of epiglottis and base of tongue (Walter G. 

Spencer) . . . . . . .49 

- of larynx: case of very uncommon laryngeal tumour (Sir Felix 

Semon, M.D.) . . . . . .64 

- - of lower lip (L. A. Lawrence) . . . .70 

-of nasal septum, rapidly recurrent (Scanes Spicer, M.D.) . 19 

-lymphomatous tumours projecting from either side of the septum, 

causing paresis of soft palate (L. H. Pegler, M.D.) . . 16 

-(large) in neck (James Donelan, M.B.) . . .21 

-of oesophagus removed by subhyoid pkaryngotomy (W. Permewan, 

M.D.) . . . . . .93 

-of tongue; patient and specimen (Morley Airar) . . 4 

-(benign) of tonsil; sketches and specimen (E. B. Waggett) . 22 

-of right vocal cord; case for diagnosis (H. Betham Robinson) . 101 

Turbinal, left inferior, necrosis with history of traumatism (L. H. Pegler, 

M.D.) . . . . . . 11, 17 

Turbinate (inferior), ozaena following removal of (W. R. H. Stewart) . 57 

Turbinectomy, causing relief in case of trigeminal neuralgia (Walter G. 

Spencer) . . . . . . .32 

Turbinotomy cautery—new instrument (E. B. Waggett) . . 32 

Ulcer (tubercular) of nasal septum (Richard Lake) . . .94 

Ulceration (syphilitic) with perichondritis of larynx (Charters J. Symonds) 89 

-(symmetrical) of tonsils (Atwood Thorne) . . .23 

Uvula; primary epithelioma (J. Walker Downie, M.B.) . , 48 

-papilloma (L. A. Lawrence) . . . .99 

Ventricle of larynx; €€ hernia *' or “ prolapse ” (W. Jobson Horne, M.B.) . 98 

-of Morgagni: prolapse of ventricle of Morgagni (Dr. Worthington 

and Percy Kidd, M.D.) . . . . .12 

Vertigo: patient with laryngeal paralysis who had recently had several 
epileptiform and vertiginous attacks associated with laryngeal spasm 
and irritation (Atwood Thorne and William Hill, M.D.) . . 87 

Vocal band (right) : disease of right vocal band for diagnosis (L. H. 

Pegler, M.D.) . . . . . .12 

Vocal cord : sessile fibroma (Charters J. Symonds) . . .90 

-almost fixed cords from syphilis simulating bilateral 

abductor paralysis (H. Betham Robinson) . . .82 

-immobility of left cord and partial immobility of right 

after tracheotomy (j. W. Bond, M.D.) . . . .18 

-nodal agmination of secretion on vocal cords of singer 

(J. Dundas Grant, M.D.) . . . . .85 

-mechanical fixation of vocal cords (Herbert Tilley, M.D.) . 58 

-bilateral abductor paresis of vocal cords—for diagnosis 

(Atwood Thorne) . . . . . .71 

-(right): small fibroma, removal (J. Dundas Grant, M.D.) . 96 

-immobility (F. W. Wilcocks, M.D.) . . 47 

-paralysis probably due to nerve lesion high up in 

neck (Scanes Spicer, M.D.) . . . . .8 

-tuberculoma on right vocal cord (Richard Lake) . 94 

--tumour—case for diagnosis (H. Betham Robinson). 101 

-(left), epithelioma (Stephen Paget) . . .50 

-early epithelioma (Herbert Tilley, M.D.) . . 47 

-microscopical specimen (E. B. Waggett) . 62 






116 


PAGB 

Vocal cord (left), complete recurrent paralysis (Charters J. Symonds) . 36 

-paralysis of left vocal cord and dilator of pupil, 

with ptosis of same side (Scanes Spicer, M.D.) . . .18 

Vocal lips, position and condition in chest and head registers (W. Jobson 

Horne, M.B.) . . . . . .16 


Waggett (E. B.), sketches and specimen of benign tumour of the tonsil . 

-sketches and specimen of papillary hypertrophy of the tonsils 

-radical operation for frontal sinus disease 

-new instrument—turbinotomy cautery 

-radical cure of long-standing antral empyema . 

-microscopic specimen of early epithelioma of vocal cord from Dr. 

Tilley’s case, shown at February, 1898, meeting . 

Walkeb (T. J., M.D.), original drawing and description by Sir Robert 
Christison of a method for removal of a double fish-hook from the 
gullet (date 1819) (shown for Dr. Walker by Dr. StClair Thomson) . 
Walsham (W. J.), case of syphilitic pharynge^J stenosis 
Willcocks (F. W., M.D.), immobility of right cord . 

-adhesion of soft palate to posterior pharyngeal wall 

Williams (P. Watson, M.D.), formative osteitis (leontiasis ossium) 

-laryngeal forceps. ..... 

Wingbave (Wyatt), thyro-hyoid cyst .... 
■ papillomata of faucial tonsil .... 

-subpharyngeal cartilage of the tonsil 

-cyst of the epiglottis ..... 

-case of chronic pharyngitis .... 

-microscopical section of tissue from frontal sinus (Dr. Dundas 

Grant’s collection) ...... 

Wobthington (Dr.), prolapse of ventricle of Morgagni 

* 

Ye aesley (P. Macleod), papilloma of septum nasi 


22 

22 

31 

32 
45 

62 


60 

63 

47 

63 

38 

99 

10 

17 

34 

73 

74 

76 

12 

78 


VU1NTBD BY ADLABD AND SON, BAUTHOLOMBW CLOSE, LONDON, B.C. 





PROCEEDINGS 


OF THE 


LARYNGOLOGICAL SOCIETY 

4 OF 

LONDON. 


VOL. VT. 

1898 - 99 . 


WITH 

LISTS OF OFFICERS. LIST OF MEMBERS, ETC. 


LONDON: 

PRINTED BY ADLARD AND SON, 
BARTHOLOMEW CLOSE, E.C. 


1899 . 




L AR YNGOLOGTC AL SOCIETY 


OF 

LONDON. 


LIST OF MEMBERS. 

1899 . 


LONDON: 

PRINTED BY ADLARD AND SON, 

BARTHOLOMEW CLOSE, E.C. 


1899 





HONORARY MEMBERS. 


Fraenkel, Professor B., 4, Belle Vue Strasse, Berlin, N.W. 
Garcia, Manuel, Mon Abri, Shoot-up hill, Cricklewood. 
Lepferts, G. M., 212 Madison Avenue, New York, U.S.A. 
Massei, Professor, 4, Piazza Municipio, Naples, Italy. 

Moure, E. J., 25bis, Cours du Jardin Publique, Bordeaux. 
Schmidt, Professor Moritz, Frankfort-on-the-Main, Germany, 
v. Schrotter, Professor, 3, Marianengasse I, Vienna. 
Solis-Cohen, J., 1431, Walnut street, Philadelphia, U.S.A. 


DECEASED HONORARY MEMBERS. 


Johnson, Sir George . Died 1896. 

Meyer, Hans Wilhelm, M.D. . Died 1895. 
Stork, Professor.... Died 1899. 



ngolagical $omtg of ^onbon 


LIST OF MEMBERS, 

DECEMBEB, 1899. 


INDEX TO ABBREVIATIONS, 

Indicating Past or Present Officers of the Society. 

(P.) President. ( L .) Librarian. 

( V.-P.) Vice-President. (S.) Secretary. 

(T.) Treasurer. (C.) Councillor. 

(O.M.) Original Member. 


LONDON. 

Members who pay their Annual Subscription through a Banker's 
Order (to be obtained from the Treasurer) have an asterisk pre¬ 
fixed to their names. 

Elected. 

1899 Abercrombie, Peter, M.D.G-lasg., 60, Harley street, W. 
1899 Agar, Mobley, 76, Wimpole street, W. 

1893 *Aikin, William Arthur, M.D., 14, Thurloe square, S.W. 
1893 Ayreb, Charles James, M.D., 65a, Welbeck street, 
Cavendish square, W. 

O.M. Ball, James Barry, M.D., 12, Upper Wimpole street, 
W. 0. 

1896 Bateman, F. A. N., 4, Charles street, St. James’s, S.W. 
O.M. Beale, Edwin Clifford, M.B., F.R.C.P., 23, Upper 
Berkeley street,. W. S. L. T. 



IV 


Elected. 

O.M. *Bond, James William, M.D., 26, Harley street, W. C. 

V. -P. 

O.M. Bowlby, Anthony Alfred, F.R.C.S., 24, Manchester 
square, W. G. V.-P. 

O.M. Butlin, Henry Trentham, F.R.C.S., 82, Harley street, 

W. T. P. 

1895 Cathcart, G-eorge C., M.B., C.M., 35, Harley street, 
Cavendish square, W. 

1895 *Cheatle, Arthur H., F.R.C.S., 117, Harley street, W. 

1893 Colbeck, Edmund Henry, M.D., M.R.C.P., 14, Porchester 

terrace, W. 

1899 Collier, M. P. Mayo, F.R.C.S., 133, Harley street, W. 

1894 *Cripps, Charles Cooper, M.D., 187, Camberwell grove, 

S.E. 

O.M. *Crisp, Ernest Henry, 43, Fenchurch street, E.C. 

1899 Davis, Henry J., M.B., M.R.C.P., 9, Norfolk crescent, 
Hyde park, W. 

1898 Dixon, F. J., M.B., B.C., Dulwich Village, S.E. 

1893 # Donelan, James, M.B., 2, Upper Wimpole street, W. 

1896 Dorman, Marcus R. P., M.B., B.C., 9, Norfolk crescent, 

Hyde park, W. 

1894 Drysdale, John Hannah, M.B., M.R.C.P., 25, Welbeck 

street, W. 

1898 Ferqusson, Arnold, F.R.C.S.Ed., 34, Canfield gardens, 

Hampstead. 

1896 Glover, Lewis Gladstone, M.D., 1, College terrace, 
Fitzjohn’s avenue, N.W. 

1895 Gordon, A. Knyvett, M.B., B.C., S.E. Fever Hospital, 

New Cross, S.E. 

O.M. *Grant, J. Dundas, M.A., M.D., F.R.C.S., 8, Upper 
Wimpole street, W. C. L. 

O.M. *Hall, Francis de Havilland, M.D., F.R.C.P., 47, Wim¬ 
pole street, W. L. V.-P. P. 

1895 Hamilton, Bruce, 9, Frognal, West Hampstead. 

1893 Harvey, Frederick George, F.R.C.S.Ed., 4, Cavendish 

place, Cavendish square, W. 

1899 *Heath, Charles, F.R.C.S., 3, Cavendish place, W. 

* O.M. *Hill, G. William, M.D., 26, Weymouth street, W. 

8. G. 

1894 Hill-Wilson, A. E., 217, Goldkawk road, W. 



V 


Elected. 

O.M. Holmes, W. Gordon, M.D., 10, Finsbury square, E.C. 

1894 Horne, Walter Jobson, M.B., 27, New Cavendish street, 

Harley street, W. 

O.M. Hovell, T. Mark, F.R.C.S.Ed,, 105, Harley street, W. 

1895 Jakins, Percy, M.D., 120, Harley street, W. 

1894 Jessop, Edward, 81, Fitzjohn’s avenue, Hampstead, N.W. 
1897 *Kelson, William H., M.D., B.S., F.R.C.S., 96, Queen 

street, Cheapside, E.C. 

O.M. Kidd, Percy, M.D , F.R.C.P., 60, Brook street, Grosvenor 
square, W. G. 

1895 *Lack, Lambert Harry, M.D., F.R.C.S., 48, Harley 

street, W. 8. 

1893 Lake, Richard, F.R.C.S., 19, Harley street, W. 

O.M. *Law, Edward, M.D., 35, Harley street, W. C. V.-P. 
O.M. Lawrence, Laijrie Asher, F.R.C.S., 4, Queen Anne 
street, W. 

1899 Lazarus, A. B., M.B., C.M.Edin , 77, Wiinpole street, W. 
O.M. Macdonald, Greville, M.D., 85, Harley street. C. 

1895 *Macgeagh, T. E. Foster, M.D., 23, New Cavendish street, 
W. 

1894 Mackenzie, Hector William Gavin, M.D., F.R.C.P., 59, 

Welbeck street, W. 

1897 Paget, Stephen, F.R.C.S., 70, Harley street, W. 

1893 *Pegler, Louis Hemington, M.D., 27, Welbeck street, 

W. 

1895 Perkins, J. J., M.B., 41, Wimpole street, W. 

O.M. Pollard, Bilton, F.R.C.S., 24, Harley street, W. 

1894 Potter, Edward Furniss, M.D., 27, New Cavendish 

street, W. 

1894 *Poulter, Reginald, 4, Gordon mansions, Francis street, 
Gordon square, W.C. 

1899 Powell, H. Fitzgerald, M.D., F.R.C.S.Ed., 7, Connaught 
street, Hyde park, W. 

1897 Ramsay, Herbert, F.R.C.S., 35a, Hertford street, May- 

fair, W. 

O.M. Rees, John Milsom, F.R.C.S.Ed., 53, Devonshire street, 
Portland place, W. 

1898 Robinson, H. B., M.S., F.R.C.S., 1, Upper Wimpole street, 

W. 

1894 *Roughton, Edmund, M.D., B.S., F.R.C.S., 38, Queen Anne 
street, W. 



Y1 


Elected. 

1893 Santi, Philip Robert William de, M.B., F.R.C.S., 42, 

Harley street, Cavendish square, W. 

1896 Schorstein, Gustave, M.B., F.R.C.P., 11, Portland place, 
W. 

O.M. *Semon, Sir Felix, M.D., F.R.C.P., 39, Wimpole street, W. 
P. V.-P. C. 

1894 Sharman, Henry, M.D., 16, Frognal, Hampstead. 

1893 Spencer, Walter Georoe, M.S., F.R.C.S., 35, Brook 

street, Grosvenor square, W. C. 

1898 Spicer, Fredk., M.D., 57, Devonshire street, W. 

O.M. Spicer, Scanes, M.D., 28, Welbeck street, Cavendish 
square, W. 8. G. V.-P. 

1895 Stephen, G. Caldwell, M.D., 54, Evelyn gardens, South 

Kensington. 

1898 Steward, Francis J., M.S., F.R.C.S., 24, St. Thomas’s 
street, S.E. 

O.M. Stewart, William Robert Henry, F.R.C.S.Ed., 42, 
Devonshire street, Portland place, W. S. G. V.-P. 
O.M. *Symonds, Charters James, M.S., F.R.C.S., 26, Wejmouth 
street, Portland place, W. G. V.-P. 

1894 *Thomson, StClair, M.D., 28, Queen Anne street, Caven¬ 

dish square, W. 8. G. 

1896 *Thorne, Atwood, M.B., 10, Nottingham place, W. 

1893 Tilley, Herbert, M.D., B.S., F.R.C.S., 101, Harley 
street, W. 8. G. 

1893 Waooett, Ernest Blechynden, M.B., 45, Upper Brook 
street, Grosvenor square, W. 8. 

O.M. Walsham, William Johnson, M.B., F.R.C.S , 77, Harley 
street, W. T. 

1896 Whait, J. R., M.D., C.M., Charltons, Fairhazel gardens. 
South Hampstead. 

O.M. Whistler, William MacNeill, M.D., M.R.C.P., 18, 
Wimpole street, W. V.-P. C. 

1893 White, William Hale, M.D., F.R.C.P., 65, Harlev street, 
W. 

O.M. Willcocks, Frederick, M.D., F.R.C.P., 14, Mandeville 
place, Manchester square, W. 

O.M. * Wills, William Alfred, M.D., M.R.C.P., 29, Lower 
Seymour street, W. 



Vll 


Elected. 

1897 *Winorave, Y. H. Wyatt, M.R.C.S., 11, Devonshire street, 
W. 

1897 Yearsley, P. Macleod, F.R.C.S., 33, Weymouth street, W. 


COUNTRY. 

The names of Country Members who have paid a‘ “ Compounding ” 
Fee are printed in heavier type. 

Elected. 

O.M. Baber, Edward Cresswell, M.B., 46, Brunswick square, 
Brighton. C. V.-P. 

1895 Bark, John, F.RC.S.Ed., M.R.C.P.I., 54, Rodney street, 
Liverpool. 

1895 Baron, Barclay J., M.B., 16, Wkiteladies road, Clifton. 
C. 

1897 Bean, C. E., F.R.C.S., 19, Lockyer street, Plymouth. 

O.M. Bennett, Frederick William, M.D., 25, London road, 

Leicester. C. 

1895 Brady, Andrew John, 3, Lyons terrace, Hyde park, 
Sydney, New South Wales. 

O.M. Bronner, Adolph, M.D., 33, Manor row, and 8, Mount 
Royd, Bradford. C. V.-P. 

1894 Brown, Alfred, M.D., Sandycroft, Higher Broughton, 

Manchester. 

1898 Burt, Albert H., Throat and Ear Hospital, Brighton. 
1893 Ohabsley, Robert Stephen, The Barn, Slough, Bucks. 
1898 Claremont, Claude C., M.D., B.S., 57, Elm grove, South- 

sea. 

1893 Davison, James, M.D., M.R.C.P., Streate place, Bath 
road, Bournemouth. 

1895 Downie, J. Walker, M.B., 4, Woodside crescent, Glasgow. 
1893 *Embleton, Dennis C a wood, M.D., St. Wilfrid’s, St. 

Michael’s road, Bournemouth. 

1893 Foster, Michael, M.B., Villa Annita, San Remo. 

1898 Foxcroft, F. W., M.B., 33, Paradise street, Birmingham. 
1898 Frazer, Wm., Johannesberg, South Africa. 



Ylll 


Elected. 

1900 Hates, George Constable, F.R.C.S., 22, Park Place, 
Leeds. 

1897 Herdman, Ronald T., M.B., C.M., Gwelo, Rhodesia, 

South Africa. 

O.M. Hodgkinson, Alexander, M.B., 18, St. John street, 
Manchester. V.-P. 

1894 Hunt, John Middlemass, M.B., C.M., 55, Rodney street, 

Liverpool. 

1898 Hutchison, A. J., M.B., 225, Bath street, Glasgow. 

O.M. Johnston, Robert McKenzie, M.D., F.R.C.S.Ed., 2, 
Drumsheugh gardens, Edinburgh. C. 

1898 Kelly, A. Brown, M.B., C.M., 26, Blythswood square, 
Glasgow. 

1895 Lindsay, David Moore, 373, Main street, Salt Lake City, 

Utah Territory, U.S.A. 

1895 Macintyre, John, M.B., C.M., 179, Bath street, Glasgow. 

1894 Mackern, George, M.D., Club Estrangeros, Calle Vittoria 

536, Buenos Ayres, Argentina. 

O.M. *McBride, Peter, M.D., F.R.C.S.Ed., 16, Chester street, 
Edinburgh. V.-P. 

1898 Marsh, F., F.R.C.S., 34, Paradise street, Birmingham. 

1893 Milligan, William, M.D., 28, St. John street, Manchester. 

C. 

O.M. Newman, David, M.D., 18, Woodside place, Glasgow. 
G. 

O.M. *Parker, Charles Arthur, F.R.C.S.Ed., High street, 
Rickmansworth, Herts. 

O.M. Paterson, Donald Rose, M.D., M.R.C.P., 18, Windsor 
place, Cardiff. 

1893 Permewan, William, M.D., F.R.C.S., 7, Rodney street, 
Liverpool. 

1899 Reid, St. George Caulfield, Thornton Heath, Croydon. 

1895 Reynolds, Arthur R., M.D., 36, Washington street, 

Chicago, U.S.A. 

1895 *Ridley, W., F.R.C.S., Ellison place, Newcastle. 

1895 *Sandford, Arthur W., M.D., M.Ch., 13, St. Patrick’s 
place, Cork, Ireland. 

1898 Scatliff, J., M.D., 11, Charlotte street, Brighton. 

1897 Sendziak, Dr. Johann, 139, Marszatkowska-Strasse, 
Warsaw, Russian Poland. 



IX 


Elected. 

1898 Snell, Sydney, M.D., 2, Pavilion square, Scarborough. 
1896 Tomson, W. Bolton, M.D., Park street West, Luton, Beds. 

1896 Turner, A. Logan, M.D., F.R.C.S.Ed., 20, Coates crescent, 

Edinburgh. 

1895 Vincent, George Fourquemin, Hallaton, Leicestershire. 

1897 Walker, Henry Secker, F.R.C.S., 45, Park square, Leeds. 
O.M. Walker, Thomas James, M.D., 33, Westgate, Peter¬ 
borough. V.-P. 

1895 * Warner, Percy, Woodford. 

1900 Westmacott, Frederic H., F.R.C.S., 8, St. John street, 
Manchester. 

1893 Williams, Patrick Watson, M.D., 2, Lansdowne place, 
Victoria square, Clifton, Bristol. G. 



X 


LIST OF EXCHANGES. 


Periodicals : 

The Journal of Laryngology, Rhinology, and Otology (London) 
The Laryngoscope (St. Louis, U.S.A.). 

Annales des Maladies de T Oreille, &c. (Paris). 

Revue de Laryngologie, &c. (Bordeaux). 

Centralblatt fiir Laryngologie. 

Archiv fiir Laryngologie (Berlin). 

Monatsschrift fiir Ohrenheilkunde, &c. 

Archivio Italiano di Otologia (Turin). 

Bollettino delle Malattie dell’ Orecchio, &c. (Florence). 
Archivii Italiani di Laringologia (Naples). 

Archives Internationales de Laryngologie, Otologie, et Rhino- 
logie (Paris). 

Transactions of the following Societies: 

British Laryngological, Rhinological, and Otological Associa¬ 
tion. 

American Laryngological Association. 

American Laryngological, Rhinological, and Otological 
Society. 

Gesellschaft der Ungarischen Ohren- und Kehlkopfarzte. 

New York Academy of Medicine, Section of Laryngology. 
Wiener Laryngologische Gesellschaft. 

Niederlandische Gesellschaft fiir Hals-, Nasen-, und Ohren¬ 
heilkunde. 



OFFICERS AND COUNCIL 


OF THE 

Harpgolojjical j&otietg of ionium 

ELECTED AT 

THE ANNUAL GENERAL MEETING, 

JANUARY 6th, 1899. 


Urmbent. 

F. DE HAYILLAND HALL, M.D. 

A. BRONNER, M.D. W. R. H. STEWART, F.R.C.S. (Edin.) 

Srcaanm. 

E. CLIFFORD BEALE, M.B., F.R.C.P. 


librarian. 

J. DUNDAS GRANT, M.D., F.R.C.S. 

Swwtaries. 

WILLIAM HILL, M.D., B.Sc. H. LAMBERT LACK, M.D., F.R.C.S. 


Cmnrtil. 

EDWARD LAW, M.D. WALTER SPENCER, M.S. 
F. W. MILLIGAN, M.D. A. A. BOWLBY, F.R.C.S. 
HERBERT TILLEY, F.R.C.S. 



PRESIDENTS OP THE SOCIETY. 


(From its Formation .) 

ELECTED 

1893 Sib G-eorge Johnson, M.D., F.R.S. 
1894-6 Sir Felix Semon, M.D., F.R.C.P. 
1897-8 H. Trentham Butlin, F.R.C.S. 


1899 F. de Havilland Hall, M.D., F.R.C.P. 



PROCEEDINGS 


OP THB 

LARYNGOLOGICAL SOCIETY OF LONDON. 


Ordinary Meeting, November 4 th, 1898. 

Henry T. Butlin, Esq., F.R.C.S., President, in the Chair. 

Herbert Tilley, M.D., 7 « . . 

WiLiiiM Hill, M.D., j 8ecretancs - 

Present—36 members and 3 visitors. 

The minutes of the previous meeting were read and confirmed. 

The following gentlemen were elected members of the Society : 

F. J. DixorfTM.B., B.C., Welbeck Street, W. 
Frederick Spicer, M.D., Devonshire Street, W. 


Lupus op the Larynx (with Microscopical Sections and Draw¬ 
ings from a Case). 

Shown by Professor Ferdinand Massei, Naples (Honorary 
Fellow of the Society). A girl set. 10 was seen last year by Pro¬ 
fessor Massei suffering from typical lupus of the larynx. A year 
previous the case had been sent to him as one of syphilis, the cutaneous 
manifestations having been diagnosed as such by a competent derma¬ 
tologist. In spite of energetic antisyphilitic treatment matters 
underwent no amelioration, and whatever change took place was for 
the worse. Professor Massei then decided that the affection of the 
larynx was lupus, and the cutaneous appearances confirmed this 
diagnosis. The lungs were normal. Sections of tissue removed 
from the epiglottis showed giant-cells around which were disposed 

FIRST SERIES—VOL. VI. 1 



2 


epithelioid cells in the manner characteristic of tubercle. Inocula¬ 
tions of guinea-pigs were, however, unfruitful, but recently the patient 
presented symptoms of pulmonary phthisis. 

He proposes to do away with the distinction between tuberculosis 
and lupus, holding that they are identical, as shown in this case by 
the microscopical appearances and the recent development of con¬ 
sumption. The negative result of inoculation is not, in his opinion, 
a disproof, because it goes along with the extreme scantiness of the 
bacilli in lupus tissue, which is so well recognised. 

(Professor Massei has presented to the Society the sections from this 
case, and they may be seen on application to the Librarian.) 

Mr. Wyatt Wingrave thought that the non-differentially stained 
specimen presented by Professor Massei was hardly sufficient evidence 
of the pathological identity of lupus and tubercle; and since there was 
much difference of opinion as to their respective histological details, 
a demonstration of bacilli would have proved of great interest and 
importance. 

Sir Felix Semon said that he thought it was generally agreed that 
lupus and tubercle were essentially the same, but that the former 
was characterised by its chronic course and the paucity of tubercle 
bacilli, whereas comparatively opposite conditions held in tubercle. 


Man aged 51 with Hypertrophic Laryngitis of Doubtful 

Nature. 

Shown by Dr. StClair Thomson. The patient, J. H—, set. 51, 
had been hoarse for eight months. There was no specific history; 
the lung-sounds were normal; and the patient confessed to having 
taken very freely of alcohol. He has been under iodide of potassium 
for over a month without any improvement. There is an irregular 
growth on the right processus vocalis; the right cord is decidedly 
impaired in its movement. There is thickening of the opposite (left) 
processus vocalis and general hypertrophic laryngitis. No glands are 
to be felt. The patient has not lost flesh. There is a good deal of 
chronic rhinitis. 

Sir Felix Semon was not certain that the case was simply hyper¬ 
trophic laryngitis; there was some defective mobility of the right 
vocal cord, and a small excrescence ou the vocal process. 

This suggestion of malignancy was also endorsed by Dr. Bond, 
who thought that the absence of any intervals of improvement (which 
were frequent in simple chronic laryngitis) rather favoured the idea 
of grave disease. 



3 


Mr. Lake had seen the patient some time before, and on account 
of the rapid loss of weight and suspicious appearance had suggested 
exploratory laryngo-fissure. 

Dr. StClair Thomson proposed to remove a portion of the 
growth from the right processus vocalis, and report to the Society as 
to its microscopical characters. 


Epithelioma op Larynx. 

Shown by Dr. Barclay Baron (Bristol). Patient male aet. 64. 
About twelve months ago he fouud him suffering from extensive 
growth affecting the front parts of both vocal cords, especially the 
right and the anterior commissure. This was removed at several 
sittings by means of forceps and curette. The growths were multiple, 
not ulcerated, and ihere was no redness or swelling of surrounding 
structures, and the case was regarded as probably anon-malignant one. 
Some months ago he again came to the hospital, and the whole larynx 
was filled with warty growth, with redness and swelling of the right 
ventricular band. This was removed by a surgical colleague after 
thyrotomy, and proved to be epithelioma, and it has extensively re¬ 
curred since the operation last June. Dr. Baron queried if this is 
not a case of transference of a benign into a malignant growth. 

Sir Felix Semon rather questioned whether the papillomatous 
nature of the growth in the first instance was not more apparent than 
real. The warty appearance might be merely superficial, the separate 
papillomata growing from a common base. The man’s age, again, 
was not in favour of a benign growth. Under all circumstances he 
thought the supposed transformation could not be classified otherwise 
than “ extremely doubtful.” He himself had hardly any doubt that 
the disease was malignant from the first. 


Sarcoma of Nosh. 

Dr. Baron also showed a case of growth in the right nostril of a 
woman aet. 34 years. Three months ago she found some epiphora; an 
attempt was made to pass a probe through the lachrymal duct by her 
medical adviser, but he was unable to reach the nose. Since then 
there has been much pain over the eyebrow and roof of nose, some 
discharge from the nostril, and a gradual obstruction of it. She was 
seen in consultation, and the whole nostril found to be filled with a 
greyish growth which projected into the naso-pharynx. It bled freely 



4 


on probing, and removal of a piece with a snare caused very free 
haemorrhage. She also said that she had bled freely three times in a 
fortnight. There was a soft elastic swelling at the inner angle of the 
eye. Microscopically the growth appeared to be a mass of round 
cells, aud the clinical history and appearance were believed to point to 
sarcoma. 

Mr. Spencer did not think that there were definite evidences of 
sarcoma present. The mass of granulations bathed in muco-pus 
might have an inflammatory origin, e.g. be gummatous, or have 
arisen in one of the sinuses. He advised that the nose should be 
first of all cleared out by curetting under an anaesthetic with the 
head hanging low, and then be plugged. In a day or two, on the 
removal of the plug, it would be possible to examine the interior of 
the nose and naso-pharynx completely. The subsequent course of 
the case would then enable a diagnosis to be made. 

The President agreed entirely with Mr. Spencer as to the course 
of treatment he had suggested, aud thought the mass had more 
the appearance of a benign than a malignant growth. He thought it 
would be very difficult to differentiate microscopically between a 
chronic inflammatory mass of this kind and a small round-celled 
sarcoma. 

Mr. Waggett thought the microscopic specimen could not be 
distinguished from a mass of granulation tissue. 

Dr. Hill had a similar case under his care eight years ago; as the 
pathological report declared a portion removed for microscopy to be 
undoubtedly malignant, he handed the case over to Mr. Page, who 
cleared the nose out by Rouge’s operation. Slight recurrence took 
place from time to time, but the patient was still living aud well, 
and the speaker had long ago been compelled to recognise that the 
case was really one of granulomatous growth associated with 
suppuration from the sinuses. 

Mr. r Robinson thought that there was a possibility of the lesion 
being tuberculous, the nose becoming infected subsequent to the 
injury. The crusted, dry appearance, and its localisation to one 
cavity, did not seem to favour the view of its sarcomatous nature. 

The President thought that the smoothness of the swelling out¬ 
side, and the ulceratiou inside, seemed to point more to an infective 
disease than to a new growth. 


Nasal Case for Diagnosis. 

Dr. Baron also showed a young man who had a blow on the nose 
six months ago. Three weeks afterwards he noticed a swelling on the 
outside of the nose, and this has increased steadily. It is red and 
hard, and presents no fluctuation. There was no discharge until 



5 


about three weeks ago, when some pus came from the nostril, and 
Mr. Morton, under whose care the case was admitted at the Bristol 
General Hospital, took away a piece of necrosed cartilage. There is 
no history of syphilis, but he has taken antisyphilitic doses of iodide 
of potash for a month or so with no effect. There is some history of 
tubercle in the family, but the man is quite healthy excepting for the 
nose trouble. 

The case was shown to get the opinion of the members as to the 
nature of the swelling, Dr. Baron believing it to be inflammatory, with 
necrosis and sequestrum of cartilage as the cause of it. 

Cancer op (Esophagus with Paralysis of one Yocal Cord. 

Shown by Dr. Watson Williams. W. D—, male, set. 64, com¬ 
plained July 1st, 1898, cf difficulty in swallowing, but early in the 
previous January he had noticed some difficulty in swallowing a piece 
of meat, which had increased gradually until he could only swallow 
soft food. -He lost flesh considerably—nearly three stone in weight. 
In August, 1897, his voice had become slightly thickened and hoarse, 
and remained so since. 

Laryngoscopic examination showed the right vocal cord in the cada¬ 
veric position, and pointed to a right recurrent nerve paralysis. There 
was no obvious cause for this, neither were physical signs in the chest 
indicative of organic lesions found. A No. 20 oesophageal bougie 
was easily passed into the stomach. No history of syphilis. Best in 
bed and small doses of iodide of potash were followed by rapid im¬ 
provement in swallowing powers and in his general health. 

In five weeks* time marked inspiratory dyspnoea developed, in¬ 
creasing so rapidly that a low tracheotomy was performed with relief. 
He now expectorated quantities of mucus, and, rapidly sinking, died 
four days after the operation. 

Post-mortem examination disclosed a circular perforation in the 
trachea two inches above the bifurcation, three quarters of an inch in 
diameter, and communicating with the gullet. The right posticus 
muscle was atrophied. The anterior gullet wall was invaded by an 
epitheliomatous growth, which involved also a post-tracheal gland. 
The right recurrent laryngeal nerve was involved in the growth and 
compressed. Old caseating tubercular deposits were found in both 
pulmonary apices, and the bases were affected with septic pneumonia. 



Dr. "Williams pointed out that the value of recurrent paralysis as a 
symptom of malignant disease of the gullet depends much on the 
presence or absence of signs of organic disease in the chest cavity, 
which might also produce a similar paralysis. The early improve¬ 
ment under treatment in this case certainly might have at first sug¬ 
gested a thoracic aneurysm. It is worthy of note that the right cord 
was probably paralysed five months before he suffered from dys¬ 
phagia. 

Sir Felix Semon thought that in all cases where a patient 
died with paralysis of a vocal cord the laryngeal muscles should 
be carefully examiued for varying degrees of degenerative changes, 
so that we might gain further and more exact information as to 
the question whether in organic progressive disease of the re¬ 
current laryngeal nerve the abductor muscle was the first to 
succumb. Dr. Friedrich’s descriptions of such cases had been most 
valuable. 


A Case of Paroxysmal Sneezing associated with Great 
Hypertrophy of Tissues in Neighbourhood of the Septal 
Tubercle (shown at June Meeting). 

Shown by Mr. Akthur Cheatle. A man complained of nasal 
obstruction and violent attacks of sneezing. On the right side 
a pink soft mass, springing from the septum opposite the middle 
turbinal, extending downwards and forwards, having a broad base 
with slightly overhanging lower edge, quite obscured the middle 
meatus and reached down to the inferior turbinal. The same condi¬ 
tion existed on the left side, but to a much less degree, the mass 
being pale. 

With a cold snare a large portion of the mass on the right side 
was removed. Sections showed great hypertrophy of the normal 
tissue; numerous glands, giving an almost adenomatous appearance 
with large blood-spaces, and great increase of connective tissue. 

Dr. Pegleb thought one would be scarcely justified in designating 
this case an adenoma of the septum, because, although the microscopic 
sections displayed an abundance of racemose glands, this was a common 
condition in mucous membrane hypoplasiae of the septum and 
turbinals. 






I. 







A (Hard Sf Son. 


Mr. Arthur Cheatle’s Case. 





7 


Growth in Anterior Commissure has been Removed, but 
Paresis of Right Cord remains (Patient shown at March 
Meeting) . 

Shown by Dr. Pegler. The small commissural fibroma of left 
cord was removed with forceps six months ago, i. e. immediately after 
patient was shown to the Society. 

All trace of the growth has now disappeared, but the abductor 
paresis of the opposite (right) cord remains unchanged. 

The voice is much improved. 


Case of Large Angioma of Larynx. 

Shown by Dr. Bond. Patieht male set. 55. When a boy he used 
to shout tremendously. He has had hoarseness for about twenty- 
eight years; some twenty years ago he was under Sir M. Mackenzie, 
who found and treated the tumour in larynx. Since then the patient 
has occasionally attended at Golden Square. An account of the case 
was published by Dr. Wolfenden in 1888 in the ‘ Journal of Laryn¬ 
gology/ At various intervals patient has spat up blood, and when 
seen by me in March last was coughing up blood and phlegm freely. 

He has a dark bluish tumour on right ventricular band, covering 
quite two thirds of it; there is a separate little offshoot above, and a 
third one on left ventricular band in front. The cords are apparently 
free. 

Patient says that he used to be treated weekly with the galvano- 
cautery. It is a question, considering the severe haemorrhage last 
March, whether one should not do a more radical operation, and the 
opinion of the Society on this point was desired. 

Mr. Spencer supported the proposal of Dr. Bond to perform 
thyrotomy and freely excise the disease. He noted that the cord on 
the right side moved very little, and there was a small glandular 
enlargement in front of the carotid on that side. It was possible 
that the growth was tending to show malignant characters. 

The President concurred with the suggestion of surgical inter¬ 
ference. 



8 


? Epithelioma op Larynx. 

Shown by Mr. Steward for Mr. Symonds. D. H—, set. 55, 
attended at Guy’s Hospital on August 5th, 1898, for partial loss of 
voice and pain in the throat and below the right ear. The loss of 
voice began in December, 1897, after an attack of influenza, and since 
that time has been gradually increasing. Examination showed an 
irregular thickening of the right vocal cord, which, however, was dis¬ 
tinctly moveable. Iodide of potassium was prescribed. A fortnight 
later the right cord was found to be fixed, and some irregularity of the 
false cord was noticed. 

On September 23rd the growth was distinctly larger, and some 
blood had been coughed up. A small piece of growth was removed, 
and reported, after examination by the pathologist, to be inflammatory. 
After this some improvement in symptoms took place, for on October 
23rd the patient reported that he was free from pain, and that he 
could speak with less effort. There was, however, no change in the 
laryngoscopic appearances. 

Drs. Spicer and Grant thought the case was malignant. 

Sir Felix Semon could not, however, satisfy himself that the 
ulceration described by the first speaker was at all obvious. 


Large Lipoma of Soft Palate. 

Shown by Dr. Bond. Patient is a female set. 49. She has a 
large semi-fluctuating tumour in soft palate on right, side, extending 
on left beyond mid-line and on the right behind angle of jaw. Eight 
years ago he removed a large, many-lobed fatty tumour through ex¬ 
ternal incision in parotid region. The mass removed weighed several 
ounces. The operation was followed by right facial paralysis, from 
which patient has almost recovered. 

The original tumour was a parotid one; the present one has pro¬ 
bably developed from some fragment left. 

Six years ago her right breast was removed in one of the London 
hospitals. 

The President thought that it would be possible to remove the 
tumour of the palate, which might easily shell out through a fair 
incision. 



9 


Tubercular Laryngitis after Removal of Large Inter- 

arytenoid Mass. 

Shown by Mr. Lake. The patient, a girl of 21, had been under 
treatment for eight months. When first seen she had bilateral ulcera¬ 
tion of the vocal cords, great bilateral swelling of the arytsenoid car¬ 
tilages, and a very large interarytaenoid mass. The arytsenoids were 
treated by double curettage in April, and had not been enlarged since, 
and the cords were quite healed. The mass removed from the inter¬ 
arytaenoid fold was shown, as also were Mr. Lake’s forceps for the 
removal of such growths. 

Dr. Herbert Tillet thought that Mr. Lake was not only to be 
congratulated on the excellent result attained in this case, but also 
for bringing the instruments to such perfection and making it a com¬ 
paratively easy task to deal with such cases of tubercular laryngitis. 
He has seen great relief afforded patients by removal of these cede- 
matous masses, and had no doubt that they would see many more in 
the immediate future. 


A Case of Membranous Laryngitis. 

Shown by Mr. Lake. The patient, a man set. 25, was the subject 
of a laryngitis of combined tubercular and syphilitic origin. He had 
loss of voice of eight weeks’ duration. On October 17th a white 
membrane was noticed on the posterior surface of the epiglottis, which 
had recurred after removal. 

In reply to Dr. Thomson, Mr. Lake said that no bacteriological 
examination had yet been made, but a further report was promised. 

Paresis of the Right Facial Nerve and of the Right Side 
of the Palate following Tympanic Suppuration. 

Dr. William Hill showed a female set. 24 exhibiting this unusual 
condition. Right tympanic suppuration followed measles eight 
years ago; a polypus was removed about four years later, and after 
this operation the right side of the face was said to be “ drawn up ” 
two years ago, however, this side “ got weak,” and the face was drawn 
up on the opposite side. For a year she has experienced some difficulty 
in swallowing, especially solids, though fluids have occasionally passed 
into the naso-pharynx; she has continuously “ felt a lump” in her 
throat. 



10 


There is now, iD addition to facial paresis, marked asymmetry of 
the palate, the arch being much higher on the left side; the right is 
flaccid, and the uvula is adherent to this side. The reflex, which is 
very active on the left side, appears to be absent on the right. There 
is reaction of degeneration in the right facial nerve, but for want of 
a suitable electrode this test has not yet been applied to the palate. 

The view that the palate was partly supplied by the facial through 
the vidian and large superficial petrosal nerves has been taught by 
anatomists since the time of Sir Charles Bell down to the present 
decade; but neurologists have for several years, on clinical and experi¬ 
mental grounds, combated this teaching, pointing out that the true 
motor supply of the palate is from the medullary fibres of the spinal 
accessory. The case was therefore of great neurological interest, few 
reliable cases having been recorded, and it was desirable to ascertain 
the views of the members as to whether the asymmetry of the palate 
was actually due to motor paresis (and not to an acquired or congenital 
deformity); and if so, the further question had to be faced, whether 
the paresis of the facial muscles and of the palate were due to a common 
lesion within the temporal bone rather than representing an accidental 
association. 

Dr. Dundas Grant was of the opinion that the median position of 
the dimple in the palate during phonation was a strong argument 
against the diagnosis of hemiplegia of the larynx. He considered the 
appearance, apart from the phonation, as inconclusive, and was inclined 
to think that the asymmetry then present was due to inflammatory 
changes in the pillars of the fauces, and not to nerve lesion. 


Frontal Sinusitis. 

Dr. Hill also showed a male set. 40, on whom he had recently 
operated for chronic suppuration of the frontal sinus by the Ogston- 
Luc method. The chief points of practical interest in the case were : 
(1) the shortness of the skin incision along the brow; (2) the perfect 
aesthetic effect, as the scar was barely visible, and the previous dis¬ 
placement outwards of the eye had disappeared; (3) no drainage- 
tube was employed. 

Dr. Herbert Tilley, in reply to a question as to what instrument 
was used to make a free passage into tlie nose, said that he had found 
a Krause’s antrum trocar fulfil the object very well, the slight curve 
on the instrument being just that which was necessary. 



11 


Case op (?) (Esophageal Pouch. 

Shown by Mr. Cresswell Babek. F. G—, a butler, get. 62. 
First seen at the Brighton Throat and Ear Hospital on October 24th, 
1898. For over a year he had had a peculiar sensation in his throat 
as if his uvula were too long, aud he brought up a quantity of phlegm. 
Seven or eight months ago he first noticed that he returned lumps of 
undigested meat which had been taken the day before. This usually 
happens in the morning after breakfast, when they return together 
with fragments of that meal. There is no marked difficulty in swallow¬ 
ing, but occasionally he has to make two efforts before the act can be 
accomplished. Solids are more troublesome to swallow than liquids. 
He feels satisfied after a meal, and is conscious that he swallows most 
of the meal without any difficulty. No vomiting or pain. He has a 
“ croaking ** or gurgling noise in his throat, especially when lying 
down and at meals, which is followed by the bringing up of quantities 
of phlegm. He often has to leave the table because of the dis¬ 
comfort. 

On examination the pharynx is irritable and congested, and uvula 
thick. Larynx congested, especially the cords; otherwise it is normal. 
Much white frothy secretion is seen coming up behind the arytsenoids. 
External examination shows a doubtful fulness in the left posterior 
inferior triangle of the neck, but I have not examined him after a full 
meal. Pressure with the fingers above the clavicles, especially at the 
left side, produces a gurgling noise, and escape of gas by the mouth ; 
and after he has swallowed some milk and bread, pressure in this 
region causes it immediately to return. Liquid taken alone is partly 
returned when he stoops sharply forward. Patient is well nourished, 
and has not lost flesh to any extent. His weight, which on July 26th, 
1898, was 12 st. lbs., and on August 30th 12 st. 13 lbs., is now 
(October 31st) 12 st. 11 lbs. I have passed two large-size elastic 
bougies down, and they both became arrested about nine inches past 
the teeth. The ends could not be distinctly felt in the left posterior 
inferior triangle. Chest normal, except a narrow patch with slightly 
impaired resonance under the left clavicle. 

Dr. StClair Thomson suggested that the case afforded a useful 
field for the employment of the Rontgen rays. He had not himself 
had such a case, but it had occurred to him that if two metallic 
bougies were passed down the oesophagus, one into the pouch and 



12 


the other into the stomach, and if an X-ray photograph were then 
taken of the neck and chest, we might get very useful information as 
to the situation and relationship of this pouch. 

The President said that before operating to remove the pouch the 
patient should be carefully examined in order to ensure he was in a 
fit state of health, and that it should be clearly ascertained that there 
was no organic stricture of the oesophagus, a probe passing easily into 
the stomach as well as into the pouch. 


An Exceptional Case op Cleft Palate. 

Shown Jby Mr. Mobley Agar. The bony cleft was on the left side, 
and only showed the inferior turbinate in its whole length. There 
was also some deformity of the vomer. 

Mr. Robinson was of opinion that this deformity was not very 
unusual. He explained it as a complete cleft from front to back, but 
to the left side of the mid-line, so that there was non-union on the 
left side of the maxilla to the pre-maxilla, and of the palatal 
processes of maxilla and palate to their fellows on the right side. 
The appearance posteriorly was due to the dragging well to the right 
of the soft palate and the sloping edge of the bones, and the right 
posterior choana thus coming into view. 


Notes of a Case of Ulceration of the Soft Palate. 

Shown by Mr. Parker.. A. G—, male, set. 32. Last Easter his 
throat became very sore—was said to be ulcerated. After ten weeks’ 
treatment it got quite well, and remained so till a few days ago. He 
has always been a strong healthy man, and denies all history of 
syphilis. He had gonorrhoea thirteen years ago. He is married and 
has three healthy children, but he states that his wife has had two or 
three miscarriages. 

On examination the soft palate and uvula are found to be covered 
with a ragged, straggling ulceration of a superficial character; 
between the patches of ulceration there is a peculiar nodular appear¬ 
ance, and there is a small areola of redness round the diseased parts. 

The diagnosis lies between tertiary syphilis and tuberculosis. The 
former seems to be more probable. 



PROCEEDINGS 


OF THE 

LARYNGOLOGICAL SOCIETY OF LONDON. 


Ordinary Meeting, December 2nd, 1898. 

F. de Havilland Hall, M.D., Vice-President, in the Chair. 

Hebbebt Tilley, M.D.,) a , . 

Williah Hill, M.D., j Secretar.es. 


Present—37 members and 10 visitors. 

The minutes of the previous meeting were read and confirmed. 

The following gentleman was nominated for election at the next 
meeting: 

H. St.George Reid, 25, Old Burlington Street, W. 


Report of the Morbid Growths Committee. 

Slide L.S.L. 16.—Section of growth removed from a female patient 
of Dr. Barclay Baron's, shown at meeting November 4th, 1898.' The 
Committee report that the specimen submitted to them contains a 
mass of large polyhedral embryonic cells, which some would term an 
alveolar sarcoma, others spheroidal-celled carcinoma. Some of these 
cells are in an active stage of proliferation. The arrangement of the 
cells tends to show sonie trace of alveolation, and it is noticeable that 
there is an intra-cellular fibrous structure. In deeper portions of the 
section there are evidences of inflammatory change, some recent and 
some of longer standing. Blood spaces are seen without definite walls. 
In our opinion the growth belongs to a class which behaves in many 
respects like sarcoma, but showing slight and local malignancy. 

Slide L.S.L. 17.—Sections of glands under sterno-mastoid to- 

2 


FIRST SERIES—VOL. VI. 



14 


gether with portion of internal jugular vein, removed from patient 
shown by Dr. Bond May 13th, 1896, p. 86; November 11th, 1896, 
p. 4. Report on section January 13th, 1897, p. 40. Case “ Sarcoma 
of Nose.” 

The Committee regret that owing to some mistake in the consti¬ 
tution of the fluid in which the growth was originally placed, the 
mass had almost decomposed before they received it, and only one 
small portion was at all suitable for sections. This portion was un¬ 
doubtedly of malignant nature, but whether it was a spheroidal-celled 
carcinoma or an alveolar sarcoma the condition of the section rendered 
it impossible to decide. 


Wall Charts for Teaching Signs of Suppuration in the 

Nasal Sinuses. 

Shown by Dr. Dundas Grant. These charts were drawn up by 
Dr. Grant to illustrate his lectures in June, 1898, and were founded 
mainly, but with various modifications, on the classifications of signs 
ns presumptive, probable, and certain, given by Lermoyez in his work 
on the treatment of diseases of the nose and sinuses of the face. 


Section of Cyst removed from the Naso-pharynx. 

Shown by Mr. Arthur Cheatle. A man set. 19 came to the 
Royal Ear Hospital complaining of nasal obstruction. Besides some 
turbinal hypertrophy and a spur in the nose, a smooth pink mass, the 
size of half a walnut, was seen in the naso-pharynx immediately behind 
the septum and stretching from one Rosenmiiller’s fossa to the other. 
Under chloroform it felt tense, and was ruptured with the finger-nail 
before removal. A microscopical section through the mass showed a 
large and a small cyst, each lined with columnar ciliated epithelium, 
with a slight amount of adenoid tissue outside on the cut surface. 


Preparations of Hypertrophied Tonsils. 

Mr. Wyatt Wingrave exhibited sections of enlarged tonsils for 
inspection by the naked eye. They illustrated the conditions of 
simple hypertrophy unattended with any inflammatory changes. 



15 


The points of chief interest were the scantiness of the connective- 
tissue elements, the depth of the lacunae, which reached to the 
“ bed ” of the tonsil, and the fact that one aperture was common to 
several lacunae. 

The tonsils before cutting had been soaked in collodion, which 
method binds the tissues together and prevents the lymph follicles 
falling out. 


Sections of Lupus of Larynx. 

✓ 

Shown by Mr. Wyatt Wingrave. The sections were stained by 
the Ehrlich triple Biondi process, a method which had the great 
advantage of differentiating the three most prominent histological ele¬ 
ments, viz. the small-cell tissue, the epithelial cells, and the sclerotic 
bands. Neither in this nor in other instances had he been able to 
demonstrate a specific bacillus. 

Apart from the question of the bacillus, he considered that histolo¬ 
gical differences between tubercle and lupus were to be explained by 
the respective rates of inflammatory changes. 


Microscopic Sections of Papilloma of the Larynx. 

Shown by Mr. Wyatt Wingrave. Prom a case of Dr. Dundas 
Grant’s. It was of the simple stratified squamous variety. 


Microscopic Sections of Rhino-scleroma. 

Shown by Mr. Wyatt Wingrave. Prom a case of Dr. Dundas 
Grant’s. 


Specimen of Pachydermia Laryngis. 

Shown by Mr. Lake. The larynx shown was removed from a 
patient ®t. 34, who had been hoarse, or, as the patient had described 
it, “ had had a man’s voice since the age of four years.” His family 
history was good. He had suffered with phthisis for one year, but his 
larynx showed no traces of this. 



16 


la reply to Dr. Grant, Mr. La.ee said the hoarseness antedated the 
phthisis by about thirty years. 


Tubercular Larynx from a Child aged 6 years. 

Shown by Mr. Lake. This was shown on account of the com¬ 
parative rarity of this disease in childhood. When first seen the child 
had laryngeal stenosis due to subglottic swelling ; later destructive 
ulceration set in, and he died nine weeks later. 


Report on a Specimen of Membrane (Epiglottis) from a case 
of Membranous Laryngitis shown at the last meeting 
(November) by Mr. Lake. 

Three organisms were shown to be present in the cultivations, viz.: 

(1) Staphylococcus pyogenes albus. 

(2) A small diplococcus (morphologically identical with the gono¬ 
coccus, but staining by Gram's method). 

(3) A small-celled torula. 

Walter D. Severn. 

Recurrent Nasal Tumour from Female aged 23. 

Shown by Mr. Lake. 

Empyema of Antrum cured by Repeated Irrigations by means 
of Lichtwitz’s Trocar and Cannula. 

Shown by Dr. Dundas Grant. Mrs. M— was seen on July 21st, 
1898. There was'dulness on transillumination, and a free exit of 
fcetid pus following the use of Lichtwitz’s trocar and cannula. 

For nine years the patient had been subject to “ colds in the head,” 
chiefly affecting the right nostril, but the history of a fcetid discharge 
only dates about four weeks before her application for relief. Pos¬ 
sibly the chronic recurring discharges were due to attacks of suppura¬ 
tive inflammation in the right frontal sinus from which the antrum 
was secondarily “ charged.” Transillumination of the right frontal 
sinus shows less translucency than that on the left side. The signs of 
antral empyema, which were typical, entirely disappeared after eleven 
irrigations with Lichtwitz’s instrument. The teeth were sound, and 



17 


lienee the intra-nasal treatment was adopted in place of any of the 
buccal methods. 


Chronic Empyema ok the Antrum cured by Intra-nasal Treat- 
' ment" (Anterior Turbinectomy—Krause's Trocar). 

Shown by Dr. Dundas Grant. M. A. L—, set. 31* schoolmaster, 
seen April 22nd, 1898, complaining of offeipive purulent nasal discharge 
which had lasted continuously for six months. Antral empyema was 
diagnosed by means of.Lichtwitz’s trocar and cannula. Three carious 
teeth were removed, and the discharge did not return for jtwo days. 
Temporary relief followed irrigation by the latter instrument. Alveolar 
puncture and irrigation were then instituted, and the latter carried 
out till June 18th, at the first with temporary success, but with pain 
in the process and no actual "cessation of discharge. The alveolar 
puncture was allowed to close. 

Anterior turbinectomy was then performed, and under. cocaine 
Krause's trocar and ctmnula introduced; through the latter the antrum 
was washed out and then insufflated with iodoform and finally iodol. 
Twenty-eight irrigations through the alveolus had been unsuccessful, 
but after twelve.through the intra-nasal cannula the discharge and smell 
had entirely ceased. ... - \ 

The patient is now quite free from any symptoms of his antral 
disease, there is no pus on irrigation, andTthe dulness on transillumi¬ 
nation has diminished. 

, m 

« ■ * 

Dr. Herbert Tilley thought that the great disadvantage of this 
treatment was that in the majority of cases the irrigation had to be 
done by the surgeon rather than by the patient himself—a matter of 
very considerable importance. The alveolar method, which was with¬ 
out this disadvantagejma5e.it most suitable ^fpr the general run of 
cases as the first line of treatment) for once the patient - had been' 
provided .with a'suitable plug and had been shown how to use the 
syringe, he could carry on the treatment .for himself. . • 

In reply to Dr. Spicer, Dr. Tilley said that he did not for a 
moment wish to underrate the value of the more radical operations In 
protracted cases, and cases where it was probable antral polypi were 
keeping r up the discharge.- He had- himself found them invaluable. 
His contention was, that in ordinary cases associated with carious 
teeth the treatment should commence by removal of the latter and 
insertion of a plug, removable for constant irrigation ; that the lotion 
should be constantly changed,’ and not until these methods-were 
found to fail should more nadical operations be performed,—one great 
4 ? . 



18 


disadvantage of which was that patients could not carry out the 
treatment themselves. He was surprised that Dr. Spicer had met 
with so few cases cured by the alveolar method. 

Dr. Pegler thought the operation of anterior turbinectomv, as 
performed by Dr. Grant in this case, would become a more general 
accessory procedure in the treatment of antral disease where a Krause 
opening was to be made. He had noticed that the inferior turbinal 
tended to become chronically inflamed and swollen in the presence of 
much purulent discharge, and in its turn aggravated matters by- 
hindering drainage and keeping up sepsis, besides rendering the 
Krause’s opening more difficult of access. Subsequent treatment by 
irrigation with a catheter through this opening was also much facili¬ 
tated by an anterior turbinectomy. 

In reply to Dr. Tilley, Dr. Pegler said he could show cases in 
which the habitual passage of a, vulcanite catheter through the Krause 
opening, during home treatment by the patient, had been carried out, 
after a little practice, without any great difficulty. 

Dr. Soanes Spicer felt it his duty to join issue with Dr. Tilley on 
two points. Firstly, a* to the assumed difficulty of patients washing 
out the antrum per nares through the operative artificial ostium 
maxillare. With a proper bent tube, and one or two demonstrations, 
the patient found no difficulty in doing this within a few days of the 
operation. He had recently sent a case out of hospital fourteen days 
after radical operation, and as she was going to Bristol for a month 
he asked her to present herself at Dr. Watson Williams’ clinic, and 
the speaker believed that that gentleman would say there was not the 
slightest difficulty. In fact, since he had adopted entire nasal irriga¬ 
tion after operation, he had found that patients had far less difficulty 
and discomfort than with the tooth-socket tube irrigation. Secondly, 
he protested against the routine use of tooth-socket tubes and a plate 
for “tw r o months” in well-proved cases of chronic empyema. This 
doctrine was retrograde, and directly in opposition to all recent 
English, Continental, and American advances, and should be dis¬ 
countenanced by a society of specialists. Oases of cure of chronic 
empyema by tooth-socket tubes were most rare, while he had come 
across several cases of supposed “ cures ” who had gone on wearing 
their tubes for ten, fifteen and more years, and were still doing so, 
and using irrigations one, two, or three times a day for the suppura¬ 
tion and smell. It therefore appeared to him better to adopt at once 
a radical method which was safe, rapid, and practically certain, instead 
of wasting time and money on a method which almost never succeeded. 

Dr. StClair Thomson suggested that in the matter under dis¬ 
cussion the feelings of the patient might be slightly considered, and 
that in his experience when the facts of the case were put before a 
patient, the larger majority preferred to have the alveolar opening 
only whenever there was a suitable empty tooth-socket on the same 
side. A long history of suppuration does not necessarily mean an 
intractable case, for in his case, referred to by Dr. Scanes Spicer, the 
patient had had symptoms for seven years and the empyema had been 
definitely diagnosed two years before operation was decided upon. 

Dr. Watson Williams had had a case under his care which 



19 


showed the ease with which a patient could syringe out her own 
antrum. 

Dr. Grant, in reply, quite agreed that the convenience of the 
alveolar operation was such that it could never be altogether done 
away with. At the same time he had seen cases in which it had 
done no good, and improvement only began when the alveolar opening 
began to close and other methods of treatment were initiated. On 
principle he contended that an opening between the mouth and nose 
was bad physiologically, and still worse bacteriologically. He had 
therefore tried what could be done by intra-nasal treatment. He 
showed an instrument for enlarging the opening made with Krause’s 
trocar, and cited a case in which such an opening had persisted. 
Anterior turbinectomy had at the same time been performed, and the 
patient could pass a Eustachian catheter into the opening. 


X-Ray Photograph op Foreign Body (Silver Tube) in the 

Antrum op Highmore. 

Shown by Mr. Cheatle. The patient was wearing a tube through 
the canine fossa for chronic antral suppuration ; the top broke o(F, 
and the patient continued to wear it. One morning on waking it had 
disappeared. In order to see if it was inside the antrum, Mr. Low 
took the photograph, which clearly showed it lying across the cavity. 

Dr. Dundas Grant had in one case of opening the antrum through 
the canine fossa found a vulcanite tube which had broken off from its 
plate. This had been adopted after the alveolar operation, and was 
supposed by the patient to have dropped out. 

Dr. Watson Williams cited a case where a peg similarly got lost 
in the antrum, but passed out into the nose through the ostium 
maxillare without operative interference. 

Dr. William Hill recorded another case where the loss of a tube 
in the antrum was fortunate for the patient, as it necessitated opening 
the front wall of the sinus, which was found to be diseased, and a 
radical cure was made of the case. 


Spreading Ulcer op the Nose. 

Shown by Mr. Wyatt Wingrave. Charles T—, set. 50, labourer, 
seen on Nov. 14th, 1898, complaining of pain over nose and stink¬ 
ing discharge of six weeks’ dui’ation. On examination, nostrils were 
full of foetid crusts, which on removal showed perforation of vomerine 
region of nasal septum with granulation tissue in all directions. 

He gave a history of syphilitic sore thirty years ago, with falling of 



20 


hair, but no other signs. Married twenty years; wife had two mis¬ 
carriages, at the second and fourth pregnancies. He had usually 
enjoyed good health. Two months later a red patch appealed on the 
outside of each ala at junction of bone and cartilage; this rapidly 
broke down and the ulceration spread to cheeks and upper lip, the tip 
of nose remaining free. He suffered considerable pain, and the dis¬ 
charge was profuse and foetid. He was treated with pot. iodide aijd 
bromide, also inunctions of mercury, with negative results. 

Cultivations were taken, butta special micro-organism was found, 
and injections of mallein and tuberculin gave no response. He has 
not lost flesh to any very great extent. The temperature has some¬ 
times been as high as 103°, but for’last six weeks has kept about 
normal. <At the present moment the disease is not spreading as fast 
.as it was, and the pain is but slight. He continues to take biniodide 
of mercury, which he has been under for the last three months. The 
ulceration is now much irforo superficial than it was, and shows a 
tendency to heal. 4 . 

He thought that the case possessed interest from its resemblance to 
one which was presented to the Society, by Dr. McBride in 1896, and 
seen by Sir Felix Semon and Dr. Milligan, who were all in doubt as to 
its nature. ' • 

The cases were alike in their resistance to mercury and iodides, their 
negative evidence df gla'nders, and their clinical history. He thought 
at first that it might be an unusually rapid case of lupus, sinee the 
history of syphilis was decidedly equivocal, 'and scrapings afforded no 
evidence of tubercle bacilli. , 

Mr. Spencer considered the case one of malignant ulceration, 
including under that term rodent ulcer. He would employ thorough 
eraskm and the cautery, and, later on cover healthy granulations with 
epidermal grafts. 

. Dr. Logan Turner said that he had had the opportunity of 
constantly observing Dr. McBride’s case of destruction of *the nose 
and face, which had been referred to by Mr.. Win grave.' The micro¬ 
scope, bacteriological investigation, and specific treatment had failed 
to establish any diagnosis. In spite of operative interference the 
ulceration had 'extended and death followed. Post-mortem examina¬ 
tion revealed * nothing of a definite nature. It differed from Mr. 
Wingrave’s case in the deeper *and more complete destruction both of 
the softjjatis and of the bones. In his (Dr. Turner’s) opinion the 
patient now shown presented rather the appearance of a case of 
lupus. • ' 

Mr. Bowlby suggested that it might well be a form of rodent 



21 


ulcer, in which case the term epithelioma should not be applied, as 
they were not identical diseases. 

In reply, Mr. Wyatt Wingrave said that the fragments examined 
afforded no evidence of epithelioma or tubercle, and that no surgical 
treatment had been attempted. There was no’ response to the active 
mercurial treatment*- which was thorough. 


Case of Syringomyelia, with Paralysis of the Right Side of 
the. Palate and Pharynx, aj^d of the Right Vocal Cord. 

• Shown by Dr. Herbert Tilley. The exhibitor expressed his 
great indebtedness to Br. Risien Russell for the help he had given 
him in the examination of the patient's nervous system. 

[Dr. Russell, at the invitation of the President, described the chief 
neryous symptoms of the case.] ; 

C. S—, set. 15 years, applied to the Gulden Square Hospital, 
complaining of " hoarseness and inability to use her hands properly.” 

Patient's mother liajl “chorea” when seventeen years of age, and 
her mother’s grandfather was the subject of fits, and died in an 
'‘asylum. She was born at full term; labour difficult, and instrumental 
'•delivery with injury to the head resulted. Has always enjoyed fairly 
good health, but has always been subject to eczema of hands since 
quite young. Mensescnot established. Weakness.of hands noticed * 
first about two years ago, when she found she whs unable to open her 
hands properly. * Hoarseness seems to have existed before the latter 
trouble was noticed. 

About tw.o months ago she received a large burn on the hypothenar 
eminence of left hand, and knew nothing of it till the blister acci¬ 
dentally broke. 'She experienced no pain as the result of the burn. 

Present state {November 28th, 1898).—Patient is a pale, well- 
nourished girl, with noisy .breathing and a hoarse voice. Nystag- 
mical jerks of both eyes are observed on lateral and upward movements ; 
they are more marked when the eyes are directed to the right than 
when turned to the left^ ajfd the movements of the globus being 
lateral, with a certain degree of rotation added. ' 

There is complete paralysis of'the right half of the palate, pharynx, 
and right vocal cord, as opposed to a normal movement of the same 
. on the left side. ' 



22 


All the neck muscles act well, and show no evidence of atrophy. 
The scapular and shoulder muscles, also those of upper arm, are 
intact, and all movements of the shoulder-joint and elbow are well 
executed. There is moderate wasting of the extensors and flexors of 
the forearms, with weakness of extension and flexion at the wrist— 
the defect being more marked in the extensors. 

The fingers of both hands are in the “ main en griffe ” position, 
and there is marked atrophy of the small muscles of the hands on 
both sides, but more advanced in those of the left. The wasting of 
the thenar eminence and first interosseal space is more pronounced 
than elsewhere. The hand grasps are very feeble; separation and 
adduction of fingers feeble; inability to extend the second and third 
phalanges. Adduction of thumb possible, but feeble on both sides. 
Opposing power of thumb almost nil. 

All muscles of forearm respond to faradism, but need a stronger 
current to evoke contraction than do those of the upper arm. No 
response of palmar muscles to faradism; dorsal interossei respond 
slightly. On right side, in addition to the response from the dorsal 
interossei there is very slight contraction of the palmar muscles. 
Markedly diminished reaction to galvanism is noted in the small 
muscles of the hands; no response in the palmar muscles (with the 
strength of current available, viz. one producing powerful response 
from normal muscles), including those of the thenar eminence on both 
sides. Dorsal interossei respond K.C.C. > A .C.C. 

The trunk and back muscles are practically normal, but there is a 
pronounced lateral curvature of the spinal column, involving the 
whole of the thoracic vertebrae, and with its convexity to the right. 

The low r er extremities, both in nutrition and function, are normal. 

Tactile sensibility is everywhere preserved, but there is blunting of 
painful impressions on both superior extremities; the analgesia, 
however, is not pronounced. There is complete loss of appreciation 
of thermal impressions all over both superior extremities, and there 
also appears to be a similar defect on the back of neck and trunk. 

Thermal impressions seem to be normally perceived on the face, but 
there appears to be some slight defect on the neck and trunk down to 
the third rib on right side, and again from, costal margin to about the 
level of the umbilicus ; on the left side the defect appears to be more 
definite, and extends all the wav down the neck and trunk to about 
t he level of Poupart’s ligament. 



23 


Knee-jerks are exaggerated, but no ankle-clonus can now be elicited 
as was possible a week ago. 

Recent trophic disturbances are seen, and scars, the result of 
similar past affections in connection with skin of fingers; also some 
sores about the elbows, looking as if they w r ere abrasion. Sphincters, 
thoracic and abdominal organs, present no clinical evidences of 
disease. 

The President thought the case very interesting, as hitherto he 
had been unable to find any records of syringomyelia associated with 
laryngeal paralysis. 

Mr. Spencer pointed out that the nuclei in the lower third of the 
bulb giving rise to pharyngeal and laryngeal fibres were in this case 
affected, whilst the fibres arising from the upper part of the spinal 
cord, going to the steruomastoid and trapezius, were untouched. 
Doubtless in other cases both groups were affected. But the possi¬ 
bility of one group being alone attacked confirmed the view of a 
distinct origin. 


Hyperostosis op Maxillary and other Bones causing Nasal 

Stenosis. 

Shown by Mr. Bowlby. E. P—, set. 43. She has noticed diffi¬ 
culty in nasal breathing and pain about eighteen months. She has 
been deaf to some extent for nineteen vears, but has not got worse 
lately. Now complains chiefly of the frontal pain and difficulty of 
nasal respiration. 

Present condition .—There is exophthalmos, especially on the left 
side. The left temporal fossa is occupied by a bony growth which is 
continuous with an enlargement of the left malar and superior maxillary 
bones. The left supra-orbital ridge is thickened. Both maxillary 
bones show overgrowth of their nasal processes, but the nasal bones 
themselves are not enlarged. There is a bony growth in the floor of 
each nostril, covered by smooth mucous membrane, and as large as a 
large almond. The turbinate bones also appear enlarged ; the palate 
bones and the alveolar processes of the maxillae are normal; the lower 
jaw is normal. Pulse 130. No tremors; occasional palpitations. 
Thyroid apparently normal. No definite evidence of syphilis, but 
has'“ had bad health ” since marriage, has lost five out of six children, 
and had an “ eruption on the face.” 

Mr. Spencer asked Mr. Bowlbv if be would trv ti’eatmeut by 



24 


thyroid extract on purely experimental grounds; it might do some 
good, and probably no harm. 


A Case of Paresis of Left Side of Larynx. . . 

Shown by Dr. Willcocks- J. T—, male, set. 37, came under 
observation about the middle of November. The alteration in his 
voice began last April, accompanied by dyspnoea and noisy inspiration. 
For the last six weeks.the voice has been worse. Patien$ had a penile 
sore followed by a rash about six years ago, and has also been a good 
deal exposed to vicissitudes of weather in his occujfotion. 

The view of the interior of the larynx is much, obscured by the 
epiglottis, which is very pendulous and almost immobile. The left 
arytaenoid is much restricted in its movements on phonation, while the 
right side moves freely. There is no definite evidence of intra-thoracic 
pressure, such as aneurysm of the aorta, and there is no local evidence 
of disease in the larynx itself. The questions raised as to the nature 
of the condition were whether the partial paralysis on thg left side was 
due to pressure on the left recurrent within the thorax (of which there 
is at present no definite evidence), or whether the restricted movement 
of the left arytaenoid depended on some local mischief,* such as adhe¬ 
sion, anchylosis, &c. 

The ViCE-PRESiDENT-remarked on the difficulty that such cases as ' 
these presented as to whether the immobility was due to mechanical 
fixation or paralysis,. 

Dr. Lack had examined the case very carefully, and considered the 
appearances were those of recurrent paralysis and not of mechanical 
fixation, . 


--- Varix or N^ivus of the Posterior Pawcial Pillar. 

Mr. Ernest Waggett showed a young pian who had for a few 
weeks complained of pain % and difficulty in swallowing. 

A knot of dilated veins were to be seen under the mucous membrane 
of the left posterior faucial pillar, connected above with a small 
nsevoid patch occupying the surface of the upper part of the corre¬ 
sponding tonsil.- Attention had recently been drawn to the throat 
by frequent examination for throat lesions, necessitated on account of 
the occurrence of a.suspicious sore on the penis. The symptoms 


- . 



25 


complained of dated from the occasion on which the patient for the 
first time became acquainted with the abnormality described, and his 
nervous demeanour warranted the symptoms being regarded as 
constituting a mere mental obsession. Presumably the abnormality 
was of congenital origin, or at all events one of very long standing, 
and, until recently, not noticed. No surgical procedure seemed 
called for. 

Mr. Waggett, in answer to the Chairman, said that he was 
unaware that any lesion could be described as “ a typical varix of the 
posterior pillar.” He had shown the case as an unusual curiosity, 
and considered the condition to be very unimportant intrinsically, 
and one merely forming the basis of a pharyngeal obsession in a 
nervous patient. 


A Case of Functional Hoarseness in a Woman aged 37. 

Shown by Dr. Hector Mackenzie. The patient had been under 
observation for over six months. About the end of May she was 
sent up from the country to Brompton Hospital, supposed to be 
suffering from pulmonary and laryngeal tuberculosis. She had then 
been hoarse or aphonic for some months. She said her throat was 
painful, and that she had difficulty in swallowing. The history was 
strongly suggestive of tubercle. In June, 1897, she was said to 
have brought up a large quantity of blood. Her father died of 
phthisis when she was seven years old, and her mother died of asthma 
and lung disease. One was quite prepared, therefore, to find both 
pulmonary and laryngeal disease. On examining the larynx, how¬ 
ever, one notiqed the extreme tolerance the patient showed to 
examination, so that there was not the slightest difficulty in at once 
getting a thorough and complete view. This contrasted strongly 
with the great irritability usually exhibited in tuberculous cases. 
The movements of the larynx were irregular, and on attempted 
phonation the cords did not come together, while the ventricular 
bands tended to overlap them. In adduction the left arytsenoid 
persistently occupied a position slightly posterior to the right. The 
mucous membrane was lax, but there was no sign of swelling or 
ulceration, and the cords were of a normal colour. No abnormal 
signs were found on examination of the chest. 

From the appearances the conclusion was arrived at that the 



26 


laryngeal condition was functional. The faradic current was applied 
to the hands, with the result that the voice became at once quite 
normal. The voice remained normal for some weeks. The patient 
was greatly relieved in her mind by the restoration of the voice, and 
improved considerably in general health, putting on nine pounds in 
weight in six weeks. There has been a tendency for the hoarseness and 
aphonia to recur, but the voice has always been easily restored to a 
normal condition by the application of the battery. Unfortunately 
the patient lives at a considerable distance from London, so that 
treatment has been carried out at some disadvantage. 

Dr. StClair Thomson was of opinion that the laryngitis was 
entirely functional. If the patient was put through certain vocal 
exercises with the laryngeal mirror in position, it was seen that the 
vocal cords were perfectly healthy and mobile, and that the ventricular 
bands were much hypertrophied. The patient, in fact, bad developed 
what the Germans call “ taschenbandsprache,” and he thought that 
with suitable exercises she might be induced to desist from speaking 
with her ventricular bands, and return to the natural use of her vocal 
cords. 

Dr. Grant suggested that she should constantly practise inspiratory 
phonatiou, which he had found useful in a similar case. 


Papilloma op Tonsil. 

Shown by Mr. dk Santi. The patient, a girl set. 19, suffered occa¬ 
sionally from enlarged tonsils. No other trouble. When examined a 
papillomatous growth was discovered on left tonsil. The tonsil and 
growth were removed together. 


Malignant Disease of Nose in an Old Man. 

Dr. Bond showed a case on whom radical operation on the nose and 
two operations for removal of glands had been performed, the patient 
having twice previously been shown to the Society and reports made 
on microscopic sections of tissues removed. 

In May, 1898, the nose was clear of disease, but there was a large 
mass of glands in left side of neck the size of a hen's egg. This was 
cut down upon and removed with all adherent structures, viz. much 
of the sternomastoid fasciae, the internal jugular vein, and the spinal 



27 


accessory nerve. The patient is now apparently free from malignant 
disease and in good health. 

The case is of interest since—1st, the left side of palate and left 
cord have become paretic; 2nd, the remnant of left sternomastoid 
and trapezius have wasted; 3rd, the general condition of the patient 
is good, after suffering from undoubted malignant disease for some 
six years. 

In reply to the Vice-President, Dr. Bond thought that the para¬ 
lysis of the cord might be explained by the fact that the vagus was 
considerably pulled about during the operation, and of course it was 
possible that pressure was being exercised upon it by a deeper set of 
glands. 


Recurrent Papilloma of Larynx in Girl of 18. 

Shown by Dr. Bond. This patient came to Golden Square about 
eight years ago with papilloma of larynx, which she seems to have 
had all her life. When first seen, in 1892, she had not, and was 
said never to have had, any voice. She was thought to be dumb, was 
said to have no laugh, and had considerable dyspnoea. Both cords 
were covered with papillomatous growth on the upper surfaces and 
edges, and there was a considerable amount below cords in front. The 
growths have been cleared away every few months during the last eight 
years. The patient has now a fair voice and the cords are almost clear, 
though it is some four months since the last operation. The case is of 
interest owing (1) to the great length of time during which the 
growths have persisted; (2) to the fact that the growths are recurring 
with less and less vigour as the patient gets older; (3) the fact that 
a child of ten could be thought to be dumb owing to the presence of 
these growths seems a novelty in laryngology. 

In reply to a question by the Vice-President as to whether Dr. Bond 
had used any local applications, the latter said that perchloride of iron 
grs. vij ad 3j had been used. 

