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PROCEEDINGS

OF THE

LARYNGOLOGlCAE

' * t 1 >

SOCIETY

LONDON.

VOL. VIII.

1900 — 1901 .

WITH

LIST OF OFFICERS, LIST OF MEMBERS, ETC.

/ '

LONDON:

PRINTED BY ADLARD AND SON,

BARTHOLOMEW CLOSE, E.C.

1901 .

i It.22.

L% 3 >

OFFICERS AND COUNCIL

OF THE

^targngological of §Uttimi

ELECTED AT

THE ANNUAL GENERAL MEETING,

JANUARY 4th, 1901.

IPwsibtnt.

E. CRESS WELL BABER, M.B.

Uiee-|lresib.mts.

V A. A. BOWLBT, F.R.C.S. GREYILLE MACDONALD, M.D-

'5 E. LAW, M.D.

\ Crtasurer.

E. CLIFFORD BEALE, M.B., F.R.C.P.

. 1 ' librarian.

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

Stmfams.

' E. B. WAGGETT, M.B. C. A. PARKER, F.R.C.S. (Edin)

(Comttil.

J. DE HAYILLAND HALL, M.D.
.HERBERT TILLEY, F.R.C.S.
"'BARCLAY BARON, M.B.

WILLIAM HILL, M.D.
Sir FELIX SEMON, M.D.
LAMBERT LACK, M.D.

421899

PRESIDENTS OF THE SOCIETY.

ELECTED

1893

1894-6

1897-8

1899-1900

(From its Formation.)

Sir George Johnson, M.D., F.R.S.

Sir Felix Semon, M.D., F.R.C.P.

H. Trentham Bhtlin, F.R.C.S.

F. de Havilland Hall, M.D., F.R.C.P.

1901

E. Cresswell Baber, M.B.

PROCEEDINGS

OP THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Sixtieth Ordinary Meeting, November 2nd, 1900.

F. de Havilland Hall, M.D, President, in the Chair.

Lambert Lack, M.D.,
Ernest Waggett, M.B.,

| Secretaries.

Present—89 members and 3 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:

Herbert William Carson, F.R.C.S., Craigholm, Upper Clapton,
N.E.

Edward John Budd-Budd, Eagle House, 73, South Side,
Clapham Common.

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

Frederick J. J. Wilby, M.B., B.S.Durh., 23, Henrietta Street,
W.

Braine Hartnell, Cotswold Sanatorium.

George Jones, 8, Church Terrace, Lee, S.E.

J. Stewart Mackintosh, St. Ives, Platt’s Lane, Hampstead.

FIRST SERIES-VOL. VIII. 1

2

The following cases and specimens were shown:

A Case op Mucous Polypus op Larynx.

Shown by Mr. Stewart. A woman aet. 78, for eleven years
has had catching of the breath when laughing, and for three
years increasing hoarseness. Examination shows a mucous
polypus occupying the whole of the right vocal cord. In my
experience laryngeal mucous polypi are comparatively rare, and
very rare in old people. They usually occur in middle life.
Mackenzie in his book gives only one case over 50, and that was
in a woman aged 70.

The President suggested the removal of the growth. It was a
cyst and could be readily taken away.

Mr. Stewart had suggested operation, but the patient said the
tumour had been present from birth, and she would rather keep it.

Specimen op Cancer of the (Esophagus, causing Complete

Laryngeal Paralysis.

Shown by Mr. W. G. Spencer. The patient from which the
specimen was taken was admitted into hospital with rapidly
progressive laryngeal dyspnoea. It was difficult to examine the
larynx on account of the dyspnoea, and therefore no exa,ct
diagnosis could be made, but it was particularly noted that
there was no dysphagia.

I explored the larynx by thyrotomy and found the left cord
absolutely immobile and the right scarcely moving at all. The
left vocal cord was completely removed and the patient recovered
apparently well, his breathing being quite relieved. But soon
after the wound had healed he developed a tracheo-oesophageal
fistula which was quickly fatal.

The specimen shows extensive epitheliomatous ulceration of
the oesophagus which has extended to the trachea and the glands
so as to involve the, recurrent laryngeal nerves.. The position of
the left vocal cord is occupied by a fine scar. The temporary-
relief to the patient was even more satisfactory than a tracheo¬
tomy could have been.

3

: The President said that the case Was originally under his care.
The causation of the paralysis was extremely obscure, nothing definite
being ascertainable. The operation of thyrotomy and excision of the
Yocakcord as performed by Mr. Spencer, though objected to in the
past, certainly gave the patient considerable relief, and it was,- per¬
haps, the best thing that could be done.

Sir Felix Semon said they all knew that in cases of thyrotomy for
malignant disease when a vocal cord was removed a cicatricial band
formed at the level where the vocal cord was removed. Under these
circumstances the advantage of the operation so far as the relief to
breathing was concerned seemed to him very doubtful. If the patient
had lived a little longer than he did, one would have expected a
recurrence of the stenosis to occur. This theoretical reasoning found
a practical corroboration in the experience that when a vocal cord was
cut out in roaring horses no lasting benefit whatever to the breathing
was effected.

Mr. Spencer questioned whether in thyrotomy sufficient growth
was always removed. In the specimen only a fine scar was to be
seen. Had this patient lived longer would he have had a cicatricial
band ?

Sir Felix Semon remarked that it was impossible to remove more
than was done in a case of malignant disease where everything in the
neighbourhood of the growth was removed.

The President suggested the occasional devotion of a meeting to
the exhibition of sequelae of cases previously shown to the Society]
such cases were apt to be lost sight of and much valuable information
was thus wasted.

Case op Progressive Sinking of the Bridge op the Nose;
following Bilateral Hematoma op the Septum.

Shown by Mr. W. Gr. Spencer. About two years ago the boy
had a fall on his face. There was no displacement nor fracture
of the nose, but on each side a well-marked hsematoma just within
the anterior nares. These were absorbed without suppuration
and the nose appeared to be unaltered by the accident; but a
month ago the boy was again seen, as a progressive sinking of
the bridge of the nose had occurred. On examination the septum
is seen to be twisted, the muco-periosteum thickened, and the
nasal passages much narrowed. There is no evidence of inherited
syphilis.

The case is exhibited because the injury seems to have set up
a chondritis and softening such as may happen in joints after
slight injuries. There is always much doubt as to whether spurs

4

and deviations of the septum are congenital or traumatic in
origin. The case shows that these deformities may arise
gradually some time after a slight injury and yet be really due
to it.

The President related the case of a lady of about sixty, who had
complained of a swollen septum which interfered with nasal respira¬
tion, and of pain in the arch of the nose, which was somewhat reddened.
At the time he had not taken a grave view of the case. Ten days
after seeing the patient there was a rapid increase of the swelling.
An abscess formed; the cartilage came away, and in a fortnight the
bridge of the nose was sunken. At his examination of the case he had
used cocaine, to the application of which the patient had attributed
the subsequent trouble. This was an extremely rapid case, in which
there was no history of syphilis, and absolutely no cause to explain
the mischief. It formed a considerable contrast to the gradual pro¬
gression which had taken place in the case under discussion.

Dr. StClair Thomson asked the President whether in his case
the nasal bones fell in or the end of the nose.

The President said the nasal bones had fallen in.

Dr. StClair Thomson had watched carefully one or two cases of
hsematoma of the septum. One was of interest by reason of the sup¬
puration which had occurred: it seemed to be a hsematoma, but was
in reality an acute abscess. He attributed it to infection from a sup¬
purating maxillary antrum. A portion of the cartilage came away.
All the cases recovered without any injury to the appearance of the
nose. He would suggest in this case that the collapse of the bridge
was due to inherited syphilis. Certainly there was no distinct history,
but the mother had had miscarriages and dead children, and she states
that there is sometimes a nasty smell from the boy’s nose. There was
still a good deal of purulent matter about the middle turbinals.

Mr. Paget said it was surely inconceivable that loss of the carti¬
laginous septum could have any effect on the shape of the arch of the
nose.

Dr. Dundas Grant asked what degree of disfigurement there was
at the time of the injury ? Might not the distortion be part of the
original injury ?

Dr. Watson Williams had seen a patient in whom he could find
no portion whatever of the cartilaginous septum. There was no
external deformity of the nose. The patient was open and frank and
denied any history of syphilis.

Mr. Baber said it was commonly held that no amount of destruc¬
tion of cartilage was sufficient to account for collapse of the nose; the
tip of the nose might be affected but not the bones. He was of
opinion that it would be most interesting for members to see a photo¬
graph of the patient taken before the accident.

Dr. Lack said that nearly every haematoma and abscess of the
septum was due to an injury. In his experience such injury was
always attended by some subsequent deformity and depression of the

/

/

5

tip of the nose, though he granted it might not be evident for a few
weeks, until the swelling produced bj the injury allowed the result to
be seen.

Mr. Vinbace asked whether the pharyngeal condition existed at the
time of the accident. There was now present a condition of the
naso-pharynx which he thought must be of constitutional origin and
not the result of injury.

Dr. Wyatt Wingrave considered that deformity was not sur¬
prising since the structures were only partially developed. In adults
deformity was rare, unless the traumatism or subsequent inflamma¬
tory changes involved more than the septum, such as the nasal bones
and nasal process of the maxilla.

Mr. Spencer, in reply, said the boy’s nose was mainly altered in
the cartilaginous portion; there was no alteration in the roof or bony
part. He had watched the haematoma disappear, until the nose was
quite free. Then arose marked progressive nasal obstruction, and
later appeared a discharge of muco-pus and crusts, which he had left
alone to show the members. There was no ulceration or abscess.
Inquiries had been made as to congenital syphilis with negative
results; but it was impossible to exclude it with certainty. One heard
of general practitioners being blamed for not having the nose put
straight in such cases. Here was a case where, although there was
no obvious damage at the time or a month after, after two years had
elapsed there was distinct deformity of the nose. In adults there
might be destruction of the lower end of the septum without any
alteration in the shape of the nose.

Case of Laryngeal Growth in a Man .et. 49.

Shown by Dr. Barclay Baron. Patient, a man aet. 49 years,
who has drunk hard, but denies syphilis, noticed a little dryness
of the throat about a year ago, and some obstruction in May last,
when he had a good deal of nose bleeding. Since then the
difficulty in swallowing has increased, but he can still swallow
well-masticated meat; the breathing is obstructed, the voice is
altered and there is pain shooting up into the right ear; the larynx
is practically filled up with a large growth, with irregular
surface covered with creamy secretion; the epiglottis is pushed
towards the left side. The growth increases in size, but it is
believed to be an innocent tumour.

The President said he had never seen such a large growth in the
larynx.

Dr. William Hill said that tracheotomy would probably be done
unless members thought it unnecessary. Dr. Baron did not think it

6

was malignant and asked for a diagnosis. It had not yet given
serious trouble to the patient.

Dr. Dundas Grant asked if there was any certainty as to which
part of the larynx it grew from.

Sir Felix Semon said there was a distinct margin between the epi¬
glottis and the growth.

Dr. Watson Williams said it was attached low down and laterally
to the ventricular band.

Ethmoidal Cell-cutting Forceps.

Dr. Watson Williams showed some cutting forceps for opening
up the ethmoidal cells, which had been made for him by Messrs.
Mayer and Meltzer. The cutting ends were sharp-pointed, and
turned up at an angle of 50° with the shank, so that they readily
pierced the thin bony walls of the cells. He had found these
forceps of great service in opening either the anterior or pos¬
terior ethmoidal cells in sinusitis and in radical operations on
nasal polypi.

Case op Laryngeal Tumour.

Shown by Dr. Herbert Tilley. A female set. 39, whose chief
symptom was hoarseness. She also had a troublesome cough.
Laryngoscopic examination showed a sessile tumour, occupying
the anterior two thirds of the left ventricular band. It was con¬
gested, considerably raised above the surrounding surface, and
had a granular mammilated surface. The vocal cords moved
freely, although the left was sluggish compared with the right.

In answer to Dr. StClair Thomson, Dr. Tilley said that suspicions
of pulmonary phthisis existed, but that he was anxious to gain the
unbiassed opinion of members who had only seen the growth, as
many of its features did not suggest its tubercular nature.

Case of Probable Primary Specific Ulceration of the

Tonsil,

Shown by Dr. Dundas Grant. A woman aet. 32, was first
seen on October 11th, 1900, complaining of sore throat of three
months’ duration. It was followed at an interval of about one
month by the appearance of a few brownish spots on the skin;

7

mote recently there has been a slight falling of the hair. On
examination there was an enlargement of the right tonsil and
an irregular ulcer occupying the region of its upper third. The
glands at the angle of the jaw were slightly enlarged, and
according to the patient’s account had previously been larger
still. The pain was most marked during swallowing. On the
right anterior pillar there was an ill-pronounced opalescent
patch, and the same, in a slighter degree, on the left one. There
were no symptoms of genital inoculation, but the husband’s
tongue presented ample evidence of old-standing tertiary
changes, with a slight erosion on each side. The primary
inoculation dated more than twelve years back. During the
first week the patient was treated by means of pills of mercury
and opium, but the effect produced was comparatively slight.
During the following week mercurial inunction was practised,
with the result that at the end of that time the discomfort in the
throat had very markedly diminished, and the ulceration on the
tonsil had become less pronounced. The patient has advanced
six months in gestation. Dr. Eddowes, whtj saw the rash during
the first week, gave the opinion that it was a syphilide, but at
present it is too indistinct to afford ground for a very definite
opinion. The diagnosis is somewhat open to question, but there
seems little doubt that it is specific, and of a primary rather than
tertiary nature.

The President thought they were all agreed as to the diagnosis.

Dr. Dundas Grant said that the change which had taken place had
deprived the case of much interest. If members had seen the case a
fortnight ago, before the treatment which had confirmed the diaguosis
so absolutely, he thought the opinion of the Society would have been
the same as his own.

The President had seen a case of undoubted primary chancre of
the tonsil in which the result of the treatment was very rapid. The
patient was thought to have malignant disease of the tonsil, but the
improvement was so great that after a week the tonsil regained its
normal size. Four or five weeks later the diagnosis was confirmed
by the appearance of a secondary eruption.

Case op Alveolar Epithelioma of the Ethmoidal Cells and

Antrum.

Shown by Dr. Dundas Grant. The patient, a woman set. 53,
was first seen in October, 1900, on account of blocking of the

8

left nostril, discharge, and loss of smell, with pain in the left
nostril and cheek, swelling of the left cheek and in the orbit,
pushing the left eye upwards and outwards. Her illness was of
about nine months’ duration, commencing with symptoms of cold
in the head, and the formation of a polypus. At the end of July
a polypus was removed, but on the next day the blockage was as
complete as ever- Dr. Grant made a diagnosis of malignant
disease, probably sarcomatous; but a specimen removed for
microscopical examination was found by Dr. Wingrave to be of
the nature of alveolar epithelioma. It was decided that a radical
operation should be performed without delay. The superior
maxilla was exposed. The disease was found to have eaten away
the anterior wall of the antrum and a large portion of the floor
and inner wall of the orbit. The incision was continued upwards
on the inner side of the orbit, and the whole of the diseased
tissue was scraped away from the ethmoidal cells, the lachrymal
bone and os planum of the ethmoid being almost completely
removed. The floor of the antrum was found to be free from
disease, and the alveolar and palatal processes were therefore
left in position, the rest of the superior maxilla being extracted.
The raw surfaces were swabbed with chloride of zinc, grains
thirty to the ounce; iodoform was insufflated, and the cavity was
packed with iodoform gauze from the mouth, the external wound
being carefully sutured. The packing was removed two days
later, and the cavity was washed out with a weak Sanitas lotion.
After other three days the stitches were removed, the whole
wound having united with the exception of a small opening at
the inner angle of the eye. The patient was discharged on the
fourteenth day after the operation, and returned home complain¬
ing of no other discomfort than conjunctivitis of the left eye.

Mr. Spencer said that the saving of the alveolar process was an
advantage. The growth was a burrowing carcinoma of the most
malignant type, and one which offered a very poor prognosis. If
Dr. Dundas Grant had succeeded in removing the whole of it he was
very fortunate.

Mr. H. Betham Kobinson referred to a case recently under his
care where the growth in the antrum extended into the ethmoid, and
before operating it was impossible to define its exact limits. He had
removed the ethmoid freely up to the cribriform plate, but even then

9

the disease was not eradicated, for the growth appeared again some
weeks later.

Dr. Dundas Grant, in reply to Mr. Spencer, said that he thought
he removed all the growth, but it extended so close to the cribriform
plate that discretion had to be used in scraping it away. Up to the
present there is no sign of recurrence.

Case op Sarcoma op Thyroid Gland, Extirpation, Fatal

Result.

Shown by Dr. Dundas Grant. The patient, a nurse set. 64,
was the subject of an intensely hard swelling of the thyroid
gland of about six months’ duration. There was a slight
myxoedematous swelling of the face, and considerable dyspnoea
with tracheal stridor, worse on exertion. The larynx was
displaced to the left side and cedematous to such an extent
that the vocal cords could not be seen. Swallowing was partially
obstructed, and fluids tended to regurgitate into the larynx,
giving rise to troublesome cough. There was no enlargement of
the glands, and the thyroid rose during swallowing, though to a
less extent than normal. The dangers of the operation being
placed before the patient, she decided to submit to it rather than
continue as she was. During the detachment of the left lobe of
the thyroid, extreme laryngeal stridor supervened, and it was
necessary to perform tracheotomy. The thyroid body was
removed in its entirety, and on microscopical examination was
found to be infiltrated with sarcoma. The patient rallied from
the operation, but speedily began to acquire a very troublesome
cough; fluids appeared to enter the air-passages through the
larynx and through the tracheotomy wound in the trachea; the
right lung became completely dull, and death took place on the
fourth day. Regurgitation of fluids into the larynx is probably
a very unfavourable symptom when operations on the air-
passages are carried out, involving great risk of septic pneu¬
monia. In this case it might have been better if a tampon can¬
nula had been introduced instead of a simple tracheotomy tube,
and if the extirpation wound had been left open and plugged
with antiseptic gauze instead of being closed up. Tracheotomy
could not have been performed before the thyroid gland was
removed.

10

Case op Malignant Disease op the Larynx.

Shown by Dr. Dundas Grant. The patient, a man set. 57,
came under observation on August 2nd, 1900, complaining of
hoarseness and pain in his neck, of gradual onset, and of three
months’ duration. The larynx externally was normal to the feel,
but now Dr. Grant thinks it is slightly spread out. On laryngo-
scopic examination the epiglottis was seen to be folded in to a
considerable extent on the left side. The arytaenoids were much
swollen, especially the left one, which shaded off into a large
thickened aryepiglottic fold; the left cord was invisible, but
there was seen with great difficulty in the midst of the thickened
tissue, a fringe of a somewhat granular appearance, corre¬
sponding to the anterior half of the left vocal cord, or it might
be growing out of the ventricle of the larynx. The right
ventricular band was swollen somewhat, overhanging the cord.
There was no history of specific infection and no history of
phthisis in his family, although it was somewhat doubtful
whether or not his father died of that disease. In his case,
however, there was no evidence in the thorax, nor did the
sputum contain tubercle bacilli. The nature of the case was not
at all obvious, although the probabilities were in favour of its
being carcinoma^ The patient was put upon iodide of potassium
(ten grs.) with perchloride of mercury (one drachm of the solution)
three times a day. His weight decreased slightly, but when
seen again in September there was practically no change in the
condition; subsequently dyspnoea became marked, and it was
necessary to perform tracheotomy. Dr. Grant had postponed
this in view of the doubt which he felt that the disease might be
tuberculous, in accordance with the impression it made upon an
experienced colleague. The patient has improved very much in
general condition since the tracheotomy, which is sufficiently
exceptional in tuberculosis to make it justifiable to exclude that
disease. There is little doubt that the disease is malignant, epi¬
thelioma or sarcoma, the extent of infiltration as compared
with the amount of ulceration affording some probability in
favour of the latter. The exhibitor abstained from the removal
of a portion for microscopical examination, as the patient had
not consented to a radical operation.

11

Mr. Spencer remarked that the man complained of pain in the ear,
indicating infiltration of the posterior third of the tongue. He
considered the case too advanced for successful removal.

Dr. Lambert Lack was doubtful about the diagnosis, but even if
it were an epithelioma he thought it better left alone.

Dr. G-rant was anxious to elicit an opinion as to whether this case
was best left with the tracheotomy tube as at present, or whether the
risk of removing the larynx was justifiable.

The following microscopic specimens illustrating Dr. Grant’s
cases were shown by Dr. Wingrave :

1. Squamous epithelioma of larynx.

2. Alveolar epithelioma of maxillary antrum and nose. It
apparently commenced in the glands of the inner wall of the
antrum near the ostium.

3. Sarcoma of thyroid gland. Round-celled (small) variety,
evidently commencing in the stroma. It had involved the whole
of the gland, since none of the normal structure could be found.
It was interesting, as it followed closely upon a sarcoma of the
larynx, also under Dr. Grant’s care, in which the thyroid gland
was probably invaded secondarily, as much of its normal structure
remained.

Case op Laryngeal Papillomata.

Shown by Dr. Wyatt Wingrave. A girl set. 8, was first seen
in June, 1898, complaining of thick voice with occasional aphonia,
gradual in onset, and of two years’ duration.

Several small papillomata were seen at the anterior commis¬
sure, and one on the left cord in its anterior third. There were
no adenoids, but the faucial tonsils were slightly enlarged. Since
that date as many as twelve fragments have been removed, after
each time the larynx appearing clear of growth.

. The warts were treated also with formalin (one per cent.) and
salicylic acid, the latter affording the better result but not
removing the growth. In removal the ring curette proved more
efficient than forceps or snare. Histologically each fragment
was a digitated squamous papilloma. With regard to their
pathology, Dr. Wingrave was inclined to consider them relics of

12

an exaggerated vocal commissure, notwithstanding that the
symptoms did not become marked until six years of age.
Although there were no adenoids she was a confirmed mouth
breather, a habit of which her mother has nearly broken her.

The slightly enlarged tonsils were removed in January last,
but this did not seem to materially influence the course.

When last seen her voice was fairly clear and strong, and the
larynx had been free from growth since October 2nd, when the
last fragment was removed. At present there is a slight
thickening in the anterior commissure.

Dr. Herbert Tilley inquired what anaesthetic was used in the
case, and if a general one, what position was the patient placed in
during the operation. He had recently removed a large papilloma
from a child’s throat (four years old) which on two occasions had
almost caused asphyxia, and had been struck by the ease with which
the operation could be performed when the patient was chloroformed
deeply and maintained in the sitting position. Under such circum¬
stances it was necessary to push the chloroform until the laryngeal
reflex had just disappeared, and during the thirty seconds or so
following to remove as much growth as possible before the reflex
returned again.

Mr. Vinrace inquired why Mr. Wingrave ascribed the condition
to a congenital cause, no symptoms having presented themselves until
the child was five years old. It was difficult to understand how the
original structure in its entirety failed to cause symptoms and altera¬
tion in the voice.

Mr. Wingrave, in reply, said that he had found cocaine was simpler,
since the patient well tolerated inspection and manipulation. He did
not consider the absence of voice symptoms for the first three years as
evidence against congenital origin, since he remembered an instance in
which symptoms of a congenital web of the anterior commissure were
not recognised till the age of twenty-seven. He felt that the situation
of the growth was much in favour of its congenital origin.

Laryngeal Case for Diagnosis (? Tubercular).

Shown by Dr. StClair Thomson. The patient is a draper aet. ■
48, who states that he has been hoarse for twelve months.
There is slight though not marked dysphagia, but his weight has
fallen from ten stone ten pounds to nine stone four pounds. The
right vocal cord is nearly entirely concealed by a smooth, round,
red, soft-looking swelling of the right ventricular band, aryepi-

13

glottic fold, and aryteenoid. This swelling on phonation
impinges on the left ventricular band, on which it appears to
have caused some abrasion. Glands are not enlarged. There is
a specific history. The pulse is hurried (110), the temperature
is 100’2°, but the chest sounds are normal. The sputum has
not yet been examined. Under small doses of iodide of potas¬
sium the obstruction has in a week sufficiently diminished to
show a small portion of both cords, which are now seen to be
pale and slightly ulcerated. Dr. Thomson was therefore now
inclined to the diagnosis of tuberculosis.

The President considered the appearance was that of malignant
disease.

Dr. Dundas Grant wished to support Dr. Thomson’s own diagnosis
of tuberculosis.

Dr. StClair Thomson said he had only seen the patient twice.
There was so much obstruction and catarrh that he did not at first
like to give him iodide, but on five-grain doses there had been some
improvement in the last week. He wished for suggestions as to treat¬
ment. Probably everyone was agreed as to the necessity for tracheo¬
tomy. He would report again on this case at a later meeting.*

Case of Fracture of the Larynx.

Shown by Mr. Waggett. A female set. 52, in whom fracture
of the thyroid cartilage had occurred as the result of severe
pinching of the larynx between the fingers and thumb of a per¬
secutor. Severe dyspnoea lasted for some days, external swell¬
ing was present, and much pain experienced.

At the present date, some two months after the injury, nothing
abnormal could be seen by the mirror. External palpation of
the somewhat enlarged larynx caused pain, and indicated the
presence of an ununited fracture of the thyroid cartilage, separat¬
ing the upper half of one ala from its fellow close to the anterior
angle. The fracture was vertical above, curving to the right at
its lower end. The semi-detached antero-superior portion of the
right ala could be made to ride over the left ala. The voice was
stated to have altered in character since the receipt of the injury,

* Since the date of meeting the report on the sputum shows the presence of
tubercle bacilli.

14

but the action of the vocal muscles showed no gross sign of
impairment. He did not propose any surgical interference.

Hr. Herbert Tilley very much doubted if the feeling of crepitus
in this case was not entirely due to the movement of the larynx on the
vertebral column. He had, while the patient leant well forward, lifted
the larynx away from the column, and could not obtain the crepitus,
however carefully he manipulated the larynx, but immediately the
latter touched the spinal column the crepitus at once became evident.
It was difficult also to conceive that the inflammation, which was evi¬
dently produced by the traumatism, should have so completely resolved
as to leave the cartilaginous fragments loose. One would have expected
the traumatic perichondritis to have firmly welded them together.

Hr. Fitzgerald Powell thought if fracture of the cartilage existed
it would result in severe and continuous dyspnoea.

Mr. Parker said that he quite agreed with Hr. Tilley with regard to
the possibility of obtaining crepitus on lateral movement of the larynx
in most people, but in this case the crepitus was even more marked on
the patient’s swallowing, which was unusual. He therefore thought
there was a fraeture of the thyroid cartilage.

Hr. Bund as Grant thought he felt a crepitus, as if there was
fracture of the lower cornu of the thyroid cartilage, just above where
it articulated with the cricoid.

Mr. Waogett, in reply to Hr. Tilley, said that he believed the
crackling or crepitus of which the latter spoke had nothing to do with
the fracture, but was such as could be detected when the larynx of
any thin person was pushed from side to side over the underlying
structures. In the present instance a fine crackle was produced when
by lateral pinching the thyroid cartilage was distorted, an act which
caused a portion of the right ala to ride over the left, leaving a sharply
defined groove between the two.

In answer to Hr, Powell he drew attention to the history of severe
dyspnoea confining the patient to bed for three weeks.

Case of Hemorrhage on the Vocal Cords.

Mr. Charles Parker showed a case of haemorrhage on the
vocal cords in a woman aet. 35, a school teacher. The haemor¬
rhages were situated about the middle of the upper surfaces
of either cord. The patient complained of hoarseness and
aching of the throat after using her voice. There were no signs
of any tendency to haemorrhages elsewhere.

In answer to Hr. Lack, Mr. Parker stated that he felt confident
that when he first examined the case there was a haemorrhage only on

15

the left cord. She was examined by several people, and being rather
intolerant strained and choked a good deal, and on finally examining
the case Mr. Parker found that a haemorrhage had occurred on the
right cord. This was more than a month ago, and yet both haemor¬
rhages remained unaltered.

The President had never before seen such an interesting example
of this condition.

Dr. Grant had brought before the Society the case of a young lady
with sudden loss of voice—as if an hysterical attack of aphonia—
which was accompanied by an effusion under the mucous membrane
of the cord.

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Ordinary Meeting, December 7th, 1900.

F. de Havilland Hall, M.D., President, in the Chair.

Lambert Lack, M.D.,
Ernest Waggett

t.H., \

, M.B., }

Secretaries.

Present—35 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 :

John Stewart Mackintosh, St. Ives, Platt’s Lane, Hampstead.

Frederick J. J. Wilby, 23, Henrietta Street, W., and The
Wych, Avenue Road, Highgate.

The President said that Sir Felix Semon, who was unavoidably
absent, was anxious to point out that the treatment of nasal polypus
depended on its precise variation, and hoped the result of the dis¬
cussion would be to draw some distinction between the different forms
of nasal polypi, which required different treatment. The title of the
subject under discussion suggested only nasal polypi in general, with¬
out any reference to the various forms.

He then called upon Dr. Lambert Lack and Mr. Cresswell Baber
to open the discussion upon

first series—VOL. VIII.

2

18

THE TEEATMENT OF NASAL POLYPUS.

Dr. Lambert Lack said:

Mr. President and Gentlemen,—I deeply appreciate the high
honour conferred on me by the Council in inviting me to open
the discussion on this important subject. Many members will
no doubt have interesting remarks to make, and therefore I
shall detain you as short a time as possible while I briefly
enumerate the results of my own investigations, and leave the
discussion to others.

The rational treatment of polypus must depend upon the view
we take of its pathology. This subject was fully discussed at
the meeting of the British Medical Association in London in
1895, when the general opinion seemed to be that polypi were
in some way the products of inflammation, but both Woakes’s
theory of “ necrosing ethmoiditis ” and Griinwald’s of sinus
suppuration were considered disproved or inadequate, and in
fact the discussion only showed the truth of Mackenzie’s state¬
ment that the cause of polypus was still unknown.

The theory I wish to maintain is that the ordinary nasal
polypus is essentially a simple localised patch of oedematous
mucous membrane, and that this oedema is a result of disease in
the underlying bone.

The first point is proved by both clinical and microscopical
examinations. Histologically polypi consist of loose fibrous
tissue, the meshes of which are filled by serous fluid. The
growth contains vessels and glands, and is covered by the
normal epithelium of the part. The glands are more numerous
near the attachment of the growth, and vary in number in
different polypi, sometimes,'particularly in chronic cases, being
very numerous. In addition to this there are signs of inflam¬
mation, the vessel walls are enlarged and thickened, and there
are scattered collections of round-cells, especially marked around
the vessels and glands. The glands are sometimes healthy,
sometimes undergoing degeneration. The acini may be dilated
from obstruction of the ducts due to pressure of the inflam¬
matory exudation, and the cysts commonly seen in polypi are
thus derived. Thus it is seen that polypi contain all the struc¬
tures of the normal mucous membrane plus a certain amount of

19

inflammatory exudation, serum, and round-cells ; and further, a
polypus passes gradually and imperceptibly at its edge into the
normal mucous membrane.

It is obvious that growths containing such diverse and highly
differentiated structures are neither tumours nor granulations.
The latter in the nose, as elsewhere, consist of round-cells,
spindle-cells, young vessels, and the early stages of fibrous tissue.
Moreover, as seen after intra-nasal operations, or when produced
by the irritation of a foreign body, a sequestrum, etc., they are
quite different from polypi. Again, clinically there is every
stage between oedema of the mucous membrane and a polypus,—
a slight oedema, a marked localised oedema, a broadly sessile
polypus, and a typical pedunculated polypus. It is purely a
question of degree, a small diffuse, non-moveable mass being
usually described as oedema, whilst a larger, more sharply
defined, more moveable growth is considered a polypus. Also
the microscopic structure of the two is identical. Griinwald
asserted that by tightly packing an antrum oedema of the lower
lip of the ostium maxillare could be produced, and that this
oedematous tissue had the microscopical characters of a polypus.

The second point, that polypi are due to disease of the under¬
lying bone, was first, I believe, definitely asserted by Woakes;
hut his views have obtained very little credence. However
much exception may be taken to Woakes’s own work and investi¬
gations, it seems to me his theory of bone disease is the most
adequate explanation hitherto offered of polypi, and especially
of their tendency to recur, and further that the independent
evidence of Thurston and Martin, based upon microscopic
examination, ought not to be lightly overlooked..

More than two years ago, when I took up this work, I collected
pieces of bone from over thirty cases of nasal polypi and pre¬
pared them for microscopical examination. In every case bone
changes were found of the nature of a rarefying osteitis.
Briefly, the sections showed that the process commences as a
proliferation of the cells in the deeper layer of the periosteum.
In places numerous large cells or osteoclasts appear in contact
with the bone, and gradually eat it away, forming irregular little
bays along its edge. At the same time the bone cells themselves
enlarge and become more numerous, and give the bone a more

20

cellular appearance. As this process of rarefying osteitis
extends the bone ultimately becomes disintegrated, and the
fragments, surrounded on all sides by osteoclasts, are slowly
eaten away and absorbed. No true necrosis was seen. The
appearances were found in both extensive and simple cases of
polypi. Thus the pathological evidence supporting that of
Thurston and Martin is fairly complete, in spite of some few
contrary observations of Zuckerkandl, Luc, etc.

Since this paper was written these observations have been
confirmed by Cordes (* Archiv fur Rhin. und Laryng/ of last
month), who has described some investigations with almost
identical results, except that he did not always find bone
changes in mild cases of polypi.

The following are some of the clinical signs of bone disease:

(1) Digital examination under general anaesthesia. If the
finger be passed carefully up into the ethmoidal region in cases
in which no operation has ever been performed, it often
impinges on soft jelly-like tissue in which spicules and loose
pieces of bone can be plainly felt, although it is very rare to feel
rough bare bone.

(2) The probe may be used in a similar way, but it is
obviously much less reliable. Very great care must be taken
in employing it and in drawing deductions from its use. A
blunt ended probe and one which can be easily bent to pass in
any direction must be used, and even then it is difficult to avoid
perforating the softened mucous membrane. The ease, however,
with which this is done, and the feeling of bare bone obtained,
is quite different from the normal condition.

(3) In a severe case of polypus in which no operative inter¬
ference has ever been attempted, if the polypi be carefully
removed with the snare without touching the bone in any way,
it is sometimes possible to observe that the entire middle
turbinate has disappeared, and its place has been filled up by
masses of small polypoid-looking growths.

(4) The results of operations as regards recurrence when the
diseased bone is completely removed. This further proves that
the bone disease is the cause of the polypi, and not vice versa , as
some have stated.

The probable history of a case of polypus is as follows:

In an acute inflammation of the ethmoidal region, and
especially in the severer and more lasting forms of it occurring
in connection with the exanthemata, erysipelas, influenza, and
septic affections, such as sinus suppurations, it is probable that
the periosteum covered only by the thin mucous membrane, and
even the bone may be involved. In such cases the middle
turbinate is especially liable to be affected, and on examination
this structure appears large and rounded, and covered by a
thickened cedematous mucous membrane. Microscopical exami¬
nation of such a middle turbinate shows the early stage of the
rarefying osteitis above described, and the overlying cedematous
mucous membrane has all the microscopical characters of a
typical nasal polypus.

As the disease slowly progresses the bone becomes disinte¬
grated and at the same time expanded, and the cell commonly
present in its anterior end may become distended and form a
bony cyst.

The osteitis spreads to the neighbouring parts until the whole
ethmoid may become affected. The outlines of the bone are
lost, the middle turbinate can be no longer recognised, but loose
pieces of bone, polypi, cedematous granulations, and gelatinous
mucous membrane fill the whole upper part of the nose. In
this extremely slow but progressive process the bone is slowly
but surely eroded and absorbed. In some cases the disease is
ultimately arrested, and then the bone becomes very dense and
sclerosed. Such a condition is found in cases in which only a
single polypus or perhaps two polypi are present, and in these
cases, as is well known, recurrence of the growth after removal
is rare.

As just said, the oedematous mucous membrane overlying the
affected bone in the early stage is indistinguishable micro¬
scopically from a polypus, and clinically the two conditions pass
from one to the other by imperceptible stages, and can only be
artificially divided. Moreover oedematous infiltration in these
parts is apt to become large and, bulging, as the, mucous, — \

brane is extremely loosely 'attached; aud:e&§%; thrdwK^ xfito ; Y
folds. After a time these swellings, well applied',with nourish¬
ment, apparently take on a more or legsY^dejJeudenVg^pwth;
the increase in size is doubtless assisted,-by, the .dependent

22

position of the growths and the action of gravity. Their
tendency to become pedunculated is also partly due to the
action of gravity, and partly, perhaps, to the effect of blowing
the nose, which would tend to make the growth swing about.
These considerations explain the chief facts in the clinical
features of polypi, their liability to recur after simple removal,
the fact that they grow only from the ethmoidal region of the
nose where the bone is covered by a thin muco-periosteum, and
that they are more common on the middle turbinate and about
the regions of the ostia of the accessory sinuses where the
mucous membrane is excessively lax.

Treatment .—If this theory of the pathology of nasal polypus
is accepted the whole question of treatment must be re¬
considered, for it follows that our efforts must be directed
towards the eradication of the bone disease and not simply
towards the removal of the polypi, one of its effects.

For the sake of convenience the following four groups of
cases may be taken :

(1) Cases in which one or two polypi only are present, which
are of long standing, in which there is no sign of active disease
still present, and in which it is probable that the initial bone
disease has completely passed off. In such cases simple removal
with the snare may be practised. It is a matter of every-day
experience that recurrence in such cases is rare.

(2) Simple cases of early bone disease, in which there is en¬
largement of the anterior end of the middle turbinate,. with
overlying oedema of the mucous membrane, or the early stage of
polypous formation. The affected part should be removed, and
this generally resolves itself into a typical amputation of the
anterior end or more of the middle turbinate.

(3) Cases in which a few polypi only are present, and in
which there is apparently a very limited area of bone disease.
These cases may also be treated with the snare, but an attempt
should always be made to hitch the wire loop as high as possible
round the base of the growth, so as to encircle the piece of bone
frprn'whibh .it jgfdwfe. .AfteV, the, polypi and as much bone as
possible "have T5een* removed in tliis way, at a subsequent sitting
the affedt^d; region sKpu}d be thoroughly examined by probing
and illumination, and’ all diseased bone and mucous membrane

r »

«• !«• •

23

should be clipped away by G-riinwald’s forceps. The middle
turbinate should be removed if diseased, or if necessary to give
access to the affected region. In other cases it may be necessary
to scrape away the affected part, and in such circumstances
nitrous oxide anaesthesia should be employed, and the operation
performed with a ring-knife under good illumination.

The results of operation in these three groups of cases is almost
invariably good, and the operation itself apparently in no way a
serious one.

(4) In the cases of extensive bone disease in which there are
many polypi involving an extensive part of the ethmoid a more
radical procedure is necessary. In such cases simple removal
of polypi is useless, as recurrence rapidly takes place, and I
believe it is better in the first place to give a general anaesthetic,
and to remove not only the polypi but the whole of the affected
part of the ethmoid bone.