Dr. Grant suggested the use of a 5 per cent, solution of salicylic 
acid and absolute alcohol. 




PBOCEEDINGS 


OP TUB 

LARYNGOLOGICAL SOCIETY OF LONDON. 


Annual General Meeting, January 6th, 1899. 


Henry T Butlin, Esq., F.R.C.S., President, in the Chair. 


Herbert Tilley, M D m ") 
William Hill, M D., ) 


Secretaries. 


Present—45 members and 3 visitors. 

The minutes of the Sixth Annual Meeting were read and con¬ 
firmed. 

Mr. Wyatt Wingrave and Mr. Milsom Rees were appointed 
Scrutineers of the ballot for the election of Officers and Council 
for the ensuing year; they reported the result of the ballot as 
follows: 

President. —F. de Havilland Hall, M D, 

Vice-Presidents. —A. Bronner, M.D.; W. H. Stewart, F.R.C.S.Ed. 

Treasurer. —Clifford Beale, M.D. 

Librarian. —J. Dundas Grant, M.D. 

Secretaries. —William Hill, M.D.; Lambert Lack, M.D. 

Council. —Edward Law, M.D. ; Walter Spencer, M.S. ; F. W. 
Milligan, M.D.; A. Bowlby, F.R.C.S.; Herbert Tilley, F.R.C.S. 

The following Report of Council was then read and adopted : 

The Council are pleased to report the continued prosperity of the 
Society, as evinced by the increase in the number of its members and 
the enthusiasm thrown into the work of the ordinary meetings. 

Thirteen gentlemen have been elected ordinary members during the 
past year, which including the nine honorary members brings the 
total membership of the Society to 135. 

The meetings of the Society have been well attended, the average of 
thirty-five attendances for the ordinary meetings during the past year 
being the highest hitherto recorded. 

IIBST 8KEIE8—VOL. VI. 


3 



30 


A special meeting of the Society was held July 13th, 1898, to 
discuss—1. Whether it was desirable to limit the membership of the 
Society. It was decided to add the words “and as proficient in 
laryngology ” to the present declaration on the nomination paper, and 
also that the name of each candidate for election should be brought 
before the Council before being submitted to the ordinary meeting for 
election. 

2. Whether, in deference to the opinions expressed by certain 
provincial members, it was desirable to alter the day of the ordinary 
meetings. A letter was sent to each member of the Society asking 
his opinion in the matter, and in accordance with the wishes expressed 
by the majority of those who replied, it was decided to hold the 
ordinary meetings on the first Friday of the month in place of the 
second Wednesday as heretofore. 

Bye-laws were passed giving effect to these alterations in the 
Rules, subject to confirmation at the next Annual Meeting (January 
6th, 1899). 

During the past year two gentlemen have resigned their connection 
with the Society, and we have to regret the loss through death of 
Mr. John Fallows, L.R.C.S.Ed., who perished in the wreck of the 
Mohegan. 

The Society especially deplores the early death of Professor A. A. 
Kanthack, lately of Cambridge University. Professor Kanthack 
was one of our original members, and made many valuable contribu¬ 
tions to our Proceedings. Before he determined to devote himself to 
pathology he turned his attention to laryngology, and, while in Berlin, 
studied with success some interesting points in the anatomy and 
pathology of the larynx. The results of his researches were published 
in ‘ Virchow’s Archiv.’ After he had given up clinical medicine and 
surgery he still continued his interest in matters connected with 
laryngology, to the good fortune of our Society, which loses in him 
one of its most active and able members. 

The Treasurer’s Annual Statement was then presented as 
follows: 

The actual receipts for the year are £152 5s. This amount in¬ 
cludes six subscriptions for 1899 and one for 1900. 

There are still fifteen subscriptions (£18 18s.) outstanding for 
1898, the majority of which are good. 

The seven outstanding subscriptions for 1897 (£7 7s.) mentioned 
in last year’s report have been paid during the current year. 

The actual expenditure is £111 10s. 6d., which leaves a balance for 
the year of £40 14s. 6d. This, added to the balance from 1897 
(£170 0s. 5 d.), leaves in the Treasurer’s hands a total balance of 
£210 14s. lid. 



31 


BALANCE-SHEET, 1898. 


Income. 

£ 9 . d. 

Balance from 1897 .... 170 0 5 
111 Subscriptions at £1 1*. . 116 11 0 
12 „ at £2 2s. . 25 4 0 

1 Compounding Fee at 

£10 10 *. 10 10 0 


Expendituee. 

£ *. d. 

Bent and Electric Light (20, 

Hanover Square) .... 31 10 0 
Adlard for Printing and 
Postage, May, 1897, to 

August, 1898 . 71 18 3 

Strangeways (Photo-engrav¬ 
ings) .10 0 

Professor Kanthack (re¬ 
funded for hire of micro¬ 
scopes) .1 10 0 

Indexing volume, 1898 

(Clarke).110 

Mathew (porter), 3 meetings 

(1897), 8 meetings (1898) . 1 18 6 
Petty Cash— 

Rogers (Carbolic Acid 
and Spirit) . . £0 10 6 

Receipt books (Cres- 

wiek).0 6 6 

Rank Charges . .006 

Baker (hire of micro¬ 
scopes) . . . . 0 12 0 

Dr. Tilley (secre¬ 
tarial expenses) . 0 11 3 
Hon. Treasurer’s ex¬ 
penses (postage, &c.)0 12 0 

- 2 12 9 

Balance in Treasurer’s hands 210 14 11 


Total . . £322 5 5 


Total . . £322 5 5 


The income for the 

year is . . ♦ £152 5 0 


The expenditure for 

the year is * . £111 10 6 


Audited and found correct, f PHILIP R. W. DE SANTI. 

January 6, 1899. \ L. HEMINGTON PEGLEIt. 

The following embodies the Librarian's Report, which was 
then read: 

I beg to report that since the last Annual Meeting I have received 
the following periodicals, and shall endeavour to have them bound in 
time for the next meeting: 

Revue Internationale de Rliinologie, Laryngologie, et Otologie (Natier). 

Revue hebdomadaire de Laryngologie, d’Otologie, et de Rliinologie (Moure). 

Arehivi Italiani di Laringologia (Massei). 

Belletino delle Malattie, Ac. (Grazzi). 

Archiv fur Laryngologie (Frankel). 

Journal of Laryngology (1). Grant). 

Laryngoscope (StClair Thomson). 

Annales des Maladies de l’Oreille, du Larynx, du Nez, et du Pharynx (Gouguen- 
lieim). 

Monatsschrift fur Ohrenheilkunde (Gruber). 

The Brooklyn Medical Journal (Vol. XII. from June). 








32 


Moure, Dr. E. J. De la Tracheo-thyrotomie dans le Cancer du Larynx (Travail 
de la Clinique de Moure). 

Moure, Dr. E. J. Sur les Traiteraent des Sinusites (Travail de la Clinique de 
Moure). 

Moure, Dr. E. J. Traitement de l*Oz&ne (1897). 

Catalogus Vau de Boekerij der Nederlandsche Keel-, Neuw-, eu Oorheelkundige 
Vereenigung, 1897 and 1898. 

Brighton and Sussex Medico-Ckirurgical Society Proceedings and Annual Report, 
1897-8. * 

Gesellsehaft der Ungarischen Ohren- mid Kehlkopfarzte Jahrbiicher, B ind III. 

Niederlandische GesCllsclnflt fur Hals, &c., 1897-8. 

Laryngologische Gesellsehaft zu Berlin Verliandlungen, Band VIII. 

American Laryn. Assoc. Transactions of the 19th Annual Meeting. 

Eighteen Monographs in reprint from Professor Gradenigo. 

Five Monographs in reprint from Professor Grazzi. 

Several microscopical specimens have been added to the Society’s collection, includ¬ 
ing Lupusof the Larynx (Professor Massei). 

Volumes bound as completed. 

The following bye-laws (vide Council Report) and sugges¬ 
tions from the Council were then discussed, and it was agreed 
that they should henceforth be regarded as rules of the Society : 

(a.) That the words “ and as proficient in laryngology ” be added 
to the nomination papers for future candidates. (Special meeting, 
July 13th, and Council meeting, October 7th.) 

(6) That the names of candidates for the membership of the 
Society shall be submitted to the Council before being placed before 
the ordinary meeting for ballot. (Council meeting, October 7th.) 

(c) That the ordinary meetings of the Society be held on the first 
Friday (instead of the second Wednesday as heretofore) in each 
month, from November to June inclusive (see Rule 19). (Council 
meeting, October 7th.) 

(d) That in Rule 3 the reference to provincial members be expunged. 
(Council meeting, December 2nd.) 


The Forty-sixth Ordinary Meeting of the Society was subse¬ 
quently held, the President being in the Chair. 

Chronic Nodular Laryngitis in a Boy aged Fifteen. 

Shown by Dr. StClair Thomson. This case was shown as 
illustrative of the nodular laryngitis of children described by 
Moure of Bordeaux. This latter observer, however, had attri¬ 
buted the condition to the straining of the voice, especially in 
children with treble voices who were compelled to sing seconds. 
In the present case there was no such history of voice abuse. 
He was brought with a history of a few months’ hoarseness, but 



33 


on further inquiry it appeared that he had been more or less 
hoarse since an attack of croup at the age of three or four. 
On examination it would be seen that there was a rounded 
thickening at the junction of the middle and anterior thirds of 
both vocal cords—the usual site of singers’ nodules,—but in the 
present instance, instead of being situated on the free margin, 
the nodules were on the upper surfaces. 

The cords were generally injected. Some adenoids had been 
removed in October last without relief, and since then he had 
been treated with insufflations of alum, sprays of iron, lactic 
acid, &c., without relief. Rest to the voice has been prescribed. 

Dr. de Havilland Hall thought that at the present time Dr. 
StClair Thomson would probably feel inclined to alter the nomencla¬ 
ture of the case, as the appearances were those of a chronic laryngitis, 
the nodules not being distinct. The case, in Dr. Hall’s opinion, 
resembled a chronic laryngitis due to nasal obstruction. 

Two Cases op Chronic Laryngitis, entirely limited to the 
Right Vocal Cord, and probably Tubercular in Character. 

Shown by Dr. StClair Thomson. One case was that of a 
young woman who had been hoarse for more than a year; the 
other was that of a man who had been hoarse for the last nine 
months. He had at one time lost flesh, but had latterly put on 
weight. In neither case were there any definite physical signs 
in the lungs, and there was no expectoration to examine. The 
temperature was not raised. In each case there was a red fleshy 
condition of the right vocal cord, and it was interesting to note, 
as confirmatory of Dr. Jobson Horne’s pathological researches on 
this subject, that the free edge of the cord was but slightly 
affected, while the granulations on the cord appear to originate 
from the mouth of the ventricle of Morgagni. The diagnosis 
was arrived at by a process of exclusion. Both cases were 
decidedly improving under general treatment, although they 
lived in London. 

Dr. Hall thought that the evidence in favour of a tuberculous 
laryngitis was not decisive in Dr. StClair Thomson’s second case. 

Dr. Clifford Beale observed that the limitation of the affection 
to one or the other side of the larynx must always be a strong point 
in diagnosis in cases of doubtful tubercular infiltration where evidence 
of other specific diseases was wanting. 



34 


Dr. Herbert Tilley agreed with Dr. Thomson in looking upon 
these cases as tubercular. The speaker had shown at a former meeting 
a man who had tubercular ulceration of the tip of the epiglottis 
which had been almost completely cured by lactic acid applications and 
curetting. He had had him under observation nearly twelve months, 
and when he saw him two days ago he noted a marked granular 
congestion of the left vocal cord and vocal process, the rest of the 
larynx being normal. There was well-marked tubercular mischief in 
both pulmonary apices. 

Dr. StClair Thomson in reply said he had been led to the 
diagnosis of tuberculosis in these cases by the one-sidedness of the 
affection, the absence of symptoms of new growth or syphilis, the 
chronic nature of the complaint, and the situation and appearance of 
the fleshy granulations. It was hardly likely that a simple chronic 
catarrh would remain limited to one vocal cord for a whole year, and 
that it would not disappear completely under vocal rest, such as 
these patients had tried. Recovery—and these two cases were im¬ 
proving—was not necessarily opposed to this view, for tuberculosis 
of the larynx, as of other parts, got well, and in some instances even 
without treatment. 

Sir Felix Semon said that whilst fully recognising the diagnostic 
importance of isolated congestion of one vocal cord—a point, in fact, 
which he had always emphasised himself—he should not go so far as 
to make a definite diagnosis from this appearance alone. In his 
opinion the discovery of such an isolated congestion ought to draw the 
observer’s attention to the possibilities of tuberculosis, malignant 
disease, and syphilis, and no doubt in the majority of cases one of 
these affections would be found later to develop in the congested 
part; on the other hand, however, he looked back personally upon a 
small but definite number in which such an isolated congestion was 
not followed by any further untoward developments. He should not, 
therefore, pin his faith upon the discovery of the appearance named 
alone, but simply look upon it as a valuable warning signal. 


Case op Cure of Chronic Empyema of Maxillary Antrum by 

Radical Operation. 

Dr. Scanes Spicer showed this patient, operated on by him 
six weeks ago. 

A. B—, set. 23, eight years ago had attacks of pain and re¬ 
current abscesses for two years over region of left upper first 
molar. Six years ago this tooth was removed, and there has 
remained a fistulous track high up on anterior wall of gum, dis¬ 
charging foetid pus on and off ever since. In October, 1898, 
increase of swelling, pain, and foetor in left nostril. No loose 
bone could be detected with a probe. Patient, actively engaged 



35 


in business, pressed for an immediate cure. Exploration was 
advised under an anaesthetic, and permission obtained to remove 
any sequestrum, or to deal with the antrum as might be deemed 
necessary. 

On November 29th this was done. A large gap was found 
in the anterior bony wall of superior maxilla of irregular shape, 
and in tbe membranous structure filling this gap were small, 
loose, thin, bare scales of bone. The probe and finger easily 
passed into the antral cavity, which was filled with thick inspis¬ 
sated pus, cheesy debris, also polypi and granulation tissue, 
with indescribable foetor. The cavity was thoroughly cleaned 
out, and the naso-antral bony wall found to be similarly absorbed; 
tbe fiDger passed into the antrum with the slightest pressure met 
the finger passed into the corresponding nasal fossa, breaking 
through the membranous portion in the inferior meatus region. 
The opening was enlarged with finger and curette so as to admit 
a large drainage-tube, which was cut off near the nostril, and 
the tube secured by silk threads tied behind each ear. The 
muco-antral opening was sutured (apparently not sufficiently so, 
as this incision has not yet healed). 

The patient’s doctor carried out all subsequent irrigation and 
drainage by this nasal tube, and after its removal in five days 
through the naso-antral opening. 

Patient reports there has been no pus or foetor since the end 
of the third week. 

The case is interesting for the following reasons : 

(1) It exemplifies the polypoid proliferation and caseation of 
retained pus, so usually found in chronic antral empyema. 

(2) There was a co-existence of a rarefying osteitis of superior 
maxilla with necrosis of small scales of bone, rendering use of 
trephines, gouges, or Krause’s trocar unnecessary to open and 
drain the antrum. 

(3) The cure of foetor and suppuration of eight years’ standing 
was rapid, and performed well within the time allowed the 
patient by his governing board. 



36 


Specimen op Dead Bone, Polypi, and Debris removed prom a 
Case op Chronic Empyema op Antrum cured by Radical 
Operation in Eight Weeks. 

Dr. Scanes Spicer showed this specimen. The patient from 
whom it came, E. P—, female, set. 18, had complained of uni¬ 
lateral nasal stench and evacuation of foul crusts for nearly 
eighteen months. This stench was relieved by the evacuation 
of a crust, and then gradually increased for two or three days, 
until another crust was discharged. All teeth were present and 
apparently sound. Diagnosis confirmed by transillumination. 
Patient’s parents had brought her from the north of England 
for cure, and were staying in London for that purpose. Radical 
operation as in last case was advised and performed. The 
patient returned after eight weeks with no fcetor or suppuration, 
and several reports up to Christmas, 1898, state there is no re¬ 
currence of foetor or pus as before. 

The presence of the sequestrum (suspended in the bottle by a 
silk thread), and the polypi, &c., which filled the bottle at time 
of operation, indicate the extreme improbability of cure being 
effected by tooth socket tube. 

Dr. Scanes Spicer also showed the temperature chart of 
another patient on whom he had performed the radical opera¬ 
tion in St. Mary’s Hospital for cure of chronic empyema of 
antrum, to illustrate that the modern form of operation was by 
no means the severe and dangerous procedure which had been 
stated. On no day had the temperature subsequent to operation 
exceeded the normal by a degree. The patient will attend at a 
subsequent meeting. 


Further Report op Case op Sarcoma op the Nose shown at 

November Meeting. 

Dr. Barclay Baron (Bristol) reported that he had sent a piece 
of growth removed from his case of sarcoma of the nose shown at 
the November meeting to the Morbid Growths Committee. 
They reported it to be an alveolar sarcoma, and showed sections 
of it at the December meeting. The growth rapidly increased 



37 


both within the nose and externally, displacing the eye outwards. 
At Dr. Baron’s request, Mr. Charters Symonds kindly undertook 
its removal, full view of the growth being obtained by enlarging 
the opening in the superior maxilla made by the disease. The 
dura mater was found to be exposed in one place, the bone 
covering it having been destroyed, and it would, therefore, have 
been a dangerous procedure to attempt to curette the interior 
of the nose without seeing what was being done. 

The patient made a quick recovery, and there is very little 
disfigurement. 

Mr. Symonds, in describing the operation, said that when he first 
saw the case in the wards at Guy’s Hospital it seemed to him to 
presently clinically the ordinary appearance of a sarcoma of the 
nasal fossa. The elastic projection at the inner corner of the eye 
which had been noticed in November had projected and displaced 
the eye both upwards and outwards. In respect to the various 
opinions expressed as to the nature of this swelling, he carefully 
exposed it and found it to be composed chiefly of soft growth. It 
was limited by the stretched periosteum, and between the two was 
some thick nasal mucus, an arrangement which would account for 
the sense of fluctuation. The incision was carried down to the ala 
of the nose and another outwards below the orbit, then with a 
keyhole saw a part of the nasal process of the superior maxilla, 
and of the floor of the orbit and anterior wall of the maxilla, were 
removed. The aperture thus obtained, together with that made by 
the growth, which had destroyed the lachrymal bone and a part of 
the ethmoid, gave a large opening into the upper part of the nasal 
cavity. Through this the entire growth was removed. A sterilised 
pad was plugged into the posterior naris. On removing the growth 
the dura mater, as Dr. Baron had mentioned, was exposed; this was 
not due to the forcible removal of bone, for the growth itself lay in 
contact with this membrane. That it was dura mater was clear 
from its bluish-white colour and its density; thus it was obvious that 
a large part of the ethmoid had been destroyed, and that the starting- 
point of the new growth was somewhere in the mucous membrane 
covering this bone. The mucous membrane round the area was cut 
away with scissors, including the middle turbinal, and the edges of bone 
around the site were also removed by cutting forceps. The maxillar y 
sinus, which had been slightly opened, was freely laid bare by removing 
the inner wall. The wound was sutured, and the patient went home in 
a week. The eye returned nearly to the normal position, and the move¬ 
ments were unaffected and there was no diplopia. The microscopic 
examination which was made by the surgical registrar at Guy’s 
Hospital, Mr. Fagge, confirmed the report of the Morbid Growths 
Committee that it was alveolar sarcoma. The structure was 
identical in all parts of the tumour: it may be added that the growth 
extended from the nostril to the pharynx, but did not occupy the 
antrum. 



38 


In his report Mr. Fagge stated that the microscopic appearances 
were those not uncommon in neoplasms of the nasal fossae. 

Mr. Symonds added that he usually, in operations upon the upper 
jaw, preferred, instead of the set procedure usually recommended, to 
use a keyhole saw, and surround the growth, leaving any portion 
that appeared to be quite healthy, for in this way more or less of the 
palate in some cases might be preserved. 


Specimen op Peg removed from Maxillary Antrum through 

Ostium Maxillare. 

Shown by Or. Watson Williams. 


Lupus of Nose. 

Shown by Mr. Wyatt Wingrave. Female aet. 30 complained 
of nasal obstruction with discharge of five years’ duration. Four 
months ago the floors of both nasal fossrn were found occupied 
by granulations, which extended as high as the middle turbinals. 
Large quantities were removed by sinus forceps and curette, 
only to be followed by rapid recurrence. They are much less 
numerous now, but have involved the turbinals. The cartila¬ 
ginous septum is perforated, and there is some evidence of 
old pathological changes in the soft palate. The larynx is 
normal. 

Owing to the large amount of granulation tissue, the existence 
of severe pain, and evidence of caries on probing, syphilis was 
suspected, but no history could be obtained, and she did not 
respond to specific treatment. The tissue on examination gave 
no evidence of tubercle bacilli, but presented the usual features 
of lupus. 

She has lost one brother and one sister from consumption, 
and suffers from lung trouble herself. 

Mr. Cresswell Baber and Dr. Thomson thought the appearances 
and fcetor resembled syphilis. 

Dr. Watson Williams suggested that in the discussion of such 
cases the terms lupus and tubercle should be used synonymously, as 
they were essentially identical diseases, and differing only in their 
chronicity and mode of growth. 

Dr. be Havilland Hall upheld'this restriction of nomenclature. 



39 


Tubercular Laryngitis in a Dwarf. 

Shown by Dr. Herbert Tilley. Patient is a female set. 45, 
height 3 feet 2 inches. In February, 1898, she had an attack 
of influenza and bronchitis, since when she has had a chronic 
cough and hoarseness. 

The larynx is very small, the vocal cords being only about 
15 mm. long; both of them were ulcerated, also the right vocal 
process. 

Tubercle bacilli had been found in the expectoration. 


Two Cases of Epithelioma and One of Sarcoma of the Larynx 

TREATED BY ThYROTOMY, AND KEEPING WELL TWO AND A HALF 
YEARS, ONE AND A HALF YEARS, AND SIX MONTHS RESPECTIVELY 
AFTER OPERATION. 

Shown by Sir Felix Semon. Case I (already described by 
the patient himself, Mr. C. Fleming, L.R.C.P., &c., in the ‘ Lancet ’ 
of October 16th, 1897).—Medical man, get. 47, noticed in June, 

1895, slight huskiness, which steadily increased. In November 
a whitish, pointed, sessile thickening was seen in the middle of 
left vocal cord. The cord itself congested, its movements free. 
In May, 1896, voice much worse, no other symptoms. Posterior 
part of left vocal cord generally thickened, slightly cedematous, 
no distinct growth visible, movements of cord still free. Two 
months later conditions unchanged. Proposal of exploratory 
thyrotomy supported by Mr. Butlin. Operation on - July 21st, 

1896. Left vocal cord was found to be tumefied in its entire 
length, and was removed with an area of healthy tissue around 
it. Mr. Shattock pronounced the growth as a typical squamous- 
celled carcinoma in the early stage, with little homy transfor¬ 
mation. Convalescence took place without any complications, 
and the patient resumed his practice within a month from the 
performance of the operation. Since then perfectly well. Voice 
very good. On laryngoscopic examination a marked cicatricial 
ridge is seen in the position of the former left vocal cord. 

Case II.—Naval officer, set. 57, sent by Dr. Clay of Plymouth 
on March 30th, 1897, on account of increasing hoarseness. Both 



40 


vocal cords very irregular, considerably thickened and congested, 
particularly in their anterior two thirds. Their movements free. 
Differential diagnosis between chronic laryngitis and malignant 
disease doubtful. The latter suspected on account of the 
unusual amount of thickening, and expectoration on one occa¬ 
sion of slightly blood-tinged sputum. Two months later hardly 
any change. Consultation with Mr. Butlin, who shared my 
suspicion of malignancy. Intra-laryngeal removal of some 
small projecting pieces of the general thickening for micro¬ 
scopic examination. Mr. Shattock’s report on the largest of 
these ran as follows :—“ I took the greatest pains to cut the 
section of the small flat piece of tissue at right angles to its 
slightly uneven and granulated surface. The result was wholly 
successful, and then I saw at once that the growth is a squamous- 
celled carcinoma. It is so marked that there can be no two 
opinions about it. The growth has a slight tendency to be horny, 
i. e. less malignant than other forms.” Operation on May 31 st, 
1897. Thorough removal of both vocal cords, scraping of bases. 
Uninterrupted convalescence. Two months afterwards granula¬ 
tion tumour in anterior commissure, which was removed intra- 
laryngeally. Patient has enjoyed good health since operation, 
but the voice of course has been reduced to a whisper, as both 
vocal cords had to be removed, and as the cicatricial ridges 
which have been formed do not compensate for their loss. 

Case III.—Private gentleman, set. 69|, sent by Dr. Branfoot, 
of Brighton, on July 15th, 1897, on account of gradually in¬ 
creasing hoarseness, which had already lasted several months. 
A reddish,- irregular, mammillated, broad-based growth occupied 
the greater part of the much congested right vocal cord, beneath 
which it seemed to pass into the subglottic cavity. Mobility of 
cord, if at all, certainly not much impaired. Differential dia¬ 
gnosis doubtful between fibroma and malignant new growth. 
Microscopic examination (Mr. Shattock) of intra-laryngeally 
removed fragment showed the tumour to be a sarcoma, nowhere 
undergoing fibrous transformation, but in part the seat of leuco¬ 
cytic infiltration, and altogether apparently of a highly malignant 
type. Thyrotomy on July 21st, 1898. The thyroid cartilage 
was completely ossified, and had to be divided by sawing. The 
larynx having been opened, it was seen that the growth was 



41 

partly pedunculated, but in part infiltrated the anterior part of 
the right vocal cord. The growth and the anterior half of the 
right vocal cord were removed and the basis scraped. The 
posterior part of the right vocal cord was stitched to the right 
ventricular band. The whole wound was immediately closed 
after operation, and only a small drainage-tube left in its lowest 
part. This, too, was removed on the second day after operation. 
The temperature rose in the evening of the first day to nearly 
101°, and came only very gradually down until the normal was 
reached on the sixth day. In all other respects uninterrupted 
progress. The patient returned home a fortnight after operation, 
and ever since has been perfectly well. His voice has an almost 
normal character, and is still improving in strength. 

Mr. Spencer asked for information on three points: (1) What 
antiseptics were used. (2) Whether the thyroid cartilage was always 
sutured. (3) Whether the muscles of the neck were sutured together 
before closing the skin wound. 

Sir Felix Semon (in replying to Mr. Spencer) said that his 
methods of operation had been described in the ‘ Lancet ’ of 1894, 
and in the ‘ Archiv fur Laryngologie ’ for 1897; that he always 
rubbed iodoform into all the tissues before closing the wound; that he 
sutured the thyroid cartilage by means of catgut or silver ligatures; 
that he now closed the wound in its entire length, withdrawing the 
sponge cannula immediately after the operation, and only left in its 
lowest part a drainage-tube; that he was not quite certain whether 
this modification represented a real improvement, as he thought he 
had observed that the temperature kept up longer than when the 
lower third of the wound, as previously, was left open for three or four 
days, and that he might possibly revert to the latter method. He had 
only once had to suture the muscles, and this was in a case of tuber¬ 
cular disease of the larynx, in which the wound had become infected. 
He added that the appearance of a tumour in the anterior commis¬ 
sure of the vocal cords was—to conclude from his own experiences— 
rather suggestive of the formation of a granuloma than of a recurrence 
of the malignant growth; and secondly, that a recent communication of 
Professor Chiari’s in the * Archiv fur Laryngologie ’ had shown him 
that the idea of painting the laryngeal mucous membrane with a 
20 per cent, cocaine solution to diminish bleeding and reflex irritation 
had not originated with him, as he had thought, but that he had been 
forestalled with regard to this by the late Professor Billroth. 



42 


Specimens. 

Dr. Milligan showed the following specimens: 

1. Lymphangioma of Yocal Cord. 

2. Laryngeal Papilloma. 

3. Naso-pharyngeal Fibro-sarcoma. 

4. Large Exostosis removed from Maxillary Antrum. 


Multiple and Diffuse Papillomata of the Larynx. 

Dr. Jobson Horne showed a case of multiple papillomata 
occurring in the larynx of a woman get. 22. Change of voice 
had been noticed by the patient’s friends for upwards of eighteen 
months, gradual in onset,—at first only a roughness of voice, which 
had developed into complete hoarseness. Difficulty in respiration 
had been experienced after physical exertion, especially after 
going up and down stairs, and after prolonged talking. Latterly 
the patient has been distressed by nocturnal attacks of dyspnoea 
on first lying down, but had not been disturbed by them in the 
course of the night. It was on account of these attacks that 
the patient first sought advice. 

Laryngoscopic examination showed a subcordal mass of papil¬ 
lomata attached in the neighbourhood of the anterior commissure, 
which when driven upwards during phonation occupied more 
than half the glottis. Diffuse papillomata also covered both 
cords. 

The subcordal mass was removed, and the attacks of dyspnoea 
had ceased, and some improvement had taken place in the voice. 

The growth under the microscope was found to be a simple 
papilloma. 


Tubular Epithelioma of the Nose. 

Dr. Bronner (Bradford) showed a microscopic specimen of a 
tubular epithelioma of the nose. The growth was of the size of 
a large pea, and had been removed from the nasal mucous mem¬ 
brane just above the anterior part of the lower turbinated bone 
of a man of forty-seven nearly ten years ago. 



48 


There was a history of slight nasal obstruction and frequent 
slight haemorrhage from the nostril. The growth had been 
removed by scissors, and the base then thoroughly burnt with 
the galvano-cautery. There has been no recurrence. The 
report of the Clinical Eesearch Association was :—“ The growth 
is malignant, of an epithelial type; it may be classed with the 
tubular epithelioma. At the periphery beneath the mucous 
membrane tubules with a definite lumen can be seen. 

Mr. Butlin thought it would be very difficult to decide whether it 
was an adenoma or carcinoma, and suggested that sections should be 
made by the Morbid Growths Committee. 


Case op Eight Eecurrent Paralysis with Paresis op Trape¬ 
zium, Sterno-mastoid, and Palate, with Slight Ptosis and 
Facial Paralysis, all on the same Side. 

Shown by Mr. E. Lake. This patient, an intelligent man set. 36, 
was sent to me for an affection of the larynx. The following 
history was obtained. Eleven years ago he was stabbed over 
right eye, and had subsequently Jacksonian (?) epilepsy, the last 
attack twelve months ago. No history of syphilis. He has had 
a cough since August, 1898, and loss of voice for three weeks, 
dysphagia, and food going the wrong way for two months. His 
right shoulder is lower than the left; wasting and want of 
power are noticed in the trapezium and sterno-mastoid, some 
paresis of palate; reflex present on both sides, the same with 
pharynx. Left pupil large, and only reacts slightly to accom¬ 
modation, but not to light. Slight right ptosis and loss of power 
in the right labial muscles. No Eomberg’s symptoms. The 
patient has been taking 90 grains of iodide of potash daily, and 
had mercurial inunctions every other day for the past six weeks. 
The dysphagia is getting worse; the voice is now, and has been 
for the last week, nearly normal. 


Growth of Left Vocal Cord in a Man aged Thirty-two. 

Shown by Mr. C. A. Parker. History .—Voice began to be 
slightly husky about the middle of August last. The huskiness 
varied at first, but has been getting gradually worse during the 



44 


last eight weeks. The patient is a tea inspector, and he is con¬ 
stantly inhaling tea dust. There is no loss of flesh and no 
history of syphilis. 

When first seen on October 14th there was a large growth 
of left vocal cord, especially affecting the anterior half of the 
cord, where there appeared to be a superficial slough. From its 
appearance it seemed to be a simple papilloma. The cord was 
then moving freely. 

On October 28th the anterior portion of the growth was 
removed and examined microscopically by Dr. Hewlett, who 
reported it to be a papilloma. Since then the growth has 
recurred to a great extent, and now looks more an infiltration of 
the cord than a growth attached to the cord; meanwhile the 
movement of the cord has become impaired. 

The case is before the Society for suggestions on the diagnosis 
and treatment. It seems at present to be something more than 
a simple papilloma, and in spite of his age (thirty-two years) one 
is inclined to think it may be a case of early malignant disease. 

He has taken 10 grains of iodide of potassium three times a 
day for six weeks without the slightest improvement. 

Sir Felix Semon thought it looked very like malignant disease, 
and advised thyrotomy. 

Mr. de Santi expressed similar views. 


After History of a Case of Recurrent Paralysis of Vocal 

Cord. 

Dr. Willcocks, who showed the patient at the December 
meeting, reported that he had since had pneumonia, and died 
suddenly of intra-thoracic haemorrhage, pointing with little doubt 
to aneurism which during life had presented no physical signs. 




PKOCEEDINGS 

OF THE 

LARYNGOLOGICAL SOCIETY OF LONDON. 


Ordinary Meeting, February 3rd, 1899. 

F. de Havilland Hall, M.D., President, in the Chair. 


William Hill, M.D., 
Lambert Lace, M.D., 


| Secretaries. 


Present—31 members and 3 visitors. 

The minutes of the previous meeting were read and confirmed. 

The President briefly thanked the members of the Society 
for the honour they had conferred on him in electing him to 
preside at their meetings. He promised that he would spare 
neither time nor energy in furthering the interests of the Society, 
and in endeavouring to maintain the high standard of his dis¬ 
tinguished' predecessors in the chair. 

The President announced that at the Council meeting just 
held it had been decided, owing to the large number of clinical 
cases shown, to increase the number of the electric lamps. To 
facilitate the reporting and enhance the value of the proceed¬ 
ings a shorthand writer would attend at the next meeting. It 
was decided further that one meeting, viz. May 5th, should be 
entirely devoted to a discussion on “ Asthma and its relation to 
diseases of the upper air-passages.” 

FIRST SERIES-VOL. VI, 


4 



46 


The following gentlemen, their names having been previously 
submitted to the Council, were nominated for election at the 
next meeting: 

H. Fitzgerald Powell, M.D.(St.And.), F.R.C.S.Edin. Practice, 
Laryngology and its branches. 

Mark Purcell Mayo Collier, M.S., F.R.C.S. Practice, Laryngology 
and Surgery. 

St. George Caulfield Reid, M.R.C.S. Practice, General and Special. 

Dr. Lack was elected a member of the Morbid Growths 
Committee in place of the late Dr. Kanthack. 

The following cases and specimens were shown. 


Slight Defective Abduction of the Right Vocal Cord. 

Shown by Mr. H. Betham Robinson. F. E—, set. 37, came 
on December 22nd, complaining of increasing weakness of 
his voice in singing for some three months, with some pain on 
the right side of his neck. There was no sore throat and no 
cough, but occasionally he had night sweats. 

His occupation is that of clerk, but he sings a good deal. 
No history of syphilis. 

His father had disease of the knee-joint after an injury ten 
years before; for this it was excised and subsequently ampu¬ 
tated, from which operation he succumbed. 

On examination there was slight impaired abduction of the 
right cord with some injection of both cords; there was no other 
intra-laryngeal lesion. On the right side of the neck, below the 
posterior part of the right ala of the thyroid cartilage, was some 
fulness and slight tenderness on pressure. There was no 
evidence of any nerve lesion. The treatment was iodide of 
potassium and benzoin inhalations. 

On January 19th his condition seemed decidedly better as far 
as the external fulness was concerned, and he remained in the 
same state when shown. 

The lesion was regarded as an extra-laryngeal infiltration 
mechanically interfering with the action of the right cord through 



47 


involvement of muscle or hindrance of proper movement at 
crico-arytaenoid articulation. This, in spite of its subsidence 
under iodide of potassium, was regarded as probably tuberculous. 

Dr. Dundas Grant considered that the defective movement of the 
right cord was due to mechanical fixation. 

Mr. Milsom Rees thought that the appearance of defective abduc¬ 
tion arose from a distortion of the larynx, the epiglottis being twisted. 

The President remarked the right cord showed evidence of inflam¬ 
matory changes; and 

Mr. Robinson, in reply, said that both cords were congested when 
the case first came under observation. 


Tumour op Right Vocal Cord. Case after Removal. 

Shown by Mr. H. Betham Robinson. F. G—, aet. 48, was 
exhibited at the meeting on June 8th, 1898, with a small sessile 
swelling on the right cord at the junction of its anterior third 
with the posterior two thirds. It was convex, of a whitish 
colour, and compressible. Its removal was advised. This was 
accordingly done effectively with Grant’s forceps under cocaine 
about ten days later. The tumour was very soft, and smashed 
up in the forceps, exuding a mucous fluid; thus no microscopical 
examination could be made. Its nature was either a cyst con¬ 
taining mucus or a myxoma. 

The patient had now complete absence of symptoms, and on 
examination his right cord would be pronounced normal. 

The President congratulated Mr. Robinson on the excellent result. 


Paralysis (? Complete) of Left Cord. 

Shown by Dr. Fuuniss Potter. The patient, a man aet. 48 
years, came under observation on the 3rd of January last, 
complaining of hoarseness, which had come on gradually seven 
weeks previously. History of a “ sore ” twenty years ago, but 
none of rash, sore throat, or other sign indicating constitutional 
infection. Always had good health. 

On examination the left cord was seen to be fixed and prac¬ 
tically immoveable in a position rather external to a line midway 



46 


between the extremes of adduction and abduction. The left side 
of the soft palate was markedly paretic, there was some diminu¬ 
tion of sensation, chiefly along the lower border; the tongue when 
protruded deviated to the left side; no affection of trapezius, 
sterno-mastoid, or orbicularis oris. There were slight lateral 
nystagmoid movements of the eyes; the knee-jerks appeared to 
respond rather too readily. Examination of the chest gave 
negative result. Patient had been taking ten-grain doses of 
iodide of potassium for the last month, but with no appreciable 
effect. 

Sir Felix Semon asked why Dr. Potter hesitated to call the case 
complete recurrent paralysis. He regarded it as a perfect case, the left 
cord being in the typical cadaveric position. 

Dr. Herbert Tilley thought that such cases as these tended to 
uphold clinically what had been experimentally proved by Horsley and 
Beevor, viz. that the nerve-supply of the palate, contractors of the 
pharynx, and probably the muscles of the larynx, was the spinal 
accessory. This was the fourth case of the kind the speaker had seen 
within two months, and he thought it was very doubtful if the facial 
nerve innervated the palate at all, as had until recently been taught in 
our schools. 


Case op Ulcer op Nasal Septum. 

Shown by Mr. Bowlby. Female aet. 32, married, and with 
several healthy children. No history of tubercle or syphilis, and 
no evidence of either. Had some swelling of the septum nasi 
about a year ago. This remained covered by normal mucous 
membrane for six or eight months, and recently has become 
ulcerated. There is now an ulcer about the size of a large pea 
at the upper part of the cartilage of the septum. It is not pain¬ 
ful. There is no bare bone and no other disease of the nose. 
The ulceration progresses very slowly in depth, and not at all in 
extent. No tubercle bacilli have been found. 

Dr. Dundas Grant considered the perforation more irregular in 
outline than the typical perforating ulcer, and more suggestive of 
tubercle or lupus. This idea was confirmed by the patient’s tint and 
the injurious influence of cold weather. 

Dr. StClair Thomson agreed that the ulceration was situated too 
far in the nose to be a simple traumatic perforation from the irritation 
of dust or nose-picking. He thought that against the suggestion of 
syphilis was to be placed the consideration that the disease had lasted 



49 


a considerable time without the progress which is to be found in 
specific affections. The characteristic odour of nasal syphilis was also 
absent. He thought the indolent thickened margin and the situation 
both suggestive of tuberculosis. He had shown a similar case at the 
Clinical Society, where in portions of the removed granulations he had 
discovered typical giant-cells. In his case it had been objected that 
tubercle bacilli were not found in the sections, although carefully 
sought for. But as his patient had been treated, with tuberculin and 
reacted strongly, he thought his diagnosis fully confirmed. Tuberculin 
might be used in the present case both for diagnostic and curative 
purposes. 

Mr. Waggett said that the history of previous bilateral swelling 
and the presence of the much thickened and inflamed edges differen¬ 
tiated the ulcer in Mr. Bowlby’s case from what was generally known 
as the perforating ulcer. The latter was characterised throughout its 
course by an atrophic process. 

Dr. Scanes Spicer thought that the ulceration was probably syphi¬ 
litic in nature, in spite of the absence of a characteristic stench. 

The President said it was certainly not a case of ordinary atrophic 
ulceration. He had observed such cases from the commencement, and 
in one case had been, able to predict a perforating ulcer. There was 
never previous thickening of the mucous membrane, but always 
atrophy. 


Specimen of Abscess of the Lakynx. 

Shown by Dr. de Havilland Hall. The larynx shown was 
removed from a female aet. 17. The patient was admitted into 
the Westminster Hospital on December 17th, with acute Bright’s 
disease and lobar pneumonia of septic origin. Shortly after 
admission she became hoarse, and suffered from dysphagia. A 
satisfactory laryngoscopic view was impossible on account of the 
patient’s condition. She died December 24th. At the necropsy 
about an ounce of dark green foetid pus escaped from around 
the larynx, the cartilages of which were quite necrosed; the 
abscess had recently perforated the larynx through a small 
aperture. Both lungs were pneumonic. There were old thin 
pericardial adhesions. The cardiac valves were normal with the 
exception of the mitral, round which was a ring of large coarse 
vegetations. In the right lobe of the liver was a hydatid 
cyst, the size of an orange, containing hydatid membrane and 
thick olive-greenish viscid pus. The rest of the liver was 
febrile. The spleen and kidneys sliow r ed the ordinary changes 
of toxaemia. 



50 


Infant exhibiting a Peculiar G-runting Inspiratory Sound. 

Shown by Dr. William Hill. The noise was practically con¬ 
tinuous, being just as well marked during sleep as at other times, 
but there was an occasional intermission during one or two 
respirations. The grunt was not affected by retracting the 
palate, and was, he believed, produced in some part of the larynx 
and not in the trachea. He had not passed a Schroetter’s tube 
into the larynx, but such a measure would serve to differentiate 
between a tracheal and laryngeal sound. He thought the case 
belonged to the group described by Dr. Gee and Dr. Lees, and 
more recently by Dr. Lack, and he accepted the latter’s explana¬ 
tion (which was an amplification of Dr. Lees’ theory of the in¬ 
fluence of the epiglottis) that the vestibular structures were here 
exceptionally lax, and collapsed during inspiration. This could 
be seen by the aid of the mirror. The sound was unlike those 
produced in the glottic region, and there was no reason to suspect 
stenosis from paralysis, or from any intra-laryngeal swelling. 

The President did not consider the case agreed in all particulars 
with those described by Dr. Gee as cases of respiratory croaking in 
infants. 

Sir Felix Semon thought that in this case the stridor was produced 
in the trachea, or at any rate below the larynx. He alluded to some 
recent papers pointing to enlargement of the thymus gland as the 
possible setiological factor in such cases. He thought intubation would 
certainly settle the point as to whether the stridor arose in the larynx. 

Mr. Milsom Rees remarked that the stridor ceased when the child 
cried, and asked if it continued in sleep. 

Dr. Lack looked on the case as one of the milder forms of the 
affection commonly known as congenital laryngeal obstruction, and 
due, as in all such cases, to collapse of the vestibule aided by curling 
of the epiglottis. Where there was very marked obstruction the in¬ 
spiratory sound was "like a chicken crowing,” and occasionally asso¬ 
ciated with slight expiratory stridor. In less marked cases like Dr. 
Hill’s the stridor was of a “ purring,” “ grunting ” character, with no 
expiratory sound. In all cases of tracheal obstruction due to pressure 
of an enlarged thymus expiratory stridor only was present, or at any 
rate much more marked than inspiratory. 

Dr. Hill said the stridor continued during sleep. He would give 
the child chloroform and ascertain if the stridor continued then, and 
intubate with a long tube so as to exclude a laryngeal origin for the 
sound. Personally he thought it appeared to arise from the parts above 
rather than below the larynx. 



51 


Case op Papillomata op Larynx. 

Shown by Mr. Richard Lake. Patient has been hoarse for 
five years, but worse since an attack of typhoid fever last year. 
There is now a large papilloma in the anterior commissure spring¬ 
ing from the right vocal cord, and also one of moderate size on 
the left vocal process. 


Man j:t. 51 , shown at the November Meeting as a Case op 
Hypertrophic Laryngitis of Doubtful Nature, which is 
now seen to be Tuberculous. 

Shown by Dr. StClair Thomson. The history of this case 
is described in the ‘ Proceedings ’ for November, 1898, p. 2. At 
that period the patient presented no evidence of pulmonary 
tuberculosis, and some suspicions were expressed that the case 
was malignant, and it was advised that a portion of the growth 
should be removed for microscopic examination. This was 
done, but with a negative result. The patient was put upon 
large doses of iodide of potassium. An ulcer, very suspicious of 
tuberculosis, appeared on the epiglottis, and the patient rapidly 
wasted. Further examination showed commencing phthisis, and 
the expectoration, which had previously been absent, revealed 
numerous tubercle bacilli. The case was now evidently one of 
tuberculosis, and was shown as illustrative of the difficulties 
which this affection in the larynx might present. From this 
point of view the case was similar to the one shown by Mr. 
Stephen Paget at one of the meetings last year. 

Dr. Clifford Beale asked if the oedema occurred suddenly in this 
patient, remarking that he had commonly observed its rapid onset in 
similar cases where iodide of potassium was prescribed. Once present, 
however, it remained, and thus differed from acute oedema. 

The President suggested that the iodide could be used like tuber¬ 
culin, as a diagnostic test for tubercle. 

In reply, Dr. StClair Thomson said the development of oedema of 
the arytenoids was as Dr. Clifford Beale suggested; it occurred quite 
suddenly in one week. 



52 


Large Naso-pharyngeal Polypus. 

Shown by Dr. Herbert Tilley. The polypus was removed 
from a woman set. 45. The post-nasal space was filled by the 
growth, and it extended by a nipple-like process below the level 
of the uvula, producing, especially at night, a feeling of suffoca¬ 
tion. It was removed with Lowenberg’s forceps, and the 
resulting haemorrhage was slight. 

Sir Felix Semon inquired if the polypus had undergone cystic 
degeneration. In his experience, almost all nasal polypi which pro¬ 
truded into the post-nasal space contained larger or smaller cysts, 
whilst such were not nearly so frequently found in the myxomatous 
polypi situated in the nose itself. 

Dr. Hill thought this was, properly speaking, a case of nasal, and 
not post-nasal polypus, the growth apparently arising from the 
interior of the nose. Further, he objected to the term myxoma being 
applied to nasal polypi. 

Sir Felix Semon said he had used the term inadvertently from old 
custom. 

Dr. Lack said he had quite recently removed a nasal polypus pro¬ 
truding both from anterior and posterior nares, and very firm, with no 
cystic degeneration. The specimen was very similar to Dr. Tilley’s in 
shape and size. 

Dr. Spicer agreed that nearly all polypi springing from both 
anterior and posterior ends of the middle turbinate contain cysts, often 
eight to ten small ones. He suggested that large cysts are often 
dilated ethmoidal cells. 

Mr. Waggett wished to corroborate Sir Felix Semon’s statement 
that cysts were generally evident in polypi removed from this position. 
Moreover small glandular cysts were to be found in the large majority 
of all nasal polypi. 

In reply, Dr. Tilley said that he removed the polypus with 
Lowenberg’s forceps passed into the post-nasal space. He had used 
the term naso-pharyngeal in an anatomical sense, and not as indicative 
of the pathological nature of the new growth. The polypus contained 
one or two large cysts, and measured five inches in its longest and 
three and a half inches in its shortest diameter. 


Epitheliomatous Ulceration of Naso-pharynx. 

Shown by Dr. Herbert Tilley. Patient is a man set. 55. 
He complains of difficulty in breathing through the nose, and an 
unpleasant discharge into the mouth, also general weakness. 



53 


The palate is seen to be immobile and almost vertical in 
direction, obviously due to something in the post-nasal space. 
Its free borders are so thickened and congested that only a 
small aperture just sufficient to admit the index finger to the 
naso-pharynx is present. On introducing the finger the ulcera¬ 
tion is very evident, and the discharge peculiarly offensive, 
reminding one of that which is so characteristic of advanced 
epitheliomatous disease of the tongue. There is an enlarged 
gland under the upper part of the left sterno-mastoid. A 
mixture of iodide of potash and mercury perchloride during the 
last week has had no visible effect on the disease. 

Dr. StClair Thomson had had a similar case in a patient set. 34. 
He had considered it a case of late adenoids, although the growth 
appeared rather congested. Operation was attended with profuse 
haemorrhage. Patient was seen a few months later with recurrence of 
growth and enlarged glands in neck. He died shortly after, and the 
diagnosis of epithelioma of Luschka’s tonsil was confirmed by necropsy 
and microscopical examination. 

Mr. Milsom Bees had recently had a similar case. 


Case of Empyema of the Antrum cured by Alveolar Irrigation 
after Failure of Intra-nasal Treatment. 

Shown by Dr. Dundas Grant. In this case an endeavour had 
been made to treat the condition by irrigations by means of 
cannulas introduced into the antrum through the inferior meatus 
according to Lichtwitz’s method, but without bringing about any 
continuous cessation of the discharge. The condition obviously 
arose from disease of several teeth, the stumps of which were 
thoroughly removed. The alveolar puncture was then resorted 
to, and the patient irrigated her antrum night and morning 
without difficulty, with the result that extremely rapid improve¬ 
ment took place, and there was every prospect that eventually a 
cure would be effected. Dr. Grant brought forward this case 
to show that his advocacy of intra-nasal methods did not prevent 
him from recognising the value and unequalled convenience of 
the alveolar puncture in suitable cases. 

Sir Felix Semon thought the Society should be very grateful to 
Dr. Grant for bringing this case forward, as a contrast to the one 

4 * 



shown at the last meeting. Sometimes one method, sometimes another, 
was to be preferred; tnere was no royal road to success. 

Dr. Hill and the President suggested this case was of dental 
origin, and therefore alveolar puncture was successful when intra-nasal 
failed. 

In reply, Dr. Grant stated that he had in that Society formulated 
the proposition that antral empyemata of dental origin should be 
treated through the alveolus, those of other origin through the nose. 



PROCEEDINGS 


OF TUB 

LARYNGOLOGICAL SOCIETY OF LONDON. 


48th Ordinary Meeting, March 3rd, 1899. 


F. de Havilland Hall, M.D., President, in the Chair. 


William Hill, M.D., ) gecretarieg 
Lambebt Lack, M.D., j becretanes - 


Present—27 members and 1 visitor. 


The minutes of the previous meeting were read and confirmed. 

The following gentlemen were unanimously elected memberi 
of the Society: 

Mark Purcell Mayo Collier. 

St. George Caulfield Reid. 

H. Fitzgerald Powell. 

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

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

Peter Abercrombie, M.D.Glasgow. 

Alfred B. Lazarus, M.B., C.M.Edinburgh. 


The following cases were shown : 


Case of Laryngeal Paralysis secondary to Stricture of the 

(Esophagus. 

Shown by Mr. Bowlby. Man aet. 50. Suffers from diffi¬ 
culty in swallowing and loss of voice. His symptoms began 

FIR8T SERIES-VOL. VI. 5 



56 


twelve months ago, when he had a very slight difficulty and 
pain at about the middle of the sternum on swallowing. Six 
months ago he suddenly lost his voice, and has had partial 
aphonia ever since. Swallowing has gradually become more 
difficult, and for three months he has been unable to take any¬ 
thing more solid than soaked bread. 

Present condition .—On the left side of the neck there is some 
fulness, and a mass of hard, matted lymphatic glands can be 
felt reaching from the clavicle upwards to the level of the cricoid 
cartilage. On passing an oesophageal bougie a stricture can be 
felt at a distance of seven inches from the teeth. Laryngo- 
scopical examination shows that the larynx is natural, except 
that the left vocal cord is fixed in a position midway between 
abduction and adduction. In front of the processus vocalis the 
free edge of the left cord is concave. Nothing abnormal in the 
chest. Pulses equal. Pupils equal. 

I have seen paralysis of the vocal cords in cases of oesophageal 
stricture on several occasions, the left cord being more often 
involved. I think it may be compressed either by the original 
growth or by enlarged and infiltrated glands. In the present 
Case the concavity of the cord is very marked, a condition pro¬ 
bably due to paralysis of the internal tensor. 

Dr. Clifford Beale described a case he had just seen which was 
almost similar, but at a somewhat more advanced stage. The patient 
had been for some time under observation, the first evidence of mis¬ 
chief being obstruction of the larynx. On the left side of the trachea 
there was a swelling which was acutely tender. Under large doses of 
iodide of potassium the swelling had considerably diminished, and the 
pain absolutely disappeared. The larynx showed complete abductor 
paralysis, the cords lying in the cadaveric position. When first seen 
she spoke with a clear voice. As the patient was subject to adductor 
spasm, tracheotomy had to be performed. It was now possible to 
examine freely, and all down the neck on the left side of the oesophagus 
a hard infiltration could be felt. Under chloroform the top of the 
growth could be made out with the finger. There was no evidence to 
indicate how long the paralysis of the cords had lasted, as the voice 
had not been affected, and up to the time he had first seen her there 
had been sufficient breathing space. 

Sir Felix Semon would not undertake to say off-hand whether, in 
his experience of oesophageal stenosis, the right or the left vocal cord 
was .more frequently affected, but he could recall several cases of 
oesophageal obstruction in which the right vocal cord had been para¬ 
lysed. It was possible that the latter cases made a greater impression 




57 


on their minds, since in cases of left-sided paralysis an aneurism was 
more often the cause than oesophageal mischief. With reference to 
the flaccid and excavated appearance of the left vocal cord, and the 
question whether that was due to participation on the part of the 
superior laryngeal nerve, or whether implication of the recurrent was 
alone sufficient to explain it, he believed that the latter fully sufficed, 
because, if the internal tensor became paralysed, the result, in his 
experience, was the excavated and flaccid appearance of the vocal cord 
exhibited by Mr. Bowlby’s patient. It has been recently stated that 
if the recurrent laryngeal nerve was completely paralysed, the crico¬ 
thyroid muscle would, being no longer opposed by any antagonistic 
muscle, from mere inactivity undergo degeneration and atrophy. 
This statement, he was convinced, was purely theoretical. He need 
only point to cases of abductor paralysis in tabes, such as shown in 
this Society, in which the affection had lasted for ten or more years, 
and yet the patient had been able not only to speak with a perfectly 
normal voice, but even to sing. If that period was not sufficient to 
produce paralysis of the crico-thyroid from inactivity, he wondered 
what time was required for the purpose. Besides, Dr. Friedrich, of 
Leipzig, and Dr. Herzfeld, of Berlin, had found on post-mortem 
examination the crico-thyroid perfectly normal in cases of complete 
and long-standing recurrent paralysis. He would suggest that every 
opportunity be seized in such cases of making a post-mortem examina¬ 
tion and instituting a thorough macro- and microscopic examination 
of the crico-thyroid, and publishing the results of the observation. 

Dr. de Havilland Hall could see no anatomical reason why, in 
cases of malignant disease of the oesophagus, one vocal cord should be 
more frequently affected than the other. He thought he had himself 
seen more cases of right than of left-sided paralysis, but, as Sir Felix 
Semon had remarked, right-sided paralysis probably made more im¬ 
pression on their minds than left-sided, which was so comparatively 
common that they were not surprised to find it, whereas a case of 
right-sided paralysis put them on the qui vive to ascertain its cause. 
As for the place of involvement of the nerve, he found that on pressing 
the enlarged gland of the neck the man had a distinct attack of spasm 
of the glottis, and there was marked stridor. This, he thought, the 
left cord being paralysed, must have been through the afferent fibres 
and down the vagus on the right side. 


Case of Lupus of Nose. 

Shown by Dr. Edward Law. Female, aet. 33, came to the 
hospital three years ago suffering from lupus of the skin of the 
left ala nasi, with a few granulations inside the nasal orifice. 
Perfect cicatrisation took place after scraping, &c., and no re¬ 
currence was noticed for eighteen months, when granulations 
appeared on the floor of the left nasal fossa and extended up to 



58 


the middle turbinal, with nodules on the posterior margin of the 
septum. Curetting, and applications of lactic acid brought about 
a satisfactory result, and the patient was discharged apparently 
cured. A few weeks ago, a posterior rhinoscopic examination 
revealed a small swelling in the soft palate, immediately behind 
the posterior margin of the septum. 


Case of Nasal Polypi complicated by Well-marked Bilateral 

Septal Obstruction. 

Shown by Dr. Edward Law. Patient, aet. 31, came under 
observation at the end of last year on account of difficulty in 
nasal respiration, one or other side being constantly blocked. 
There is a history of the nose having been broken whilst playing 
football sixteen years ago, and of a similar accident five years 
ago, “when there was some difficulty in keeping the three pieces 
in their proper position.” 

Examination showed an irregularly deflected septum, with 
well-marked bilateral prominences at the lower margin of the 
nasal bones, and an unusually large, long, and thick spur 
running parallel to, and in union with, the inferior turbinate on 
the left side. The whole septum is much thickened, and there 
are polypi in each nasal cavity behind the obstructions. At first 
it was impossible to obtain a posterior rhinoscopic image on 
account of the great irritability which accompanied the naso¬ 
pharyngeal catarrh. This disappeared after the discontinuance 
of tobacco, malt liquors, and attention to diet, &c. The posterior 
extremities of both inferior turbinals are somewhat hyper¬ 
trophied. The case is interesting, and the opinion of members 
is requested as to the methods and extent of operative inter¬ 
ference. 

A discussion ensued on operative interference in cases of 
stenosis of the nose in general. 

Sir Felix Semon said he had recently had a series of cases in 
which the tendency to adhesiou, which was so marked a peculiarity 
after operations in the nose, had been even more prominent than 
usual. In one case in which he had removed, by sawing and cutting, 
a projecting part of the turbinate bones and the septum, every means 


/ 

r 




59 


lie had tried to keep the passage open had failed. The patient had 
been nnable to bear plugging with gauze or wadding; neither could 
she stand gutta percha, celluloid, or silver. Ivory was the only thing 
she could bear. He had tried every astringent and sedative he knew 
of, and had employed cocaine so as to contract the mucous membrane. 
Nothing availed; everything irritated and gave pain; and each time 
the plugging was left off adhesions formed. He had sent the patient 
to her home, and there the parts grew together again, so that he had 
anew to operate. She was now wearing an ivory plug. When it was 
taken out she breathed as freely through one nostril as the other, but, 
although there was a distance of 2 mm. between them, the opposite 
surfaces touched and united when the plug was left out for six hours. 
He would like to know if anyone could suggest what to do in such a 
case. At present he was merely applying pure paroleine, and there 
was no pain now. 

Dr. William Hill said that within the last few months he had 
operated on a case seven times. First he had cut away a piece of the 
turbinal and a small bit of septum. On removal of the plug, a clot 
or a scab would form and a bridge appear. In this case he had cut 
with scissors the turbinal on the outer side, and destroyed the bridge 
quite six times. He had used the soft rubber plug, which he believed 
was least irritating, though not very aseptic, and it had been borne 
well. He believed that if they simply went on persistently with a 
suitable plug, healing must in course of time occur. 

Dr. Waggett said he had had a similar case that gave great trouble. 
He had come to the conclusion that the prolonged use of plugs after 
operation was disadvantageous, in that it caused a local anaemia of the 
injured parts and prevented healing. The parts could be kept asunder 
without pressure by inserting a sheet (not a plug) of celluloid, which 
took up little room and left quite enough space for the escape of dis¬ 
charge from the surfaces of the ulcers. The celluloid should be 
removed daily, and the nose syringed. 

Mr. Spencer said it was the continuance of the local treatment that 
was the difficulty, owing to the pain caused, especially in the hyper- 
aesthetic cases. In Dr. Law’s case there were two very thick ridges of 
half cartilage, half bone, close down upon the floor of the nose. To 
treat such a case by Bosworth’s saw on either side would be exceedingly 
difficult, the nose was so narrow. Every case should be treated, if 
possible, under cocaine, but there was a more complete method of 
treatment, namely, to remove, under an anaesthetic, the whole of the 
inferior turbinal, either by knife or scissors, and at the same time, if 
the nose were excessively narrow, to dilate it till it was thoroughly 
free Dr. Hall had sent a young man to him in whom there was 
marked hyperaesthesia. The anterior part of the inferior turbinal had 
been removed by a practitioner, but an adhesion to the septum had 
formed. A plug had been put in, but the pain prevented its retention. 
Under a general anaesthetic, the whole inferior turbinal bone was 
removed, the nose was plugged for a day, then douched, and under 
this treatment had healed, leaving a free passage. 

Dr. Scanes Spicer said he felt sure Dr. Law’s case was one of those 
in which, having obtained permission to remove whatever was necessary 



60 


to radically clear the nasal obstruction, a general anaesthetic should 
be given and the thing done thoroughly. It might be necessary to 
remove the spurs on both sides and to tackle the middle (for the case 
was complicated with polypi and purulent sinusitis) as well as the 
inferior turbinates. That, of course, would mean ten days or a fort¬ 
night’s confinement to hospital; but such a case as this was best and 
quickest treated in this radical fashion. Referring to Sir F. Semon’s 
case, of late years he had had no troublesome adhesions after nasal 
operations until last December, when, through not continuing long 
enough personal attention to the nose, he had seen two. One patient, 
having been in London for ten days, was allowed to return home too 
soon after operation; a “ cold ” supervened, a bridge formed, and she 
had to return to London, and it took over a fortnight to conquer the 
bridge. In the second case exactly the same thing happened. He 
had worked at this case for two months, and the patient was not yet 
out of the wood. In obstinate and irritable cases he believed the 
proper plan was to give the patient a complete rest and allow the 
bridge to consolidate, simply lubricate with soothing unguents, and 
get all inflammation down; then, later, attack the non-inflamed 
bridge. In such a case as Sir Felix Semon had described, a temporary 
policy of masterly inactivity, such as recommended, would in the end 
prove most efficient and shortest. It was possible that in these cases 
freer removal of adjacent parts should have been done, and would have 
prevented this bridging. For his own part the speaker felt his errors 
had been invariably in the direction of removing too little rather than 
too much. 

Dr. de Havilland Hall said that nothing short of the heroic 
measures taken in the case instanced by Mr. Spencer would have 
succeeded, the condition being one of long adhesion in narrow nostrils. 
The result was exceedingly satisfactory. 

Dr. Donelan said he had had much trouble with an adhesion asso¬ 
ciated with a good deal of hypersesthesia. There was eczema of the 
auditory meatus, for which he was using Burow’s solution of acetate 
of lead and alum. He at last tried this in the nose, separating the 
adherent surfaces with lint soaked in it. The hypersesthesia was at 
once relieved, and the adhesion was soon overcome. He further 
referred to the occasional ill effects of turbinectomy, and mentioned a 
case in which necrosis of the upper jaw and facial paralysis had 
followed that operation. 

Dr. Dundas G-rant said that he had performed inferior turbinectomy 
for the purpose of getting rid of an adhesion with satisfactory result; 
but in one case, where there was no previous adhesion, plugging after 
complete removal of the inferior turbinate body was followed by such 
inflammatory reaction that an adhesion formed. In one case of adhesion 
between the left turbinate and the septum in a medical man he had 
removed the anterior extremity of the turbinate; but that did not 
prove sufficient. The patient then asked him simply to remove the 
band, and he would try to keep it open by means of a nasal bougie 
made of the silk-wove material used in urethral bougies. This the 
patient cut short, and went about with it in situ all day. He was now 
cured. It was sometimes a question whether adhesions required to be 



61 


interfered with. In a case in which the nasal obstruction was so 
marked that he could only remove the polypi at the posterior part 
after sawing away a spur on the septum, an adhesion formed which 
seemed to cause no discomfort, and the relief from the partial opera¬ 
tion was so great that he was exercising a “ masterly inactivity.” Use 
of cocaine had two effects, ansesthetisation and contraction. But a 
spray of 4 per cent, of antipyrin would bring about contraction of 
longer duration. It was, however, rather irritating, and he preceded 
it by a spray of 5 per cent, eucaine. With that combination an 
enormous amount of comfort was afforded without risk. In reply to 
a remark by Mr. Atwood Thorne, that bridges did not seem to him to 
form unless both terminal and spur were operated on at one time, and 
his suggestion that they should be dealt with at different times, 
Dr. Grant replied that there had been cases of adhesion which had 
arisen without any operative interference at all. 

Dr. Edward Law, in replying to the discussion, said that unless 
the adhesion mentioned by Sir Felix Semon was a very broad one, he 
should certainly let it heal, and not tamper with it for six or twelve 
months. One had occasionally to break down adhesions in order to 
pass the Eustachian catheter, and he had been surprised at the ease 
with which the surfaces could be kept apart compared with the ad¬ 
hesive tendency manifested after any operations in the nose. This 
freedom from adhesion in the case of the division of bridges of long 
duration was probably accounted for by the adjacent mucous mem¬ 
brane being in a more or less normal condition. 


Case of Complete Adhesion of the Soft Palate to the 
Posterior Wall of the Pharynx. 

Shown by Dr. de Havilland Hall. The patient, a married 
woman of 33, was quite unaware of her condition until informed 
of it, but she noticed that she could not blow her nose like other 
people. She has never suffered from sore throat or skin affection. 
The left central incisor, upper jaw, is notched and pegged. 
Eyes not affected. Patient had one child 12 years ago, and has 
had no miscarriage. She is an only child, and states that her 
mother had miscarriages. The case is clearly one of inherited 
syphilis. 


Foreign Body impacted in the Naso-pharynx for Four Years. 

Shown by Dr. D. R. Paterson. This was a metal regulator 
for rubber tubing frequently used with infants’ feeding bottles. 



62 


It was removed from a child aged six years, who came with the 
history of otorrhcea of the left side and foetid discharge from 
the left nostril. There was inability to breathe freely through 
the nostrils, and something could be distinguished in the pos¬ 
terior nares on looking through the left nostril. Under an 
anaesthetic a hard mass was felt above the soft palate, fixed 
immediately behind the posterior choanae, and on removal was 
found to be the foreign body thickly coated with phosphates. 
A history was obtained that when the child was fifteen months 
old, and was playing with a regulator, it suddenly showed diffi¬ 
culty of breathing, which was relieved by suspending with head 
downwards, though from that time the nasal breathing became 
obstructed and the child suffered in health. At various times 
bougies were passed by different medical men into the oeso¬ 
phagus with a view of disabusing the parents of the notion that 
there was a foreign body in the throat, and it was for relief of 
the aural and nasal trouble that advice was lately sought. 

Mr. Parker related what might be called a surgical freak. A boy 
had come to him complaining of obstruction of the nose. By the 
aid of the posterior mirror he saw a large grey mass in the posterior 
nasal space, but, unable to determine what it was by inspection, he had 
put his finger up. This did not reveal the nature of the body ; but 
just then the boy gave a great heave, and from the back of his nose 
came a piece of drainage-tube about two inches long and half an inch 
in diameter. The boy had had an abscess in his neck two years pre¬ 
viously, in connection with which the drainage-tube had been used. 


Case of Laryngeal Vertigo. 

Mr. Atwood Thorne showed a man, aet. 51, who came to Dr. 
William Hill at St. Mary’s Hospital, on January 5th, 1899, com¬ 
plaining that “ whenever he had a fit of coughing he felt giddy 
and lurched towards his right front.” He has been subject to 
paroxysms of coughing on and off for two years, but the con¬ 
dition has been getting worse lately. He has never fallen, but 
has to catch hold of something to prevent his doing so. 

He is slightly deaf, and for the past two months has had 
noises “ like heavy traffic ” in his head. 

He has polypoid hypertrophy of both middle turbinates, some 
lymphoid hypertrophy at the base of the tongue, and some 



63 


slight swelling in the interarytaenoid space. There is some pul¬ 
monary emphysema. No other cause for vertigo being ascer¬ 
tained, the case is brought forward as one of laryngeal vertigo. 

Fifteen minims of dilute hydrobromic acid have been given 
three times a day, and the man describes himself as rather 
better. 

While at the hospital the man has never had an attack, 
forced coughing not having affected him in any way. 

Dr. Law thought it was possibly a case of aural vertigo. The 
patient complained of deafness and tinnitus; the tympanic mem¬ 
branes were retracted. He thought that catheterisation would reveal 
the Eustachian tubes to be over patent. The man had probably for 
some time given his ear repeated concussions either by coughing or 
blowing his nose. He should be recommended not to blow his nose 
violently, and some remedies should be given to relieve his cough. 

Dr. Hill said the man had been under him for aural treatment. 
He at first had assumed the case to be one of aural vertigo, but 
finding the patient had signs of exhaustion sinusitis before one of the 
attacks, he then was inclined to think it was a case of nasal vertigo. 
Afterwards it was found that the attack always_ came on in connection 
with some laryngeal irritation and cough, and narrowed down in that 
way; he believed it was really an instance of laryngeal vertigo. 

Dr. Dundas Grant said although the theory of aural vertigo had 
been propounded by some authors, he was indisposed to accept it, if 
only because of the extreme rarity with which vertigo followed inflation 
of the middle ear, a result he himself had never seen. In a case of 
very definite laryngeal vertigo, or rather syncope, as it was better 
called, there was a strong gouty tendency, after treatment for which 
he believed the vertigo disappeared. 

Dr. StClair Thomson suggested that it might be cardiac syncope. 
The patient’s pulse was very small and quick, and slightly irregular. 
The man himself said that when he bent forward to lace his boots he 
felt inclined to fall on his nose. 


Case op Tuberculous Interarytaenoid Growth. 

Shown by Mr. J. S. Lucas for Mr. Lake. 

The patient, a female aet. 33, has been hoarse for four months. 
For the last eight weeks she has been under treatment, and the 
throat has been painted with formalin in 3 per cent, solution. 
She has improved greatly, but still complains of pain if the 
throat is not painted daily. The swellings in the interarytaenoid 
region are rather unusual, being very irregular. 



64 


Two Cases op Extra-laryngeal Cyst. 

Mr. Waggett showed two young men exhibiting cystic form¬ 
ations in the thyro-hyoid region. 

In the one case a cyst the size of a hazel-nut was found lying 
upon the thryo-hyoid membrane on the left side. In the second 
case a tumour, partly cystic, and about the size of a walnut, was 
present on the left side over the thyro-hyoid membrane and 
extending down over the corresponding ala of the thyroid 
cartilage. This was probably a cyst developed from the pyra¬ 
midal lobe of the thyroid gland. 

Mr. de Santi thought the first case a bursal cyst, extra-laryngeal 
and unconnected with the thyroid. It might be necessary to 
make a deep dissection, but he thought Dr. Waggett could cut 
down and remove it. He could not get “ blowing out.” 

Dr. StClair Thomson asked whether the possibility of so-called 
pneumatocele had been considered, as the tumour could be distended 
by blowing with closed bps. 

Mr. Waggett had at first considered the second case to be one of 
pneumatocele. He had, however, convinced himself that the slight 
enlargement which occurred on coughing was due to venous engorge¬ 
ment. On external pressure a slight prominence occurred in the 
region of the left aryepiglottic fold, but it was quite impossible to 
cause any diminution in the size of the tumour by prolonged manipu¬ 
lation. He felt certain that the cyst in no way communicated with the 
lumen of the air-passages. Mr. Waggett agreed with Mr. de Santi in 
thinking the first case to be one of bursal cyst. As it caused no incon¬ 
venience he did not propose to operate. 


Case op Multiple Laryngeal Papillomata in a Child ast. 3| 

Years, completely removed in three sittings by Endo- 

LARYNGEAL METHOD UNDER COMBINED GENERAL AnACSTHESIA AN D 

Local Cocainisation, and without Tracheotomy. Result : 

Full Restoration op Voice and Normal Breathing. 

Dr. Scanes Spicer showed this case. Boy, aet. 3£, lost his 
voice after a cold at the age of seven months, and has always 
spoken since in a breathy whisper; there is no sound in 
his laugh or cough, and his breathing is noisy, especially at 
night. He is highly intelligent, but shy, and can say anything 



65 


in his peculiar whisper. His tonsils are enlarged, and there is 
post-nasal adenoid hyperplasia. Laryngoscopic examination not 
practicable without anaesthetic. 

February 1st.—Dr. Fred. Hewitt administered gas, ether, and 
chloroform, and patient was placed in intubation position in 
nurse s lap.*,The condition was:—Large median, cauliflower 
mass, whole length of glottis, flapping freely in air current, 
and attached somewhere on right side ; right cord embedded 
in multiple, pale, warty growths; left cord perfectly healthy 
and mobile. The median mass only was removed by antero¬ 
posterior cutting forceps, as the larynx was irritable, and pre¬ 
parations had not been made to tackle the growths on that 
occasion. 

8th.—No return of voice, but breathing much quieter, especially 
at night. Anaesthetic was given again as before, and the larynx 
was sponged with a few drops of 20 per cent, cocaine solution, 
and well mopped out. This was done two or three times 
until the larynx was tolerant of the probe and forceps. Eight 
or ten large clusters of growths were then removed, blood being 
mopped away at times. After this the tonsils and adenoids were 
removed. 

16th.—The patient still speaks in a whisper, but there is 
sound in the cough and laugh. Anaesthetic given again and 
cocainisation as before. Small growth removed and larynx seen 
to be absolutely free. Recovering from anaesthetic a curious 
croupy inspiration was observed, which was especially marked 
when anyone was in the room, but subsided when patient was left 
alone. The sound of voice did not return for some days, and only 
gradually. Apparently determined effort was requisite to produce 
the voice, and it had a raucous, monotonous character devoid of 
inflexion. 

This case is interesting as a further proof of the practicability 
of removing laryngeal growths in young children by the method 
described by the writer some years ago. He then had had four 
such cases, later one more, and, until the present one, no case of 
the kind for five years. This case has been far more rapid than 
any of the others, and the operator has been much indebted to 
Dr. Hewitt for many suggestions in connection with the anaes¬ 
thetic and position. It is also a point of much interest that the 



66 


voice did not return at once, though there was no mechanical 
impediment to adduction. This might have been due to slight 
bruising during operation, or it might have been a result of the 
threefold co-ordination of breath, articulation, and adduction 
never having been established at the time when the child lost 
its power of adduction. 


Sir Felix Semon thought the result most satisfactory, and one upon 
which Dr. Spicer ought to be congratulated. He had himself seen 
the child before the operation. It was then in a very bad condition, 
perfectly aphonic, and with loud laryngeal stridor, and a suggestion 
of tracheotomy had been made. 

Dr. William Hill said Dr. Spicer’s results put the question of 
treatment of papillomata in children of three or four years of age on 
quite a new basis. Instead of putting off operation till the patient 
was seven or eight, Dr. Spicer cleared out the larynx at any age. He 
had himself seen two cases in which the finger nail was used at his 
suggestion to remove some of the growths. 

Dr. Scanes Spicer said the growths were removed under the guid¬ 
ance of the mirror. The longest time occupied at a sitting in his 
earlier cases was two hours. There was a good deal of trouble in con¬ 
nection with the chloroform. Very little cocaine solution was used. 
He followed up the spray immediately with a dry cotton-wool mop, 
giving it a brisk turn round so that no cocaine was swallowed, and a 
local ansesthetisation was thus procured, which supplemented the 
chloroform and allowed the field to be operated on without exciting 
reflex contraction and closure. In the present case Dr. Frederic 
Hewitt had given the chloroform, and had much facilitated the opera¬ 
tions. 


Case of Pachydermia of the Larynx, probably due to 

Chronic Rhinitis. 