This operation should also be practised in cases in which
recurrence has followed other operations for the removal of
polypi, and cases associated with suppuration in the ethmoidal
cells or in other accessory sinuses. In the former case it is
necessary to open the ethmoidal cells for the suppuration itself,
and in the latter it is especially necessary to clear the approach
to the ostium of the affected sinus.

The operation is performed as follows. The patient being
anaesthetised, the ethmoidal region is thoroughly examined by
the finger, both through the nose and also through the post-nasal
space, to determine as far as possible the extent of the disease.
If the middle turbinate be present it may be removed by means
of the spokeshave, and any large polypi should be removed by
means of the forceps. Then the lateral mass of the ethmoid
should be thoroughly scraped away by means of a large ring-
knife, such as Meyer’s original adenoid curette. This is the
only effective instrument ; sharp spoons are quite useless. In this
way large masses of polypi, degenerated mucous membrane, and
fragments of bone are removed. The finger is introduced from
time to time to observe the progress, to feel for any spicules of
bone and soft patches, and the scraping is continued until all
friable tissue has been removed. Healthy parts of the ethmoid
are easily distinguished by the finger and even by the curette,

24

as they are smooth, firm, resistent, and give little hold to the
knife. In some cases the operation is completed by a smaller
ring-knife, but this must be employed with the greatest care.
Of course great caution must be used when it is felt that the
region of the cribriform plate is being reached, but the whole
inner wall of the orbit may be scraped away with impunity.

The operation should be performed with the patient turned
well over on to his side, and in cases where the posterior part
of the ethmoid is unaffected a large sponge may be pushed up
into the post-nasal space. Directly the operation is over haemor¬
rhage is arrested by packing the nose with a strip of gauze
soaked in glycerine-iodoform emulsion, and a piece of lint soaked
in evaporating lotion is then applied to the face. This gauze
packing should be changed every second or third day, and the
nose irrigated. If it is easily tolerated it may be continued for
a fortnight, in other cases it should be omitted earlier.

Results .—The large majority of cases run an afebrile course.
In a few cases numerous granulations appear in the field of
operation, and may even become exuberant. If the operation
has been thoroughly performed these usually disappear spon¬
taneously in a few weeks, and meantime the patient experiences
no discomfort from their presence. After five to eight weeks a
large dry cavity, lined by healthy adherent mucous membrane,
will be seen in the upper part of the nose.

One would theoretically expect operation in such a region to
be somewhat dangerous, but although I have operated now
between fifty and sixty times, and others have also performed it,
no symptoms causing real anxiety have yet been seen. Of ill
results following the operation the following have been noted.
A black eye is not uncommon, but usually subsides in three to
four days, under cold applications. In one or two cases acute
suppurative otitis occurred, but passed off under treatment.
Such a result may follow any similar operation. In a few cases
a considerable rise of temperature has occurred, but only in
cases in which sinus suppuration has been present. Such cases
have readily yielded when the packing has been omitted and
nasal irrigation adopted.

In one case of extensive ethmoidal caries, with suppuration in
the ethmoidal cells, and probably also in the frontal sinus, an

25

orbital abscess accompanied by necrosis of a portion of the
inner wall of the orbit followed some three weeks after the
operation, and a week or ten days after the patient had left the
hospital. This is not a very rare occurrence in cases of eth¬
moidal cell suppuration, but it may have been due to or hastened
by the previous operation. The abscess was opened externally,
a sequestrum removed, and a cure followed.

In no cases have any cerebral symptoms been noted, and no
death has occurred. Even if the operation entail some danger
there is some, and probably a greater risk in leaving the dis¬
ease alone, or in employing the small nibbling operations which
are commonly recommended. The risk of operating is probably
greater in cases in which suppuration is present, but the neces¬
sity for it, and the danger of leaving, the disease alone, is also
greater. I am more fearful, if the operation is widely adopted,
that it should fail to cure from want of being practised with
sufficient thoroughness, than that it should cause fatalities by
being performed too boldly.

The results as regards recurrence are very good. In all
simple cases of polypi a cure has resulted, and this has been
permanent for several years in some cases, in which snare opera¬
tions had been repeatedly followed by recurrence. Such cases
I have already shown here, and I hope at later meetings to
show more. In suppurative cases recurrence has been rare, and
when it has occurred the disease has not been the intractable
affection it was before operation. In such cases occasional
removal with the snare will usually give immunity for months,
until if the suppuration be cured the polypi no longer recur. In
a few cases I have operated a second time, but in every case in
which I have performed the first operation myself, the bone has
appeared quite firm and dense, and there has been practically
nothing to remove.

The only alternative procedure—repeated small operations,
such as nibbling away with forceps, so commonly advocated—
may perhaps effect a cure in time, but it has many and great dis¬
advantages. The operation is always painful, as cocaine acts by
no means satisfactorily in these cases. Ten, twenty, and even
more sittings are often required, as very little can be done at a
time. This is extremely tedious and discouraging to the patient,

2 §

26

and the constant pain and dread of it causes general ill-health.
Little or no benefit following the earlier operations, the patient
often abandons treatment. In cases associated with suppura¬
tion each operation exposes a raw surface, over which pus flows,
and there is necessarily a tendency to septic absorption, and to
the spread of the bone affection. Finally, fatal results have
occurred from meningeal infection apparently directly due to
operation, and I believe these repeated timid procedures are
more dangerous than a single severe but curative measure.

In conclusion, then, I would urge that this operation, carried
out with due precaution, should be performed in all cases of
nasal polypi in which there is extensive disease of the ethmoid
bone, in which recurrence of polypi has repeatedly followed
other methods of removal, and in which suppuration is present in
the ethmoidal cells or other accessory cavities.

[Dr. Lambert Lack’s paper was illustrated by (1) a series of
diseased middle turbinate bodies, showing the transition stages
between simple oedema and true polypus, and (2) a series of
microscopic slides of sections of the bone underlying polypi,
showing various degrees of periostitis and osteitis.]

Mr. Cresswell Baber said: Gentlemen, the subject of the
treatment of mucoiis polypi of the nose is one of perennial in¬
terest, because of the exceeding commonness of these growths,
and of the difficulty they often present in treatment.

The Treatment resolves itself into two stages: (1) removal of
the growths; (2) after-treatment with the view to preventing
their recurrence.

(1) Removal of the growths. It is pretty generally agreed
this should be carried out with a snare, hot or cold. I am
always in the habit of using the cold snare, and with a rather
thick steel wire. I have repeatedly made up my mind to use the
galvanic loop, but have always, after a short trial, come back to
the cold, chiefly because I find no special advantage from the
hot, and considerably more trouble in using it. My own practice
is to snare out the growths as carefully as possible at sittings
with about a fortnight's interval, even removing small roots in
the middle meatus by this method. The adjustment of the snare

27

when a somewhat thick steel wire is used scarcely ever meets with
any difficulty, hut in the event of such an occurrence the polypi
may be drawn forwards with a sharp hook or a fine pair of
catch forceps.

In getting the loop round a polypus projecting through the
choana a finger in the naso-pharynx is of course invaluable, and
if it be impossible to secure a polypus in this position, by this
method, Lange’s blunt hook may be used, or, if necessary, a pair
of forceps guided by the finger. The use of forceps for the
removal of polypi is not, in the ordinary way, to be recom¬
mended.

(2) After-treatment. The routine after-treatment hitherto
adopted consists in burning the so-called roots of the polypi with
the galvanic cautery. This method is only suitable for cases in
which the point of origin of the growths is visible, for to plunge
a cautery blindly into the interstices of the ethmoid bone seems to
me a useless and dangerous proceeding. The same remark applies,
perhaps with less effect, to the use of a chemical caustic, such as
chromic acid. It has been my habit for some years to use a
spray of rectified spirit (as first recommended by Miller),
varying from 25 per cent, to full strength, for its shrinking
properties on the mucous membrane, and I think with benefit.

A word of caution is necessary to the effect that in old people
(those over seventy) it is advisable either to leave the growths
alone, or to operate on a small amount at a time, partly on account
of shock, and partly on account of the haemorrhage, which,
though it may be minimised by extract of supra-renal capsule
used in addition to cocaine or eucaine, is not a negligible
quantity. The question of shock is more important still in
galvanic cautery operations on the middle turbinate body, and
should always be considered, especially as these growths are
often found in persons with asthma and weak hearts.

We next come to the question whether any further treatment
is advisable. This must depend on the diagnosis which we are
able to make in each individual case. Mucous polypi, which
according to most recent authors may be defined as the result of
an inflammatory serous infiltration of the mucous membrane of
the ethmoid, seem liable, speaking clinically, to be produced by
almost any irritation. They may be caused not only by disease

28

confined to the ethmoid, but also by the irritation of the dis¬
charge from an empyema of the antrum, or of the frontal or
sphenoidal sinuses, and by such different conditions as foreign
bodies in the nose and malignant disease.

They are not, as assumed by some observers, necessarily asso¬
ciated with suppuration of an accessory sinus, or even with
suppuration at all. These different conditions must therefore be
carefully searched for before any further treatment is under¬
taken.

Having excluded non-ethmoidal causes, the form of the
disease in which the morbid changes are confined to the ethmoid
remains to be considered. Our knowledge of the pathology of
this affection is still imperfect; but it is generally considered by
recent observers that the inflammatory trouble giving rise to
mucous polypus may be limited to the mucous membrane, or
that chronic proliferating periostitis, and osteoplastic or rarefying
osteitis (or both), may also be present. Hajek considers that,
except in constitutional dyscrasise (tuberculosis and syphilis),
these processes result from the extension of the inflammatory
infiltration of the mucous membrane and the periosteum into
the bone and its medullary spaces. According to the latest pub¬
lished researches, those of Cordes, the bone may be primarily
affected from typhus, influenza, scarlet fever, and other exanthe¬
mata ; or secondarily from the mucous membrane. This author,
by the way, does not confirm the presence of rarefying osteitis,
although he admits that absorptive changes constantly accom¬
pany the osteoplastic processes. When all the polypi have been
thoroughly extirpated, and the exposed mucous membrane either
burnt or removed, and no recurrence takes place, it is assumed
that the mucous membrane only is implicated, and no further
treatment is necessary. It is impossible to ascertain the per¬
centage of these cases, because, as a rule, the patients do not
return to the surgeon more than once or twice for inspection. It
must also be borne in mind that very long intervals between the
recurrences (if not actual absence of the same) occur in cases in
which to all appearance the ethmoid bone has undergone dis¬
tinct hyperplastic changes. A single polypus projecting into
the choana often does not recur in my experience, but as a rule
it is impossible to foretell the likelihood of recurrence. If

29

frequent and rapid regrowth occur, we may take it for granted
that the bone is affected with osteitis, as above mentioned, or at
least that the mucous membrane in the cells, which escapes our
vision, is participating in the disease. In these cases the only
method of preventing recurrence is to remove the. affected bone
and cells, and this is indicated whether we regard the bone or
the mucous membrane as the starting-point of the disease.

In the former case, the bone requires removal, as the source of
irritation, in the latter because without removing the bone, the
.mucous membrane in the cells, which is giving rise to the trouble,
is inaccessible. The first step is the removal of the anterior half
of the middle turbinated body with forceps or scissors, and
snare, if it has not been done already for examination or treat¬
ment of the frontal or maxillary sinuses. This little operation
renders the anterior ethmoidal cells more accessible. If this is
insufficient, the ethmoidal cells and walls may be removed with
Grunwald’s or similar forceps, and curetting them with scoops of
various shapes, due regard being had to any possible injury to
the cribriform or orbital plates. In my experience the removal
of the middle turbinated body is satisfactory, but the other
measures are less so, on account of the haemorrhage which so
rapidly obscures the view, and prevents much being done at one
time. Neither of these measures, however, as far as I know,
gives a certain guarantee against recurrence. When the dis¬
charge from the ethmoidal cells is distinctly purulent there is
more necessity for opening them freely, as suppuration in these
cavities is not devoid of danger to the surrounding parts. Of
the exact procedure recommended by Dr. Lack, i. e. the re¬
moval of all the ethmoidal cells at one sitting with a Meyer’s
ring knife, I have no personal experience ; I presume that such
an operation would only be employed in cases of frequent and
rapid recurrence, but even in these cases I think it is only to be
recommended under two conditions: (1) if it can be shown
that the operation gives immunity from recurrence; (2) if it can
be performed without risk of injury to the contents of the
cranial or orbital cavities. Whether it has a deleterious effect
on any remaining sense of taste or smell perhaps Dr. Lack will
be able to tell us. At the same time it must be admitted that
any operation which, without danger, will prevent recurrence

2 § §

30

of these growths will be a great boon to sufferers from this
disease.

Although for the sake of clearness I have divided the
ethmoidal cases from the cases of polypus due to disease in the
other sinuses, it must be understood that the two conditions
often co-exist, and that the relation between them is not yet
clearly established.

On the whole, I think that the chief advance in the treatment
of mucous polypi lies in the direction of a more accurate
diagnosis of the cause in each case, which is the only guide to
rational treatment.

In these few remarks I have omitted all reference to papil¬
lomata and other non-malignant growths which are sometimes
called polypi, in order to keep the discussion to the important
subject of mucous polypi, neither have I inade any reference to
the treatment of empyema of the larger accessory cavities, or of
polypi contained in them.

If the discussion draws forth the opinions of members on the
comparative value of the different methods of removing
mucous polypi, and of the various forms of after-treatment,
especially in regard to the removal of bone from the ethmoid,
it will not have missed its object.

Mr. W. G-. Spencer agreed with the treatment set forward by Dr.
Lack, but not with his pathology of polypus, which, he thought,
remained unknown. The inflammatory theory required a great deal
of further evidence for its firm establishment. By the acceptance of
the latter, the pathology of the nose was entirely separated from the
pathology of other mucous membranes, and of the polypi which occurred
in them. No doubt the nose was the favourite locality for the forma¬
tion of muco-polypoid growths, yet there were varieties of this forma¬
tion in other mucous membranes, e. g. of the rectum, bladder. In
the latter there was fairly strong evidence that they originated in the
submucous tissue, whether they began as actual fibromata or were
always of a myxomatous nature. It was generally agreed that the
shape of polypi was due to the action of gravity, but their occur¬
rence in several places, and sometimes on each side of the nose, in
the frontal and ethmoidal cavities and maxillary sinuses, afforded
little clinical evidence of a previous primary inflammation of the
bone or periosteum. When this was present the resulting growths
were not typical mucous polypi, although, as in the case of other
tumours, inflammatory conditions and incomplete removal promoted
recurrence. But there must be an essential difference between the

31

vascular granulations, however cedematous, which occurred after, e. g.
syphilitic necrosis, injury, or the presence of a foreign body in the
nose, and an ordinary mucous polypus. Again, the mucous polypi
were certainly the most frequently occurring, and Dr. Lack had
referred to the difficulty in some cases of distinguishing them from
inflammatory conditions of the inferior turbinate, which was of course
very commonly inflamed, yet not the common site of the polypi.
There was no sharp line of distinction between true mucous polypi
(nasal or naso-pharyngeal) and those which ultimately turned out to be
sarcomata. Even carcinomata in the nose had very often projecting
polypoid masses indistinguishable microscopically, or very nearly so,
from the simple polypi.

Turning to the question of the bone change, it was an oft-discussed
matter, and difficult to prove either way. In the specimens shown by
Dr. Lack, which he had not very carefully examined, he saw no reason
which would cause him to make up his mind on the subject. The
changes in the bone were secondary, but not primary in his opinion.
Polypi in other situations had nothing to do with the periosteum or
with the bone, yet Dr. Lack would try to show that nasal polypi were
the result of perichondrial or periosteal disease. Changes in the bone
varied, but a great deal of the permanent bone of the nose was can¬
cellous, and some of the specimens appeared to present this normal
cancellous bone. Very little information on this point had been added
to the subject of the old controversy between Dr. Woakes and Dr.
Sidney Martin. No doubt many of the specimens showed secondary
atrophic osteitis occurring in connection with the pedicle of the poly¬
pus ; the larger the polypus became the more marked the appearance
was. So he thought that very little trustworthy clinical evidence had
been adduced to prove that polypi were preceded by inflammatory
changes. The true untouched muco-fibromatous polypus had more
the appearance of a real benign tumour, single or multiple as the case
might be.*

With regard to treatment, he was in accord with Dr. Lack’s method
in extensive cases, where it was of great value to commence the treat¬
ment by a thorough removal under an anaesthetic. He thought,
however, that recurrence might take place in some cases. Its value
lay in the reduction of the number of sittings hitherto necessary for
the patient when there was extensive change present. It was necessary
to remove the pedicle of the tumour, and because of the convoluted
structure of the nose to remove a large amount of bone in order to
get at the pedicle. He preferred to insist upon the necessity of
removing the whole of the pedicle, viewing it as a tumour, rather
than, as Dr. Lack held, of removing bone primarily diseased.

Mr. Charles Parker said: I should like to add what weight I
can to the reasonings and conclusions advanced by Dr. Lack. I have,
I think, seen every case on which he lias operated during the last

* Gerard Marcbant, iu ‘ Traite de Chirurgie,’ Duplay et Reclus, 2me ed., 1898,
t. iv, p. 670.

Ziegler, ‘Lehrbuch d. allg. u. spec, pathol. Anat.,’ 9te Aufl., 1898, Bd. ii, S. 626;
also H. Mackenzie, “ A Case of Diffuse Papillomatous Degeneration of the Nasal
Mucous Membrane,” ‘Lancet/ 1896, vol. ii, p. 460.

32

three years, and have watched their progress afterwards; moreover I
have myself frequently adopted the measures he advocates for the
cure of polypi. The microscopic specimens before us to-night clearly
prove that accompanying polypi there is a bone disease, presumably
of the nature of rarefying osteitis. The fact that simple removal of
polypi does not cure the disease points to the conclusion that the
origin of the trouble has been left behind; and on the other hand,
the old and recognised fact that if the bone underlying the attach¬
ment of a polypus can be removed with the polypus recurrence is far
less likely to occur, suggests that in this case the cause has been
removed. Again, it is undoubtedly possible to trace clinically every
stage of a polypus, from a mere oedema of the mucous membrane
covering the anterior end of the middle turbinated bone, to a definite
fully formed pedunculated polypus, and to prove that there are as
definite, though less marked, bone changes when the mucous membrane
is only oedematous as when it has degenerated into true polypus; from
which it is, I think, fair to argue that the bone trouble precedes the
polypus. Therefore one must conclude that both the microscope and
clinical experience favour the view that the bone disease is the cause
rather than the result of polypi. This being so, operative measures
must have for their object the removal of every portion of diseased
bone, and this in a confined cavity like the nose can only be done by
some such method as that put before us to-night. In several cases in
which I have adopted Dr. Lack’s treatment I have had reason to
realise the futility of my previous efforts to cure the case with a
snare; for having by this latter means removed all visible definite
polypi and brought the case to that point where on examination one
sees only a lot of small polypoid excrescences springing from the
ethmoid bone, and situated where the middle turbinated should be,
I have proceeded to the more radical operation, and have been
astounded by the quantity of large polypi removed by means of the
ring-knife—literally handfuls. It was evident that directly the lower,
visible polypi had been removed, and thus pressure relieved, others
had descended by gravity to take their place, and, judging from the
number afterwards taken away with the ring-knife, there were suf¬
ficient polypi to last these patients a lifetime had I continued treat¬
ment by means of the snare. As to the operation, I follow the same
procedure as Dr. Lack, and do not think his methods can be improved
upon. As to the results, I think they are very satisfactory. In all
my own cases, and those of Dr. Lack’s which I have observed, there
has invariably been very great improvement, and in the majority of
cases I think the word “ cure ” is none too strong. Considering the
chronicity of these cases, and the frequency with which they are
operated upon, I think the patients themselves become good judges of
the results, and after this more radical operation they all agree in
saying that they have not been so comfortable for years, even if they
cannot be classed amongst the cured; and so far I have never seen
any really serious ill results. Finally, I think this operation should
be employed in all cases where recurrence has occurred more than
three or four times, in all cases of multiple polypi accompanied by
suppuration, from whatever source, and in those cases where the

33

middle turbinated has disappeared and its place been taken by mucous
membrane in a state of polypoid degeneration. In these latter cases
there is sure to be very extensive disease hidden from view.