Shown by Dr. Dundas Grant. Man, set. 21, was first seen 
by Dr. Grant on the 25th February, when he complained of 
huskiness of the voice which had persisted for two months 
subsequent to a cold, also frequent coughing and hawking. He 
attributed the condition to an attack of diphtheria nine years 
before. It appeared that on at least two occasions such hoarse¬ 
ness had followed colds and had lasted for several months. On 
examination of the larynx there was found a dry congestive 
condition of the vocal cords, with a pale irregular fringe on both 
vocal processes. The thickness on the vocal processes was 



67 


irregular, and the processes appeared on phonation to dovetail 
into each other. 

In the nose there was hypertrophy of the inferior turbinated 
bodies and increased muco-purulent secretion. There was no 
history of specific disease nor of excessive use of the voice. 
The patient is otherwise in excellent health, and the condition, if 
not absolutely typical of pachydermia, seems to approximate to 
it extremely closely. The treatment proposed is the removal of 
the hypertrophied portions of the inferior turbinated body and 
application of the alcoholic solution of salicylic acid to the 
larynx. 


Dr. de Havilland Hall doubted whether the case could be called 
one of pachydermia. It did not extend far enough along the processus 
vocalis. He had seen pachydermia in alcoholics who were also voice 
users. Sir Felix Semon having remarked that he had seen it most 
frequently in clergymen, Dr. de Havilland Hall further remarked that 
one of his cases was that of a clergyman in whom lipomata on the 
nape of the neck had led him to suspect alcoholism. 

Dr. Dundas Grant thought his case approximated closely to pachy¬ 
dermia, though not of the typical shirt-button type, and was a hyper¬ 
plasia of the epithelial tissue. 


Case of Papilloma of the Larynx previously shown in an 
Elderly Man. Complete Removal. 

Shown by Dr. Dundas Grant. Man, aet. 60, came under 
my care on the 28th October on account of hoarseness and loss 
of voice of a year’s duration. The growth in this case was 
removed by means of Grant’s forceps, and on microscopical 
examination presented the characteristics of a soft papilloma. 
The stump underwent some regrowth, but the alcoholic solution 
of salicylic acid was applied and the forceps again used, leaving 
only a slight roughness on the site of the growth. This was 
treated with local application of salicylic acid two or three times 
a week, and at present the voice has reached its normal con¬ 
dition ; the edge of the cord is nearly smooth, though its colour 
is still abnormally red. 



68 


Case of Multiple Papillomata. 

Shown by Dr. Dundas Grant. A woman aet. 59 came under 
my care on February 23rd on account of hoarseness and loss 
of voice of two years’ duration. On the edge and upper sur¬ 
face of the right vocal cord was a sessile mass of a soft, warty 
appearance, which was, from its mobility, apparently of soft con¬ 
sistency, the papillation of the surface being particularly marked. 
This extended to the anterior commissure, where there was a 
roundish outgrowth. The left vocal cord was reddish and 
irregular at its edges, but was partially concealed by the growth 
from the other side. The movement of both sides of the larynx 
appeared to be normal, the voice was almost lost, and was more 
whispering than hoarse. By means of Grant’s forceps a large 
portion of the growth was at once removed, but no particular 
effect on the voice was produced. Three days later, further 
removal was effected by means of the same instrument, but the 
growth at the anterior commissure could not be reached, pro¬ 
bably on account of the length of the beak of the forceps 
employed. This was, however, removed completely by means 
of MacNeill Whistler’s forceps. On the 1st of March the 
larynx was free from any large mass of growth. There still 
remained a slight fringe on the right cord, and there was seen 
below the middle of the left one a pale smooth sessile growth of 
very small dimensions. A 5 per cent, solution of salicylic acid 
was then applied between the cords. At this date the voice 
seemed as toneless as ever, but with a little insistence the 
patient was induced to utter hoarse but fairly loud sounds. It 
seemed as if the habit of whispering had become established, 
and that even after removal of the new growth in the larynx 
this would have to be overcome by practice. 


Case of Large Gumma in Posterior Pharyngeal Wall. 

Shown by Mr. Arthur Cheatle. A woman, aet. 37, came to 
the Royal Ear Hospital ten days ago, complaining of difficulty 
of swallowing, and “ a lump ” in her throat. A smooth swelling. 



69 


an inch and a half in breadth, situated slightly to the left of the 
middle line, reached from high up in the naso-pharynx down¬ 
wards to the level of the top of the larynx. It was soft and 
fluctuating in the centre, hard at the edges, where it faded into 
surrounding parts. There was a history of numerous mis¬ 
carriages and some stillbirths. Resolution was taking place 
under iodide of potassium and perchloride of mercury. 


Case op Fixation of Left Yocal Coed with Fibrillar Move¬ 
ments. 

Shown by Mr. W. G-. Spencer. The patient, set. 62, served in 
the navy, but having suffered from repeated attacks of rheuma • 
tism, he was invalided. His voice has not been good for years, 
and he has had attacks of aphonia. During the last four 
months he has been very hoarse or completely aphonic. The 
left vocal cord is fixed as regards voluntary movements. The 
arytaenoid cartilage is fixed and drawn forwards, forming a 
ridge. The cord itself is unaltered, but continually exhibits 
fibrillar movements. Some congestion of the larynx has become 
less under treatment. 

Dr. Herbert Tilley suggested that the curious appearance pre¬ 
sented was due to tilting and fixation of the arytaenoid cartilage, and 
that there might be some trouble (possibly rheumatic) in the crico- 
arytaenoid joint. The twitching movements of the tissues covering the 
fixed arytaenoid reminded him of a similar condition seen in a case of 
syringomyelia, with palatal and left abductor laryngeal paralysis, 
shown to the Society by Dr. Home (June 9th, 1897). 

Sir Felix Semon referred to a former paper of his on the subject, 
which described a case in which there was also complete tilting of the 
arytaenoid cartilage, with fixation of the cord and the formation of a 
ridge in consequence of the drawing of the parts. In that case there 
appeared to be congenital anchylosis and luxation of the crico-ary- 
taenoid joint. 


Case of Recurrent Papillomata of Larynx. 

Shown by Mr. C. A. Parker. The patient, a man set. 25, was 
first seen three years ago, when he had been hoarse for four 
months. The larynx was then found to be almost entirely filled 



70 


with papillomatous growths. The growths were removed, with 
great improvement to the voice. At intervals of a few months 
the patient has returned with recurrence of the growths, which 
have been removed on about twelve occasions. The patient has 
not been seen until now for fourteen months. The voice is im¬ 
paired, and he has pricking pain on swallowing. The whole of 
the anterior part of the larynx seems to be filled up with 
growths, the posterior wall alone is free. 


A Skiagram of Foreign Body in the (Esophagus. 

Mr. de Santi showed a skiagram of a halfpenny tightly wedged 
in the oesophagus, opposite the level of the top of the sternum. 

The patient was a child of 2 years 11 months, who had 
swallowed a halfpenny eleven days before Mr. de Santi saw 
him. 

The mother of the child stated she had carefully examined 
the stools passed, but had seen no halfpenny. Beyond having 
occasional attacks of vomiting there had been no symptoms. 

When brought to Mr. de Santi the mother stated the child 
complained of pain in the right iliac fossa. On examination 
the child cried on that locality being pressed. 

Mr. de Santi ordered the air-passages to be skiagraphed. The 
halfpenny was then clearly seen in the oesophagus. Under 
chloroform the top of the coin was with difficulty felt with the 
tip of the index finger. It was extracted by means of the coin- 
catcher, although tightly wedged. 

The child made an uninterrupted recovery. The interest of 
the case lay: (1) in the length of time the coin had remained 
impacted in the oesophagus, i. e. twelve days; (2) the absence 
of any localising symptoms, such as pain, dysphagia, or dys¬ 
pnoea ; (3) the presence of pain around caecum, suggesting 
lodgment of the coin in that neighbourhood; (4) the absence 
of any inflammation or ulceration in the neck where the coin was 
wedged. 



PROCEEDINGS 


OF THE 

LARYNGOLOGICAL SOCIETY OF LONDON. 


49th Ordinary Meeting, April 7 th , 1899. 

A. Bowlby, Esq., F.R.C.S., in the Chair. 

William Hill, M.D., ) 0 , • 

T t \r - r \ ? Secretaries. 

Lambert Lack, M.D., ) 


Present—22 members and 5 visitors. 


The minutes of the previous meeting were read and confirmed. 


The following gentlemen were unanimously elected members 
of the Society: 

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

Peter Abercrombie, M.D.G-las. 

Alfred B. Lazarus, M.B., C.M.Edin. 


The following cases and specimens were shown : 


Case of Pachydermia Laryngis. 

Shown by Mr. C. A. Parker. A. C—, male, set. 32, was first 
seen five years ago, suffering from well-marked and typical 
pachydermia laryngis, the greater swelling being on the right 
vocal cord. At first it yielded to none of the ordinary methods 
of treatment, but finally it was reduced by means of electrolysis, 
small portions also being removed by means of forceps. Two 
FIRST SERIES — VOL. VI. 5 A 



72 


years ago the pachydermatous swellings had almost entirely 
disappeared, and the voice had much improved, but considerable 
general thickening of the larynx remained. Since then he has 
had several attacks of laryngitis which have yielded to treat¬ 
ment. Three months ago, however, he returned with a marked 
pachydermatous thickening on the posterior third of the right 
vocal cord and a corresponding swelling on the left. This is 
again yielding to astringent applications locally, and iodide of 
potassium internally, but it is still well marked, and there is a 
great amount of general thickening of the mucous membrane of 
the whole larynx with laryngitis. 

There is no history of syphilis. He drinks about one pint of 
beer a day, and he does not use his voice to any unusual extent. 
As a boy, up to the age of seventeen years, he sang in a choir, 
and was able to take very high notes. 

The long duration and the obstinacy of the case led me to 
bring it before the Society in the hope of suggestions as to 
future treatment. 


Case of Paresis of the Right Yocal Cord. 

Shown by Dr. StClair Thomson. When the title of this case 
was sent in to the Secretary the right cord was perfectly fixed 
in the cadaveric position. It was now seen, however, to be 
moving fairly well. The case was interesting from the vari¬ 
ability of the symptoms. The patient was a man aged thirty- 
four, who contracted influenza last autumn, and has been hoarse 
since November. When first examined in January last he was 
seen to have paresis of both internal tensors. This was con¬ 
firmed at a second visit, and by several observers. At the end 
of a few weeks, although the patient felt his voice stronger, 
there was found to be complete abductor paralysis of the right 
vocal cord. There was nothing to account for this in his neck, 
chest, or general symptoms. 

There was no history of syphilis, but as his wife had had 
several miscarriages he was put upon specific treatment. The 
laryngeal condition improved at first, then relapsed, and was 
now again rapidly improving. 



73 


Mr. Bowlby mentioned the case of a gentleman, set. 48, who 
after influenza nearly lost his voice and had attacks of difficulty of 
breathing, having to gasp for breath after coughing. Examination 
revealed paresis of the abductors of both cords. At the end of three 
months this condition gradually passed away under no special treat¬ 
ment, and the patient had since been perfectly well. Paresis of some 
of the muscles of the larynx was not a very uncommon thing. 


Specimen of Large Thyroid Cyst. 

Shown by Dr. Herbert Tilley. The cyst measured ten and 
a half inches in circumference, and weighed eleven and a 
quarter ounces. It was removed from the left lobe of the 
thyroid gland in a female, aged thirty-five, who was suffering 
from difficulty of breathing owing to displacement of the trachea 
to the right. * 


Specimen of Old-standing Bronchocele, becoming Malignant 

AND CAUSING PRESSURE ON THE (ESOPHAGUS AND TRACHEA. 

Shown by Mr. de Santi. The patient was a woman aet. 60, 
and had had a bronchocele for some twenty years. For a few 
weeks before applying to the hospital she had had dyspnoea 
which increased and caused much trouble. On examination a 
large fibrous bronchocele was found; there was marked in¬ 
spiratory dyspnoea, and no view of the larynx could be got. 
The bronchocele not only extended laterally, but also down¬ 
wards behind the sternum. It had not increased much 
latterly. 

A median incision was made and a large part of the centre of 
the tumour removed. This gave complete relief for eight 
months. The growth microscopically was benign. 

The patient was readmitted for severe dyspnoea and dys¬ 
phagia eight months after the first operation, and some more of 
the thyroid was removed. The trachea was not seen. Relief 
was obtained, but the patient died three weeks later from sudden 
cardiac syncope. 

The specimen showed that the trachea was much deflected to 
the right, and was not only scabbard shaped but also flattened 
antero-posteriorly. The oesophagus was also much narrowed 



74 


and deflected to the right. The enlargement extended mesially 
down to the left innominate vein. 

Microscopically the thyroid showed no malignant characters, 
but the mediastinal glands in the neighbourhood showed com¬ 
mencing carcinomatous changes. Mr. de Santi referred to the 
difficulties such cases presented as regards tracheotomy, and 
stated that it was by no means uncommon to find these old- 
standing bronchoceles becoming malignant after many years, 
although orginally innocent. 

Mr. Bowlby said the case illustrated exceedingly well the impossi¬ 
bility of removal of these tumours. It was a common experience, as 
far as malignancy was concerned, to find it commencing in a previously 
enlarged gland. 

Dr. Herbert Tilley asked Mr. De Santi if he could say whether 
in this case the malignant disease started in the parathyroid structure, 
because in a lecture on goitre recently given by Mr. Horsley he had 
pointed out that such was often the case, a probability enhanced by 
the vascular and epithelial nature of this structure. 

Mr. Bowlby said that was not his experience. He had seen malig¬ 
nant disease start in the substance of the thyroid itself, not in the 
parathyroid. 

Sir Felix Semon had seen several cases start in the thyroid itself 
after the original goitre had remained unchanged for twenty years or 
more. 


Case op Primary Epithelioma op the Right Tonsil with 
Extension to the Tongue and Cervical G-lands. 

Shown by Mr. de Santi. The man, aet. 37, had first noticed 
swelling in the right tonsil at Christmas, 1898, and had seen a 
doctor who said nothing was the matter with him. He was 
again seen later when he was told he had tonsillitis and given a 
gargle. 

Now there was well-marked cachexia. A foul ulcer was seen 
in the right tonsil. The base of the tongue was involved and 
bound down, and there was inability to open the mouth wide. 
The right cervical glands were typically enlarged and hard. 
The case was inoperable and of very rapid growth. 

Mr. Bowlby thought there could be no doubt as to the diagnosis, 
'i nd that operative treatment was impracticable. 



75 


Swelling in Inter-arytenoid Region. 

Shown by Dr. Furniss Potter. The patient was a man aet. 
31, a meat salesman and voice user, who had suffered from 
hoarseness for about two months previously, and had had a 
cough with expectoration for an indefinite period—could not 
remember how long. On examination there was general hyper- 
aemia of the larynx, the cords being thickened and slightly 
reddened. In the inter-arytaenoid space was a pyramidal-shaped 
swelling, grey in colour as if covered with mucus. 

According to patient's statement he had been a teetotaler for 
the last three years, but previously had indulged freely in 
alcohol. There was no history of syphilis. No loss of flesh. 
Examination of sputum for tubercle bacilli yielded a negative 
result. No definite abnormal physical signs in chest. 

Sir Felix Semon thought care should be exercised in the use of the 
expression “ growth in the inter-arytaenoid fold,” as it was the expe¬ 
rience of practically everybody that benign growths in that region— 
he referred to real new formations—were amongst the greatest rari¬ 
ties of laryngological literature. Was Dr. Potter’s case not much 
more likely to be an instance of inflammatory thickening, and in such 
circumstances was the use of the term “ growth ” justifiable ? 

Mr. Bowlby agreed with Sir Felix Semon, and asked if Dr. Potter 
would be willing to alter the title of the case. The term “ growth ” 
so definitely conveyed the idea of tumour formation as apart from 
inflammatory swelling that it was unfortunate to use it in a case like 
that before them. 

Dr. Potter said he had had some doubt in describing the condi¬ 
tion as a “ growth.” Perhaps “ excrescence ” or “ swelling ” would be 
more applicable. 

Dr. William Hill thought the condition was not like an ordinary 
swelling or infiltration, if by that was meant something mound¬ 
shaped. It seemed to him rather of the shape of the typical tuber¬ 
cular growth in that position than of a mere tubercular swelling. 


Case of Lupus of Nose and Pharynx. 

Shown by Dr. Watson Williams. About two years ago 
patient, set. 21, had a violent blow on the nose at football. The 
nose bled freely, and shortly afterwards became more or less 
persistently blocked on the left side. Crusts and discharge 
shortly after came from the left nostril, and after an interval of 

§ 



76 


about six months from the right nostril also. About this time 
a bicycle fell on his nose, producing the depression of the bridge 
so suggestive of syphilitic disease. There is no history of 
syphilis, nor any family history of tuberculous disease. 
Latterly the throat has been dry, and the voice husky. 

The cartilaginous septum has completely disappeared, but I 
find no evidence of necrosis of the bone. The inferior turbinal 
and the remains of the septum appear to be superficially infil¬ 
trated with lupus. 

The soft palate has been partly eaten away, and the remains of 
the uvula shows lupus nodules, with clean superficial ulceration 
in parts. 

The posterior pharyngeal wall and the vocal processes in the 
larynx show lupus infiltration. 

I was suspicious of a syphilitic infection, and put the patient 
on large doses of iodide of potassium, and also on mercury; but 
he developed iodism, while the local conditions only progressed. 
The local application of lactic acid 50 per cent, does not appear 
to control the disease. I have applied nitric acid to the 
pharynx and soft palate, and I propose to curette away as much of 
the infiltrated tissue as seems justifiable, and apply nitric acid. 

Mr. Bowlby thought the suggestion, based on the statement of the 
patient, that the condition was the result of injury an exceedingly 
unlikely supposition. He believed it a case of syphilitic disease. 

Dr. William Hill pointed out that the disease actually had 
extended to the larynx, there being an ulcer in the inter-arytsenoid 
region, and there was also considerable destruction of bone in the nose, 
which was against the diagnosis of lupus. 

Dr. StClair Thomson also believed it syphilitic. A blow would 
have to be a very straight one in the middle line of the nose to flatten 
it out as it had flattened this one. He did not think lupus, though it 
might destroy the nose very extensively, produced such retraction as 
this case showed; and the pharyngeal condition confirmed this view. 
Dr. Watson Williams had previously shown a case of true tuberculosis 
of the septum which had been treated with tuberculin, and he would 
suggest the idea of testing this case in that way before going in for 
any extensive treatment. If that procedure gave a negative reaction 
it might be advisable to treat the patient actively with inunctions of 
mercury before taking surgical measures. 



77 


A Case of Laryngeal Disease for Diagnosis. 

Shown by Dr. W. H. Kelson. E. B—•, a girl aet. 15, came 
complaining of loss of voice; duration two years ; onset 
gradual. 

Family history .—Parents alive; no history of consumption in 
family, but father has had bad throats, and sisters and brothers 
have had bad throats and eyes. Patient suffered from abscesses 
in the neck as a child. Three years ago suffered from inter¬ 
stitial keratitis, and as the eyes recovered deafness came on and 
loss of voice. 

Conditwn on admission .—Patient is fairly well nourished. 
Auscultation of chest showed nothing abnormal; corneas hazy. 
Central incisors rather pegged. Scars of old glandular disease 
in submaxillary regions. 

Larynx .—Pinkish growths, having their origin apparently 
from the ventricles, obscure the view of the cord on both sides; 
portions of the growth have a warty appearance, other parts are 
smooth; the larynx is not at all tender on external manipula¬ 
tion. 

Three months after admission: the patient has had two grains 
of Hydrarg. c Creta in pill every day, and small portions of the 
growth have been removed with some improvement of the voice. 

Present condition of the larynx: on the right side the growth 
has much receded and a slightly thickened cord is plainly 
visible. On the left side there is still much growth and only 
occasional glimpses of the cord can be obtained. The left side 
also does not move so freely as the right, and the arytsenoid 
outline is not quite so sharply defined. 

Sir Felix Semon thought it probably a case of syphilitic peri¬ 
chondritis with fixation of the crico-arytsenoid joint and partial luxa¬ 
tion of the arytsenoid backwards, the processus vocalis springing more 
forward than was natural. With the other evidences to that effect, 
the explanation that it was a case of congenital syphilitic disease was 
a very likely one 

Mr. Spencer also thought it due to congenital syphilis. 

Mr. Bowlby agreed with this opinion, and remarked that it was 
not a common experience to find the swelling clear up as it had done 
on the right side, leaving a perfectly free cord. 



78 


Case op Polypoid-looking Growth springing from the Right 

SuPRA-TONSILLAR FOSSA. 

Shown by Mr. Arthur Cheatle. A female patient set. 21 
had complained of discomfort in swallowing for a month. 

On examination a smooth, pale growth, about one and a 
quarter inches in length, was seen projecting from the supra- 
tonsillar fossa and hanging over an enlarged tonsil but quite 
distinct from it. Sections of the growth will be shown at the 
next meeting. 


A Case of Old Syphilitic Disease in the Nose of a Woman 

AGED THIRTY-SIX. 

Shown by Dr. Donelan. There was. extensive destruction of 
all the intra-nasal structures. He desired the opinion of the 
Society as to whether a patch of thickened and inflamed skin on 
left side of nose was not an added tuberculous infection. There 
had been no change in this patch under anti-syphilitic treatment, 
though in the ten days it had been under observation the intra¬ 
nasal disease had been completely arrested. 

Mr. Bowlbt thought this case probably syphilitic. The term 
“ lupus ” might be employed indicating that it was a syphilitic lupus, 
but he did not think it at all like a tubercular affection. 

Sir Felix Semon suggested that a tuberculin test might be 
applied. 


Case of. Miliary Tuberculosis of Fauces, &c. 

Shown by Dr. Lambert Lack. Patient, a female set. 26, is 
very anaemic and wasted. She has suffered from a cough for 
about two years; has been wasting for six months ; and for the 
last six weeks has complained of sore throat. 

On examination, the mucous membrane of the fauces and 
adjacent part of tongue and pharynx on the left side is reddened 
and slightly swollen. The surface is covered with minute, 
superficial, clearly-defined ulcers, with ashy grey, sloughy bases. 
At the periphery of the affected part the ulcers are distinct, and 



79 


vary in size from a pin’s liead to a millet seed. In the centre 
the ulcers are partly confluent. 

The upper part of the larynx, the epiglottis, ary-epiglottic 
folds, and aryteenoids are greatly swollen, and covered with 
superficial worm-eaten ulceration. The cords, as far as they can 
be seen, are normal. The voice is clear but weak. There is 
active phthisis at both apices with cavitation at the right. 

At the first glance the condition of the fauces much resembles 
herpes. 

Mr. Bowlby said the condition was not at all a common one, and 
described the case of a young man, set. 24, who came to him com¬ 
plaining of a tickling cough and some trouble in the back of the 
throat, but was supposed to be otherwise in tolerably good health. 
The affection was well marked, though not so far advanced as in Dr. 
Lack’s case. It appeared to be a case of miliary tuberculosis, and 
heralded a very considerable extension of the disease, from which the 
patient died in three months time. 

Dr. Herbert Tilley described an identical case, that of a man 
set. 65, which was under his care last year, and in which there was 
laryngeal tubercle as well. The condition extended right on to the 
hard and soft palate, the base of the tongue also appearing super¬ 
ficially ulcerated. After a short while the patient died. Before coming 
to the hospital he had been practically starved because of the pain in 
swallowing. Nothing relieved the dysphagia so much as orthoform, a 
little of which blown on his pharynx and palate enabled him to 
swallow anything given him with perfect comfort for some twelve 
hours after the application. 

Sir Felix Semon spoke of a case he was at present treating for 
laryngeal tuberculosis in which orthoform was proving of great use. 
The maximum effect of the application, according to the patient, was 
experienced in an hour; it lasted for about three hours. The suscepti¬ 
bility of different patients to its influence seemed to vary. Orthoform 
was not poisonous, and in that respect more advantageous than 
cocaine; it could in an emergency be left in the hands of untrained 
people with impunity. Its effect was also more continuous. For the 
application to be effective there must, in his hitherto limited experience, 
be a breach of surface. In cases of simple infiltration he had so far 
found it had no effect whatever. It was a useful application in cases 
where only palliative measures could be adopted. It had been lately 
recommended in Germany as an excellent thing in vasomotor coryza; 
but in two cases in which he had tried it, it had been absolutely in¬ 
effective. 

Dr. MacGeagh had also obtained good results from the use of 
orthoform in tubercular disease of the larynx, the effect lasting for 
two hours. 

Dr. StClair Thomson said he had tried orthoform to relieve the 
dysphagia after removal of the tonsils, but with no success. The pain 
in that case seemed to be more traumatic. 



80 


Dr. Lack had found orthoform extremely useful in preventing the 
neuralgia which occasionally followed the dressing of wounds, as in 
the case of the mastoid or maxillary antrum when the cavity was 
packed. 


Case of Lympho-sarcoma (?) of Tonsils. 

Shown by Dr. Lambert Lack. The patient, a man aet. 46, has 
noticed a small swelling on the left side of the neck for six 
years. The swelling has been increasing ever since, but during 
the last twelve months it has grown more rapidly. Patient has 
always been subject to attacks of acute tonsillitis. 

Present condition .—Both tonsils are enlarged, the left being 
very large, projecting beyond the mid-line, and very broad. It is 
firm, not densely hard, and is not ulcerated. There is a large, 
hard mass of glands in the anterior triangle on the left side, 
firmly fixed to the angle of the jaw and the surrounding muscles 
&c. A few small glands, also fixed, in a similar position on the 
right side. The left side of the tongue is paralysed and com¬ 
pletely atrophied. The larynx is pushed over to the right. The 
pupils are unequal, the right being the larger. The man is in 
good health, has no pain, can swallow easily, and complains only 
of the swelling in the neck. 

Mr. Bowlby thought it a case of malignant disease, more probably 
lymphosarcoma than carcinoma, and that it was inoperable. The 
glands seemed to be more movable, rounded, and circumscribed, less 
hard, and causing less infiltration of the tissues and contraction 
around than in carcinoma. After a lymphomatous mass had existed 
for years it often took on more rapid growth, and in some cases was, 
in others was not, amenable to arsenic. 

Mr. Spencer said that the glands seemed hard and the infiltration 
of the hypoglossal nerve suggested that a good deal of the enlarge¬ 
ment of the tonsil was secondary or inflammatory, and that there 
must be a deep-seated ulcer behind the tonsil which had extended 
to the glands. Unless it be the very malignant, infiltrating, and 
bleeding forms, lymphosarcoma caused a large tumour in the throat, 
and had been easily removed. It also generally occurred in women. 
From the infiltration of the hypoglossal nerve he should have thought 
the disease carcinoma. 


Case of Cyst of Thyro-hyoid Bursa. 

Shown by Dr. Fitzgerald Powell. Patient, a man aet. 40, states 
that seven or eight months ago he caught cold, after which he 



81 


felt a small swelling on the outside of his throat which, after a 
time, completely disappeared, but on again catching cold the 
swelling returned and has gradually got larger ever since. 

There is no tenderness on pressure and no pain and the tumour 
gives rise to no inconvenience. 

On presenting himself at the hospital, a round, movable, 
fluctuating tumour, the size of a pigeon’s egg, was felt to the 
left of the thyroid cartilage. It moved up and down on swal¬ 
lowing, and apparently was attached above to the hyoid bone. 

I considered this to be a cyst of the thyro-hyoid bursa. 

Mr. Bowlby thought that, on account of its lateral position and its 
feel, it might turn out to be a cyst of the pyramid of the thyroid gland 
on the left side. Bursal cysts he believed to be more in the middle 
line. In the case of bursal cysts passing up behind the hyoid, it was 
better to leave them alone unless they caused much trouble. He was 
inclined to advise removal in the case of this laterally placed cyst, 
although it did not at present give much inconvenience. 

Dr. Pegler asked if members had met with successful results of 
operations in such cases. 

Mr. Bowlby said he had successfully operated on a patient who had 
been three times previously operated on for a sinus left after removal 
of a bursal cyst. He had seen other cases cured after operation, but 
they were certainly very troublesome. 

Dr. Fitzgerald Powell asked whether tapping or injecting should 
be employed when these cases were not operated on. 

Mr. Bowlby thought it would not be wise. The cyst should either 
be left alone or simply removed. 


Case op Laryngeal Ulceration. 

Shown by Dr. Fitzgerald Powell. Patient, a man aet. 23, 
complains that in December of 1898 he caught a severe cold in 
his throat, accompanied by cough and loss of voice, from which 
he had, however, quite recovered under treatment by his medical 
attendant. 

In March, 1899, the loss of voice again occurred, and has 
continued to get worse up to the present. He says he has no 
pain or expectoration and no difliculty in swallowing. He has 
not lost weight or flesh, but, on the contrary, has gained both. 

Laryngoscopic examination reveals considerable swelling and 
redness of the whole of the larynx, particularly the ventricular 
bands, cords, and inter-arytsenoid region, the swelling extending 



82 


on to the under surface of the arytaenoids themselves. The vocal 
cords are much thickened and irregular, and about the centre of 
the right cord is a dirty-looking greyish patch of ulceration and 
another at the posterior end of the left cord. The arytaenoids 
are red in colour and are not oedematous. 

There is no history or evidence of syphilis, and careful exami¬ 
nation fails to reveal any tubercular disease in lungs or else¬ 
where. His voice has slightly improved under treatment by 
iodide of potassium and soothing inhalations. 

Dr. Herbert Tilley thought the case was a tubercular one, and 
suggested that the patient’s evening temperature should be taken for a 
fortnight. It was possibly true there were no physical signs in the 
lungs, but.in cases of tubercular disease of the larynx where physical 
signs in the lungs had been slight the evening temperature often gave 
a good clue as to the nature of the disease. 


Case op Perverse Action op Yocal Cords. 

Shown by Dr. Herbert Tilley. Patient is a female eet. 23, of 
markedly neurotic temperament who sought hospital relief for 
loss of voice of five weeks’ duration. 

Inspiration was accompanied by laryngeal stridor, and every 
few seconds the patient made a curious barking noise which 
could be scarcely called a cough. Examination showed that the 
vocal cords were adducted during inspiration. The passage of 
a laryngeal brush through the glottis practically cured the 
symptoms. 



PROCEEDINGS 


OP THE 

LARYNGOLOGICAL SOCIETY OF LONDON. 


50th Ordinary Meeting, May 5th, 1899. 

F. de Havilland Hall, M.D., President, in the Chair. 

William Hill, M.D., ) a , . 

Lambert Lace, M.D.. f Secretaries. 

Present—33 members and 9 visitors. 


The minutes of the previous meeting were read and confirmed. 

The following gentleman was nominated for election at the 
next meeting: 

Charles Heath, F.R.C.S., 3, Cavendish Place. 


DISCUSSION ON ASTHMA IN ITS RELATION TO 
DISEASES OF THE UPPER AIR-PASSAGES. 

The President in a few introductory remarks said that it had been 
decided to devote this meeting to a discussion upon “ Asthma in its 
relation to Diseases of the Upper Air-passages.” This subject in many 
respects was a purely medical one, and illustrated the importance of 
the laryngologist being not only a surgeon but an able physician. 
He was glad to announce that Dr. Percy Kidd had consented to open 
the discussion with the medical aspect of the case, and that Dr. P. 
McBride would follow, and treat the subject from the point of view 
of those who practised more especially in the diseases of the upper 
respiratory tract. 

Dr. Percy Kidd said: In accepting the invitation of the Council to 
first series—VOL. vi. 6 



84 


assist in opening the present discussion, I felt more than the 
traditional hesitation professed on such occasions from the conviction 
that there must be many members of the Society who have had a 
larger experience of the subject in certain of its aspects. But hearing 
that my task was to be shared with Dr. McBride I took courage, for 
I had the assurance that any deficiency on my part would be more 
than made good in his address. In order to promote discussion and 
not to occupy too much time I shall endeavour to make my remarks 
as short as possible, avoiding any attempt to discuss the literature of 
the question, and dealing mainly with matters of which I have had 
personal experience. According to the generally prevailing view, 
asthma is essentially a neurosis, in which the respiratory system is 
predominantly engaged, though reflex relations with other organs are 
often manifested. In speaking of asthma I refer only to what is 
commonly described as bronchial asthma, no mention being made of 
cardiac or renal asthma. It is well known that nasal symptoms, 
sneezing, hypersecretion, and obstruction of the nares, are not 
uncommonly met with in connection with asthma, and great attention 
has been devoted to this relation since Yoltolini succeeded in curing 
a case of asthma by removing nasal polypi. The pathology of the 
asthmatic seizure is still somewhat uncertain, the theories most in 
favour ascribing the dyspnoea either to spasm of the bronchial muscles, 
or to vasomotor dilatation of the blood-vessels of the bronchi. A 
considerable advance in our knowledge was undoubtedly made when the 
close relations of bronchial and hay asthma became recognised, for a 
strong side-light was thereby thrown on the pathology of the asthmatic 
paroxysm. In view of the phenomena of hay fever one can hardly 
doubt that vascular dilatation plays a very important part in the 
production of asthma, whatever the influence of spasm may be, and 
the tenacious pearly sputum of asthma with its peculiar spiral threads 
is quite as easily explained according to this view as by the assumption 
of a special form of bronchiolitis. 

To return to the subject of the relation of nasal disease to asthma. 
It appears to me that the frequency of this association has been much 
exaggerated, particularly by Bosworth, who says, to quote his own 
words, that “ a large majority, if not all cases of asthma are dependent 
upon some obstructive lesion in the nasal cavity.” It is assumed by 
this writer and others that nasal symptoms in asthma are invariably 
the result of some definite local lesion, and that asthma is a reflex 
result of the morbid condition of the nose. It cannot be denied that 
nasal symptoms may precede, accompany, or alternate with attacks of 
asthma, but the evidence forthcoming in support of the view that the 
two groups of phenomena necessarily stand in the relation of cause 
and effect is not altogether convincing. It cannot be said that there 
is anything characteristic in the nasal changes found in asthmatic 
subjects polypi, periodical swelling of the mucous membrane of the 
inferior turbinal and other parts, hypertrophic rhinitis, cedematous 
swelling over the cartilaginous septum, and various obstructive de¬ 
formities, such as spurs and deviations of the septum. These condi¬ 
tions are common enough, and yet it is quite the exception to find 
them associated with asthma. According to my experience, the state 



85 


of the nasal cavity in asthmatic persons is generally substantially 
sound. The strongest proof of the influence of nasal disease upon 
asthma consists in the relief to the paroxysms of dyspnoea that 
sometimes follows surgical treatment of the nose. 

In some cases (I should say, a very few) the amelioration is so 
marked as to suggest that the asthma was a reflex result of the nasal 
disorder. But in most instances any improvement that ensues is 
temporary and incomplete. If we remember what marked mitigation 
of the asthmatic seizures may follow an unimportant modification of 
drugs, a change of residence, or some powerful emotion, we shall be 
loth to credit any slight improvement to surgical operations on the 
nose. One of the worst cases of asthma I have seen obtained more 
relief from a course of compressed air-baths than from any other 
measure, including hypodermic injections of morphia. It is hard to 
resist the suspicion that the success of the compressed air-bath was 
largely due to psychical influences, and some of the apparent triumphs 
of nasal surgery are perhaps susceptible of a similar explanation. 

To sum up my own experience. I have seen two or three cases of 
asthma associated with polypi, and in two of these removal of polypi 
was followed by manifest relief to the asthmatic condition. Unfortu¬ 
nately the patients were lost sight of, and their subsequent history is 
unknown to me. A moderate degree of swelling of the inferior 
turbinal, more particularly of its posterior extremity, was met with in 
a few asthmatic subjects. But in only one instance was there any 
noteworthy obstruction to nasal respiration, and except in the case of 
this patient, I have not felt justified in proposing cauterisation or 
removal of the swollen tissues. The patient referred to remains under 
observation and has been recommended to undergo appropriate local 
treatment, the uncertainty of the result qua asthma having been 
explained to him. Periodical swelling of the inferior turbinal may 
have existed in some cases from the history of passing nasal obstruc¬ 
tion given by the patients, but I have had no opportunity of verifying 
this surmise. I do not remember to have seen any instance of gela¬ 
tinous swelling of the anterior septal region, or of any marked 
development of spurs, in this connection. No cases of asthma with 
adenoid vegetations in the naso-pharynx have come under my observa¬ 
tion. Of localised areas of hypersesthesia in the nasal cavity I 
have no experience to offer. It may seem that this account reads 
very like a confession of inexperience. But it must be borne in mind 
that the cases to which I refer presented themselves on account of 
asthma primarily, whereas asthmatics that apply for relief to 
specialists in the domain of laryngology and rhinology, are likely to 
comprise an unduly large proportion of cases of pronounced nasal 
disease. The clinical history of cases in which sneezing and other 
symptoms of hay fever alternate with, or are succeeded by, spasmodic 
dyspnoea may be regarded as supporting the reflex nasal origin of 
asthma; and the same view may be taken of asthma induced by the 
smell of the cat, horse, dog, powdered ipecacuanha, violets, roses, &c. 
But, as Semon and Watson Williams point out, where the attacks 
ensue on the inhalation of irritant particles like pollen and ipecacuanha, 
it is not impossible that asthma may be the result of a bronchial 



86 


rather than a nasal reflex, some of the fine powder reaching the lower 
air-passages as well as the nose. It is generally admitted that for the 
production of hay fever at least two factors are required, viz. an 
external irritant and a morbidly sensitive nervous system. Some 
writers consider that a further element, a pathological condition of 
the nasal mucous membrane, is also necessarily present, a statement 
which I cannot accept as correct for all cases. I am inclined to 
believe that too much is now-a-days expected of the nose, and the 
result is that the happy individuals that would be certified as 
possessing an ideally healthy nose are comparatively few. If rhino- 
logical examination is conducted according to this counsel of perfection, 
we need not be surprised that most if not all patients with nasal 
symptoms are found wanting. 

The following conclusions appear to be justified. In some cases 
asthma is relieved by the removal of polypi, though the explanation 
of this effect is still very obscure. Hay asthma may sometimes be 
benefited by treatment of morbid conditions of the nose and naso¬ 
pharynx, an experience of which, at present, I can claim no personal 
knowledge. The prospects of improvement in such circumstances as 
in the case of polypi seem to be very uncertain, but in the presence of 
definite nasal stenosis local treatment is not only warranted but 
advisable. In the ordinary form of asthma uncomplicated by hay 
fever or polypi, nasal symptoms are not uncommon, but the nose is 
generally healthy and requires no local treatment, though a spray of 
cocaine is said to give relief in some cases. Here the nasal symptoms 
may be regarded as merely part of a general vaso-motor neurosis of 
the respiratory tract. The history of some instances of hay asthma, 
in which spasmodic attacks persist in the winter although the nasal 
symptoms are then in abeyance, shows how important is the neurosal 
element, quite apart from the existence of peripheral irritation of the 
nares. 

Dr. McBride said: In addressing an audience of specialists it 
would be out of place—it would almost be an impertinence—to con¬ 
sider the relation of asthma to the upper air-passages from an his¬ 
torical point of view. The names of Voltolini, Hack, B. Frankel, and 
many others will at once occur to you all as pioneers whose teachings 
have been of great value in calling attention to a connection which is 
admitted by all thoughtful physicians and specialists of to-day. 
Again, it would be equally out of place to ask you to follow me 
through the immense mass of literature which relates to reflex neuroses, 
of which asthma is probably the most important. This literature is 
in its main facts, no doubt, familiar to all here. As you are aware, it is 
abnormal conditions of the nose which have been most generally found 
to cause asthma, and it has seemed to me, therefore, best to begin my 
remarks with the heading— 

Nasal Asthma. 

The most generally known form is undoubtedly the variety which 
occurs in the course of hay fever and allied conditions. You are all 
familiar with the chain of events in these cases—the symptoms of 
coryza induced by the pollen of grasses and flowers, dust, and the like, 



87 


or more rarely by emanations from animals, chemicals, and a variety 
of other causes, followed in certain persons by asthma which differs in 
no respect from the affection as commonly described in our medical 
text-books. In this chain of events we have an illustration of nasal 
asthma in its most familiar form, and it is generally admitted that 
hay fever requires for its development a neurasthenic, or at least a 
neurotic condition which acts as a predisposing cause. Of course you 
are all aware that in a proportion of cases we find more or less marked 
abnormalities in the nasal passages, but I am quite sure that in a very 
large number of instances these parts are, excepting during the attacks, 
for all practical purposes normal. 

I take it that the course of events is as follows : the specific irritant 
touches the mucous membrane, which, in order that the other phe¬ 
nomena may result, must be hypersesthetic; erectile swelling then 
occurs followed by hypersecretion. In certain persons a reflex asthma 
is set up by the nasal irritation. It is well known that hay fever is to 
some extent dependent upon race, thus Anglo-Saxons are more prone 
to be affected than persons of other nationalities. It seems also to be 
influenced very materially by social position, for I presume that most 
of us have observed it either chiefly or entirely among the better or, 
shall I say, wealthier classes. Speaking for myself I have seen 
numerous cases, but with one or two exceptions they have always 
occurred in private patients. 

A less common but still a relatively common form of nasal asthma 
is that which seems to depend upon the presence of nasal polypi. In 
these cases the nostrils are usually not completely occluded, so that the 
presence of the growths may escape observation unless attention be 
directed to this point. I have now seen a considerable number of 
people who suffered from asthma, and in whom nasal polypi existed. 
Where this combination occurs I consider that we may very reason¬ 
ably expect to benefit the former by removal of the latter. It is 
somewhat difficult to explain why small polypi should be more liable 
to cause asthma than large growths, but probably the former being 
more mobile are for this reason more likely to irritate the mucous 
membrane. 

In certain cases of hypertrophic catarrh and deviations, or out¬ 
growths from the septum, we also meet with asthma which may be 
benefited by local treatment. Sometimes the pathological condition is 
obvious and so marked as to interfere with nasal respiration, and thus 
give rise to local discomfort. In such cases there can be no great 
difficulty in determining upon the proper line of treatment. In other 
instances, however, deviations from the normal are slight—so slight 
that perhaps we should not be justified in calling them pathological. 
Gentlemen, I know I am treading on thin ice when I say that we have 
as yet no satisfactory definition of a normal nose. We know very 
well what the anatomically correct organ should look like—the nasal 
septum should be straight and have no outgrowth, the middle and 
inferior turbinated bodies should be of a certain size, shape, and 
colour. This is the ideal, but we rarely find it, just as it is uncommon 
to find perfection elsewhere in this world. I have introduced this 
matter in order to lead up to the fact that we are often called upon to 



88 


make rhinoscopic examinations of asthmatics, and frequently find 
nothing, which if discovered in another person we should be justified 
in stigmatising as pathological. I think I may say without offence 
that rhinologists all over the world are divided into two classes. One 
holds that it is most desirable for a man’s nose to be symmetrical, not 
only externally, which we all admit, but also internally. Gentlemen 
of this persuasion make it their business to straighten every septum 
which is not mathematically straight, to remove any excrescences 
which they find disagreeable to the examining eye, and finally to 
reduce the turbinated bodies to such size as seems proper to them. 
Those who belong to the opposite camp tend to limit treatment to 
cases in which the condition of the nose is such as to produce nasal 
symptoms appreciable as nasal by the patient. I fancy that most of 
us here hold with the second class, and I need hardly say that my 
own views are decidedly conservative with regard to nasal surgery. 
At the same time if these conservative views in their entirety be 
brought to bear upon nasal asthma they may prove misleading, and, 
moreover, if your patient falls into the hands of a nasal specialist 
who believes no nose normal, he may effect a cure where you have 
failed. 

I do not wish to say that I have met with nasal asthma in an abso¬ 
lutely normal nose, but it appears to me that in some asthmatics nasal 
treatment is permissible and even desirable, where the conditions are 
such that on other grounds operative measures would certainly not be 
indicated. Thus, if the bronchial attack be preceded by sneezing and 
nasal hypersecretion, the application of the electric cautery may be 
beneficial, just as it is in some cases of hay fever, even if at the time 
of application the parts are fairly normal. I take it that in some of 
these cases this treatment is beneficial by destroying nerve-endings 
through which reflex vasomotor changes are produced, while in others 
good results are obtained by the formation of cicatrices, which bind down 
the erectile tissue and thus prevent swelling. I do not think, however, 
that in all cases the paroxysm is preceded by nasal symptoms, even 
where nasal treatment may do good. I have, however, found that in a 
considerable proportion of asthmatics there can be detected on the 
nasal mucosa spots which, when touched with a probe, produce cough. 
My experience lias been that in almost every patient who shows this 
phenomenon, the application of the electric cautery to these sensitive 
areas will produce marked amelioration, amounting, in some instances, 
to a practical cure. These cough spots may be met with in any part 
of the mucous membrane, but are most commonly situated on the in¬ 
ferior turbinated body, while occasionally the reflex ai*ea may be 
encountered while passing a probe between a projection from the 
septum and the outer wall. I have said that I consider the presence 
of this reflex cough as an indication in favour of intra-nasal treatment, 
but I have not found that when it is absent such treatment is always 
useless, although in the one case we are entitled to express a convic¬ 
tion in favour of the probability of benefit, while in the other opera¬ 
tive measures must be looked upon as more or less experimental so far 
as the asthma is concerned. I cannot help thinking that the clinical 
value of this symptom has been overlooked, although I have repeatedly 



89 


called attention to it for many years. In this connection a very 
interesting question confronts us, may it not be possible to benefit 
asthma in certain cases by applying the cautery to a normal nostril P 
The fact that we speak of a nasal reflex asthma implies that we admit 
something like the following chain of events : a stimulus travels from 
the periphery to a centre, and there sets up molecular changes, which 
result in a paroxysm of asthma. Observe we admit that an irritant 
applied to the nasal mucosa may effect molecular changes in a centre 
which is responsible for asthma. It almost follows as a carollary that 
we can influence this centre from the nose, and I very much question 
whether many asthmatics—even those with normal noses—might not 
be benefited by the use of the electric cautery, not as a destroyer of 
tissue, but as a counter-irritant. 

It may, perhaps, not be amiss to glance for a moment at the prognosis 
of nasal asthma. I do not think it is ever safe to promise the patient 
a cure, because every thinking rhinologist will admit that the nose is 
rarely, if ever, the only cause of asthma. In cases of polypi, however, 
we can usually do much good by removal of the growths, and when we 
have the introduction of a probe into the nostrils followed by cough, 
the probability of benefit is much increased. In ordinary hypertrophic 
catarrh, and in the case of spines or deviations, the last-named symptom 
becomes of even more significance. 

Asthma caused by othek Parts of the Upper Respiratory 

Tract. 

While nasal asthma is comparatively common, it is in my experience 
rare to have this neurosis produced by other parts of the upper 
respiratory tract. I am aware that cures have been reported after 
removal of enlarged tonsils and after destroying granulations upon the 
posterior pharyngeal wall, but I do not remember to have met with 
such cases myself. On one occasion only have I found asthma 
apparently cured by removing adenoids from a young boy. I have 
thought it well, thus, at the risk of appearing egotistical, to confine 
my remarks to an expression of personal experience and views. To 
discuss the subject by any other method would have occupied much 
time without any commensurate advantage. 

In conclusion, I would venture once more to express my conviction 
that while the upper air-passages may be the exciting causes of asthma, 
its occurrence depends upon some individual predisposition. We can 
therefore hardly speak of cures by local treatment of the nose and 
throat without modifying the expression, and we must not forget to 
use such general remedies and modifications of regimen as have been 
found useful by physicians generally. 

Dr. J. C. Thorowgood expressed his thanks to the Society for 
allowing him to be present as a visitor, and to be able to listen to such 
interesting papers, whose wisdom he admired. He thought with the 
last speaker that it was quite right not to promise the patient cure 
from asthma, and he remembered a case in which he had been 
consulted where, by following this plan, he had been able to prevent 
troublesome consequences. Speaking from his own experience, he 



90 


could not agree with Dr. McBride that asthma was not very often 
associated with adenoid growths; he had come across cases where the 
removal of adenoid growths had much mitigated the attacks of 
asthma, and in one case the patient had been almost free from asthma 
owing to the removal of these growths. He was quite convinced that 
there are certain areas in the air-passages which, when touched, give 
rise to paroxysms of asthma—this had occurred on the removal of 
polypi; one had to be particularly careful not to excite these centres 
in highly neurotic patients. In alluding to the effect of asthma on 
the circulation, he mentioned a case in which, other remedies having 
failed, chloral gave marked relief. Being a dilator of the vessels, 
theoretically chloral ought to answer if, as he believed, the asthma was 
due not to vaso-motor dilatation so much as to violent spasmodic 
contraction of the vessels. 

Mr. Waggett believed that it was very seldom that a causal rela¬ 
tionship between true spasmodic asthma and nasal disease could be 
established on a strictly logical basis. Although he had many oppor¬ 
tunities of meeting with these cases he could remember but one 
instance in which the nasal origin of the trouble was proved with any 
real certainty. The case in question was that of a man of forty, who 
complained of distressing attacks of asthmatic character which had 
persisted for twelve years in spite of medical treatment. The attacks 
occurred at all times of the day but more particularly after lunch, and 
lasted about an hour or so. To quote the patient’s own report: 
“ They commenced with tightness amounting to severe pressure across 
the bridge of the nose; suffocating feeling about the throat, and 
apparent inward pressure from the ears. There was distinct tightness 
of the chest—very little wheeze—but difficult breathing with much 
effort to clear the throat; generally, too, there was dryness of the 
throat, and, on the whole, the feeling was that one would fall down.” 
On examination a very large septal spur was found pressing tightly 
against the right inferior turbinate in its middle part, the nose, in 
other respects, being unusually patent. The spur was removed and 
the attacks immediately ceased. Eight months later the patient 
returned, stating that the attacks gradually recommenced about two 
months after the operation and were again very distressing. A large 
bony bridge was discovered stretching between the inferior turbinate 
and the site of operation. This was removed and the attacks at once 
ceased. Five weeks ago the patient reappeared, stating that the 
attacks recommenced about four months after his previous visit. A 
narrow bony bridge was again found in the former situation. This 
was removed and the patient reported himself as being, for a third 
time, relieved of his attacks. The general conditions of the patient as 
to occupation and place of residence had remained unaltered through¬ 
out the course of the case. On no occasion could an attack be induced 
by experimental irritation of the nasal fossae. The interest of the 
case, which was one of diffuse neurosis embracing the symptoms of 
true spasmodic asthma, lay in the sequence of events, the cardinal 
point being the disappearance of the special symptoms on three 
occasions as a sequel to three almost identical intra-nasal operations. 
Even in this case a causal relationship between the neurosis and the 



91 


nasal lesion could not be absolutely established, as no evidence was 
forthcoming that the reappearance of symptoms coincided in point of 
time with the bridge formation. The speaker was compelled to 
believe that true nasal asthma was a rare disease, and inasmuch as it 
was often spoken of as an everyday occurrence, he thought it would 
be valuable if members would take this opportunity of furnishing 
statistical data. 

Dr. MacIntyre (Glasgow) said, while he could fully understand 
the desire to obtain exact statistics we had to remember one difficulty. 
The patients who came back to us were very often those in whom the 
treatment had been unsuccessful, judged from the standpoint of being 
cured, whilst those that got relief were not so easily traced. Judged 
from every standpoint, however, he thought that from his own experi¬ 
ence he could recall a few cases of which it would be justifiable to use 
the term cured. These were a very small minority, and, like others, his 
experience had been such as to induce him to speak of relief rather 
than cure where success was claimed for treatment. He thanked both 
gentlemen for the manner in which they had introduced the subject, 
knowing the difficulties in opening such a debate. On the one hand, 
while there might be over-enthusiasm and too great a tendency to 
surgical procedure, nevertheless the openers of such a discussion had a 
certain responsibility in presenting their views, because it was possible 
to throw such an amount of doubt upon the matter as to damp the 
enthusiasm and ardour of those who are inclined to investigate this 
difficult and as yet experimental branch of surgery. Further, it was 
exceedingly difficult before beginning the treatment of a case to give 
an exact prognosis, notwithstanding the fact that in a certain number 
of cases, as a matter of experience which could scarcely be conveyed in 
language, the surgeon felt more hopeful than in others. Asthma 
might lie induced from an irritation of the nasal membrane, but other 
causes might exist in the same patient. He gave instances of the 
difficulty of arriving at a prognosis by quoting two cases in which 
patients had been sent for surgical treatment in the nostrils, and in 
one of which it was ultimately found that the irritation was due to a 
sarcoma at the base of the skull, and a second was ultimately traced 
to a neoplasm in the mediastinum. There was one point which had 
not been spoken of as yet, and that was the information which might 
be got from a study of the action of the diaphragm, which was not 
always the same in cases of asthma, but which could now be observed. 
At present he was engaged in a series of investigations not yet pub¬ 
lished bearing upon this, and it was not at all impossible that, in 
some cases at least, light would be thrown upon the subject by the 
differential diagnosis which might be got by means of the X rays. 

Dr. Herbert Tilley said that his experience was very similar to 
Mr. Waggett’s, and he thought that only a minority of cases of 
asthma would be found amenable to surgical treatment of the nose. 
Cases of inherited asthma had received no benefit from intra-nasal 
treatment at his hands, and his experience in these cases was, perhaps, 
larger than is usual, because both in his own and his wife’s family 
asthma was an unfortunate constitutional legacy. He had recently 
operated on a young sister-in-law who had commenced her asthmatic 



92 


career—the paroxysms coming on at night or even in the daytime 
after violent exercise, e. g. cycling uphill or horse-riding. He removed a 
post-nasal growth, and later on the anterior ends of both inferior 
turbinates because they were producing marked nasal obstruction, and 
the patient was always suffering from sneezing fits and severe colds. 
Here was a case which seemed to be an excellent test case for intra¬ 
nasal treatment. It was now nearly two months since the treatment 
was carried out, the patient expresses herself as delighted with the 
comfort of free nasal respiration, but the asthma attacks are “ about 
the same, if anything a little better, but the medicine (Potassium Iodide, 
stramonium and arsenic) keeps the attacks off as long as it is taken.” 
He thought that such would be the experience of others in inherited 
cases, as also in gouty asthma; at the same time he would not deny that 
occasionally cases might be immensely relieved by intra-nasal treat¬ 
ment, on the same principle that epileptic attacks had been completely 
cured by removal of nasal polypi, but such cases would be a minority. 
The speaker described his own personal experience of asthma, which 
was typical of “ place asthma,” i. e. in certain parts of England he was 
almost sure to get an attack about 2 o’clock in the morning, the 
attacks lasting some two hours and then completely passing off. In 
London he was always free, and if returning from the country with an 
attack upon him, nothing produced such splendid relief as a journey 
by the underground railway. Recently going down the Channel he 
had had two severe attacks whilst in his cabin below deck, the attacks 
passing off immediately he went on deck. He considered his case was 
probably gouty asthma, as his father was a martyr to the latter 
disease. His asthma attacks were not preceded by any nasal irritation 
or catarrh, and in spite of the suggestion of his friends he scarcely 
thought it worth while at present to undergo nasal treatment. With 
reference to destroying the sensitive areas in the nasal mucous mem¬ 
brane referred to by Dr. McBride, he had almost discarded the 
galvano-cautery for this purpose, because trichloracetic or even glacial 
acetic acid seemed to possess more penetrative and permanent 
properties. The only cases in which he could consider he had cured 
asthma by surgical treatment were those in children where the disease 
was associated with large tonsils, post-nasal growths, and accompany¬ 
ing bronchial and nasal catarrh with much secretion—these were very 
favourable cases, but he could not say the same for cases of genuine 
spasmodic asthma in the adult. 

In reply to Dr. MacIntyre Dr. Herbert Tilley said that he thought 
it was scarcely scientific in a test case to give iodide of potassium whilst 
surgically treating the nose, because they all knew what relief that drug 
alone would give. 

Dr. Scanes Sptcer considered that Dr. McBride had very judici¬ 
ally reviewed the question under discussion. On the present occasion 
he would desire to remark on two points mentioned in Dr. McBride’s 
opening, i.e. (1) the word “experiment” as applied to a surgical 
measure; (2) the term “ a normal nose.” As to the word “ experi¬ 
ment,” the public is apt to be misled by ambiguous terms. The word 
experiment is ambiguous. Most persons regard it, used surgically, as 
equivalent to a vivisection or laboratory research, and as implying 



93 


something rash and risky—a kind of “kill or cure” procedure. 
This idea is widespread. The consequence is that a critic who 
describes a suggested procedure as “ an experiment ” tends to excite 
a prejudice against it and to prevent dispassionate consideration, 
whereas all the critic is justified in predicating is, that the proce¬ 
dure is not certain to “cure radically” every case—which, indeed, is 
true of all therapeutic measures. Unless, indeed, he desires to be 
understood as meaning by the word a procedure of which the 
iesult is sure and unvarying, as in a chemical or physical experi¬ 
ment. Since, then, the idea that any given surgical procedure is 
not an infallible cure for every case can be expressed in unambiguous 
English terms, and those not calculated to excite prejudice, the speaker 
thought that the use of the word experiment in clinical therapeutics 
was inappropriate and unwise, and should be discouraged. He re¬ 
gretted that it had, in this connection, crept into Dr. McBride’s 
excellent book. With reference to “ a normal nose ” no definition had 
yet been agreed upon. Could any nose be called normal in which the 
patient was conscious of suffering or discomfort ? Thus, although no 
spur, polypus, or other gross lesion might be found on examination, 
the nose may regularly be obstructed at night and cause insomnia, rest¬ 
lessness, &c., as a consequence of the nasal discomfort; that is to say, 
a nose which may appear normal during the day when patient is erect, 
becomes insufficient at night when he is horizontal. And here a protest 
should be entered against a widespread notion that spurs should be 
operated on qua spurs and as deviations from a theoretical symmetrical 
ideal. Such a procedure should be strongly discountenanced. The 
correct indications for attacking a spur are: (1) that it acts as an im¬ 
pediment to the due physiological intake of air, with consequent 
alteration of normal air tension on the nasal mucosa and in the pneu¬ 
matic accessory spaces; (2) that it is in abnormal contact with other 
intra-nasal structures, either permanently, or periodically on mucosa 
turgescence, and leads to irritative and reflex disturbances. Hence, a 
large spur may often be ignored if in a cavity otherwise roomy, where¬ 
as a small one in other relations and situations demands attention. It 
is this insufficiency of passage and presence of abnormal contacts 
which form the true criteria of interference. Hence, a nose which 
presents no obvious pathological changes, and may so be regarded in 
one sense as normal, is abnormal, if from arrested evolution its 
channels are inadequate to admit the air demanded by the organism of 
which it is a part. His own experience had convinced him of the 
positive and great benefits derived in many cases of “asthma” from 
thorough nasal treatment, which was not to be expressed in terms of 
polypi and galvano-cautery. A few patients were prepared to maintain 
they were cured, while the majority obtained great relief; but the 
speaker’s cases were not, with very few exceptions, drawn from the 
class of fossil asthmatics which would gravitate to the chest physicians, 
and were in nearly all instances less confirmed cases of spasmodic 
dyspnoea, in which other troubles—usually nasal—were as prominent as 
the asthmatic condition. 

Dr. P. Watson Williams (Bristol) reported one case in which 
intra-nasal treatment, in conjunction with general treatment, had 



94 


apparently resulted in practically a complete cure, as for three years 
the patient had been free from asthma. J he patient came to him live 
years ago with constant asthma, which had persisted more or less for 
eighteen years. She was having at least two paroxysms every twenty- 
four hours, as they came on both day and night. The mucous membrane 
of the nose was very hypersesthetic, but there were no particular spots of 
special irritability, nor did sneezing, cough, or asthma occur on probing. 
The mucosa over the septum and turbinals was cedematous, and to such 
a degree overlaid the middle turbinals as to be polypoid. The polypi 
were snared and the bases and surrounding sodden area cauterised. 
Violent attacks of paroxysmal sneezing alternated with the attacks of 
asthma, and the patient experienced marked temporary relief from the 
use of a cocaine spray. There was therefore good reason to believe 
that the intra-nasal irritation had a close connection with the asthma 
in this case. 

We do not know for certain what is the actual condition of the 
bronchi in asthma, but it seemed to him that there is sufficient ground 
for believing that the paroxysm is due to excessive contraction of the 
bronchial muscular coat and of the bronchial arteries. He was unable 
to accept the view that it is due to vascular dilatation. Radcliffe Hall, 
cited by Walshe, considered the use of the bronchial muscular coat 
was by its “ tonus ” to counteract the effect of coughing. But is it 
not possible that it, like the alae nasi and vocal cords, may rhythmically 
dilate and contract with deep inspiration and expiration, and that in 
asthma the normal “ tonus ” is heightened, and while imperfect dila¬ 
tation occurs during inspiration, the contraction phase is excessive during 
expiration ? There is expiratory, not inspiratory dyspnoea; conse¬ 
quently the air in asthma, and in bronchitis too, distends the chest. 
It is difficult otherwise to understand why dyspnoea is expiratory and 
the chest gets distended. If there be such a closely associated physio¬ 
logical action between the movements of the upper and lower respira¬ 
tory tracts, we can readily comprehend how in some cases there seems 
such close interdependence in their morbid relationship. 

When we come to discuss this relationship between intra-nasal dis¬ 
ease and asthma, we are confronted at the outset by the difficulty in 
deciding what constitutes a morbid condition of the nasal passages. 
He had no manner of doubt that in a very large percentage of asth¬ 
matic patients the nasal passages present conditions which cannot be 
regarded as ideal, and when we have excluded all septal deflections 
and spurs, turbinal hypertrophies, polypi, general hyperaemias, &c., 
there will be only very few cases left to participate in the other very 
numerous intra-nasal defects which civilised humanity is heir to. 
Moreover, we have ample testimony that removal of these defects— 
especially, in my experience, removal of polypi and cauterisation of 
markedly hypertrophic turbinal bodies—will be followed in a very 
large proportion of cases by more or less prolonged amelioration, or 
even cessation, of asthmatic attacks. But it was very difficult to 
decide how far the nasal affection is the cause of the asthma, even in 
those cases in which intra-nasal treatment has proved successful in 
relieving the asthma. 

When one bears in mind the association of asthma with various 



neuroses and with gout and renal disease, the very frequency with 
which nasal disease is associated with asthma should make one sus¬ 
picious that there was something more than simple cause and effect in 
their relationship. Dr. Watson Williams thought that most fre¬ 
quently the intra-nasal affections, such as hypertrophic rhinitis, water¬ 
logged mucous membranes, and perhaps even sometimes cedematous 
polypi (he took but little notice of minor septal deformities), are the 
consequence and not the cause of the asthma, and sometimes there may 
be no evidence whatever of their existence until after the asthmatic 
paroxysms have recurred for years. Yet such experience as he had 
had made him very unwilling to leave untreated any obvious intra¬ 
nasal defects in an asthmatic patient which could really be a cause of 
irritation or an embarrassment to nasal respiration; since the 
removal of any contributory factors towards the occurrence of the 
paroxysms, although they might not be the essential cause, will often 
materially aid our efforts in other directions to combat the disease, 
whilst occasionally the happy results that follow the intra-nasal treat¬ 
ment seem conclusive proof that therein lay the essential cause of the 
malady. 

Dr. Theodore Williams could recall one case of asthma cured by 
the removal of nasal polypi, but from the discussion which had taken 
place he gathered that the Society was not in favour of operating on 
the nasal cavities in order to cure asthmatic attacks, a conclusion of 
some comfort to himself, as he doubted whether he had recommended 
operations as often as he might have done. For the medicinal treatment 
of genuine spasmodic bronchial asthma generally, he found iodide of 
potassium in eight to ten grain doses three times a day combined with 
stramonium, henbane, or belladonna of great advantage, and if these 
failed, compressed air baths, such as were used at the Brompton 
Hospital, gave great relief. 

Dr. W. Permewan thought the distinction between “ great relief ” 
and “ cure ” was an extremely narrow one; cure was a large word, and 
not very properly used in a question of this kind. In the majority of 
cases relief was very great, and unmistakably the result of treatment 
was to give relief. 

Sir Felix Semon : How long lasting ? 

Dr. Permewan : Until necessity arose for further intra-nasal treat¬ 
ment. Of the variety of nasal diseases polypi were by far the most 
important, and he agreed with tho>e who deprecated the indiscriminate 
use of the cautery. He thought that a normal nose, considered from 
a surgical point of view, was one which offered no point of attack to 
the surgeon. He believed that asthma was the result of a nasal con¬ 
dition, and that he was perfectly justified in healing the nose though 
he could find objectively nothing to attack. He emphasised the 
importance of respiration through the nose; if a patient’s nose was 
blocked up with polypi, and he is unable to breathe through it; that 
is the factor which starts asthmatic paroxysms, and not a reflex centre. 
The speaker thought one was justified in promising the patient more 
than one could accurately say was the whole truth; this was an 
important element in dealing with neurotic patients; but of course 
this praclice might be abused. There were two sides to this question— 



9G 


the “ practical ” and the “ scientific,” and while the exact sequence of 
cause and effect might be open to criticism from the scientific side, 
from the practical side there could be no doubt as to the propriety of 
nasal treatment in cases of asthma. 

Dr. Dundas Grant thought that Dr. Theodore Williams ought to 
have been more impressed by the result of the first case he mentioned, 
where nasal treatment had been of such great service and might with 
advantage have been carried out at a much earlier stage. Dr. Grant 
thought the discussion was too pessimistic on the one hand and too 
sanguine on the other, and that the truth was far from these extremes. 
He then related the history of a case in his early practice in east 
London. The patient was a chronic sufferer from bronchial asthma, 
and a very remunerative client. He urged the removal of nasal 
polypi importunately ; finally the man consented and was practically 
cured. He had seen the mere act of ti’eating the nose for asthma 
make the condition for the moment worse though ultimately curing it. 
He had had a fair proportion of cases in which bronchial asthma had 
totally disappeared after nasal treatment. This was natural enough 
when one considered the class of cases likely to come into the hands of 
the nasal specialist. It was the duty of a physician, if treatment by 
drugs failed, to submit the case to the observation of someone accus¬ 
tomed to explore the nose, and capable of giving a reliable report as to 
whether or not an operation on the nose should be carried out. There 
should be a judicious combination of the medical and surgical treat¬ 
ments so as to give the patient a double chance of cure. Dr. Grant 
found the gouty diathesis well marked in a number of the cases which 
had been referred to him, an opinion confirmed by the beneficial effect 
of the administration of salicylate of soda, a drug which he thought 
might with advantage be more frequently employed in the treatment 
of asthma. The g.ilvano-cauterv in some cases acted beneficially by 
pinning down the turgescent mucous membrane, but its beneficial 
effect was often no doubt due to its action as a counter-irritant. 
After the application of the galvano cautery he was in the habit of 
applying deliquescent trichloracetic acid, which appeared to him to 
diminish the inflammatory reaction. Antipyrin in a 4 per cent, spray 
reduced the swelling, but it was irritating and it ought therefore to be 
preceded by the application of eucain which acted, so far as anaesthesia 
was concerned, like cocain, and was in other respects freer from objec¬ 
tion. Glycerine extract of supra-renal capsule applied in the form of 
a spray was often valuable as a vaso-constrictor. 

Dr. Clifford Beale, in speaking of continued nasal treatment for 
asthma, described a case recently observed in which several operations 
had been performed from time to time until most of the interior of 
the nose had been removed. The attacks of asthma, relieved for a 
time after each operation, had regularly recurred. There was no evi¬ 
dence to show that the attacks arose from any sensitive point in the 
upper air-passages, whereas there were abundant morbid changes in 
the lower air-passages, which might equally well be assumed to be the 
starting point of a reflex spasm. In the heart, also, one might look for 
such causes. Some years ago he had a run of such cases. Four boys, 
all occupied in work that involved considerable heart strain, and all 



97 


about fourteen years of age, suffered from what appeared to be 
genuine asthmatic attacks, which were relieved by antispasmodic 
inhalations and rest. In these there was no reason to suspect any 
nasal reflex, but the attacks were far more likely to have found their 
origin in the over-strain of the immature heart. He quoted the 
observation of Dr. Moritz Schmidt to the effect that the nasal cavity 
if carefully searched with a probe might sometimes be found to 
present sensitive points, the irritation of which set up respiratory 
spasm. He thought that unless some definite evidence could be 
obtained that the source of irritation was in the nose, any operation 
except for the relief of obstruction was hardly justified. 

Dr. William Hill could not agree with the last speaker that it 
was “unjustifiable” to apply intra-nasal treatment unless a cough 
reflex was obtained; we had a plain duty to do the best we could for 
our patient, who rightly expected us to try not only every medical 
means, but also every surgical procedure which held out a reasonable 
chance of affording relief. A cure, in the strict sense of the word, 
could not, of course, be promised, nor often even expected, but a fair 
measure of relief, amounting in some instances to a practical cure, 
might, in his experience, be looked for in considerably more than half 
the cases where asthmatic symptoms were associated with obvious 
disease in the nose. If practitioners neglected intra-nasal treatment 
because they could not promise their pa ients an absolute cure, they 
not only ran the risk of being scored off by more enterprising neigh¬ 
bours, but, what was more serious, they laid themselves open to the 
charge of not having done their duty and their utmost for their 
patient. It was necessary to speak thus strongly because he feared that 
visitors at this debate, especially physicians who did not practice 
rhinology, would take away a very wrong impression of the attitude 
and experience of those who had dealt with a considerable number of 
cases of asthma with associated nasal disease. Not only was it 
necessary that a thorough examination of the nose should be made, in 
order that nothing abnormal might escape observation, but if intra¬ 
nasal treatment appeared to be indicated it was essential that this 
should be carried out in a very thorough way. Half measures were 
worse than useless, as they not only either failed to relieve at all, or led 
to early relapse, but unfortuately brought undeserved discredit on 
what was often a valuable remedial measure. He could not agree with 
Dr. Kidd’s conclusions, but it was easy to understand difference of 
opinion here, as that physician, whose experience of asthma in general 
was large, frankly admitted that he had seen and treated very few 
cases indeed where there was a co-existing nasal factor. He desired to 
associate himself with the views of Dr. McBride, who had admirably 
summarised the scientific and clinical aspects of the subject, and whose 
practical suggestions on treatment all would do well to follow. Dr. 
Hill had not himself tried intra-nasal cauterisation where there was no 
obvious morbid condition in the nose, but he had made a note of what 
the opener of the discussion had said on that subject. In conclusion 
he thought he was considerably below the mark in asserting that marked 
relief might be expected in 50 per cent, of cases of asthma plus nasal 
disease, provided the nasal treatment was carried out with requisite 



98 


thoroughness; overlooking a small morbid area might make all 
the difference. He had no doubt it was our duty to advise our patients 
to submit to these surgical procedures, which were, after all, not 
formidable ones. 

Sir Felix Semon, in a short historical retrospect, referred to the 
publication by the late Prof. Hack in 1884, entitled “ Eadical Cure of 
Hay Fever, Asthma, &c.,” in which that author endeavoured to esta¬ 
blish the existence of an intimate connection between affections of the 
nose and asthma. Long before that time, however, cases had been 
noted by good observers, such as Yoltolini, Bernhard, Fraenkel and 
others, in which the mere removal of nasal polypi, not undertaken 
with any view to cure co-existing asthma, had been followed by that 
result, i. e. the asthma attacks—which had formerly been very trouble¬ 
some, either entirely disappeared, or became less intense after the 
removal of the polypi—returned or became intensified with the 
recurrence of the polypi, and improved again after renewed removal. 
This was a very clear proof that asthma may be positively produced 
from the nose, and it was certainly a grave fault to altogether deny 
such a possibility. Nor were nasal polypi, although in the speaker’s 
experience by far the most obvious, the only cause of nasal asthma; 
other forms of nasal obstruction could produce this effect, such as 
great tumefaction of the nasal mucous membrane, considerable devia¬ 
tion or excrescences from the septum, &e In no class of cases, 
however, was the connection more clearly established than in cases of 
nasal polypi. In the speaker’s experience, relief might be given by 
nasal treatment in such cases,—occasionally even when the asthma had 
been in existence for a long time, although the number of cases of 
the last-named category in which he had obtained satisfactory results 
was extremely small. Altogether the number of cases in which a 
short-lived success had been obtained was in his own experience 
infinitely greater than the number of those in which a long-lasting 
relief had been afforded. He himself had never been able to produce 
an asthmatic attack from the nose by exploring that cavity with the 
probe. In one single instance only had he been able to produce 
very violent paroxysmal cough by that method of investigation. 
With such experiences, he asked himself, what was one to tell a 
patient in whom asthma existed together with nasal disease ? They 
had heard that afternoon diametrically opposed opinions in reply to 
that question. He invited them, however, to consider the enormous 
number of cases of asthma that had been treated since Hack’s publi¬ 
cation by intra-nasal interference. How small in proportion to these 
had been the number of those cases in which a real cure or, at any 
rate, a long-lasting improvement had been seen even by the warmest 
advocates of that treatment! In view of that fact, was one justified 
in promising any definite success to a patient ? And what had struck 
him most in this discussion was that no mention had been made of 
those, in his experience most frequent cases, where no results had been 
obtained at all! Personally he divided these patients into three 
classes : ( a ) Lasting success obtained, exceedingly small percentage ; 
(6) Temporary benefit, comparatively large percentage; (c) No 
success at all, very large percentage. Now considering that he had 



99 


to frankly confess that he was himself unable to make out beforehand, 
by any method of examination whatever to which of these three 
classes the individual patient would ultimately belong, what was the 
treatment in such cases but an “ experimental ” one ? He stuck to 
this word most emphatically. He was in the habit of telling those 
patients suffering from asthma, in whom considerable nasal abnor¬ 
malities existed : “ Undoubtedly in a number of cases such as yours, 
in which the nose is treated, relief has been obtained; whether in 
your own case relief will be permanent or temporary, or whether there 
will be no relief at all, I cannot tell you beforehand. If your suffer¬ 
ing are great, and if you should like to undergo this treatment, I 
consider your case a legitimate one for it, but you must understand 
that it is purely experimental.” He had not found that his patients 
misunderstood so simple a statement. 

Dr. StClair Thompson suggested the addition of a fourth class to 
Sir Felix Semon’s classification, viz. those who were considerably 
damaged by the intra-nasal treatment. He had met these cases, who 
had suffered from a too forward policy of the nose and throat, at 
foreign health resorts, trying to get back their lost mucous membrane. 
He thought that in some cases of asthma the nasal conduction may 
be causal, but in many cases it was consequential. 

Dr. Lambkrt Lack thought the undoubtedly frequent relation of 
asthma to nasal disease was not a simple reflex. He was very sur¬ 
prised to hear Dr. McBride’s statement, on which he laid particular 
emphasis, that an irritant applied to the nasal mucosa may effect 
molecular changes in a centre which is responsible for asthma. In 
his experience he had never met with a single case in which irritation 
of the nose, as by probing, had produced an asthmatic attack, and he 
would much like to know if any other member had met with such a case. 
Dr, Thorowgood and others who supported this theory quoted instances 
in which cough had been produced. This Dr. Lack thought a not 
very uncommon result of nasal irritation, but he could not admit that 
a true asthmatic attack could be experimentally excited in such a way. 
He could add one case to those which had been cited, in which asthma 
was closely related to adenoid growths. The patient was a child, the 
subject of inherited asthma and gout. Removal of the adenoids was 
followed by complete freedom from asthmatic attacks; eighteen months 
later the asthma returned, and on examination there was found to be 
recurrence of the adenoids with nasal obstruction. Operation for the 
relief of the nasal obstruction was again followed by complete cessation 
of the asthma. 

The President said they might be reasonably satisfied with the 
result of this discussion, which was of great interest; to a certain 
extent, the atmosphere was clarified. They had heard extreme views 
from both sides—those who thought no good was to be obtained, and 
those who believed that most benefit is derived from the adoption of 
intra-nasal treatment. Personally, he took the middle course, and he 
was quite certain that he had seen in a very fair proportion of the 
cases considerable and permanent relief; he mentioned the case of a 
lady whose polypi had been removed, and who had spent the winter 
in the Riviera, who had severe asthma, from which she had been 

6 * 



100 


practically free for the last year. He thought they would all agree 
with the remark made by Goodhart that the “ chronic asthmatic was 
almost as hard to cope with as the chronic epileptic,” and they must 
not expect to work miracles or they would be disappointed. They 
should look to getting hold of the cases at an earlier stage, when 
relief is more easily given, especially in the case of adenoids. 

Dr. Perct Kidd said that his remarks had been misunderstood in 
some respects. He said that if there was obvious disease of the nose, 
local treatment was advisable, though the uncertainty of the result as 
regards the asthma should be clearly explained to the patient. 

Dr. McBride said that owing to the kind reception his remarks had 
received, there was little left for him to reply to. With regard to the 
question of adenoids and asthma, he said that he had often seen cases 
where the patients were said to be asthmatic, but on inquiry it was 
generally found that the difficulty in breathing was due to the local 
causes. He had, however, on one occasion, as mentioned, immensely 
relieved a truly asthmatic child by removing adenoids. Questions had 
been asked as to the cure of asthma, but he considered that asthma, 
like epilepsy, could hardly be considered cured so long as the patient 
lived. He mentioned several cases illustrating the fact that asthma 
can be much benefited by local treatment of the nose, both in polypi 
and hypertrophic conditions. With regard to Dr. Beale’s remarks, he 
begged to observe that he had never seen asthmatic paroxysms pro¬ 
duced by touching the mucous membrane, but he would again refer 
to the great importance to be attached to the presence of a cough 
reflex in cases of suspected nasal asthma. With regard to Dr. 
Theodore Williams’ remarks, Dr. McBride thought that they showed 
that laryngologists must be singularly devoid of the power of express¬ 
ing their meaning clearly—it would not, of course, be proper to 
suggest another alternative. He failed altogether to see how Dr. 
Williams could have arrived at the conclusion that most of the speakers 
thought local treatment useless in asthma, and it would be a thousand 
pities that his remarks should be published as a serious contribution 
to the debate. Dr. McBride had no doubt that his words were spoken 
in jest, but every reader of the report might not be aware of this. 
With regard to Dr. Lambert Lack’s criticism, he would refer him (1) 
to the fact that reflex nasal asthma was generally admitted to exist; 
(2) to the experiments of Lazarus which had been confirmed by 
Sandmann. It has thus been shown that irritation of the nasal 
mucous membrane can produce spasm of the bronchi and that such 
spasm ceases after section of the vagi. 



PROCEEDINGS 


OF THE 

LARYNGOLOGICAL SOCIETY OF LONDON. 


51st Ordinary Meeting, June 2nd, 1899. 

F. de Hayilland Hall, M.D., President, in the Chair. 

William Hill, M.D., 7 a , • 

Lambebt Lace, M.D., \ Secretaries. 

Present—32 members and 5 visitors. 


The minutes of the previous meeting were read and confirmed. 

The following gentleman was unanimously elected a member 
of the Society: 

Charles Heath, F.R.C.S., 3, Cavendish Place. 

The following cases and specimens were shown : 


Case of Unilateral Paralysis of Palate, Pharynx, Larynx, &c. 

Shown by Dr. Herbert Tilley. The patient, a female set. 
29, had been complaining of hoarseness and dryness of 
throat with difficulty of swallowing for three months. There 
was an accumulation of saliva in the throat and some difficulty 
of swallowing solid food, and occasional regurgitation of fluids 
through the nose. Patient had probably had syphilis. Exami- 
9IRST SERIES - VOL. VI. 7 



102 


nation showed the left half of the soft palate, left half of the 
pharynx, and left vocal cord paralysed, the last being in the 
cadaveric position. 

Sensibility was much diminished on the paralysed parts. The 
upper part of the left trapezius and the left sterno-mastoid 
showed unmistakable signs of commencing degeneration. There 
was no paralysis of the tongue or the facial muscles, and no 
evidence of any other cranial nerves being affected. 

The exhibitor remarked that during the past four months he 
had met with four similar cases, and these tended to prove 
clinically, what Horsley and Kethi had shown experimentally, 
that it was the spinal accessory nerve which innervated the 
muscles of the larynx, the pharynx (partly), and the soft palate. 


A Cask op Disseminated Sclerosis with Paresis op Left Half 
op Soft Palate and Larynx, and a Case op General 
Paralysis with Paresis of Left Half of Larynx. 

Shown by Dr. Jobson Horne. 

Dr. Permewan asked what was meant by “ general paralysis ” in 
these cases. Did it mean “ general loss of power ” ? 

Sir Felix Semon would not have used the word “ paralysis.” A 
point of great interest in Dr. Home’s case was the nystagmus-like 
movements of the left vocal cord; abduction was separated into three 
distinct movements. He thought this a very interesting phenomenon, 
of which he was unable to give any elucidation; it might be a lesion 
below the fourth ventricle. 

Dr. Jobson Horne said by general paralysis was meant general 
loss of power. 


A Specimen of Larynx blocked by a Mass of Papillomatous 
Growth from a Boy aged Eleven. 

Shown by Dr. Permewan. Six years ago, while the patient 
was under the care of Mr. Murray at the Liverpool Infirmary 
for Children, Dr. Permewan had seen him and removed some 
growths with the intra-laryngeal forceps. The dyspnoea still 
continuing, Mr. Murray performed thyrotomy, removed the 



103 


growths, and cauterised the base of them thoroughly. This 
was followed by much relief, but three years later the symptoms 
had recurred, and the operation was repeated, again with relief. 
In April of this year he was admitted into the Northern 
Hospital with evident signs of growths, but with no apparent 
urgency of symptoms; he was, however, found dead one morning, 
evidently from asphyxia. On post-mortem examination the 
larynx was found almost completely blocked by a large mass of 
papilloma as shown. 

Dr. Permewan thought the point to be emphasised here was 
the fact that two complete thorough operations had failed to 
cure the case; he doubted whether thyrotomy was any more 
radical in its effects than the repeated removal by intra-laryn- 
geal methods, difficult though that might be in young children. 

The President suggested that a discussion might at some time be 
devoted to the treatment of these cases. 

Dr. Powell asked if tracheotomy was performed on this case. 

Dr. Permewan said that tracheotomy was done (before he had seen 
the patient) six years ago for urgent symptoms. The case showed too 
clearly the great tendency of these papillomatous growths to recur 
after complete removal. He thought it was better not to perform 
indiscriminate thyrotomy. 


Specimen op Larynx prom a Case op Perichondritis. 

Shown by Dr. Permewan. The patient was admitted into the 
Liverpool Southern Hospital under Dr. Cameron in September, 
1898, having been ill six weeks. There was then much cough 
and dyspnoea, which necessitated tracheotomy. The epiglottis 
and ary-epiglottic folds were much swollen, and the larynx 
externally measured 2f inches across. There were enlarged and 
painful glands on both sides of the neck, particularly the right 
side. The diagnosis lay between malignant disease and peri¬ 
chondritis of the thyroid cartilage; the lungs were healthy, but 
there was chronic bronchial catarrh. There were no tubercle 
bacilli in the sputum. 

After some time the glands began to soften and break down; 
an abscess formed on the right side, and was opened, and bare 
cartilage found at the bottom of it. This was repeated two or 



104 


three times, and a small bit of cartilage came away. The laryn¬ 
geal symptoms became less marked and more favourable, but six 
weeks before death he began to complain of pain in the lumbo¬ 
sacral region of spine. This was rapidly followed by angular 
curvature, followed by paraplegia, paralysis of the rectum, and 
bleeding, from which he died. 

Larynx shows necrosis of thyroid cartilage, but no growth. 
No examination was made of the spine. 


Case op Parathyroid Tumour causing Symptoms of Malignant 
Disease of the Larynx; Operation and Recovery. 

Shown by Mr. de Santi. Patient, male get. 58, sent to me by 
Mr. Eliot, who stated that he had been persistently hoarse for 
ten months, had a brassy cough and some stridor. Dr. Mitchell 
Bruce could find no chest affection to account for it. There was 
no pain or dysphagia, no expectoration, and no loss of flesh. 
Patient denied syphilis. 

There was found very impaired mobility of right vocal cord 
and marked limitation in abduction. The right cord was uni¬ 
formly red and somewhat swollen; there was no ulceration or 
neoplasm visible. No glands to be felt in the neck; old scar¬ 
ring of right face and cheek suggestive of old syphilis. Voice 
very hoarse and feeble. I considered it most probable that the 
case was one of early malignant disease of the larynx, with an 
alternative of syphilis or mediastinal tumour pressing on right 
recurrent laryngeal nerve. I ordered rest of voice, no smoking, 
and iodide of potassium. 

In September, 1895, the patient’s voice was almost a whisper. 
He had gone downhill rapidly, having lost much in weight. 
The right carotid artery pulsated visibly, and seemed pushed 
forward by a smallish, indefinite, probably glandular swelling 
deep in the neck, and about the level of second or third ring of 
trachea. 

Id December, 1895, the swelling in the neck was smaller, the 
voice better, the right vocal cord a little more moveable, and 
there was a gain in weight. 

During 1896 the patient was in very fair health, had gained 



105 


weight; the voice, though hoarse, was stronger, and the swelling 
in neck moveable, softer, and more defined; the right vocal cord 
was in statu quo. 

In February, 1899, patient had an attack of flatulence and 
dyspepsia; this was shortly followed by difficulty in swallowing 
solids, and later liquids. He lost flesh rapidly, half a stone be¬ 
tween February 6th and March 29th. At the same time a very 
marked increase in the size of the cervical swelling was noted. 
There was regurgitation of food, and sensation of blockage at 
level of cricoid cartilage. 

Examination of larynx showed right vocal cord more fixed, but 
otherwise the same. I passed a No. 18 oesophageal bougie, and 
met some considerable obstruction about level of upper part of 
sternum; no blood or pus on withdrawal. 

The lump in the neck felt to be the size of a Tangerine orange. 
It seemed elastic, and not stony hard. I took a grave view of 
the case, and advised exploratory incision in the neck, as I con¬ 
sidered from the whole course of the events that the main 
trouble was extra-laryngeal. 

An incision was made over the anterior border of the right 
sterno-mastoid down to the level of the sternum and a large 
tumour exposed, situate in the lower carotid triangle, extending 
down to and under the upper part of the sternum. By careful 
dissection this tumour was gradually defined; I found it dis¬ 
tinctly encapsuled, the carotid artery and jugular vein were 
pushed far over to the outer side : the whole tumour was very 
vascular. I eventually clearly isolated it, the chief difficulty 
being with the right recurrent nerve, which was attached to the 
tumour and flattened, and with the inferior thyroid artery; the 
right innominate and part of the left innominate vein were 
exposed, as the tumour was partly substernal. The oesophagus 
was seen to be distinctly compressed by the tumour; the latter 
had no connection with the thyroid gland, but there was some 
fibrous infiltration of the oesophagus opposite the seat of pres¬ 
sure. 

A cross cut and partial division of the sterno-mastoid had to 
be made to thoroughly get at the tumour. The right dome of the 
pleura, the right phrenic nerve, and the right subclavian artery 
were seen at the time of operation. 



106 


Recovery was uneventful, and swallowing powers improved 
almost at once. 

Microscopic sections show the tumour to be of the nature of 
parathyroid tissue and essentially innocent. The growth itself 
is completely encapsuled, and there is a large cyst in the centre. 

The case seems to be of great interest. At first everything 
pointed to early malignant disease of the right vocal cord—the 
age of the patient, the uniform redness and impaired mobility of 
the cord, the hoarseness, and later the presence of a lump like a 
gland externally; on the other hand, time proved the trouble not 
to be intrinsic carcinoma. Later on, i. e. in February, 1899, 
everything again pointed to malignant disease, though more of 
the neck than the larynx. 

Though the microscopic appearances are those of innocent 
tumour, I am still inclined to think that the tumour was com¬ 
mencing to become malignant, for the clinical course of sudden 
and rapid increase in activity in a man of sixty-two, of a tumour 
anywhere which may have remained dormant even for years, is 
always very suspicious, and I consider clinical evidence more 
important in such cases than microscopic evidence. 


Case of Complete Paralysis of one Vocal Cord and Impaired 

Abduction of the other. 

Shown by Dr. StClair Thomson. This patient, a boy get. 17, 
was said to have been hoarse since his voice changed at the age 
of fourteen, and it was therefore to be presumed that the 
laryngeal condition had existed for three years. The condition 
is sufficiently described by the title of the case. There is nothing 
in the boy’s neck, chest, or nervous system to explain the cause 
of the paralysis. The exhibitor suggested influenza as a possible 
cause, and wished to know if others had seen cases at this early 
age. 

Dr. Permewan had had three cases of paralysis of the right vocal 
cord, of which he was not able to discover the cause; possibly 
it was due to disease of the top of the pleura. He did not agree 
with the other part of the title, viz. “ impaired abduction of the other 
cordfrom his own view, it moved quite freely. Dr. StClair Thomson’s 
suggestion of influenza ought to be taken into account. He had a 



107 


patient who suffered from influenza and had recurrent paralysis, which 
remained for some' weeks. The patient then became convalescent and 
got well again. 

Sir Felix Semon said he had seen several cases of laryngeal para¬ 
lysis after influenza, amongst them those of two medical men who 
both got well in a short time. With regard to Dr. StClair Thomson’s 
question as to the age of these cases, he bad seen loss of abductor 
power in patients of one and a half to five years of age. 

The President remembered seeing a case with Sir Felix Semon, 
which almost completely recovered; he had also reported to the 
Society a case of double abductor paralysis in a child of six. 

Dr. StClair Thomson said he had shown a case undoubtedly due 
to influenza, which had cleared up between the announcement and the 
patient’s appearance at the meeting, but in that case the patient had 
had the paralysis only six months, whereas in the case under notice 
the disease was of three years’ standing. 


Case op Laryngeal Ulceration with Calcification, of the 

Fascia of the Neck. 

Shown for Mr. Charters Symonds by Mr. Steward. The 
patient, a woman set. 32, complained of loss of voice and diffi¬ 
culty in breathing, and gave the following history. 

When a child she had an abscess on the right side of the neck, 
and at about the same time she became deaf. 

About ten years ago swelling and stiffness of the neck began, 
and this has gradually increased since that time. 

The present attack of hoarseness commenced three months ago. 
The patient is very deaf, the skin is pallid, the bridge of the 
nose is broad and flattened. The eyes and teeth are normal. 
Just behind the angle of the jaw on the right side is a large scar. 
The whole of the structures in the front of the neck are hard and 
matted. There is great thickening around the hyoid bone and 
thyroid and cricoid cartilages, and these structures appear to be 
united into a dense hard mass. 

There are several enlarged glands in the submaxillary region, 
and lower down in the neck are several very hard nodules, one par¬ 
ticularly hard being situated in the right sterno-mastoid muscle. 
The soft palate and pharynx are much scarred, and are adherent 
to one another. 

The upper opening of the larynx is red and swollen, and there 
is ulceration on the right ventricular band. 



108 


Sir Felix Semon said that he had a strong suspicion that this case 
was specific. The configuration of the patient’s face and the large 
distance between the eyes pointed to congenital syphilis. With regard 
to the pharynx, the adhesions are very characteristic of either tertiary 
or inherited syphilis. 

Dr. William Hill said that Mr. Symonds was doubtful as to the 
correctness of the term “ calcification.” To him it seemed to be an 
extensive line of scars rather than calcification. 

Mr. Steward said that the whole thing might be syphilitic. There 
was considerable swelling on the right side of the larynx, loss of voice, 
and troublesome dyspnoea, which was steadily getting worse in spite of 
calomel baths and doses of iodide of potassium for three weeks. 


Case op Sloughing Ulceration op the Pharynx. 

Shown by Mr. Steward for Mr. Charters Symonds. Male 
aet. 31, has always been healthy till nine months ago; has no 
history of syphilis. 

At the end of October, 1898, patient had a thick discharge from 
the nose, with headache and pains in the back. Shortly after 
this a hard round lump appeared below the left ear, and a similar 
lump soon appeared on the right side. These were followed by 
other lumps, which coalesced to form large swellings. Later 
the tonsils were enlarged, and a large ulcer with yellow surface 
appeared on the left one, and soon afterwards the right tonsil 
became similarly affected. The left tonsil healed, but the swell¬ 
ings in the neck steadily increased. 

When first seen on December 11th, 1898, there was a large 
ulcer involving the lower part of the right tonsil, and extending 
on to the base of the tongue. The ulcer was covered with yellow 
slough, and the edge was hard, raised, and indurated. There 
were also large masses of swollen glands on each side of the 
neck; some of these were soft and fluctuating, others quite hard. 

Patient was ordered iodide of potassium in increasing doses, 
and for a time improved. 

On March 9th the ulcerations had considerably increased, as 
had also the swellings in the neck. Small hard glands were 
found in the left axilla and right groin. Calomel vapour-baths 
were ordered in addition to the potassium iodide, and on March 



109 


14th the ulcers were curetted, and then cauterised with nitric 
acid. 

After this considerable improvement took place and the 
throat nearly healed, but early in May a relapse occurred, and 
spread of ulceration took place. 

On the 9th several softening glands were opened and cu¬ 
retted, and one was removed; the throat was also again curetted. 

The softened glands contained a semi-fluid material of 
yellowish-brown colour. Microscopically the excised gland 
showed caseating foci and a small-celled infiltration, but no 
definite evidence of tubercle. 

Mr. Crbsswrll Baber said that in his opinion the case was syphi¬ 
litic. 

Sir Felix Semon thought there was little doubt it was a case of 
lympho-sarcoma, and advised the administration of arsenic. He had 
seen three or four such cases in which tumours had formed and disap¬ 
peared almost entirely; suddenly they would appear again and assume 
a serious form. He always treated them by increasingly big doses of 
arsenic. 

Mr. Steward said the man had been treated with large doses of 
iodide and mercury, but had not had arsenic. It might be of interest 
to mention that the man had several glands in the right axilla and in 
the left groin. As regards the examination of the stuff from the 
opening in the neck and gland, the view of lympho-sarcoma was sup¬ 
ported. Under the microscope was seen a mass of small round cells, 
with fair-sized nuclei, and there were caseous foci in the gland itself. 
Ho tubercle bacilli were found. 

Dr. William Hill thought if the suggested arsenic treatment was 
of no avail it would be well to try electrolysis. 


Tumour op the Nasal Cavity. 

Patient and specimen shown by Mr. Cresswell Baber. A 
female aet. 66 came as out-patient on March 17th last, com¬ 
plaining of right nasal obstruction since the previous summer. 
She had also had a sore throat and pain in the right ear. No 
deafness. A large polypus was snared from the right nostril. 
On April 7th a polypus was felt in the right choana with the 
finger, and snared from the front. April 14th.—Right side still 
much obstructed, also much muco-purulent discharge. Pos¬ 
terior rhinoscopy, with the aid of the palate-hook, showed a red 



110 


growth in the right choana; two more pieces of reddish, friable 
growth snared from the front. May 1st.—On palpation, a 
small mammillated moveable growth was felt in the right 
posterior naris. May 2nd.—The growth could be just discerned 
from the front, and was moveable, but whether it grew from the 
inferior turbinated body, or from the outer wall of the nasal 
cavity, could not be ascertained—it was not attached to the 
septum. Transillumination on April 21st and May 2nd showed 
both infra-orbital regions light. No enlarged glands. 

The growth removed on April 14th was reported on by the 
Clinical Research Association as “ columnar-celled carcinoma 
arising from the nasal mucous membrane.” I decided to take 
steps to lay the disease freely bare, so that its extent could be 
more clearly seen, and, if necessary, a radical operation per¬ 
formed. With this object, on May 6th I removed, under general 
anaesthesia, the growth in the posterior naris with the spoke- 
shave, and subsequently the inferior turbinated body with the 
same instrument. The outer wall of the nasal cavity was then 
freely curetted with a large sharp spoon. Afterwards, on in¬ 
serting the little finger into the nasal cavity, I could feel that 
there was an aperture into the antrum, probably the result of 
the curetting. The growth was soft and irregular. The patient 
recovered from this well, and has been kept carefully under 
observation. 

Her present condition—more than three weeks after the 
operation—is as follows:—There is some dirty-looking, foetid, 
muco-purulent discharge coming from the right nasal cavity. 
In consequence of the removal of the inferior turbinated body 
the nasal cavity can be easily inspected. The only sign of the 
growth is what looks like small, rather vascular roots of mucous 
polypi, between the lower margin of the middle turbinated body 
and the outer wall. No growth seen by posterior rhinoscopy, 
though there is a red spot on the margin of the right choana at 
its upper outer part, where the last growth may have sprung 
from. Still plunging pain in the right ear. Both antra light 
up on transillumination, but the right seems a shade darker 
than the left. Possibly some of the discharge may have got 
into the antrum. 

Mr. Baber asked the opinion of members as to the malignancy 



Ill 


of the growth, and the advisability of further operative mea¬ 
sures. 

Dr. Pegh.br thought that the groyrth was not malignant; one 
corner of the slide showed doubtful-looking cells, but not characteristic 
of carcinoma. He suggested the specimen should be referred to the 
Morbid Growths Committee. 

Dr. William Hill asked whether it was ulcerated on the surface, 
and if there was any haemorrhage before operation. It was not pos¬ 
sible to make a diagnosis, as the sections did not go to the root of the 
tumour. 

Mr. Baber said Mr. Butlin had seen them, and thought the case 
was one of carcinoma. 

Dr. Waggett said it would be a valuable section to have in the 
cabinet for reference in subsequent years. 

Mr. Baber said he would do no further operation unless there was 
a recurrence. 

The President moved that the specimen be referred to the Morbid 
Growths Committee. This was adopted. 


Specimen of Epithelioma of (Esophagus causing Bilateral 
Paralysis of Vocal Cords. 

Shown by Dr. Clifford Beale. L. H—, set. 33, female 
domestic servant, admitted January 13th, 1899, for cough and 
muco-purulent expectoration of long standing, with some dys¬ 
phagia and occasional dyspnoea. The patient was a good deal 
emaciated, and complained of recent acute tenderness of the left 
side of the thyroid. Some swelling and tenderness was present. 
On examining the larynx the vocal cords were seen to be 
normal in appearance, but lay during normal and forced respi¬ 
ration in the cadaveric position. On phonation they were 
brought together, and a fair volume of sound was produced. 
While under observation in hospital many attacks of adductor 
spasm occurred, and the voice gradually got feebler until it was 
lost altogether. The sensation within the larynx was unim¬ 
paired. Tracheotomy became necessary and gave immediate 
relief. Dysphagia increased especially for solid food, and it was 
noted that fluids and sometimes solids were occasionally regur¬ 
gitated through the tracheotomy tube; and hence, after a short 
period of rectal feeding, gastrostomy was performed, and the 
patient was fed directly into the stomach for the five weeks pre- 



112 


ceding her death. The constant welling up of muco-pus from 
the oesophagus, and the occasional regurgitation of the food in 
the stomach, led by slow degrees to a septic broncho-pneumonia, 
which was the immediate cause of death on April 12th, 1899. 

The specimen showed infiltration of the mucous membrane 
and submucous tissue of the oesophagus by a cancerous growth. 
The growth began below the level of the larynx, and extended 
for about two and a half inches downwards, embracing the 
whole lumen of the tube. At the anterior part a perforation 
communicating with the trachea was visible. The oesophagus 
above and below the growth was healthy though somewhat 
engorged. The thyroid body was enlarged and thickened in 
both lobes, being exceedingly tough and fibrous on section. 
The trunk of the vagus was seen to be compressed, together 
with the vessels, on one side, while the recurrent laryngeal 
nerve could be traced into the body of the thickened thyroid 
gland on the other side. No other cancerous growth was dis¬ 
covered in any part. The growth in the oesophagus was a 
typical epithelioma. 


Case op Unusual Pharyngeal Tumour. 

Shown by Sir Felix Semon. The patient, a female, was 
shown at the March, 1898, meeting of the Society, and was now 
again brought forward to show that the condition remained 
absolutely in statu quo. 

Dr. William Hill asked Sir Felix Semon to explain why he took 
such pride in keeping this tumour. 

Sir Felix Semon had the greatest pleasure in answering that 
question; he did not feel justified in doing anything because he did 
not know what the growth was or how far it went. That it was 
intimately connected with the vagus he suspected because the least 
pressure caused coughing and retching; meanwhile it caused the 
patient no inconvenience whatever. 


A Case op Stricture op the Larynx following Tracheotomy 
for Diphtheria successfully treated by Dilatation. 

Shown by Dr. Lambert Lack. The patient, a child set. 6, had 



113 


tracheotomy performed for diphtheria one year ago. Three 
months later, it being impossible to remove the tube, an explo¬ 
ratory thyrotomy was performed by Mr. Stanley Boyd, and an 
ulcer of the larnyx with much granulation tissue, almost com¬ 
pletely obstructing the lumen, was found just below the vocal 
cords. The granulation tissue was removed and the wound 
allowed to heal. Attempts were then made to dilate the 
stricture of the larynx by intubating with O’Dwyer’s tubes; but 
after a month of intermittent treatment this method was aban¬ 
doned, its tediousness and painfulness seriously affecting the 
child’s health. It was then resolved to dilate the stricture from 
below. A metal plug with a shield attached to fit over the tracheo¬ 
tomy tube was made. Under chloroform the tracheotomy 
wound was enlarged and the stricture forcibly dilated with 
curved forceps ; the plug and the tracheotomy tube were then 
inserted. The plug was worn continuously for five months 
without causing any inconvenience ; it was then removed, and 
the tracheotomy tube was corked up. The child being able to 
breathe freely through the mouth both day and night, after a 
month the tube was dispensed with. The wound soon healed, 
and the patient now—a month later—seems cured. 

The President congratulated Dr. Lack on his success in this case. 
Many attempts had been made and much time had been spent in 
trying to dilate laryngeal strictures, but generally in vain. 

Dr. Lack, in replying to a question by Dr. Permewan, said that the 
dilatation was done through the tracheotomy wound with ordinary 
dilators and a plug inserted to keep the parts dilated, and worn for 
about five months continuously. He had treated the case with intu¬ 
bation tubes, but directly they were left out the trouble recurred. 


Case op Node in Nasal Process op the Right Inferior 
Maxilla and Ulcerative Rhinitis in a Tubercular 
Girl. 

Shown by Mr. Atwood Thorne. The patient, a girl set. 7, 
came to St. Mary’s Hospital complaining that for the last two 
months the nose had been gradually growing broader, and the 
nostrils becoming increasingly blocked. The trouble was attri¬ 
buted to a fall on the nose. 



114 


On examination there was found a mass as large as a hazel¬ 
nut attached to the nasal process of the right superior maxilla, 
and there was some swelling in a similar position on the left 
side. The nostrils were almost completely blocked by pale 
granular masses, and there was a thin watery discharge. 

With the exception of a very small opacity of the left cornea 
(said to be due to an accident) there was nothing to suggest 
congenital syphilis, while the patient had been in St. Mary’s for 
the treatment of a tubercular ulcer of the foot, and had had an 
operation at Golden Square for enlarged cervical glands. 

The President asked if the nasal secretion had been examined for 
tubercle bacilli. 

Dr. Hill suggested the case was a mixture of syphilis and tubercle. ^ 


Case op Tumour op Palate in Woman a:t. 34. 


Shown by Dr. Bond. The swelling was first noticed twelve 
years ago shortly after the extraction of three teeth. It slowly 
increased in size, but lately has grown more rapidly. There is 
now an elastic, painless, non-tender swelling covering the hard 
palate, and extending into the alveolus on the right, and also 
into the soft palate. It is rather more dusky than the normal 
mucous membrane; in the centre is a paler area. There are no 
enlarged glands in the neck. The floor of the nose is normal. 

The growth was thought by several members to be an 
adenoma. Dr. Bond proposed to report further on the case 
after operation. 

Mr. de Santi took the swelling of the palate to be an adenoma, 
and considered it would be quite an easy matter to dissect it out. 

Dr. Watson Williams said that many years ago one of the first 
cases he saw in a young girl about fourteen was very similar to this. 
The tumour had existed for some years, and was increasing in size 
very greatly. It contained numerous small cysts. He had opened 
the growth and introduced weak chromic acid, with the result that the 
growth was inflamed for some days and soon after disappeared entirely, 
and it had not recurred a few years later. 

Dr. Bond said he proposed attempting to remove the growth in a 
few days. 



115 


Female mt. 26 , with Large Sarcomatous Tumour op the 

Naso-pharynx. 

Shown by Dr. StClair Thomson. Though not by any means 
rare in early life, this case was shown as an example of malig¬ 
nant disease in a young adult. The patient had traces of 
having been operated upon for tuberculous glands in the neck, 
and it was therefore a little difficult to say whether the glands, 
which were now evident on each side of the neck, were also 
tuberculous, or whether they were secondary to the malignant 
growth. They were sufficiently hard. The growth pushed 
forward the soft and hard palates without invading them. It 
completely obstructed the choanae, and had seriously interfered 
with swallowing and breathing. The author invited discussion 
as to whether an attempt should be made to remove the growth, 
and as to whether the patient should have tracheotomy or 
gastrostomy or both. 

Mr. de Santi looked upon this swelling as probably of a malignant 
nature; its rapid growth and general appearance were consistent with 
such a diagnosis. The glands, though originally the patient had had 
tubercular cervical glands removed, were probably sarcomatous. 
Though the case might be one of mixed infection, tracheotomy should 
be done soon, and then an attempt to explore the palatal growth 
might be made. It would be interesting to know the microscopic 
appearances. 

Dr. Bond thought that tracheotomy ought to be done; then it 
would be possible to get away some of the mass from the mouth: a 
large part, might be snared off. In any case after tracheotomy, it 
should be thoroughly examined with the finger. He thought some¬ 
thing might be done to relieve the case for a time. 

Dr. Tilley asked if the glands were secondary to the particular 
growth in the palate or independent. 

Dr. StClair Thomson was encouraged to follow the advice given. 
The woman had had tubercular glands in the past, and he thought 
they were not secondary to this growth. 


A Case of Laryngeal Disease for Diagnosis. 

Shown by Mr. E. W. Roughton. A man set. 42, suffering 
from hoarseness, cough, and dyspnoea of three months' duration. 



116 


There was a swelling involving and fixing the left cord and 
arytaenoid. No evidence of tuberculosis and no history of 
syphilis. He asked for a diagnosis. 

Mr. de Santi was of opinion that this was a case of epithelioma. 
There was marked infiltration of the parts and very impaired mobility. 
Moreover the redness was quite unilateral, and fulness could be seen 
below the cord. An early laryngo-fissure was urgently needed. 

Dr. William Hill said he was inclined to think it was malignant. 
There were no glands on the outside; it was the sort of case well 
suited for an exploratory thyrotomy. 

Sir Felix Semon suggested removing a piece first. 

Dr. StClaib Thomson said the cord was quite fixed, and the growth 
extended below the cord. He thought it a good case for laryngo- 
fissure. 

The general opinion of members was that the case was very suitable 
for exploratory thyrotomy. 


Case op Malformation op Palato-pharyngei Muscles. 

Shown by Dr. Fitzgerald Powell. A man aet. 22 presented 
himself for treatment at the hospital, suffering from suppuration 
of the middle ear, with hypertrophic rhinitis. This condition 
followed scarlet fever fourteen years previously. 

On looking into his pharynx it was seen that the palato- 
pharyngei muscles forming the posterior pillars of the fauces on 
both sides, instead of passing down in the normal position, were 
drawn backwards and united together, leaving a small opening 
below the uvula into the post-nasal space. 

The united muscles spread out over the posterior wall of the 
pharynx and became attached to it for some distance, when they 
parted and fell away in crescentic folds to their attachment to the 
posterior border of the thyroid cartilage. 

The appearance on examination conveyed the impression that 
this condition was caused by extensive ulceration, and the 
history of severe scarlet fever deepened this impression, though 
on further and more prolonged inspection doubts arose as to 
whether this malformation was not due to congenital mal-develop- 
ment, the condition was so very symmetrical. 

Mr. Baber thought it was the result of an ulceration, secondary to 
scarlatina rather than congenital. In the first year of this Society he 



117 


had shown a similar case. He was not sure whether it was from 
scarlet fever. 

The President had seen almost the same thing. He thought a 
deep ulceration, if in the centre, would cause that symmetry. 


A Case op Epithelioma op the Pharynx. 

Shown by Mr. Atwood Thorne for Dr. Dundas Grant. The 
patient, a clerk aet. 58, came to the hospital on May 25th com¬ 
plaining that for two months he had had increasing pain on 
swallowing. He had also been losing flesh somewhat for about 
the same period. 

On examination there is seen a craggy mass on the right side 
of the pharynx, extending to the base of the tongue on the same 
side. With the finger the mass is found to be of almost carti¬ 
laginous hardness. There is marked involvement of the glands 
on the right side of the neck. 

The case was shown especially for the consideration of the 
advisability of operation. 


A Case of Pachydermoid Laryngitis treated with 

Salicylic Acid. 

Shown by Dr. Dondas Grant (per Mr. Atwood Thorne). The 
patient, a man set. 56, “ chucker-out” at a music hall, came to 
the hospital at the beginning of April complaining of a “ husky 
voice.” 

The cords were partially concealed by very swollen ventri¬ 
cular bands; they were obviously less tense than normal, and on 
their edges there was what looked like a layer of desquamating 
epithelium. The rest of the cords was red and succulent, and 
in the interarytsenoid space the mucous membrane was swollen 
and sodden-looking. The nasal mucous membrane was in 
general hypertrophied, and there was a considerable excess of 
mucous secretion. 

The patient was advised to give up all alcoholic drinks (in 
which he usually indulged somewhat freely), and twice a week, 
in gradually increasing strength, an alcoholic solution of sali- 

7* 



118 


cylic acid has been applied to the thickening in the larynx. 
At the same time he has been ordered an alkaline lotion to wash 
out his nose. He has now quite regained his voice, and though 
the swelling has not altogether disappeared, the whitish thick¬ 
ening on the edges of the cords is hardly perceptible. 


Case of Bilateral Abductor Paralysis, &c. 

Shown by Mr. Richard Lake. The patient is a man, and has 
suffered from cough and dyspnoea for three months ; now both 
cords seem fixed in the cadaveric position: there is a breaking- 
down gumma of the right tonsil. There is slight ptosis of the 
left eye, the left pupil is large and inactive, there is paralysis of 
all the recti muscles and of the inferior oblique. Under iodide 
the conditions have improved. 

A case of pachydermia laryngis in a tubercular patient was 
also shown by Mr. Lake. 



INDEX 


PAGH 


Abductor paralysis, bilateral (Richard Lake) . . . 118 

Abduction, slightly defective, of right vocal cord (H. Betham Robinson) . 46 

Abscess of larynx : specimen (F. de Havilland Hall, M.D.) . . 49 

Adhesion (complete) of soft palate to posterior wall of pharynx (F. de 

Havilland Hall, M.D.) . . . . .61 

Agab (Morley), an exceptional case of cleft palate . . .12 

Air-passages: asthma in its relation to diseases of the upper air-passages 

(discussion) . . . . .83 

Ansesthesia and local cocainisation for removal of multiple laryngeal 

papillomata in child set. 3} (Scanes Spicer, M.D.) . • 64 

Angioma of larynx (J. W. Bond, M.D.) . . ' . .7 

Antrum, chronic empyema of, cured by intra-nasal treatment (anterior 

turbinectomy; Krause’s trocar) (J. Dundas Grant, M.D.) . . 17 

-specimen of dead bone, polypi, and debris removed from 

case (Scanes Spicer, M.D.) . . . . .36 

-empyema of, cured by alveolar irrigation (J. Dundas Grant, M.D.) 53 

-cured by repeated irrigations by means of Lichtwitz’s 

trocar and cannula (J. Dundas Grant, M.D.) , . .16 

-of Highmore: X-ray photograph of foreign body (silver tube) in 

antrum of Highmore (Arthur Cheatle) . . .19 

-(maxillary), empyema of; case of cure by radical operation (Scanes 

Spicer, M.D.) . . . . . .34 

-specimen of peg removed from, through ostium maxillare 

(Watson Williams, M.D.) . . . . .38 

Arytmnoid: swelling in interarytmnoid region (E. Furniss Potter, M.D.) . 75 

-tubercular laryngitis after removal of large interarytsenoid mass 

(R. Lake) . . . . • .9 

Asthma in its relation to diseases of the upper air-passages (discussion) . 83 


Babbb (E. Cresswell), case of (?) oesophageal pouch . . .11 

-tumour of the nasal cavity .... 109 

Babon (Barclay, M.B.), epithelioma of larynx . .3 

-sarcoma of nose . . . . . .3 

-nasal case for diagnosis . . . . .4 

-further report of case of sarcoma of the nose shown at November 

meeting . • . . . • .36 

Bbalb (E. Clifford, M.B.), discussion on asthma in its relation to diseases 

of the upper air-passages • . . .96 

-specimen of epithelioma of oesophagus causing bilateral paralysis 

of vocal cords ...... Ill 

Bond (J. W., M.D.), case of large angioma of larynx . . .7 

-large lipoma of soft palate . . . .8 

malignant disease of nose in old man . .26 

■■■■ recurrent papilloma of larynx in girl of 18 .27 

-case of tumour of palate in woman set. 34 114 


FIRST SERIES—VOL. YI 


8 




120 


PAGB 

Bone (dead) removed from case of chronic empyema of antrum: specimen 

(Scanes Spicer, M.D.) . . . . .36 

Bones: hyperostosis of maxillary bones causing nasal stenosis (A. A. 

Bowlby) . . . . . . .23 

Bowlby (A. A.), hyperostosis of maxillary and other bones causing nasal 

stenosis . . . . . . .23 

- - case of laryngeal paralysis secondary to stricture of the oesophagus 55 

-case of ulcer of nasal septum . . . .48 

Bronchocele: old-standing bronchocele becoming malignant, and causing 

pressure on the oesophagus and trachea (P. de Santi) . . 73 

Broknbb (A., M.D.), tubular epithelioma of the nose . . .42 

Bursa, thyro-hyoid, cyst of (Fitzgerald Powell, M.D.) . . 80 

Calcification of fascia of neck in case of laryngeal ulceration (shown by 

Mr. F. J. Steward for Mr. C. J. Symonds) . . . 107 

Cancer of oesophagus (Watson Williams, M.D.) . . .5 

Cannula (Lichtwitz’s) : empyema of antrum cured by repeated irrigations 

by means of Lichtwitz’s trocar and cannula (J. Dundas Grant, M.D.) 16 

Cervical glands: primary epithelioma of right tonsil with extension to 

the cervical glands (P. de Santi) . . . . 74 

Charts: wall charts for teaching signs of suppuration in the nasal sinuses 

(J. Dundas Grant, M.D.) . . . . .14 

Cheatle (Arthur), a case of paroxysmal sneezing associated with great 
hypertrophy of tissues in neighbourhood of the septal tubercle (shown 
at June meeting) . . . • • .6 

-section of cyst removed from naso-pharynx . . .14 

-X-ray photograph of foreign body (silver tube) in the antrum of 

Highmore . • . . . .19 

-case of large gumma in posterior pharyngeal wall . . 68 

-case of polypoid-looking growth springing from the right supra- 

tonsillar fossa . . . . . .78 

Cocainisation (local) and anesthesia for removal of multiple laryngeal 

papillomata in child et. 3£ (Scanes Spicer, M.D.) . . 64 

Commissure, anterior: growth in anterior commissure removed with 

paresis of right cord remaining (L. H. Pegler, M.D.) . • 7 

Cord : see Vocal cord. 

Council: report of Council, 1898 . . . . .29 

-list of Officers and Council, 1899 . . . .29 

Cyst, extra-laryngeal (E. B. Waggett) . . . .64 

-— large thyroid (Herbert Tilley, M.D.) . . .73 

-of thyro-hyoid bursa (Fitzgerald Powell, M.D.) . . 80 

-— section of, removed from naso-pharynx (Arthur Cheatle) . 14 

D6bris removed from case of chronic empyema of antrum (Scanes Spicer, 

M.D.) . . . . . . .36 

Diagnosis, case of laryngeal disease for diagnosis (W. H. Kelson, M.D.) • 77 

-(E. W. Roughton) .... 115 

-nasal case (Barclay Baron) . . . .4 

Dilatation of larynx in successful treatment of stricture following tracheo¬ 
tomy for diphtheria (H. Lambert Lack, M.D.) . . 112 

Diphtheria: tracheotomy for diphtheria followed by stricture of larynx 

(H. Lambert Lack, M.D.) . . • . . 112 

Donelan (James, M.B.), a case of old syphilitic disease in the nose of a 

woman aged thirty-six . . . . . 78 

Dwarf: tubercular laryngitis in a dwarf (Herbert Tilley, M.D.) . 39 

Epiglottis from case of membranous laryngitis; report (Walter D. Severn) 16 
Epithelioma: epitheliomatous ulceration of naso-pharynx (Herbert Tilley, 

M.D.) ••••••• 52 



121 


Epithelioma of larynx (Barclay Baron, M.B.) 

-two cases treated by thyrotomy (Sir Felix Semon, M.D.) . 

-? epithelioma of larynx (F. J. Steward, shown for Mr. C. 

J. Symonds) ...... 

-of oesophagus causing bilateral paralysis of vocal cords (E. Clifford 

Beale, M.B.) ...... 

-of the pharynx (case shown by Mr. Atwood Thorne for Dr. Dundas 

Grant) ....... 

-primary, of right tonsil, with extension to the tongue and cervical 

glands (P. de Santi) ..... 

-tubular, of nose (A. Bronner, M.D.) .... 

Empyema of antrum cured by alveolar irrigation (J. Dundas Grant, M.D.) 

---cured by repeated irrigations by means of Lichtwitz’s 

trocar and cannula (J. Dundas Grant, M.D.) 

-chronic, of antrum cured by intra-nasal treatment (anterior 

turbinectomy—Krause’s trocar) (J. Dundas Grant, M.D.) . 

-specimen of dead bone, polypi, and d&bris removed 

from case (Scanes Spicer, M.D.) .... 

-of maxillary antrum, case of cure by radical operation 

(Scanes Spicer, M.D.) . 

Fascia: calcification of fascia of neck in case of laryngeal ulceration 
(shown by Mr. F. J. Steward for Mr. C. J. Symonds) 

Fauces, miliary tuberculosis of (Lambert Lack, M.D.) . 

Faucial pillar, posterior, varix or nsevus of (Ernest B. Waggett) 

Fibrillar movements: fixation of left vocal cord with fibrillar movements 
(W. G. Spencer) ...... 

Fixation of left vocal cord with fibrillar movements (W. G. Spencer) 
Foreign body impacted in naso-pharynx for four years (F. de Havilland 
Hall, M.D.) . . 

-in oesophagus; skiagram (P. de Santi) 

Fossa, right supra-tonsillar, polypoid-looking growth springing from 
(Arthur Cheatle) ...... 

Frontal sinusitis: see Sinusitis , frontal. 


Glands, cervical: primary epithelioma of right tonsil with extension to the 
cervical glands (P. de Santi) ..... 
Grant (J. Dundas, M.D.), wall charts for teaching signs of suppuration 
in the nasal sinuses ...... 

-empyema of antrum cured by repeated irrigations by means of 

Lichtwitz’s trocar and cannula .... 

-chronic empyema of the antrum cured by intra-nasal treatment 

(anterior turbinectomy—Krause’s trocar) 

- case of empyema of the antrum cured by alveolar irrigation after 

failure of intra-nasal treatment .... 

-— case of pachydermia of the larynx, probably due to chronic rhinitis 

-case of papilloma of the larynx previously shown in an elderly 

man; complete removal 

-case of multiple papillomata .... 

-discussion on asthma in its relation to diseases of the upper air- 

passages ....... 

-a case of epithelioma of the pharynx, shown by Mr. Atwood 

Thorne . . . . . .’ 

-a case of pachydermoid laryngitis treated with salicylic acid, shown 

by Mr. Atwood Thorne 

Growth of left vocal cord in a man set. 32 (C. A. Parker) 

-— polypoid-looking growth, springing from right supra-tonsillar fossa 

(Arthur Cheatle) ...... 

•-tuberculous interarytssnoid (J. S. Lucas, shown for Mr. R. Lake) . 


PAGE 

3 

39 

8 

111 

117 

74 

42 

53 

16 

17 

36 

34 


107 

78 

24 

69 

69 

61 

70 

78 


74 

14 

16 

17 

53 

66 

67 

68 

96 

117 

117 

43 

78 

63 




122 


PAG-B 

Grunting: infant exhibiting peculiar gruuting inspiratory souud (William 

Hill, M.D.) . . . . . .50 

Gullet: see (Esophagus . 

Gumma, large, in posterior pharyngeal wall (Arthur Cheatle) . . 68 

Hall (P. de Havilland, M.D.), specimen of abscess of the larynx . 49 

-case of complete adhesion of the soft palate to the posterior wall of 

the pharynx , . . , .61 

-discussion ou asthma in relation to diseases of the upper air- 

passages . ... . . 83, 99 

Hill (William, M.D.), paresis of the right facial nerve and of the right 

side of the palate following tympanic suppuration . . 9 

- x frontal sinusitis . . . . . .10 

-infant exhibiting a peculiar grunting inspiratory sound . . 50 

-discussion on asthma in its relation to diseases of the upper air- 

passages . • . • . . .97 

Hoarseness, functional, case of, in woman ®t. 37 (Hector Mackenzie) . 25 

Horne (W. Jobson, M.B.), multiple and diffuse papillomata of the larynx 42 

■■ ■ a case of disseminated sclerosis, with paresis of left half of soft 
palate and larynx, and a case of general paralysis with paresis of the 
left half of larynx ...... 102 

Hyperostosis of maxillary and other bones causing nasal stenosis (A. A. 

Bowlby) . . . . . . .23 

Hypertrophy of tissues in neighbourhood of septal tubercle in case of 

paroxysmal sneezing (Arthur Cheatle) • . . .6 

-of tonsil: preparations (Wyatt Wingrave) . . .14 

Infant exhibiting peculiar grunting inspiratory sound (William Hill, M.D.) 50 

Interarytssnoid growth, tuberculous (J. S. Lucas, shown for Mr. R. Lake) 63 

Irrigation, alveolar, in case of empyema of antrum (J. Dundas Grant, M.D.) 53 

-empyema of antrum cured by repeated irrigations by means of 

Lichtwitz’s trocar and cannula (J. Dundas Grant, M.D.) • . 16 

Eblson (W. H., M.D.), a case of laryngeal disease for diagnosis . 77 

Kidd (Percy, M.D.), discussion on asthma in its relation to diseases of the 

upper air-passages . . . . • 83, 100 

Lack (Lambert, H., M.D.), case of miliary tuberculosis of fauces, etc. . 78 

-case of lymplio-sarcoma (?) of tonsils . . .80 

- discussion on asthma in its relation to diseases of the upper air- 
passages . • . • • • .99 

-a case of stricture of the larynx following tracheotomy for diph¬ 
theria, successfully treated by dilatation . . . 112 

Lake (R.), a case of membranous laryngitis . . . .9 

-tubercular laryngitis after removal of large interaryt®noid mass . 9 

-specimen of pachydermia laryngis . . . .16 

-tubercular larynx from child set. 6 . . . .16 

-recurrent nasal tumour from female set. 23 . .16 

-case of right recurrent paralysis with paresis of trapezium, sterno- 

mastoid, and palate, with slight ptosis and facial paralysis, all on the 
same side . . . . . • .43 

- case of papillomata of larynx . . .51 

case of tuberculous interarytsonoid growth, shown by Mr. J. S. 

Lucas . . . - • • .63 

—— case of bilateral abductor paralysis, etc. . . . 118 

-see Severn (Walter D.), report on a specimen of membrane (epi¬ 
glottis) from a case of membranous laryngitis shown at the last 
meeting (November) by Mr. Lake . . . .16 

Laryngitis, chronic nodular, in a boy »t. 16 (StClair Thomson, M.D.) . 32 





123 


Laryngitis, chronic, two cases (StClair Thomson, M.D.) 

-hypertrophic, of doubtful nature (StClair Thomson, M.D.) 

-man set. 51, shown at the November meeting as a case of 

hypertrophic laryngitis of doubtful nature, which is now seen to be 
tuberculous (StClair Thomson, M.D.) . 

-membranous (R. Lake) 

-report on specimen of membrane (epiglottis) from case 

shown by Mr. Lake (Walter D. Severn) 

-(pachydermoid); case treated with salicylic acid (shown by Mr, 

Atwood Thorne for Dr. Dundns Grant) . 

-tubercular, after removal of large interarytmnoid mass (R. Lake) 

in a dwarf (Herbert Tilley, M.D.) 


Larynx, abscess of; specimen (F. de Havilland Hall, M.D.) 

-angioma of (J. W. Bond, M.D.) 

-disease of, for diagnosis (W. H. Kelson, M.D.) 

- extra-laryngeal cyst, two cases of (E. B. Waggett) 

-epithelioma of (Barclay Baron) 

-P-* (F. J. Steward, shown for Mr. C. J. Symonds) . 

-two cases treated by thyrotomy (Sir Felix Semon, M.D.) 

case of laryngeal disease for diagnosis (E. W. Roughton) 


lupus of; sections (Wyatt Wingrave) 
- with microscopical sections and 


(Ferdinand Massei) 
malignant disease 


drawings from a case 


symptoms of malignant disease of larynx caused 


(j 


PAGB 

33 


51 

9 

16 

117 

9 

39 

49 

7 
77 
64 

3 

8 
39 

115 

15 


by parathyroid tumour (Philip de Santi) 

— pachydermia of (J. Dundas Grunt) . 

-(C. A. Parker) 

— specimen of pachydermia laryngis (R. Lake) 

papilloma of, previously shown in elderly man; complete removal 
, Dundas Grant, M.D.) . . . . 

-microscopic sections (Wyatt Wingrave) 

— recurrent papilloma of, in girl of eighteen (J. W. Bond, M.D.) 

— papillomata of (Richard Lake) 

— multiple and diffuse papillomata of (W. Jobson Horne, M.B.) 

— multiple laryngeal papillomata in child set. 3^ years, completely 

removed in three sittings by endo-laryngeal method (Scanes Spicer, 

U.9.^ ....... 

— recurrent papillomata of (C. A. Parker) 

— specimen of larynx blocked by mass of papillomatous growth in 

boy set. 11 (W. Permewan, M.D.) .... 

— paralysis of, secondary to stricture of the oesophagus (A. A. Bowlby) 

-unilateral (Herbert Tilley, M.D.) 

— paresis of left half of larynx in case of general paralysis (W. 

Jobson Horne, M.B.) ..... 

— paresis of left half of soft palate and larynx in case of dissemi¬ 
nated sclerosis (W. Jobson Horne, M.B.) 

— paresis of left side (P. Willcock, M.D.) 

— specimen from case of perichondritis (W. Permewan, M.D.) 

— sarcoma, case treated by thyrotomy (Sir Felix Semon, M.D.) 

— stricture, following tracheotomy for diphtheria successfully treated 
by dilatation (H. Lambert Lack, M.D.) 

— tubercular, from child rot. 6 years (R. Lake) . 

—— ulceration of (Fitzgerald Powell, M.D.) 

— -case of laryngeal ulceration with calcification of fascia of 

neck (shown by Mr. F. J. Steward for Mr. C. J. Symonds) 


vertigo, laryngeal (Atwood Thorne) . 


Law (Edward, M.D.), case of lupus of nose 

-— case of nasal polypi complicated by well-marked bilateral septal 

obstruction 

Librarian ; report of Librarian ..... 


104 

66 

71 

15 

67 

15 

27 

51 

42 


64 

69 

102 

55 

101 

102 

102 

24 

103 

39 

112 

16 

81 

107 

62 

57 

58 
31 





124 


PAGE 


Lichtwitz’g trocar and cannula: repeated irrigations by means of Licht- 
witz’s trocar and cannula in cure of empyema of antrum (J. Dun das 
Grant, M.D.) . . . . . .16 

Lipoma, large, of soft palate (J. W. Bond, M.D.) . . .8 

Lucas (J. S.), case of tuberculous interarytaenoid growth (shown for Mr. 

Lake) . . . . . . .63 

Lupus of larynx, with microscopical sections and drawings from a case 

(Ferdinand Massei) . . . . . . 1 

-— - sections (Wyatt Wingrave) . . . .15 

-of nose (Edward Law, M.D.) . . . .57 

- : -(Wyatt Wingrave) . . . .38 

-— and pharynx (Watson Williams, M.D.) . . 75 

Lympho-sarcoma (?) of tonsils (Lambert Lack, M.D.) . . .80 

Maoi&ttbe (John), discussion on asthma in its relation to diseases of the 

upper air-passages . . . . . .91 

Mackenzie (Hector, M.D.), a case of functional hoarseness in a woman 

at. 87 . . . . . .25 

Malformation of palato-pharyngei muscles (Fitzgerald Powell) . . 116 

Malignant disease of nose in old man (J. W. Bond, M.D.) . . 26 

-old-standing bronchocele becoming malignant (P. de Santi) 73 

-symptoms of malignant disease of larynx caused by para¬ 
thyroid tumour (Philip de Santi) .... 104 

MASSki (Ferdinand), lupus of the larynx (with microscopical sections and 

drawings from a case) . . . . .1 

Maxilla: node in nasal process of right superior maxilla (Atwood Thorne). 113 
Maxillary antrum : see Antrum (maxillary). 

—-— bones, hyperostosis causing nasal stenosis (A. A. Bowlby) . 23 

McBride (P., M.D.), discussion on asthma in its relation to diseases of the 
upper air-passages (nasal asthma and asthma caused by other parts of 
the upper respiratory tract) .... 86, 100 

Membrane from case of membranous laryngitis, shown by Mr. Lake; re¬ 
port (Walter D. Severn) . . . . .16 

Milligan (W., M.D.), specimens shown . . . .42 

Morbid Growths Committee: reports . . . .13 

Muscles: malformation of palato-pharyngei muscles (Fitzgerald Powell) . 116 


Navtis or varix’of posterior faucial pillar (Ernest Waggett) . . 24 

Nasal sinus : see Sinus (nasal). 

Naso-pharynx, foreign body impacted in, for four years (F. de Havilland 

Hall, M.D.) . . . . . .61 

—-large riaso-pharyngeal polypus (Herbert Tilley, M.D.) . . 62 

-— large sarcomatous tumour of naso-pharynx in female at. 26 . 115 

Neck: calcification of fascia of neck in case of laryngeal ulceration (shown 

by Mr. F. J. Steward for Mr. C. J. Symonds) . . . 107 

Nerve, right facial, paresis of, following tympanic suppuration (William 

Hill, M.D.) . . . . .9 

Node in nasal process of right superior maxilla (Atwood Thorne) . 113 

Nodules: chronic nodular laryngitis in boy at. 15 (StClair Thomson, M.D.) 32 

Nose : nasal asthma (P. McBride, M.D. [in discussion on asthma]) . 86 

—*-nasal case for diagnosis (Barclay Baron) . . .4 

-— chronic empyema of antrum cured by intra-nasal treatment (turbi- 

riectomy—Krause’s trocar) (J. Dundas Grant, M.D.) . . 17 

-— epithelioma, tubular (A. Bronner, M.D.) . . .42 

--epitheliomatous ulceration of naso-pharynx (Herbert Tilley, M.D.) 52 

-— hyperostosis of maxillary and other bones causing nasal stenosis 

(A. A. Bowlby) . . . • . .23 

-lupus of (Edward Law, M.D.) . . . .67 

- -(Watson Williams, M.D.) . . . .75 

■ ■ —- Wyatt Wingrave) . , , .38 





125 


PAGE 

Nose, malignant disease of, in old man (J. W. Bond, M.D.) • . 26 

-node in nasal process of right superior maxilla (Atwood Thorne) . 113 

-paroxysmal sneezing associated with great hypertrophy of tissues 

in neighbourhood of the septal tubercle (Arthur Cheatle) . . 6 

—— case of nasal polypi complicated by well-marked bilateral septal ob¬ 
struction (Edward Law, M.D.) . . . .68 

■ - sarcoma of (Barclay Baron) . . . .3 

-further report of case shown at November meeting (Barclay 

Baron, M.B.) . . . . .36 

-old syphilitic disease in (James Donelau, M.B.) . . 78 

-tumour of nasal cavity (E. Cresswell Baber) . . . 109 

-: recurrent nasal tumour from female ®t. 23 (Richard Lake) . 16 

-ulcer, spreading (Wyatt Wingrave) . . . .19 

-ulcer of nasal septum (A. A. Bowlby) . . .48 


(Esophagus, old-standing bronchocele causing pressure on oesophagus (P. 

de Santi) . . . . . . .73 

-cancer of (Watson Williams, M.D.) . . . .6 

-epithelioma of oesophagus causing bilateral paralysis of vocal cords 

(E. Clifford Beale, M.B.) ..... Ill 

-(?) oesophageal pouch (E. Cresswell Baber) . . .11 

-skiagram of foreign body in (P. de Santi) . . .70 

-stricture of oesophagus; secondary laryngeal paralysis (A. A. 

Bowlby) . . . . . . .66 

Operation (ralical) in cure of chronic empyema of antrum (Scanes Spicer, 

M.D.) •••••• 34, 36 

Ostium maxillare: specimen of peg removed from maxillary antrum through 

ostium maxillare (Watson Williams, M.D.) . . .38 

Pachydermia laryngis (C. A. Parker) . . . .71 

-(J. Dundas Grant, M.D.) . . . . .66 

--- specimen (R. Lake) . . . . 16 

Palate (soft), adhesion to posterior wall of pharynx (F. de Uavilland Hall, 

M.D.) ...... 61 

-cleft, exceptional case (Morley Agar) . . . 12 

-malformation of palato-pharyngei muscles (Fitzgerald Powell) . 116 

-paralysis (unilateral) (Herbert Tilley, M.D.) . . . 101 

-case of syringomyelia with paralysis of right side of palate and 

pharynx and of right vocal cord (Herbert Tilley, M.D.) . . 21 

-paresis of right side, following tympanic suppuration (William 

Hill, M.D.) . . . . . .9 

-paresis of left half of soft palate in case of disseminated 

sclerosis (W. Jobson Horne, M.B.) .... 102 

-paresis of left half of soft palate and larynx in case of dis¬ 
seminated sclerosis (W. Jobson Horne, M.B.) . . 102 

-in case of right recurrent paralysis (R. Lake) . . 43 

-tumour of palate in woman set. 34 (J. W. Bond, M.D.) . . 114 

-large lipoma of (J. W. Bond, M.D.) . . .8 

-ulceration (C. A. Parker) . . . .12 

Papilloma of larynx: microscopic sections (Wyatt Wingrave) . . 16 

----previously shown, in elderly man; complete removal (J. 

Dundas Grant, M.D.) . . . . .67 

-recurrent, of larynx, in girl of eighteen (J. W. Bond, M.D.) . 27 

-specimen of larynt blocked by mass of papillomatous growth in boy 

sb t. 11 (W. Permewan, M.D.) . . . . . 102 

Papillomata of larynx (Richard Lake) . . ’ . .61 

-- multiple (J. Dundas Grant, M.D.) . , . .68 





126 


PAGE 

Papillomata, multiple laryngeal, in child ®t. 3|, completely removed in 

three sittings by endo-laryngeal method (Scanes Spicer, M.D.) . 64 

-multiple and diffuse, of larynx (W. Jobson Horne, M.B.) . 42 

-recurrent, of larynx (C. A. Parker) . . . *69 

-of tonsil (P. de Santi) . . . . .26 

Paralysis: abductor, bilateral (Richard Lake) . . . 118 

-(? complete) of left cord (E. Furniss Potter, M.D.) . . 47 

-complete paralysis of one vocal cord and impaired abduction of the 

other (StClair Thomson, M.D.) . 106 

-: facial, in case of right recurrent paralysis (R. Lake) . . 43 

-(general) : case of general paralysis with paresis of left half of 

larynx (W. Jobson Horne, M.B.) . . . . 102 

-: laryngeal, secondary to stricture of oesophagus (A. A. Bowlby) . 65 

-right recurrent, case of (R. Lake) . . . .48 

-of right side of palate and pharynx and of right vocal cord, in case 

of syringomyelia (Herbert Tilley, M.D.) . . .21 

-unilateral, of palate, pharynx, larynx, etc. (Herbert Tilley, M.D.) . 101 

-of vocal cords, bilateral; caused by epithelioma of oesophagus (E. 

Clifford Beale, M.B.) . Ill 

-in case of cancer of oesophagus (Watson Williams, M.D.) . 5 

-recurrent; after-history of case (F. Willcocks, M.D.) . 44 

Parathyroid tumour causing symptoms of malignant disease of larynx; 

operation and recovery (Philip de Santi) . . . 104 

Paresis of left half of larynx in case of general paralysis (W. Jobson 

Horne, M.B.) . . . . . . 102 

-of left half of soft palate and larynx in case of disseminated 

sclerosis (W. Jobson Horne, M.B.) .... 102 

-of left side of larynx (F. Willcocks, M.D.) . . .24 

■ of right facial nerve and of right side of the palate following 

tympanic suppuration (William Hill, M.D.) . . .9 

-of right vocal cord (StClair Thomson, M.D.) . . .72 

---after removal of growth in anterior commissure (L. H. 

Pegler, M.D.) . . . • . .7 

— of trapezium, stemo-mastoid, and palate in case of right recurrent 
paralysis fR. Lake) . . . . . .43 

Pabkeb (C. A.), notes of a case of ulceration of the soft palate . • 12 

- growth of left vocal cord in a man set. 32 . .43 

- cA8e of recurrent papillomata of larynx . . .69 

-case of pachydermia laryngis . . . .71 

Patebson (D. R.), foreign body impacted in the naso-pharynx for four 

years . . . . . . .61 

Peg removed from maxillary antrum through ostium maxillare (Watson 

Williams, M.D.) . . . . . .38 

Pegkleb (L. H., M.D.), growth in anterior commissure has been removed, 
but paresis of right cord remains (patient shown at March 
meeting) . . . . . . .7 

Perichondritis: specimen of larynx from case of perichondritis (W. 

Permewan, M.D.) ...... 103 

Pebmewak (W., M.D.), discussion on asthma in its relation to diseases of 

the upper air-passages . • • . .95 

-- a specimen of larynx blocked by a mass of papillomatous growth 

from a boy aged eleven ..... 102 

-specimen of larynx from a case of perichondritis . . 103 

Pharynx: complete adhesion of soft palate to posterior wall (F. de Havil- 

land Hall, M.D.) . , . . . .61 

-- epithelioma (case shown by Mr. Atwood Thorne for Dr. Dundas 

Grant) ....... 117 

-large gumma in posterior pharyngeal wall (Arthur Cheatle) . 68 

-- lupus of (Watson Williams, M.D.) . . . .75 

-malformation of palato-pharyngei muscles (Fitzgerald Powell) . 116 







127 


PAGE 

Pharynx: paralysis (unilateral) (Herbert Tilley, M.D.). . . 101 

-case of syringomyelia with paralysis of right side of palate and 

pharynx and of right vocal cord (Herbert Tilley, M.D.) . . 21 

-(tumour) : unusual pharyngeal tumour (Sir Felix Semon, M.D.) . 112 

- (ulceration) : cases of sloughing ulceration of pharynx (shown by 

Mr. F. J. /Steward f 0 r Mr. C. J. Symonds) . . . 108 

Photograph (X rays) : see R&ntgen rays. 

Polypi, nasal, complicated by well-marked bilateral septal obstruction 

(Edward Law, M.D.) . . . . .58 

-removed from case of chronic empyema of antrum (Scanes Spicer, 

M.D.) . . . . . . .36 

Polypus, large naso-pharyngeal (Herbert Tilley, M.D.) . . 52 

-polypoid-looking growth springing from right supra-tonsillar fossa 

(Arthur Cheatle) . . . . . .78 

Pottbb (E. Furniss, M.D,), paralysis (? complete) of left cord . . 47 

■ swelling in interarytronoid region . . . .75 

Pouch (P), oesophageal (E. Cresswell Baber) . . .11 

Powell (Fitzgerald, M.D.), case of cyst of thyro-hyoid bursa . . 80 

-case of laryngeal ulceration . . . .81 

-case of malformation of palato-pharyngei muscles . . 116 

Ptosis, slight, in case of right recurrent paralysis (R. Lake) . . 43 

Rhinitis (chronic), probable cause of pachydermia of larynx (J. Dundas 

Qrant, M.D.) . . . . . 66 

- (ulcerative) in a tubercular girl (Atwood Thorne) . . 113 

Rhino-scleroma : microscopic sections (Wyatt Wingrave) . . 15 

Robinson (H. Betham), slight defective abduction of the right vocal cord 46 

-tumour of right vocal cord; case after removal . . 47 

Rdntgen rays : see also Skiagram . 

-: X-ray photograph of foreign body (silver tube) in the antrum of 

Highmore (Arthur Cheatle) . . . . .19 

Rottohton (E. W.), a case of laryngeal disease for diagnosis . . 115 

Salicylic acid in treatment of case of pachydermoid laryngitis (case shown 

by Mr. Atwood Thorne for Dr. Dundas Grant) . . . 117 

BE Santi (Philip), papilloma of tonsil . . . .26 

-a skiagram of foreign body in the oesophagus . . .70 

-specimen of old-standing bronchocele, becoming malignant and 

causing pressure on the oesophagus and trachea . . .73 

-- case of primary epithelioma of the right tonsil with extension to 

the tongue and cervical glands . . . .74 

-- case of parathyroid tumour causing symptoms of malignant disease 

of the larynx; operation and recovery .... 104 

Sarcoma: large sarcomatous tumour of naso-pharynx in female set. 26 

(StClair Thomson, M.D.) . . . . . 115 

-of larynx, case treated by thyrotomy (Sir Felix Semon, M.D.) . 39 

■ of nose (Barclay Baron, M.B.) . . . .3 

-further report of case shown at November meeting (Barclay 

Baron, M.B.) • • • • . .36 

-see also Lymjpho-sarcoma . 

Scleroma (Rhino-) : see Rhino-scleroma. 

Sclerosis, disseminated, with paresis of left half of soft palate and larynx 

(W. Jobson Horne, M.B.) ..... 102 

Semon (Sir Felix, M.D.), two cases of epithelioma and one of sarcoma of 
the larynx treated by thyrotomy, and keeping well two and a half years 
and one and a half years and six months respectively after operation . 39 

■ ■ — discussion on asthma in its relation to diseases of the upper air- 

passages ...... 95,98 

-— case of unusual pharyngeal tumour .... 112 

Septum (nasal): see Nose. 



128 


PAGE 

Sevbbn (Walter D.), report on a specimen of membrane (epiglottis) from 
a case of membranous laryngitis, shown at the last meeting (November) 
by Mr. Lake . . . . . .16 

Sinus (nasal), w all charts for teaching signs of suppuration in the nasal 

sinuses (J. Dundas Grant, M.D.) . . . .14 

Sinusitis, frontal (William Hill, M.D.) . . . 4 .10 

Skiagram of foreign body in oesophagus (P. de Santi) . . .70 

Sneezing, paroxysmal, associated with great hypertrophy of tissues in 

neighbourhood of the septal tubercle (Arthur Cheatle) . . 6 

Spbnceb (W. G.), case of fixation of left vocal cord with fibrillar move¬ 
ments . . . . . . . 60 

Spiceb (Scanes, M.D.), case of cure of chronic empyema of maxillary 

antrum by radical operation . . . . .34 

-specimen of dead bone, polypi, and debris removed from a case of 

chronic empyema of antrum, cured by radical operation in eight weeks 36 
-case of multiple laryngeal papillomata in a child ®t. 3k years com¬ 
pletely removed in three sittings by endo-laryngeal method under com¬ 
bined general anaesthesia and local cocainisation, and without trache¬ 
otomy. Result: full restoration of voice and normal breathing . 64 

-discussion on asthma in its relation to diseases of the upper air- 

passages . . . . . . .92 

Stenosis, nasal, caused by hyperostosis of maxillary and other bones (A. 

A. Bowlby) . . . . . .23 

Sterno-mastoid, paresis of, in case of right recurrent paralysis (R. Lake) . 43 
Stbwabd (F. J.), ? epithelioma of larynx, shown for Mr. Symonds . 8 

-case of laryngeal ulceration with calcification of the fascia of the 

neck, shown for Mr. Charters Symonds .... 107 

-case of sloughing ulceration of the pharynx, shown for Mr. C. J. 

Symonds ....... 108 

Stricture of larynx following tracheotomy for diphtheria, successfully 

treated by dilatation (H. Lambert Lack, M.D.) . . . 112 

-of oesophagus: secondary laryngeal paralysis (A. A. Bowlby) . 55 

Suppuration, tympanic, followed by paresis of right facial nerve and of 

right side of palate (William Hill, M.D.) . . .9 

■ wall charts for teaching signs of suppuration in nasal sinuses (J. 

Dundas Grant, M.D.) . . . . .14 

Swelling in interarytaenoid region (E. Furniss Potter, M.D.) . .76 

Symonds (C. J.) : ? epithelioma of larynx, shown by Mr. Francis J. Steward 8 

-case of laryngeal ulceration with calcification of the fascia of the 

neck, shown by Mr. Francis J. Steward.... 107 

-case of sloughing ulceration of the pharynx, shown by Mr. Francis 

J. Steward ...... 108 

Syphilis : old syphilitic disease in nose of woman aged 36 (James Donelan, 

M.B.) . . . . . . .78 

Syringomyelia, case of, with paralysis of right side of palate and pharynx, 

and of right vocal cord (Herbert Tilley, M.D.) . . .21 

Thomson (StClair, M.D.), man ®t. 51 with hypertrophic laryngitis of 

doubtful nature . . . v . . .2 

-chronic nodular laryngitis in a boy aged fifteen . . 32 

-two cases of chronic laryngitis, entirely limited to the right vocal 

cord and probably tubercular in character . . .33 

-man set. 51, shown at the November meeting as a case of hyper¬ 
trophic laryngitis of doubtful nature, which is now seen to be tuber¬ 
culous . . . . . • .61 

—-— case of paresis of the right vocal cord . . .72 

-discussion on asthma in its relation to diseases of the upper air- 

passages . . . . . . .99 





129 


PAGE 

Thomson (StClair, M.D.), case of complete paralysis of one vocal cord and 

impaired abduction of the other .... 106 

-female set. 26, with large sarcomatous tumour of the naso-pharynx 116 

Thorne (Atwood), case of laryngeal vertigo . . .62 

-case of node in nasal process of tfie right superior maxilla and 

ulcerative rhinitis in a tubercular girl .... 113 

-- a case of epithelioma of the pharynx (shown for Dr. Dundas Grant) 117 

-a case of pachydermoid laryngitis treated with salicylic acid . 117 

Thyro-hyoid bursa, cyst of (Fitzgerald Powell, M.D.) . . .80 

Thyroid: see parathyroid. 

Thyroid cyst (Herbert Tilley, M.D.) . . . .73 

Thyrotomy: two cases of epithelioma and one case of sarcoma of the larynx 

treated by thyrotomy (Sir Felix Semon, M.D.) . . .39 

TlliLEY (Herbert, M.D.), a case of syringo-myelia, with paralysis of the 

right side of the palate and pharynx and of the right vocal cord . 21 
—-— tubercular laryngitis in a dwarf . . . .39 

—— epitheliomatous ulceration of naso-pharynx . . .52 

-large naso-pharyngeal polypus . . . .52 

-specimen of large thyroid cyst . . . .73 

-— case of perverse action of vocal cords . . .82 

-discussion on asthma in its relation to diseases of the upper air- 

passages . . . . . .91 

-case of unilateral paralysis of palate, pharynx, larynx, etc. . 101 

Tissues, hypertrophy of, in case of paroxysmal sneezing (Arthur Cheatle) . 6 

Tongue, primary epithelioma of right tonsil with extension to the tongue 

(P. de Santi) . . . . . .74 

Tonsil, hypertrophy, preparations of (Wyatt Wingrave) . . 14 

- - —lympho-sarcoma (?) of (H. Lambert Lack, M.D.) . . 80 

-papilloma of (P. de Santi). . . . .26 

-polypoid-looking growth springing from right supra-tonsillar fossa 

(Arthur Cheatle) . . . . . .78 

-(right), primary epithelioma of (P. de Santi) . . .74 

Trachea, old-standing bronchocele causing pressure on (P. de Santi) . 73 

Tracheotomy for diphtheria followed by stricture of larynx (H. Lambert 

Lack, M.D.) ...... 112 

Trapezium, paresis of, in case of right recurrent paralysis (R. Lake) . 43 

Treasurer, annual statement . . . . .30 

Trocar, Krause’s, chronic empyema of antrum cured by intra-nasal treat¬ 
ment (turbinectomy—Krause’s trocar) (J. Dundas Grant, M.D.) . 17 

-- (Lichtwitz’s), empyema of antrum cured by repeated irrigations by 

means of Lichtwitz’s trocar and cannula (J. Dundas Grant, M.D.) . 16 

Tubercle, septal, great hypertrophy of tissues in neighbourhood of (Arthur 

Cheatle) . . . . . . .6 

Tuberculosis: man set. 51, shown at the November meeting as a case of 
hypertrophic laryngitis of doubtful nature, which is now seen to be 
tuberculous (StClair Thomson, M.D.) . . . .51 

■ —— miliary, of fauces (Lambert Lack, M.D.) . . .78 

■ tubercular laryngitis after removal of large interarytsenoid mass 

(R. Lake) . . . . . .9 

-in a dwarf (Herbert Tilley, M.D.) . . 39 

-tubercular larynx from a child set. 6 (R. Lake) . . 16 

-tuberculous interarytaenoid growth (J. S. Lucas, shown for Mr. R. 

Lake) . . . . . . .63 

-two cases of chronic laryngitis, probably tubercular in character 

(StClair Thomson, M.D.) . . . . .33 

-ulcerative rhinitis in a tubercular girl (Atwood Thorne) . . 113 

Tumour: large sarcomatous tumour of naso-pharynx in female set. 26 

(StClair Thomson, M.D.) ..... 115 

-of the nasal cavity (E. Cresswell Baber) . . . 109 

-of palate in woman set. 34 (J. W. Bond, M.D.) .. . 114 




180 


PAGB 


Tumour, parathyroid, causing symptoms of malignant disease of larynx; 

operation and recovery (Philip de Santi) . . • 104 

-of pharynx; unusual pharyngeal tumour (Sir Felix Semon, M.D.). 112 

-of right vocal cord; case after removal (H. Betham Robinson) . 47 

—*— recurrent nasal, from female aged 23 (R. Lake) . . 16 

Turbinectomy: chronic empyema of antrum cured by intra-nasal treatment 

(turbinectomy—Krause’s trocar) (J. Dundas Grant, M.D.) . . 17 

Tympanum: paresis of right facial nerve and of right side of palate follow¬ 
ing tympanic suppuration (William Hill, M.D.) • • .9 

Ulcer of nasal septum (A. A. Bowlby) . . . .48 

-spreading, of nose (Wyatt Wingrave) . . .19 

Ulceration, epitheliomatous, of naso-pharynx (Herbert Tilley, M.D.) . 52 

-laryngeal, with calcification of fascia of neck (shown by Mr. F. 