Dr. Donelan desired to add his tribute of congratulations to the
readers of the two papers. He thought the operation described by
Dr. Lack would prove a valuable one in the severer cases, while in
others the snare would continue to be used. Notwithstanding the
specimens, he felt the theory that the disease originated in the bone
was “ not provenand the fact that one of the authorities quoted by
Dr. Lack had admitted that the bone was not affected in the slighter
cases, led one to believe that the disappearance of the turbinals was
due to more familiar causes, such as pressure and impaired blood-
supply, rather than to a rarefying osteitis. Instances had been given
of mucous polypi in the rectum, and at another point in the antipodes
of our interests, where the only “osseous” structure was the os uteri;
but he thought examples of mucous polypi unconnected with bone
might be found nearer home — as, for instance, on the soft palate,—
and he had at present a case in which he had removed five or six polypi
from the angle between the cartilaginous septum and the ala, and at
some distance from the nasal bones. If the rarefying osteitis were
admitted to occur as extensively as Dr. Lack claimed, he would like
to ask him what prevented the process from extending more widely
through the cranium.

Dr. Scanes Spicer had hoped that, in order to promote the fullest
ventilation of the subject, some one would have risen to advocate the
opposite side of the case to that put forward by Dr. Lack. He him¬
self could not do so, for be agreed with Dr. Lack practically in toto.
But, in justice to previous workers on nasal problems, he must point
out that operative procedures identical with those described by Dr.
Lack had been performed in suitable cases both in England and
Germany, at all events, for many years. Ever since an advance copy
of Grunwald’s work on ‘ Die Lehre von den Naseneiterungen ’ had
been sent to him for review in 1895 he had tentatively used all the
methods and instrument s described by that author, and amongst them
his method of attacking severe cases of polypus and suppuration of
ethmoidal labyrinth—surely the same thing as polypus and suppura¬
tion of lateral mass of ethmoid. [See cases 149, 151, 155, which can
now be read in Lamb’s English translation of Grunwald’s work.]
Further, after a large experience of these methods, he had himself
exhibited cases at the Laryngological Society in which these very
procedures had been carried out on the ethmoid body for multiple
polypoid degeneration combined with ethmoidal suppuration,* i. e.
after having formally excised the middle turbinated bones, to curette
away with due caution any diseased tissue in the subjacent ethmoidal
labyrinth; and he had further supported and advocated the adoption
of these measures ( loc . cit .) in suitable severe cases—which a further
experience now enables him to even more strongly recommend. He
therefore felt it incumbent on him to make it clear that in conse¬
quence of Grunwald’s work these methods were known to some nasal

* * Pro<;. Laryng. Soc. Lond.,’ vol. iv, pp. 79—81, 1897.

34

workers at least five years ago, and have been tried, and to a large
extent adopted—in order to clear English rhinology from the unjust
imputation of being so many years behind the times.* Nevertheless
he heartily congratulated Dr. Lack on his bold and powerful advocacy
of the application of sound surgical principles to these nasal disorders,
on his admirable re-statement of the whole problem, and on his
painstaking re-investigation of the histological changes. Here Dr.
Lack’s results appeared to him to agree with those of Griinwald and
Woakes, except for the difference with the latter as to the amount
and frequency of necrosis. As far as he knew, he believed the credit
of first maintaining the causal connection between ethmoid bone
disease and polypus belonged to Dr. Woakes. He had the more
pleasure in stating this, for he was by no means a supporter of the
latter in his use of the term “ necrosing ethmoiditis.” In a few cases
the speaker was well aware of real necrosis—large sequestra—in cases
quite free of syphilitic taint, and it was the comparative rarity of
genuine necrosis that had led him to question the propriety of
applying the epithet “ necrosing ” to a condition of which necrosis
was only a late and occasional accident. He feared that Dr. Woakes
bad delayed that recognition of his work (which was justly his due)
for many years by that unfortunate term—unfortunate in that it was
taken to imply that he taught there was some special necrosing
pathological process found in the ethmoid and confined to it, which
was essentially different to any known to occur elsewhere in the body.
The speaker thought that if the changes observed had been originally
described in terms of general surgical pathology as “muco-peri-
ostitis,” “ rarefying osteitis,” “ sclerosing osteitis,” “ dry caries,” etc.,
and had been recognised as not affecting the ethmoid only, but many
of the adjacent bones of the head, the meaning would have been at
once grasped, and full recognition accorded. With reference to the
performance of the operation in question, the speaker has from the
first adopted the methods and instruments of Griinwald, with some
modifications. The neck of the middle turbinated is first cut through
with Griinwald’s forceps ;+ the cold wire snare is then passed well
into the slit made, over the genu, and back over the middle turbinated
as far as possible, and then tightened up so as to cut off the anterior
half. The posterior half is then removed with the turbinotome when
diseased. Polypi, cysts, abscesses, granulations, cholesteatomatous
debris, soft bone, and necrotic pieces, are then cautiously but
thoroughly curetted and removed with Griinwald’s spoons and
curettes, X until no polypus or other diseased tissue is left, and healthy
firm bone is felt. Of course great caution is necessary to avoid
getting into the orbit or through the cribriform plate. The speaker
nearly always operated under a general anaesthetic and in the sitting
posture, and staunched haemorrhage as he went, so as to have the
parts well in view, and kept the anatomical relations well in mind.
Occasionally he operated with cocaine only. He had seen no bad
result. On the other hand, the patients had been mostly well satis-

* Speaker’s review of Griinwald’s 2nd ed., ‘Journal of Laryngology,’ May, 1896.

t Table II, fig. 1, 2nd German ed.

J Table II, loc. cit.

35

fied with the result of the operation, in the way of much greater
relief of symptoms, of prolonged freedom from recurrence, and of
diminished suppuration, and in many cases of cure lasting now over
three or four years. He preferred not to plug after the operation,
and it was very seldom necessary. He insufflated iodoform, and
applied parolein and soothing ointments freely, to prevent the secre¬
tions consolidating into hard dry scabs, which were difficult to get
away, and sometimes led to epistaxis in dislodging. After the first
day he used sprays and irrigations of weak warm alkaline antiseptic
lotions. To revert to the aetiology of polypus, each speaker had
referred vaguely to “ disease of the bone ” without giving any clue as
to what the cause of this disease was. There was too great a ten¬
dency to avoid this vital point. One must not assume that disease is
some inexplicable inherent vice until the position has been excluded
that it is a departure from the normal due to some defective adjust¬
ment of the organism to the external, or some traumatism from out¬
side, Are such to be found in traumatisms due to falls and blows,
initiating changes in the muco-periosteum which are not recovered
from, and become chronic ? Are polypi, etc., more common in erect
humans than in quadrupeds, which are less liable to nasal injury
from falls and blows ? Are not the rapid and extreme variations of
temperature of our inspired air, the irritation of dust and pathogenic
organisms, and the chronic congestion due to nasal stenosis enough
to explain the persistence of an existing traumatic muco-periostitis, if
not to initiate the latter, with its sequels of polypus and bone disease ?

Mr. de Santi, whilst admitting the excellence of the paper by the
opener of the discussion, could not but feel some disappointment that
there was nothing new in it. Firstly, as regards the treatment of
nasal polypi, he had for a long time past considered and taught that
more radical measures for their removal were required. The removal
of polypi by galvano-caustic loop, or by the cold wire snare, was ex¬
tensively practised up to the present time, but he considered that,
though in certain cases these methods were suitable, they were gene¬
rally only palliative and not curative in result. Certainly, in his
opinion, the cold-wire snare was infinitely preferable to the galvano-
caustic loop, as the fom et origo of the polyp could be torn away by it,
whereas with the galvano-caustic loop the origin of the polyp was
left. Taking into consideration the great frequency of recurrences in
these cases, the numerous sittings required if the snare be used, Mr.
de Santi strongly advocated removal by some such radical measure
as described by Dr. Lack. To say that radical measures were new
was totally wrong; the older surgeons, such as Mitchell Banks,
Jacobson, etc., had strongly advocated removal of the middle turbinals
with all the polypi that might be growing from them, and though it
had been the custom for laryngologists to decry these operations and
speak of them as barbarous, Mr. de Santi was glad to hear at this
meeting that laryngologists were inclined to favour the more frequent
use of general operative measures. Dr. Lack’s operative procedure
was hardly new; the speaker himself had on several occasions scraped
out masses of polypi under general, anaesthesia, sometimes with
the sharp spoon, sometimes with the ring-knife, and he also used

36

forceps and scissors. In Mr. de Santi’s opinion, therefore, radical
operation should be resorted to much more frequently for the cure of
nasal polypi. Under the older methods of treatment by the snare the
patient became a regular “ annuity” to the surgeon, and at the end,
after an expenditure of much time and money, and suffering a good
deal, was often no better. As regards the pathology of nasal polypi,
he considered there was not the slightest evidence of rarefying osteitis
as the cause. Why should there be rarefying osteitis ? Surely such
a condition would have an origin such as syphilis, injury, etc. He
looked upon any rarefying osteitis that might be present as secondary
to the polypi, and not a primary condition. As a matter of fact he
came to the conclusion that nothing was really known as to the
pathology of nasal polypi; at all events he himself was quite ignorant
of their causation, and he believed that to be the condition of most
members of the Society present.

Dr. Herbert Tilley thought that Mr. de Santi should have drawn
a definite distinction between Dr. Lack’s operation and the somewhat
promiscuous intra-nasal operations with which Mr. de Santi had
credited other surgeons. In the presence of so distinguished a sur¬
geon as his former teacher, Mr. Christopher Heath, the speaker
hesitated to deprecate too strongly the use of forceps in the removal
of nasal polypi, because in his student days he had constantly seen
them used. He was constrained, however, to point out the ease and
perfection with which nasal polypi could be painlessly removed by
means of a wire snare, guided by means of a reflected light. This
was a very different proceeding from the use of forceps. Under the
latter circumstances he had frequently seen healthy mucous mem¬
brane and pieces of middle and inferior turbinate bones removed, while
more often than not, only a few polypi were removed, and inefficient
removal was talked of as “ recurrence of the growths.” The opera¬
tion advocated by Dr. Lack was an entirely different procedure, in
that it was scientifically conceived, and should be carefully and skil¬
fully executed; furthermore, the operation was limited to diseased
structures. The speaker could testify to the efficiency of the opera¬
tion in those cases where careful removal by means of a snare had
failed to produce immunity from recurrence. He had obtained some
excellent results in such cases. He thought that in some cases,
possibly the majority, mucous polypi originated in the mucous mem¬
brane, and that the bone was secondarily involved. The inflamed
bone would then keep up the formation of polypi, even though the
latter were from time to time removed. In support of this view he
adduced those somewhat exceptional cases where mucous polypi grew
from the septum, and those common cases in which they lined the
walls of suppurating accessory cavities in which the underlying bone
was not as a rule diseased. As to the primary cause of the inflamma¬
tion, he had as yet no definite opinion to offer. That well-marked
bone changes were met with in cases of nasal polypi seemed obvious,
and he could not understand how members could differ from this
view after examining the microscopic specimens illustrating these
bone changes which had been placed at their disposal by the intro¬
ducer of the debate.

37

Dr. StClair Thomson still suspended his judgment on the subject
of debate, and would therefore limit his remarks to some side points.
He knew that it had gone out of fashion to quote authorities on
scientific, and particularly on medical mattters; any appeal to
authority might savour of dogma. Still, he thought it would be well
before entirely accepting the views which had been advanced in the
debate to recall the teaching of two well-known and trustworthy
rhinologists. Hajek had thoroughly investigated the pathology of
polypus, and had consistently taught that the inflammation spread
from' the outside inwards, and not from the bone outwards. Then
Griinwald, in the latest edition of his book, which showed enormous
research, expressed the opinion that “ polypi, in a majority of all
cases, are almost as good as pathognomonic of empyemata of the
accessory cavities, or focal suppuration in the nasal passages.” From
his own experience the speaker was inclined to agree with this, for
the more expert he became in recognising empyemata, the fewer cases
he had of recurring polypi. In cases where the polypi had been most
persistent, their growth ceased at once when the offending accessory
sinus had been drained. Possibly the operation recommended owed
some of its success to the fact that the removal of the middle turbinal
facilitated drainage from the frontal and maxillary cavities, and for
suppurating ethmoiditis it was, of course, particularly suitable. He
understood Dr. Lack to say that one of the indications for the opera¬
tion was suppuration in an accessory sinus. Unless the sinus
happened to be the ethmoidal cells, Dr. Thomson thought the detec¬
tion of suppuration elsewhere was, on the contrary, a contra-indica¬
tion. Mr. Baber had drawn attention to a practical point, which the
speaker did not remember to have seen mentioned in most text-books.
This was the danger of collapse and also of haemorrhage in operating
on nasal polypi in elderly subjects. Those who had not met with this
occurrence would hardly believe what alarming symptoms sometimes
ensued from removal of a simple nasal polypus in an old person.

Dr. FitzGerald Powell said that he thought they were under a
debt of gratitude to Dr. Lambert Lack for having brought forward
this scientific and practical method for the treatment of nasal polypi.
Although he may not have been the first to remove by scraping
diseased bone and polypi from the nose, he was, undoubtedly, the
first to teach them, in a systematic and scientific manner, the best
method for obtaining an early and radical cure. He had himself,
since its introduction by Dr. Lack some years ago, been in the habit
of practising this operation, from time to time, in suitable cases, and
his experience was that it was most efficacious, entirely safe, and
having the great advantage that it caused much less suffering to the
patient than the repeated sittings, with the application of cocaine,
and the cold snare, with their attendant pain and mental agitation.
Much had been said as to the danger of the operation, and the likeli¬
hood of injury to the cribriform plate of the ethmoid, but, having
regard to the anatomy of the skull, it would be a difficult matter, and
force would have to be used to push a large Meyer’s ring-knife up so
far. On the other hand, it would not be difficult to injure the orbit,
but with care this can be avoided. With regard to the pathology, he

38

had no doubt that in a large number of cases, a condition of rarefying
osteitis, or perhaps necrosis resulted, the causation of which might
well be ascribed to syphilis, tubercle, traumatism or sepsis. But on
the other hand, he thought it quite possible that a condition of
inflammatory oedema might arise in the mucous membrane, blocking
the orifices of the mucous follicles, and to this cause he ascribed in
some cases the presence of one or two small polypi, such as he had
found growing from the septum or the upper edge of the posterior
choana and projecting into the post-nasal space. He had removed
them with the cold snare at one sitting, and had had no recurrence
after two years. During the operation there was a considerable
amount of haemorrhage, and after the commencement of the curetting
he was not able to see very much, and had to rely on what he could
feel with the finger and the curette. He considered it very necessary
for the control of the haemorrhage to plug the nose, and he always
did so, using strips of iodoform gauze, which he kept in the nose
generally for two days, changing the gauze after the first twenty-four
hours. Occasionally a recurrence of the polypi did take place after
the operation, but they were few in number, and could be removed by
the snare or a second scraping, which effectually removed the ten¬
dency to recur.

Mr. Waggett said that apropos of Dr. StClair Thomson’s remarks
re ethmoidal cell disease, it was interesting to note a paper by
Lichtwitz, in which attention was drawn to the unexpected frequency
of accessory sinus empyema, as detected in the post-mortem room.
That author stated that, whereas in the Special Clinics of Chiari and
himself, only 2 per cent, of the total number were noted as empyema
cases; the evidence of general post-mortem rooms showed that class
of disease to be vastly more frequent. The reports of Harke, E.
Frankel, and Lapelle recorded over 100 cases from a total of 700
autopsies. Among sixty-three cases detected in the post-mortem room
only one had been suspected during life. With regard to the general
question of the relation of mucous polypi to bone changes, it was
interesting to note that some of the speakers, while admitting such a
relation, asserted that the bone changes were of secondary origin and
due to the polypoid degeneration of the mucous membrane. In the
face of Dr. Lack’s thesis the assertions of dissentients should be sup¬
ported by evidence. It was not surprising that the ethmoid bone,
which differed in many respects from any other bone in the skeleton,
should be subject to a pathological change of the character of a rare¬
fying osteitis not met with elsewhere.

Dr. William Hill hoped that a wrong impression would not be
created outside the Society by reason of the general terms in which
those who approved of radical measures on the ethmoidal cells had
spoken on this occasion. The object, of course, of those who attacked
a case of polypous disease with ethmoidal suppuration, whether
according to the method of Lack or Griinwald, or other operation
similar in principle, was to remove the whole of the disease under
general anaesthetic at one sitting. As a matter of personal experience,
however, he felt bound to admit that this ideal was not always
attainable, even at a long sitting. He had the advantage of possess-

39

mg a slender little finger, with which he explored the nasal fossae
during the course of an operation ; but in spite of every precaution he
had often either left some polypi behind or insufficiently opened the
ethmoidal cells, so that further operations under anaesthesia were
sometimes necessary; and there was generally some trimming up to
be done with snare or punch forceps at subsequent sittings under
cocaine. The snare operation alone was only useful in simple cases,
and was rarely, if ever, radical in recurrent and suppurative ones. In
clinical teaching, whilst calling the attention of students to the inar¬
tistic and sanguinary methods of treatment adopted by those general
surgeons who used blindly to push forceps up the nose and remove all
they could lay hold of, including an occasional turbinal, diseased or
otherwise, the speaker had always been careful to call attention also
to the fairly good results attending such measures, in spite of the
absence of technique; and what was more remarkable, as far as he
could gather, no fatal result had attended the use of the forceps, even
in inexpert hands; and generally speaking, the operation had not led
to harmful sequelae, though doubtless it often failed in its object from
imperfect removal. In conclusion, he agreed with those speakers who
insisted that where ethmoidal suppuration was present some radical
measure, such for instance as that advocated by Dr. Lack, was essen¬
tial to insure a cure of nasal polypus.

Dr. Dundas Grant said that there could be no doubt that Dr.
Lack’s operation ought to be looked upon as a received surgical
procedure, the only possible difference of opinion being with regard
to its indications. Those laid down by Dr. Lack pointed to suppu¬
ration of the ethmoidal cells. With regard to the necessity for
radical operation in cases of recurrent polypi, he thought it might
sometimes take other forms, e. g. there were cases in which the polypi
could only be eradicated after an opening bad been made into the
antrum. Dr. StClair Thomson indicated that free washing out of the
antrum had caused disappearance of polypi; he had himself also
observed this. In other cases that had not occurred, and several
times he had thought it justifiable to open the antrum of Highmore
and clear away its entire inner wall with the unciform process for the
purpose of eradicating polypi situated in the middle meatus. Some¬
times there might be polypi growing from the front of the sphenoid
bone. He related a case in which he had removed such a polypus.
With regard to polypi in the post-nasal space, a general anaesthetic
was in his opinion necessary, the left forefinger being introduced
into the naso-pharynx. The difficulty in putting the snare round
such a polyp was considerable, and the forceps, passed through the
nose under the guidance of the finger in the naso-pharynx, was the
only instrument which could be used under a short anaesthesia like
that of nitrous oxide gas. In order to get complete removal of
polypi and to get a snare applied to as many polypi as possible, it was
often necessary to remove the anterior part of the middle turbinate
body. There was sometimes another form of obstruction which had
to be removed, and that was the polypoid swelling on the anterior lip
of the hiatus semilunaris, which sometimes projected to a considerable
degree into the nasal cavity; and the only way of removing it satis-

40

facto rily was that recommended by Killian, which he (Dr. Grant) had
himself done several times. It was to pass the point of a sharp pair
of scissors right into the middle of the growth, and to remove the upper
and lower half separately by means of the snare. This had enabled
him to reach and remove a polypus which was inaccessible both to
vision and to touch until that was done. Nobody, he was sure, would
regret more than Dr. Lack if it became the custom for all and
sundry to perform his operation on every patient who had polypi of
the nose. In a wisely selected number of cases, however, it was
absolutely indispensable and offered the most promising results.