J. Steward for Mr. C. J. Symonds) .... 107 

-of larynx (Fitzgerald Powell, M.D.) . . . .81 

-of soft palate (C. A. Parker) . . . .12 

-(pharyngeal), case of sloughing ulceration of pharynx (shown by 

Mr. F. J. Steward for Mr. C. J. Symonds) . . . 108 

Varix or nsevus of posterior faucial pillar (Ernest B. Waggett) . . 24 

Vertigo, larvngeal (Atwood Thorne) . . . .62 

Vocal cord (left), fixation, with fibrillar movements (W. G. Spencer) . 69 

-growth of left vocal cord in a man aged 32 (C. A. Parker) 43 

-(right), growth, case after removal (H. Betham Robinson) . 47 

-(left) paralysis (? complete) (E. Furniss Potter, M.D.) . . 47 

-(right), slight defective abduction (H. Betham Robiuson) . 46 

-two cases of chronic laryngitis entirely limited to right 

vocal cord (StClair Thomson, M.D.) . . . .33 


-cade of syringomyelia with paralysis of right side 

of palate and pharynx, and of right vocal cord (Herbert Tilley, M.D.) 21 

-paralysis, in case of cancer of oesophagus (Watson Williams) 5 

-complete paralysis of one vocal cord and impaired 

abduction of the other (StClair Thomson, M.D.) . . . 106 

-recurrent paralysis, after history of case (F. Willcocks, 

M.D.) . . . . . . .44 

-bilateral paralysis of vocal cords caused by epithelioma of 

oesophagus (E. Clifford Beale, M.B.) .... Ill 

-i-paresis of, after removal of growth in anterior 

commissure (L. H. Pegler, M.D.) . . . .7 

-paresis of (StClair Thomson, M.D.) . . 72 

-perverse action of vocal cords (Herbert Tilley, M.D.) . 82 

Waggett (Ernest B.), varix or ncevus of the posterior faucial pillar . 24 

-two cases of extra-laryngeal cyst . . .64 

-discussion on asthma in its relation to diseases of the upper air- 

passages . . . . . . .90 

Willcooks (F., M.D), case of paresis of left side of larynx . . 24 

-after-history of a case of recurrent paralysis of vocal cord . 44 

Williams (C. Theodore, M.D.), discussion on asthma in its relation to 

diseases of the upper air-passages . . . .95 

Williams (Watson, M.D.), cancer of oesophagus with paralysis of one 

vocal cord . . . . . .5 

-specimen of peg removed from maxillary antrum through ostium 

maxillare. . . • • • .38 

-case of lupus of nose and pharynx . . . .75 

—— discussion on asthma in its relation to diseases of the upper air- 

passages . ..... 93 




131 


PAGB 


WiNGRAVB (Wyatt), preparations of hypertrophied tonsils . . 14 

-microscopic sections of papilloma of the larynx . . 16 

-microscopic sections of rhino-scleroma . . .16 

-sections of lupus of larynx. . . . .16 

-spreading ulcer of the nose . . . .19 

-lupus of nose . . . . . .38 


X-ray: see Rontgen rays. 


PRINTED BY ADLARD AND SON, BARTHOLOMEW CLOSE. 






PROCEEDINGS 


OF THE 

L AR YN GOLOGIC AL SOCIETY 


LONDON. 


VOL. VII. 

1899 — 1900 . 


WITH 

LISTS OF OFFICERS, LIST OF MEMBERS, ETC. 


LONDON: 

PRINTED BY ADLARD AND SON, 
BARTHOLOMEW CLOSE, E.C. 




OFFICERS AND COUNCIL 


OP THE 

Harpjjdogual Societg of ^onion 

ELECTED AT 

THE ANNUAL GENERAL MEETING, 

JANUARY 5th, 1900. 


I^resibtnt. 

F. DE HAYILLAND HALL, M.D. 

Uict-|ittsibenls. 

A. A. BOWLBY, F.R C.S. W. R. H. STEWART, F.R.C.S. (Edin.) 

E. LAW. M.D. 

ftrrasurer. 

E. CLIFFORD BEALE, M.B., F.R.C.P. 
librarian. 

J. DUNDAS GRANT, M.D.. F.R.C.S. 

Secretaries. 

H. LAMBERT LACK. M.D , F.R.C.S E. B. WAGGETT, M.B. 

Coancil. 

F. W. MILLIGAN, M.D. HERBERT TILLEY, F.R.C.S. 

WALTER SPENCER, M.S. BARCLAY BARON. M B. 

WILLIAM HILL, M.D. 



PRESIDENTS OF THE SOCIETY. 


(From its Formation .) 


ELECTED 

1893 Sib G-eobge Johnson, M. D., F.R.S. 

1894-6 Sib Felix Semon, M.D., F.R.C.P. 

1897-8 H. Tbentham Butlin, F.R.C.S. 

1899-1900 F. de Havilland Hall, M.D., F.R.C.P. 


r 

f 



PROCEEDINGS 

OF THB 

LARYNGOLOGICAL SOCIETY OF LONDON. 


52nd Ordinary Meeting, November 3rd, 1899. 

F. de Havilland Hall, M.D., President, in the Chair. 

William Hill, M.D., ) 0 , . 

Lahbebt Lace, M.D., J Secretaries. 

Present—21 members and 3 visitors. 

The minutes of the preceding meeting were read and con¬ 
firmed. 


The President referred to the loss laryngology had sustained 
by the death of Prof. Stork, of Vienna, one of the earliest and 
most distinguished laryngologists and an honorary member of 
this Society. 

The following cases and specimens were shown : 


Microscopical Section op a Growth (Lymphangioma ?) removed 
prom the Right Ventricular Band op a Man aged Forty. 

Shown by Dr. Furniss Potter. The specimen was brought 
before the notice of the Society because there was some doubt 
as to its nature, and also because, as far as the exhibitor 
knew, a growth on the ventricular band was not of common 
Occurrence. 


FIRST SERIES—VOL. VII. 


1 



2 


Mr. Waggett said lie had been asked by Dr. Fumiss Potter to 
suggest that this case might be referred to the Morbid Growths 
Committee, as Dr. Potter had some doubt as to whether it was 
lymphangioma. 

The suggestion was supported by the President and adopted. 


Case op Enlargement op the Nose. 

Shown by Dr. William Hill. A boy aet. 8, the subject of 
congenital syphilis, first came under observation as an out¬ 
patient a year ago with necrosis of the pre-maxilla and ulcera¬ 
tion of the septum. Subsequently a large sequestrum was 
removed under an anaesthetic. About a month ago signs of sym¬ 
metrical periostitis of the nasal bones and of the nasal processes 
of the maxillary and frontal bones appeared. The enlargement 
and deformity of the nose had steadily increased; the swelling, 
which was very painful to touch, had now extended halfway up 
the forehead; the usual depressions at the inner angles of the 
orbit had disappeared, and the cheeks were becoming puffy. 
There appeared to be no active destruction now going on in the 
septum, but there was present a condition of crusty rhinitis. 
The boy had been taking grey powder, but the condition was 
gradually getting worse, and the exhibitor asked whether any 
one present could suggest any local or constitutional treatment 
likely to arrest the morbid process; otherwise much destruction 
and deformity seemed to be inevitable. 


A Case op Lateral Enlargement op the Nose. 

Shown by Dr. Hill. The patient, a girl mt. 11, had been 
under observation as a sufferer from atrophic rhinitis for more 
than a year. Owing, presumably, to retarded growth of the 
septum, the shape of the nose, with its now depressed bridge, 
was quite different from what it was formerly, and the patient 
had been gradually altering in appearance for two years. Within 
the last two or three months, however, a more rapid change had 
taken place. This consisted of a lateral widening of the nose; 
the nasal bones, instead of forming a bridge, have become 



3 


markedly flattened out, and the nasal processes of the superior 
maxillae were now widely separated and formed prominent ridges, 
rising above the level of the depressed and flattened nasal bones. 
The question asked was, could anything be done either to correct 
the present deformity or to arrest its progress ? 


Female aged Twenty-four with Enlargement of Nose. 

Shown by Dr. StClair Thomson. This patient applies for 
relief for frontal and occipital headache and nasal obstruction. 
She states that her nose was always rather broad, but that 
lately it has increased. The bridge of the nose appears expanded 
on either side, the ridge of the nose is ill defined, and (apparently 
from distension of the skin) appears thin, and the capillary 
circulation in it is marked, while the alae seem thickened. 

She has cacosmia, but states that she cannot smell on the right 
side. Both nostrils are patent; there is no pus on either side, 
and no marked pathological change in the nose, except that the 
middle turbinal is enlarged and pushed inwards against the 
septum. A view has not been obtained of the post-nasal space. 


Male aged Fifteen with Enlargement of Nose. 

Shown by Dr. StClair Thomson. In this case the nose is not 
only enlarged externally, but it is red and decidedly tender. 
The tenderness is slight over the lower wall of the frontal sinus, 
hardly perceptible over the centre of both maxillary sinuses, but 
is increased over the nasal process of the superior maxilla, while 
it becomes very marked over the nasal bones and on pressure 
at the inner canthus of the eye on the region of the ethmoidal 
labyrinth. 

The patient states that for twelve months the discharge from 
his nose has smelt badly both to himself and others. 

Pus has been seen on the posterior wall of the cavum and on 
the floor of the right choana, as well as a slight amount in the 
left middle meatus. 



4 


Nasal Case for Diagnosis. 

Shown by Mr. Atwood Thorne. The patient is a boy aet. 12. 
Six weeks ago it was noticed that his nose was broader than 
usual, and since that time it has been getting gradually worse. 

He has also had increasing difficulty in breathing through his 
nose. 

There is a history of a blow three months ago, when his nose 
bled a good deal for an hour or two and then ceased. 

He came to St. Mary’s Hospital on November 3rd, and was 
seen to have a broad nose with a depressed bridge. He could 
not breathe at all through either nostril. On examination both 
nostrils were found to be filled with hard, blood-stained masses. 
On clearing these away the septum was found to be thickened 
and ragged immediately within the columella, and beyond was a 
large perforation of the cartilaginous septum. 

There is nothing in the boy to suggest tuberculosis. 

There is nothing in the teeth or eyes to suggest hereditary 
syphilis, but he is the youngest child, and the mother had a 
miscarriage three and a half years after his birth. 

Dr. William Hill said: I think Dr. StClair Thomson’s two 
cases are instances of perichondritis and periostitis of a more or less 
acute character, and we can dismiss, at any rate as a prime factor, the 
question of ethmoiditis, though secondarily the ethmoid region may 
be involved. I have had cases resembling them before in which I had 
thought I had excluded syphilis, but on more than one occasion they 
eventually turned out to be syphilitic; others were apparently of an 
erysipelatous nature. 

In the female I cannot help thinking that there is perichondritis 
of the septum present owing to the thickness of septum, and if so 
that might explain the condition of the rest of the nose, because 
when you get perichondritis of the septum the inflammation often 
does spread to the adjacent structures; I cannot, however, throw any 
light on the aetiology of the case. 

Dr. Scanes Spicer said in the boy’s case the bony and cartilagi¬ 
nous framework of the nose appeared quite normal and not hypertro¬ 
phied, whereas the hyperplastic condition was confined to the soft 
tissues of the tip, dorsum, and alee, and appeared to be only of the skin 
and subcutaneous cellular tissue. The explanation of this seemed to 
him not clear in all cases. Doubtless sometimes this enlargement 
resulted from oedema of an acute inflammation which did not com¬ 
pletely subside. At others it was secondary to the congestion con¬ 
sequent on systemic circulatory disorder. Reflex congestion from 



* 

o 


intra-nasal irritation might explain other cases; and sometimes, as in 
this case, a stagnation of lymph-flow was suggested, although, one 
could not determine the fact of blockage of lymph vessels. 

Dr. F. de Havilland Hall: The first case reminds me of the 
case of a lady who consulted me some years ago, though in my case 
there was more swelling, redness, and tenderness. In order to get 
a satisfactory examination I applied cocaine to the interior of the 
nostril. There was no change in the nose, and I sent her back to her 
medical adviser in the country. To my dismay I heard three weeks 
later that, a few days after I had seen her, acute mischief set up in 
her nose with the formation of an abscess and destruction of the 
bony framework, so that the bridge of the nose fell in. At the time 
there was very little more to be noticed than in the case we are 
discussing; it had been going on for some weeks, and seemed a chronic 
or subacute case, and I had no idea that such rapid mischief was in 
progress. I have been unable to satisfy myself of the final result, as 
the lady would never come near me again. 

Sir Felix Semon : I have had the opportunity of seeing a good 
many similar cases, and in the majority I have satisfied myself that 
the origin of the enlargement was traumatic. It appears that often 
enough after a fall in early infancy, or after a blow during school-time, 
or a fall in the hunting-field, etc., an inflammation is set up, not only 
of the soft parts, but also of the perichondrium or periosteum, the 
acute symptoms of which (pain, obstruction, epistaxis) quickly sub¬ 
side. But later on it progresses very slowly and insidiously. So 
much is that the case that patients often, when first asked about a 
history of traumatism, distinctly deny such; but on a subsequent occa¬ 
sion return with the statement that, on further thinking about the 
matter, they remember having had months or even years ago an injury 
to the nose. The best treatment I have always found in such cases 
consists in applications of ice-water externally, and iodide of potassium 
internally. 

Dr. Dtjndas Grant : I share the diffidence which seems to usually 
possess the members of this Society with regard to these cases; 
personally I have a good deal to learn about them. With regard to 
the youth whose case was brought before us by Dr. StClair Thomson, 
I agree with Dr. Scanes Spicer that the condition is more that of 
vascular congestion from pressure, owing, I think, to the size of the 
medial turbinated bones ; and I am of the opinion that a very consider¬ 
able diminution will take place if the turbinated bones are removed. 
Very often early swelling is due to some skin disease affecting the 
lining of the vestibule, and I think that repeated small follicular 
abscesses will leave this enlargement. 

With regard to the case of Dr. Hill, it is a very serious one indeed: 
the child seems to have been inoculated with some virulent form of 
suppurative disease, which has resulted in a chronic atrophic condition 
and cirrhotic contraction of the parts; afterwards this has resulted in 
the falling down of the soft tissues which bring with them the nasal 
bones, which do not seem to have acquired their attachment to the 
nasal processes of the superior maxilla, as they would do at a later 



6 


period of life. I do not think it is necessary to assume a syphilitic 
condition in that case. 

Dr. Fitzgerald Powell : To help clear up this matter I wish to 
ask Dr. StClair Thomson to tell us whether any cultures have been 
made from the nasal secretions, especially in the case of the boy. 
I think we must look further afield in the majority of such cases 
for the cause, and if sought for it will be found in certain blood dys- 
crasias such as tubercle, syphilis or perhaps septic infection. In 
traumatism no doubt we may have the exciting cause, the disease 
remaining latent until the blow or iujury has been received. We 
know in septic, tubercular, and other forms of osteitis, a blow or other 
injury is often the starting-point of the disease, which not infre¬ 
quently runs a rapid course. In these nose cases tubercle or syphilis 
will, I think, generally be found at the base of the trouble, and not 
septic infection. 

Dr. StClair Thomson in replying said : I am very glad to have 
raised a discussion, and I hope that members having similar cases will 
bring them before the Society. Firstly, I would say that no cultures 
have been made from either of my patients. While no doubt trauma¬ 
tism is a cause in a large number of cases, I hardly think it will 
explain all cases. Among my private patients such cases have 
occurred in middle-aged ladies, who do not seem likely to be exposed 
to traumatism ; one was over fifty years of age, who was quite sure she 
had had no injury. Her nose was tender, shiny, and red, and for this 
reason she had a dislike to going into society. I had another case in 
consultation in which the condition was in an advanced stage; the 
bone and skin were distended to such an extent as to cause superficial 
ulceration. It was seen by a general surgeon in consultation; he 
could give no opinion, and regarded the case as very obscure. The 
post-nasal space was perfectly clear. Under potassium iodide (up to 
30 grs. three times a day for six weeks), given by a Manchester 
surgeon on the suspicion of syphilis, no improvement took place. 


A Case of Laryngeal Growth (Anterior Commissure) in a 
Man with Altered Voice for over Thirty-five Years. 

Shown by Dr. Hector Mackenzie. The patient is a man aet. 
48. His voice has never been natural since the age of ten or 
twelve, when it suddenly altered and became weak and hoarse. 
Since then the voice has remained high-pitched, weak, and more 
or less hoarse, but sometimes worse, sometimes better. He has 
noticed no difference recently. 

He has suffered from a cough off and on since he was a boy. 
For the last six or seven years he easily gets out of breath on 
exertion. It was on account of the cough that the patient sought 



7 


advice. He was found to have a slight degree of emphysema, 
together with some bronchial catarrh. 

On examination of the larynx there was to be seen a flat, 
smooth, reddish growth projecting from the epiglottis immedi¬ 
ately above the anterior commissure, and extending above the 
anterior fourth of the right vocal cord. The remainder of the 
larynx appeared healthy. 

During the three months that the patient has been under 
observation the growth has not altered in size or appearance. 
From the appearance, shape, size, and situation of the growth it 
is probably a fibroma. 

I have brought the case forward especially with regard to the 
question of treatment. 

The growth as far as we can observe produces no symptoms, 
unless we are to suppose that it is the cause of the alteration of 
voice, in which case we must assume that the growth has been in 
existence for thirty-five years. Is this not one of those cases 
where the growth is best left alone, the patient being seen from 
time to time and surgical interference being employed only if 
required by increased size of the growth or by interference with 
the breathing. 

I very much doubt whether it would be of any advantage to 
the patient to have a perfectly normal voice, seeing that he has 
reached the age of forty-eight with his present vocal peculiarities, 
even if it were possible to secure this by operation. What the 
man hopes from operation is to be cured of his shortness of 
breath, with which the growth has no causal relation. 

The President : If I were the patient I would prefer to go to the 
grave with my voice in the present condition. 

Dr. Dundas Grant : Is it not worth while to have that growth 
removed ? I think an attempt ought to be made. It is not always 
an easy place to get at with forceps, but the “ seat of election ” for 
operation by means of a snare. I have seen a case just like it where 
it could not be removed intra-laryngeally, and the result of removal 
by means of thyrotomy was to restore the voice, though it is gener¬ 
ally supposed that thyrotomy is attended with great risk of loss of 
voice. 

Dr. Scanes Spicer : This particular growth seems an easy one to 
remove by snaring, since it appears free from and above the vocal 
cords; with no attachment below the anterior commissure, and with a 
constricted pedicle, removal would probably entirely cure the un¬ 
pleasant hoarseness, 



8 


Mr. Waggett advised Dr. Mackenzie to remove it, or some one else 
would. 

Dr. Herbert Tilley thought that the growth might quite well be 
removed by intra-laryngeal forceps; he had recently thus treated a 
case at Golden Square Throat Hospital, and had found no difficulty 
with it. He felt bound to differ from Dr. Mackenzie’s view of the 
treatment. The fact that the patient had had a bad voice for thirty 
years seemed to the speaker a powerful argument that it was time to 
endeavour to give the patient a good voice. 

Dr. Hector Mackenzie : I am very glad to have had the opinion 
of the members of the Society about this case. I had an opportunity 
this afternoon of seeing the man’s elder brother, who confirmed what 
the patient had told me, that the change in the voice came on quite 
suddenly; he said he could remember the very place where his 
brother lost his voice, namely, a certain field in Oldham. This is 
rather difficult to explain if the cause of the alteration of voice is the 
presence of the tumour. Mr. Waggett says if one person does not 
remove the growth some one else will do it. I believe the man himself 
wants it done, because he thinks he will be cured of his shortness of 
breath. Unless I felt it was the best thing for the man I should neither 
do it nor advise it to be done. I quite agree with you, Mr. President, 
that as the man has gone about all these years—nearly forty years— 
with very little inconvenience resulting from the tumour, it is better 
to allow things to take their ordinary course. 

[The President subsequently had an opportunity of re-examining 
Dr. Hector Mackenzie’s patient, and agreed with those members who 
advocated the removal of the growth.] 


A Case of Epithelioma of the Left Ary-epiglottic Fold in 

a Man aged Sixty-five. 


Shown by Mr. Wyatt Wingrave. The only symptom was 
painful deglutition of seven months’ duration. Portions were 
removed by snare and Grant’s forceps, and proved to be squa¬ 
mous epithelioma. 

During the last two months he had lost weight, and the 
growth showed signs of extension. 


Mr. Butlin : I could not quite convinc emyself how far the growth 
extended anteriorly and posteriorly, but it seems to me from most 
points of view a good case for operation in that situation, though such 
operations are very rarely successful. The best way to do it is to open 
through the thyroid cartilage, turn back the two halves of the larynx to 
obtain a better exposure, and then deal with the growth. I have per- 


r 



9 


formed infra-hyoid laryngotomy for a growth not quite so large as 
this one under discussion; it was not a great success, there was very 
little room to get at it. I have removed very few growths from this 
situation, but such as I have done I have exposed from the front. 


Male with Unusual Indrawing of the Al.® Nasi. 

Shown by Mr. Richard Lake. This case was shown simply as 
a curiosity. 

Dr. Scanes Spicer : The stenosis of nose from alar collapse is so 
extreme in this case, that he would probably derive comfort from 
wearing tubes to keep nostrils open. 

Mr. Lake : The patient wears Schmidt’s dilators, and derives great 
benefit from their use. 

Dr. Scanes Spicer : He wants nothing more than small pieces of 
ordinary drainage-tube, which fulfil every indication and do not irritate. 

Mr. Waggett: Mr. Stewart asked me to draw your attention to 
the fact that he had a similar case which was shown to the Society, 
which perhaps will be remembered, and that he made use of an 
apparatus with a not very favourable result. 

Dr. St.Clair Thomson: The man is a neurotic subject; by 
manipulating the speculum, though I gave him a good deal of space 
and could see right through into the nose, he was still breathless. 
He has cardiac disease, and I have noticed that people with heart 
trouble, whose nasal respiration is deficient, are very neurotic. 


A Case of New Growth in the Vocal Cord, probably Cystic 

in Nature. 

Shown by Dr. Dundas Grant. Man set. 26, omnibus con¬ 
ductor, was brought under my notice by Dr. Mackintosh on 
account of the peculiar condition of his left vocal cord, of which 
he has made a very faithful portrait. The cord is shaped very 
much as if a small lemon-seed had been let into the middle of 
its vibrating part. The mucous membrane over the swelling is 
perfectly normal in colour and lustre, and the mobility of the 
cord is unimpaired; a few blood-vessels ramifying on the surface 
are just visible. There has been no pain, and the only symptom 
has been a pronounced degree of hoarseness each winter for 
four years, coming on gradually, lasting for the winter, and 



10 


then gradually diminishing, but not wholly going, as summer 
comes on. The growth appeared to me to be in the substance 
of the cord rather than on its surface, and its presence, no 
doubt, gave rise to a chronic laryngitis under unfavourable 
climatic conditions, this retrogressing under favourable ones. 
Its rounded contour suggests that it is a cyst. 

I propose making an incision, or at least a puncture, in the 
first instance, subsequently applying an electric or chemical 
cautery. 

Dr. Dundas Grant : This growth has increased in size since I 
first saw it, and has become more prominent. It has been suggested 
by Dr. Tilley that it would be better to remove it with my own forceps 
than make an incision as I proposed. Having again examined the case, 
I shall act on the suggestion. 

Dr. Herbert Tilley advised removal by means of intra-laryngeal 
forceps; the growth was freely moveable, and the treatment suggested 
would be much easier than the endeavour to puncture it and apply 
chromic acid to its interior. 

Dr. StClair Thomson : Are cystic growths common ? I thought 
I had a similar growth once, but when removed and put under the 
microscope it turned out to be a case of oedematous fibroma. 

Dr. Scanes Spicer : It also struck me as being a fibroma. 

Mr. Waggett had operated on a case very similar in appearance to 
that now shown. Microscopic examination proved it to be a cyst lined 
with columno-squamous epithelium. 

Dr. Dtjndas Grant in replying said: I hope to bring this growth 
(be it oedematous fibroma or cystic) before the Society on another 
occasion. My reason for thinking it cystic was that it was deeply 
buried in the substance of the cord, whereas fibromatous growths are 
usually outgrowths from the surface of the cord. 


A Case op Fibro-papilloma op the Vocal Cord causing Hoarse¬ 
ness; Restoration op Voice after Incomplete Removal op 
the Growth. 

r 

Shown by Dr. Dundas Grant. A teacher aet. 19 came under 
my care last September on account of extreme hoarseness of 
about two months* duration, which had come on after an attack 
of bronchitis and influenza. The laryngoscope revealed a pink 
nodule of the size of a large pin’s head on the edge of the left 
vocal cord at the junction of the anterior and middle thirds, and 
a much smaller one immediately opposite it on the right cord. 



11 


By means of my laryngeal cutting-forceps I succeeded in at 
once effecting a somewhat incomplete removal of the growth, 
which Mr. Wingrave considered to be a fibro-papilloma. The 
voice, however, was so well restored that I have not deemed it 
justifiable or requisite to carry out any further surgical treat¬ 
ment. 


Case of Sarcoma of the Post-nasal Space. 

Shown by Mr. Waggett. A young woman set. 30, who six 
months previously had begun to notice nasal obstruction, and also 
the formation of a lump in the neck. Some pain was experienced 
at the back of the neck, and otorrhoea on the left side had 
recently developed without pain. 

Examination showed infiltration of the left lateral and pos¬ 
terior walls of the naso-pharynx with a firm growth of pinkish 
white colour, ulcerated in parts. A large secondary growth 
fixed to the deep structures was present beneath the upper 
quarter of the left sterno-mastoid muscle. The primary growth 
had descended almost to the level of the palate. The nasal 
fossae were not involved. 

Dr. Bond : This is a very grave case, and it is evident that an 
operation will either sooner or later be required to relieve the girl. I 
think that an early attempt should be made, that the palate should be 
split, and the growth thoroughly examined before deciding what should 
be done further. It is possible the whole mass in the naso-pharynx 
might be snared and scraped away and the site cauterised ; one cannot 
tell before exploration, but the patient should have the benefit of the 
doubt, and an attempt be made to either cure or relieve her. I should 
recommend a preliminary laryngotomy, and then a few days later, if the 
last operation was a success, an attempt should be made to remove the 
glands. It is within the bounds of possibility that the girl can be cured ; 
she ought to have her chance. My own argument is that something 
in any case must be done. 

Dr. Soanes Spicer: I have had such a case under treatment 
during the last two years, and which has up to now been a great 
success. The patient was a gentleman aged sixty-five, with almost 
complete nasal obstruction on left side with septal exostosis and 
deflection, hypertrophied inferior and middle turbinated bodies, and 
left nasal cavity blocked with growths. These were thoroughly 
removed in December, 1897, and the nose rectified. The growths 
were myxomatous and fibromatous, and presented no evidence of 
malignancy. The nose was quite clear for some months, but there 



12 


was an undue amount of mucous secretion and post-nasal irritation 
leading to hawking. Towards the end of 1898 the passage seemed 
to be narrowing again at the back, though no growth whatever was to 
be seen in the nose or naso-pharynx. In February, 1899, owing to 
increased stuffiness the patient again sought advice and complained 
of a lump and tenderness externally, but deep behind ramus of lower 
jaw. I then suggested that Mr. Butlin should be asked to see the 
case, as it looked as if it was a case of malignant disease in an early 
stage, and that an external operation would be required. The patient 
was examined under an anaesthetic, and a portion of swollen lump in 
naso-pharynx removed for examination, and found by Mr. Butlin to 
be sarcomatous. The patient thereupon agreed to extirpation of the 
growth internally and externally at two operations. Mr. Butlin 
operated on the internal mass after dividing soft and partly the hard 
palate. The patient was weak, and made but a tardy recovery from 
the first operation, and it was decided to defer the second, at all events 
for some time until he was stronger. The cervical gland mass did not 
appear to increase in size or to spread. Arsenic was tried, but was not 
tolerated. The patient went to the Riviera for some weeks, and later 
in the summer to Switzerland. In the Engadine he consulted Dr. 
Bernhard, of Samaden, who thought it necessary there and then 
(September, 1899) to excise the enlarged masses in the neck; pain 
was a prominent symptom, and the possibility of there being deep 
suppuration in a gland or glands had been held throughout, though 
it was considered probable that the neck growth was also sarcomatous. 
Dr. Bernhard’s expert declared the tumour removed from the neck to 
be glands affected with chronic lymphadenitis with suppurative foci, 
and to be free from malignancy or tubercle. The patient left the 
Engadine within three weeks of the operation, and now, save a slight 
fistulous track over clavicle, is quite well. The practical lessons to be 
derived from this case appear to be that it is almost impossible to 
form an exact and complete opinion of such a case as this from the 
results of a histological examination of portions removed; that post¬ 
nasal sarcomata should be removed as early and as thoroughly as 
possible; and that secondary enlargements in the cervical glands 
outside are not necessarily malignant. 

Dr. de Havilland Hall : I remember one case in which a growth 
was mistaken for adenoids, and an operation performed, but which 
later was found to be a case of sarcoma. 

Mr. Atwood Thobne : I have seen a case in hospital practice which 
was taken to be adenoids, and was operated on as such. The mass 
recurred, was found to be sarcomatous, and did not admit of removal. 

Mr. Waogett : I only have to say that these cases appear to be 
much more common than the scanty literature would lead one to 
suppose. I have seen four cases during the present year, in two of 
which an erroneous diagnosis was at first made. I shall attempt to 
carry out the suggestions made by Dr. Spicer and Dr. Bond. 



13 


Case op Laryngeal Perichondritis in a Man op Twenty-six, 
the Subject op Pulmonary Tuberculosis. 

Shown by Dr. Scanes Spicer. The exhibitor called attention 
to the confinement of the disease to the right half of the larynx, 
to the considerable induration over the right half of the thyroid 
and cricoid cartilages, to the displacement and tilting of the 
larynx over to the left, and to the marked cedematous infiltration 
of the right side of larynx on laryngoscopy. 


Extra-laryngeal (?) Malignant Growth. 

Shown by Mr. Waggett for Mr. W. R. H. Stewart. A 
woman of 56, the subject of chronic throat symptoms, for 
eighteen months had suffered pain in the throat and left ear. 

Careful examination with the mirrors early in July had 
revealed no disease, the patient’s note-book bearing the remark 
that the movements of the cords were normal. Paresis of the 
left vocal cord was noted in September, and early in October 
oedema of the left arytaenoid region developed, partly hiding the 
paretic cord. A plaque, white in colour and resembling in 
appearance the surface of a furred tongue, was now seen on the 
posterior pharyngeal wall on the left side and close to the ary¬ 
taenoid. 

Digital examination revealed the presence of a hard nodular 
infiltration of the left linguo-epiglottic fold. 

The case was regarded as malignant and inoperable, though 
no glandular enlargement was detected. Consequently no 
microscopic investigation had been made. 

The President : This case is one of three,—either tubercular, 
syphilitic, or malignant. Sir Felix Semon seemed in favour of syphi¬ 
litic, and he put malignant last, though I should put it first. 

Dr. Dundas Grant : I should consider it a case of epithelioma 
of the larynx and pharynx. 

Mr. Waggett said that iodide of potassium had been used in this 
case. 

Dr. Hill : The diagnosis could readily be cleared up by snipping a 



14 


bit off for examination. This, assuming the case to be operable, ought 
to be done at once, with a view to prompt surgical measures. 

Dr. Lambert Lace : I should advise that the growth be not 
touched in any way. The diagnosis seemed quite certain, and the 
tumour was quite inoperable. 



PROCEEDINGS 

OF THE 

LARYNGOLOGICAL SOCIETY OF LONDON. 


53rd Ordinary Meeting, December let , 1899. 

F. de Havilland Hall, M;D., President, in the Chair. 

William Hill, M.D., 7 0 . . 

Lambert Lack, M.D.. j Secretaire*, 

Present—33 members and 6 visitors. 


The minutes of the preceding meeting were read and con¬ 
firmed. 

The following gentlemen were nominated for election at the 
next meeting of the Society : 

F. O'Kenealy, Capt. R.A.M.C., India. 

George Constable Hayes, F.R.C.S., 22, Park Place, Leeds. 
Frederick Hibbert Westmacott, F.R.C.S., 5, St. John Square, 
Manchester. 


The following cases and specimens were shown : 


A Diagnostic Mistake. 

By Sir Felix Semon. On October 18th, 1898, I was con¬ 
sulted by Mr. A. W—, aet. 39, on account of soreness of the 
throat on the right side, about the level of the larynx, limited 

2 


riRST SERIES-VOL. VII. 



16 


to one definite spot. He also stated that his voice had become 
gruff, and that swallowing, particularly of his saliva, was some¬ 
what inconvenient. He had not brought up any blood and 
stated that he had not lost flesh. 

On examination the pharynx was healthy, but the right vocal 
cord was fixed in about the cadaveric position, and the mucous 
membrane over the right arytaenoid cartilage and the adjoining 
portion of the plate of the cricoid was considerably tumefied. 
There was no definite evidence of new growth and no ulceration. 
On phonation the left cord crossed the median line. 

Externally there was general fulness of the glands below the 
anterior belly of the sterno-mastoid muscle, and this region was 
more tender on pressure than the corresponding part on the left 
side. There was a somewhat indefinite history of a chancre 
many years ago, apparently not followed by any secondary sym¬ 
ptoms, although the patient had never been properly treated 
for it. 

I gave him iodide of potassium in 10-grain doses for a fort¬ 
night, after which time I wished to see him again. 

On the occasion of his second visit no improvement was 
noticed; on the contrary, the laryngeal tumefaction had in¬ 
creased, and the glands on the right side of the neck were 
distinctly larger and harder than they had been before. The 
patient also complained about increased pain in swallowing, 
sometimes shooting into the right ear. The iodide of potassium 
was increased to 20 grains three times daily, and the patient 
was told to come again in a fortnight’s time. 

When he saw me for the third time, on November 18th, 
matters were again worse than before. Still no ulceration was 
visible in the larynx, but the tumefaction had increased, and he 
was now very hoarse. The pain in swallowing had also become 
worse, and there was more swelling of the glands in the anterior 
triangle than before. 

It seemed practically certain that one had to do with infiltrat¬ 
ing malignant disease of the larynx. The removal of a frag¬ 
ment for microscopic examination was impossible owing to there 
being no distinct projection, but only general tumefaction. 

As the question of operative interference became urgent, I 
sent the patient to Mr. Butlin for an independent opinion. Mr. 



17 


Butlin shared my conviction that the disease was malignant, as 
also, I understand, did Dr. StClair Thomson, whose independent 
opinion the patient sought. 

Although, on account of the extensive glandular swelling in 
the neck, I did not think the case a very suitable one for radical 
operation, still I felt it my duty to lay the alternatives of 
letting matters go on or attempting a radical cure before the 
patient, who decided in favour of operation. 

I had a consultation with Mr. Watson Cheyne, who also did 
not consider the case a favourable one ; but felt sure that if any 
radical operation were attempted at all, it ought to be complete 
laryngectomy. The patient consented to this. 

On November 26th, in the presence of Dr. Lambert Lack 
and of myself, Mr. Watson Cheyne commenced the operation. 
In making the initial incision for tracheotomy, he came at once 
across an enlarged and apparently infected gland, in the middle 
line, quite distant from the region in which one would have 
previously anticipated that infection might have taken place. 
Other enlarged glands were detected immediately afterwards, 
which seemed to come through the crico-thyroid membrane. 
Tracheotomy having been performed, and a cut joining the 
tracheotomy incision having been made parallel to the border 
of the lower jaw, a number of small glands, apparently infected, 
became visible immediately, almost along the entire line of the 
incision. 

Under these circumstances I urged that it was hardly worth 
while going on with the more serious operation originally con¬ 
templated, and Mr. Cheyne agreed with this view. The opera¬ 
tion was therefore abandoned, but the tracheotomy tube left in 
position. So far as one could judge with the naked eye, the 
glands appeared epitheliomatous; unfortunately no microscopic 
examination was made. 

The patient quickly recovered from the tracheotomy, and 
returned home a fortnight after the operation. 

On October 24th of the present year, Mr. W—, whom both Mr. 
Cheyne and I had supposed to have long since succumbed to 
his illness, suddenly called on Mr. Cheyne, looking very 
well, and saying that he had been gaining flesh and strength. 
He told him that the glands in the neck had continued to 



18 


enlarge after the operation, but had gone down a month or 
two afterwards. He had been taking “ Clay’s Mixture ” (a 
preparation of Chian turpentine). His voice was still somewhat 
hoarse but strong. He was still wearing his tube, but wanted 
to have it removed if possible, this being the reason he had gone 
to see Mr. Cheyne. There was no difficulty in breathing without 
the tube, and the difficulty in swallowing had entirely disap¬ 
peared. Nothing in the shape of glands was to be felt in the 
neck. 

Mr. Cheyne wished me to see the patient with him, and a 
consultation took place on October 27th of this year. 

The patient looked better than I had ever seen him before, 
and stated that he had gained 13 lbs. in weight since last year. 
His voice was good and strong; he wore the tube with de Santi’s 
speaking apparatus. No glands could be felt externally, the 
right vocal cord was still fixed as before, but the tumefaction on 
the right side of the larynx had quite disappeared. 

I put this case on record because it seems to me to teach the 
important lesson that, even under circumstances such as I have 
described, and which practically seemed to leave no doubt as to 
the nature of the disease, a number of experienced observers 
may be mistaken, unless indeed it be assumed that the disease 
had after all been epithelioma, and that it had been cured by 
Chian turpentine. 

What the real nature of the disease was can even now, I 
think, hardly be stated with absolute certainty. What seems 
most probable, however, is that, after all, there had been a 
syphilitic perichondritis of the larynx, in the course of which an 
extensive but purely inflammatory swelling of the cervical 
glands occurred, and that whilst the laryngeal affection for 
some unknown reason had not yielded to the iodide, later on it 
had spontaneously subsided, followed by reduction of the glands 
to their normal size. Other causes, such as a so-called “ idio¬ 
pathic ” or tubercular perichondritis, do not seem to come into 
question here. 

There can of course be no objection to the patient’s tube being 
now removed if, after preliminary corking, it is found that his 
laryngeal respiration suffices. 

The President expressed the opinion, which he was sure was 



19 


unanimous, that Sir Felix Semon had done a very kind thing in 
bringing this case before the Society; an example which they might 
all follow with advantage, for they certainly learnt more from mistakes 
than from anything else. As regards the cause of the great improve¬ 
ment, the man himself was firmly convinced that it was due to his 
mixture. Chian turpentine had a reputation at one time, and there 
might after all be something in it. It reminded him of a similar 
diagnostic mistake in a different part of the body. He had a clergy¬ 
man with chronic jaundice in the Hostel of St. Luke. His colleague, 
Mr. Wm. Rose, and he proposed to the patient that he should be 
examined surgically, to see if the obstruction could be removed. Mr. 
Rose accordingly opened the abdomen, and found a hard mass which 
he regarded as malignant disease of the liver. He (the President) was 
present at the operation and agreed with him. The patient was sewn 
up, and left the hostel in two or three weeks. Six months later he 
wrote to say he was completely well and had remained so since the 
operation. There is another example in which an incision is followed 
not immediately by improvement, but improvement some time later; 
he referred to tubercular peritonitis. He would therefore suggest 
that possibly the incision in the neck had something to do with the 
improvement. 

Mr. Butlin said: I saw this patient in consultation with Sir Felix 
Semon, and came to the conclusion that the disease was probably 
malignant, not so much on account of the appearance of the larynx as 
because of the enlarged gland at the angle of the jaw. It is a very 
unfortunate circumstance that the glands which were taken out were 
mislaid, so that no microscopic examination of them was made; for 
we very much need more knowledge of the real nature of these diseases 
which disappear spontaneously, and which yet have many of the 
characters of malignant disease. It is, of course, almost certain, but 
it is not actually proved, that the disease in this case was not 
malignant, and that the diagnosis was erroneous. As to the mere 
error in mistaking an innocent affection for malignant disease, I have 
seen that mistake made so frequently by the best surgeons that I have 
long ceased to think seriously of it. And in many of the cases the 
disease has been so situated that it could be easily handled and closely 
examined. What wonder, then, if errors of diagnosis are made now 
and again in regard to tumours of the larynx which cannot be reached 
with the fingers, and which are only seen in the distance in a looking- 
glass. The wonder is, not that mistakes of diagnosis are occasionally 
made, but that the diagnosis is so frequently correct. I suppose no 
disease is so frequently mistaken for malignant disease as syphilis; 
and I have often said that iodide of potassium has cured more reputed 
cancers than all the quack medicine in the world. 

Dr. StClair Thomson said it might interest the members if he 
read his notes of this case, as the patient consulted him a little over a 
year ago, and as he did not mention that he had been under the care 
of any colleague the notes had the value of being uninfluenced by any 
suggestion. He found on the 19th November, 1898, that the patient 
was slightly hoarse, had slight dysphagia, and no cough but some 
irritation in the throat. There was an enlarged hard gland below the 



20 


right ma.xilla.ry angle. The laryngeal mirror revealed a tumour of the 
right arytsenoid, irregular, not ulcerating, concealing the greater part 
of the glottis, but the right cord on phonation was evidently fixed. 
The left cord moved easily. There was no loss of weight; no history 
of lues. The heart and lung sounds were normal. The patient was 
advised to take iodide and mercury for a week, when the question of 
operation would have to be considered. The patient then withdrew 
from Dr. Thomson’s study, and the patient’s brother proceeded to show 
such an intimate acquaintance with thyrotomy, iodide of potassium, 
extirpation of the larynx, etc., that he was charged with having seen 
other medical men about his brother. He confessed that the patient 
had been under Sir Felix Semon’s care for the past five weeks, and 
that he had also seen Mr. Butlin. He was thereupon advised to 
return to their care, and be guided by their advice. 

Dr. StClair Thomson had not seen the patient again until he was 
shown at the meeting. In connection with this curious case, Dr. StClair 
Thomson said he would venture to refer to another, as it was not probable 
that he would be able to bring it before the Society. It was that of a 
poor professional man, set. 48, who was sent to him for loss of flesh, 
and dysphagia of three or four weeks. The left arytsenoid region was 
occupied by an irregular, dull red growth, with white necrotic-looking 
patches on it, something like the snow drifts in the hollows of high 
mountains. The speaker believed that Sir Felix Semon had referred 
to unusual snow-white appearance of tumours as pointing strongly to 
malignancy. G-leitsmann had also referred to the very white appearance 
in a laryngeal growth of unusual character. In Dr. Thomson’s case 
there was much pain and discomfort from the constant tendency to 
swallow mucus. The cord on the same side was partially hidden, but 
was seen to move, while the right cord was normal. A gland was 
felt to be slightly enlarged on the affected side. There was no specific 
history. Under these circumstances a very gloomy prognosis was 
given, and indeed the patient’s attendant in the provincial town where 
he lived was written to to be prepared for tracheotomy. Happening 
to be in the same town a month later Dr. Thomson had asked to see 
the patient, and found his voice clear, his swallowing easy, and the 
growth entirely disappeared with the exception of a slight thickening 
of the left aryepiglottic fold. The cords were clear and moved freely. 
This improvement had taken place without the administration of any 
antispecific, or any particular line of treatment. 

Mr. Spencer asked, respecting the two enlarged glands seen on the 
crico-thyroid membrane, one on each side of the middle line, were 
these glands frequently seen ? He had seen the two glands enlarged 
in an undoubtedly syphilitic patient, who had first been treated by 
iodide of potassium and mercury, but who had afterwards to be sub¬ 
mitted to thyrotomy in order to clear out the interior of the larynx. 
These glands might have been considered malignant to the naked eye 
had not the diagnosis of syphilis been certain. 

Sir Felix Semon, in replying, said, with regard to the remarks of 
the President, that he also had seen cases of tubercular peritonitis 
get infinitely better, although not entirely cured, after opening the 



21 


abdomen. He hardly thought, however, that such an explanation 
would apply to the present case,, the less so, as only a very small 
number of enlarged glands had been exposed to the air in the course 
of the operation. He certainly was not a believer in the efficiency of 
Chian turpentine in cancer. With regard to Dr. StClair Thomson’s 
observation, he begged to disclaim all responsibility for the descrip¬ 
tion of certain forms of larynygeal cancer as similar to a “ snowdrift.” 
What he had said in reality was: that if one met with a growth of 
particularly snow-white colour, which at first sight looked like a 
papilloma, but the eminences of which were not nearly so bulbous 
and rounded as in papilloma, but sharply pointed like grasses, that 
such an appearance was extremely suggestive of malignant disease. 
With regard to Dr. Spencer’s remark, he thought glands existed near 
the crico-thyroid membrane on both sides of the trachea. 


Case op (?) Myxofibroma of the Post-nasal Space. 


Shown by Dr. FitzGerald Powell. The patient, a boy set. 17, 
states that he always had good health until four years ago, 
when he began to sleep badly at night, and as soon as he 
went off to sleep he was awakened by a feeling of suffocation. 
He had also at this time attacks of free bleeding from the 
nose and mouth, which • occurred about twice a week. This 
got gradually worse. Two years ago he went to St. Bartho¬ 
lomew's Hospital and was an “in-patient” for six weeks. 
He states he had a swelling in his throat which was lanced, but 
not otherwise dealt with. For over two years he has been 
unable to breathe through his nose. The growth grew pretty 
quickly about two years ago, but the patient does not think it 
has grown of late. Since the nose has been completely blocked 
he has not had any bleeding, but has suffered from great 
drowsiness, and has had incontinence of urine for two years. 

On examination the naso-pharynx is seen to be full of a some¬ 
what soft reddish-white growth, resting on the soft palate and 
pushing it forward, but not extending below the free edge of 
the palate. It is lobulated, moveable, and is free posteriorly 
and at each side. 

# 

On pushing the finger along the front of the growth it 
appears as if its point of origin can be felt. It seems to be 



22 


firmly attached to and to be continuous with the posterior end 
of the septum, which appears to* be pushed to the left. 

The right choana is roomy and filled with a prolongation of 
the growth, which can be seen from the front. 


Dr. Herbert Tilley thought the growth was of a sarcomatous 
nature. It was soft, very vascular, with an extensive attachment, 
points which he had been enabled to determine satisfactorily by examin¬ 
ing the growth with the finger in the post-nasal space. He advised 
removal, and in view of the difficulties which might be encountered at 
the time, especially free haemorrhage, a preliminary laryngotomy or 
tracheotomy would be advisable. The soft palate should then be 
divided, and the growth fully exposed to view, so that there could be 
no difficulty in dealing efficiently with its attachments, and the whole 
treatment would be rendered easier. 

Mr. Spencer did not think this case malignant, but some of these 
growths tended to burrow extensively outward into the neighbouring 
sinuses and fossae. In a recent case he had found such a growth 
extending outwards behind the upper jaw into the temporo-malar 
region and cheek. It had been successfully removed from the face by 
cutting away the outer wall of the nose and antrum without disturb¬ 
ing the orbital plate or the alveolar border and hard palate. He did 
not see the necessity of tracheotomy if the parts were well exposed, a 
sponge drawn upwards into the naso-pharynx, and the patient well 
propped up. 

Dr. Scanes Spicer said, as far as one could see from a cursory 
examination, this was not likely to be a malignant tumour. He had 
seen many similar cases, which were like modified polypi. A more 
careful examination was necessary, and, in his opinion, the growth 
should be removed by means of a snare. He called attention to the 
large space between the soft palate and the spine, which would render 
possible almost any manipulation without dividing the palate in this 
case. He agreed with the name the exhibitor had given to the case— 
myxofibroma. 

Mr. Btjtlin said:—The tumour in this case, from its large size and 
red surface, appears to me to be probably a fibroma, and may prob¬ 
ably be removed with safety. I have had a considerable experience 
in the removal of these post-nasal tumours, and have long since come 
to the conclusion that by far the safest and most certain method is to 
divide the soft 'palate and the soft parts of the hard palate in the 
middle line, and cut away the bone of the hard palate until the 
tumour is thoroughly exposed. I am very much opposed to tem¬ 
porary resection of the upper jaw and other methods practised 
through the nose. Nor do I find it necessary to perform tracheo¬ 
tomy. The patient should be laid on his side, with the head forwards 
and low, the mouth well opened with a gag, and the light reflected 
from a head lamp or mirror. When the surface of the tumour has 
been thoroughly exposed, and its attachments have been ascertained, 
it can be freely cut out with scissors, chisel, and bone forceps. The 



23 


haemorrhage is often very severe in such cases, but it can be arrested 
by plugging with gauze if it does not cease spontaneously. The 
removal of the tumour in this manner is not likely to be followed by 
recurrence of the disease. 

Mr. Symonds said he thought that in a great many of these cases 
it was unnecessary to perform so large an operation as that proposed. 
He thought in the great majority of young people these fibromata 
could easily be removed from the mouth, while the smaller ones could 
be extracted through the nose He had on several occasions dissected 
them from their adhesions by the finger introduced from the naso¬ 
pharynx, and sometimes from the nose at the same time. While the 
haemorrhage was for the moment smart, he had never encountered any 
difficulty in arresting it immediately by a plug in the naso-pharynx, 
this plug being removed before the patient' left the table. He 
thought the haemorrhage in this case did not indicate any special 
vascularity. He had noted that there was not uncommonly an 
adhesion between the tumour and the pharyngeal wall, which bled 
freely on being torn. In a recent instance this haemorrhage led a 
surgeon of distinction to abandon a case which was successfully dealt 
with in the manner described. He would, therefore, reserve the 
larger operation for those cases where the tumour grew into the 
neighbouring fossae. He would call attention also, on the point of 
recurrence, to the fact that the mass removed on the second occasion 
might be a growth from a considerable mass left behind, and yet be 
of a simple nature. In one such instance he had at a second opera¬ 
tion removed a process from the sphenoidal sinus. 

Dr. Bond recommended that the growth be attacked through the 
mouth, which would not be difficult. The soft palate should be split, 
and thick pieces of silk should be passed through the sides of the palate 
and used as retractors, so as to afford a good view of the whole thing 
before chiselling away part of the hard palate, if that should be 
necessary. He was a strong believer in laryngotomy in operations on 
fibroids and sarcomata in the naso-pharynx, and recommended that a 
small sponge, fixed on the middle of a piece of tape, should be pulled 
down into the top of the larynx. Thus ample room was afforded the 
operator in the mouth and pharynx: he was not incommoded by 
sponges or chloroforming impedimenta; the chloroformist could do his 
work at ease, and any severe haemorrhage could be readily treated. 
The laryngotomy wound was a trivial one, and healed in two or three 
days. 

Dr. StClair Thomson referred to a paper by Doyen, who had 
operated on a considerable number of these cases, and who had come 
to the conclusion that they should be attacked from the mouth. 
Doyen’s great point was that the operator should push through 
quickly with the removal, regardless of the abundant haemorrhage, 
for the latter ceased rapidly as soon as .the growth was completely 
detached. For the operation itself specially adapted raspatories were 
advised. Dr. Thomson also suggested the adoption of the Trendelen¬ 
burg position for operations of this character. 

Dr. FitzGerald Powell, in replying, said he was glad his case 
had given rise to such an interesting discussion, and he thanked the 

2 * 



24 


members for tbe remarks they had made and for the information he 
had derived from them. In connection with the treatment to be 
adopted, he thought the first point to be settled was as to the cha¬ 
racter of the growth; was it a pure fibroma, a sarcoma, or, as he 
believed, a myxofibroma ? If the latter, its presence should not be 
attended with such serious consequences, and it was not so prone to 
invade the antrum, orbit, and other parts as the pure fibroma or 
sarcoma. It was softer and grew more rapidly than the fibroma, but 
not so rapidly as the sarcoma. So far as he could make out it was 
not attached to the “ basi-occipital” bone. His own feeling with 
regard to the operation was that it would most likely be successful, 
and his intention was to do a preliminary laryngotomy, then split the 
palate and examine the tumour and its attachment thoroughly, and if 
necessary, lift the periosteum from the hard palate and chisel away as 
much of it as was required to expose the origin and facilitate its 
removal. He hoped to show them the growth at a later meeting. 


Case op Recurrent Papillomata op Larynx. 

Dr. Bronnkr (Bradford) showed sketches of a case of recur¬ 
rent papillomata of the larynx before and after the local use of 
formalin. A man of 49 had been treated for papillomata for 
several years, and a large number of the growths had been 
removed by forceps every two or three months. Various local 
remedies had been tried. A formalin spray was used for three 
months, and the growths had to a great extent disappeared, and 
there had been no recurrence during the last nine months. The 
spray was now used only one day in the week. 

The papillomata were large, finely divided, of cauliflower 
appearance, and sprung from the vocal cords, ventricular bands, 
and interarytaenoid fold. They frequently gave rise to severe 
attacks of dyspnoea. After the use of formalin the papillomata 
became much smaller and round; the finely pointed excrescences 
had disappeared altogether. The ventricular bands were nearly 
normal, but the vocal cords were still irregular and thickened. 

In reply to Dr. Dundas Grant, 

Dr. Bronner said among other applications he had used salicylic 
acid, but it had not the slightest effect 

Dr. Bond asked the strength of the sprays used. 

Dr. Bronner replied that he began with sprays of the strength of 
1 in 2000, but gradually increased this till he employed a solution 1 
in 250 or even stronger. He would like to know if any other mem¬ 
bers of the Society had had any experience of formalin. 



2d 


Cask of Acute Ulcer of the Faucial Tonsil. 

Shown by Mr. Wyatt Wingrave. Married female, set. 32, 
was seen on Tuesday, 14th inst., when she complained of sore 
throat and painful swallowing of three days’ duration. On exami¬ 
nation a single ulcer about the size of a shilling was seen on the 
right faucial tonsil. The outline was sharply defined, edges red, 
while the base was of a greyish-white colour, and the slough 
was readily removed by throat cusps, exposing a rough mam- 
millated surface. The surrounding tissues were apparently 
normal. There was but very slight constitutional disturbance, 
temperature being 100’2°. There was no history of syphilis, 
but she had lost her father and one sister from consumption. 
Two days later the ulcer was unchanged in appearance, and her 
only trouble was constipation of the bowels. On the 21st inst. 
the ulcer had quite gone, leaving a ragged depression in the 
tonsil. 

Scrapings were examined and showed mono- and multi- 
nucleated lymphocytes, free epithelial squames, streptococci, 
staphylococci, and numerous slender rods which stained faintly 
with methyl blue. There were no tubercle, nor Klebs-Loeffler 
bacilli. The history, clinical signs, and the microscope having 
enabled one to exclude syphilis, diphtheria, and tubercle, it was 
diagnosed as acute ulcerative tonsillitis, since it conformed in all 
respects with the classical description of Moure. 

Mr. Lake exhibited a case two years ago, and described a 
special braded form of bacillus as predominating. In this 
instance the slender pale staining rods were the most numerous. 


Case of Paresis of Soft Palate. 

Shown by Mr. Wyatt Wingrave. A married man, set. 34, 
had complained of pain and a sense of constriction in his 
throat for four weeks, and of a change in his voice of one 
week’s duration. 

He stated that he had syphilis fourteen years ago, and had 



26 


enjoyed fair health till a month ago, when he became short 
of breath, had attacks of giddiness and headache occurring 
frequently. He noticed that he was gradually losing control 
over his bladder, and his knees gave way. Later still food 
returned through his nostrils and his voice became nasal. 
Deglutition was painful. 

On examination the soft palate was markedly paretic, and he 
evidently swallowed with difficulty and could not pronounce 
his gutturals. The vocal cords were normal in colour and 
texture, but abduction seemed sluggish. Although the eyeballs 
were somewhat prominent, paresis of the ocular muscles was not 
observed, nor of the facial or lingual. Sensation and reflexes 
were normal. 

He was at once ordered five-grain doses of potassium iodide, 
and in the course of three weeks has shown marked improvement, 
although the palate is still paretic and his voice still somewhat 
nasal in quality. Deglutition is painless and normal. 

The President said the patient had had some difficulty in 
swallowing, together with a very sore throat, and as diphtheria seemed 
to be excluded by the absence of the knee-jerks, he would suggest 
that it was a local neuritis due to the inflammatory condition of the 
patient’s larynx. 


Growth or Granuloma op the Epiglottis for Diagnosis. 

Shown by Mr. Waggett. The case of a robust man of 60, 
complaining merely of slight hoarseness of four months’ duration, 
sent to the hospital for removal of a papilloma of the uvula. 
Laryngoscopic examination showed an epiglottis much curled, 
deflected to the right and concealing the vestibule of the larynx. 
A mammillated excrescence was to be seen projecting from the 
posterior surface of the epiglottis near its right border. This 
excrescence had been white in colour at first, but had on a later 
examination appeared purple. The posterior part of the right 
arytsenoid region could be seen red, swollen, and immobile during 
phonation ; no glands in the neck. No evidence of pulmonary 
tuberculosis. One brother died of phthisis. A history of 
gonorrhoea. After fourteen days’ exhibition of potassium iodide 



27 


the patient expressed himself as better, but the laryngoscopic 
image was unaltered. 

Digital examination was not feasible. 


Case of (Esophageal Pouch. 

Shown by Mr. Butlin. I show here the fifth pouch which I 
have removed from the oesophagus. Like all the others, it was 
situated at the junction of the pharynx and oesophagus, and 
projected on the left side behind the oesophagus. The symptoms 
had been noticed for about eighteen years in a female 59 years 
old, and were the typical symptoms of pressure-pouch: return of 
particles of undigested food a day or more after they had been 
swallowed; escape of gas and food on pressure; the absence of 
wasting; and the impossibility of passing a bougie further than 
about nine inches from the teeth. There was no actual bulging 
in the neck. The operation presented peculiar difficulties on 
account of the large size of the pouch and consequent deviation 
of the course of the oesophagus. On this account it was ex¬ 
ceedingly difficult to pass an instrument into the stomach, even 
when the pouch was exposed in the neck, separated from its 
attachments and drawn upwards. This was, however, accom¬ 
plished before the pouch was cut out. 

The patient is now convalescent. The result of the five 
operations has been four recoveries and one death. I think, if 
I had had the experience of this case before I removed the 
pouch in the fatal case (the third in order), that I should not 
have lost the patient. I probably should not have proceeded to 
take the pouch out after exposing it, as I could not, even then, 
pass any instrument into the stomach. I look on that as a 
necessary preliminary to the safe removal of an oesophageal 
pouch. 

The President congratulated Mr. Butlin on the great success of 
his treatment in these rare cases of oesophageal pouch. 

Mr. Butlin asked if any one knew of any case having been done in 
this country; he himself had not heard of any. 



28 


Case op Double Abductor Paralysis under Treatment by Intra~ 

muscular Injections. 

Shown by Dr. Pegler. H. H—, 44, married, and in very good 
general health, came to the Metropolitan Throat Hospital in 
June, 1899, complaining of loss of voice and some difficulty in 
breathing on inspiration, especially when hurrying. The voice 
was strident and disagreeable, but not aphonic. He admitted 
having had chancres at the age of 22, when he was put through 
a mercurial course. On examination the vocal cords were seen 
in the cadaveric position, or if anything rather nearer the 
middle line, and they remained so on deep inspiration, the right 
cord abducting rather more than the left. On phonation they 
adducted slightly. A small conical projection was visible in 
the interarytsenoid space. The biniodide was administered 
freely by the mouth; in about ten days the small growth dis¬ 
appeared, and the patient felt much benefit both as regards 
breathing and voice. About a month ago, following the example 
of my colleague, Mr. Lake, I began and have continued using 
intra-muscular injections of perchloride, 1 in 120. The cords 
now move if anything a little better, and the patient insists that 
there is a still further improvement in his voice. He prefers 
the injections in every way. About 20 mins, of the solution are 
injected into the buttock twice a week. 

The President said that Sir Felix Semon had seen this case of 
laryngeal abductor paralysis, and thought one might be called upon to 
do tracheotomy for it; it was one of those cases which were always 
under a cloud. 


A Case op Tubercle op the Larynx. 

Shown by Mr. Charters Symonds. The patient, a woman set. 
48, came to the throat department at Guy’s Hospital in October 
last, complaining of loss of voice. The left ventricular band 
and cord were occupied by a deep red firm infiltration, extending 
the whole length. In the centre was a depressed irregular grey 
surface with raised edges. There was slight mobility of the 



29 


cord and ary taenoid, the appearances closely resembling those of 
malignant disease, more especially as the aryteenoid was quite 
normal, and there was a total absence of the gelatinous infiltra¬ 
tion commonly seen. At this stage the diagnosis of malignant 
disease presented some difficulty. To remove any doubt, a 
portion from the centre of the ulcer was removed, and proved 
microscopically to be tubercular granuloma. Subsequent to this 
a history of haemoptysis some years previously was obtained. 
No disease was found in the lungs. 

At the present time the appearances resemble closely those 
above described, except that the gap in the centre is larger, on 
account of the operation, and the cord is slightly more move- 
able. The patient is pale and thin, and exhibits signs of pul- 
* monary trouble. 

The object of showing this case is to mark the resemblance of 
this form of tubercle to that of epithelioma. Recognising that 
tubercular tumours may remain with little alteration for con¬ 
siderable periods in the larynx, and thus closely resemble 
malignant disease, I brought this patient to illustrate that point. 
I may add that iu a recent case the solid tubercular growth was 
sufficient to occlude the larynx. In this case there was no 
ulceration, no expectoration, none of the gelatinous swelling; in 
fact all the appearances closely resembled carcinoma. 

Dr. Clifford Beale asked whether there had been any obstruc¬ 
tion of the larynx before the piece was removed ? He thought that in 
cases of submucous tubercular infiltration without breach of surface, 
the swellings might remain for long periods without change or even 
with diminution. He had shown such cases at previous meetings, 
and in one instance under observation for five years the patient had 
died, and the larynx showed that there had been no real obstruction 
and no breach of surface. After removal of a part of the swelling a 
raw surface must remain, as in the present case, and if the patient 
happened to be bringing up tubercle bacilli in the sputum there was 
danger of reinoculation. 


Rhinolith. 

Shown by Mr. Charters Symonds. The specimen shows a 
calcareous laminated wall enclosing a cavity. When recent, 
this cavity was occupied by some soft grumous material, which 



30 


may have been an old decolourised blood-clot or some inspis¬ 
sated mucus. It was removed from a boy set. 11. He had had 
a cold for a couple of months, and it was noticed in the later 
stages that the discharge was confined to the right side and had 
become sanguineous. The rhinolith was removed by a probe. 
There was no history whatever of the introduction of a foreign 
body, nor was there any evidence of old disease in his nose. 
He was the son of well-to-do parents, and therefore had not 
been neglected. 

The object of exhibiting the specimen is, first, to show its 
peculiarities, and, secondly, to note the short duration of the 
symptoms caused by a foreign body which must have existed 
for some years. That this must be the common history in such 
cases is well known. In another instance, where a friable cal¬ 
careous mass was removed, the symptoms were also of short 
duration, but here there was a history of the introduction of 
some rose leaves into the nose six years previously. 


Case op Tertiary Specific Ulceration op the Ala Nasi. 

Shown by Dr. Dundas Grant. The patient, a married woman 
set. 36, came under my care on the 23rd of the present month 
on account of an ulcer on the right ala of the nose of about two 
months’ duration. The ulcer was about the size of a sixpence, 
and in the centre there was a small portion of tissue which 
appeared to be true skin but infiltrated. The ulceration 
furrow around this was deep, and the edges considerably 
thickened and infiltrated. 

It had first appeared six months previously to my seeing her 
as a white speck followed by spreading ulceration, but had 
healed up under the action of medicine, presumably iodide of 
potassium. In the fauces there were cicatricial changes such 
as would result from tertiary ulceration involving the loss of 
the uvula. 

Six years ago the patient suffered from a sore throat which 
lasted some weeks, and was accompanied by a rash and by 
loss of hair; and four years later she had severe ulceration of 



31 


the throat. She has two children, the youngest of which is 
thirteen years old. 

Presumably this specific affection dates about six years back. 


Case op Tuberculous Ulceration op the Pharynx and op 

the Lower Lip. 

Shown by Dr. Dundas Grant. J. R,—, aged 42, who looked 
much older, came under my care on the 23rd of the 
present month complaining of sore throat and cough, which 
had gradually developed during the last three months. The 
voice was husky, deglutition was painful, and the cough was 
accompanied by the expulsion of a yellowish coloured sputum 
tinged with blood. On inspection there was seen on the left 
half of the palate, uvula, tonsil, and anterior pillar an extensive 
ulcer, which on the flat surfaces was very shallow, but owing to 
its dipping into the irregularity of the part appeared in some 
places to be excavated. It was pale and the floor was covered 
with dusky greyish granulations from which exuded a slight 
moisture. The edges were not everted, and there was no indu¬ 
ration on palpation. There was a fiery red areola. There were 
unmistakable signs of tuberculosis in both lungs, especially the 
right, and the diagnosis was made of tubercular ulceration. 
A scraping, however, was not found to contain tubercle bacilli, 
but the examination will have to be repeated. The glands are 
scarcely perceptibly involved. On the lower lip there is a 
deeper ulcer with soft slightly cedematous edges, the base being 
covered by a yellowish scab, the condition being probably a 
secondary focus of tuberculous inoculation. 


Case op Swelling about the Bridge op the Nose. 

Shown by Mr. Waggett for Mr. Stewart. A boy of 18, 
exhibiting indolent swelling about the bridge of the nose and 
oedema of the skin in both orbital regions, a condition very 
similar to that of the cases shown at the November meeting. 
The swelling commenced two years ago and had been under 



32 


observation now for eight months with permanent improvement. 
There was a history of a kick on the nose three years ago, and 
several blows had been received since. 

Iodide of potassium had effected no change, and the same was 
to be said of the continuous application of the icebag for ten 
days. 


Ulceration op Alas Nasi. 

Shown by Mr. Charles A. Parker. The patient was a female 
set. 22, who had suffered from ulceration of the nose for two 
years. It affected both alae, but extended more on the right 
sid9 than on the left, and there was considerable loss of tissue. 

The diagnosis rested between syphilis and lupus, and the 
opinion of the Society was invited as to which of these two 
troubles was the cause of the ulceration. The patient had been 
on potassium iodide for three weeks, but had not taken it with 
any great regularity. 

The President : It struck me as lupus or chronic tubercle. 

Dr. Dundas Grant : I should say lupus decidedly. 

Dr. Lambert Lack : I should say syphilis. 

Mr. Parker thought it rested between syphilis and lupus, and 
treatment alone would settle the question. 


Case for Diagnosis. A Boy ^et. 10 suffering from 

Aphonia. 

Shown by Mr. Roughton. 

Dr. Pegler thought the boy could scarcely be considered aphonic, 
as he had succeeded in making him speak in a fairly audible though 
feeble voice. With reference to treatment, he thought the fault lay 
perhaps as much with the respiratory muscles as with those of the 
larynx. He therefore recommended a course of exercises in breathing, 
as the boy exhibited deficient chest expansion, and his vital capacity 
was probably much below par. The speaker was directing his atten¬ 
tion to this point in similar cases at the present moment, and in an 
extremely obstinate case of functional aphonia now under his care he 
found the breathing much at fault, the vital capacity being 80 in 
place of 150. The hope was that by remedying this defect the loss 



SB 


of co-ordination between the muscles of respiration and phonation 
would be restored, and there seemed some promise of its fulfilment. 
In the boy’s case the same plan was worthy of a trial, as in any case 
the exercises could but be beneficial. 

The President concurred as to the advantage to be derived from 
exercises such as those mentioned by Dr. Pegler. He started regular 
systematic exercises of the chest in a patient, whom, however, he had 
not seen since. Sir Felix Semon had suggested it was much more of 
a spastic condition than an ordinary aphonia. He (the speaker) did 
not think the air current was sufficiently large to put the vocal cords 
into proper action. 


Case of Double Uvula. 

Shown by Mr. de Santi. 

Mr. Spencer doubted whether the case should be termed one of 
“ double uvula.” The bands appeared to be congenital, stretching 
across between the posterior pillars of the fauces, and presumably 
were remains, at the junction between the stomodseum and the fore¬ 
gut, of the primitive septum. 

The President thought it looked as if some ulceration had been 
present, though there was no history of scarlet fever ; it did not look 
like a congenital production. 


Case of Tubercular Laryngitis in a Man mr . 31. 

Shown by Dr. FitzGerald Powell. When first seen on No¬ 
vember 16th he complained of loss of voice and some difficulty 
in breathing. 

The patient enjoyed good health until five years ago, when 
he caught a severe cold and lost his voice; he has regained it 
somewhat, but it has been husky ever since. Two months ago 
the voice got worse. Twelve months ago he had an attack of 
dyspnoea, but otherwise has not felt the breathing to be 
laboured, though at night he is seen to have considerable 
stridor. 

On examination the general appearance of the larynx is 
rather red; the glottis is little more than a chink. On the 
right side the arytaenoid is fixed, and the cord is obscured by 
the false cord, which is drawn over it and is ulcerated. On the 
left the vocal cord is broad and thickened, and is covered with 



84 


granulations. In the posterior commissure, rather to the left, 
there is a pedunculated growth, which flaps to and fro on 
inspiration and expiration. 

His family history is good, and I can find no history of 
syphilis. 

Signs of cavity and consolidation are found in the lungs, 
though no bacilli were found in his sputum on examination. 

On November 29th, when he was last seen, he was much 
better, and the breathing during sleep quite free from stridor. 

The right cord can now be seen beneath the ventricular band, 
the left cord is smoother, and there appears to be much more 
breathing space. 

Mr. Spicer thought this was a very complicated case, possibly a 
“ mixed” case of tubercle and syphilis. 

Dr. FitzG-erald Powell apologised for not being able to give the 
Hon. Secretary notice of this interesting case at an earlier date, to 
enable him to put it in the list of cases shown. He regretted not 
being able to have had the opinion of the members, though he believed 
some of them had seen the case, and thought with him that it was a 
case of syphilitic ulceration with later tubercular infection. 


* 



PROCEEDINGS 


OP THE 

LARYNGOLOGICAL SOCIETY OF LONDON. 


Eighth Annual General Meeting, January 5th, 1900. 

F. de Havilland Hall, M.D., President, in the Chair. 

William Hill, MJ)., Secretories . 

Lambert Lack, M.D., ) 

Present—14 members. 


The minutes of the Seventh Annual Meeting were read and 
confirmed. 

Drs. FitzGerald Powell and .Jobson Horne were appointed 
Scrutineers of the ballot for the election of Officers and Council 
for the ensuing year. They reported the result of the ballot as 
follows: 

President. —F. de Havilland Hall, M.D. 

Vice-Presidents. —A. A. Bowlby, F.R.C.S.; W. H. Stewart, 
F.R.C.S.Ed.; E. Law, M.D. 

Treasurer. —E. Clifford Beale, M.B. 

Librarian. —J. Dundas Grant, M.D. 

Secretaries. —H. Lambert Lack, M.D.; E. Waggett, M.B. 

Council. —Walter G. Spencer, M.S.; F. W. Milligan, M.D.; Herbert 
Tilley, F R.C.S.; Barclay Baron, M.B.; William Hill, M.D. 

\ 

The Report of the Council was then read and adopted. 

The Council, in making their Annual Report, have pleasure in 
calling attention to the continued prosperity of the Society. 

FIRST SERIES-VOL. VII. 3 



36 


The installation of additional lamps has enabled more cases to be 
exhibited than had previously been possible; and the average attend¬ 
ance at each meeting—thirty-six—has also surpassed any previous 
record. 

An endeavour has been made to render the printed reports of the 
proceedings a more accurate record of the discussions by the employ¬ 
ment of a shorthand writer; and further improvements in this direc¬ 
tion are contemplated in the ensuing Session. 

The Ordinary Meeting, held on May 5th, 1899, was devoted to a 
discussion on “ Asthma in Relation to Diseases of the Upper Air- 
passages,” introduced by Dr. Percy Kidd and Dr. MacBride. This 
meeting was attended by 42 members and 9 visitors, many of whom 
took part in the discussion. 

Seven new members have been elected, and three resignations of 
membership have been received since the last Annual Report; and by 
the lamented death of Professor Stoerk, of Vienna, the Society has 
lost one of its best known honorary members. 

The satisfactory financial position of the Society will be dealt with 
separately by the Treasurer. 

Tlie Treasurer’s Report was then presented and adopted. 

The actual receipts for the year 1899 amount to =£132 6s. This 
includes seven subscriptions for 1898 and two for 1900. 

Six subscriptions for 1899 and five for 1898 and 1899 are still out¬ 
standing, and one entrance fee remains unpaid. 

The actual expenditure for the year amounts to <£127 4s. 8 d., leav¬ 
ing a balance of £5 Is. 4 d., which, added to last year’s balance, leaves 
a total credit balance of £215 16s. 3d. 


BALANCE-SHEET, 1899. 


Income. 

£ 

s. 

d. 

Expenditure. 

£ 

s. 

d. 

Balance from 1898 . . . 

. 210 

14 

11 

Rent, Electric Light, etc. . 

31 

10 

0 

108 Subscriptions .... 

. 113 

8 

0 

New Electric Lamps . . . 

ii 

10 

0 

7 „ (1898) . 

. 7 

7 

0 

Adlard’s Bill—August, 1898, 




2 „ (1900) . 

. 2 

2 

0 

to December, 1899 . . . 

66 

15 

9 

9 Entrance Fees . . . 

. 9 

9 

0 

Reporting. 

10 

10 

0 





Rogers—Spirit Lamps, etc. . 

1 

4 

9 





Clarke—Indexing .... 

1 

5 

0 





Mathew (porter) .... 
Hon. Secretary's Expenses . 

1 

8 

0 





1 

3 

6 





m >» (Dr. Lack) 

Hon. Treasurer’s Expenses 

0 

9 

11 





(stamps, petty cash pay¬ 
ments) . 

1 

3 

2 





Bank Charges. 

0 

4 

7 





* 

127 

4 

8 





Balance in hand. 

215 

16 

3 

Total . . 

£343 

0 

11 

Total . . £343 

0 11 


. r , . f H. BETHAM ROBINSON. 

Audited and found conoct, | G sCHORSTEIN, 








37 


In presenting the Librarian’s Report Dr. Dundas Grant said : 

During the past year the members of the Society have made rather 
more use of the Library than previously. I have had a complete 
“ slip ” catalogue of the Library prepared by an experienced person, 
and I trust that this piece of work, which I have great pleasure in 
presenting to the Society, will be found useful by the members. As 
the Catalogue thus prepared is one which permits of indefinite enlarge¬ 
ment, I trust that members will do their utmost, by giving or procuring 
donations to the Library, to increase the bulk of the work. I append 
a list of works which have been added since my last report, and have 
revised the list of exchanges up to date. The list of microscopical 
preparations in the possession of the Society is also added. Dr. Pegler 
has kindly gone through them so as to report upon their condition, 
which I am therefore able to inform you is perfectly satisfactory. 
He has further made out a list of those specimens which have been 
exhibited to the Society or brought before the Morbid Growths Com¬ 
mittee. but which do not find a place in our collection. I have still a 
number of copies of Professor Massei’s resumed note upon ‘ 500 Cases 
of Laryngeal Neoplasms ’ for distribution to any members of the 
Society who may desire to have them. 

A number of pamphlets and monographs and various reprints have 
been received, and I should be glad to have the benefit of the assistance 
of a small sub-committee to consider the question of preserving, 
binding, or in some cases destroying this accumulating material. I 
could imagine no better group for the purpose than my predecessors 
in the post of Librarian. 

I find that the exchanges with the following have lapsed, and I 
shall at once negotiate for their resumption:—‘ Annals of Laryngology, 
Rhinology, and Otology ’ (America). Dr. Natier’s ‘ Revue Inter¬ 
nationale de Laryngologie ’ (which has merged into a journal called 
‘La Parole’). Transactions of the French and of the Parisian 
Laryngological Societies. 

Volumes of the ‘ Proceedings ’ at present in the Librarian’s charge: 
Of the bound volumes I have— 

11 copies of Vol. I. 

3 copies of Vols. I and II bound together. 

While of unbound volumes I have— 

. 4 copies of Vol. I (one copy with January missing). 

19 copies of Vol. II (one copy with January missing). 

19 copies of Vol. Ill (one copy with January missing). 

19 copies of Vol. IV (one copy with January missing). 

14 copies of Vol. V. 

11 copies of Vol. VI. 

In addition I have the following surplus copies of ‘ Proceedings : ’ 

List of Members, 1894, 2 copies. 

Supplemental List of Members, 1894, 3 copies. 

List of Members, 1896, 1 copy. 

List of Members, 1897,1 copy. 

List of Members, 1898, 4 copies. 



38 


4 Proceedings/—November, 1897, 1 copy; December, 1897, 2 copies; January, 
February, March, April, June, 1898, 1 copy ; May, 1898, 2 copies; November, 1898, 
3 copies; December, 1898, 9 copies; January, 1899, 17 copies; February, 1999, 9 
copies; March, 1899, 6 copies; May, 1895, 1 copy; October, 1895, 4 copies; 
November, 1895, 1 copy; December, 1895, 1 copy. 

Title-pages, 1894-5 and 1896 -7, 1 copy of each. 

1 Index. 

List of Various Works received during 1899, presented by 

their Authors. 

Groslieintz. On the Relation of Hypsistapbyba to Leptoprosopia. 

Moure. Case of Acute Osteitis Consecutive to Influenza. 

Moure. Some Facial Paralyses of Otitic Origin. 

Goguenheim. Traumatic Abscess of the Nasal Septum. 

Olivier. The Whispered Voice. 

Collet. On Anosmia. 

Bonnier. On Tests for Hearing. 

Natier. Neurasthenia in Relation to Certain Affections of the Nose and Throat. 
Proceedings of the Brighton Medico-Chirurgical Society for 1898-9. 

Rous^elot. History of the Practical Application of Experimental Phonetics. 
Olivier. Etiology and Treatment of certain Vocal Affections, with Remarks on 
the Treatment of Nervous Aphonia and Dysphonia. 

Natier. Recurring Spontaneous Epistaxis. 

Report of the Annual Meeting of the Dutch Society for Diseases of the Throat, 
Nose, and Ear. 

The following books have been presented by Sir Felix Semon: 

Hajek. The Pathology and Treatment of Inflammatory Affections of the 
Accessory Cavities of the Nose (German). 

Pieniazka. Laryngoscopy (Hungarian). 

Semon. The Nervous Affections of the Larynx and Trachea (German). 

Also the following shorter monographs and reprints : 

Felix , Sir Semon . 

Clinical Lecture on the Diagnostic Significance of Laryngeal Abductor Paralysis. 
Remarks on a Case of Congenital Web between the Vocal Cords associated with 
Coloboma of the Left Upper Eyelid. 

The Mutual Relationship and Relative Value of Experimental Research and 
Clinical Experience in Laryngology, Rhinology, and Otology. 

Caillots sanguins simulant des neoplasms du larynx. 

Die Thyreotomie bei bosartigen Kehlkopfneubildungen. 

Zur Frage der Radikaloperation bei bosartigen Kehlkopfneubildungen mit beson- 
derer Beriicksichtigung der Thyreotomie. 

Herr Grossman und die Frage der Posticuslahmung. 

Die Stellung der Laryngologie bei den Internationalen Medicinischen Congressen 
und die Frage ihrer Vereinigung mit der Otologie bei diesen und anlichen 
Gelegenheiten. 

Einige Bemerkuugen zu der neuen Sendziakischen Statistik fiber die operative 
Behandlung des Larynxkrebses. 

Kelly , A. Brown , Esq., B.Sc ., M.B . 

Large Pulsating Vessels in the Pharynx. 

Hopmann, Dr. 

Zur Operation der harten Schadelgrundpolypen (Basisfibrome bezw. Fibrosarkome) 
nebst Bemerkuugen iiber Nasenpolypen. 



39 


Gleitsmann > J. WM.D. 

A Case of Unusual Laryngeal Growth. 

Frankenberger , Dr. 0. 

Uu case de double reti ecissement du Pharynx. 

Chrazzi, Prof. V. 

Nouveau traitement des inflammations chroniques catarrliales du pharynx eu 
rapport purticuli&rement avec les maladies de l’oreille. 

Frankfurt, Dr. George Avellis. 

Ueber die bei kleinen kinderu ein kieferholenempyem vortauschende tubercu- 
lose des Oberkiefers. 

The periodicals so far as the volumes have been completed have 
been bound. 


Catalogue of Microscopical Specimens. 

Nose. 

1. Section of the normal mucous membrane of the inferior turbinal. 

2. Another section of ditto. 

3. Section through the # normal inferior turbinated body. 

4. Regeneration of the mucous membrane of the inferior turbinal after turbi- 

nectomy (Dr. Hill’s case). 

5. Posterior moriform hypertrophy of the mucous membrane of the inferior 

turbinal. 

6. Papilliform hypertrophy of the anterior end of the inferior turbinal. 

7. Simple anterior hypertrophy of the inferior turbinal. 

8. Tuberculous growth of the inferior turbinal (Dr. Hill’s case). 

9. Polypoid hypertrophy of the middle turbiual. 

10. Section of the middle turbinal from a case of rhinitis sicca. 

11. Polypoid hypertrophy of the septum nasi. 

12. Giant-cell sarcoma (Mr. Hadley). 

13. Fibro-angioma of the septum (Dr. Scanes Spicer). 

14 

)) 99 *9 99 

15. Polypus of the nose. 

16. Cystic polypus of the nose. 

17. Sarcoma of the vestibule. 

Accessory Sinuses. 

18. Polypoid vegetations of the antrum (Mr. Charters Symonds). 

19. „ „ of the frontal sinus (Dr. Tilley). 

Mouth and Tongue . 

20. Fibroma of the tongue (Dr. Morley Agar). 

21 . 99 99 99 99 

Nasopharynx. 

22. Adenoid vegetation. 

Fauces and Pharynx. 

23. Papilloma of the uvula. 

24. Tuberculous uvula. 

25. Chronic tonsillitis. 

NecJc. 

26. Tuberculous glands of the neck with giant-cells. 



40 


Larynx. 

27. Tubercle of the larvux with giant-cells. 

28. Normal section of the inter-ary taenoid space. 

29 . 99 99 99 99 99 

30. Lupus of the epiglottis (Professor Massei). 

The Report was adopted, and a vote of thanks was given to 
the Librarian for the excellent catalogue which he had pre¬ 
pared. 

The meeting then adjourned. 


The Ordinary Meeting of the Society was then held, A. Bronner, 
M.D., Vice-President, in the Chair. 

Present—the two Secretaries, 30 members and 4 visitors. 

The minutes of the previous meeting were read and con¬ 
firmed. 

The following gentlemen were unanimously elected members 
of the Society: 

F. O’Kenealy, Capt. R.A.M.C., India. 

G. Constable Hayes, F.R.C.S., 22, Park Place, Leeds. 

F. H. Westmacott, F.R.C.S., 5, St. John Street, Man¬ 
chester. 

Dr.‘ Watson Williams showed a series of stereoscopic lantern 
slides of anatomical and pathological preparations of the 
larynx, pharynx, nose, and its accessory cavities. He pointed 
out and demonstrated the remarkably realistic effects obtained 
by this method, and its value in showing to a large number of 
spectators or pupils various anatomical and pathological speci¬ 
mens. 

A special vote of thanks was accorded to Dr. Williams for his 
excellent demonstration. 

Dr. Jobson Horne gave a lantern demonstration of prepara¬ 
tions illustrating the following pathological conditions of the 
larynx. 



41 


1. (Edema of the Glottis .—The epiglottis, ary-epiglottic folds, 
and arytaenoid regions presented a considerable amount of 
oedema; this had been well preserved by means of the formalin 
method. The mucous membrane itself was free from ulcera¬ 
tion and erosion. There was prolapse of the mucous membrane 
lining the left ventricle of Morgagni. On the outer surface, in 
the region over the left ala of the thyroid cartilage, a cavity 
surrounded by inHammatory thickening contained pus and 
fragments of necrosed cartilage. The left ala of the thyroid 
cartilage was involved in the necrosis, and this had no doubt 
led to the detachment and prolapse of the mucous membrane 
lining the ventricle. 

The cricoid cartilage and the hyoid bone wei*e not affected, 
A’t the post-mortem, brawny swelling was noted behind the 
angles of the jaw, and also much inflammatory thickening of 
the structures about the pharynx and larynx. The posterior 
pharyngeal wall was raised from the vertebral bodies by in¬ 
flammatory products, but there was no suppuration. A scar in 
the spleen was suggestive of an old gumma. 

The patieut, a man set. 28, five months before his death con¬ 
tracted a “cold,” which was followed four months later by a 
sore throat. Inspiratory dyspnoea set in and steadily increased 
in the course of five days, when the man sought relief. Tra¬ 
cheotomy was speedily performed, but the patient succumbed 
very shortly afterwards from heart failure. When in India 
some years previously he had had enteric fever. 

2. Cyst of the Epiglottis .—The original size, shape, and tense¬ 
ness of the cyst were well preserved by means of the formalin 
method. It was mainly situated on the lingual surface, but 
occupied the free edge of the right half of the epiglottis. 

The larynx was removed from a man a)t. 34, who died from a 
mediastinal new growth with secondary growths in the neck. 
The left recurrent laryngeal nerve was implicated, and the left 
vocal cord had atrophied. 

3. Laryngeal Tuberculosis .—This preparation was from the 
larynx of a child ast. 12 months, who had died from pulmonary 
tuberculosis. A microscopic section had been cut horizontally 
through the entire larynx, passing through the arytaenoids, 
inter-arytaenoid folds, and the ventricular bands just above the 



42 


level of tlie cords. The section showed a well-developed 
tuberculous excrescence projecting from the right side of the 
iuter-arytaeiioid region into the glottis; this growth contained 
giant-cells and tubercle bacilli, which were also met with in the 
outer and posterior wall of the left ventricle. The specimen is 
important having regard to the age of the child. 

4. Pachydermia Laryngis Verrucosa .—The interior of the 
larynx had been exposed by an incision through the inter- 
arytsenoid region. The specimen was very typical of the warty 
condition seen about the vocal processes in the earlier stage of 
the disease. 

5. Another specimen illustrating the same disease, for which 
Dr. Jobson Horne was indebted to Dr. Herbert Tilley; the 
inter-arytaenoid space had been brought fully into view by an 
incision through the thyroid cartilage. 

In this case the pachydermia was more advanced and diffuse, 
the entire mucous membrane being more or less affected. The 
inter-arytaenoid space was occupied by a symmetrical pair of 
warty excrescences, one on either side of the middle line, and 
projecting forwards into the glottis. 


Case of Tabes with almost Complete Laryngoplegia. 

Shown by Sir Felix Semon. A. S—, a carman aet. 40 years, 
was admitted under the care of Dr. Hughlings Jackson into the 
National Hospital on December 11th, 1899. He had syphilis 
five years ago with secondary symptoms, and was treated only a 
few weeks. His present symptoms began fourteen months 
before admission with loss of control over the bladder. This 
was followed by numbness and shooting pains in the legs, trunk, 
and hands, ataxia and gastric crises. For nine months his voice 
had been altering and he had had shortness of breath, but 
apparently no laryngeal crises. 

Summary of Symptoms .—Extreme general emaciation. 
Arteries thickened and tortuous. Double ptosis. Reflex irido- 
plegia. Slight weakness of the right half of face. Extreme 
inco-ordination; marked hypotonia; can only walk when 
supported. Entire loss of sense of passive movement in lower 



48 


extremities. Analgesia (partial) over face, over arms and 
upper part of chest, and over lower extremities. Severe 
shooting pains and gastric crises. Complete incontinence of 
sphincters; no anal reflex. All deep reflexes absent; plantar 
reflexes show a typical tabetic response. No difficulty in 
swallowing, no return of fluids through the nose. 

Voice .—Speaks in a loud hoarse whisper. When talking he 
quickly runs short of breath, and between his utterances a sort 
of subdued inspiratory stridor is sometimes audible. He cannot 
cough in the usual way, but on attempting it a long noisy expi¬ 
ration results. 

Palate .—On attempted phonation the palate itself remains 
perfectly motionless, but the posterior arches make some rapid 
and feeble inward movements. The tactile sensibility is 
perfectly normal, but the reflex excitability is much diminished, 
though not completely abolished. 

Larynx .—During quiet respiration both vocal cords stand 
perfectly motionless in about the minimum width of the 
cadaveric position (about 3 mm.) apart, but their posterior ends 
are a little nearer one another than is usual under such circum¬ 
stances, and their free borders are not excavated but perfectly 
straight. Neither on attempted deep inspiration nor on phona¬ 
tion is the slightest movement of the cords visible. 

On touching the epiglottis with a probe, no reflex movement 
whatever is noticeable. On touching the inter-arytaenoid fold 
regular closure of the glottis takes place immediately, without 
cough being produced. 

On touching the right ventricular band reflex closure ensues. 
The same more strongly and combined with feeble cough ensues 
when the left ventricular band is touched. 

Remarks .—The case is shown on account of its extreme rarity. 
It is the third case I have ever seen of complete or nearly 
complete bilateral recurrent paralysis, and the first I have ever 
seen in tabes. There is only, so far as I know, one case of 
complete bilateral recurrent paralysis in tabes on record. This 
has been described by Gerhardt.* Another very remarkable 

* u Bewegungsstorungen der Stiminbander,” Nothnagel, € Spec. Pathologic und 
Therapie/ Bd. xiii, 1896. 


3 * 



44 


oircumstance is the comparative loudness of the patients voioe. 
As a rule in bilateral recurrent paralysis the voice is entirely 
extinct, and the whisper absolutely toneless. Finally, the 
manner in which a few fibres of the accessory and vagus have 
escaped (as shown by the fibrillary contraction of the palatinal 
muscles, by the possibility of closing the glottis on peripheral 
stimulation, by the maintained possibility of producing tension 
of the vocal cords through the orioo-thyroids, and by the 
diminished yet not quite abolished reflex irritation of the palate 
and larynx) is very remarkable. 

I have to thank Dr. Hughlings Jackson for kindly permitting 
me to show the case, and Dr. H. L. Collier for the notes of the 
general condition of the patient. 


Mr. W. G. Spencer said that this was another instance of focal 
lesions in tabes, which agreed, in his opinion, with the results of 
experiments concerning the vagus group of nerves. The case pointed 
to a bilateral lesion of the nuclei corresponding to the pneumogastric 
roots, as shown by the sensory paralysis, the impairment of the respi¬ 
ratory muscles, and the impossibility of coughing. Dr. Tilley and 
others had shown cases where the lower bulbar roots of the vagus 
were involved, in which, as distinct from the present case, there was 
noted paralysis of the abductors of the soft palate without loss of 
sensation in the larynx or disturbance of respiration, etc. There were 
also cases in which the spinal accessory nuclei were involved, and the 
trapezius and the sternomastoid muscles were paralysed; in other cases 
the hypoglossal nucleus being also involved, there had been paralysis 
of one side of the tongue. 

Sir Felix Semon said that he did not wish to say anything at 
present as to the general question of the innervation of the larynx. 
This patient had not isolated abductor or adductor paralysis, but 
practically complete recurrent paralysis. If the patient attempted to 
cough, a large quantity of air escaped through the glottis, and this 
was the cause which prevented him coughing in the ordinary fashion. 
He was not aware that Dr. Tilley had ever shown a case of adduotor 
paralysis in tabes, and doubted whether he had done so; cases of 
a&ductor paralysis in that affection of course were not rare. TTis 
reason for showing this case was that it was, so far as he knew, the 
second on record in the whole of the literature on the subject in which 
there was a complete laryngoplegia in a case of tabes dorsalis. As to 
the escape (?) of some fibres of the palate, he had pointed out in his 
paper this remarkable fact, both in the motor and sensory spheres, in 
the palate and larynx. The laryngoscopic image was not exactly as it 
would have been if the patient was suffering from complete paralysis 
of the superior laryngeal nerve, i. e. the cords were not excavated but 



45 


perfectly straight, which showed that the crico-thyroid muscles must 
have escaped, a fact which was further corroborated by the compara¬ 
tive loudness of the patient’s voice. 

Case op Injury op the Larynx in a Female. 

Shown by Mr. Lawrence. The patient was a woman set. 46, 
who in 1891 had her throat cut; the air-tube and oesophagus 
had both been divided. The case did well, and recovery took 
place in a few weeks. Since then her voice has been husky, 
and sometimes reduced to a whisper. The larynx shows the 
vocal cords normal, but they do not quite meet posteriorly 
during efforts at approximation. 

Just now the patient has a cold and some slight laryngitis, 
which rather masks the curious feature of her case. 


Case op PHARYNGO-cEsopHAaEAL Carcinoma. 

Shown by Mr. Spencer. The patient is a man about 60. He 
complains of wasting, owing to difficulty in swallowing during 
the last three months. He has a mass of carcinoma at the 
junction of the pharynx and oesophagus and involving the back 
of the larynx, causing swelling of the arytaenoids and ventri¬ 
cular bands, and there is also some infiltration of the glands in 
the neck. 

Five other such cases have been seen during the past year. 
Two had very extensive infiltration of the glands in the neck, 
with some hoarseness and dysphagia. The primary growth 
was situated in the hyoid fossa, and quite small, not more than 
1 to 2 cm. in diameter. 

No attempts at removal have been made, as there seemed no 
prospect of affording relief, especially as the larynx itself would 
have to be removed. Neither would gastrostomy have im¬ 
proved the patient’s condition. 

All the cases have tended rapidly to a fatal issue. 

Sir Felix Semon made some observations of a general character 
with regard to this case. Mr. Spencer had shown a case of early 
cancer of the pharynx in which the primary focus was very small, and 



46 


yet there were big masses of glands in the neck. He asked, Why did 
not the same happen in “intrinsic” cancer of the larynx? The 
school of Sappey was totally opposed to Luschka’s statements on this 
question, according to which the laryngeal lymphatics were of a more 
isolated character than those of the pharynx, which freely anasto¬ 
mosed with neighbouring lymphatics. Luschka’s views had at any 
rate the merit of intelligibly explaining the undeniable clinical dif¬ 
ferences between intra-laryngeal and pharyngeal cancer with regard 
to infiltration of the neighbouring lymphatics, which, if Sappey’s 
statements were correct, was absolutely unintelligible. The speaker 
thought that this was a most important question, which deserved re¬ 
investigation. 


Case op Primary Atrophic Rhinitis commencing in 

Infancy. 

Shown by Mr. Spencer. A child, set. 5, was first brought 
for treatment on account of ozsena and crusts. She has been 
for some time under Mr. Spencer, and has been treated by a 
saline douche without any marked improvement. The appear¬ 
ances in the nose are typical. There is an entire absence of 
any evidence that the rhinitis was secondary. 

The child had nothing wrong with the nose during the earlier 
months of infancy, and she has had no other illness. 

Dr. Bronner had seen several cases of ozsena which had begun 
at an early age—twelve, indeed, between two and three years of 
age. They should make a distinction between atrophic rhinitis and 
ozsena, which were distinct and separate diseases. In the north of 
England atrophic rhinitis was extremely common, especially amongst 
the mill girls. Ozsena attacked its victim early, whilst atrophic 
rhinitis began between the ages of fourteen and eighteen. The cases 
of ozsena he had seen in babies had been independent of syphilis; 
possibly, perhaps probably, they were connected with purulent dis¬ 
charge at birth caused by contagion. As regards the smell, the 
children of the working classes often smelt so badly that it would be 
difficult to detect the smell of ozsena. 

Dr. Herbert Tilley said he could find no evidence of congenital 
syphilis in this case. He had seen similar cases, and did not consider 
them very rare. It was interesting to find that no history of a puru¬ 
lent discharge preceded the present condition of scab formation, and 
therefore the case was opposed to Bosworth’s view that atrophic 
rhinitis was a late stage of purulent rhinitis in childhood. The 
speaker thought the great majority of the latter cases were due to 
adenoids. Again, such cases as Mr. Spencer’s showed how improbable 



47 


it was that “ ozaena ” arose from accessory sinus suppuration, as stated 
by Griinwald and others. 

Dr. Jobson Horne suggested that bacterioscopic examinations 
made at intervals might possibly throw some light on the aetiology of 
the condition. 

Dr. Lambert Lack said he had seen a family in which several 
members among the children suffered from ozaena, which commenced 
at an early age. He thought he could bring forward a dozen cases 
in which the discharge had commenced at as early an age as in the 
case under discussion. In the majority of these cases there was a 
history of purulent rhinitis at quite a young age, though it might not 
always be due to any special cause, such as gonorrhoea, syphilis, etc. 
He believed that, as a rule, atrophic rhinitis was the result of long- 
continued purulent rhinitis; and that if one reckoned the discharge 
as an early symptom of atrophic rhinitis, the majority of cases could 
be dated back to an early period of life. 

Mr. Waggett referred to a family case of atrophic rhinitis. The 
disease was well developed in the mother. Six years ago her daughter, 
six years of age, came to the hospital with muco-purulent catarrh. In 
spite of nose-washes, etc., she had gradually developed atrophic 
rhinitis, which was well established at the present date. Her younger 
sister had during the last two years exhibited the same sequence of 
changes. There was still another little sister, who was following the 
same course. Here was a case of family ozaena quite unconnected 
with syphilis, and making itself evident between the ages of four and 
six. 

Mr. Spencer, in reply, said the points in the case were that there 
was no evidence of congenital disease; the formation of crusts and 
the ozaena had been first noticed at ten months. Atrophic rhinitis 
was very generally secondary, but in the present instance all inquiry 
as regards a secondary origin failed. He thought the related his¬ 
tories of affected families important in relation to a possible bacterial 
origin. Hitherto the bacteriology of the nose had not advanced far. 


Case of Papillomatous Condition of Tongue. 

Shown by Dr. Ball. A healthy-looking girl, aet. 20, with 
good family history, has had discomfort in her tongue for about 
two years, and for the same period has noticed a “growth” on 
her tongue which has gradually increased in extent. The dis¬ 
comfort and soreness get worse for some weeks at a time, and 
then diminish, but never quite leave her. For the last few 
months she has felt some soreness of the throat on the right 
side. There is no history or suspicion of syphilis. Immediately 
to the right of the middle line of the dorsum of the tongue there 



48 


is a marked outgrowth over an area about half an inch broad, 
extending from near the tip to the origin of the circumvallate 
papillae. It is made up of separate nodular masses varying in 
size from a grain of rice to a small pea. The surface is redder 
than the rest of the tongue, and the papillae are enlarged. Under 
the tip of the tongue to the right of the fraenum are some small 
warty growths. The right anterior pillar of the fauces is 
congested, and presents a few small glistening elevations. 

Mr. Butlin said he had carefully examined the tongue, and 
believed that the disease should be described as a local macroglossia— 
an affection of the lymphatic system of the tongue. He had seen 
many similar cases, and this one resembled the first in which he had 
removed the disease. The patient was just such another red-faced 
country girl, and the tumour occupied the middle line of the tongue 
in two longitudinal crests. He thought they were papillary growths, 
and cut them out with scissors. The haemorrhage was very abundant, 
and continued to recur in so serious a manner that pressure had to 
be employed for part of two days before the bleeding was arrested. 
Ever since, Mr. Butlin had made a practice of cutting such growths 
out between two deep incisions which passed far into the substance 
of the tongue. The edges of the incisions are brought together with 
silk sutures, and there is no fear of recurrent or secondary haemor¬ 
rhage. 


Specimen op a Bony Cyst op Middle Turbinate Bone. 

Shown by Dr. Herbert Tilley. The specimen was a large 
bony cyst removed from the left middle turbinate of a young 
woman set. 29, who complained of nasal obstruction, aching over 
the root of the nose, and a constant discharge of clear fluid from 
the left nostril. 

The cyst would contain a horse-bean, and was interesting from 
a pathological point of view. It contains a muco-purulent 
secretion and a few oedematous granulations. It was removed 
by dividing the attachment of the middle turbinate to the outer 
wall of the nose with scissors, and then snaring the semi¬ 
detached portion. 

The patient was quite relieved of her symptoms. 

Dr. Watson Williams remarked that an ethmoidal cell sometimes 
existed normally in the middle turbinate body, and this, like the other 



49 


ethmoidal cells, might become the seat of inflammatory disease. He 
thought it probable that in this specimen, as in many of the cases of 
cysts of the middle turbinate, some such “primary accessory sinusitis” 
arose, resulting in the blocking up of the ostium, and consequent 
distension with retention of secretion and formation of the cyst. 

Dr. Jobson Horne inquired whether the cyst communicated with 
the interior of the middle turbinal body. He had met with what 
might be a somewhat similar condition, and in which he was inclined 
to regard the cyst as a modified anterior ethmoidal cell. 

Dr. Bennett said these cysts were not rare, and in one or two cases, 
owing to pressure and pain, he had had to remove such at a compara¬ 
tively early stage; there were no contents, but the space was lined 
with a perfectly smooth membrane. In one case he had to operate 
on account of the neuralgic pains. He did not understand how such 
cystic dilatations originate. He had seen larger cysts than those 
shown. 

In reply, Dr. Tilley said that he bad searched carefully for 
communication with the other ethmoid cells, but had found none. 
There was no evidence of accessory sinus suppuration. The exhibitor 
could offer no satisfactory solution as to the origin of such growths ; 
they might possibly be a dilatation of the normal cells existing in the 
middle turbinate, which became enlarged as part of a chronic inflam¬ 
matory process; or, as MacDonald has suggested, they may arise from 
incurvation of the free margin of the bone enclosing a cavity lined 
with normal nasal mucous membrane as the result of an osteophytic 
periostitis. 


Case op Male .et. 17 Years after Removal op Fibro-myxoma 

op the Post-nasal Region. 

Shown by Dr. FitzGerald Powell. The case was shown at 
the last meeting of the Society. 

On December 2nd he was placed under an anaesthetic, and 
examination disclosed the extensive character of the tumour. 

A preliminary laryngotomy was performed, aud the upper 
aperture of the larynx plugged with sponges. 

The soft palate was then split and the divided portions held 
apart by long silk threads passed through them. It was not 
necessary to remove any of the hard palate, as the posterior 
edge had beeu considerably eroded by the pressure of the growth. 
In this way the tumour was fully exposed, and was found to be 
attached to the body of the sphenoid. It filled the whole of the 
naso-pharyngeal cavity, and sent prolongations into the right 
spheno-maxillary fossa and right nostril, pushing the septum 



50 


against the external wall of the left nostril, and completely 
occluding it. 

The bony walls of the naso-pharynx were considerably eroded 
by the growth. It was removed by the aid of “ Lack’s ” snare 
and cold wire, and strong scissors curved on the flat, with which 
the toughest parts were dissected away. 

The bleeding was severe, but was controlled by hot sponges 
and pressure. 

The edges of the wound in the palate were brought together 
by silk sutures, and a sponge left in the post-nasal space for 
twenty-four hours and then removed. 

The laryngotomy tube was allowed to remain in for three 
days. 

The boy is now doing well, and returns home to-morrow. The 
wound in the palate has healed, but some of the stitches broke 
out, and there is still a small opening near its junction with 
the hard palate. This, though interfering somewhat with his 
speech, has the advantage of enabling us to observe the con¬ 
dition of the parts, and to treat the atrophic state of the naso¬ 
pharynx. 

An operation at a future time may be attempted to close the 
wound and straighten the septum, or a suitable obturator may 
be worn. 

The wound in the neck is quite healed, and gave no trouble. 

The incontinence of urine and drowsiness from which the 
patient suffered has completely disappeared. 

The tumour is a pure fibroma, dense and tough. 

Mr. Butlin said the tumour was the largest he had ever seen taken 
from the naso-pharynx, and he thought it must have opened its way 
into one, if not both, of the antral cavities by absorption of the bone. 
It appeared more likely to be a fibroma than a sarcoma, and the 
operation bid fair to be a complete success. But he was afraid the 
hole in the palate was not likely to close. 

Mr. Spencek had on the previous occasion expressed the opinion 
that the tumour belonged to the upper jaw, and should be operated 
upon through a facial wound. He thought that the case should 
be carefully watched, and if there were signs of renewed growth, this 
measure should be undertaken early. In a similar case the growth 
extended out into the spheno-maxillary fossa behind the antrum 
towards the temporo-malar and cheek region. 


/' 

j 



51 


Dr. FitzGerald Powell in reply thanked Mr. Butlin and Mr. 
Spencer for the kind way in which they had alluded to his case. 

He did not think that the growth had invaded the antrum, and he 
was quite certain it had not reached it from the nose, but it was 
possible that it had done so from behind, through the spheno-maxillary 
fossa. However, on the removal of the tumour, from its appearance 
and general contour he felt quite satisfied that he had got it all away. 
The prolongations of the growth, one into the nose and another 
which filled the spheno-maxillary fossa, were quite intact, and the 
growth itself was so tough and firm that it would have been impos¬ 
sible to break away any part of it without being able to recognise it. 

There were two interesting points in connection with such tumours. 
The first was the difficulty in determining the extent and attach¬ 
ments of the tumour, and indeed the impossibility of doing so until 
the palate had been split and the growth exposed. The second was 
with regard to the diagnosis at an early stage. 

This patient two years ago had been an in-patient at a London 
general hospital for six weeks, and was said to be suffering from a 
naevus of the throat (this was the history given by the boy’s father), 
and he thought it was quite possible for such an error to be made at 
an early stage when frequent and serious bleedings were occurring. 


Case op Intractable Aphonia with Occasional Apsithyria. 

Shown by Dr. Pegler. A girl set. 22, a school teacher, had 
long been liable to temporary loss of voice on catching cold. 

In February, 1899, she suddenly lost it altogether and, ex¬ 
cept for a slight recovery in response to a local galvanic appli¬ 
cation by the family doctor, had since been not only unable to 
speak, but often could not even whisper, and in the months of 
July and August following had either carried a conversation 
book about with her, or had communicated with her friends on 
her fingers. She came as an out-patient to the Metropolitan 
Throat Hospital in November. On examining the larynx a stam¬ 
mering action of the vocal cords was all that could be seen on 
attempted phonation, but the stimulus induced by probing the 
larynx in any situation was sufficient to create adduction and 
production of tone. The laryngeal electrode was applied to the 
vocal cords systematically about three times a week for a 
month, resulting in considerable improvement. The glottic 
chink was then elliptical, the internal thyro-arytaenoid being 
mainly affected. More latterly much of the improvement fell 
off, the arytsenoid muscle became also paretic, causing the 



52 


triangular glottis, and the girl had on more than one occasion 
become apsithyric again, so that there was distinct retrogres¬ 
sion, and the usual treatment having so far failed, fresh sug¬ 
gestions were invited from the Society. The family history 
was noteworthy. Paternal grandfather epileptic; mother liable 
during her pregnancies to violent fits of hysteria. Two 
brothers, out of a family of six living, were epileptics. Patient 
herself had shown no other manifestations of hysteria. 


Dr. Herbert Tilley gave details of a case of an inveterate nature 
in which very strong intra-laryngeal faradic shocks produced no result 
whatever, not even temporary improvement, neither had any other 
sudden painful shock been of avail, and he asked Sir Felix Semon if 
he knew of any successful means of treating such cases. In the case 
referred to by the speaker, the latter advised isolation, Weir Mitchell 
treatment, and then when the system was in a healthy condition the 
application of the strong faradic current. 

Dr. Bennett suggested that breathing exercises should be tried. 
He had recently, after two or three years of trouble with a patient 
who had been to several hospitals, tried these exercises systematically; 
the voice after a short time completely returned. No other treat¬ 
ment, such as faradisation, etc., had done any good. The patient had 
now been several months without return of the aphonia. He should 
say that in the case under discussion the upper chest breathing was 
very bad; in fact, her whole method of breathing was irrational. 

Dr. Bronner recommended the trial of the faradic current with 
the metal brush. It was extremely painful, but most useful. He had 
treated a servant some months ago who had been aphonic for several 
months, and in fact was about to be dismissed; he tried the above 
treatment, and she was cured almost immediately. 

Sir Felix Semon looked upon cases such as had been mentioned in 
the discussion, in which, apart from the aphonia, there was functional 
paralysis of the whole apparatus of articulation, including the move¬ 
ment of the lips, as examples of Charcot’s “hysterical mutism;” 
they represented, as it were, the superlative of hysterical aphonia. In 
reply to Dr. Pegler’s question, he stated that in his experience the 
vast majority of cases of hysterical aphonia could be cured in one 
sitting by intra-laryngeal applications of electricity, one electrode 
being applied to the inter-ary taenoid fold, and he wished to repeat this 
statement emphatically, in spite of the fact that this experience of his 
had been recently queried in a text-book. But it was necessary to 
exercise very considerable energy in many of these cases. With in¬ 
creasing experience, he had become more and more convinced that, 
added to the physical inability, there was in many of these cases con¬ 
siderable mental perversion. When after restoration of the voice by 
electricity, as manifested by the involuntary cry which usually was 
the first sign of the restored function of the adductors, the patients 



53 


were directed to use their voice, as in counting from one to ten, or as 
in replying to questions, many of them did not make the least effort, 
and showed themselves as wilfully obstinate as possible. He always 
insisted, in view of this mental perversion, and of the danger of one’s 
therapeutic efforts being afterwards misrepresented to the patient’s 
friends, that a friend—or, if possible, the patient’s general medical 
attendant—should be present when intra-laryngeal faradisation was 
applied. He instanced one case, occurring in I)r. Playfair’s practice, 
of the very worst form of general hysteria, in which intra-laryngeal 
faradisation, sufficiently strong and sufficiently long-continued, had 
succeeded in restoring the voice in the first sitting, but only after 
very severe applications, and emphasised the necessity of persevering 
with one’s efforts until this result had been obtained. Failure in the 
first sitting almost always meant the patient’s non-reappearance for 
the second. Whilst thus extolling the effects of intra-laryngeal fara¬ 
disation, he wished to state that a few of his cases had remained 
rebellious to it, and to every other form of treatment recommended, 
such as hypnotism, articulation exercises, use of internal remedies, 
change of air and residence, attempting to make the patient speak 
loudly when awaking from chloroform narcosis, etc. In one such 
case the voice had been restored by the unexpected application of a 
cold water douche; in others, this remedy too had failed. He parti¬ 
cularly remembered the case of a major in the army, a strong, powerful 
man, and the very last whom one would expect to become a victim to 
hysterical aphonia. This patient assiduously tried everything that 
was suggested, because loss of his voice of course meant professional 
ruin to him; however, everything failed. Fortunately, however, in 
this case, as in all other rebellious cases known to him personally in 
which medical art had failed, the voice one day without any external 
cause returned as suddenly as it had disappeared. With reference to 
Dr. Tilley’s question, whether local treatment was likely to be more 
successful after a previous course of Weir Mitchell’s treatment, he 
could not answer it, having had no experience with regard to this 
special point. Finally, with regard to a question of Dr. Pegler’s, 
asking which laryngeal muscles were chiefly affected by hysteria, Sir 
Felix said that ordinarily, in his opinion, the whole group of ad¬ 
ductors were concerned. In cases in which the inter-arytsenoid muscle 
only was afEected, with the well-known laryngoscopic image of a small 
triangular opening in the hindermost part of the glottis, the prognosis 
in his experience was not nearly so good; but then he thought that in 
a good many of these cases the paralysis was not merely functional, 
but that the small inter-arytaenoid muscle had actually undergone 
trophic chauges, and some of these cases in his experience had per¬ 
manently resisted every form of treatment, and had remained un¬ 
cured. 

In reply, Dr. Peoleb said that the patient being always accom¬ 
panied by friends, the latter had been often able to judge of the com¬ 
parative facility with which the voice could be coaxed back by a probe 
or electrode in the larynx. The faulty breathing was most apparent; 
the chest muscles also seemed to stammer in a certain sense, and she 



54 


could only count six figures before requiring to take a fresh breath. 
The spirometric reading was 50 per cent, below par, and the patient 
was under special treatment and in expert hands for that defect. 
Every precaution had been taken to allow the muscles of respiration 
free play by wearing suitable clothing in place of the old-fashioned 
tight corsets. 


Case op Naso-pharyngeal Growth (? Sarcoma). 

Shown by Dr. Pegler. A man aet. 27, complaining of com¬ 
plete inability to breathe through his nose for four years, and 
occasional profuse attacks of nose-bleeding on making the 
attempt. This case had some interest through having first come 
under observation at the Metropolitan Throat Hospital about 
two and a half yeai*s ago, when the following note was made:— 
“ On digital exploration of the naso-pharynx a soft polypoid 
mass is felt, much like adenoids, dependent from roof and 
posterior wall, chiefly to the left of mesial line. Being easily 
detached, two fleshy masses were expelled, one from each 
nostril, and the breathing became quite free. Sections of the 
material consisted of small-celled apparently lymphoid tissue.” 
The patient did not return to the hospital till January, 1900, and 
the nasal obstruction was then absolute. Inspection from the 
front showed a dark, softish, vascular and brittle growth in the 
right nasal chamber, which space it was expanding posteriorly. 
In the left naris the septal mucous membrane was turgid, and 
freely bled on the least touch. In the naso-pharynx a large 
lobulated mass could be felt depending from the roof. The free 
edge of the septum was difficult to reach owing to its absorption. 
A piece of the mass was snared off, and sections shown under 
the microscope displayed mixed cells,—small, round, and spindle, 
with no structural disposition. Lymphoid follicles and gland- 
cells were absent. 

Dr. Herbert Tilley said he had made a digital examination, and 
found a soft vascular growth occupying the post-nasal space and 
spreading forwards into the nose ; the posterior portion of the vomer 
had also been destroyed, and he thought it high time to proceed with 
the radical operation, after first splitting the soft palate and performing 
a preliminary tracheotomy. This course had also been suggested by 
Mr. Butlin, 



PROCEEDINGS 

OP THK 

LARYNGOLOGICAL SOCIETY OF LONDON. 


Fifty-fifth Ordinary Meeting, held February 3 rd , 1900. 


F. de Havilland Hall, M.D., President, in the Cliair. 


Lambert Lack, M.D., ) „ . . • 

Behest Waooett, M.B., } Secretanes - 


Present—28 members and 4 visitors. 

The minutes of the preceding meeting were read and confirmed. 

The following gentlemen were nominated for election at the 
next meeting of the Society : 

Dennis Vinrace, M.R.C.S., L.R.C.P., 24, Alexander Square, South 
Kensington. 

Felix Klemperer, M.D., Strassburg im Elsass. 

A report from the Morbid Growths Committee was read by 
the Secretary. The Committee reported that sections made 
from tissue handed to them by Dr. Cresswell Baber from his 
case of nasal tumour (see ‘ Proceedings* for June, 1899, page 
109) showed no evidence of malignant disease. They also 
reported that the tumour of the ventricular band shown by 
Dr. Furniss Potter (see ‘Proceedings’ for November, 1899, 
page 1) was a fibro-angioma. 

FIRST SERIES—VOL. VII. 


4 



56 


The following cases and specimens were shown : 

A. Case of Complete Fixation of The Left Vocal Cord. 

Shown by Mr. Wyatt Wingrave. A girl set. 19, born and 
until lately resident in India, complained of weakness in her 
singing voice and huskiness in her speaking voice, of gradual 
onset, about four months ago. There was also some dyspnoea 
on exertion and singing. She had always been somewhat pale. 

When first seen, about a fortnight ago, the left vocal cord 
was fixed in the cadaveric position, its texture and colour with 
the rest of the larynx being normal. 

There was no definite evidence of organic interference with 
the recurrent laryngeal, neither was there any history or col¬ 
lateral sign of local inflammation or hysteria. 

She was ordered complete rest from singing and nerve tonics. 

The President said that evidently the condition had altered lately, 
as the cord was now fairly moveable. Such cases of paresis were 
generally the result of some neuritis; and he thought this case pro¬ 
bably had a similar origin. 

Mr. Wyatt Wingrave said it was very gratifying to find that the 
cord was now moving. The case was interesting because only one 
cord was involved, and that one the left. 


An Unusual Form of Ulceration of the Throat in a 
Patient the Subject of Syphilis. 

Shown by Mr. Wyatt Wingrave. A male, set. 25, was first 
seen on January 16th last, when he complained of pain in the 
throat and inability to make his teeth meet of four months’ 
duration and gradual onset. 

A deep, ragged ulcer with fleshy projections was seen in the 
right post-molar fornix, from which a firm oedema extended to 
the whole of the soft palate and uvula; in appearance it was 
translucent, with milky patches. Movement of the mandible 
was painful, and the incisors did not meet by a quarter of an 
inch. Deglutition was difficult but painless. The subman¬ 
dibular and supra-clavicular lymphatic glands were thickened. 
The patient was very anaemic, and complained of great weak¬ 
ness and loss of flesh. 



57 


There was a history of syphilis five years ago, also of renal 
colic twelve months ago. His wisdom teeth were present. 

He was at once ordered potass, iodid. and bichloride of mer¬ 
cury. 

The oedema is considerably reduced. He is free from pain, 
and can now masticate without much difficulty. 

The appearance and physical character were at first some¬ 
what suggestive of malignancy (sarcoma), but so far the result 
of treatment points to syphilis. 

The President said this case reminded him of a similar one under 
his care at Westminster Hospital, which also had a history of syphilis 
— a man with gumma in the throat. He improved under large doses 
of iodide of potassium, and was discharged as cured. About a year 
later he came again with the same complaint, and again improved on 
the same treatment and was discharged. A few months later he was 
admitted a third time, and on this occasion iodide of potassium had 
little or no effect upon him, and eventually he died of malignant 
disease. At the commencement he thought his diagnosis of syphilis 
had been confirmed by the good results obtained from treatment by 
potass, iodid. 


Case of Nasal Polypi with Suppuration and (?) Absence of 

Maxillary Sinuses. 

Shown by Dr. Lambert Lack. The patient, a man set. 28, 
came under my care complaining of nasal obstruction and 
purulent discharge, with a disagreeable odour in the nose. The 
polypi having been removed, the pus appeared to flow from 
under the anterior ends of the middle turbinates. After wiping 
the discharge away and bending the patient’s head forward 
it reappeared in large quantity. On transillumination the 
cheek on both sides appeared quite dark, and the patient had 
no subjective sensation of light. The diagnosis of antral sup¬ 
puration was now considered almost certain, and the patient 
was advised to have both antra punctured from the alveolar 
margins. This was accordingly attempted under gas, but 
although the antrum drill was forced in for its full length no 
cavity was reached. I next attempted puncture from the 
inferior meatus of the nose, and used considerable force in two 
different spots, but with no better result. It seems, therefore, 



58 


that the antra mast be very small, if not entirely absent. The 
case is a somewhat embarrassing one, as the patient is naturally 
disappointed. I have broaght him forward as a very rare—in 
my experience an unique—case, and I should be glad to know if 
any members have had similar experiences. 


Mr. Spencer suggested, in the absence of any evidence of a collec¬ 
tion of pus in the frontal sinus, that the best method of treatment 
would be to remove the inferior turbinal on the left side. It must 
be one of those convoluted turbinals which form a gutter in which 
pus collects. He had seen such a case. With regard to the osseous 
condition of the nose, he had seen a man in which this condition 
was much more marked than in the case under discussion. On 
tackling the nose, he started with the idea of doing what he advised 
here, inferior turbinectomy under an anaesthetic, but there was so 
much bony thickening of the outer wall of the nose that he had to 
bore his way right back to the naso-pharynx until he could pass his 
finger through the nose. A good deal of haemorrhage resulted, 
and plugging had to be resorted to. This young man, who had 
had a swelling for several years, was now in a most satisfactory 
condition. 

Dr. Pegler could see no justification for any interference with the 
inferior turbinal body. He inquired if the cavity of the antrum had 
been explored by means of Krause’s opening. He had no doubt that 
Dr.. Lack would remove the diseased portion of the middle turbinal 
from which some polypus buds could be seen sprouting, after which 
' the source of the pus might perhaps be more easily traced. 

Dr. Herbert Tilley thought it probable that there was a small 
antrum on one or both sides, and reminded those present of Ziem’s 
paper on antral suppuration read before the British Medical Associa¬ 
tion when last held in London. He then pointed out that the antrum 
may be represented by a mere dehiscence in the bone. The speaker 
questioned the probability of an antrum so small as that producing 
•so much suppuration as in Dr. Lack’s case ; possibly ethmoidal disease 
was present also. He (Dr. Tilley) had just experienced a similar 
difficulty in finding an antrum situated high up in the maxillary 
bone, the perforator enteiing one and three quarter inches before 
striking the pus. He should advise in Dr. Lack’s case removal 
of the anterior half of the middle turbinate, and exploration of the 
antrum from the middle meatal region, if necessary making a large 
opening into it in this position. He had recently operated upon a 
young man in whom the naso-antral wall in the inferior meatus was 
so thick that the heads of two strong burrs had been broken off in 
the attempt to enter the antrum in this position, consequently the 
operation undertaken for exploration of the antral cavity developed 
into one for removing foreign bodies from the nose. 

Di*. Scanes Spicer, understanding that there had been polypi and 
suppuration on both sides, thought the probable explanation of this 
case was that a traumatism had deflected the septum and initiated 



59 


inflammatory changes in the middle turbinals. The left nose was 
now almost functionless, from the approximation of the septum and 
inferior turbinal combined with alar collapse, and the right nose had 
to do a double share of work, a state of affairs which tended to main¬ 
tain congestion, suppuration, and recurrence of polypus in the middle 
turbinals. Prom the cursory examination then alone possible and the 
history given, he thought the ethmoidal disease sufficient to account 
for the symptoms and course of the case, without assuming that the 
antra (which were doubtless small) were suppurating. 

- Dr. Lambert Lack, in reply, said that he agreed that it was a case 
of ethmoidal disease. He had brought the case forward because of 
the remarkable way in which it had simulated antral suppuration, and 
because of the failure of the attempts to perforate tbe antrum. The 
fact that the cheek was opaque on transillumination was explained by 
the osseous condition. He could not insert a trocar in any direction. 
He thought there was probably suppuration in the ethmoidal cells, 
and he intended to remove part of the middle turbinate and open 
some of these cells, and he would also at the same time endeavour to 
open the antrum from the middle meatus as Dr. Tilley suggested. 


Case of Pachydermia Laryngis. 

Shown by Dr. Jobson Horne. The patient, a married woman 
set. 23, had been troubled with hoarseness and dryness of the 
throat for nearly two years. Aphonia had developed gradually 
two years previously, during her first pregnancy, and she had 
reached the sixth month of another pregnancy. 

Both ventricular bands were considerably thickened, with 
little or no oedema. The left band presented a longitudinal 
grooving on its inner aspect, and into this there passed during 
phonation a wedge-shaped excrescence of the right band. The 
free edge of the epiglottis was a little rounded. The cords 
themselves, though partially obscured to view, moved freely and 
appeared natural, and so did the arytaenoid and inter-arytaenoid 
regions. 

The examination of the thorax yielded no signs of tuber¬ 
culosis, nOr was there any family or personal history suggesting 
tuberculosis; but the sputum had not been obtainable for 
examination. 

There was also to be noted some chronic pharyngitis and 
atrophic rhinitis. 

Dr. Jobson Horne was inclined to regard the case as one of 



60 


pachydermia laryngis, but what had given rise to the condition 
was not at present very clear. 

Dr. Dundas Grant thought from the appearance of the larynx that 
it was a tubercular pachydermia, and that it was not primary but 
secondary to tubercular disease. Perhaps Dr. Home would bring the 
case before the Society on a future occasion. 

Dr. Scanes Spicer also thought this case was one of a chronic 
tubercular laryngitis, the mass of growth being on one side only, 
extending the anterior two thirds of the cord, and there being no 
protuberance corresponding cupping over the opposed vocal pro¬ 
cesses. 


Case op Laryngeal Affection in a Tubercular Patient for 

Diagnosis. 

Shown by Dr. Cathcart. The patient, a male aet. 26, un¬ 
married, came under my care at the London Throat Hospital 
last week. He complained of chronic hoarseness, which began 
at the end of September, 1899. The family history is good, 
except that two brothers have died of consumption. For some 
months prior to July, 1899, patient had been losing weight and 
spitting blood. He had no night sweats, and only a slight cough. 
At that time tubercle bacilli were found in the sputum. 

During August he went for a holiday, and gained weight 
slightly, and also ceased to spit blood. In the beginning of 
September the sputum was again examined, but no tubercle 
bacilli were found. At the end of September he began to get 
hoarse, and has been getting gradually worse. His general 
condition at present is better than it has been for some time. 
He is not losing weight or spitting blood, and has a very good 
appetite. When his larynx was examined last week it was 
found to be very irritable, red, and inflamed; the cords were red 
and thickened. There was no swelling at the posterior part or 
over the arytaenoid cartilages, but there was a slight uniform 
swelling below the anterior commissure. I shall be glad to 
have the opinion of the members on the case. 

Dr. Clifford Beale would be rather inclined to describe the 
condition as one of simple irritation due to a local cause, which in this 
case was obviously subglottic. He did not think that the appearance 



61 


was characteristic of tubercle. It was a matter of common observation 
that mucus might collect and remain for a long time in the anterior 
commissure of the cords, and he had watched cases for several weeks 
in which such collections of mucus were always present. Dried and 
decomposing mucus was apt to give rise to irritation if undisturbed 
by coughing, and he thought that the subglottic swelling in this case 
had probably arisen in this way. Infection of such irritated areas by 
tubercular mucus from below was always likely to happen, and hence 
he should always advise early treatment by removal of such mucus 
with a mild astringent. 

The President said the condition of the larynx reminded him of 
that seen after tracheotomy, where the irritation of the tube had 
caused growth of granulation tissue below the vocal cord; he would 
agree with the views of the previous speaker. 

Dr. J. Dundas G-rant said the appearance reminded him of cases 
he had dissected of laryngeal and pulmonary tuberculosis, in which 
there were shallow oval ulcers on the mucous membrane of the trachea. 
The fact that the patient had evidence of tubercular disease made it 
only natural to suppose that the appearance in the trachea was due to 
tubercular disease. 

Dr. Cathcart said that the opinion of the majority of the members 
was that the ulceration was tuberculous. Several had suggested that 
it was perhaps syphilitic, but on questioning the man no trace of a 
syphilitic history could be found. The sputum had been examined 
that day, but there were no tubercle bacilli present. He intended to 
treat the case as one of a tuberculous nature. 


Case of Bulbar Paralysis. 

Shown by Mr. Waggett. A man set. 61, of temperate habit, 
and denying syphilis, presented the condition of progressive 
muscular atrophy, involving the region of the bulbar innerva¬ 
tion as well as other parts. 

Symptoms commenced in the spring of 1899 with difficulty in 
swallowing, lisping speech, and wasting and paresis of the 
hand muscles. Later cramps had been experienced in the 
legs and inability to walk securely. 

At the present time there was paresis of the lips ; atrophy, 
tremor, and paresis of the tongue. Paresis of the palate more 
marked on the left side, and causing escape of air through the 
nose during speech. The most marked symptom was great and 
increasing difficulty in swallowing. This symptom had slightly 
decreased since galvanism had been employed. On one occasion 



62 


temporary diplopia and a fluttering in the ear had suggested a 
recent spread upwards of the nuclear degeneration. 

With regal’d to the larynx, when first seen a fortnight ago 
there was fixation of the left cord in the middle line, with ab¬ 
ductor paresis of the right cord. At the present time there 
was marked abductor paresis on both sides. 

The question of tracheotomy was raised, and experienced 
opinion was sought as to the real value of galvanism in the 
treatment of the pharyngeal paresis. 

The President said he had experienced great difficulty in dia¬ 
gnosing a case of commencing bulbar paralysis where there was no 
impairment of the movement of the tongue. The patient was brought 
to him on account of the attacks of severe dyspnoea. On examining 
the vocal cords he found some paresis of the abductors, with a certain 
amount of adSuctor spasm. 

Dr. Dundas Grant said that the general features of the case con¬ 
firmed Mr. Waggett’s opinion that it was part of a general muscular 
atrophy, or anterior poliomyelitis, the first interossei and trapezius 
muscles having almost completely gone. 

Sir Felix Semon, in reply to Mr. Waggett’s question, said that in 
the early stages of bulbar paralysis methodical use of the constant 
current sometimes greatly improved the patient’s swallowing. He 
had had several cases which had so improved. 

The President added that his case had improved under the use of 
galvanism. 


Case op Thyrotomy for Tertiary Syphilitic Laryngitis. 

Shown by Mr. Spencer. A man set. 30, on whom he had 
performed thyrotomy three months before. A quantity of very 
tough fibrous tissue was removed, along with a portion of the 
right vocal cord. 

The man had been under observation for a year, and the 
laryngeal stenosis had gradually increased in spite of full doses 
of iodide and mercury, until he had dangerous dyspnoea at 
night. 

The choice of treatment then lay between thyrotomy and 
tracheotomy. The former had been selected because the 
larynx was already filled with such masses that no voice could 
have been anticipated after tracheotomy. Moreover, in a 
former almost identical case, in which he had done tracheo- 




63 


tomy, the patient when drank got his tube out, could not 
replace it, and was asphyxiated very quickly. 

At present the patient could breathe well at night, and had 
gone back to work. He had at present only a loud hoarse 
whisper. 

There had been some recurrence, but the patient had re¬ 
turned, and was again taking iodide in forty-grain doses. 

The President said from their experience it was difficult to say 
what was the best thing to be done. This case looked as if it were 
contracting again and tracheotomy would be required. He had had 
a distressing case in which tracheotomy was done; the growth con¬ 
tinued into the trachea, and tracheal stenosis resulted in spite of 
potass, iodid. The patient went to several London surgeons, but 
there was nothing to be done. He then went to Paris, and died on 
the operating table. The President asked all members to bring such 
cases before the Society, that they might solve the question as to the 
best mode of treatment by the consideration of a series of cases. 


Case of Ulceration of the Pharynx for Diagnosis. 

Shown by Dr. StOlair Thomson. The patient, a man get. 64 , 
has complained of sore throat for three months. There is no 
history of syphilis. When first seen the left tonsil was covered 
by a u wash leather” slough, which also extended slightly on to 
the soft palate and anterior pillar of the fauces. On examina¬ 
tion with the mirror the same condition was observed passing 
down nearly as far as the pyriform fossa. Some days later the 
slough separated and showed an ulcer with raised edges and 
somewhat hard on digital examination. There is no glandular 
enlargement. 

Sir Felix Semon said there could be little doubt as to the malig¬ 
nant nature of the ulcer. 

Dr. Tilley said the hardness of the growth confirmed the view just 
mentioned. 


Cleft Soft Palate and well-marked Post-nasal Adenoids. 

A case of a boy 00 1.13, with cleft soft palate and well-marked 
post-nasal adenoids, was also shown by Dr. StClair Thomson. 

4* 



64 


At a Special Meeting held February 3rd, at 4.30 p.m., for the 
purpose of discussing the question, it was proposed by Dr. 
Scanes Spicer, seconded by Sir Felix Semon, and carried 
unanimously: “ That it was desirable that at all International 
Congresses there should be full and separate sections for 
Laryngology and Otology.” 



PROCEEDINGS 


OF THB 

LARYNGOLOGICAL SOCIETY OF LONDON. 


Fifty-sixth Ordinary Meeting, March 3rd, 1900. 

F. de Havilland Hall, M.D., President, in the Chair. 

Lambert Lack, M.D., ) „ . . 

Ernest Waggett, M.B., } Secretanes - 

Present—26 members and visitors. 

The minutes ot‘ the preceding meeting were read and con¬ 
firmed. 

The following gentlemen were unanimously elected members 
of the Society: 

Felix Klemperer, M.D., 42, Dorrotheen Strasse, Berlin. 

Dennis Vinrace, M.R.C.S., L.R.C.P., 24, Alexander Square, South 
Kensington. 

The following cases and specimens were shown : 

Case of Sinuses in the Vault of the Naso-pharynx. 

Shown by Mr. Charles Heath. The patient, an unmarried 
woman set. 31, had suffered for some years with discomfort in 
the nose, throat, and mouth, with dyspepsia and frequent 

FIRST SERIES — VOL. VII. 5 



66 


dyspeptic ulcers ou tongue and gums. The nose showed con¬ 
siderable atrophy of the mucous membrane of the middle and 
inferior turbinals anteriorly and posteriorly; the pharynx being 
also much atrophied, the cavity large, and post-rhinoscopy 
easy. The Eustachian eminences were seen to be enormous, 
filling the fossae of Rosenmuller and reaching nearly to the 
pharyngeal roof. Just behind the upper edges of the choanae, 
on each side, there appeared a transverse elliptical opening, 
which was about half an inch long and one fifth inch across at 
the widest part on the left side, and slightly less in each dimen¬ 
sion on the right ; a probe extends apparently about a quarter of 
an inch. The openings could be easily felt, and the finger 
inserted a little into the larger one; but the floor of the cavity 
could not be felt, as the edges of the opening would yield but 
little. 

Dr. William Hill had seen a similar condition several times, 
although not so marked as in this case. These were not “ sinuses ” 
in the ordinary rhinological acceptation of the term, but merely the 
two fossae of Rosenmuller rendered much deeper than normal by the 
development of steep banks of adenoid tissue. These banks were 
formed internally by the hypertrophied lateral borders of Luschka’s - 
tonsil, and the transverse bands so prominently seen were the remains 
of the transverse alar laminae of the same tonsil passing across to a 
large Eustachian cushion. 

Mr. Baber had arrived at the same conclusion as Dr. Hill, that the 
depressions were the upper part of Rosenmuller’s fossae unusually 
well marked. On examination with the finger, he had not been able 
to feel any bony growth or sinus. 

Dr. Dtjndas Grant thought these sinuses were formed by the 
remains of adenoid tissue which had acquired adhesions. 

Sir Felix Semon did not share the opinions of the previous speakers. 
In the first place, he did not think there was any adenoid tissue present 
at all in the neighbourhood of the clefts. Secondly, these fissures 
traversed a direction parallel to the fossa, instead of longitudinally or 
vertically, and were infinitely deeper than those he had seen in the 
most developed cases of fissures in the adenoid tissue. To him it 
seemed as if there were two deep indentations into the bone itself. He 
put forward as a hypothesis, that there might be some form of arrested 
development. 

Mr. Spencer did not see with the light available the amount of 
adenoid tissue that would be necessary to explain Dr. Hill’s theory. 
He should suggest that there were sinuses growing into the bone, and 
possibly some excessive development of the sphenoidal sinus He 
asked Mr. Heath to have a very careful drawing made of the naso¬ 
pharynx, as it was an unusual condition, and he suggested that when 
made the illustration should appear in the ‘ Proceedings.’ Except that 



67 


these “sinuses” were bilateral, they might be connected with the 
development of the infundibulum of the pituitary body. 

Dr. Scanes Spicer said the boundary walls of the unusual cavities 
in the naso-pharynx were quite soft on digital examination. He 
thought the normal central adenoid tissue of Luschka’s tonsil was 
displaced laterally in this case. This was especially well seen on the 
left side, where the adenoid tissue of the posterior wall was united to 
that forming the Eustachian cushion by a fleshy bridge. He could 
not concur with Mr. Spencer’s view as to the depressions being the 
openings of the sphenoidal sinuses, for the latter were half an inch 
further forward, more in the nose, and closer to the septum. 

Dr. StClair Thomson shared Dr. Hill’s view, i. e. that there were 
no sinuses except by optical illusion. There was quite distinctly an 
Eustachian tonsil on the top of the cushion, not merely a thickening, 
and this came into contact with the roof of the cavum, forming a deep 
recess which gave the impression of a sulcus. He thought that a 
careful examination under chloroform would reveal no adhesions. 
Such conditions as these were not at all rare, but fairly common; he 
had paid a great deal of attention to them, with the object of seeing 
whether there would be any improvement in ear cases by breaking 
down the cushions and adhesions, if existing, even when there were no 
adenoid growths. 

Mr. Richard Lake said, as far as the description of the case was 
given, his opinion coincided with that of Dr. Dundas Grant. These 
“sinuses” were more outside than usual, but were caused by the 
pharyngeal tonsil. 

Mr. Heath was much gratified by the amount of interest taken in 
his case. His opinion had always been, and was still, in harmony 
with that of Sir Felix Semon, that there was some unusual development 
in this case. Some of the members seemed to have rather mistaken 
the locality of the sinuses on account of the enormous size of the 
Eustachian prominences and their upward projection, and thought 
them further downwards and backwards than they really were; as a 
matter of fact, they were close under the back part of the roof of the 
choanse. The locality was one in which adenoid tissue is rarely 
abundant, although it often runs towards the septum; the sinus was 
so close to the choanse that it could not be of adenoid origin, and in 
this case there was advanced atrophy of the mucous membrane and no 
sign of adenoid tissue. 


Case of a Female jet. 23, with Obstruction of One Nostril 
from Antral Affection of Uncertain Character. 

Shown by Dr. StClair Thomson. The patient said that she 
had not had any nasal obstruction until after acute faceache, 
some four months ago. For this she had had a number of teeth 
removed with considerable relief, and she only came to the 
hospital for the nasal obstruction. The left nostril was entirely 



68 


occluded with what appeared to be a normal hypertrophy of 
the inferior turbinal. It did not in the least diminish under 
cocaine. The left posterior choana was normal. There was no 
discharge. Transillumination showed the antra to be the same 
on both sides. The left antruin was drilled from the alveolar 
border, but no pus escaped, and no fluid could be syringed 
through into the nose. With the probe the inside of the cavity 
appeared to have a soft thickened lining. There was still some 
tenderness above the canine fossa, and he suspected that the 
trouble might prove to be entirely periostitis. 


Mr. de Santi said it was impossible to say very much about the 
diagnosis until the turbinal had been treated; he thought there was 
suppuration, and that the antrum was probably involved. 

Dr. Dundas Grant said it looked more as if there were a cyst in 
the antrum. There was a certain amount of distension; no pus or 
fluid had been washed out on puncturing. A cyst seemed the only 
growth that would distend the antrum, and at the same time give no 
dulness on transillumination. 

Mr. Spencer thought there was hyperostosis of the maxillary 
bone; similar cases had been shown to the Society. He should relieve 
the nasal obstruction by removing the inferior turbinate body. He 
had seen more marked cases, which were due to thickening of a large 
area of the side of the nose, and in which there was marked symme¬ 
trical opacity upon transillumination. 

Dr. StClair Thomson said it was his intention to remove the 
anterior end of the inferior turbinal body; and he had simply 
exhibited the case in order that members might see its present con¬ 
dition. 


Case of a Growth in the Larynx in a Male .et. 25. 

Shown by Dr. FitzGerald Powell. In October, 1899, the 
patient first noticed a slight hoarseness, which gradually in¬ 
creased until January 16th, 1900, when he came under my 
notice. 

He attributes his loss of voice to the excessive use of alcohol, 
and also to the strain of public speaking. 

Nine years ago he had pneumonia, and since then says he has 
been subject to colds which fly to his chest. On one occasion 
he strained his voice so much by speaking that he brought up 
some sputum streaked with blood. There is no history of 



69 


syphilis. There is no evidence of disease in his lungs, and he is 
increasing in weight. 

On examination the whole of the larynx, especially the ven¬ 
tricular bands and true vocal cords, are seen to be red and 
swollen, aud there is some paresis in adduction. 

At the anterior portion of the right cord a growth is ob¬ 
served apparently growing by a broad base from the substance 
of the cord, and partly free anteriorly and posteriorly. The 
inflammatory condition has recently improved, but the growth 
has increased somewhat in size. 


Sir Femx Semon stated that he did not think it was possible to 
say at present for certain what the growth was from mere laryngo- 
scopic examination. It much reminded him of one of his own cases, 
in which he was for a long time doubtful as to the nature of the dis¬ 
ease. In that case at first a small reddish growth was observed on 
the free margin, and under the middle of the left vocal cord. It 
passed very gradually over into the cord itself. In the course of the 
next twelve months it gradually spread, infiltrated the left cord more 
and more, and finally an almost uniform semi-transparent thicken¬ 
ing of the whole vocal cord occurred, and the movements became 
somewhat sluggish. Owing to the uniformity of the swelling, it was 
impossible to remove a piece for microscopic examination. Seeing 
the patient’s age (fifty-five), the unusual appearance of the growth, 
and the sluggish movements of the cord, there was a strong suspi¬ 
cion of malignancy,.and this opinion having been confirmed by Mr. 
Butlin, thyrotomy was performed, and the whole of the cord was 
removed. On microscopic examination, however, by Mr. Shattock, it 
remained doubtful as to whether the growth was of the nature of 
fibro-sarcoma, or of what he called “ continuous ” fibroma (.Fibroma 
molluscum). The case had been fully described in the speaker’s paper 
on “ Malignant Disease of the Larynx,” in the * Lancet,’ 1894. It was 
Case 12 of his tables, and a full report of Mr. Shattock’s microscopic 
examination was given in it. The gradual blending of the growth 
with the cord in Dr. Powell’s case and its semi-transparent appear¬ 
ance much reminded him of that case. Of course the comparative 
youth of the patient seemed to militate against the idea of malig¬ 
nancy, but as he had himself seen undoubted malignant disease of the 
larynx in a patient set. 27, the present patient’s youth was no abso¬ 
lute proof to the contrary. If the case were his own, he certainly 
should at once remove by intra-laryngeal operation a good-sized piece 
of the growth near the anterior commissure, where it most projected, 
and should make his further proceedings depend upon the result of 
microscopic examination of the fragment removed. 



70 


Pseudo-membranous Adhesion in the Anterior Commissure 
and Symmetrical Thickening below the Anterior Part 
op the Vocal Cords (Congenital ?) in a Young Man. 

Shown by Sir Felix Semon. The case is shown as represent¬ 
ing the lowest degree of a tendency to formation of congenital 
webs between and below the vocal cords. The patient is a 
young gentleman aet. 27, who since birth had suffered from 
extreme weakness of voice, and who was sent to the observer by 
Dr. Clayton, of Hampstead, on the 13th January, 1900, on 
account of a red, granular, elongated, mobile growth, inserted 
on the free edge and on the lower surface of the left vocal 
cord, about the border of the anterior and the middle third. 
This growth practically covered the anterior part of the glottis. 
It was removed with forceps, and turned out to be a soft 
fibroma. After its removal, however, the voice remained weak, 
and it was then seen that the vocal cords were united some¬ 
what extensively at the anterior commissure by an intermediate, 
reddish, granulating mass, whilst from the anterior commissure 
two symmetrical thickenings extended almost the entire length 
of the vocal cords and below them, simulating, as it were, a 
reduplication of the vocal cords themselves. After removal of 
a small part of the reddish mass in the anterior commissure, 
which was found to be much softer than in previous cases seen 
by the observer of congenital adhesions in the anterior com¬ 
missure and between the vocal cords, the voice became perfectly 
normal. 

The President said he understood the condition was more pro¬ 
nounced prior to commencing treatment. 

Sir Felix Semon stated in reply to this question that the mass 
previous to operation was not much bigger than at the present time. 
The single pieces removed were so small that it was hardly worth 
submitting them to microscopic examination. He wished to add to 
his description of the case that, according to the explanation given by 
Roth, at the commencement of foetal development the two halves of 
the larynx were glued together by epithelial masses, which gradually 
cleared up from behind. In normal cases the whole epithelial mass 
disappeared, whilst' in cases of arrested development an adhesion 
remained, more or less developed, in the anterior part of the glottis, 
and thickest in the neighbourhood of, and below, the anterior com¬ 
missure. His patient had incidentally mentioned to him that his 



71 


father also had always had an extremely weak voice, and being 
mindful of Professor Seifert’s series of cases, in which the develop¬ 
mental arrest in question had been observed in four members of one 
and the same family, he had obtained permission to examine his 
patient’s father, but there was no evidence whatever of a similar 
arrested development. 


Case op Bulbous Middle Turbinates. 

Shown by Mr. Richard Lake. This patient has the so-called 
adenoid facies, but there is only a trace of adenoid growth. 
Her nose has gradually become broader, and her parents brought 
her to hospital on that account. 

The middle turbinates are both “ bulbous,” that on the left 
side being apparently the larger. 

In view of the fact that this condition is not a pathological 
one, I shall be glad to have the opinion of the members as to 
any course of treatment other than operative, or, I should say, 
than of excision. 


Case op G-rowth prom the Arytenoid Region in a Male 

AST. 56. 

Shown by Mr. R. Lake. The patient when he first came 
under my care six months ago complained chiefly of dysphagia 
and otalgia with excessive secretion of ropy mucus. There was, 
and there has been, no loss of voice, nor at any time any other 
symptom pointing to the larynx as being the seat of the disease. 
The patient gave a somewhat unintelligible history of the pain 
coming on suddenly after a meal. 

The ear had been considered the seat of the trouble, and he 
had been using sedative drops for some six months. 

The objective symptoms were as follows; the pharynx was 
red and swollen, and had the appearance of a gouty pharyngitis. 
The ear was devoid of any active lesion. The larynx was 
difficult to examine, but a whitish translucent growth was noticed 
under the tip of the left arytaenoid cartilage on its anterior 
surface. • 

The patient was put under treatment to reduce the irritability 



72 


of the pharynx; this was accomplished and the removal of the 
growth suggested. At this the patient demurred, and disap¬ 
peared for some time; he however returned, and I removed the 
growth, or rather the major part of it, with the forceps (shown at 
a previous meeting of this Society). There is still a small piece 
left on the outer side, which will also be removed. The subjec¬ 
tive symptoms have almost disappeared. 

The section under the microscope is one which I think will 
interest the members of this Society. The mucous membrane over 
the growth is much thinned, but does not seem to have any con¬ 
nection with it, and there is an absence of signs of activity in 
the surrounding tissues except just below the epithelium. The 
growth consists of large epithelioid cells, and the vessels run 
chiefly in the trabeculae. 


Specimen op Bony Spur prom Ethmoid. 

Shown by Mr. Richard Lake. This specimen is the bony end 
of a septal ridge; as will be seen, the whole thickening of the 
vomer was removed. The apex of the exostosis, as it practically 
is, was firmly adherent to the middle turbinate bone, and in 
breaking through this adhesion I drove the sharp end of the 
severed base through the septum. The result was a perforation 
of the septum, which is of no importance to the patient, who 
does not know of its existence. 


Case of Pharyngeal Growth involving the Larynx in a Man 

.®t. 59. 

Shown by Dr. Furniss Potter. T. R—, set. 59, came to the 
London Throat Hospital three weeks ago, complaining of diffi¬ 
culty in swallowing, which he had first noticed six months ago. 
He stated that three years previously he had had part of the 
lower jaw removed at the RadclifEe Infirmary, Oxford. On 
examination the left ascending ramus of the lower jaw had 
obviously been removed. There was a hard sloughy swelling 
iu the left faucial and tonsillar region, including the left half of 



73 


the palate, which extended down the side of the pharynx 
involving and almost completely obscuring the larynx. There 
was a hard swelling immediately below and in front of the 
mastoid process, and also what felt like a gland just above the 
great cornu of the hyoid on the left side. The patient had 
always been a healthy man, but had lost flesh lately; no history 
of syphilis. 

He had been taking potassium iodide for three weeks, and 
asserted that he could swallow more easily and “ had more room 
in his throat.” The glandular enlargement had subsided to a 
certain extent. 

Although Dr. Potter had little doubt in his own mind as to 
the diagnosis—malignant disease,—he had ventured to show the 
case, thinking it would be of interest, though perhaps more from 
a general surgical than a purely laryugological point of view. 

The President said, with regard to the treatment of such cases, 
he remembered a doubtful one, which was treated with fifteen-grain 
doses of iodide of potassium without any benefit; on increasing the 
dose to twenty grains the improvement was most marked. 

Dr. Furniss Potter, in reply to the President, said that the iodide 
had been given in ten-grain doses, increased to fifteen during the last 
week; a larger dose had not yet been given. In reference to the 
present condition, the patient had more room in his throat, and the 
glandular enlargement had subsided to a certain extent. 


Case of Advanced Atrophic Rhinitis in a Young Girl. 


Shown by Mr. L. A. Lawrence. E. P—, a girl set. 14, was 
shown for the purpose of adding one more to the number of 
young people having advanced atrophic rhinitis. In this case 
the patient to her knowledge had suffered for three years. 

The usual crusts were present along the whole of the upper 
respiratory tract. In addition, the uvula was markedly bi- 
lobed. 

Dr. StClair Thomson mentioned that, at the last meeting of the 
Society, Mr. Spencer had said that the bacteriology of the subject had 
not been sufficiently investigated. Curiously enough, that very after¬ 
noon Dr. Thomson had been reading a long and interesting paper on 
the subject, narrating the experiments of an Italian investigator on 



74 


thirty-two cases.* As a full translation might not appear, he thought 
a brief epitome might be interesting. A Dr. de Simoni had found 
that in the secretion of ozeena pathogenic germs were constantly met 
with—the diplococcus of Fraenkel, streptococci, and pyogenic staphy¬ 
lococci. Non-pathogenic germs, such as the capsule bacillus and the 
pseudo-diphtheria bacillus, were also met with. None of these have 
any etiological importance. They may be met with in nasal cavities 
with no trace of ozena. Pure cultures were made and introduced 
into the nostrils of healthy individuals without reproducing the 
morbid process. Even when inoculated on to the mucous membranes 
of healthy individuals in association, as they are met with in the 
ozenatous mucosa, they are incapable of producing the disease. The 
same can be said of non-pathogenic germs, to which the origin of 
ozena had been wrongly attributed. Dr. Thomson added that De 
Simoni’s experiments appear to have been carried out very carefully, 
and therefore tended to exclude the idea of the infective character of 
ozsena. 


Case of Suppurative Cyst of Turbinal Bone. 

Shown by Dr. Henry A. Davis. The patient, a woman set. 
40, complained of a lump in the nose of three months’ duration. 
On examination there appeared to be a large hypertrophy of the 
left inferior turbinal, which diminished slightly under cocaine. 
In spite of treatment, the swelling increased till almost complete 
nasal obstruction on the left side ensued. The swelling was 
red, dense, and painful. 

The mucous membrane was incised with a bistoury, and 
about two drachms of thick pus escaped. On passing a probe 
into the cavity, bone was felt in all directions. 

The patient refused further treatment, and beyond inserting 
a rubber tube into the cavity (which the patient herself learnt 
to do) and syringing with creolin lotion, nothing further was 
done till January, 1899, when the patient again applied for 
active treatment. 

She was taken into the hospital, and the inferior turbinal 
sawn off j the cyst was too large to extract through the nostril, 
and it was removed piecemeal with forceps, so the specimen was 
not obtained. 

The cavity was in the substance of the turbinate; it was filled 
with pus, and surrounded by a fine shell of bone. 

* ‘ II Policlinico/ 1899, vol. vi. 



75 


Since the operation a bead of pns is always visible external 
to the middle turbinate bone j and whether this originates from 
the antrum, ethmoid, or frontal sinus, it is difficult to ascertain. 
Transillumination does not show any inequality of the infra¬ 
orbital shadows, and, if anything, owing to the absence of the 
turbinate, the left cheek is more transparent than the right. 

Dr. Herbert Tilley said he had twice examined this case, but 
found he could not agree with Dr. Davis as to his view of the topo¬ 
graphy of the parts. The speaker said that the anterior half of the 
middle left turbinate had undoubtedly been removed, and the remain¬ 
ing portion of the bone was now plainly visible and could not be mis¬ 
taken for anything else. The inferior turbinate was seen below, but 
a considerable portion of this had been removed also. The granula¬ 
tion mass seen in the middle meatus he regarded as typical of sup¬ 
puration of the anterior ethmoidal cells, and he should attack this 
with Grunwald’s forceps until a healthier region was reached, and 
thus prevent other accessory sinuses becoming infected, if that had not 
already taken place. 

Mr. R. Lake had arrived at the same conclusion as Dr, Tilley, i. e. 
that it was the middle turbinal which had been removed, and not the 
inferior. 