Dr. Bond heartily supported Dr. Lack in his method of operating,
but there were certain cases in which one might come to grief. Dr.
Lack’s method of operating was different from Bank’s, which latter con¬
sisted in taking hold of the middle and upper turbinates and pulling
away with forceps as much as possible from the top and middle of
nose. Dr. Lack’s operation was a different thing altogether, but one
might have trouble in operating if one did not pick one’s cases some¬
what carefully. The most serious cases were those referred to by Dr.
StClair Thomson, namely cases of polypi occurring in old women over
sixty. In such a case the front of the nose on each side was commonly
seen to be filled with what seemed to be ordinary polypi, but the case
was often one of malignant disease with polypi in front. If in such
a case Dr. Lack’s procedure was used under the belief that the case
was one of general nasal polypi the operator would be surprised at
the result. There were other cases where the nose was very much ob¬
structed, and a little oedema and granulomatous tissue might be seen
in front, with syphilitic necrosis, etc., behind. On scraping away
vigorously in such a case a violent haemorrhage might occur. He had
seen one instance of such a case. Somewhat active treatment at the
posterior part of the nose was carried out, and the sphenoid cavity
opened and packed, but with damage to the vessels inside the skull.
Dr. Lack's operation was, in his opinion, an admirable and successful
one. He wished to mention that there was no danger of damaging
the cribriform plate, etc., if the operation were done with ordinary
skill; such danger was in large part imaginary. The second point he
remarked on was that the cautery had ceased to be used and recom¬
mended, as in times past, in the treatment of nasal polypi. It was
recommended in the text-books as of use in treating polypi, and
cauterisation of the stumps was advocated. He believed the latter to
be a great factor in the production of bone disease. He thought
curetting of the mucous membrane should be employed more than it
had been. In conclusion, he thought the individual factor played a
very important part in the comparative success of the operation; one
operator would get good results from Dr, Lack’s method, whilst
another would get much the same result from operations with exten¬
sive curettings carried out at several sittings.

Dr. Wyatt Wingrave said, with reference to the pathological
aspect of the discussion, Dr. Lambert Lack’s specimens illustrated
one phase only of polypus formation. Many of the sections showed
only normal cancellation changes, a process of osteoporosis which is
essential to the development of the accessory sinuses, and continues

41

until very late in life. The “ osteoclastic ” operations so well seen in
this rarefying process are often misinterpreted as being morbid ; but it
is only when greatly exaggerated that it should be so construed. In
some of the slides the periosteal and osteoblastic activity was well
marked, but this he considered as bearing only a coincidental rela¬
tionship to the simple form of polypus. For all practical purposes
polypi might be divided into two groups :—(1) simple ; and (2) granu¬
lation. While the first group retained to a great extent many of the
local histological features, the second group consisted almost entirely
of small cell tissue in various degrees of myxoedematous degeneration,
so that when fully developed they could not easily be distinguished
from the simple variety. It was in the granulomatous group that
the osseous changes were the more marked, so that the polypus was
only symptomatic of deeper sinusal changes. Reference had been
made to the necessity for exercising care when removing polypi in the
aged. Whilst emphasising this, he thought that in addition to the
risk of haemorrhage from senile changes in the blood-vessels, there
was also a danger due to advanced cancellation. The rarefication
was often so extensive that the turbinals proved to be as brittle as
“ biscuit,” and great care had to be exercised in limiting the amount
of bone removed with the polypus.

The President congratulated the Society on a most useful discus¬
sion ; he thought that from this time forward a more or less new
departure would go forth to the world as being the view held by
certain members of the Society, stamped with the approval of the
Society. The only thing to be afraid of was that this somewhat radical
method of treatment might be adopted by men who had not the skill
of the great majority of the members of the Society. It was a point
which ought to be emphasised, and which had been emphasised at a
previous meeting of the Society. It was a method only to be em¬
ployed in exceptional cases, and by those who had an exceptional
amount of experience of intra-nasal disease. Another important point
was the care to be exercised when polypi occur in old people. This
had been overlooked in the past. The stress laid upon this was an
additional gain to science and medicine.

Dr. H. Lambert Lack, in reply, thanked the members of the
Society for the reception of his paper, which was more favourable
than he had expected. In reply to Mr. Baber, he said he had watched
some of his cases as long as six years, and so far from destroying the
power of smell, in some of the most chronic cases, in which the
patient had smelt nothing for years, it had returned after the opera¬
tion. With Mr. Spencer’s remarks he could not agree; but there was
not time to go into them all. He doubted whether anything at all
comparable to a nasal polypus ever arose apart from bone, for the
rectal polypus was an adenoma, and these and other similar “polypi”
were true tumours. The old idea that nasal polypi were tumours he
thought had been given up years ago, and therefore he had not
considered it worth while to allude to it. The structure and whole
history of nasal polypi quite precluded such a theory. He had, how¬
ever, very carefully separated granulation and inflammatory growths
from nasal polypi, as they were both microscopically and clinically

42

quite distinct. Again, Mr. Spencer said that there were all stages
between a nasal polypus and sarcoma. There was no evidence to
support that view. A nasal polypus might be removed year after
year and still never become a sarcoma. Several speakers, whilst re¬
luctantly admitting that bone changes take place, claim that they are
secondary to, and not the cause of, polypi, and yet can bring no
evidence. On the contrary, when the diseased bone was removed,
recurrence of polypi did not take place, but when the polypi alone
were removed the bone changes continued and the polypi recurred.
He had not claimed that he was the first to advocate the removal of
bone. This was done one hundred and fifty years ago by Morgagni
and Valsalva. Morell Mackenzie had published (in his book on
‘Diseases of the Horse’) notes of several cases of recurring polypi
in which, after he had removed the underlying bone, recurrence no
longer occurred, in spite of which Mackenzie advocated the cautery
in all cases. Further, Ferguson and Pirogoif had recommended the
removal of the bone. But they had not advocated the thorough opera¬
tion which the speaker had proposed, and neither had Griinwald.
When he started to investigate the subject of the pathology of
polypus he had an open mind, but on discovering the changes in the
bone which were illustrated under the microscope to-night, he came
to the conclusion that Woakes’s views were in large part correct.
Where Martin had not found bone changes, perhaps it was because
Woakes had removed the bone in other than polypus cases, as he
ascribed many diseases to “ necrosing ethmoiditis.” He agreed with
Dr. Powell that it was not at all easy to push a large ring-knife
through the cribriform plate, and such an accident could be avoided
with a little care. Dr. Tilley had said that in cases of polypi in the
accessory sinuses bone disease was not always present, though the
bone had never been removed for microscopical examination, and thus
there was no conclusive evidence that osteitis was not always present.
He could recall cases of polypi in the sinuses in which bone disease
was undoubtedly present. In two cases the sphenoidal sinuses were
affected, and in both the anterior wall of the sinus was extensively
carious ; and in two other cases in the antrum the inner wall was ex¬
tensively destroyed. This evidence, as far as it went, contradicted
Dr. Tilley’s statement. Dr. Thomson seemed to approve Griinwald’s
theory. He did not think it was the general experience that sinus
suppuration was invariably present in polypi. With the most careful
examination it was in all probability found in less than 50 per cent,
of the cases, and probably the same cause that produced the one
might produce the other. Mr. Waggett had quoted post-mortem
evidence to show the enormous frequency of sinus suppuration, which
only showed that post-mortem records could not be accepted. The
reasons of this frequency seemed to be that the accessory cavities had
their openings at the top, and therefore the secretion formed depended
entirely on the action of the ciliated epithelium for its removal.
Thus when just previous to death this action ceased, or became in¬
efficient, fluid accumulated in the cavity, and German authors seemed
to accept the least trace of any sort of fluid as evidence of sinus sup¬
puration. He agreed with Dr. Hill that one might have to trim up

43

the case afterwards with a snare; but in most of his cases he had
removed everything at one operation. He would try and avoid Dr.
Bond’s three classes of dangerous cases, and certainly would never
operate in the old or the feeble. In replying to Mr. Wingrave, Dr.
Lack said that although some of the bone in his sections was normal,
abnormal places were to be found in every section if looked for.

Mr. Cresswell Baber, in reply, said, with regard to the question
of the starting-point of the inflammatory trouble causing polypi,
whether in the mucous membrane or in the bone, he thought the
clinical evidence seemed in some cases to favour the former theory,
the reason being that, as he had pointed out, mucous polypi were
met with under so many different conditions. Two of the latest
observers, Hajek and Cordes, found cases in which the mucous mem¬
brane only was affected ; in these cases, then, how could the bone be
the cause ? He was interested in Dr. Lack’s operation, and thought
it was one to be tried in suitable cases; before it was done the state
of the larger sinuses ought to be investigated. He was glad that
several members agreed with him as to the necessity for caution
when removing polypi in the aged.

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Annual Meeting, Friday, January 4th, 1901.

F. de Havilland Hall, Esq., President, in the Chair.
Present—17 members.

The minutes of the last Annual Meeting were read and con¬
firmed.

Drs. Bronner and Brown Kelly were appointed scrutineers of
the ballot, and the following officers were appointed for the
year :

President. —E. Cresswell Baber, M.B.

Vice-Presidents. —A. Bowlby, F.R.C.S.; E. Law, M.D.; and
Greville MacDonald, M.D.

Treasurer. —Clifford Beale, M.B.

Librarian. —Dundas Grant, M.D.

Council. —F. de Havilland Hall, M.D.; Herbert Tilley, F.R.C.S.;
Barclay Baron, M.B.; William Hill, M.D.; Sir Felix Semon, and
Lambert Lack, M.D.

Secretaries. —Ernest Waggett, M.B., and Charles A. Parker,
F.R.C.S.(Ed.).

The report of the Council was then read and adopted.

Report op Council.

The Council has the pleasure to report that the Society continues in
a most prosperous condition. During the year thirteen new members
have been elected, while one member has resigned and two have died.
In April the Society received with deep regret the news of the death
of Dr. McNeill Whistler, a former Vice-President and an original
member.

The attendance of members at the Ordinary Meetings has been
exceptionally large, and the clinical material abundant. The Ordinary
Meeting in December was devoted to a discussion on “ The Treatment
of Nasal Polypi,” which was well attended by members, many of
whom took part in it.

Increased facilities have been provided for the exhibition of micro
FIRST SERIES—VOL. VIII. 3

46

scopieal sections which have been freely taken advantage of, and a
Cabinet to contain the specimens has been purchased and placed
under the charge of a curator.

At a Special Meeting in March it was resolved that “it was
desirable that at all International Congresses there should be full and
separate sections for Laryngology and Otology.”

The Council have been recently engaged in the consideration of the
rules of the Society, which, owing to alterations and additions at
various times, required general revision and rearrangement.

The following report of the Treasurer was read and adopted:

The total receipts of the Society from subscriptions, entrance fees,
etc., during the past year has been <£134 8s. There are still ten
subscriptions outstanding and one entrance fee, but nearly all the
outstanding subscriptions for 1899 have now been paid in.

The total expenses amount to £133 13s. 2d., leaving an excess of
income over expenditure of 14s. 10 d. for the year. To this has to
be added the balance brought forward from last year, viz. £215
16s. 3d., making a total credit balance on January 1st, 1901, of £216
11s. Id.

The Balance-sheet, duly audited and found correct by the auditors,
Dr. Jobson Horne and Dr. Purniss Potter, is appended.

Income.

Balance from 1899. . .

10 Entrance Fees . . .

110 Subscriptions . . .

5 „ (1899) .

2 „ (1901) .
1 Subscription overpaid

Total Receipts
for 1900 . £134 8

Balance Jan.

1st, 1901 . 216 11

BALANCE-SHEET, 1900.

Expenditube.

£

s.

d.

£

s.

d.

215

16

3

' Rent.

31

10

0

10

10

0

Adlard.

56

0

3

115

10

0

Reporting.

18

18

0

5

5

0

Baker—Microscopes . . .

6

10

0

2

2

0

Newton—Lantern, etc. . .

2

10

0

1

1

0

Pulman—Binding . . . .

Entertainment at Annual

4

7

2

Dinner.

Cheque returned (Dr. W.

5

5

0

Williams).

2

2

0

Clarke—Indexing . . . .

i

10

0

Burgoynes—Chemicals . .

0

14

7

0

Rogers—Spirit Lamps, etc. .

0

11

11

Mathew (porter) . . . .

1

1

0

New Cheque Book ....

0

8

4

1

Hon. Secretary’s Expenses:

Dr. Lack.

1

1

9

I

1

Mr. Waggett ....
Hon. Treasurer’s Expenses .

0

11

7

0 11

7

Total Expenditure for 1900 .

133

13

2

Balance.

216

ii

1

£350

4

3

£350

4

3

Dec. 31*1,1900.

Audited and found correct,

E. CLIFFORD BEALE, Treasurer,

/W. JOBSON HORNE.
IE. FURNISS POTTER.

47

The Librarian’s report as under was then read and adopted.

The following “ Exchanges ” have been regularly received during
the year 1900:

Arcliiv fur Laryngologie und Rhiuologie.

The Journal of Laryngology, Rhinology, and Otology.

Revue hebdomadaire de Laryngologie, d’Otologie, et de Rhinologie.

Archivii Italiani di Laringologia.

Annales des maladies de l’oreille, du larynx, du nez, et du pharynx.

Bollettino delle malattie dell* orecchio, etc.

The Laryngoscope.

Archivio Italiano d’ Otologia.

It has been found impossible to have them all bound up to the
present date, but this will be effected with the least possible delay.
The following works have been presented to the library:

By the President (Dr. de Havilland Hall).

Uorell Mackenzie—Semon. Die Krankheiten des Halses und der Nase.

Gustav Spiess. Kurze Anleitung zur Erlernung einer richtigen Tonbildung in
Sprache und Gesang.

Gustav Spiess. Ueber den Einfluss einer richtigen Stiinmbildung auf die Gesund-
heit des Halses.

L. Scbrdtter. Vorlesungen uber die Krankheiten des Kehlkopfes.

By Sir Felix Semon.

Internationales Centralblatt fur Laryngologie for the year 1899.

I have also communicated with the editors of the ‘American Annals
of Laryngology, Rhinology, and Otology/ and of the 4 Revue Inter¬
nationale de Laryngologie/ but without success.

The following have been presented by the authors:

Pini, Alberto. Sulla olfattometria.

Goldstein, M. A., M.D. Modern Therapy of the Tympanic Cavity.

,, „ Nasal Haemorrhage and the Haemophilic Diathesis.

„ „ The Radical Treatment of Follicular Tonsillitis.

„ „ Otitis Media—Diagnosis and Treatment.

„ „ What not to do in Ear, Nose, and Throat Work.

Grazzi, Prof. V. Gli effetti dei bagni in generate sull’ organo acustico.

„ „ Ricordi de VI 0 Congresso Otologico Internationale.

„ „ Sulla Laringite Tubercolare.

Hajek, Dr. M. Pathologic und Therapie der entzundlichen Erkrankungen der
Neben hohlen der Nase.

Perez, Dr. Fernand. Reclierches sur la bacteriologie de l’oz&ne.

Pieniazka, Dra Przemystawa. Laryugoskopia oraz Choroby Krtani i Tchawicy.
Polyak, Dr. Ludwig. Jahrbiicher der Gesellschaft der ungarischen Ohren- und
Kehlkopfarzte, 1899.

Semon, Sir Felix. Die Nervenkranklieiten des Kehlkopfes und der Luftrohre.
Udden, J. A. An Old Indian Village (2 copies).

The following Proceedings of Societies, etc., have also been
added:

Sitzungsbericlits der Wiener Laryngologischen Gesellschaft, 1899.

American Laryngological Association, 1899.

Brighton and Sussex Medico-Chirurgical Society, Session 1899-1900, Fifty-third
Annual Report. *

Sixth International Otological Congress.

Gesellschaft der ungarischen Ohren- und Kehlkopfarzte.

48

Niederlandische Gesellschaft fiir Hals-, Nasen-, und Ohrenhcilkunde.

Verhandlungen der Laryngologischen Gesellschaft za Berlin.

Medical Society’s Transactions, vol. xxiii.

Catalogue of Accessions to the Library of the Royal College of Physicians.

The Hospital (autumn special number).

Journal of the International Pyschical Institute (November, 1900).

Bibliographia Medica, Index medicus, tome 9, No. 1, janvier 1.

Voyages d’etudes medic ales, 1900.

Several members have availed themselves of the resources of the
library, and in several cases where these resources have fallen short
I have had the pleasure of lending works to members out of my own
private collection.

I propose bringing before the meeting the question of procuring
more extensive accommodation for our books in the rooms of the
Royal Medical and Chirurgical Society, and have been negotiating
with Mr. MacAlister in regard to it.

The suggested new rules were then read, discussed, and con¬
firmed.

The meeting then adjourned.

Sixty-skoond Ordinary Meeting, January 4th, 1901.
F. be Havilland Hall, M.D., President, in tbe Chair.

Lambert Lack, M.D.,
Ernest Waggett, M.B.,

Secretaries.

Present—32 members and 2 visitors.

The minutes of the previous meeting were read and confirmed.

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

Eugene Steven Yonge.

Arthur Ainslie Hudson.

The ballot was taken for the following candidates, avIio were
unanimously elected members of the Society :

J. C. R. Braine-Hartnell, Cotswold Sanatorium.

George Jones, 8, Church Terrace, Lee.

49

The following cases and specimens were shown:

Clonic Spasm of Palate, Pharynx, and Larynx in a

Woman jet. 30.

Shown by Sir Felix Semon, M.D. I am indebted to my col¬
league, Dr. Risien Russell, under whose care the patient is at
present at the National Hospital for Epilepsy and Paralysis, for
permission to show her to-day. In order to avoid the case being
duplicated, I beg to state expressly that the same patient was
demonstrated by Dr. Russell before the Neurological Society a
few months ago.

The patient, a married woman, who has had six children, of
whom three are dead, and one miscarriage, and whose previous
and family history are unimportant, came to the hospital in
January, 1900, complaining of clicking noises in her head and
curious movements in her abdomen. These movements were
darting in character, as if there were something alive, and
passed from the stomach into the throat, head, back, and limbs
with great rapidity. In October, 1899, she first noticed the
clicking noise in her throat, which has continued ever since. It
has apparently nothing to do with the darting movements in the
abdomen.

On examination, the patient is a fairly well-nourished woman
with red hair, who lies or stands with her head thrown well
back, the neck and chin thrust forward, the latter generally
inclined to one side or the other, and the mouth is kept slightly
open. A constant slight clicking sound goes on with an aver¬
age frequency of about four per second. On looking into the
mouth this sound is seen to be produced by rapid vertical move¬
ments of the soft palate associated with similar movements of
the floor of the mouth. These movements go on whether the
jaws are open, even widely, or closed ; but if the chin is depressed
into its natural position with the mouth closed the noise ceases,
and the movements of the floor of the mouth cease, although she
says she can still feel the palate moving.