Dr Dun das Grant said the pus might arise either from the an¬ 
terior ethmoidal cells or from the frontal sinus, and he thought it 
would be very difficult to exclude frontal sinus disease with the evi¬ 
dence at their disposal. There was a slight amount of tenderness 
over the left frontal sinus on percussion. One very characteristic 
sign of frontal sinus disease was that pus ran into the nose, chiefly 
after the patient moved about for some little while, as when on his 
way to business. This was a contrast to antral suppuration, in which 
the nose was usually full of pus on waking in the morning. As to 
the anatomical condition of the middle turbinal body, he should agree 
with Dr. Tilley’s description. 

Dr. William Hill had elicited from the patient some symptoms 
that would point to frontal sinus disease. She had a feeling of ful¬ 
ness at times, and the position of this struck him as suggestive of the 
implication of the fronto-ethmoidal cells. He thought the middle 
turbinal had been removed, and that the granular mass seen was 
much above the position of the bulla ethmoidalis, and probably sprang 
from the fronto-ethmoidal cells. 

Dr. Davis said that when the patient first came to hospital there 
was a swelling on the inferior turbinal body, as in Dr. StClair Thom¬ 
son’s case of the girl shown that day; the middle turbinal was jammed 
and pressed against the septum. The cyst was located on the inferior 
turbinal body, and he thought that what the members now saw was 
the stump of the inferior turbinal. Fourteen months had elapsed 
since the operation. The middle turbinal had been scraped, and a 
polypus had been removed from it. One could see the back of the 
pharynx on looking through the inferior meatus. 



76 


Mr. Baber agreed with Dr. Davis. On examination he had seen a 
dilated nasal cavity with apparently a small inferior turbinated body 
lying on the outer wall, which he supposed was the remains of the 
amputated inferior turbinated body; the middle turbinated body was 
thickened by disease, and pus was seen on its outer side. Treatment 
would consist in removing the anterior part of the middle turbinated 
body as much as possible, and then investigating the antrum, when 
possibly pus would be found in it. That course must be followed 
before doing anything to the frontal sinus. 


Case of Extreme Hypertrophy of Inferior Turbinals in a 

Boy. 

Shown by Dr. Henry A. Davis. The patient, a baker boy 
set. 13, has extreme hypertrophy of the turbinals on both sides. 
The hypertrophied tissues are soft and polypoid, and though 
they have been treated with cautery and snare, after a short 
time the hypertrophy is as large as ever. There is oedema of the 
root of the nose; no adenoids are present, and headache is con¬ 
stant. He is to have both turbinals removed anteriorly, and is 
brought before the Society simply as a case of interest. 

Dr. Herbert Tilley thought that such extreme hypertrophy of 
the inferior turbinals in a small boy was uncommon, and he suggested 
removal of the anterior extremities, which would give very great relief, 
whereas a galvano-cautery operation would be inefficient and not per¬ 
manent in its results, because the bone as well as mucous membrane 
was hypertrophied. 

Dr. Scanes Spicer had seen a similar extreme condition in a girl 
set. 13, at St. Mary’s Hospital that day; he had removed the hyper¬ 
trophied masses with a cold wire snare. 

Dr. Dundas Q-rant considered it might be difficult to introduce the 
scissors satisfactorily underneath the turbinal in this case, and under 
these circumstances he advocated the use of Bosworth’s saw, cutting 
from below upwards. This instrument he had used in a good many 
of these cases for the purpose of cutting through the lateral attach¬ 
ment of the anterior part of the inferior turbinated body. When this 
was done it was easy to cut through the detached peninsula by means 
of a snare. Secondary haemorrhage was never great, and coming from 
a spot so far forward in the nasal cavity, it could be easily checked by 
means of a pledget of gauze. In this respect it contrasted strongly 
with the “ spokeshaving ” operation. 

Mr. Baber said if there was no thickening at the back of the turbi¬ 
nated bodies, he should snare off all the hypertrophied tissue in front, 
and if that was not sufficient he should remove the anterior end of 
the inferior turbinated bodies with scissors and snare. As regards 
plugging, he did not think he had ever plugged the posterior nares 



77 


since he had been in practice. One ought to be able to find the posi¬ 
tion of the haemorrhage, and be able to stop it with long strips of 
gauze or lint introduced from the front. 

Dr. FitzGerald Powell asked if the galvano-cautery should not 
be given a trial in the treatment of hypertrophy of the turbinate 
bones before resorting to the more severe method of removal by the 
snares and spokeshaves. 

Dr. Davis said that on post-nasal examination there was no 
enlargement of the turbinal body, or adenoid vegetations, but some 
stenosis of the posterior pharynx. He had tried the galvano-cautery, 
and the growths had been completely snared off, but they always 
recurred. He had not applied any local treatment to the patient for 
a month. 


Case op Extensive Ulceration op the Throat for Diagnosis. 

Shown by Dr. Scanes Spicer. Patient was a man set. 19, with 
extensive, continuous, painless ulceration of the mucous mem¬ 
brane, reaching from the nasal septum over the sides and 
posterior wall of the naso-pharynx and pharynx down to the 
vocal cords, and involving the epiglottis, which was pale and 
seamed with antero-posterior cicatrices, and not ulcerating now. 
The ulcerating surface was dry and covered with a glazed 
pellicle. The ulceration was quite superficial, and the surface 
did not readily bleed. The soft palate was almost entirely gone, 
but there was no loss of bone in the hard palate. There was no 
neoplastic granulomatous raised infiltrated margin, and nothing 
like “ apple jelly ” spots ; and, except in the epiglottis, there 
was no cicatrisation going on. The condition had lasted five 
years, but what treatment had been adopted could not be ascer¬ 
tained. There were no other evidences of syphilis, congenital or 
acquired, nor of ordinary tuberculosis. The age and several 
observations led him to consider it a case of lupus, and by ex¬ 
clusion of syphilis, tuberculosis, and epithelioma, he was sup¬ 
ported in this view. 

The President said that twenty-five years ago the case would have 
undoubtedly been called a case of inherited syphilis ; but there were 
no signs of this either in the teeth or eyes or elsewhere, and no other 
syphilitic signs. His epiglottis had an appearance rather suggestive 
of lupus. Personally he would look on the case as of the chronic 
tuberculous lupoid type. 

Mr. R. Lake said this case reminded him of the class of patient 



78 


formerly described as “ syphilo-scrofula,” a disease in children with 
some syphilitic and “ scrofulous ” taint. 

Dr. StClair Thomson suggested testing of the case with the old 
tuberculin; it had not been used in these doubtful cases to the 
extent it might have been, as no harm could be done when the lungs 
were not affected; this was a matter for regret. 

Mr. Spencer thought the ulceration of the palate certainly looked 
like a syphilitic lesion, and he suggested that iodide of potassium 
and mercury might be given for some time; there did not seem to be 
any marks of tuberculous taint about the patient. 

Dr. Spicer thought there would be more destruction of tissue if 
this were syphilis, as the ulceration had been going on for five 
years. He could find also no other signs of syphilis, congenital or 
acquired. 

Sir Felix Semon entirely agreed with the President; the epiglottis 
was so characteristic of lupus that probably no one would hesitate 
to make that diagnosis were it not that the pharyngeal aspect was 
more doubtful. 

Dr. Lambert Lack thought that potassium iodide should be given 
if this had not already been done. 

Dr. Scanes Spicer said the boy was taking iodide of potassium 
in 5-grain doses since his first visit a week ago. He should be pleased 
to show the case again to the Society in three months’ time. 


Case op Hoarseness and Aphonia op Long Standing in a 

Girl jit. 13. 

Shown by Mr. de Santi. The hoarseness and whispering 
voice had been present from the time the child first began to 
talk. 

The larynx appeared normal, and there seemed to be nothing 
the matter with the nasal or pharyngeal regions. 

She had been treated with valerian and electricity, but with 
no benefit. 

He asked for suggestions as to treatment. 

The President said that the ventricular bands were thickened, 
and not as smooth and regular as in normal circumstances. 

Dr. Dundas Grant said there was evidence of chronic purulent 
rhinitis; had treatment been directed towards the nose ? 

Mr. R. Lake understood Mr. de Santi to say “ it was a rare case 
of a normal nose ” 

Mr. de Santi said treatment had not been directed to the nose. 
The patient had a brother, 22 years of age, in a somewhat similar 
condition, but there was some voice in his case. The mother was 
going to bring her son to see him (speaker). 

/ 



79 


Dr. Lambert Lace said in his opinion this was not a normal 
larynx, but a case of well-marked chronic laryngitis. 


Case op Obstructed Subdermal Lymphatics of the Face, in 

which Frontal and Antral Disease had been suspected. 

Shown by Mr. de Santi. The patient, a woman of 22, 
suffered from a curious affection of the subdermal lymphatics of 
both cheeks. 

The left eye was nearly closed through oedema of the upper 
and lower lids, and there was pufEness and oedema over both 
frontal sinuses. The case was really not one for the Laryngo- 
logical Society, but he showed it because it had been suggested 
that antral or frontal sinus mischief might be the cause of the 
trouble. 

It was, however, quite obvious this was not the case, and 
Mr. de Santi diagnosed the condition as “ blocked lymphatics.” 
As to its causation, the patient attributed it to mosquito bites in 
Holland and Paris some three months ago, and this might 
possibly be the cause. 

The treatment adopted was inunction with Ung. Belladonnas. 

Mr. Edwards remarked that this was not a laryngologies! case. 
He agreed with Mr. de Santi in the diagnosis. 


Case op Ulceration op the Larynx. 

Shown by Dr. Jobson Horne. The patient is a man set. 45, 
with symptoms of eighteen or nineteen months’ duration; at 
first weakness and uncertainty of voice at intervals, then hoarse¬ 
ness. For the last six or eight months he has been steadily 
getting worse, with at times complete aphonia. 

There is pain and oppression referred to the right side of the 
larynx, and a lump could be felt in this region for the past 
two or three months. 

There is some wasting. 

There is no history or evidence of tuberculosis in the lungs, 
and the examination of the sputum is negative. 



80 


Case of Tumour of Nasal Septum. 

Shown by Dr. Herbert Tilley. The patient, a female set. 62, 
had a dark red, broadly pedunculated tumour growing from the 
right side of the septum. Nasal obstruction and repeated 
nose bleedings drew her attention to this mass last September, 
when the growth nearly reached the external naris. 

It was removed by means of a snare, and profuse haemorrhage 
occurred some four hours afterwards, which was checked by 
plugging the nostril. 

The growth has since then recurred, and is now the size of a 
broad bean, and is of a purple-red colour and grows from the 
region of the tubercle of the septum. 

The President thought it was suggestive of sarcoma, owing to the 
large amount of bleeding and the age of the patient. He advised 
operative interference. 

Dr. StClair Thomson said the growth had the characters of a fibro- 
angeioma or bleeding polypus of the septum. He had shown a 
similar case himself, and had watched several others which had been 
shown to the Society; so that he ventured to think Dr. Tilley need 
not be alarmed at any haemorrhage which might take place, or at the 
recurrence. One of Dr. Thomson’s cases had recurred twice, and 
had been condemned as a sarcoma requiring free excision of the 
septum. The growth had simply been thoroughly snared, the base 
curetted and cauterised, and the patient was now alive and flourishing 
two years afterwards. Finally he would say “Put not too much 
faith in pathologists, but be guided by the clinical symptoms.” 

In reply Dr. Tilley said that Mr. Eobinson had suggested the 
malignant nature of the growth because the septum was bulged to¬ 
wards the side opposite the seat of the growth. He (the exhibitor) 
thought that this deviation was only part of a general deviation of 
the septum, and that the slow recurrence of the growth after its first 
removal six months ago was opposed to the view of malignancy. It 
seemed more of the nature of a fibro-angeioma; he purposed removing 
the recurrence in the course of a day or two, and microscopic sections 
of the tumour would be shown at the next meeting. 


Case of Pachydermia Laryngis. 

Shown by Mr. Charles A. Parker. This case occurred in a 
male aet. 45, who works in a forge. He came to the Throat 
Hospital a week ago on account of dyspnoea. He gave a history 



81 


of having had a bad attack of laryngitis three years previously, 
and frequent attacks of hoarseness since then. Three days 
before coming to the hospital he had apparently a most severe 
attack of dyspnoea. 

On examination there was found to be an exceptionally large 
pachydermatous mass occupying rather more than the posterior 
third of either cord, and superimposed upon this chronic con¬ 
dition there was an acute laryngitis, with a plentiful formation 
of crusts. He was admitted into hospital on account of the 
dyspnoea. The laryngitis is now much better, but the pachy¬ 
dermatous condition remains. 

The case seemed worth bringing before the Society on account 
of its being an unusually well marked example of pachydermia 
laryngis, and on account of the dyspnoea'which accompanied 
it. 


Dr. Dundas Grant considered it very suspicious of tubercular 
disease, and if it were under his care he should give a diagnosis 
accordingly. There was much infiltration of the tissues round about 
what was otherwise a typical pair of pachydermatous growths, and 
the patient himself asserted he had been wasting and felt very flabby. 
Very often a diagnosis of pachydermia laryngis proved to be incorrect 
on further development. 

Dr. Scanes Spicer did not see any evidence of tuberculosis in the 
larynx ; the ventricular bands were greatly enlarged, red, and promi¬ 
nent ; why was this ? He was not aware that this remarkable en¬ 
largement, confined to the ventricular bands, was any evidence of 
tuberculosis. The condition of the cords was pathognomonic of what 
has been called pachydermia. 

Mr. R. Lake was in accord with the opinion of Dr. Grant; he 
would like Mr. Parker to show the case again if possible. The patient 
had lost flesh in six months ; the masses of tissue were very red, 
more so than one would expect in a case of pachydermia laryngis, 
where they should be pale. 

Mr. Parker had not examined the larynx at the meeting, but he 
thought that all the surrounding thickness and redness might be 
accounted for by the laryngitis the man had a week ago. This 
swelling was subsiding. 




PROCEEDINGS 


OF THE 

LA.RYNGOLOGICAL SOCIETY OF LONDON. 


Fifty-seventh Ordinary Meeting, April 7th, 1900. 


F. de Havilland Hall, M.D., President, in the Chair. 


Lambert Lack, M.D., 
Ernest Waggett, M.B 


.} 


Secretaries. 


Present—36 members and 8 visitors. 


The minutes of the preceding meeting were read and con¬ 
firmed. 

The President referred with regret to the loss the Society had 
sustained in the death of Dr. McNeill Whistler, one of the 
original members. 

The following gentlemen were nominated for election at the 
next meeting of the Society: 

Chichele Nourse, F.E.C.S.Edin., Abchurch House, E.C. 

H. Skelding, M.B., B.C.Cantab, Bedford. 

The following cases and specimens were shown: 


Case of Laryngeal (?) Whistling. 

Shown by Sir Felix Semon. The patient, a boy set. 13£ years, 
who shows this physiological curiosity, was brought to the 
observer on account of a nervous cough. His father incidentally 
mentioned that the boy was able to produce a curious noise of a 

6 


FIRST SERIES-VOL. VII. 



84 


shrill whistling character with his mouth wide open. The 
Society will convince itself that this is so. The whistling sounds 
as if it were produced in the ordinary way, but as the boy can 
produce it whilst a laryngoscopic examination is being made, it 
is obvious that the origin of the sound must be in the larynx or 
even lower down. When he produces the sound it is seen that 
the epiglottis is forcibly drawn downwards, so that it is impossible 
to see the cords in their entire length. Enough, however, is 
seen of the posterior parts of the cords, and of the arytaenoid 
cartilages to show that the glottis is not closed in its entire 
length, but that the inner surfaces of the arytsenoids stand at 
least one and a half to two millimetres apart from one another 
whilst the whistling is produced. No abnormal movement of 
the chest can be perceived when the boy is stripped and then 
produces the sound. It is therefore very likely that the sound 
is actually produced in , the larynx, although it is difficult to 
understand how it can be with comparatively so widely open a 
glottis. 

The President thanked Sir Felix Semon for bringing this case 
before the notice of the Society. It was certainly a rare phenomenon. 
He wondered if any member had ever come across a similar case; he 
certainly had not himself. He thought they would all agree with Sir 
Felix Semon that the sound was produced in the larynx; he did not 
think there was any need for the mark of interrogation which was 
applied to the word “ laryngeal.” 

Dr. Fttrniss Potter said it would be interesting to know if the 
whistling would take place if the epiglottis were held up. It seemed 
to him that on expiration the epiglottis became doubled upon itself, 
and was drawn down upon the arytsenoid region. He wondered if it 
were possible that the whistling sound might be produced by the air 
passing through the chink formed by this drawing down of the 
epiglottis ? 

Mr. Spencer did not think the whistling was due to the position of 
the epiglottis; the whistle had still been heard under the conditions 
the previous speaker mentioned; besides, the epiglottis was not drawn 
down so far as Dr. Potter imagined. 

Mr. Waggett asked if Sir Felix Semon had obtained a view of the 
bifurcation of the trachea? Was it certain the boy had not some 
structure resembling the syrinx of a bird ? The notes produced had 
the characters of the birds’ notes. 

Dr. Bond mentioned that some twelve years ago he remembered a 
student at the Golden Square Hospital who could whistle with the 
top of his larynx. He had abnormal power over his throat muscles 
altogether; for instance, he could put the tongue behind the soft palate 
and swab out the naso-pharynx. It was easy to see the larynx during 



85 


whistling. The student simply used the sides of the brim of the 
larynx, i. e. the ary-epiglottic folds, in the same way that he used the 
lips when whistling with his mouth. The epiglottis had nothing to 
do with the production of the sound. He did not remember whether 
whistling with the larynx and the mouth at the same time could be 
performed. 

Sir Felix Semon, in reply, said that although he had seen a good 
way down the trachea he had not seen the bifurcation. He did not 
think that either the epiglottis or the aryteeno-epiglottidean folds had 
anything to do with the production of the sound. There could be no 
doubt that during its production the vocal cords remained a good deal 
apart. His own—although very theoretical—explanation was, that 
the boy probably had an unusual amount of control over the crico¬ 
thyroid muscles, and that it was owing to their forcible contraction, 
and to the unusual amount of tension of the vocal cords produced 
thereby, that when a forcible expiration was made the sound was 
produced. Mr. Waggett’s idea of the syrinx was very interesting, but 
he could not say whether it applied to the case. 


Case of Rhinoscleroma. 

Shown by Dr. Dundas Grant. A female set. 26, came under 
my observation on July 14th, 1898, on account of complete 
obstruction of both nostrils. The tip of the nose was found to 
be hard and swollen, and the nostrils were completely blocked 
by a reddish growth of almost fibrous consistency; there were 
fine symmetrical scales on the soft palate, and the uvula had 
completely disappeared. It was impossible to obtain a rhino- 
scopic view, but the finger introduced into the naso-pharynx 
enabled one to detect a firm dense bar extending horizontally 
across the lower margin of the posterior nares. A microscopic 
preparation of a portion of tissue removed was made by Mr. 
Wingrave, and Dr. St. George Reid made a cultivation which he 
considered showed the capsuled bacillus typical of rhinoscle¬ 
roma. 

The case disappeared for about a year, but about six weeks 
ago she returned with the nostril quite blocked, my previous 
treatment of scraping and dilating having had only a temporary 
effect. I managed to introduce a fine tangle-tent through the 
diminutive orifice, and then inserted a small pledget of cotton 
wool dipped in pure lactic acid. 



86 


The President said the case was similar to one shown by Sir Felix 
Semon and Dr. Payne at the Pathological Society a good many years 
ago; that was the last case of rhinoscleroma he had heard of in 
London. 

Dr. Watson Williams asked if the condition of the soft palate had 
been modified to any great extent by treatment ? 

Mr. W. G. Spencer asked if there had been any infection or any 
history of inoculation from any members of the family, or from any 
persons in the district where she lived with whom she had associated. 

Sir Felix Semon referred to the case which Dr. Payne and he had 
shown many years ago at the Pathological Society, and the illustra¬ 
tions of which in that Society’s ‘ Transactions ’ he handed round. In 
that case the changes were even more pronounced than in Dr. Grant’s 
case. Two hard, red, semi-globular tumours protruded from the 
nostrils, whilst the palate was in a condition similar to that seen in 
Dr. Grant’s case. The hardness of the tip of the nose in the present 
case was very characteristic. The result so far obtained by Dr. Grant 
by the application of lactic acid in one nostril was very satisfactory, 
but be was afraid that it would be as temporary as the one obtained 
by himself in his own case, by means of the galvano-cautery. In that 
instance directly the treatment ceased the disease returned. The 
patient had passed out of his hands into those of the late Sir Morell 
Mackenzie, who had published a note about the case in the ‘ British 
Medical Journal.’ He, too, had obtained no lasting results. 

Dr. StClair Thomson asked if the palate was characteristic of the 
disease. In the few cases he had seen in Vienna, the palate was never 
left so mobile as in this instance, though this was merely a question 
of degree; nor did the rhinoscleroma heal up so completely—it was 
more thickened and leathery. He also inquired if this case coincided 
with the pathological tests—bacteriological and histological—of rhino¬ 
scleroma. 

Dr. Dundas Grant, in reply to Dr. Watson Williams, said the 
palate was in exactly the same condition now as when the patient first 
came to see him ; nor was she conscious of ever having had particu¬ 
larly sore throats. He was unaware when the change took place. In 
reply to Mr. Spencer, he was not aware of any infection or inoculation. 
The patient had had iodide of potassium, but it made no difference to 
the condition. Cultures had been taken and answered exactly to the 
description of rhinoscleroma. They were totally dissimilar to those 
of leprosy. They showed diplo-bacilli, with extraordinarily large 
capsules. 


Specimen op Larynx removed on account op Sarcoma. 

Shown by Dr. Dundas Grant. A female, aet. 49, came under 
my care on 6th February, on account of loss of voice and difficulty 
in breathing, the former having gradually developed since the 
month of July, and the stridor since December. The stridor 



87 


seemed from its tone to arise somewhat deeper than the larynx ; 
it was purely expiratory in character, and was accompanied by 
excursion of the larynx. There was no pain on swallowing. 
On examination externally I found a well-marked bulging of or 
on the right ala of the thyroid cartilage, and the laryngoscope 
revealed a rounded sessile growth underneath the right vocal 
cord, the surface of which was fairly smooth ; the left vocal cord 
was immobile and almost completely hidden by the ventricular 
band, the left half of the vestibule being distinctly swollen. 
The diagnosis lying between malignant disease, probably epi¬ 
thelioma, and syphilis, inquiry elicited that she had had one 
miscarriage, then one stillborn child, then four boys, all strong 
and well, and afterwards one girl, who only lived for forty hours, 
and lastly the youngest child, now aged sixteen, and who is rather 
short in stature. I decided to give antisyphilitic remedies a 
trial, but in view of the possible danger of oedema of the larynx 
arising from iodide of potassium, I recommended her coming 
into the hospital, where for a fortnight she was treated with 
iodide of potassium and mercurial inunctions. Her dyspnoea 
seemed very slightly to improve, but practically things remained 
in statu quo , as when she moved about the disturbance in 
breathing was quite as bad as ever, and the voice became if 
anything weaker. My colleagues agreed with me that it was a 
case of malignant tissue, and with one exception, considered it 
a suitable one for extirpation of the larynx. My friend Dr, 
Lambert Lack kindly placed his experience, both in the 
diagnosis and operative treatment, at my disposal, and on the 
3rd March I removed the larynx, as you see. The patient is 
still in hospital; the opening into the pharynx is rapidly dimin¬ 
ishing in size, and I hope to bring her before the Society at a 
later date, and to give the clinical details with more complete¬ 
ness. Meanwhile the preparation shows the larynx opened 
from behind; the stump of the epiglottis is visible, as also the 
rounded growth under the right vocal cord, which was singularly 
conspicuous in the laryngoscopic image; the much larger growth 
underneath the left vocal cord somehow eluded inspection, 
probably because it was hidden by the infiltrated parts on the 
right side. The section under the microscope shows it to be a 
well-marked sarcoma, which, I presume, has grown from the 



88 


perichondrium on the inner surface of the thyroid cartilage. 
Had it started from the outer surface, I venture to believe that 
the external swelling would have attained much greater dimen¬ 
sions during the eight months that the disease has certainly 
existed. 

The President hoped Dr. Grant would show the patient later on. 


Case op a Girl with Hereditary Syphilis causing Hypertrophic 
Laryngitis, and showing Recesses in the Naso-pharynx 

PRODUCED BY THE APPROXIMATION OP THE REMAINS OP 

Luschka’s Tonsil and the Eustachian Cushions. 

Shown by Dr. StClair Thomson. After the various opinions 
enunciated at the last meeting apropos of Mr. C. Heath’s case. 
Dr. StClair Thomson feared there might have been a plethora 
of cases shown by members to illustrate their divergent views. 
He himself could easily have brought half a dozen cases from 
his clinic to demonstrate that what had been called “ sinuses in 
the vault of the naso-pharynx” were nothing but depressions 
produced as the title of his communication described. 

The case shown was selected for exhibition, as it also illus¬ 
trated the laryngitis which sometimes developed with hereditary 
syphilis. He had found that the hoarseness and loss of tone in 
the voice in these cases was apt to remain in spite of specific 
treatment, and he would be glad of suggestions on this point. 
The girl had been under inunctions of mercury for some time. 

Mr. Yearsley thought most members could bring cases forward 
showing the recesses formed by Luschka’s tonsil quite as well. One 
noticed them pretty frequently iu one’s clinic. 


Six Cases op Frontal Sinus Empyema. 

Dr. Herbert Tilley showed six cases of chronic frontal sinus 
empyema, upon five of which he had performed the external 
radical operation. Three cases were bilateral, and of these one 
had been operated upon on both sides; the others, as yet, on 
one side only. 



89 


In three of the cases, after freely removing the anterior wall, 
curetting away the diseased mucous membrane, and making a 
large opening into the nose, a Luc’s drainage-tube was inserted, 
and the external wound sutured at the close of the operation. 
In the remaining two the sinuses were packed with gauze 
instead of inserting the tube, a method which Dr. Tilley con¬ 
sidered far preferable to Luc’s operation. The exhibitor 
thought that the success of the operation depended upon careful 
attention to three main points : 

1. Removal of the anterior end of the middle turbinal and all 
chronic inflammatory products in the mid-meatal region before 
proceeding to the external operation. 

2. Making a free passage into the nose. 

3. Careful curetting of the diseased mucous membrane, 
followed by packing with gauze until a healthy lining of granu¬ 
lation tissue was produced. 

By making the incision in or immediately below the eyebrow 
the scar, as in the cases exhibited, was scarcely noticeable. The 
sixth case was interesting in that over the region of the left 
frontal sinus was an expansion of the outer wall of the sinus, 
resembling superficially a syphilitic boss the size of a five- 
shilling piece. The patient had complained of very severe 
headaches, accompanied by profuse discharge of pus from the 
nose, and the nostril was blocked by many large polypi. Since 
these had been removed the headache had entirely ceased, and 
it was easy to irrigate the sinus through the nose. 

[This case was operated upon the following day ; the left sinus 
was so large that a double thickness of iodoform gauze, two 
inches wide and three feet ten inches in length, was easily 
packed into the cavity.] 

Dr. Pegler asked if all these cases had been treated alike without 
drainage-tubing, and stuffed with gauze only ? 

Dr. Watson Williams asked how many of these cases were found 
to have the fronto-ethmoidal cells involved. The cosmetic, as well as 
the surgical results, were excellent in all, and surprisingly good in 
most of the cases. The series presented certainly reflected great credit 
on rhinology, and on Dr. Tilley in particular. 

Dr. Powell congratulated Dr. Tilley on the most excellent results 
obtained. With regard to the cases that went wrong, and the dangers 
that had occurred after the operation, he had always been of the 
opinion that it was possibly due to too much interference with the 



90 


posterior wall of the sinus. The posterior wall was generally scraped 
too much, and the interference gave rise to septic embolism and 
thrombosis. Perhaps Dr. Tilley would mention his views on this 
point. 

Mr. Waggett asked to what extent the lining of the sinus was 
removed, whether to the bone or not ? 

Dr. Dundas Grant asked whether in operating freely through the 
floor of the sinus there was not great liability to damage the trochlea 
and the superior oblique muscle ? 

Dr. Lambert Lack wished to know if he was correct in under¬ 
standing that Dr. Tilley did not open the sinus through the anterior 
wall. He thought there was almost if not quite as much danger in 
operating from the floor of the sinus as from the anterior wall. It 
was necessary to remove the anterior wall in a certain number of cases 
to obtain a proper view of the sinus; the danger resulted only in the 
cases in which proper drainage was not subsequently provided for. 
It was his (the speaker’s) general procedure to detach the pulley of 
the superior oblique, but this had never given rise to diplopia. 

Dr. Scanes Spicer asked if Dr. Tilley found he could explore every 
part of the sinus from the inferior wall ? 

Dr. Tilley, in reply, said that he always removed the anterior wall, 
but not the floor of the sinus, which was really the roof of the orbit, 
and which, he considered, it was wise to treat with a certain amount 
of respect. He thought it would be impossible to treat the sinus 
satisfactorily if the surgeon attempted to enter it from the floor, 
whereas removal of the anterior wall gave free access to the cavity. 
The cases had not all been similarly treated; in the earliest cases he 
had used a Luc’s tube and sewn up the external wound at the close of 
the operation, but he thought such a method was extremely risky. If 
suppuration recurred, the inflammatory products were pent up under 
tension, because the drainage-tube was very liable to become blocked 
or not to drain efficiently, and septic phlebitis of the diploeic veins bad 
occurred in at least seven recorded cases. This complication was 
almost certainly a fatal one, but it was an almost impossible one if 
packing or free drainage through the external wound and fronto-nasal 
canal was permitted. As to how much of the diseased mucous mem¬ 
brane was curetted away Dr. Herbert Tilley said he could not give a 
perfectly definite answer, he curetted until all granulation tissue and 
obviously diseased products were removed, but a certain thickness of 
lining membrane would be left. Temporary strabismus was not un¬ 
common after the operation, but passed off within a week or fortnight 
as a ruleit was due to disturbance of the pulley of the superior 
oblique muscle during the operation, and possibly to inflammatory 
exudation following the operation. In small sinuses, removal of the 
whole exterior wall produced an excellent result and obliteration of 
the cavity ; in larger sinuses, especially in females, the surgeon would 
be guided by the size and conformation of the cavity as to the amount 
of the anterior wall he would remove. 



91 


Case op Abnormal Pulsating Pharyngeal Vessel. 

Shown by Dr. Herbert Tilley. The patient is a girl set. 6 
years, suffering from enlarged tonsils aud adenoids, compli¬ 
cated by the presence behind the right posterior pharyngeal 
pillar of a large pulsating vessel, possibly an abnormal ascending 
pharyngeal artery. He desired the experience of members as 
to the advisability of operating upon the tonsils and growths. 

Mr. Spencer advised that the pharynx should be scraped. He saw 
no danger in the case; the c i rotid must be quite half an inch or so 
distant, and the pulsation was communicated. 

Mr. Bobinson thought it was as likely as not to be a large ascending 
pharyngeal artery; it was very difficult to say which it was. As far 
as operative measures were concerned, there was no need to fear any 
damage because of the position. 

Dr. Scanes Spicer thought that the adenoids in this case might be 
safely removed—by an experienced operator. He added this because 
he had heard of two operations in which the pharyngeal aponeurosis 
was cut through, one case ending fatally from multiple abscesses and 
septicaemia. 


Specimen op Nasal Angiosarcoma, shown at last meeting. 

Shown by Dr. Herbert Tilley. The specimen was prepared 
by Dr. Jobson Horne, who regarded it as an angiosarcoma. 


Case op (Esophageal Stricture under Tubage por Twelve 

Months. 

Mr. Charters Symonds showed a man of 63, who came to Guy's 
Hospital February 24th, 1899. The symptoms had existed for 
a year. The stricture admitted a No. 12, and was thirteen iuches 
from the teeth. A four-inch tube was inserted. This was 
removed April 21st, and left out. On April 24th he was 
admitted with complete obstruction. A long tube was passed 
and withdrawn May 1st, when a short tube was inserted. May 
28th the tube was removed and another (No. 13) introduced. 
Since then this tube has remained in position, a period of eight 
months, and is still useful. The man hqs maintained his weight. 



92 


can attend to his business, and has no discomfort. He takes 
finely minced meat besides fluids and eggs. 

The points of interest are, the long duration—two years—of a 
stricture apparently malignant in this situation; the possibility 
that the case is one of sarcoma ; the complete relief afforded by 
the tube; and the durability of the silk and tube. It may be 
added that the silk in the mouth is protected as usual by a piece 
of rubber tubing. 

The President commented on the excellent condition which the 
man presented—he looked the picture of health. He congratulated 
Mr. Symonds on the success of the case. 


Case of Extensive Necrosis following Nasal Polypi and 

Sinus Disease. 

Mr. Spencer exhibited a woman about 40, who, previously to 
being seen by him, had for many years suffered from polypi in 
the nose, and suppuration in the maxillary antrum and ethmoidal 
and frontal sinuses. Extension had taken place by the nasal 
duct, causing purulent conjunctivitis, which had left a central 
corneal opacity. The maxillary antrum and the interior of the 
nose had been actively treated; also the front wall of the frontal 
sinus, including the upper margin of the orbit, had been removed. 
But there remained a long sinus extending backwards to beyond 
the anterior sphenoidal fissui’e, where dead bone was to be felt. 
Attempts to scrape away the dead bone in this position had been 
attended by profuse haemorrhage, aud it seemed only too 
probable that the necrosis would continue. 


Case of Malignant Disease of Pharynx and Larynx. 

Shown by Mr. Macleod Yearsley. The patient, a woman 
get. 59, had been suffering from “ sore throat ” for some two and 
a half years. Recently she had been getting worse and had 
considerable dysphagia. On laryngoscopic examination the 
disease was found to involve the lower and posterior part of the 
left tonsil, the base of the tongue, and the upper orifice of the 
larynx. There was no specific history, but the case had been 



93 


placed upon antisyphilitic treatment. The patient denied that 
she had been under any treatment but that of her private 
doctor, but since her arrival at the meeting she had informed 
Mr. Yearsley that she had already been shown to the Society 
by Mr. Waggett. 


Case of Tonsillar Ulceration of Uncertain Origin. 

Shown by Dr. Dundas Grant. A female, set. 39, came under 
my observation on the 22nd March, 1900, complaining of sore 
throat and deafness. The former commenced five weeks before 
with considerable suddenness, with pain on the left side of the 
throat, extending to the left side of the head, face, and the left 
ear. Her voice was extremely thick, and she complained of a 
tickling in the throat giving rise to cough and sickness; the 
pain in the throat was most marked during the swallowing of 
solids. On examination there was a considerable irregular 
swelling of the left tonsil, and round its outlines was an irregular 
sinuous, somewhat rough margin of an opalescent tinge tending 
to white; on the left tonsil there were irregular opalescent 
patches with slightly raised edges. On palpation the left tonsil 
was felt to be extremely hard. At the commencement she 
stated that there was a considerable enlargement of the glands 
at the left angle of the lower jaw, which lasted for about three 
weeks; just before she presented herself her voice became 
extremely hoarse, and the right side of the throat became 
painfully swollen. Her hair was falling to a notable extent for 
about a week before the throat manifestation, and continued to 
do so until mercurial preparations were administered. In 
November she was nursing what was described as a “ premature 
baby,” born at six months, and which only lived a fortnight; 
the child was much wasted, and suffered from erythema of the 
nates. 

The physical aspect of the case suggested secondary specific 
affection of the mucous membrane, but the induration of the left 
tonsil had some of the characters of malignant disease. A 
provisional diagnosis was made, therefore, of primary infection 
of the left tonsil with secondary mucous patches of both. Mer¬ 
curial pill with opium was ordered, and at the end of a week the 



94 


patient announced herself as considerably better, although 
inspection of the fauces revealed little change. 


Case in which there was Difficulty in removing a 
Tracheotomy Tube. 

Shown by Mr. Roughton. The patient was a girl set. 5 years, 
upon whom tracheotomy had been performed four months 
previously. There was now complete laryngeal obstruction, and 
the tube could not be dispensed with. He asked for suggestions 
as to treatment. 

The President referred Mr. Roughton to a paper read before the 
Medical Society of London by Mr. Bernard Pitts, some four or five 
years ago,* which dealt with intubation. It struck him at the time 
as giving servicable methods for treatment. 

Dr. Dundas Grant said he had just operated on such a case; the 
patient was a little girl of about four. He tried to introduce an 
intubation tube, but it stuck absolutely. He then dissected down on 
the trachea, and worked upwards till he reached what was thought to 
be the level of the cricoid cartilage, where there was a narrow struc¬ 
ture, through which it had been impossible to pass a bougie of 
greater size than No. 3. He then introduced the intubation tube 
through the larynx and stitched up the whole wound. This was 
done on a Tuesday, and on the Friday following she was breathing 
through the tube, but there was great difficulty in taking it out—on 
doing so, dyspnoea returned, so he again restored the tube, and was 
now awaiting further developments. 

Dr. Davis said that obstructions occurred in the great majority of 
cases if adenoids were present. The child, judging from the enlarged 
glands, had big tonsils and so presumably adenoids. Adenoids should 
always be removed in every instance. Where this had been done he 
found that the tube could be taken out with ease. 

Dr. Lambert Lack had shown a case to the Society at a previous 
meeting, in which intubation had been tried for a long time, and it 
worried the child’s life out. The child could not swallow well with 
the tube in position, and therefore it had to be frequently removed and 
replaced. It was impossible to dilate any fibrous stricture unless the 
dilating instrument was kept in place for a long time. A tube or plug 
passing from the tracheotomy wound upwards into the larynx, or the 
T-shaped tube, was much more comfortable, and could be worn con¬ 
tinuously. One case of laryngeal stricture after diphtheria was com¬ 
pletely cured by this means. A solid plug was better than a tube, as 
it was easier to remove, and did not collect mucus. 

Mr. Spencer thought an intubation tube a source of trouble. It 
was necessary to remove the fibrous tissue and granulations. He 

* The date of paper was December, 1890, 



95 


would then insert a T-shaped cannula, made in two pieces for con¬ 
venience of removal. The tube leading outwards could be blocked at 
will, so as to re-accustom the child to breathing through the larynx. 


Laryngeal Case for Diagnosis. 

Dr. Scanes Spicer showed a lad who had two months ago 
exhibited a distinct, small, sessile papilloma about the centre of 
the left cord, associated with multiple papillomata on the hands, 
arms, and body. The application of a spray of salicylic acid in 
alcohol ( 33 s to 3 j) had been followed by the complete disap¬ 
pearance of the wart on the cord, but the hoarseness was not 
better, and on examination the ventricular bands were seen to 
be in a rough, reddened state; a thickened mass was seen on the 
inter-arytaenoid part of the posterior wall, and the right cord did 
not move freely. As these latter appearances were not present 
two months ago, the question arose as to whether they were due 
to extension of the papillomatous growth, or were tubercular, or 
if they resulted from the irritation of the salicylic application. 
This had only been used three or four times, and had been dis¬ 
continued for six weeks. He asked if other members had seen 
any similar results from application of salicylic acid in this 
region. 

The President suggested that possibly the salicylic acid spray was 
responsible for the condition seen; the boy was suffering from hoarse¬ 
ness, and had small papillomata in the larynx. Certainly these when 
irritated might bring about such a chronic inflammatory condition. 
He advised leaving off the local treatment for the present, and in view 
of the warty growths on the hands, giving some arsenic, which had a 
wonderful power of clearing up warts on the skin ; the larynx might 
be benefited by this treatment. 

Mr. Spencer remarked upon the enlarged glands in the neck, 
especially the laryngeal. The sputa should be examined in view of 
possible tuberculous disease. 




PROCEEDINGS 


OF THE 

LARYNGOLOGICAL SOCIETY OF LONDON. 


Fifty-eighth Ordinary Meeting, May 5th, 1900. 


Sir Felix Semon in the Chair. 


Lambert Lack, M.D., 
Ernest Waggett, M.B 


.} 


Secretaries. 


Present—32 members and 5 visitors. 


The minutes of the preceding meeting were read and con¬ 
firmed. 

The following gentlemen were unanimously elected members 
of the Society: 

H. Skelding, M.B., B.C. Cantab., Bedford. 

Chichele Nourse, F.R.C.S.Ed., London. 

The following cases and specimens were shown: 


A Specimen op Acute (Edema op the Larynx. 

Shown by Dr. Logan Turner. The larynx had been removed 
from a man aet. 34, who died suddenly from asphyxia before 
surgical assistance could be obtained. He had suffered for some 
months from hoarseness, but had never had any respiratory 
difficulty, and had continued working as a stonemason until two 
days before his death. He then appeared to be in fairly good 
health and spirits. During the night before his death he had 
FIRST SERIES — VOL. VII. 7 



98 


experienced some slight difficulty in breathing, but on the 
following morning had expressed himself as feeling quite able to 
go out. After breakfast, however, he suddenly developed 
dyspnoea, and died within half an hour. 

Post-mortem examination showed the internal organs healthy 
with the exception of the lungs, which were tubercular. In the 
larynx the glottic chink was invisible, owing to marked 
oedematous swelling of the ary-epiglottic folds, arytsenoid region, 
and ventricular bands. The epiglottis preserved its normal 
contour, being free from oedema. Further examination of the 
larynx revealed almost complete destruction of the left vocal 
cord, and some superficial ulceration of the right, while an ulcer 
of considerable size and depth occupied the inner and upper 
aspect of the left ventricular band. The case is of special 
interest as a demonstration of a possible sudden fatal complica¬ 
tion in the course of laryngeal tuberculosis, without any previous 
symptoms of difficult respiration. 

Sir Felix Semon said that a genuine oedema of the larynx very 
rarely supervened in cases of tuberculosis. In this case the nature of 
the oedematous infiltration was quite different from the ordinary 
pseudo-cedematous infiltration of laryngeal tuberculosis. He was not 
aware that such a case had ever been described. Perhaps other mem¬ 
bers had seen similar cases ? 

Mr. Waggett had seen a case of sudden death from asphyxia 
occurring in the course of tubercular laryngitis, in the case of a woman 
suffering from myxoedema. 

Dr. Herbert Tilley cited the case of a young girl who was under 
treatment for tubercular laryngitis, in which difficulty of breathing 
was a prominent symptom. She died suddenly of asphyxia before 
surgical aid could be procured. 

Dr. Watson Williams could recall two cases in which there had 
been considerable localised true oedema of the larynx in the course of 
laryngeal tuberculosis ; but it was never so extensive in either case as 
to cause a fatal result. 

Dr. Turner (in reply) was glad to hear the remarks which had been 
made, because he had looked into the literature of the subject for the 
past twelve years, and had come to the conclusion that the case was 
very uncommon. 


Case of Tracheal Stenosis. 


Shown by Mr. Stephen Paget for Dr. Pasteur. A young 
man, 19 years of age, had enlargement of the thyroid gland of 



99 


three years’ duration, and stenosis of the trachea, which was 
narrowed from side to side. The patient had been admitted to 
the Middlesex Hospital in October of last year, with severe 
dyspnoea. Mr. Paget suggested that the narrowing of the 
trachea might be due, not to the enlargement of the thyroid 
gland, but to some congenital malformation. 

Dr. Dundas Grant considered this a typical case of “ scabbard¬ 
shaped ” narrowing of the trachea, due to pressure exerted on it by the 
enlarged thyroid. 

Dr. Watson Williams considered that the tracheal stenosis was 
not a congenital stricture, but was directly connected with the enlarged 
thyroid gland, and that the unusually narrow appearance of the 
tracheal rings must be due to foreshortening. He recently had a 
similar case under his care, in which there was a peculiar oblique 
scabbard-shaped stenosis of the trachea. 

Dr. FitzGerald Powell said that lately he had under his care 
a boy of 16 years of age, who suffered from considerable interference 
with his breathing, due to pressure upon his trachea by an enlarged 
thyroid. On removing the isthmus and right half of the gland, which 
were found to be the seat of cystic degeneration, the trachea was seen 
to be in exactly the same condition as in the case under discussion, %. e. 
scabbard-shaped. Complete relief to the breathing was obtained after 
removal of the diseased gland. 

Dr. Bronner had seen three cases in which the pressure on the 
trachea had been of a different kind from the cases quoted ; it had been 
caused by fibrous bands, which crossed from one side to the other. A 
very small thyroid with the presence of such bands could produce 
tracheal stenosis. These three cases were associated with small 
thyroids, and operation was necessary to relieve the difficulty of 
breathing. 

Mr. Paget said that, in view of the opinions expressed, he withdrew 
his suggestion that the narrowing of the trachea was due to congenital 
malformation. He would watch the case, and would report on it again 
at some later meeting of the Society. 


New Instruments for the Treatment of Antral Empyema. 

Shown by Mr. Acland (introduced by Dr. Watson Williams). 
Through the kindness of my colleague, Dr. Watson Williams, I 
am enabled to bring before you to-day some instruments which 
I have devised for the treatment of antral empyema. 

I generally choose to perforate through the alveolar ridge, 
and these instruments are intended for use in this method. 

No. 1. The borer is of special size and shape. It cuts the bone 



100 


of the alveolus very readily when rotated forwards (i. e. from 
left to right—like a screw), by reason of the fluting or grooving 
of its edges. 

No. 2. The measurer may be used to ascertain the depth of the 
bone traversed before the antral floor is reached. So that if 
necessary the tube (No. 4) may be cut. 

No. 3. The tube carrier is a modified screw-driver, on which 
the antral tube (No. 4) fits, and by which the tube is screwed 
into the hole made by the perforator. 

No. 4. The antral tube is a silver-gilt tube which is intended 
to be screwed into the perforation. It has a screw-thread on its 
outside, and a slot on its flanged end like a screw-head. In fact 
it is a hollow screw, which fits on the carrier. No. 3, like a cannula 
on a trocar. This tube is intended to be worn by the patient 
during the whole time of treatment, and is provided with a 
split-pin stopper to keep the food out. The length as supplied 
is found to be satisfactory for most cases, but in young subjects 
it may be necessary (after measurement by No. 2) to shorten it 
with a fine fret saw. 

No. 5. The two-way nozzle exactly fits the antral tube, and, 
having a longitudinal septum in it, provides an inlet and exit 
for the fluids used in washing the antrum. 

The inlet branch has a modified Higginson syringe attached 
to it, and the exit branch a piece of rubber tubing which conveys 
the fluid to a receiver. My colleague, Dr. Watson Williams, 
and I, have each done several cases with this apparatus, and 
find it very successful. 

I may mention that I have found it possible to extract a 
diseased tooth or root, bore the hole and insert the tube under 
one dose of gas. 

I have brought with me one of our Bristol students, on whom 
I had to operate for antral disease, and I propose to demonstrate, 
with his aid, the advantages of this apparatus in free flushing of 
the cavity. 

The President was sure that the Society was much obliged to Mr. 
Acland for the interesting demonstration he had given, and also for 
his kindness in coming such a distance to show his very ingenious 
apparatus to them. 

Dr. Watson Williams said that he knew from actual practice that 



101 


the apparatus worked as well as it gave promise of doing in the 
demonstration. He mentioned a case—the second in which this 
apparatus had been used; the patient, a child of twelve years of age, 
had suffered from antral empyema for some years, and the apparatus 
worked so completely and so satisfactorily, that after a week or two 
there was no discharge of pus whatever. He had accidentally dis¬ 
covered a method by which the tube might be removed. Feeling that 
the tube projected too far upwards into the antrum of this patient, he 
had it shortened and reinserted; it answered very well for a time, but 
naturally, since it did not project into the antrum, the hole had almost 
closed over the tube. By allowing the top of the canal to close over, 
it would be very easy to remove the tube from the lower half and let 
it fill up. There was no reason to believe the apparatus was difficult 
to work. He had seen Mr. Acland on many occasions remove a tooth, 
enter the antrum, put in the tube and stopper during a single “ gas ” 
anaesthesia, and he had never seemed to have any hitch or trouble in 
completing the operation before the patient recovered consciousness. 
For all cases in which alveolar drainage was suitable, Mr. Acland’s 
apparatus appeared to be most simple, comfortable, and effectual. 

Dr. Dundas Grant thought that if a tube of this sort was inserted 
for permanent retention in the treatment of empyema of the antrum, 
it was essential that the tube should be as perfect a one as it was 
possible to get, otherwise the patient was better without one at all. A 
good many cases did well without the retention of any such tube, 
simply having a wire fitting into the hole, and a syringe having to 
make its way through each time. At the same time he had seen great 
improvement take place in very obstinate cases of antral empyema, 
where a permanent tube was employed, although the tube was very 
far from being nearly perfect. He thought the spiral wire drainage- 
tube, which was left open all the time, very undesirable; for it did not 
prevent the entrance of material from the mouth, and it acted as a 
cause of irritation. As far as he was able to judge from the demon¬ 
stration, he certainly thought Mr. Acland’s apparatus was a valuable 
step in the right direction. 

Dr. FitzGerald Powell thought the method of entering the 
antrum of Highmore through the tooth socket for the cure of em¬ 
pyema had a great deal to be said in its favour. It was necessary to 
have a good-sized opening to allow of free drainage, and to curette 
the antrum. He was afraid the drills or perforators and tube shown 
by Mr. Acland were too small to admit of this. He had had drills 
made which he had used with some success—they were the size of No. 
12 to 14 silver catheters,—and had used silver wire tubes a size smaller, 
through which the cavity could be well flushed, and which allowed fair 
drainage. This method had answered well even in chronic cases, and 
in one case of three years’ standing he got a complete cure. In this 
case he had had gold tubes, the size of No. 11 catheter, fixed in by a 
plate attached to teeth on both sides, it being a double empyema. 
Experience had taught him that the cavity should be curetted, and 
the tube should extend a good way into the antrum to prevent its being 
blocked by granulations. Both the tubes for drainage and the per¬ 
forators were much larger than Mr. Acland’s. 



102 


Mr. Ac land was gratified by the various favourable remarks which 
had been made by the members of the Society about his little dodge 
for the treatment of antral empyema. 


A New Universal Laryngeal Forceps. 

Shown by Dr. Watson Williams. The essential feature of 
the instrument was the immobility of one blade, which could be 
placed in position and kept fixed in contact with the growth or 
foreign body to be removed, while the other blade was opposed 
by means of the thumb alone, the forceps being held by the 
fingers. Moreover the blades could be readily converted from 
the antero-posterior to the lateral or up and down action, or again 
a snare could be fitted to it. 


Inflammation of Crypts in the Mucous Membrane covering 
a defined recess in the roof of the Naso-pharynx, 

GIVING RISE TO OTALGIA AND OTHER SYMPTOM8. 

Shown by Dr. Jobson Horne. The patient, a man set. 25, for 
three or four months previous to his coming under treatment 
had experienced pain in the left ear, likened to “ a gathering/’ 
and his hearing had become impaired. 

Clinically nothing was found in the ear itself, or in the mouth 
or fauces, to account for the pain. By means of posterior rhino¬ 
scopy, however, small circular, sharply punched out crypts or 
depressions, not larger than the bore of a No. 1 vulcanite Eusta¬ 
chian catheter, were detected in the outermost pai't of the roof 
of the naso-pharynx, directly above the cushion of the Eusta¬ 
chian orifice and the arch of the posterior naris ; one on the left 
side contained pus, and the edges were inflamed and gave the 
appearances of an ulcer. 

Dr. Horne also showed some anatomical preparations of the 
region mentioned, in order to demonstrate the area he wished 
to define. This may be described as a secondary dome in the 
roof, immediately above the outer part of the arch of the 
posterior naris and the cushion of the Eustachian orifice, and 



103 


enclosed in an arc drawn from the extreme base of the vomer to 
the summit of Rosenmuller’s fossa. The mucous membrane 
covering this dome or recess has at times, and more often in 
elderly and thin subjects, a cribriform appearance, occasioned 
by the mucous membrane being carried in between the sepa¬ 
rated and superjacent fibres. Purulent matter may readily find 
its way into one of these crypts and set up a localised inflam¬ 
mation, and occasion the symptoms in illustration of which the 
case was shown. 

Under treatment the symptoms had completely disappeared, 
and the hearing was restored to normal, so that the ulcerated ap¬ 
pearance was no longer visible; but the crypts which contained 
the pus could be readily seen. The treatment had consisted of 
nasal douching, and a mixture containing quinine and iodide of 
potassium ; but there was no evidence suggesting lues. 

Dr. StCijAir Thomson thought that Dr. Horne had withdrawn the 
term ulceration entirely. There was no ulceration at the present time, 
although some of the members were still of that opinion. The case 
was very interesting as being a pendant to the case he (the speaker) 
had shown at the previous meeting, and to that shown by Mr. Chas. 
Heath at the March meeting of the Society. Mr. Heath had called 
attention to so-called “ sinuses ” in the naso-pharynx. What was 
visible in the present case was the remains of Lusclika’s tonsil, with 
adhesions which crossed to the Eustachian tube and intervening 
lacunae If the remains of adenoid tissue were thoroughly removed 
with the curette, in all probability all the symptoms would disappear. 
He ventured to suggest that some of the changes in the anatomical 
specimen were post-mortem ones. The specimens showed the lacunae 
he referred to. 

Dr. Jobson Horne thought that the anatomical specimens which 
he had shown went to prove that Dr. Thomson’s theory was not alto¬ 
gether tenable. 


A Specimen of a Curtain Ring removed from the Pharynx 

of a Child. 

Shown by Dr. Lambert Lack. The ring was an ordinary 
brass curtain ring, about one and a half inches in diameter, and 
about the thickness of a small Eustachian catheter. The upper 
part of it was free in the post-nasal space, the lower part free in 
the lower pharynx behind the ary taenoids, the sides being firmly 



104 


embedded beneath the mucous membrane of the lateral walls of 
the pharynx. Under chloroform the upper part of the ring was 
forcibly pulled forwards from behind the soft palate, and the 
lower part then with some difficulty cut through with bone 
forceps. This latter part was opened out by the fingers, and 
the ring extracted easily by pulling upwards. The history was, 
that the child, who is now nine years old, swallowed the ring at 
nine months of age. There was much choking, etc., at the time, 
and the child was taken to a hospital, where, after examination, 
the mother was told there was nothing wrong. The symptoms 
had gradually passed off, and the child had enjoyed fair health, 
being brought to the hospital recently on account of adenoids. 


Two Cases of Nasal Polypi treated by a new Radical Method, 
with Microscopic Sections of the Bone removed. 

Shown by Dr. Lambert Lack. The first case was a female 
aet. 25, who had suffered from purulent nasal discharge and 
polypi on the left side for three or four months. The polypi 
had been twice removed with the snare, but without much 
improvement. On examination, several large polypi with pus 
exuding between them were seen in the left middle meatus. 
Under gas this region was thoroughly and firmly scraped with 
a large ring knife (Meyer’s adenoid curette), and many polypi 
and loose bits of bone were removed. A large cavity was 
excavated in the lateral mass of the ethmoid. The patient made 
an uneventful recovery, the nasal obstruction was completely 
removed, and the purulent discharge ceased. In about a month 
a large dry cavity could be seen in the upper part of the middle 
meatus, and there has been no return of the disease and no other 
treatment. The operation was performed eighteen months ago. 

The second case was that of a man who had suffered from 
polypi in both nostrils for many years, and had undergone 
numerous operations with only temporary benefit. Although 
the polypi had been recently removed, very large masses of 
polypoid tissue, large fragments of bone, and degenerated 
mucous membrane were scraped away uuder general anaesthesia 
from both nostrils. As far as could be judged almost the entire 



105 


ethmoid, with the exception of the cribriform plate and lamina 
papyracea, were removed. The operation was performed only 
six days ago; the patient has recovered well, and states that he 
has lost the constant headache and sense of fulness at the top of 
the nose from which he had previously suffered, and feels 
“ clearer” than ever he did. 

The microscopic sections show extensive changes in the bone 
removed. These are of the nature of a rarefying osteitis. The 
periosteum is much thickened, especially in its deeper layer, 
which consists of rows of large nucleated cells. The surface of 
the bone is ragged from the formation of numerous little bays, 
which are filled with very large, often multinucleated cells. 
The bone cells are larger and more numerous than normal, 
especially where the bone is invaded. In places the changes 
have advanced so far that the bone is entirely broken up into 
fragments, surrounded by osteoclasts, and evidently undergoing 
absorption. 


Mr. Waggett wished to avoid on this occasion entering upon the 
vexed question of the primary lesion in cases of nasal polypus. It 
was, however, desirable to insist upon the well-recognised fact that in 
advanced cases the bony structures were in a state of rarefying osteitis, 
and often so far deprived of their lime salts as to be flexible and semi¬ 
transparent. 

Mr. Parker supported Dr. Lack’s operation in these cases. He had 
watched many of his (Dr. Lack’s) cases carefully during the last two 
or three years at the Throat Hospital, Golden Square, and he had 
himself been doing the same operation with results very much better 
than any other method of treatment would have given as far as he 
could see. He was now coming to the conclusion that cases of 
multiple polypi with suppuration had much better be treated in this 
way ; under the more conservative methods of treatment the polypi 
had to be removed time after time, which constituted a frequent 
nuisance to the patient, the suppuration continued, the polypi recurred, 
and finally one had no other course but to proceed to a more radical 
operation in a large number of cases. The method of the operation 
as performed by Dr. Lack seemed fairly free from danger. Dr. Lack 
recommended the biggest ring knife of Meyer in the first instance, 
and after that the small ring knife to finish up with ; thus performed 
the operation did not seem likely to give rise to much danger by 
encroachment on the dangerous regions. The great point was to make 
quite sure of removing all the crumbling and diseased portions of the 
ethmoid bone, and to get rid of the degenerating mucous membrane; 
if that were done, the results, as far as he had observed in his own 
cases and those of Dr. Lack, had been very good indeed. 



106 


Dr. Scanes Spicer also supported very strongly Dr. Lack’s pro¬ 
cedure in suitable cases. He had done it for years himself with 
similar good results, and congratulated Dr. Lack on the prolonged 
immunity from recurrence. He thought, however, the disease was 
not quite eradicated here; there were two or three small “ buds ” on 
the left middle turbinal, and the anterior portion of the opposite 
middle turbinal body appeared to be undergoing polypoid degeneration. 
In spite of this the results were very satisfactory, because there was 
no substantial recurrence for eighteen months, which would have taken 
place if the extensive polypoid degeneration of the middle turbinate 
body had been treated by simple snaring of individual polypi. 

Dr. Dtjndas Grant thought it would be a pity if the radical opera¬ 
tion such as described by Dr. Lack—excellent as it was in suitable 
cases—should be looked upon as the routine treatment of multiple 
polypi. If this turned out to be the case, it would be a decidedly 
retrograde step in rhinology. They had advanced a great deal in 
delicate intra-nasal manipulations, and therefore they should all the 
more be very jealous of any principle or method of procedure which 
tended to interfere with progress in that respect. He had seen many 
cases in which the persevering removal of polypi as they recurred re¬ 
sulted in a complete cure; first of all there was a longer and longer 
interval between the recurrences, and then finally complete cure. It 
was sometimes necessary to remove the anterior half of the middle 
turbinal body, which was done secundum artem with very much less 
laceration than would be produced by the ring knife. He would urge 
a strong plea for the thorough trial of the more delicate manipulatory 
treatment before such radical measures were adopted. He had not 
the slightest doubt that there were cases in which nothing short of 
the operation described by Dr. Lack was of any use, but from his 
experience, their frequency was of the slightest possible. Cases of his 
own might have “ strayed ” from his observation and care, and got 
into the hands of more radical operators, but he must say for the 
present he saw very great reason for persevering with the more con¬ 
servative treatment. 

Dr. Permewan did not think the discussion would be complete 
without the remarks of Dr. Grant. He, personally, was bound to say 
he was entirely in accord with the words of the last speaker. It seemed 
to him that there were two great objections to making this method of 
operation anything like the routine treatment. First of all, there was 
the great risk incurred; and secondly, the fact that you can never be 
quite sure of having removed the whole of the disease. It was true a 
previous speaker had insisted on the careful removal of the whole of 
the crumbling bone, together with the disintegrating mucous mem¬ 
brane, but he did not see how you could be sure of having taken it all 
away; consequently one great argument in favour of this treatment 
disappeared. The risk of it must be more or less considerable. He 
should think that any violent interference with the ethmoid bone 
might produce injury elsewhere than at the spot at which you wished 
or intended. In supporting Dr. Grant, he would say that he believed 
in the majority of cases that nasal polypi, subjected to a carefully 
protracted and repeated treatment, would in the long run be practi- 


/ 



107 


cally cured, if you could induce the patients to come back often enough 
to have them treated; he hesitated to use the word “cured” without 
an epithet, in face of the results of Dr. Lack’s operation. There was 
one other point he wished to add. It was odd, when reflecting on the 
great number of times that this operation had been performed by various 
speakers, that these two cases now under discussion were the only two 
shown to the Society at the present time, and that it should be thought 
necessary to congratulate Dr. Lack on the unusually favourable termi¬ 
nation to the cases. He thought that showed that such radical results 
were not obtained as one was at first apt to imagine. Nor did he think 
in these two cases that the tendency to polypus formation had disap¬ 
peared. On the contrary, on both sides there are to be seen signs of 
recurrence. Personally he had had no experience of this operation, 
but be should, after hearing what had been said by other members, 
consider it in exceptional cases with a view to doing something of the 
kind ; tbe warning should be borne in mind that the treatment must 
not be rashly undertaken, though it might, after all, be necessary in 
some cases. 

Mr. Parker said, “ I said I was almost coming to the conclusion 
that in cases of multiple polypi with suppuration this would probably 
be the best treatment.” 

The President said that he thought too big a subject had been 
entered upon in what was only intended to be a casual discus¬ 
sion, particularly in view of the many cases which still remained 
to be discussed, and of the lateness of the hour. It, however, 
seemed to him an excellent subject for a general discussion by the 
Society, and he hoped that it would recommend itself as such to the 
Council. Personally he would only say that there seemed to bim 
quite a host of questions connected with this subject: (1) Did nasal 
polypus arise from disease of the mucous membrane, or of the bone ? 
(2) Was it possible that in some cases there was the one, and in others 
the other origin ? (3) Why was there in some cases (in his own experi¬ 
ence in a small minority only) suppuration connected with the exist¬ 
ence of polypi, whilst in others, and indeed in the great majority, it 
was conspicuous by its absence ?—These questions seemed to bim 
an excellent basis for a general discussion. He agreed with Dr. Grant 
that the radical treatment recommended by Dr. Lack ought not at 
present to be taken up as a routine treatment, seeing (1) that all the 
questions he had mentioned had not been solved, and (2) that, accord¬ 
ing to his own personal experience, in the great majority of cases, if 
the patients presented themselves periodically and regularly for exa¬ 
mination after a thorough removal of the polypi, ultimately the disease 
reappeared at longer and longer intervals, and finally, and by no means 
exceptionally only, did not recur any longer. A cure, of course, could 
never be promised, in view of the fact that sometimes, even after an 
interval of five years or more, a fresh recurrence took place; but it 
remained to be seen whether a similar recurrence was entirely excluded 
by the radical treatment proposed by Dr. Lack. In conclusion the 
President said that the whole discussion had revived in a very inter¬ 
esting manner the controversy which, many years ago, had taken 
place between Dr. Woakes and Dr. Sidney Martin, about the changes 



108 


seen tinder the microscope in the specimens removed by the former. 
No agreement, it would be remembered, was at the time arrived at as 
to whether the changes in the bone were of a primary or of a secondary 
nature, yet this was a question of prime importance. Could Dr. 
Lack, he wondered, advance the disputed point, since the adoption of 
his radical treatment seemed to him to mostly depend upon that very 
question ? 

Dr. Lambert Lace, in reply, said that the controversy between 
Woakes and Sidney Martin was entirely over the clinical features of 
the disease, and that Martin had never retracted his statements as to 
the pathological changes found in the bones removed by Woakes. As 
to whether the bone disease was primary, and the cause of polypi, or 
whether it was secondary to changes in the mucous membrane causing 
the polypi, he thought this question could be very well answered by 
the results of treatment. If one removed the polypi and left the bone, 
the polypi recurred; but if one removed the bone at the same time as 
the polypi, the latter did not return. The speaker had operated upon 
over fifty cases in the last five or six years, and that had been his 
experience. He quite agreed that in a large number of simple polypus 
cases a cure could be obtained with the snare if treatment were per¬ 
sisted in for a sufficiently long time, but even in the simplest cases he 
thought a successful result was more quickly obtained if one succeeded 
in passing the snare round the piece of bone from which the polypus 
was growing, and in removing both at the same time. If this failed 
in these simpler cases, he was in the habit of subsequently clipping 
away the bone with cutting forceps. But in the severer cases of nasal 
polypus, and especially in those associated with suppuration, such 
methods were useless. One of his cases had had polypi removed 
regularly every fortnight for three years, and yet the nose had never 
been clear; and the man shown to-night had not been able to breathe 
through his nose for two years, in spite of frequent operations. In 
such cases he advocated the clearing out of the whole ethmoidal region, 
by scraping with the ring knife under a general anaesthetic; in some 
cases he had even removed a large portion of the inner wall of the 
orbit. This method, which removed the whole trouble at one sitting, 
was surely more advantageous to the patient than the protracted treat¬ 
ment and frequently repeated operations that were otherwise necessary, 
and which were sometimes ultimately successful; and Dr. Grant’s 
patients would probably prefer it, although it would not give him 
the same opportunity of acquiring operative dexterity. What some 
members took to be signs of recurrence of the polypi, was only granu¬ 
lation tissue, which now the diseased bone was removed would shrivel 
up, and did not require any treatment. Finally, as to the risk, he 
could only say that having performed the operation as extensively and 
frequently as he had already said, he had not yet had a result which 
he could describe as dangerous or serious, and he did not believe the 
danger was as great as the sum total of the danger resulting from 
the repeated small nibbling operations. 



109 


Case op Chronic Ethmoiditis simulating so-called “ Cleavage ” 
of the Middle Turbinate. 

Shown by Dr. Herbert Tilley. The patient, a girl aet. 18, 
complained of severe pain over the nose and around the right 
side of the face. The middle turbinal was easily visible, and on 
its under side was a well-marked swelling, between which and 
the turbinal a probe could be passed. It was impossible to pass 
a probe to the outer side of the swelling referred to. Kauffman 
had stated that such a swelling was pathognomonic of antral 
suppuration, but the exhibitor thought that while such an 
appearance was met with in chronic inflammatory lesions located 
in the ethmoidal region, it was only significant of antral disease 
when associated with suppuration. 

In the present case exploration of the antrum showed it to be 
free from pus. 


Dr. Dundas Grant wished to ask Dr. Tilley which of the structures 
he saw in the nose he considered to be the middle turbinate bone. The 
more one saw of the nose, the more excuse one could make for anyone 
who considered the growth in the case under discussion to be the 
middle turbinal bone. He had seen many cases of hypertrophied 
mucous membrane over the uncinate process which resembled exactly 
the middle turbinate body, and could only be distinguished from it by 
means of the probe. He thought in Dr Tilley’s case he saw three 
swellings, viz. the uncinate process, the bulla, and the middle turbinate. 
It was sometimes extremely difficult—and it was only possible by using 
one of those long, very narrow specula, such as Killian’s, for median 
rhinoscopy—to make out which was which. The question of so-called 
cleavage was one really of old time, which arose when the minuter 
knowledge of the anatomical parts of the nose was less familiar than 
now. 

With reference to Dr. Grant’s remarks, Dr. Tilley said the middle 
turbinal was easily visible, and could not be mistaken for any other 
structure. The case was shown to illustrate that it only resembled a 
cleavage of the mid-turbinal, but was in reality only a periostitis in the 
neighbourhood of the uncinate process. 


Case of Laryngeal Ulceration. 

Shown by Dr. Edward Law. The patient first came under 
my care on December 29th, 1899. He complained chiefly of 



110 


soreness of the left side of the throat of thirteen months’ 
duration, and of hoarseness of three weeks’ duration. For eight 
months he had also suffered from bad cough, with free expecto¬ 
ration. There was no difficulty in swallowing or breathing, and 
he considered that his general health was satisfactory. There 
was no history of syphilis. On examination a large deep irre¬ 
gular ulcer was seen involving the left upper edge of the 
epiglottis. The whole of the larynx was red and swollen, with 
marked impairment of movement on the left side. He would 
not remain in London for further observation, but promised to 
return in three weeks. A mixture containing Pot. Iod. grs. x 
and Liq. Hydrarg. Perchlor. 3 ] three times a day was prescribed, 
along with a pastille of aristol and cocaine. 

He did not return till May 4 th, 1900, but the dose of Pot. Iod. 
had been meanwhile increased to grs. xx by his own physician. 
On examination the ulceration was seen to have destroyed the 
left half of the epiglottis, and there was almost complete fixation 
of the left half of the larynx. 

Personally I believe the case to be malignant, but I should 
like to have the opinion of the members. 


The President particularly asked members with experience of such 
cases to express an opinion, as the case had been shown with a special 
request for the opinion of members. Personally, he was afraid it was 
a malignant growth; it did not look to him in the least either specific 
or tubercular. There was extensive tumefaction and immobility of the 
left half of the larynx, and complete loss of the left half of the epi¬ 
glottis, with considerable enlargement and fixation of the cervical 
lymphatic glands on the left side of the neck. All this pointed de¬ 
cidedly to malignant disease. Radical operation, if undertaken at all, 
would have to be very extensive, and the prospect was not good. 

Dr. Scanes Spicer hesitated to differ from the diagnosis of the 
President, who had had more experience than himself in these cases, 
but the extent of the superficial ulceration in this case, together with 
the small amount of infiltration, appeared to him to favour the theory 
of a syphilitic process. There was, besides, the bright red colour of 
the growth and the man’s good general health to consider. The con¬ 
dition had existed for several months, and if it was malignant, it would 
(being extrinsic) have had some effect on the man’s general condition. 
It was true there was glandular infiltration, but this might result from 
the enormous surface of ulceration, which invaded the whole left side 
of the larynx. The left vocal cord did not seem to be involved in new 
growth, or to be displaced inwards, as would, he thought, be the case 
if the ulcerated surface were that of a malignant neoplasm. 



Ill 


Dr. Herbert Tilley had examined the growth with his finger, but 
was struck by the absence of that induration so characteristic of 
malignant disease. This fact, coupled with the long history of the 
ulceration and the excellence of the patient’s general health, seemed to 
throw some doubt on the malignant nature of the case. 

Dr. Lack thought it was a typical case of malignant disease. There 
could not be much doubt with such hard granular infiltration. 

The President thought it was quite time that the idea was given 
up that the presence of malignant disease of the larynx in its early, 
and sometimes even in more advanced stages, necessarily interfered 
with the general health of the patient. He had seen too many in¬ 
stances of good general health with quite extensive malignant disease 
of the larynx to countenance the notion of the regular early co-existence 
of general cachexia, which, in his experience, as a rule occurred very 
late in the progress of the disease. 


Case of Ulceration of Epiglottis. 

Shown by Dr. FitzGerald Powell. A male set. 44 came 
to the hospital on May 1st to seek relief for deafness and 
severe tinnitus, which he states came on suddenly four months 
ago. 

On making a general examination of the upper air-passages, 
the epiglottis was seen to be swollen, very red and congested, 
and on its laryngeal surface on the right side a considerable 
patch of ulceration was observed, the rest of the larynx being 
normal. 

A small hard gland was felt in the left cervical region oppo¬ 
site the thyro-hyoid space. On being questioned, he stated he 
had some pain in swallowing for two weeks. 

He gives a history of having a chancre when a boy, which 
was treated by local applications, and which healed in three or 
four weeks. He had no constitutional treatment, and has had 
no further signs of syphilis. 

He is married, and his wife has had eight children, all healthy. 
He has had severe cough, and has lost flesh during the last four 
months. 

There are no abnormal signs in the chest. 

Dr. Jobson Horne regarded the case as tuberculous. It would be 
as well to have an examination made of the thorax and sputa before 
deciding that it was not tuberculosis. 



112 


Case of Enlargement of Lingual Tonsils in a Woman ,®t. 39 

with Secondary Syphilis. 

Shown by Dr. Henry J. Davis. The patient came to the 
hospital in January, looking 1 extremely ill, with ulcerative tonsil¬ 
litis and marked adenitis. There was a deep kidney-shaped 
excavation of the right tonsil. 

Faucial tonsillar tissue is now almost absent, having been 
undermined and destroyed by the severity of the ulceration ; but 
if the tongue be depressed or protruded, the lingual tonsils, both 
of which shared in the general inflammation, though) oddly 
enough, not in the ulcerative process, can be seen as elevated 
symmetrical masses rising above the sides of the dorsum of the 
tongue. They are not so large as they were, though still 
plainly visible. 

The severity of the disease has been aggravated by the fact 
that even the smallest dose of iodide of sodium produces a well- 
marked rash with the other signs of iodism. The patient is 
being treated with mercury; but the rash persists, though the 
throat is well. 

The disease was contracted from her husband, a groom, who 
also at first had severe throat lesions, ulcerative laryngitis and 
tonsillitis, with mucous patches on the palate, tongue, and lips. 

He stated that he was suffering from blood poisoning, result¬ 
ing from the bite of a vicious horse, but as horses are considered 
immune against syphilis, I did not agree with his diagnosis. 


Case of Growth in the Neck associated with (Edema of One 

Ary-epiglottic Fold. 

Shown by Dr. Dundas Grant. A middle-aged labourer came 
under my observation on May 3rd, 1900, on account of a swell¬ 
ing on the side of his neck. There is a hard oval swelling at 
about the level of the thyroid cartilage, with its long axis 
pai’allel to the internal jugular vein. It is extremely hard, and 
is quite moveable, both under the skin and on the subjacent 
tissues, and it does not rise with the larynx during the act of 
swallowing. Above, below, and behind it are isolated enlarged 



113 


glands. It has taken eight months to develop to its present 
size, the enlargement being more rapid towards the latter part 
of that period. There is no pain, no difficulty in swallowiug, no 
affection of the voice or respiration. On laryngoscopic examina¬ 
tion the only abnormality perceptible is a slight oedema of the 
right ary-epiglottic fold, and such an inward bulging of the 
outer wall of the pharynx as to conceal from view the hyoid 
fossa of that side, while the opposite one is easily discernible. 
On palpation no hardness suggestive of malignant disease is 
detectable, although the finger appears to reach the ary-epiglottic 
fold. There is no apparent dental trouble to account for the 
enlargement of the gland, which at first sight seems an ordinary 
indolent tuberculous gland. Associated with this swelling of 
the adjacent portion of the framework of the larynx, the question 
arises as to whether the two conditions may not be connected, 
and that we have to deal with a malignant affection. An opinion 
on this point is specially requested. 


Mr. Spencer thought there was an ulcer in the lateral hyoid fossa. 
This and the feel of the glands in the neck, and the sickly appearance 
of the patient, gave most likelihood of tuberculosis. On passing the 
finger down the gland, there was none of that distinct nodular feel 
which one expected in cancer. 

Dr. Dun das Grant would suggest in the first place a course of 
iodide of potassium; if that did not produce a marked effect he would 
recommend excision of the enlarged gland, whether malignant or tuber¬ 
cular. 


A Case of Inter- and Sub-cordal Growth, with Hoarseness 
of remarkably Sudden Development. 

Shown by Dr. Dundas Grant. A man set. 66 came under my 
care on May 3rd, 1900, complaining of hoarseness and loss of 
voice of four months’ duration. About Christmas time he was 
attacked with “ cold in the chest,” which in a week disappeared; 
but the hoarseness and aphonia remained from that time to this 
unchanged. On inspection there is seen ou the anterior part of 
the larynx a pale granular irregular-surfaced growth, which is 
bilobate, the upper part being rather the smaller, and lying 
between the vocal cords, the larger and lower half lying below 



114 


them. It appears to spring from the middle line anteriorly. 
There is a swelling on the right carotid artery at the level of the 
left thyroid ala. It is impossible to detach it from that vessel, 
and it is very doubtful whether it is an enlarged gland, being 
more probably an irregularity in the shape of the artery. 