The clicking sound is audible when she speaks, between the
single words, but is said to cease, as well as the movements,
during sleep. The movements on the whole are rhythmical, but

are occasionally interrupted by momentary irregular intervals,
hardly lasting longer than a second or two, after which they re¬
commence.

The epiglottis makes similar movements synchronous with
those of the soft palate. These movements also take place in
a vertical direction. The arytaenoid cartilages and the vocal
cords move with equal frequency and very energetically, but
their movements are from side to side, not up and down; like
those of the palate and the floor of the mouth, they are oc¬
casionally interrupted for a moment, after which they begin
again. Usually they are so energetic that, during quiet respi¬
ration, the inner surfaces of the arytaenoids, when the inward
movement is executed, touch one another, but the oscillatory
movements continue even when the glottis is wide open. During
phonation everything appears normal.

Externally the mylo-hyoid can be seen and felt contracting,
whilst the whole larynx is constantly being spontaneously moved
a little up and down, and at the same time somewhat forwards
and backwards, the movements being energetic enough to be
communicated to the examining finger.

Her memory, attention, and intelligence are good, but she is
distinctly depressed. She has no delusions except that she is
sure she has something alive inside her.

The optic discs are healthy, the muscles everywhere well
developed, and the movements well performed without inco¬
ordination or tremor. Reflexes everywhere normal, gait normal
except for the position of the head described above, and nothing
abnormal found on examination of the abdomen.

Speculation as to the cause of this peculiar clonic spasm, as
to its mechanism, and as to the exact localisation of the focus of
irritation appears, in the present state of our knowledge, idle.

It is only desired to put the case on record.

Dr. Lambert Lack wished to call the exhibitor’s attention to a
paper he contributed to the ‘ Laryngoscope ’ in 1898, in which, under
the title of “ Pharyngeal Nystagmus and Allied Conditions of the
Pharynx and Larynx,” he had described several cases similar to the
one now shown. The speaker and Dr. Bond had each brought a
similar case before the Society, although their cases were less marked
and the movements were limited to the pharynx and soft palate,

51

As far as Dr. Lack had been able he had collected in the paper
referred to all the previously recorded cases of spasmodic and tremu¬
lous movements of the pharynx and larynx. He found they could
be divided into two distinct classes : (1) the most severe and extensive
cases, which were usually due to some gross lesion of the central
nervous system, e. g. cerebellar tumours, etc.; and (2) the milder cases,
which were of reflex origin and apparently due to some small local
lesion, e. g. post-nasal catarrh, pharyngitis sicca, etc.

Dr. Herbert Tilley related a minor case of the same affection
occurring in an adult, in which only the left side of the pharynx
showed constant spasmodic movements which extended the whole
length of the pharynx. The affection supervened on a carriage acci¬
dent—the patient was thrown out and suffered severe concussion and
bruising. The patient’s speech was becoming very indistinct, knee-
jerks absent, tongue tremulous, and the pupils responded to Argyll-
Robertson’s test. The diagnosis in the case referred to seemed to
point to incipient general paralysis of the insane.

Dr. Watson Williams believed that instances of clonic pharyn¬
geal spasm were not so very uncommon in general paralysis. The
vocal cords were more rarely implicated. It seemed to him that
these convulsive tics were possibly the analogue (bulbar) of psychic
tics (cortical), and they were sometimes associated, for echolalia and
coprolalia had been observed in association with clonic pharyngeal
spasm by Kellogg.

Dr. Clifford Beale called attention to the fact that the move¬
ment of both larynx and pharynx ceased directly the patient’s atten¬
tion was drawn to the acts of phonation or respiration. The cases
which Dr. Lack had referred to differed in this respect from the one
under discussion.

Dr. Scanes Spicer considered the sucking noise to be produced in
the larynx by the separation of the moist opposed surfaces of the
arytsenoid pyramids, for the sound continued unaltered when the soft
palate was firmly pinned against the spine. He had an impression
that Sir Felix Semon had shown a somewhat similar case before, but
unilateral, and in which the orbicularis palpebrarum of the same side
was affected.

Mr. Cresswell Baber remarked that pharyngeal spasm was not
uncommon; it was described as a clicking noise, and as objective
tinnitus ; he had not seen laryngeal spasm, or any case in which the
spasm took place so rapidly.

The President was sure that they were all thankful to Sir Felix
Semon for bringing forward this unique case.

Sir Felix Semon, in reply, agreed with Mr. Baber’s observations.
He had seen several cases of “ clicking ” palate, but in these the
spasm was limited to the soft palate and did not affect the larynx.
He was grateful to Dr. Lack for drawing his attention to his paper in
the ‘ Laryngoscope,’ which was unknown to him. He was unaware
that anything like his case had been previously described, although he
knew that Gerhardt had mentioned tremulous movements of the vocal
cords as the only sign of a cerebral tumour pressing upon the tem¬
poral convolutions.

52

IP.8 .—Since making the above statements, I have learned from
Dr. Lack’s very interesting paper in the ' Laryngoscope,’ June, 1898,
that several similar though not quite identical cases have been de¬
scribed.— F. S.]

Chronic Frontal Sinus Empyema treated by Kuhnt’s Radical

Operation.

Shown by Dr. Herbert Tilley. A woman set. 46, upon whom
this operation had been performed. The symptoms complained
of were constant left supra-orbital headache, chronic discharge
of pus, and nasal obstruction (due to polypi) upon the left side.

In performing the external operation the anterior bony wall
of the sinus was completely removed, the pathological products
curetted away, a large opening made into the nose, the sinus
walls painted with chloride of zinc, gr. xl ad the cavity
packed with iodoform gauze, and the soft parts finally sutured
with catgut for the other half of the wound. The end of the
gauze was led out of the inner angle of the wound.

After five days some six inches of the gauze were removed,
and the remainder of it after a further interval of four days.
The sinus cavity seemed quite healthy, and external pressure
was now applied to the soft parts so that they were pressed on
to the posterior wall of the sinus, to which they had firmly
adhered, thus obliterating the cavity. The patient was in the
hospital seventeen days, and there has been no discharge of pus
from the nostrils since the day of operation, five weeks ago.

Case op Cured Maxillary}(Double), Ethmoidal, and Frontal

Sinusitis.

Shown by Dr. StClair Thomson. The patient was a gentle¬
man aet. 41, who had suffered from nasal suppuration for eight
years. 1 ^ Twice in Natal, where he lived, he had had the alveolar
tooth socket drilled, and the right antrum washed out for some
months. The pus soon returned when the washing was discon¬
tinued. It was found that the frontal sinus on the same (i. e.
right) side was affected, and in hopes that the maxillary antrum
only acted as a reservoir, it was simply drained through a tooth

53

socket while the frontal sinus was opened from the outside. As
a result of this operation pus ceased to descend from the fronto¬
nasal duct which was obliterated, and the exposed part of the
sinus filled with cicatricial tissue. But still pus oozed from the
external corner of the frontal wound, and on placing the patient
again under chloroform it was found that this proceeded from a
diverticulum of the main frontal sinus, with which it communi¬
cated by a narrow neck which had been overlooked at the first
operation. This pocket, running outwards and backwards
above the outer orbit, had been opened up and plugged so that
it healed from the bottom, just as a mastoid wound does. It
was a slow process, taking three months, but there was no dis¬
figurement.

The maxillary sinus on the same side had been treated by the
Caldwell-Luc operation, and the ethmoidal cells had been
curetted. The left maxillary antrum was simply drained, as it
appeared to be only of recent infection from the right side.

It would be seen that the patient was not disfigured exter¬
nally, as the incision was well under the eyebrow. Internally the
right nasal chamber had not been interfered with physiologi¬
cally by the removal of the anterior ends of the inferior and
middle turbinals. There was no pus in the nose, but a little dry
scab formed daily over the ethmoidal-cells opening. The patient
expressed himself as struck by the recovery of the sense of
general well-being. He said that he felt ten years younger
than at the beginning of treatment, and now knew that he was
then growing prematurely old.

Sir Felix Semon suggested to Dr. Tilley that it would be worth
while in cases of this nature, in which the whole of the anterior wall
of the frontal sinus was removed, to put in a plate either of aluminium,
platinum, decalcified bone, or of ivory. Such devices acted well in
other parts, and why should they not in the frontal sinus region ?
Disfiguration might thereby be lessened considerably, or even be totally
avoided.

Dr. Watson Williams remarked that at the Portsmouth meeting
of the British Medical Association in 1899 reports of two cases of
diffuse suppurative osteitis, following operations for frontal sinus
empyema, were reported. He desired the opinion of members of the
Society as to the possibility of increasing the risk of such an oc¬
currence by putting pressure upon the frontal sinuses, after opening,
curetting, and cleaning them, as in the radical cure.

Mr. Cbesswell Babes said it seemed as if surgeons were now coining

3 §

54

back to the operation of Kuhnt, who removed the whole of the ante¬
rior wall of the frontal sinus. He himself had shown at the Society
a most refractory case, in which cure had resulted from resorting to
this radical operation after all other measures had failed. The de¬
pression was not marked in his case, and the results were satisfactory.
He asked, was it advisable to make a large opening into the nose or
not ? In the radical operation the discharge escaped on to the surface,
and the sinus was filled with healthy granulation tissue. He took it
for granted that the anterior part of the middle turbinate was re¬
moved previous to operation on the frontal sinus.

Dr. Scanes Spicer thought that in both of these cases he would him¬
self have removed much more completely the front part of the middle
turbinated and anterior ethmoidal cells before operating externally on
the frontal sinus. He had seen many cases presenting all the symptoms
and signs of frontal empyema get well after this procedure without
the need of an external operation; and had found that even if this
did not happen, the drainage of the frontal sinus into the nose was
much facilitated by such free removal. While acknowledging the
necessity for complete resection of the anterior wall in rare cases, he
dreaded the deformity resulting, and thought that clearing out the
anterior ethmoidal region well would render it still less often neces¬
sary.

Dr. StClair Thomson, in reply, said that the anterior half of the
middle turbinate was removed before the operation on the frontal
sinus. The suggestion of Mr. Baber was one to be considered—
whether it was not much more desirable to obliterate the fronto-nasal
duct, and cut off all communication with the nose. He started in this
case with the Ogston-Caldwell-Luc operation on the frontal sinus,
and passed his little finger up the nose into the sinus. During the
treatment he changed his mind, and succeeded, by exerting a little
pressure, in cutting off the frontal sinus from the nose The patient
ran no risk of being reinfected because he now had no sinus. The
idea of Sir Felix Semon was worthy of attention. He had a patient
who told him that the bank clerk next to him had a platinum plate
in his forehead, and feels very well. Other substances besides platinum
might be used. In the ‘ Medical Press and Circular ’ of recent date
solidified vaseline was suggested for this purpose.

In answer to various questions Dr. Tilley said that he would only
recommend so complete an operation in exceptional cases, because of
the deformity produced. In some seven cases which he had previously
shown to the Society equally good results had been attained with no
deformity, and in these instances far less of the anterior wall had been
removed. He had performed Ifuhnt’s operation in this case really to
satisfy himself as to how much deformity it produced. He considered
that there was very little, in fact no risk of septic osteomyelitis
ensuing if the external wound was not sewn up at the close of the
operation. To avoid the complication it was also wise to make a
large opening into the nose, which had the additional advantage of
breaking down the anterior ethmoidal cells, which were always diseased,
and which, if left alone, were very liable to reinfect the sinus, however
carefully the latter was treated by curetting and disinfection.

55

Case of Epithelioma of the Tonsil and Glands in the Neck;

Operation; Recovery.

Shown by Dr. Lambert Lack. The patient, a man set. 50 ,
came under my care one month ago, complaining of a painful
lump in the throat. An ulcer was seen in the position of the
right tonsil, about the size of a florin. It spread on to the pos¬
terior pillar of the fauces, slightly on to the lateral wall of the
pharynx, and downwards to within a quarter of an inch of the
tongue. The edges of the growth were hard and everted. No
enlarged glands could be felt in the neck. As the man was
willing to be operated on, and the case appeared to be an
eminently suitable one, a piece of the growth was at once re¬
moved for microscopic examination. The sections showed the
growth to be an undoubted epithelioma.

The operation that was performed may be divided into four
stages :

1. An incision was made along the anterior border of the
sterno-mastoid, and the large vessels in the anterior triangle
freely exposed. Some enlarged glands were found, and, to¬
gether with the fascia over the vessels, were cleanly cut away.
Ligatures were placed on the external carotid and some of its
branches, but were not tightened. A pad of gauze was packed
in between the carotids and the lateral wall of the pharynx.

2. Tracheotomy was performed, and a Hahn’s cannula in¬
serted.

3. The cheek was slit back from the angle of the mouth to
the ramus of the jaw. A large sponge, with tape attached, was
pushed into the larynx.

4. The pillars of the fauces were cut through with scissors,
and the growth partly cut out with scissors and partly separated
from the lateral pharyngeal wall by dissection with the finger.
The wound in the mouth remained separated from the wound in
the neck by a thin layer of fascia. There was no bleeding to
speak of.

The temporary ligatures on the carotids were removed, and
the wound in the neck and cheek sewn up. The tracheotomy
tube was retained until the following day. After twenty-four
hours the patient was able to swallow, and his further progress

56

was uneventful. The wounds in the neck and cheek healed by
first intention. The patient was allowed up on the seventh day,
and left the hospital on the fourteenth day.

The patient was brought forward to illustrate the excellent
immediate result that can be obtained by such an apparently
severe procedure. The whole safety of the patient depends
upon the wound in the neck not communicating with, and being
infected from, the wound in the mouth. The danger of haemor¬
rhage is entirely avoided by the temporary ligature of the
vessels and the tracheotomy. The case also illustrates again
the fact that even considerably enlarged glands in the neck
may not be palpable, and the consequent necessity for an incision
in the neck in every operation.

The President thought they would all agree in congratulating Dr.
Lack upon the success which had attended his case. 11 was a perfect
result, and one could not wish for a better either with regard to the
completeness of the removal or the rapidity of the healing.

Bilateral Webbing of the Fauces.

Shown by Dr. Henry J. Davis. This is a woman, set. 52, with
bilateral webbing of the fauces. The webbing may be entirely
the result of old ulceration, but the symmetrical appearance of
these fine bands of tissue would seem to indicate cicatrisation
following ulceration of some congenital malformation of the
faucial pillars, e. g. an accessory palato-pharyngeus.

Since childhood speech has been indifferent, and she had “ a
sore throat for ten years at one time,” which favours this sup¬
position. She is suffering from tinnitus and deafness.

The President had no doubt at all that this was a case of ulcera¬
tion of scarlatinal origin. He had seen a similar case following small¬
pox, but scarlet fever was the most frequent cause. He did not think
for one moment that its origin was congenital.

Dr. StClair Thomson had seen a similar case, which was even and
regular, in which he could discover no history of syphilis or scarlatina.
He had discussed the case with Mr. Bland-Sutton, who informed him
that this defect did not correspond to any developmental defect.

Dr. FitzGerald Powell had shown a somewhat similar case to
the Society some time ago. At the time he thought the abnor¬
mality must be developmental in character, the posterior pillars of the
fauces being attached low down to the posterior wall of the pharynx

57

on both sides, each being very regular in outlines. The trend of the
opinion of the Society on that occasion was that it was probably the
result of scarlatinal or other ulceration. He thought Dr. Davis’s case
was due to this cause.

Sir Felix Semon, with great respect for Mr. Bland-Sutton’s
opinion, begged to differ from the statement attributed to that
authority. He thought that such cases might be developmentally
explained; there was no doubt of the existence of quite a number of
cases with slits in the anterior pillars of the fauces, absolutely symme¬
trical, without any ulcerative agency to account for their presence.
He promised to bring before the Society a drawing of a case of his
own bearing on that point, and he remembered that similar cases had
been described by Professor Lefferts. With regard to Dr. Davis’s
case he would be probably found to be in a great minority ; but he
agreed with Dr. Davis that this case very likely represented a mixture
between arrested development and acquired ulceration.

Dr. Watson Williams’ impression was that this was a mixed
case, in which there had been nine or ten years ago a sore throat with
an ulcerative process going on; but the symmetrical condition of the
faucial webbing suggested a congenital origin. The patient said she
had not noticed it before. He himself had had a patient brought
before his notice who did not know he had anything the matter with
His throat, but he was found to have almost absolutely symmetrical
webbing on either side of the fauces, very synilar to this patient; in
that case the condition was of congenital origin. He promised to
show the Society a drawing of this case.

Dr. Clifford Beale thought it was a matter of considerable
interest to determine whether these cases were due to scarlatinal
poison in the first instance. In favour of such a view was the dis¬
tribution of the splitting of the palate, which followed the lines of
inflammation of the soft palate, so often seen at the onset of scarla¬
tina. Against the theory, however, was the fact that, although in the
course of hospital practice, one may examine a very large number of
throats which have been affected at some time with scarlet fever, such
clefts, apart from cicatricial contraction, were rare

Dr. Herbert Tillet was of opinion that the pharyngeal appear¬
ances were the result of ulceration, and most probably pust-scarlatinal
in origin. He had recently seen an almost identical case in a lady
who had consulted him for deafness, which was also post-scarlatinal
in origin.

Mr. Baber had no doubt that it was due to previous ulceration in
the throat.

Dr. Dijn das Grant suggested that a drawing should be made,
because the case presented its features in a remarkably striking way.
It seemed to him that the congenital condition was represented on
the right side of the throat, but on the left side that there had been
an abscess contemporaneously with the acute suppurative otitis due
to scarlet fever, which she had as a child. He had seen in the fever
hospitals several cases among children where such a condition existed
as that on the tonsil of the left side produced by scarlatinal periton¬
sillar abscess.

58

Dr. Davis said the patient had always had some impediment of
the speech and a periodical sore throat; one such “ had lasted for ten
years about fifteen years ago.” What she complained of was tinnitus
and internal and middle-ear deafness. He would try and get a drawing.

Case of Enlarged Thyroid cured by Iodide of Potassium.

Shown by Dr. Davis. This young woman came under my
care last June, at the London Throat Hospital, with a large
pulsating asymmetrical swelling of the thyroid, causing dys¬
pnoea, stridor, and considerable functional derangement ; a very
rapid pulse but only slight prpptosis were present. The
“ tumour had been growing for eight years, but had suddenly
grown rapidly, getting larger whenever she had a cold/ 5

The patient asked for time to consider operation, which at
that time seemed the only treatment. She was treated with five
grains of Potass. Iod., five grains of Ferri et Ammon. Cit. in a
mixture ; and she was ordered to rub equal parts of Ung. Potass.
Iod. and Ung. Hydrarg. Biniodidi into the neck every night.
She also inhaled the vapour of iodine crystals in a saucer.

In six weeks the tumour disappeared, all other symptoms
rapidly subsiding. The iodide treatment was left off four
months ago, and the thyroid showed signs of swelling, which
again vanished under the same treatment.

The girl, beyond being slightly anaemic, is now perfectly well.

Mr. Spencer said he should not use the word “ cure,” although
good results, as in this case, did very often follow treatment by iodide
of potassium and thyroid tabloids; but recurrence happened sooner or
later, and surgery ultimately had to be relied on for the treatment of
the masses containing cysts, etc. The tumours had a tendency to
subside and come back, especially in young patients, such as that of
Dr. Davis.

Dr. Davis said he did not literally mean “ cure,” which perhaps
was not quite correct. All symptoms had disappeared under iodide,
then recurred; and under a further course of iodide and ointment
(biniodide) had again disappeared. The patient was now under no
treatment. There was a small cystic dwelling on the right side,
which was hardly noticeable. When he first saw the patient, in June,
the goitre was a very large one.

Dr. StClair Thomson said that in decided thyroid tumours
medicinal treatment was of little use. He had lately had the oppor¬
tunity of discussing the subject with Professor Kocher, of Berne,

59

whose experience in the question was unsurpassed, and who said that
patients must make up their minds between putting up with the
inconvenience of the growth or submit to the knife. He preferred
cocaine as an anaesthetic.

Hr. FitzGerald Powell said in his experience medicinal treat¬
ment by iodides and iron was certainly of great use. He had had a
number of cases of cystic goitre in which the cysts had been reduced,
but this was not always the case, and then operation became neces¬
sary. The iron was largely answerable for the improvement in some
of the cases, especially those occurring in young women with men¬
strual disorders and anaemia.

Dr. Bennett supported the last speaker. He believed that
permanent benefit frequently followed the use of iodides. One case
especially occurred to him, in which the patient consulted a leading
London specialist, who advised operation. The patient afterwards
desired to try medical treatment first, and he had given iodides with
excellent result. The patient had remained free from the trouble now
for several years.

Dr. Ball said that formerly he was in the habit of treating those
cases with iodides internally and iodine preparations externally, and
that he often got apparent cures. For the last seven or eight years
he had completely abstained from employing any special treatment,
and he had got precisely the same results. Some cases improved
spontaneously, as they did formerly under iodide treatment. He had
absolutely no belief in the efficacy of any specific medicinal treatment
of goitre.

Dr. Don elan remarked that medicinal treatment produced no
permanent benefit. It caused a contraction of the gland, which might
be compared to the effect of the injections which were formerly so
much in vogue. The gland diminished, and remained small for a
considerable time, and treatment was abandoned; but later the
growth increased more rapidly than previously. These cases, in his
opinion, did as well without as with medicinal treatment; the severe
cases all eventually came into the hands of the operating surgeon.

Sir Felix Semon called to mind that Sir Morell Mackenzie once
told him that he had injected iodine in the case of a patient who had
previously asked him if there was any danger in it. Sir Morell
Mackenzie, speaking from the experience of hundreds of cases, had
replied decidedly in the negative. The patient thereupon consented,
but died five minutes after the injection in the consulting room.
Speaking from twenty-five years’ experience, he could say that he had
cured a good many cases permanently by iodide.

Dr. Scanes Spicer wished to emphasise the view that many of
these thyroid enlargements were inflammatory in origin, being
attended with local pain, tenderness, and rise in temperature. Such
symptoms soon disappeared on rubbing in some mild preparation of
iodine, even if they were accompanied by some of the signs of Graves’s
disease, such as tachycardia, palpitation, and exophthalmos. He had
no doubt they sometimes went away by themselves, as Dr. Ball had
observed.

Sir Felix Semon wished to define his previous statement a little

60

more accurately. His experience was that soft and absolutely
parenchymatous goitres, especially when occurring in young girls,
were favourable for the iodide treatment. With iodine and iodide of
potassium—internally and externally—in the form of ointment and
mixtures he had effected a good many cures. In cases where cysts or
fibroid elements developed, the medicinal treatment, needless to say,
was not nearly so successful. In the case under discussion he could
not see any inflammatory action whatever.

Dr. Bbonnee said many cases which had resisted iodide of potas¬
sium were controlled by tabloids of iodothyrin.

Dr. Watson Williams mentioned a case of goitre which had been
cured many years previously by purely medicinal treatment at the
hands of Sir Felix Semon. There was now not a vestige of the
tumour.

The President referred to the injection of iodine. At one time he
had used it extensively, but entirely abandoned it, owing to the death
of a well-developed young guardsman, who died within a minute of
the injection.

A Case or Swelling op Left Cheek and Eyelid.

Shown by Dr. Davis. For two years this patient, a female
get. 23, has had a puffiness of the left lower eyelid, with
swelling over the root of the nose and left upper jaw. On the
supposition that she had antral disease the antrum was opened
through the socket of an extracted molar. She wore a plug,
and was under treatment for nine months. No disease was
found, and nothing in the nose—beyond some slight enlarge¬
ment of the middle turbinals—can be found to account for the
disease. The nasal duct is free. The swelling is worse in the
morning and late at night, but varies in the course of the day,
and it appears to me to be lymphatic in nature. Her condition
is unaltered by treatment. There is no albumen in the urine,
and the general health is good. It may be a case of angioneu¬
rotic oedema.

Dr. Bbonnee said these cases were fairly common, but seen more
by ophthalmic surgeons. They always occurred in young women.
Their nature was unknown, and they were generally unilateral.

Dr. Soanes Spicer had seen the condition associated with eth¬
moidal cell suppuration.

Dr. Watson Williams regarded it as a case of recurrent erysipelas.
It occurred in fairly definite attacks at the outset, followed by periods
of quiescence, and leaving more and more persistent thickening. He

61

had had two or three cases, but did not know what to do for their
treatment.

Mr. de Santi had shown a case to the Society in a similar con¬
dition, except that it was more extensive; it resembled the description
given by Dr. Watson Williams. His case was apparently due to a
mosquito bite. He considered the condition was one of lymphatic
cedema, and probably due to the specific cocci of cutaneous erysipelas.

Dr. Davis said the swelling had gradually increased eight years,
and had then suddenly grown more rapidly. After taking iodide
internally, and TJng. Pot. Iod. and Ung. Hyd. Biniod. externally, for
about a month, it began to disappear rapidly.

Recurrent Angiofibroma involving Ventricular Bands and

Vocal Cords.

Shown by Dr. Furntss Potter. The patient, a man set. 42,
came under observation in the summer of 1899, complaining of
hoarseness, which had come on gradually. On laryngoscopic
examination the anterior third of the glottic space was seen to
be filled, and the anterior thirds of both cords were obscured
by (what appeared to be) a trilobed tumour, which on further
examination with probe, and on subsequent removal, was found
to consist of two parts, one attached to the left ventricular band
—on microscopic examination reported as simple papilloma,—the
other attached chiefly to the right ventricular band, and involv¬
ing also the right vocal cord, the upper surface of which
presented a ragged, torn-looking surface.*

The case has been under constant observation, and has con¬
tinued to recur, notwithstanding that several removals have
from time to time been effected with snare and forceps when¬
ever the growth has become sufficiently protruding to be seized
with instruments.

The surface now involved is more extensive than when first
seen, the anterior commissure and left ventricular band and
cord (?) being considerably affected.

During the last few months the patient states that he has had
several attacks of haemorrhage, on which occasions he has
coughed up about a teaspoonful of blood. He suffers from
much vocal disability, which seriously interferes with his occu-

# A section of this was exhibited at this Society November, 1899, and was re¬
ported on by the Morbid Growths Committee as angiofibroma.

62

pation—a builder’s foreman,—which necessitates much use of
the voice.

He would be glad to have any suggestions for further treat¬
ment other than Avhat had been pursued.

The President would call this case by another and more grave
name, i. e. malignant disease of the larynx.

Dr. Clifford Beale commented on the free movement of the cords
in the case, and asked how far one was justified in ignoring the rule
that cancerous growths of the larynx usually produced impaired
movements. The appearance of the growth itself certainly suggested
malignant disease.

Sir Felix Semon said he had defined his position with regard to
the question of mobility of the affected vocal cord in malignant
disease of the larynx so often and so precisely before, that he was
sorry there could still be any doubt on that point. It depended
entirely on the depth of the infiltration whether or not there was any
impairment of movement. If the disease was somewhat superficial
there might be free movement, even though the affection be already
rather extensive; whilst, on the other hand, in a case of deep infiltra¬
tion there might already be defective movement, though the actual
outgrowth was still small. The question, therefore, stood thus: the
absence of defective movement was no counterproof to the existence
of malignant disease, whilst its presence in cases where it was doubt¬
ful whether a growth was innocent or malignant was a valuable aid
to diagnosis.

Mr. Waggett said Dr. Potter asked him to get the opinion of the
Society whether it was desirable to do a thyrotomy, in order to sec
what the condition really was.

Mr. Scanes Spicer inquired if the patient had had a course of
iodide of potassium.

Mr. de Santi said the sooner thyrotomy was done the better. He
advised an exploratory thyrotomy.

Recurring Nasal Polypi.

Shown by Mr. de Santi. A girl, set. 18, suffering from
persistently recurring nasal polypi. She had been under
constant treatment at various hospitals for four and a half years
before coming under his care at the Westminster. The
polypi had been removed innumerable times by means of the
snare.

He found large masses of toughish polypi in both nostrils,
occupying the whole of the cavities; there was marked “ frog
facemicroscopically they consisted of mucous and fibrous

63

tissue. He took the patient into hospital, and under a general
anaesthetic turned up the nose by dividing the reflection of
the mucous membrane of the lower lip and gums, and thus got
at the polypi; these were removed with the aid of suitable for¬
ceps and curetting. The patient remained free from the growths
for some six to seven months ; they then recurred, and subse¬
quently another free removal under an anaesthetic was carried
out: there was immunity from the growths for eight months.
Now the patient is again in much the same condition as before.
From the general appearance of the polypi and the free suppu¬
ration going on, Mr. de Santi considered there was accessory
sinus suppuration. In connection with the last meeting of the
Society, when the treatment of nasal polypi was under con¬
sideration, he brought the case forward as showing the results
of the different methods of treatment and their failure. He
was anxious to know if Dr. Lack’s method of operation would
he generally recommended, though one of Mr. de Santi’s two
operations consisted, in his opinion, in very much the same
technique as Dr. Lack’s.

Dr. Herbert Tilley had no doubt but that the case was one of
chronic suppurative inflammation of the accessory sinuses. He had
proved this as regards the frontal sinus, because the withdrawal of a
probe passed into it was followed by a free flow of pus. Unless
these accessory cavities were efficiently dealt with the polypi would
continue to recur as they had done formerly. The breadth of the
upper portion of the patient’s nose was very suggestive of chronic
ethmoiditis.

Mr. de Santi asked Dr. Tilley if he was of opinion that the nasal
polypi were secondary to frontal sinus suppuration in his case.

Dr. Tilley said emphatically that this was his view.

Growth op Right Cord in a Man ^et. 35. (Patient

and Specimen.)

Shown by Dr. W. H. Kelson. Patient was shown at the end of
last summer session, and, as there was some difference of opinion
about the case, the President had requested that it be shown
again, but as the patient is a teacher the growth was removed
from the right vocal cord in August. The microscope showed
it to bo a papilloma.

64

Dr. FitzGerald Powell remembered having seen this case when
it was shown to the Society at a previous meeting. There still ap¬
peared to be a small portion of growth remaining below the anterior
commissure which might have to be removed.

Dr. Kelson thought there might be a small papilloma below the
cord on the right side. The patient had recovered his voice, and had
passed an examination in singing, and so he thought it better to
leave it alone at present.

Lupus of the Pharynx.

Shown by Mr. R. G. Johnson for Mr. Richard Lake. This
patient states she has suffered from “ ulcerated sore throat ”
with dysphagia since November, 1899. There is no history of
phthisis or of syphilis, congenital or acquired.

In April, 1900, the tonsils were removed, immediately after
which her voice became affected.

At the present time there are well-marked signs of phthisis at
the left apex.

On examination the whole of the uvula, both posterior pillars
of the fauces, the left tonsil, a small part of the soft palate to
the left of the uvula, the surface of the lingual tonsil, what
remains of the epiglottis, the ary-epiglottidean folds, with the
aryt.ganoids and ventricular bands, are seen to be involved in a
lupoid process, which is, however, in a fairly stationary con¬
dition.

✓

Dr. Davis had seen the case in the Middlesex Hospital; a piece
was removed from the tonsil, examined, and pronounced to be lupus.

Case of Bilateral Abductor Paralysis.

Shown by Dr. J. B. Ball. A young man, act. 24, admitted
recently to the West London Hospital for a haematocele of the
testicle. Surgical interference being considered desirable, ether
was administered. While under ether, and before the operation
was begun, his breathing stopped, and he became cyanosed.
Artificial respiration was performed, and air began to enter with
loud stridor. Artificial respiration was kept up for about ten
minutes, but the stridulous breathing continued for three quar-

6r>

ters of ail hour. The next day Dr. Ball was asked to examine
the larynx. The condition present is that of bilateral abductor
paralysis. It is not quite typical, however. There is some
obliquity of the line of the glottis, and some asymmetry of the
cords. The history points to the condition having existed for a
very long period, if, indeed, it was not congenital. The patient
states that, as long as he can remember, his breathing is noisy
and difficult on the least exertion. His mother states that as
an infant his breathing was always troublesome and frequently
crowing in character, and that when he was born he was not
expected to live owing to his difficult breathing. The knee-
jerks are present, and there is no sign of disease in the chest.
Patient has not had syphilis.

Mr. Spencer said it was a very curious-looking larynx. One cord
was completely paralysed. The left cord, however, retained a good
deal of movement. It might be congenital or syphilitic in origin.
The question was, what would happen to the boy F Was it safe to
allow it to go on as it was ? There was not much room there, and
with a little inflammation he might soon get into a dangerous con¬
dition.

Dr. Watson Williams thought the right vocal cord appeared
quite fixed, and there was certainly movement of the left cord. He
suggested that some old inflammatory mischief caused fixation of the
right cord, and that the present condition of the left, viz. abductor
paralysis, was due to some more recently developed affection. The
increased pulse rate, 96 a minute, suggested the existence of a bulbar
lesion.

Sir Felix Semon said he had laid it down many years ago as a
rule that in every case of bilateral abductor paralysis, if medical or
surgical treatment did not succeed in actually restoring the activity
of the abductors, it was the duty of the laryngologist to perform
tracheotomy as a prophylactic measure, and rid the patient of the risk
of suffocation. Since then, however, he had seen several cases in
which fairly severe bilateral abductor paralysis had existed for many
years with impunity. He reminded the Society that he himself had
shown to it two such cases a few years ago, one of which he had
already shown on the occasion of the International Medical Congress
of 1881, i. e. fully twelve years before his last demonstration. This
had made him somewhat doubtful as to whether his previous
dogmatism was justified; although, on the other hand, several cases
had been recorded in which the non-observance of his rule had led
to sudden death by asphyxia. His course now was to tell patients
plainly how matters stood, and leave them to decide. Certainly it did
not increase the amenities of life to go about for years with a tracheo¬
tomy tube. On the other hand, an attack of simple laryngeal catarrh

66

might put the life of the patient in danger at any time, as actually
happened in the case from which he had deducted his rule.

Dr. Watson Williams mentioned a case apropos of Sir Felix
Semon’s remarks. The patient was brought to the Royal Infirmary
at Bristol, and had marked inspiratory dyspnoea with stridor. On
examining the larynx he found well-marked bilateral abductor
paralysis. No reason for it could be discovered. Bearing in mind
the dictum laid down by Sir Felix Semon, he was tracheotomised.
He was able to breathe very comfortably, and in the course of a
fortnight, owing to the left thyro-ary taenoideus internus having become
paralysed, he was able to do without the tube.

Dr. Bronner recommended the use of large intubation tubes in
cases of abductor paralysis with difficulty in breathing. The tube
should be worn for a few hours daily, or constantly if possible, for
a few weeks; this in many cases permanently relieved the dyspnoea.

The President: It was a very difficult question to decide what
should be done. There was a well-known member of Parliament
some ten or eleven years ago, with more or less mechanical fixation of
the cords; adduction was good, but abduction very incomplete. He
was able to speak in the House. The condition dating from small¬
pox had existed upwards of thirty years. He caught a slight cold,
and died from laryngitis. Probably if something had been done his
life would have been spared.

Specimen or Cyst. ? Dermoid.

Shown by Dr. Fitzgerald Powell. The specimen shown was
removed from the floor of the mouth of a girl a)t. 16 years.
The swelling which it caused was first noticed thirteen months
ago, and had been gradually increasing in size.

When first seen I found, on examination, a considerable
rounded swelling, extending from below the symphysis to just
above the hyoid bone ; it was moveable, soft, and fluctuating, and
on looking into the mouth it was seen to push the floor upwards,
and could be felt well back under the tongue; it had somewhat
the appearance of a ranula, but was more regular in shape, and
occupied both sides of the frcenum linguae.

I removed the cyst by a median incision through the skin,
extending from just below the symphysis to just above the
hyoid. The superficial structures were carefully divided, bleed¬
ing points secured, when the white glistening cyst wall was
exposed, and by sweeping the finger round the growth it was
easily enucleated and brought out. The wound healed by first
intention, and little scar was left.

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Sixty-third Ordinary Meeting, February 1 st , 1901.

E. Cresswell Baber, M.B., President, in the Chair.

Ernest Waggett, MB., 7 0 , .

Charles A. Parker, F.R.C.S.(Ed.), j Secretaries -

Present—28 members and 4 visitors.

The minutes of the preceding meeting were read and con¬
firmed.

The ballot was taken for the following gentlemen, who were
elected members of the Society:

Eugene Steven Yonge, M.D., C.M.(Edin.), 3, St. Peter’s
Square, Manchester.

Arthur Ainslie Hudson, M.A., F.R.C.S.(Edin.), 3, Ellerdale
Road, Hampstead, N.W.

It was proposed by the President, seconded by Sir Felix
Semon, and carried unanimously, that the following be sent to
the King’s Most Excellent Majesty :

“ The members of the Laryngological Society beg to offer to your
Majesty their expression of sincere sympathy in the great sorrow that
has befallen the Royal Family and the Empire, and to submit to your
Q-racious Majesty their respectful congratulations and allegiance upon
your accession to the Throne.”

FIRST SERIES-VOL. VIII.

4

68

The following cases and specimens were shown:

A Case op Nasal Polypi with marked Deformity.

Shown by Dr. Donelan. The patient, a w'aiter aet. 23, had
noticed increasing nasal obstruction since about 1892, which
became complete in 1896, causing great spreading of nasal
bones and the same marked deformity as now existed. A large
number of polypi were then removed with the snare, but re¬
currence gradually took place.

In December, 1900, he came to the Italian Hospital, Queen
Square, with complete obstruction due to the nose and post¬
nasal space being crowded with polypi.

The patient underwent a preliminary clearance of polypi, and
the middle turbinals were removed, any polypi that escaped
being subsequently snared, and finally, on January 9th, the
nares and ethmoidal sinuses were thoroughly curetted. It was,
however, to be feared that recurrence was again about to take
place. Dr. Donelan requested the advice of members as to
further measures.

The President said it was a case in which the polypi had come
back after an operation of a radical nature had been done. It seemed
to him that, before any further operation was undertaken on the
ethmoid, the condition of the large sinuses ought to be investigated.

Dr. Herbert Tilley agreed with the President that the intra¬
nasal appearances afforded strong evidence of primary accessory sinus
disease. He asked if the antra had been transilluminated.

Dr. Wm. Hill said a very interesting point was the cause of the
enlargement of the maxillary bones, the nasal processes of which
were enormously prominent and thickened. If polypi were really a
sign of bone disease, one could understand disease extending in these
advanced cases to other bones of the nose besides the ethmoids.
G-reat enlargement of the “ uncinate body,” so evident in this case,
was diagnostic of sinus disease, more especially of the antrum.

Dr. Dundas Grant said it was an interesting question as to how
much deformity might be produced by a benign growth. Deformity
of the face was classed among the signs of malignancy; the deformity
in the case under discussion was frequently produced without there
being anything of a malignant nature.