Mr. Spencer thought the tumour was malignant. It was awkward 
that it involved the middle line in front, as, if anything were done, no 
unilateral operation would be sufficient. He advised an exploratory 
thyrotomy, and removal of the soft parts only on both sides. 

Dr. Grant would remove, as suggested by the President, a portion 
of tbe growth for examination, and act according to the results ob¬ 
tained. He did not know whether members of the Society would 
advise removal of the larynx in toto in a man of that age, though he 
was in very good health. The fact of the tumour being in the middle 
line made a unilateral operation impossible. He thought both vocal 
cords could be removed without danger. 


Case op Pharyngeal and Laryngeal Growth in a man jit. 59 

—SHOWN AT THE MARCH MEETING—WITH MICROSCOPIC SEC¬ 
TIONS op Portion op Growth removed. 

Shown by Dr. Furniss Potter. The section had been 
reported on by the Clinical Besearch Association, who stated 
that it showed “ young inflammatory formation—no signs of 
tubercle or malignant growth.” 

Dr. Jobson Horne had kindly also examined the specimen and 
expressed the opinion that “ the histological structure in places 
was undoubtedly that of sarcoma.” As regards the clinical 
progress of the case, the man had, on the suggestion of the 
President, had the dose of iodide increased to grs. xx, and had 
been taking this dose since the beginning of March. Looking 
at the throat it certainly appeared as if considerable absorption 
had taken place, and the patient was most decided in expressing 
the opinion that he felt much more room in his throat, and could 
swallow with very much greater ease. Dr. Potter said that he 
had ventured to bring the case again before the Society, as he 
considered it of interest, by reason of the uncertainty of dia¬ 
gnosis, and the difference of opinion expressed on the microscopic 
section. 



115 


The President suggested that the specimen be submitted to the 
decision of the Morbid Growths Committee, in view of the difference 
between Dr. Horne’s opinion and that of the Clinical Research 
Society. 

Dr. Turner agreed with Dr. Horne as to the microscopical sections; 
the character of the cells and blood-vessels was distinctly sarcoma¬ 
tous. There was inflammatory tissue as well, and the clinical appear¬ 
ance of the case supported the microscopical diagnosis, even though 
the patient had improved under treatment. 

Dr. Potter said that the evidence for and against a diagnosis of 
malignant disease seemed to be evenly balanced. He had intended in 
describing the case to ask for an expression of opinion with regard to 
the treatment. He himself felt that the progress of the case under 
iodide of potassium justified him in cont inuing the drug. He proposed 
to adopt the suggestion of Dr. Thomson that mercurial inunction 
should be given for a time. 


Case op Laryngeal Growth. 

Shown by Dr. Kelson. A man set. 37, a teacher, came com¬ 
plaining of loss of voice of five years’ duration and gradual onset. 

No history of tubercle or syphilis. 

Laryngoscopic examination revealed the presence of an 
opalescent somewhat granular-looking growth, about the size of 
a threepenny piece, and corresponding to the anterior and 
middle parts of the right vocal cord, and preventing the contact 
of the cords on adduction. 

Patient stated that two years ago portions of the growth had 
been removed at Gray’s Inn Road Throat Hospital, with consider¬ 
able, but only very temporary, relief. 


Mr. Spencer asked if the growth could be removed completely by 
intra-laryngeal methods. The growth was very broad, and not peduncu¬ 
lated, and well under the cord. He advised that laryngotomy should 
be performed ; it was quite a trivial operation, and one would have to 
make only a small opening to remove the growth. 

Dr. Grant said the growth was attached below, and not above, the 
right vocal cord, although the mass of it was above; he had examined 
the case with great care, and caught one glimpse of the edge of the 
vocal cord in its entire length, which showed it must be subcordal. 
The ventricular band bulged over the cord and made it difficult to see 
the entire edge. The growth might be just below the edge of the cord, 
and his laryngeal forceps might suffice to remove it completely or 
s uffi ciently ; that course should certainly be tried before laryngotomy 



116 


was resorted to. He presumed Mr. Spencer did not mean to divide 
the thyroid cartilage completely. 

Mr. Spencer meant no division of cartilage at all, but a little hole in 
the region of the crico-thyroid membrane, which would enable one to 
get in quite well and to remove the growth. 

Dr. Powell and other members discussed the case, and expressed 
great differences of opinion as to whether the growth was attached 
above or below the cords. 

Dr. Kelson thought the growth was above the cord. He was 
standing by the man at the time other members were expressing the 
contrary opinion, which greatly surprised him. 

The President was strongly inclined to the belief that the growth 
was above the cord. Would Dr. Kelson bring the case to the next 
meeting ? 

Dr. Kelson promised to bring the case again, and if possible to do 
nothing in the meanwhile. 


Case of Bilateral Abductor Paralysis. 

Shown by Mr. Wyatt Wingrave. A female set. 50 came to 
the hospital on Tuesday last, complaining of loss of voice, 
attacks of difficult breathing, and difficulty in swallowing. 

The onset was sudden three months ago, without any pain, and 
unassociated with any illness. 

On examination the soft palate was almost fixed, the con¬ 
strictors of the pharynx paretic, and the vocal cords immo¬ 
bile on phonation. The arytaenoids moved slightly, but the 
cords were flaccid, leaving but a very narrow glottis ; their 
edges flapped about with inspiration and expiration. 

Beyoud some slight swelling of ventricular bands the texture 
of the larynx was normal. Although sensation of the pharynx 
and larynx is somewhat diminished, laryngoscopic inspection 
produces violent inspiratory stridpr. 

On swallowing food returns through the nostrils. The voice 
is not completely aphonic, and the faulty articulation is probably 
due to palatal paralysis, as tongue, lips, and cheeks move well. 
There are no tremors of the tongue; the pupillary reflex and 
knee-jerks are normal. 

Beyond some harsh breathing, a few bronchial r&les, and the 
conducted laryngeal sounds, the chest affords no evidence of 
disease. 

She has a pulsus paradoxus, and she has lost weight lately. 



117 


The President said there could be no doubt that the patient suf¬ 
fered from bilateral abductor paralysis, more developed on the right 
than on the left side. There also was unilateral paralysis of the 
palate. He should give iodide of potassium in the first place, and be 
guided as to further steps by the progress of the case. 

Dr. Grant said the suddenness of the lesion suggested a haemor¬ 
rhage, but perhaps the history was unreliable. 


Case op Ulceration op Larynx. 

Shown by Dr. Davis in the absence of Mr. Paget. The man 
was a soldier who had syphilis twenty years ago, for which he 
had never been systematically treated. There were no signs of 
tuberculosis of the larynx. The patient in addition had a gumma¬ 
tous ulcer of the right lip involving the gums—it was first 
mistaken for an epithelioma, but was now granulating slowly 
under iodide of potassium ; the laryngeal lesions were now also 
less marked than they were. 

Dr. Jobson Horne said that, although there was undoubted 
evidence of syphilis, he was quite prepared to hear it suggested that 
there was an element of tuberculosis in the case. 


Case op Radical Operation for Chronic Frontal Sinus 

Empyema. 

Shown by Dr. Herbert Tilley. When first seen the patient 
complained of severe frontal headaches, and discharge of pus 
from the left nostril, which was completely occluded by polypi. 
There was no discharge from the right nasal cavity, which 
seemed in every way normal. Over the left sinus there was a 
well-marked expansion of the bone, the size of a five-shilling 
piece, which closely resembled an area of syphilitic periostitis. 
The patient also suffered from enlarged tonsils and adenoid 
growths. These and the nasal polypi were removed on different 
occasions before the external operation was performed. The 
left antrum contained no pus. The headaches disappeared when 
the nasal polypi and the anterior half of the left middle turbinal 



118 


were removed, thus allowing free drainage from the upper sinus. 
It was quite easy to irrigate the latter by means of a Hartmann’s 
cannula. 

Having cleared the nose of pathological products the external 
operation was performed. An incision was made through the 
inner half of the eyebrow, curving downwards and inwards to 
just above the internal palpebral ligament. On retracting the 
soft parts a considerable portion of the anterior sinus wall was 
removed. The cavity was filled with a degenerate polypoid 
mucous membrane, in which were three definite collections of 
pus. A large perforation in the septum maintained a communi¬ 
cation between the right and left sinuses. The left cavity was 
curetted free from diseased products, and was then found to be 
very extensive, passing outwards nearly to the temporal fossa, up- 
wards to thefrontal eminence, and backwards about one and a half 
inches in its deepest part. Some idea of the size of the cavity 
may be gained from the fact that it was possible to pack into it 
a strip of gauze two inches wide, of double thickness, and three 
feet ten inches in length. This was removed daily, owing to a 
discharge of pus which was seen to be coming through the 
perforation from the right sinus, but which at the operation 
seemed only to be an extension of the left sinus. Within a week 
of the original operation the right sinus was opened and dealt 
with, as the left had been, in both cases a free drain having been 
made into the nose. Small drainage-tubes were inserted into 
both sinuses and led out of the corresponding nostrils, lateral 
perforations having been made in the upper part of the tube 
which corresponded with the lumen of the sinus. The external 
wounds were stitched up with the exception of the lower inner 
angles, through which the drainage-tube projected. The sinuses 
were syringed out twice daily for a week with boracic lotion, 
then only once a day. During the last week of the patient’s 
stay in hospital the right tube was entirely removed, and for 
the left a V-shaped piece of silver wire was substituted, which 
could be removed and replaced for syringing. 

Exactly a month from the date of the first operation, the 
patient left the hospital with very slight scarring, and has not 
had any sign of suppuration since. 

The case was interesting because of—(1) the large sinuses in so 



119 


young a patient ; (2) the obvious expansion of the anterior wall of 
the left sinus; (3) the communication through the septum of the 
two cavities; (4) the absence of any sign of suppuration in the 
right nasal cavity, although the frontal sinus on that side was 
full of pus and chronic inflammatory products. 

The President congratulated Dr. Tilley on the brilliant results 
obtained in this case. 




PROCEEDINGS 


OF THE 

LARYNGOLOGICAL SOCIETY OF LONDON. 


Fifty-ninth Ordinary Meeting, June 1st, 1900. 


F. de Havilland Hall, M.D., President, in tbe Chair. 


Lambert Lack, M.D., 
Ernest Waggett 


7 

, M.B., 5 


Secretaries. 


Present—29 members and 5 visitors. 


The minutes of the preceding meeting were read and con¬ 
firmed. 

The ballot was taken for the following gentlemen, who were 
unanimously elected members of the Society: 

Hunter Finlay Tod, F.E.C.S. 

John Norcot d’Esterre. 

The following gentlemen were nominated for election at the 
next meeting of the Society : 

t 

Edward John Budd-Budd, Eagle House, 73, South Side, 
Clapham Common. 

Herbert William Carson, F.E.C.S., Craigholm, Upper Clapton, 
N.E. 

Dr. W. A. Aikin then read a paper on “ The Resonators of 
the Voice.” 

FIRST SERIES —VOL. VII. 


8 



122 


The following cases and specimens were shown: 

A Case op Primary Sarcoma of the Tonsil in a Woman a:t. 

58; Successful Extirpation through the Mouth. 

Shown by Dr. Walker Downie. The patient, a woman set. 
58, was seen by me on 17th August, 1899, when she complained 
of a swelling of her right tonsil, which had been slowly increas¬ 
ing in size since the beginning of that year. 

Early in January she had first experienced a sense of fulness 
and discomfort in her throat, particularly on swallowing. It 
came on without apparent cause, and at first gave her no con¬ 
cern. But as the discomfort persisted, she used various simple 
astringent gargles without benefit. In March she consulted a 
doctor, who informed her that the tonsil was inflamed and 
ulcerated, and he prescribed an astringent solution to be painted 
over the tonsil. The tonsil at this time was evidently enlarged ; 
there was no sharp pain, but a sense of slight difficulty on 
swallowing. She continued to apply the astringent referred to 
till June. During those three months she not only felt no local 
improvement, but was convinced that the affected tonsil was 
slowly increasing in size; and also she felt that she was losing 
flesh, and was becoming so weak generally that she was quite 
unable to perform her ordinary household duties. 

In June she consulted another doctor, who proposed to excise 
the affected tonsil, but on her return two weeks later to have 
this done, the tonsil was found to have so increased in size in 
that interval that he deferred operation. 

She called on me with a note from her doctor on August 17th, 
by which time there was no doubt as to the nature of the new 
growth. 

Her temperature was normal. She appeared to be in mode¬ 
rately good health, though complaining of weakness and ex¬ 
haustion on slight exertion. Her speech was somewhat thick, 
and she complained of pains shooting up from the right side of 
the throat to the right ear. She could swallow with comparative 
ease. 

On examination through the mouth a tumour occupying the 
position of the right tonsil was seen, somewhat resembling an 
hypertrophied tonsil. It was nearly the size of an average 



123 


walnut; it had the form of an enlarged tonsil, was of a deep red 
colour, with several greyish patches of superficial erosion dis¬ 
tributed over its surface. It was firm to the touch, non-fluc- 
tuant, and palpation caused no pain. The faucial pillars were 
not adherent to the tumour, which was as a consequence freely 
moveable; and the lymphatics in the neighbourhood were un¬ 
affected. 

On 23rd August she was placed under chloroform, and with 
the mouth widely opened the new growth was enucleated by 
means of the finger-nail and scissors. Firm pressure over the 
raw surfaces checked what bleeding there was. Ice was given 
frequently for the first few hours after operation, and thereafter 
small doses of dilute hydrochloric acid several times daily until 
the parts were healed. 

The report on the microscopic examination of the tumour by 
Dr. A. R. Ferguson was as follows:—“The cells are large, uni¬ 
nuclear, and spindle-shaped, with in addition numerous very 
irregular large rounded cells. An infiltration of the remaining 
tonsillar tissues with these cells singly or in small groups is also 
observed/’ 

It is now nine months since the operation. There is no trace 
of the former growth, nor of the operation performed for its 
removal. There is no recurrence, and the patient is in excellent 
health. 


Case op Perichondritis op the Larynx, following the Intro¬ 
duction or the Retention op a Tube in the (Esophagus. 

Shown by Mr. Butlin. A- man set. 29, who was suffering 
from the typical symptoms of primary dilatation of the oeso¬ 
phagus, was admitted into St. Bartholomew’s Hospital on the 
3rd January of the present year. He was losing flesh and 
suffered severely from cough, which appeared to be due to the 
arrest and retention of food in the oesophagus. Mr. Butlin de¬ 
termined to treat him by the retention of a vulcanised india- 
rubber tube, so that he might be fed through the tube for a 
couple of months. The tube was introduced into the stomach 
with very little difficulty, and he was fed through it until the 
28th January, when he went home, still wearing the tube. He 



124 


was at that time much better, did not bring up any food, and 
had almost entirely lost his cough. 

On the 18th February he was seized with a violent fit of 
coughing, during which the tube was ejected. He at once 
came to the hospital, when the tube was replaced without any 
apparent difficulty by the house surgeon. 

On the morning of February 19th he woke with difficulty of 
breathing, and coughed severely, when the tube was again dis¬ 
placed. It was not put back, but his difficulty of breathing 
increased until February 23rd, when he came back to the 
hospital, and was admitted. 

During the first few days he rapidly improved. On the 1st 
March an attempt was made to introduce a soft tube, but he 
was seized with dyspnoea and the attempt was desisted from. 

On the following day, March 2nd, his breathing was so bad 
that tracheotomy was performed. 

On his admission to the hospital the posterior parts of the 
larynx were extremely swollen, red, and oedematous, and the 
interior of the larynx was in the same condition. His voice was 
extinct, and he suffered from slight difficulty in swallowing. 
The appearances were those of perichondritis of the larynx. 

At the present time he is still suffering from the appearances 
of general perichondritis of the larynx, but especially of the 
back part, and the tracheotomy tube has to be permanently 
worn. It is proposed to open the larynx and examine the con¬ 
dition of the cartilages, with a view to the removal of necrosed 
or carious portions. 


Case op Radical Operation for Nasal Polypi. 

Shown by Mr. C. A. Parker. A male, set. 30, was first seen 
seven years ago suffering from polypi, with suppuration appa¬ 
rently from the ethmoidal cells in both nostrils. 

The polypi were carefully removed by means of a snare, and 
after six months’ constant treatment, consisting of trimming up 
and using the cautery, the case was for the time being appa¬ 
rently cured. This was in February, 1893. In April, 1894, 
polypi had recurred, and another course of treatment was re- 



125 


sorted to again with favourable results. The patient, however, 
again came under treatment in 1897-98, and again with benefit. 
In October, 1899, the patient was as bad as ever, so on No¬ 
vember 21st an anaesthetic was administered, and the polypi, 
the middle turbinate, and the ethmoidal cells were all thoroughly 
removed. The patient made a rapid recovery from the opera¬ 
tion without any unpleasant symptoms. 

He states that he has been far more comfortable since the last 
and radical operation than he has been for nearly ten years 
past, and is himself quite pleased with the result. 

At the present time no sign of polypoid formation an be 
seen. On the right side there was an adhesion between the 
outer and inner wall, which a fortnight ago I attempted, not 
very successfully, to remove. It rather hides the view of the 
upper parts. 

The patient, in writing to me, says the symptoms which used 
to trouble him most were—thickness of speech, obstruction of 
the nose, violent sneezing, especially in the morning, frequent 
sore throats and occasionally quinsy, loss of the sense of smell. 
He adds, “ The first four seem quite cured, and I am gradually 
regaining the sense of smell.” 


Mr. Baber regretted his inability to attend the previous meeting, 
when this subject was discussed at some length. As he had not heard 
what was the radical operation referred to, he would be glad if Mr. 
Parker would briefly mention the procedure. 

Mr. Parker, in reply, said that seeing that Dr. Lambert Lack, who 
had originated the operation, was present, he thought that the Society 
could not do better than ask Dr. Lack to reply to Mr. Baber’s 
question by giving a short account of the method used in this opera¬ 
tion. 

Dr. Lambert Lack said that the essentials of the operation were to 
give a general anaesthetic, such as ether or chloroform, and then to 
remove not only all polypi, but as much of the ethmoid bone as was 
possible. With a large ring knife, such as Meyer’s original adenoid 
curette, he broke up the ethmoidal cells and removed the middle 
turbinate, and in some cases the greater part of the ethmoid bone. 
The scraping was continued until all loose friable bone was removed 
and healthy bone was reached. The latter was easily recognised by 
its firmness both to the knife and finger. If this were thoroughly 
done, recurrence of polypi might be prevented even in the worst cases. 
He had never seen this operation advocated or performed by others; 
the curetting so often spoken of was essentially different, consisting as 
it did of repeated small scrapings, 



126 


Mr. Baber asked how Dr. Lack managed to avoid wounding the 
cribriform plate, and also whether he was liable to make an opening 
into the orbit. A very thorough removal of bone had been advocated 
by Griinwald with forceps and curette. 

* Mr. Butlin hoped Dr. Lack would not recommend the operation on 
a very large scale, because he was sure awkward accidents would occur 
if it was used extensively. The distance between the base of the brain 
and the ethmoidal sinuses was so short that even a jerk of the forceps 
might perforate the ethmoidal plate. 

The President was glad to hear these words of caution. In in¬ 
expert hands there would be great danger of setting up septic menin¬ 
gitis. The operation certainly ought to be confined to men with large 
experience of the operative procedure; it was not an operation to be 
recommended as a generality for practitioners, especially beginners. 

Dr. Lambert Lack thought he might add that the danger was far 
more apparent than real. He had operated now for six years, dui ing 
which period he had done the operation in more than sixty cases; he 
had in many cases used considerable force, but had never any ill- 
results. In some cases he had removed a large portion of the inner 
wall of the orbit, and had exposed the periosteum in this region, but 
without producing any ill effect beyond a temporary black eye. He 
thought that with care the cribriform plate was not endangered. 


Case of Chronic Frontal Sinus Empyema cured by Radical 

External Operation. 

Shown by Dr. Herbert Tilley. A female aet. 49, on whom 
this operation had been performed. The symptoms of headache, 
nasal obstruction, and purulent discharge had lasted for five 
years. The left antrum also discharged pus. The patient had 
been in the hospital exactly three weeks. Since the antrum had 
been drained and irrigated through the alveolus the discharge 
had much diminished, and if it did not entirely cease in the 
course of a few weeks, he thought it would be wise to advise 
a radical operation upon the antrum. 


Case of Double Frontal Sinus and Antral Empyema with 
G-reat Distension of Bridge of Nose. 

Shown by Dr. Herbert Tilley. A young man aet. 18, present¬ 
ing symptoms of multiple sinusitis. It was quite easy to irrigate 
the frontal sinuses and wash out a quantity of pus. Both antra 
were being irrigated and drained. The nostrils had been cleared 



127 


of polypi, and a considerable portion of the diseased ethmoids 
had also been removed. Dr. Tilley purposed operating on the 
frontal sinuses in the course of a few days. The interesting 
feature in the lad’s appearance was the great broadening of the 
nose, which was probably an evidence of chronic ethmoidal 
inflammation. 


Case of Laryngeal Occlusion in Typhoid Fever. 

Shown by Mr. Waggett. A man of 30, in whom tracheotomy 
had been performed some two months ago during typhoid fever. 
The larynx, though pale, was tumefied throughout with the excep¬ 
tion of the epiglottis. The cords remained fixed in apposition, 
and were partly concealed by the ventricular bands. In the 
region of either vocal process was an eminence, presumably a 
granulation, the size of half a pea. These no doubt pointed to 
the presence of ulceration in this the typical region, but the 
actual seat of ulcer was hidden by the conformation of the parts. 
The whole of the posterior cricoid region was in a state of volu¬ 
minous pale oedema. Probing at the seat of ulcer had failed to 
detect a fistula leading to the cricoid cartilage. Assuming that 
necrosis of the cartilage was present, was it advisable to cut 
down and remove the sequestrum, as would be done in any other 
part of the body ? 

The President asked Mr. Waggett if it was a case of so-called 
secondary affection of the larynx, or whether the laryngeal affection 
was primary. He could only recollect one case of complication of the 
larynx in typhoid fever; it was certainly rare in this country. It was 
that of a man with supposed acute laryngitis, but of a different type 
to that he was accustomed to see. There was high temperature and a 
good deal of pain. The diagnosis was cleared up in a few days, the 
man developing typical enteric fever. It seemed as if the larynx were 
primarily affected, the abdominal symptoms occurring later. 

Dr. Clifford Beale said the question of laryngeal ulceration in 
typhoid fever had been discussed at the Society some three years ago, 
and since then he had taken every opportunity that offered itself—and 
these were fairly numerous—of examining the larynx in cases of 
typhoid fever where hoarseness was present. He had not been able to 
detect anything in the way of ulceration either of the epiglottis or 
within the larynx itself; the general condition was one of simple, 
general congestion. In one case, however, there had been decided 



128 


swelling of the epiglottis. He remembered on the occasion of the 
former discussion that Mr. Bowlby gave the Society the experience he 
had gained from post-mortem examinations at St. Bartholomew’s 
Hospital to the effect that laryngeal ulceration was outside his experi¬ 
ence. Personally, he could not help thinking that laryngeal ulceration 
was a very uncommon complication of typhoid fever in this country. 

Dr. Jobson Horne inquired whether it was possible to state how 
soon after the occurrence of typhoid the laryngeal lesion developed, 
and also whether the patient had been subject to any infection other 
than that of typhoid. 

Mr. Waggett said, in reply to Dr. Home’s questions, he would not 
be certain when the laryngeal occlusion commenced, because the 
patient did not come to the hospital till late; nor did he obtain a 
definite clinical history. He was inclined to think it was rather late in 
showing itself. Remembering Dr. Horne’s remarks at a previous 
meeting, he had inquired into the question of possible tuberculosis in 
this patient, but had found no evidence of it; the sputa contained no 
tubercle bacilli. He wished for the opinion of members as to the 
cause of the great amount of oedema on the back of the cricoid. There 
was no doubt in his mind that the man had inter-ary taenoid ulceration. 
He had been in hopes of finding that it represented the orifice of a 
fistula, and that a probe on insertion would come upon necrosed 
cartilage. The probe had failed to find any fistula, but should 
necrosis be subsequently proved, would it not be well to remove a 
sequestrum after thyrotomy before the larynx was permanently 
ruined ? 

Dr. Dundas Grant said if the evidence of necrosis were fairly 
complete it would be a good operation to do a thyrotomy, and remove 
the sequestrum from the front. 


Female Patient, ^et. 49, from whom the Larynx had been 

COMPLETELY REMOVED ON ACCOUNT OF SARCOMA. 

Shown by Dr. Dundas Grant. This was a patient the prepa¬ 
ration of whose larynx was shown to the Society on April 7th, 
1900, and the history of the case will be found in the proceedings 
of that meeting. I performed the operation on the 3rd March. 
She underwent with great cheerfulness and courage a long and 
somewhat tedious course of after-treatment, involving feeding by 
means of a tube. The wound in the neck was plugged at first 
with iodoform gauze, then with gauze moistened with red wash; 
now there remains only an elliptical slit, about half an inch in 
length, below the hyoid bone; by pinching the sides of this 
together with her fingers, the patient is able to consume liquid 
food of any kind. There is no sign of recurrence either locally 



129 


or in other parts of the body, and the question now arises as to 
whether it is most desirable to revive the edges of the opening 
and effect its complete closure, or to allow it to contract at its 
present slow rate, leaving the aperture for the introduction of 
an artificial larynx. The opinion of the members on this point 
will be gladly received. 

Dr. Lambert Lack suggested that most of such patients were more 
comfortable with the fistula wholly closed^ It could easily be done 
by some small plastic operation. 


Case of Tonsillar Ulceration of Uncertain Origin 

(Specific) . 

Shown by Dr. Dundas Grant. This patient was brought 
before the Society on April 7th. There was some uncertainty 
in regard to the possibility of the case being one of epithelioma. 
A provisional diagnosis was made of a primary infection of the 
left tonsil with secondary mucous patches on both. 

Since the last occasion on which she was brought before the 
notice of the Society, she has been treated by means of mercurial 
inunctions, at first at home, and latterly in hospital, with the 
result that the circinate edges have entirely lost their opalescence 
and their everted character, and although the left tonsil is still 
swollen it is quite soft, and the floor of the depression correspon¬ 
ding to the excavated ulcer has acquired the tint and smoothness 
of the surface of the normal tonsil. 


Case of Intercordal Tumour (Tubercular) of the Larynx in 

an Elderly Man. 

Shown by Dr. Dundas Grant. John S. came under my care 
May 3rd, 1900, complaining of hoarseness and loss of voice of 
four months’ duration. About Christmas-time he was attacked 
with “ cold in the chest,” which disappeared, but the hoarseness 
and aphonia remained unchanged. On inspection, there is seen 
on the anterior part of the larynx, a pale, granular, irregular 
surfaced growth, which is bilobate, the upper part being rather 



130 


the smaller, and lying between the vocal cords, the larger and 
lower half lying below them. The growth appears to spring 
from the middle line anteriorly. There is a swelling on the 
right carotid artery; it is impossible to detach it from that 
vessel. 

A t the last meeting. May 4th, when this patient was seen, the 
nature of the growth was considered extremely doubtful, and it 
was generally agreed that there was a great probability of its 
being epitheliomatous, and the question of removing it by thyro- 
tomy was discussed, subject to microscopical confirmation as to 
its nature. The growth appeared to originate at the anterior 
commissure. I endeavoured to remove it by means of a snare, 
but with this instrument I only detached a very small portion of 
it, and I then, without much expectation, tried my own forceps 
of the form opening from side to side. By means of the late 
McNeil Whistler’s forceps, however, I succeeded in removing 
a large mass presenting the outward appearance of papilloma, 
which I hand round, and a portion of which was submitted to 
Mr. Wingrave for microscopical examination. He reported it to 
consist chiefly of small round-cells interspersed with fibrous 
tissue, but containing very well marked giant-cells, the whole 
being fairly typical of tubercle. On staining a section for 
bacilli a confirmatory result was obtained. It is evident, there¬ 
fore, that we have to deal with a tuberculous tumour, although 
the pulmonary evidences are almost negative; there is, however, 
a suspicious comparative diminution of resonance on percussion 
at the right apex. The sputum has, from an oversight, not been 
examined for bacilli, but the diagnosis seems to be sufficiently 
certain. On laryngoscopic examination it will be found that the 
growth had its origin not merely in the anterior commissure, but 
also on the anterior fourth of the edge of the right vocal cord. 
The larynx is now being submitted to daily applications of lactic 
acid in from 40 to 60 per cent, solution, and some improvement 
has taken place. 


Specimen Mounted to show Ulceration op the False Cords, 
True Cords, and Interarytainoid Region. 

Shown by Mr. Bergin for Mr. Lake. The specimen was 



131 


removed from a man set. 52, who died at the Consumption 
Hospital, Hampstead. There was a large cavity in the upper 
lobe of the right lung, and miliary infiltration of the rest of the 
lungs. There had been difficulty in swallowing for two years. 


Specimen showing Tubercular Ulceration of the Larynx. 

Shown by Mr. Bergin for Mr. Lake. The larynx was ob¬ 
tained from a patient who died of pneumothorax supervening 
on pulmonary tuberculosis. 


Case of Carcinoma Laryngis. 

Shown by Mr. Waggett. The patient is a man set. 60, with a 
large carcinomatous mass involving the epiglottis. The voice is 
deep and hoarse; the glottis is not to be seen. There is no 
glandular enlargement. The base of the tongue appears to be 
slightly involved. As radical operation seemed impossible was 
it advisable, on account of the dysphagia present, to remove the 
epiglottic mass with the hot snare, or merely to perform tra¬ 
cheotomy ? 

Mr. Btjtlin did not think the radical operation would do good. He 
would not do anything if the case were under his care. 


Case showing the Orifice of the Sphenoidal Sinus. 

Shown by Mr. Waggett. The patient was a man £et. 40, in the 
last stage of atrophic rhinitis, in whom the orifice of the left 
sphenoidal sinus could be very beautifully seen, and the dimen¬ 
sions of the cavity could be made out with the probe. 

Mr. Waggett ventured to bring the case before the notice of the 
Society in view of the discussion which arose about certain crypts in 
the naso-pharynx at a previous meeting, and in order to demonstrate 
that the sphenoidal sinus opening is a long way in front of the post¬ 
nasal space. One was liable to think that it was at the top of the 
post-nasal space; as a matter of fact the osteum was at the anterior 
end of the sinus : this was very well exemplihed in his case. 



132 


Case of a Male ast. 29, with Tubercular Laryngitis. 

Shown by Mr. Hamilton Burt. Three years ago patient first 
noticed a small ulcer the size of a pea on the post-pharyngeal wall; 
despite treatment under several doctors it continued to spread. 
Loss of voice was first noticed eighteen months ago, when I saw 
him. The condition then was a sharply-cut deep ulcer, the size 
of a sixpenny bit, covered with grey slough; other parts of mouth 
and pharynx were healthy. 

Larynx .—Ulceration of left cord and left ventricular band, 
cedematous-looking swelling of left arytaenoid and interarytae- 
noid space as far as middle line, and also some swelling of ary- 
epiglottic fold. Voice only a whisper. 

Treatment .—Painted larynx with solution of lactic acid, be¬ 
ginning with 10 per cent, solution. There was no specific 
history admitted, but the pharyngeal ulcer suggested syphilis, 
so potassium iodide was administered in increasing doses up to 
3ss t. d. s. In six months all the swelling in larynx disap¬ 
peared and ulceration healed; the ulcer of pharynx also com¬ 
pletely healed, and no sign of it could be seen. Patient 
remained well for over a year. 

The President thought the laryngeal condition looked syphilitic 
rather than tubercular. 

Dr. Burt said that the ulceration had cleared up completely under 
iodide of potassium, given in doses increasing to half a drachm ter 
die. 


Case of a Male .et. 20, with Distension of the Maxillary 

Antrum. 

Shown by Dr. Lambert Lack. This patient was sent to me 
by Mr. J. G. Turner, who also conducted the transillumination 
of the antrum. He presents the following points of interest. 
The upper wall of the left antrum is pushed upwards, can be felt 
bulging into the orbit, and the left eyeball is at a higher level 
than its fellow. The inner wall of the antrum is bulging into the 
nose, and the nasal fossa is partially obstructed. There is a nasal 



13 & 


polypus in the opposite nostril. The other walls of the antrunl 
appear normal. There is no trace of pus in the nose. Both 
antra are equally translucent on transillumination. There was 
no pus on puncturing and irrigating the antrum. The cavity 
was, therefore, opened freely from the canine fossa and found to 
be filled up with ordinary mucous polypi. These were removed, 
and part of the antro-meatal septum cut away. The antrum 
distension is now apparently subsiding. The case is of a diag¬ 
nostic interest, as the presence of antral distension combined 
with translucency led to a confident diagnosis of cyst or hydrops 
of the antrum. 

Dr. DunDas Grant thought it a very important addition to the 
knowledge of transillumination that a mass of polypi was translucent, 
because hitherto it had been generally believed that only a cyst could 
distend the antrum and at the same time be translucent. 

Mr. Cresswell Baber asked whether a strong or rather weak light 
was used in transilluminating; by using a weak light and graduating 
its strength, one could often see a difference between the two sides, 
which was otherwise undetected. 

Dr. Lambert Lace, in reply, said that the light used was a strong 
one, but that there was absolutely no difference between the two sides. 


Case of a Child, mt. 3, with a Cyst at Base of Tongue. 

Shown by Dr. FitzGerald Powell. This child was brought 
to the hospital by his parents, who stated that he had a lump in 
his throat. 

Three months ago they noticed that he had some difficulty in 
swallowing, and on looking into his mouth saw that he had a 
lump far back on the tongue. It was then about the size of a 
large hazel-nut, and appeared to fill up the throat. They say the 
lump was much larger, but that it burst, remaining small for a 
fortnight, and then filling up again. 

When seen by me the first time the lump was very small, and 
was situated on the dorsum of the tongue, about the position of 
the “ foramen caecum.” It has continued to fill up and burst, 
when the tissue covering it gets thin and transparent. Latterly 
it does not get so large, and does not appear to give rise to in¬ 
convenience. 



134 


Mr. Butlin believed the case to be one of cystic dilatation of the 
glossal portion of the thyro-glossal duct. He had seen cases of mixed 
cystic and solid growth in that situation, and had described two cases 
in the Clinical Transactions some years ago. But, he had never seen 
the pure cystic form. In the new edition of * The Diseases of the 
Tongue,’ Mr. Spencer liad collected accounts of cases of that kind. 
The cysts are generally lined with ciliated cylindrical epithelium, and 
the wall contains a little thyroid gland tissue. Haemorrhage appears 
to be a common occurrence in connection with them. He believed that 
in this case, the best treatment would be to cut the cyst away with a 
galvano-cautery loop under an anaesthetic, and to cauterise the depres¬ 
sion of the foramen caecum freely. 


Case of Pedunculated Tonsil. 


Dr. Herbert Tilley showed a woman aet. 43, in whom the left 
tonsil, or a large portion of the same, was attached by a pedicle, 
which caused the patient to complain of what seemed to her a 
foreign body in the throat. The pedicle seemed to originate in 
the upper part of the tonsil, and possibly grew from the region 
of the supra-tonsillar fossa. The exhibitor considered it con¬ 
sisted of tonsil substance and was not a papilloma, and he based 
his belief on the ground that the left tonsil, which was broad 
and flat, was undergoing a similar kind of change, i. e. the free 
portion consisted of an association of small pedunculated masses. 
The right tonsil will be submitted to microscopic examination, 
and reported upon at the next meeting. 


The President thought that on the right side it was a papilloma 
rather than a pedunculated tonsil. It seemed to him a new growth. 
He supposed the question could be easily settled by removal of a piece 
of the growth for microscopical examination. 

Mr. Waggett had seen a similar case, but it was not such a 
beautiful specimen; the tissue proved microscopically to be tonsil 
tissue. 

Dr. FitzGerald Powell thought the growth was a papilloma. Its 
origin was from the “ supra-tonsillar fossa,” from which it grew by a 
narrow pedicle, hanging down in front of the tonsil. It certainly had 
the appearance of a papilloma. One frequently saw small papilloma 
growing from about the tonsil and soft palate, and he thought this 
was of the same character, only, of course, much exaggerated in size. 

Dr. Jobson Horne thought the left tonsil had more of the appear¬ 
ance of a papilloma than the right, but that the histological structure 
of a papilloma would be met with in neither. 



135 


Case op Lupus op the Nose in a Female jet. 35. 

I 

Shown by Dr. Edward Law. Dr. Law wished to ask the 
opinion of the members of the Society as to whether they would 
feel disposed in this case to do anything to the posterior margin 
of the septum, which was also involved, as well as the anterior 
naris. Could one get sufficiently far forward in the nostril by 
operative interference through the posterior naris to eradicate 
all the disease, which was situated behind the contraction just 
within the nostril and in front of the infiltrated posterior margin 
of the septum. 

Mr. Waggett had a case exactly resembling this one, in which the 
lupus had not recurred. He adopted the plan of making a careful 
drawing under cocaine of all the lupus growth, and of keeping the plan 
in front of him during the operation. In this way one could make 
fairly certain of removing all the diseased parts without forgetting any 
portion. 




INDEX 


PAGE 

Abductor paralysis, bilateral (Wyatt Wingrave) . . . 116 

-double, under treatment by intra-muscular injections 

(L. H. Pegler, M.D.) . . . . .28 

Acland (Mr.), new instruments for the treatment of antral empyema . 99 

Adenoids, post-nasal, well-marked (StClair Thomson, M.I).) . . 63 

Adhesion, pseudo-membranous, in anterior commissure (Sir Felix Semon, 

M.D.) . . . . . .70 

Aikin (W. A.), the resonators of the voice . . . . 121 

Aim nasi: see Nose. 

Angiosarcoma of nasal septum (H. Tilley, M.D.) 80, 91 

Annual General Meeting, January 6th, 1900 . . .35 

Antrum : antral affection of uncertain character causing obstruction of one 

nostril (StClair Thomson, M.D.) . . .67 

- empyema of, new instruments for treatment (Mr. Acland) . 99 

-double frontal sinus and antral empyema, with great distension of 

bridge of nose (H. Tilley, M.D.) .... 126 

-maxillary, distension (H. Lambert Lack, M.D.) . . 132 

Aphonia and hoarseness of long standing in a girl »t. 13 (P. de Santi) . 78 

-boy set. 10, suffering from (E. W. Houghton) . . . 32 

-intractable, with occasional apsithyria (L. H. Pegler, M.D.) . 51 

Apsithyria, occasional, in case of intractable aphonia (L. H. Pegler, M*D.) 51 

Ary-epiglottic fold : growth in neck associated with cedema of (J. Dundas 

Grant, M.D.) . . . . . . 112 

-(left): epithelioma of (Wyatt Wingrave) . . 8 

Arytenoid : growth from arytsenoid region in male set. 56 (R. Lake) . 71 

6ai^l (James Barry, M.D.), case of papillomatous condition of the tongue 47 
Bbbgin (Mr.), specimen mounted to show ulceration of the false cords, 

true cords, and in ter arytsenoid region (shown for Mr. R. Lake) . 130 

- specimen showing tubercular ulceration of the larynx (shown for 

Mr. R. Lake) . . . . . . 131 

Bone : bony cyst of middle turbinate bone (Herbert Tilley, M.D.) . 48 

-bony spur from ethmoid (R. Lake) . . . .72 

-removed with nasal polypus: microscopic sections (H. Lambert 

Lack, M.D.) . . . . . 104 

-turbinal, suppurative cyst of (H. J. Davis, M.D.) . . 74 

Bbonnbb (Adolph, M.D.), case of recurrent papillomata of larynx . 24 

Bulbar paralysis (E. B. Waggett) . . . . .61 

Bulbous middle turbinates (R. Lake) . . . .71 

Bust (A. Hamilton), case of a male set. 29, with tubercular laryngitis . 132 

Butlin (Henry T.), case of oesophageal pouch . .27 

— - case of perichondritis of the larynx, following the introduction or 

the retention of a tube in the oesophagus . . 123 

FIRST SERIES—VOL. VII. 


9 





138 


PAGE 

Calculus, nasal: see Rhinolith. 

Carcinoma of larynx (E. B. Waggett) .... 131 

- pharyngo-cesophageal (W. G. Spencer) . . .45 

Cathcaet (George C., M.B.), case of laryngeal affection in a tubercular 

patient for diagnosis . . . . .60 

“Cleavage” of the middle turbinate (so-called), simulated by case of 

chronic etbmoiditis (Herbert Tilley, M.D.) . . . 109 

Commissure, anterior, pseudo-membranous adhesion in (Sir Felix Semon, 

M.D.) . . . . . .70 

Congresses, International: separate sections for Laryngology and Otology at 64 
Council: report of Council, 1899 . . . .35 

-list of Officers and Council, 1900 . . . .35 

Curtain ring exhibited, removed from pharynx of child (H. Lambert Lack, 

M.D.) ... . . . .103 

Cushions, Eustachian: approximation of remains of Luschka’s tonsil and 
Eustachian cushions, producing recesses in naso pharynx (StClair 
Thomson, M.D.) . . . . . .88 

Cyst of epiglottis : lantern demonstration (W; Jobson Horne, M.D.) . 41 

-at base of tongue in case of a child set. 3 (H. FitzGerald Powell, 

M.D.) . . . . . .133 

-probably cystic nature of new growth in vocal cord (J. Dundas 

Grant, M.D.) . . . . .9 

-suppurative, of turbinal bone (H. J. Davis, M.D.) . . 74 


Dayis (Henry J., M.D.), case of suppurative cyst of turbinal bone . 74 

-case of extreme hypertrophy of inferior turbinals in a boy 76 

-case of enlargement of lingual tonsils in a woman ret. 39, with 

secondary syphilis . . . . .112 

-case of ulceration of larynx (shown for Mr. S. Paget) . 117 

Diagnosis, cases for: boy ret. 10, with aphonia (E. W. Rough ton) . 32 

-growth or granuloma of epiglottis (E. B. Waggett) . 26 

-laryngeal affection in tubercular patient (G. C. Cathcart, 

M.B.) . . . . . .60 

-laryngeal cases (R. H. Scanes Spicer, M.D.) . , 95 

-nasal case (Atwood Thorne) . . . .4 

-ulceration of pharynx (StClair Thomson, M.D.) . . 63 

--extensive ulceration of throat (R. H. Scanes Spicer, M.D.). 77 

■■■ - mistake in (Sir F. Semon, M.D.) . . . 15 

Distension, great, of bridge of nose in case of double frontal sinus and 

antral empyema (H. Tilley, M.D.) .... 126 

-of maxillary antrum (H. Lambert Lack, M.D.) . 132 

Downie (J. Walker, M.B.), a case of primary sarcoma of the tonsil in a 

woman ret. 58; successful extirpation through the mouth . 122 


Empyema, antral: new instruments for treatment of (Mr. Acland) . 99 

-chronic, of frontal sinus, cured by radical external operation (H. 

Tilley, M.D.) . . . . . .126 

-double frontal sinus and antral, with great distension of bridge of 

nose (H. Tilley, M.D.) . . . . . 126 

-of frontal sinus, radical operation (H. Tilley, M.D.) 117 

-six cases (H. Tilley, M.D.) . . . .88 

Enlargement of nose (G. William Hill, M.D.) . . 2 

-(StClair Thomson, M.D.) . . . . 3 

-■-(lateral) (G. William Hill, M.D.) . . .2 

-of lingual tonsils in case of secondary syphilis (H. J. Davis, M.D.) 112 

Epiglottis, cyst: lantern demonstration (W. Jobson Horne, M.B.) 41 

-ulceration (H. FitzGerald Powell, M.D.) . . Ill 

Epithelioma of left ary-epiglottie fold (Wyatt Wingrave) . 8 

Ethmoid: bony spur from (R. Lake) . . . 72 



139 


PAGE 

Ethmoiditis, chronic, simulating so-called cleavage of middle turbinate 

(H. Tilley, M.D.) . . . . .109 

Eustachian cushions : see Cushions , Eustachian. 

Extirpation of primary sarcoma of tonsil through mouth, successful (J. 

Walker Downie, M.B.) ..... 122 

Face: case of obstructed subdermal lymphatics of face, in which frontal 

and antral disease had been suspected (P. dc Santi) . • 79 

Fibro-myxoma of post-nasal region : case after removal (H. FitzGerald 

Powell, M.D.) . . , . . .49 

Fibro-papilloma of vocal cord, causing hoarseness; incomplete removal 

with restoration of voice (J. Dundas Grant, M.D.) . . 10 

Fixation, complete, of left vocal cord (Wyatt Wingrave) . . 56 

Forceps, new universal laryngeal (P. Watson Williams, M.D.) . . 102 

Frontal sinus : see Sinus , frontal. 

Glottis; oedema: lantern demonstration (W. Jobson Horne, M.B.) . 41 

Grant (J. Dundas, M.D.), a case of new growth in the vocal cord, prob¬ 
ably cystic in nature . . . . .9 

- a case of fibro-papilloma of the vocal cord causing hoarseness; 

restoration of voice after incomplete removal of the growth . 10 

- case of tertiary specific ulceration of ala nasi . . 30 

- case of tuberculous ulceration of the pharynx and of the lower lip 31 

- case of rhinoscleroma . . . . .85 

- specimen of larynx removed on account of sarcoma .86 

- case of tonsillar ulceration of uncertain origin . . 93 

- case of growth in the neck associated with cedema of one ary- 

epiglottic fold . . . . . .112 

- a case of inter- and subcordal growth, with hoarseness of remark¬ 
ably sudden development . . . . .113 

-female patient, set. 49, from whom the larynx had been com¬ 
pletely removed on account of sarcoma . . . 128 

- case of intercordal tumour (tubercular) of the larynx in an elderly 

man ....... 129 

- case of tonsillar ulceration of uncertain origin (specific) . 129 

Granuloma, or growth of epiglottis for diagnosis (E. B. Waggett) . 26 

Growth from arytaenoid region in male set. 56 (R. Lake) . . 71 

- in larynx of male set. 25 (H. FitzGerald Powell, M.D.) . . 68 

- in neck associated with cedema of one ary-epiglottic told (J. Dun¬ 
das Grant, M .D.) . . . . . .112 

- inter- and subcordal, with hoarseness of sudden development 

(J. Dundas Grant, M.D.) . . , . 113 

- laryngeal (W. H. Kelson, M.D.) .... 115 

-in a man with altered voice for over thirty-five years 

(Hector Mackenzie, M.D.) . . . . ♦ 6 

- naso-pharyngeal: ? sarcoma (L. H. Pegler, M.D.) . . 54 

- pharyngeal, involving larynx in man ait. 59 (E. Furniss Potter, M.D.) 72 

-and laryngeal, with microscopic section (E. Furniss Potter, 

M.D.) . ... . . . .114 

- (new) in vocal cord, probably cystic (J. Dundas Grant, M.D.) . 9 

- or granuloma of epiglottis for diagnosis (E. B. Waggett) . 26 

-see also Malignant growth. 

Heath (Charles), case of sinuses in the vault of the naso-pbarynx . 65 

Hill (G. William, M.D.), case of enlargement of the nose . .2 

-a case of lateral enlargement of the nose . . .2 

Hoarseness caused by fibro-papilloma of vocal cord (J. Dundas Grant, M.D.) 10 

-of remarkably sudden development in case of inter- and sub¬ 
cordal growth (J. Dundas Grant, M.D.) . . . 113 

——— and aphonia of long standing, in a girl act. 13 (P. de Santi) 78 




140 


PAGE 


Horne (W. Jobson, M.B.), lantern demonstrations:—(1) oedema of the 
glottis; (2) cyst of the epiglottis; (3) laryngeal tuberculosis; (4) 
pachydermia laryngis verrucosa . . . 40,41,42 

- case of pachydermia laryngis . . * .59 

-case of ulceration of the larynx . . . .79 

— inflammation of crypts in the mucous membrane covering a defined 
recess in the roof of the naso-pharynx, giving rise to otalgia and other 
symptoms ...... 102 

Hypertrophy, extreme, of inferior turbinals (H. J. Davis, M.D.) . 76 

Indrawing, unusual, of al® nasi (Richard Lake) . . .9 

Infancy, primary atrophic rhinitis commencing in (W. G. Spencer) . 46 

Inflammation of crypts of mucous membrane covering defined recess in 

roof of naso-pharynx (W. Jobson Horne, M.B.) . . . 102 

Injections, intra-inuscular, in treatment of double abductor paralysis (L. 

H. Pegler, M.D.) . . . . . .28 

Injury of the larynx in a female (L. A. Lawrence) . . .45 

Instruments, new, for treatment of antral empyema (Mr. Aclaud) . 99 

-see also Forceps . 

Iuterarytaenoid region ; ulceration of false cords, true cords and inter- 

arytsenoid region (specimen shown by Mr. Bergin for Mr. R. Lake) . 130 

Intra-muscular injections in treatment of double abductor paralysis (L. II. 

Pegler, M.D.) . . . . . .28 

Intubation: case in which there was difficulty in removing tracheotomy 

tube (E. W. Houghton) . . . . .94 

-perichondritis of larynx following introduction or reduction of tube 

in oesophagus (H. T. Butlin) ..... 123 

-see also Tubage. 

Kelson (William H., M.D.), case of laryngeal growth . . . 115 

Lack (H. Lambert, M.D.), case of nasal polypi with suppuration and 

(?) absence ot maxillary sinuses . . . .57 

-a specimen of a curtain ring removed from the pharynx of a child . 103 

-two cases of nasal polypi treated by a new radical method, with 

microscopic sections of the bone removed . . . 104 

-case of a male set. 20, with distension of the maxillary antrum . 132 

Lake (Richard), male, with unusual indrawing of the aim nasi . . 9 

-case of bulbous middle turbinates . . .71 

-case of growth from the arytmnoid region in a male ®t. 56 . 71 

-specimen of bony spur from ethmoid . . .72 

-specimen mounted to show ulceration of the false cords, true 

cords, and interarytmnoid region (shown by Mr. Bergin) . . 130 

" ■ ; - specimen showing tubercular ulceration of the larynx (shown by 
Mr. Bergin) ...... 131 

Laryngitis, hypertrophic, caused by hereditary syphilis (StClair Thomson, 

M.D.) . . . . . . 88 

-tubercular, in a man aet. 31 (H. FitzGerald Powell, M.D.) . 33 

-in case of male mt. 29 (Hamilton Burt) . . 132 

Laryngology: separate section for, at all International Congresses . 64 

Laryngoplegia, almost complete, in case of tabes (Sir Felix Semon, M.D.) . 42 

Larynx: anatomical and pathological preparations shown by lantern slides 

(P. Watson Williams, M.D.) . . . . .40 

-carcinoma of (E. B. Waggett) .... 131 

-growth (W. H. Kelson, M.D.) . . . .115 

-(anterior commissure) in a man with altered voice for over 

thirty-five years (Hector Mackenzie, M.D.) . . .6 

-growth in, in case of male cot. 25 (H. FitzGerald Powell, M.D.) . 68 

-pharyngeal and laryngeal, with microscopic speci¬ 


men (E. Furniss Potter, M.D.) . . . 114 





141 


PAGE 

Larynx involved by pharyngeal growth in case of man set. 59 (E. Furniss 


Potter, M.D.) . . . . . .72 

-injury of, in a female (L. A Lawrence) . . .45 

-laryngeal affection in tubercular patient for diagnosis (G. C. Cath- 

cart, M.B.) . . . . . .60 

-laryngeal case for diagnosis (R. H. Soanes Spicer, M.D.) . 95 

-laryngeal forceps, new universal (P. Watson Williams, M.D.) . 102 

-laryngeal (?) whistling (Sir F. Semon, M.D.) . . 83 

-malignant disease of pharynx and larynx (P. Macleod Yearsley) . 92 

-extra-laryngeal (?) malignant growth (shown by Mr. E. B. Waggett 

for Mr. W. R. H. Stewart) . . . . .13 

-occlusion, case of, in typhoid fever (E. B. Waggett) . . 127 

-acute oedema, specimen (A. Logan Turner, M.D.) . . 97 

-pachydermia laryngis : case (W. Jobson Horne, M.B.) . . 59 

---case (C. A. Parker) . . .80 

-verrucosa: lantern demonstration (W. Jobson 

Horne, M.B.) . . . . . .42 

-papillomata, recurrent (A. Bronner, M.D.) . . .24 

-perichondritis of, complicating pulmonary tuberculosis (R. H. 

Scanes Spicer, M.D.) . . . . .13 

-perichondritis of, following introduction or retention of tube in 

oesophagus (H. T. Butlin) ..... 123 

—:-removal for sarcoma (J. Dundas Grant, M.D.) . . 128 

-specimen of, removed on account of sarcoma (J. Dundas Grant, 

M.D.) . . . . . . .86 

-tubercle of (C. J. Symonds) . . . .28 

-— tuberculosis, lantern demonstration (W. Jobson Horne, M.B.) . 41 

-— intereordal tumour (tubercular) in elderly man (J. Dundas Grant, 

M.D.) . . . . . . .129 

-ulceration (W. Jobson Horne, M.B.) . 79 

-(E. Law, M.D.) ..... 109 

-(case shown by Dr. H. J. Davis for Mr. S. Paget) . 117 

-tubercular (specimen shown by Mr. Bergin for Mr. R. Lake) 131 

Law (Edward, M.D.), case of laryngeal ulceration . . . 109 

-case of lupus of the nose in a female set. 35 . . 135 

Lawrence (Laurie Asher), case of injury of the larynx in a female . 45 

-case of advanced atrophic rhinitis in a young girl . . 73 

Librarian : report of Librarian for 1899 . . . .37 

Lip, lower: tuberculous ulceration (J. Dundas Grant, M.D.) . . 31 

Luschka’s tonsil: see Tonsil , Luschka’s. 

Lymphangioma (?), growth removed from right ventricular band of man 

set. 40 (Furniss Potter, M.D.) . . . .1 

Lymphatics, obstructed subdermal, of face, in case in which frontal and 

antral disease had been suspected (P. de Santi) . . .79 

Lupus of nose (E. Law, M.D.) ..... 135 

Mackenzie (Hector, M.D.), a case of laryngeal growth (anterior commis¬ 
sure) in a man with altered voice for over thirty-five years . .6 

Malignant disease of pharynx and larynx (P. Macleod Yearsley) . 92 

(?) Malignant growth, extra-laryngeal (shown by Mr. E. B. Waggett for 

Mr. W. R. H. Stewart) . . . . .13 

Maxillary sinus: see Sinus (maxillary). 

Mistake in diagnosis (Sir F. Semon, M.D.) . . . .15 

Morbid Growths Committee: report . . . .55 

Mouth: successful extirpation of primary sarcoma of tonsil through 

mouth (J. Walker Downie, M.B.) .... 122 

Mucous membranes: inflammation of crypts of mucous membrane cover¬ 
ing defined recess in roof of naso-pharynx (W. Jobson Horne, M.B.) 102 

Myxo-fibroma (?) of post-nasal space (H. FitzGerald Powell, M.D.) 21 

§ 





142 


PAGE 


Naso-pharynx : inflammation of crypts of mucous membrane covering de¬ 
fined recess in roof of naso-pharynx (W. Jobson Horne, M.B.) . 102 

-recesses in, produced by approximation of remains of Luschka’s 

tonsil and Eustachian cushion (StClair Thomson, M.D.) . . 88 

-sinuses in the vault of (Charles Heath) . . .65 

Neck: growth in, associated with oedema of one ary-epiglottic fold (J. 

Dundas Grant, M.D.) ..... 112 

Necrosis, extensive, following nasal polypi and sinus disease (W. G. 

Spencer) . . . . . . .92 

Nose : aim nasi, unusual indrawing (Richard Lake) . . .9 

-anatomical and pathological preparations shown by lantern slides 

(P. Watson Williams, M.D.) . . . . .40 

-calculus of: see Mhinolith. 

-distension (great) of bridge of nose in case of double frontal sinus 

and antral empyema (H. Tilley, M.D.) . . . 126 

■ — ■■ enlargement of (G. William Hill, M.D.) . . .2 

-(StClair Thomson, M.D.) . . . .3 

-fibro-myxoma of post-nasal region; case after removal (H. Fitz¬ 
Gerald Powell, M.D.) . . . . .49 

— lupus of (E. Law, M.D.) ..... 135 

-(?) myxo-fibroma of post-nasal space (H. FitzGerald Powell, M.D.) 21 

-nasal case for diagnosis (Atwood Thorne) . . .4 

-nasal polypi followed by extensive necrosis (W. G. Spencer) . 92 

-radical operation (C. A. Parker) . . . 124 

-treated by new radical method (H. Lambert Lack, M.D.) 104 

-with suppuration and (?) absence of maxillary sinuses (H. 

Lambert Lack, M.D.) . . . . .57 

-naso-pharyngeal growth (? sarcoma) (L. H. Pegler, M.D.) . 54 

-post-nasal adenoids, well-marked (StClair Thomson, M.D.) . 63 

-post-nasal sarcoma (E. B. Waggett) . . .11 

-swelling about bridge of nose (shown by Mr. E. B. Waggett for 

Mr. W. R. H. Stewart) . . . . .31 

-tumour of nasal septum [angiosarcoma] (H. Tilley, M.D.) 80, 91 

-ulceration of aim nasi (C. A. Parker) . . .32 

-(tertiary specific) of aim nasi (J. Dundas Grant, M.D.) . 30 

Nostril: obstruction of one nostril from antral affection of uncertain 

character (StClair Thomson, M.D.) . . . .67 

Obstruction of one nostril from antral affection of uncertain character 

(StClair Thomson) . . . . . .67 

Occlusion, laryngeal, in typhoid fever (E. B. Waggett) . . 127 

(Edema of the glottis: lantern demonstration (W. Jobson Horne, M.B.) . 41 

-acute, of the larynx, specimen (A. Logan Turner, M.D.) . 97 

(Esophagus: perichondritis of larynx following introduction or retention 

of tube in oesophagus (H. T. Butlin) .... 123 

-pharyngo-oesophageiil carcinoma (W. G. Spencer) . . 45 

-pouch of (H. T. Butlin) . . . . .27 

-stricture of: case under tubage for twelve months (C. J. Symonds) 91 

Otalgia and other symptoms caused by inflammation of crypts in mucous 
membrane covering defined recess in roof <rf naso-pharynx ( W. Jobson 
Horne, M.B.) ...... 102 

Otology, separate section for, at all International Congresses . , 64 


Pachydermia laryngis: case (W. Jobson Horne, M.B.) 

-(C. A. Parker) . 

-verrucosa : lantern demonstration ( W. Jobson Horne, M.B.) 

Pagkt (Stephen), case of tracheal stenosis (shown for Dr. Pasteur) 

-ease of ulceration of larynx (shown by Dr. H. J. Davis) . 

Palate (soft), cleft (StClair Thomson, M.D.) . 

-paresis (Wyatt Win grave) . 


5 J 

8 ^ 

4- 

9° 

11 ' 

6 ° 

25 





143 


PAGE 


Papilloma : papillomatous condition of tongue (J. B. Ball, M.D.) . 47 

Papillomata, recurrent, of larynx (A. Bronner, M.D.) . . .24 

Paralysis, abductor, bilateral (Wyatt Wingrave) . . . 116 

-double, under treatment by intra-muscular injections (L. H. 

Pegler, M.D.) . . . . . .28 

-bulbar (E. B. Waggett) . . . . .61 

Paresis of soft palate (Wyatt Wingrave) . . . .25 

Parker (Charles A.), ulceration of alra nasi. . . .32 

-case of pachydermia laryngis . . . .80 

-case of radical operation for nasal polypi . . . 124 

Pasteur (W., M.D.), case of tracheal stenosis (shown by Mr. Stephen 

Paget) . . . . . . .98 

Pedunculated tonsil (H. Tilley, M.D.) .... 134 

Pegler (L. Hemington, M.D.), case of double abductor paralysis under 

treatment by intra-muscular injections . . . .28 

- case of intractable aphonia with occasional apsithyria . . 51 

-case of naso-pharyngeal growth (? sarcoma) . . .54 

Perichondritis, laryngeal, complicating pulmonary tuberculosis (It. H. 

Scanes Spicer, M.D.) . . . . .13 

-laryngeal, following introduction or retention of tube in oeso¬ 
phagus (H. T. Butlin) ..... 123 

Pharynx : abnormal pulsating pharyngeal vessel (H. Tilley, M.D.) . 91 

-anatomical and pathological preparations shown by lantern slides 

(P. Watson Williams, M.D.) . . . . .40 

-carcinoma, pharyngo-cesophageal (W. G. Spencer) . . 45 

-curtain ring removed from pharynx of child (H. Lambert Lack, 

M.D.) . . . . . . .103 

-growth of, involving larynx, iu man set. 59 (E. Furniss Potter, M.D.) 72 

-naso-pharyngeal (? sarcoma) (L. H. Pegler, M.D.) . 54 

-pharyngeal and laryngeal, with microscopic section (E. 

Furniss Potter, M.D.) . . . . .114 

-malignant disease of pharynx and larynx (P. Macleod Tearsley) . 92 

-ulceration: case for diagnosis (StClair Thomson, M.D.) . . 63 

-tuberculous (J. Dunclas Grant, M.D.) . . .31 

Polypus: nasal polypi followed by extensive necrosis (W. G. Spencer) . 92 

-treated by new radical method (H. Lambert Lack, 

M.D.) . . . . . . .104 

-with suppuration and (?) absence of maxillary 

sinuses (H. Lambert Lack, M.D.) . . . .57 

-radical operation for nasal polypi (C. A. Parker) . . 124 

Pottkr (Furniss, M.D.), microscopical section of a growth (? lymph¬ 
angioma) removed from the right ventricular band of a man set. 40 . 1 

-case of pharyngeal growth involving the larynx in a man set. 59 . 72 

-case of pharyngeal and laryngeal growth in a man set. 59—shown at 

the March meeting—with microscopic section of portion of growth 
removed ....... 114 

Pouch, oesophageal (H. T. Butlin) . . . . .27 

Powell (H. FitzGerald, M.D.), case of (?) myxo-fibroma of the post-nasal 

space . . . . . . .21 

-case of tubercular laryngitis in a man set. 31 . . .33 

-case of male set. 17 years, after removal of fibro-myxoma of the 

post-nasal region . . . . . .49 

-case of a growth in the larynx in a male set. 25 . .68 

-case of ulceration of epiglottis . . . .111 

-case of a child rat. 3, with a cyst at base of tongue . . 133 

Resonators of the voice (W. A. Aikin) .... 121 

Rhinitis, advanced atrophic, in a young girl (L. A. Lawrence) . . 73 

-primary atrophic, commencing in infancy (W. G. Spencer) . 46 

Rhinolith (C. J. Symonds) . . . . .29 





144 


lthinoscleroma, case of (J. Dundas Grant, M.D.) 

Rotjghton (E. W.), case for diagnosis; a boy, set. 10, suffering from 
aphonia ....... 

-case in which there was difficulty in removing a tracheotomy tube 

db Santi (Philip), case of double uvula . 

-case of hoarseness and aphonia of long standing in a girl set. 13 

-case of obstructed subdermal lymphatics of the face, in which 

frontal and antral disease had been suspected 
Sarcoma of larynx: case after removal of larynx (J. Dundas Grant, M.D.) 

--specimen of larynx removed on account of (J. Dundas 

Grant, M.D.) *. 

-naso-pharyngeal growth (?) sarcoma (L. H. Pegler, M.D.) 

-of post-nasal t-pace (E. B. Waggett) 

-primary, of tonsil: successful extirpation through mouth (J. 

Walker Downie, M.B.) . 

Semon (Sir Felix), a diagnostic mistake .... 

-case of tabes with almost complete laryngoplegia 

-pseudo-membranous adhesion in the anterior commissure and sym¬ 
metrical thickening below the anterior part of the vocal cords (con¬ 
genital ?) in a young man ..... 

-case of laryngeal (?) whistling .... 

Sinus, frontal: disease of, followed by extensive necrosis (W. G. Spencer) 

-empyema of, six cases (H. Tilley, M.D.) 

-chronic empyema of, cured by radical external operation 

(H. Tilley, M.D.) . 

-double frontal sinus and antral empyema with great dis¬ 
tension of bridge of nose (H. Tilley, M.D.) 

-radical operation for empyema of (H. Tilley, M.D.) 

- maxillary : question of absence of maxillary sinuses in case of 

nasal polypi (H. Lambert Lack, M.D.) .... 

-(sphenoidal), case in which orifice of sphenoidal sinus was shown 

(E. B. Waggett) ...... 

Sinuses in the vault of the naso-pharynx (Charles Heath) 

Spencer (Walter G.), case of pharyngo-cesophageal carcinoma . 

-case of primary atrophic rhinitis commencing in infancy 

-case of thyrotomy for tertiary syphilitic laryngitis ». 

-case of extensive necrosis following nasal polypi and sinus disease . 

Sphenoidal sinus: see Sinus , sphenoidal. 

Spicer (R. H. Scanes, M.D.), case of laryngeal perichondritis in a man of 
twenty-six, the subject of pulmonary tuberculosis 

-case of extensive ulceration of throat for diagnosis 

-laryngeal case for diagnosis .... 

Spur, bony, from ethmoid (R. Lake) .... 

Stenosis, tracheal (case shown by Mr. Stephen Paget for Dr. Pasteur) 
Stewart (W. R. H.), extra-laryngeal (?) malignant growth (shown by Mr. 
E. B. Waggett) ...... 

-case of swelling about the bridge of the nose (shown by Mr. E. B. 

Waggett) ....... 

Stricture of oesophagus; case under tubage for twelve months (C. J. 
Symonds)....... 

Suppuration in case of nasal polypi (H. Lambert Lack, M.D.) 

Suppurative cyst of turbinal bone (H. J. Davis, M.D.) 

Swelling about the bridge of the nose (shown by Mr. E. B. Waggett for 
Mr. W. R. H. Stewart) ..... 

Symonds (Charters J.), a case of tubercle of the larynx 

-rhinolith ...... 

-case of oesophageal stricture under tubage for twelve months 

Syphilis, hereditary, causing hypertrophic laryngitis (StClair Thomson, 
M.D.) ....... 


PAGE 

85 

32 
94 

33 

78 

79 
128 

86 
54 
11 

122 

15 

42 


70 

83 

92 

88 

126 

126 

117 

57 

131 

65 

45 

46 
62 
92 


13 

77 

95 

72 

98 

13 

31 

91 

57 

74 

31 

28 

29 

91 


88 





145 


PAGE 

Syphilis, secondary, enlargement of lingual tonsils in case of (H. J. Davis, 

M.D.) . . . . . . 112 

-ulceration of tonsil of uncertaiu origin (specific) (J, Dundas 

Grant, M.D.) . . . . . . . 129 

-tertiary specific ulceration of alae nasi (J. Dundas Grant, M.D.) . 30 

-thyrotomy for tertiary syphilitic laryngitis (W. G. Spencer) . 62 

-unusual lorm of ulceration of throat in case of (Wyatt Wingrave) • 56 

Tabes, case of, with almost complete laryngoplegia (Sir Felix Semon, 

M.D.) •...••« 42 

Thickening, symmetrical, below anterior part of vocal cords (Sir Felix 

Semon, M.D.) . . . . . .70 

Thomson (StClair, M.D.), female ast. 24 with enlargement of nose . 3 

-male set. 15 with enlargement of nose . . „ .3 

-case of ulceration of the pharynx for diagnosis . . 63 

- cleft soft palate and well-marked post-nasal adenoids . . 63 

-case of a female set. 23, with obstruction of one nostril from antral 

affection of uncertain character . . . , .67 

-case of a girl with hereditary syphilis causing hypertrophic laryn¬ 
gitis, and showing recesses in the naso-pharynx produced by the 
approximation of the remains of Luschka’s tonsil and the Eustachian 
cushions . . . .. . . .88 

Thokne (Atwood), nasal case for diagnosis . . . - .4 

Throat: ulceration, extensive; case for diagnosis (R. H. Scanes Spicer, 

M.D.) . . . . . . ... 77 

-unusual form in patient the subject of syphilis (Wyatt 

Wingrave) . . . . . .56 

Thyrotomy for tertiary syphilitic laryngitis (W. G. Spencer) . . 62 

Tilley (Herbert, M.D.), specimen of a bony cyst of middle turbinate bone 48 

-case of tumour of nasal septum . . . .80 

-six cases of frontal sinus empyema . . . .88 

-case of abnormal pulsating pharyngeal vessel . .91 

-specimen of nasal angiosarcoma, shown at last meeting . . 91 

-case of chronic ethmoiditis simulating so-called “cleavage” of 

the middle turbinate . . . . 109 

-case of radical operation for chronic frontal sinus empyema . 117 

-case of chronic frontal sinus empyema cured by radical external 

operation . .' . . . . 126 

-case of double frontal sinus and antral empyema, with great dis¬ 
tension of bridge of nose ..... 126 

-case of pedunculated tonsil .... 134 

Tongue: cyst at base of, in case of a child ®t. 3 (H. FitzGerald Powell, 

M.D.) . . . . . .133 

- papillomatous condition (J. B. Ball, M.D.) . . .47 

Tonsil, pedunculated (H. Tilley, M.D.) . . . . 134 

-primary sarcoma: successful extirpation through mouth (J. 

Walker Downie, M.B.) . . . . 122 

-ulceration of uncertain origin (J. Dundas Grant, M.D.) . 93 

-(specific) (J. Dundas Grant, M.D.) . . . 129 

-(t'aucial) ulcer, acute (Wyatt Wingrave) . . .25 

-(lingual) enlargement of lingual tonsils in case of secondary 

syphilis (H. J. Davis, M.D.) ..... 112 

-Luschka’s: approximation of remains of Luschka’s tonsil and 

Eustachian cushions producing recesses in naso-pharynx (StClair 
Thomson, M.D.) . . . . . .88 

Trachea : stenosis (case shown by Mr. Stephen Paget for Dr. Pasteur) . 98 

Tracheotomy tube, case in which there was difficulty in removing (E. W. 

Houghton) . . . . . . 94 

Treasurer : Annual Report, 1899 . . . . .36 

Tubage : see also Intubation . 



146 


PAGE 

Tuberculosis: intercordal tubercular tumour of larynx in elderly man (J. 

Dundus Grant, M.D.) . . . . . 129 

-laryngeal affection in tubercular patient for diagnosis (G. C. Cath- 

cart,M.B.) . . • . . . ,60 

-laryngeal, lantern demonstration (W. Jobson Horne, M.B.) . 41 

-r pulmonary, complicated by laryngeal perichondritis (R. H. Scanes 

Spicer, M.D.) . . . . . .13 

-tubercle of larynx (C. J. Symonds) . . . .28 

-tubercular laryngitis in a man set. 31 (H. FitzGerald Powell, M.D.) 33 

*---in case of male set. 29 (Hamilton Burt) . . 132 

-ulceration of larynx (specimen shown by Mr. Bergin for 

Mr. R. Lake) . • . . . . 131 

-•> tubercular ulceration of pharynx and lower lip (J. Dundas Grant, 

M.D.) ••••••• 31 

Tumour of larynx (intercordal, tubercular) in elderly man (J. Dundas 

Grant, M.D.) ...... 129 

-of nasal septum (angiosarcoma) (H. Tilley, M.D.) . 80, 91 

Turbinal bone, suppurative cyst of (H. J. Davis, M.D.) . . 74 

Turbinals, inferior, extreme hypertrophy (H. J. Davis, M.D.) . . 76 

Turbinate bone, bony cyst of (Herbert Tilley, M.D.) . . .48 

-middle, "cleavage” simulated by case of chronic ethmoiditis (H. 

Tilley, M.D.) . . . ... 109 

---bulbous middle turbinates (R. Lake) . . .71 

Turner (A. Logan, M.D.), a specimen of acute oedema of the larynx . 97 

Typhoid fever, occlusion of larynx in (E. B. Waggett) . . 127 

Ulcer, acute, of faucial tonsil (Wyatt Wingrave) . . .25 

Ulceration of ala nasi, (C. A. Parker) . . . .32 

— ■ of ala nasi, tertiary specific (J. Dundas Grant, M.D.) . . 30 

-of false cords, true cords, and interarytaenoid region (specimen 

shown by Mr. Bergin for Mr. R. Lake) .... 130 

-of epiglottis (H. FitzGerald Powell, M.D.) . . . Ill 

-of larynx (W. Jobson Horne, M.B.) . . . .79 

-(E. Law, M.D.) . . . . .109 

-(case shown by Dr. H. J. Davis for Mr. S. Paget) . 117 

-tubercular (specimen shown by Mr. Bergin for Mr. R. 

Lake) ....... 131 

-of pharynx: case for diagnosis (StClair Thomson, M.D.) , 63 

-and of lower lip, tuberculous (J. Dundas Grant, M.D.) . 31 

-of throat, extensive: case for diagnosis (R. H. Scanes Spicer, 

M.D.) . . . . . .77 

-unusual form in patient the subject of syphilis (Wyatt 

Wingrave) . . . . .56 

-of tonsil, of uncertain origin (J. Dundas Grant, M.D.) . . 93 

-(specific) (J. Dundas Grant, M.D.) . . . 129 

Uvula, double (P. de Santi) . . . . .33 

Ventricular band (right), growth removed from (lymphangioma ?) (Furniss 

Potter, M.D.) . . . . . .1 

Vessel, pharyngeal, abnormal pulsating (H. Tilley, M.D.) . . 91 

Vocal cord: pseudo-membranous adhesion iu anterior commissure and 
symmetrical thickening below anterior part of vocal cords (con¬ 
genital ?) (Sir Felix Semon, M.D.) . . . .70 

-ulceration of false cords, true cords, and interarytsenoid region 

(specimen shown by Mr. Bergin for Mr. R. Lake) . . 130 

-(left) : complete fixation (Wyatt Wingrave) . . .56 

- -fibro-papilloma causiug hoarseness (J, Dundas Grant, 

M.D.) . . . . . . .10 

-new growth in, probably cystic (J. Dundas Grant, M.D.) . 9 



147 


PAGE 


Voice, alteration in, extending over thirty-five years in a man with 

laryngeal growth (anterior commissure) (Hector Mackenzie, M.D.) . 6 

-resonators of (W. A. Aikin) .... 121 

-restoration after incomplete removal of fibro-papilloma of vocal 

cord (J. Dundas Grant, M.D.) . . . .10 

Waggett (E. B.), case of sarcoma of the post-nasal space . 11 

-extra-laryngeal (?) malignant growth (shown for Mr. W. R. H. 

Stewart) . . . . . . 13 

-- growth or granuloma of the epiglottis for diagnosis . . 26 

-case of swelling about the bridge of the nose (shown for Mr. W. R. 

H. Stewart) . . . . . .31 

-case of bulbar paralysis . . . . .61 

-case of laryngeal occlusion in typhoid fever . . 127 

-case of carcinoma laryngis. .... 131 

-case showing the orifice of the sphenoidal sinus . .131 

Whistling, laryngeal (?) (Sir F. Semon, M.D.) . . .83 

Williams (P. Watson, M.D.), stereoscopic lantern slides of anatomical 
and pathological preparations of larynx, pharynx, nose, and accessory 
cavities . . . . . . 40 

-a new universal laryngeal forceps .... 102 

Wingbaye (Wyatt), a case of epithelioma of the left ary-epiglottic fold in 

a man aged sixty-five . . . . .8 

-case of acute ulcer of the faucial tonsil . . .25 

-case of paresis of soft palate . . . .25 

-a case of complete fixation of the left vocal cord . 56 

-an unusual form of ulceration of the throat in a patient the subject 

of syphilis . . . . . .56 

-case of bilateral abductor paralysis . . . .116 

Yeabslby (P. Macleod), case of malignant disease of pharynx and larynx . 92 


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Full text of "Proceedings of the Laryngological Society of London 5.1898 - 7.1900"

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