Dr. FitzGerald Powell said this was an exaggeration of a con¬
dition not infrequently seen as the result of the expanding pressure
of polypi, accompanied by rarefying osteitis. The best results would
be obtained by free curetting with a ring-knife, which would relieve
the tension, remove diseased bones, and check suppuration. At the

69

same time attention should be directed to the maxillary sinuses, which
should be drained if necessary.

Dr. Bronner said that in the provinces cases of very great de¬
formity frequently occurred. It generally disappeared even in adults
in the course of a year or two after the removal of the polypi.

The President had seen these cases of deformity, and considered
them due to dilatation from the pressure of the growths. He had
not, like Dr. Bronner, seen the deformity disappear.

Dr. Vine ace wished to know whether Dr. Donelan attributed the
deformity to anything except obstruction and the long time during
which the condition had existed.

Dr. StClair Thomson supported Dr. Bronner in his remarks.
Within the last three weeks he had had under his care a case in
which marked deformity was present. He had operated on one side
of the nose, and more or less completely cleared it of polypi, and left
the other alone. In the former the condition subsided, and in the
latter it remained unaltered. In his (Dr. Thomson’s) case the nose
was so distended that there was a separation between the nasal bone
and the nasal process of the superior maxilla on each side. The
difference between the two sides was remarkable even after a few
days.

Dr. Donelan thought from the first that the ethmoidal sinuses
were certainly affected, and after the first curetting it became obvious
that they were so on both sides. The left antrum was also affected,
but he did not think the frontal sinuses were. The deformity was
due, he thought, to the pressure of the mass of the growth. It was
four years since the nose was completely cleared, and, as far as the
patient could tell, there was no improvement in the deformity; there
certainly was not any since it was cleared before Christmas last.

A Fatal Case of Exophthalmic Goitre.

Shown by Dr. Donelan. The patient, an Italian girl set. 16,
was admitted into hospital on December 20th, 1900. There was
no family history of goitre, and no history of any previous illness
of importance. In September, 1899, the history begins with
symptoms of palpitation, oppression, and dyspepsia, which were
relieved by treatment and never caused much inconvenience.
In September, 1900, during her father’s absence she lived with
some relatives who treated her cruelly, and on one occasion
seized her by the throat and nearly strangled her. She had
noticed no previous enlargement of the throat, but from that
time the growth of the thyroid was rapid and continuous.

She first attended the hospital on December 14th, 1900, when
she complained of the ordinary symptoms of exophthalmic goitre.

70

There was considerable thyroid enlargement, the neck measuring
fifteen inches, moderate exophthalmos, a rapid pulse (140), and
a mitral systolic murmur without apparent loss of compensation.
She was advised to rest and to take a mixture containing ten
minims Tr. Belladonna; and five minims Tr. Digitalis. She
rapidly became worse, and was therefore admitted into the
hospital on December 20th. She had tremors affecting the head,
neck, and thumbs, violent cramps of limbs and body lasting five
to seven minutes, vertigo with a tendency to fall to the left,
marked retinal pulsation, and traces of optic neuritis.

Von Graefe’s sign was present, but Stellwag’s absent. The
pulse rate gradually increased from 140 to 160; nervous
vomiting became persistent on the fourth day; finally she
became comatose, and when with difficulty roused she com¬
plained of intense headache. She died, apparently of heart
failure, on the sixth morning after admission.

The treatment consisted of belladonna and digitalis as before
until vomiting became persistent. Citrate of potassium as re¬
commended by Dreschfeld failed to check this, and rectal feeding
was carried out, and ice applied to head and spine.

Extract from report of post-mortem made by Dr. Pareira:—
“ Brain intensely congested. Cerebellum very large and con¬
gested. Pineal gland much enlarged. Careful sections failed
to show any other abnormality in these organs or in the medulla.
Cervical sympathetic atrophied, thoracic normal. Thyroid gland
much enlarged. Trachea much compressed though dyspnoea
had not been present. A few small cysts in thyroid. Thymus
gland persistent and much enlarged. Stomach atrophied. Uterus
ill-developed and infantile. No corpora lutea in ovaries.”

Dr. Donelan did not consider this disease was due to the fright
caused by the assault, though doubtless the symptoms were
thereby accelerated. There were evidently symptoms a year
before, pointing to the commencement of the condition which,
when thoroughly established, is called exophthalmic goitre.
Without reviewing the various theories that had been put
forward to account for this group of symptoms, the exhibitor
desired to call attention to an important pathological feature,
namely, the persistence and enlargement of the thymus gland.
This persistence is found in practically every fatal case in

71

which it is carefully looked for, and enlargements may also
occur as in the present instance. He would not presume to add
another to the existing theories, but he thought the pathology
of the disease had to be sought for in an earlier period of life.
The thymus gland is a foetal structure disappearing normally
pari passu with the development of the thyroid. Its persistence
is obviously evidence of an abnormal condition occurring in
infant, if not in uterine, life. Evidence should be collected with
a view to showing whether the failure of the thymus to undergo
the normal retrogression reacts on the thyroid gland and nervous
system through the medium of the blood in such a way as
ultimately to produce these well-known symptoms.

Sir Felix Semon said it was new to him to learn that in cases of
exophthalmic goitre one almost regularly found an enlarged thymus.
He would like to ask Dr. Donelan to give more information on that
interesting point.

Dr. Donelan said, in reply, that he had just lately looked up the
literature of the subject, and, as far as he was able to ascertain, it
was generally mentioned that the thymus gland was persistent in the
majority of cases. Some authors, amongst whom might be mentioned
Osier, said it could be found in all cases if carefully looked for. Up
to the present no pathological changes had been described as occur¬
ring in the gland. He thought the association of the enlarged
thymus with subsequent increase in the thyroid was a point to be
noted for further investigation. It might have something to do with
tbe real cause of the disease. The thymus in this case was, he
believed, unusually large.

Specimen of Mucous Patch on the Tonsil.

Shown by Dr. Wyatt Wingrave. The 'section conforms to
the classical descriptions of histological details, in that the
stratified surface epithelium is considerably thickened, and
exhibits all stages of necrosis, from simple cloudy swelling to
complete vacuolation and disintegration. The nuclei are broken
up into granules, while the protoplasm remains clear and lique¬
fied, but the invading leucocytes are few and multinucleated.

The subjacent structures exhibit but slight activity beyond
distension of the lymph spaces and multiplication of the mono-
nucleated lymphocytes.

72

Cutting Trephine for operating on Spurs and Deviations

of the Nasal Septum.

Shown by Dr. Bronner. This trephine was used in conjunction
with Spiesz's nasal speculum. The short blade of the speculum
was placed in front of the spur, and the long blade over the
lower turbinated bone. The trephine was worked by an electro¬
motor. The operation could be performed with cocaine or
eucaine, and was practically painless. Spurs and deviations
of the nasal septum were very common, and caused nasal
obstruction, preventing the passage of the Eustachian catheter.
The lumen of the trephine was about the same size as that of
the largest intubation tube. Messrs. Down and Co. were the
makers of the trephine.

The President thought Dr. Bronner’s trephine was about the
best form of such instruments to use, especially with the speculum
shown, and the Society was indebted to the exhibitor for bringing it
forward. Personally he always preferred a saw, and used a straight
and not an angular one, because the latter “ locked ” so easily. After
anaesthetising locally, a line was marked with the galvanic cautery
where the sawing was to take place. This diminished the haemor¬
rhage, especially if a solution of supra-renal capsule were also used.
He did not think that, theoretically, a circular trephine was the best
instrument to remove a spur from a flat surface like the septum,
although in practice it might answer perfectly.

Dr. StClair Thomson wished to elicit the opinion of members
who had tried both the trephine and the saw. He himself had no
experience of the trephine, but he had heard complaints of it
“ jamming,” and of its liability to stop suddenly. Would those
members who had tried both say whether they were in favour of the
trephine ?

Dr. William Hill had used the nasal trephine, with and without
serrated edges, a great deal in times gone by. It, unfortunately, did
not leave a really level surface, even when several pieces were
removed. He therefore generally used a saw now, but he often felt
that if he had a dental engine or motor ready at hand he would use a
trephine, on account of its being more expeditious and less painful
than the saw.

Dr. Herbert Tilley pointed out how very efficiently a nasal spur
may be removed if a deep groove be first made with an intra-nasal
saw, and the “ spokeshave ” then applied behind the groove and
rapidly withdrawn. The cutting edge keeps accurately in the groove
already made, and a flat surface is left upon the septum. This

73

method can be used for bony and cartilaginous spurs, but in the first
case a deeper groove should be made with the saw. In a fairly
tolerant patient the operation could be performed with cocaine alone.

Dr. Bronneb, in reply, said in using the trephine the “ jamming”
was not so great as with the saw if a sufficiently powerful motor
were used. It was practically painless with cocaine or eucaine, and
the quicker the instrument rotated, the less was the pain caused. In
treating a deviated septum it was often necessary to apply the
trephine twice, in order to remove a sufficiently large piece of cartilage.
The cartilage in these cases was generally very thick.

Congenital Symmetrical Gaps in loth Anterior Pillars op the
Fauces, with Complete Absence op Tonsils.

Shown by Sir Felix Semon. The patient was a girl a 3 t. 11,
who was seen by the reporter on September 28th, 1881. There
was a tubercular family history, and the patient herself was very
strumous-looking. She was brought to the hospital on account
of naso-pharyngeal catarrh.

On examination of the throat two large ovoid gaps were seen
to extend almost through the entire length of the anterior
pillars of the fauces. They were perfectly symmetrical, and
their edges were absolutely soft. Nowhere in the throat was
there any evidence of scarring. A probe introduced through
either of these gaps entered into the niche reserved for the
tonsils. There was, however, not the least trace to be seen of
any tonsillar tissue in these receptacles on either side. Neither
mother nor child knew anything of the existence of the abnor¬
mality.

His reasons for considering the defect in the light of a con¬
genital arrest of development were not merely the absolute
symmetry of the gaps, and the absence of all scarring as well as
of any history of ulcerative disease, but particularly the com¬
plete absence of the tonsils.

On looking through the literature at his disposal he has
found that in three out of about twenty cases of an analogous
kind, noted in the ‘ Internationales Centralblatt fur Laryngo-
logie ’ since 1884, a similar absence of the tonsils was expressly
reported.

This fact seemed to him very striking, and considerably added

74

to the view that these gaps must be regarded as a result of
arrested development, a view in which most of the observers
who had seen similar cases agreed. Possibly they may represent
the inner openings of incomplete branchiogenous clefts, a possi¬
bility which Chiari suggested when describing a case of this
sort in 1884 (* Monatsschrift fur Ohrenheilkunde/ August, 1884),
although he then admitted, as the reporter does now, that a
fully satisfactory explanation cannot yet be given. (The
reporter is indebted for the drawing accompanying this descrip¬
tion to Mr. E. Waggett, who has very kindly drawn it on an
enlarged scale from a sketch made at the time.)

The President said it looked undoubtedly like a case of mal¬
formation.

Dr. StClaib Thomson said that in calling the case “ congenital,”
Sir Felix Semon had anticipated the decision of the question. In his
opinion it was a doubtful point, and until a similar condition was
detected in early infancy the question would remain open. It was
new to him to hear of the absence of tonsils in this condition, and he
briefly narrated the particulars of symmetrical gaps in a woman in
whom the tonsils were still remaining. Since the last meeting he had
seen two cases; one was bilateral and symmetrical, and had some
slight scarring on the pharynx, though there was no previous history
pointing to ulceration. The other case occurred in a medical man,
who was willing to come to the Society. He had a gap on one side
only, which had existed as long as he could remember. He has never
had scarlet fever or syphilis.

Case of Serous Cyst of Inferior Turbinated and Floor of

the Nose.

Shown by Dr. H. J. Davis. This patient, a woman aet. 25,
has suffered from graduallv increasing nasal obstruction for
some years. Ten days ago, when she came to the Middlesex
Hospital, there appeared to be a marked hypertrophy of the
anterior end of the right inferior turbinate, the floor of the nose
being involved in the swelling, which was as large as a pigeon’s
egg, and was firm and resistent to the probe.

The tissues did not shrink under cocaine, and the swelling
being mistaken for a growth an attempt was made to remove a
piece for examination, which failed. An aural paracentesis

knife was then passed into the upper part of the swelling; a
jet of greenish clear fluid spurted out of the nostril, and the
swelling rapidly and entirely collapsed.

The cyst is slowly refilling, and can be seen as a fluctuating
projection in the floor of the nostril. The patient has had no
further treatment beyond the primary puncture.

Dr. MacBride thought the case must have been of great interest
before the cyst was evacuated. He believed himself to have been the
first to describe this form of cyst a number of years ago. To
him the special point of interest was the origin of such cysts; it was
difficult to imagine where they could originate. Had Dr. Davis
formed any theory as to the causation ? He might mention that Dr.
Brown-Kelly, of Glasgow, had found glands with very long canals in
this region of the nose, which he thinks may explain the occurrence of
cysts. One of his (the speaker’s) earlier cases kept on refilling, and
had to be dissected out by raising the upper lip.

Dr. Davis, in reply, said he had considered the origin to be due
probably to retention of secretions in one of the glands—a retention
cyst, in fact. In this case the cyst was much more prominent two
days ago, but the woman had had some sanious discharge from the
nose that day, and it had again collapsed. If one looked carefully,
one saw that the under surface of the inferior turbinate had been
expanded, and the cyst was evidently of considerable depth beneath
that bone.

Case of Mucocele of the Frontal Sinuses.

Shown by Dr. Lambert Lack. This boy has already been
shown at the Ophthalmological Society before operation. There
is marked divergence of the eyes, and the bridge of the nose is
widely distended, especially on the left side. When he first saw
the case the mass of the growth seemed bony, but there was a
fluctuating area at the upper and inner corner of both orbits.
The history was four years’ duration with steady increase. The
diagnosis—mucocele of the frontal sinuses with dislocation
downwards and outwards of both lachrymal bones—was con¬
firmed by operation. The left frontal sinus was enormously
distended, its anterior bony wall being practically absorbed,
its cavity extending backwards and inwards behind the right
frontal sinus, and downwards in the direction of the infun¬
dibulum. The mucoid contents were evacuated, and a large
opening made through into the nose and maintained by a

4 §

76

plug which is still worn. This sinus is now secreting pus, but
is becoming more dry, and as the opening into the nose is
probably permanent it may be possible to shortly close the
external wound. The right sinus was smaller, and an attempt
was made to obliterate it without making a communication with
the nose, but it has not yet healed. The infundibulum on the
left side was probably first obstructed, and the right infundi¬
bulum obliterated by the pressure of the expanding left sinus.
These cases are rare, and I should be glad to receive any sug¬
gestions to hasten the cure.

Dr. Herbert Tilley thought, considering the long duration of
the treatment, and the nature of the operation already performed,
that nothing short of a further radical operation offered any prospect
of cure. He therefore suggested that, as the patient was a growing
lad, and as much of the present deformity would be permanent, a
more extensive removal of bone was indicated.

Dr. MacBride asked Dr. Tilley to explain exactly how he pro¬
posed to proceed. The left frontal sinus was of very great depth.
This case was just one of those where the frontal sinus was so deep
that it seemed to him that the method proposed by Dr. Tilley prac¬
tically amounted to performing Kuhnt’s operation, but then the
upper wall of the orbit would have to be removed; if the soft parts
were allowed to fall in on the sinus, there would still be a consider¬
able space which could not be filled up or covered. He thought there
must be a cavity left owing to the depth of the sinus. He had
operated on a good many frontal sinuses, and he found those de¬
scribed in the text-books were perfectly easy to deal with; but in a
large proportion of cases one had cavities containing pus behind the
orbit, and one could not let the soft parts fall in in such cases

In answer to Dr. MacBride, Dr. Tilley said he would propose a
horizontal incision over the lower central part of the forehead, which
should join the incisions already present and partially healed. The
soft tissue covering the lower part of the forehead could then be
drawn upwards, and a complete removal of the anterior bony walls of
both sinuses carried out. The septum could simultaneously be re¬
moved, and so allow the soft parts to fall on to the posterior walls of
the sinuses, and bring about their obliteration. The receding angle
between the roof of the orbit and the lower part of the posterior wall
would, he thought, fill up with granulation tissue, which would even¬
tually organise; and even if a small cavity eventually remained in this
position, it would probably be harmless if free drainage into the nose
was secured. In such a growing lad the deformity, he thought,
would not be greater than at present, and it was obvious that some¬
thing must be done to ameliorate the present condition of things.

The President said that it seemed to him that the only way of
obliterating the sinus was by Kuhnt’s operation, which consisted in
the removal of the whole of the anterior wall except about an

77

eighth of an inch along the supra-orbital ridge. The periosteum
and skin should be carefully stitched down, a rubber tube, projecting
at the inner angle, being kept in the wound. Granulation tissue
would form and obliterate the sinus. This must leave a certain
amount of depression. The case he had done and shown to the
Society was satisfactory as far as the result was concerned. The case
was one of a large mucocele, and if the same procedure were carried
out in the case under discussion he thought the patient would get
equally well.

Dr. Vine ace inquired what were the urgent symptoms demanding
operation, and suggested it might have been better to leave the case
longer before proceeding to such grave surgical measures.

Case of Persistently Recurring Nasal Polypus with Sup¬
puration in Frontal and Ethmoidal Sinuses ; Operation ;
Result.

Shown by Dr. Lambert Lack. This patient is shown as a
contrast to the case exhibited by Mr. de Santi at the last meet¬
ing' of the Society, which I take it was intended as a direct
challenge to me. The two cases are very similar. This patient
had had polypi for many years, commencing when she was
about fifteen, accompanied by profuse sinus suppuration, and
for three years had had them removed as often as every fort¬
night, but in all that time had been unable to breathe through
her nose. Two years ago wh*en I first saw the patient I scraped
out the nose under gas. The operation had to be done as an
out-patient, and therefore was not so thorough as I could have
wished, but in spite of this the patient has had free nasal respi¬
ration ever since. On three occasions small pieces have sub¬
sequently been removed with a snare, but now for more than
two years there has been no return of the polypi. After the
operation the discharge from the nose also greatly lessened, but
did not completely cease until the frontal sinuses had been
obliterated. This operation, which I always recommend where
practicable, as I believe it to be the only sure curative measure,
entails the complete removal of both the anterior and inferior
walls of the sinus, but in spite of this the deformity may be
scarcely noticeable, as this ca,se shows. My experience of this
operation makes me think that a deformity such as occurred in
the case Dr. Tilley showed at the last meeting is quite excep¬
tional.

78

Dr. StClair Thomson thought the case showed the necessity for
care in specifying beforehand the amount of relief we might secure,
and how we should be slow to claim a complete cure in these cases.
There was a distinct foetid odour from the nose of this patient;
although she had washed out her nose twice already that day there
was pus in each middle meatus ; and she informed him that although
the operation had been done nearly two years ago, she still had to
syringe her nose three times a day. Now both Dr. Tilley and he had
shown completed cases of operation for frontal sinusitis at the last
meeting, but candour compelled him to say that neither of them was
then completely cured. In Dr. Tilley’s case there was some pus in
the middle meatus. His own patient had washed out his nose in the
morning before coming to the meeting, and by 5 o’clock the secretion
had not accumulated in such quantity as to be distinctly evident. This
secretion could not possibly come from the frontal sinus, as he (Dr.
Thomson) had seen that the fronto-nasal duct was quite obliterated
before allowing the operation wound under the eyebrow to heal up.
It must, therefore, have come from the ethmoidal cells, and these had,
since last meeting, been well curetted ; a slight crust of dried mucus
still formed over them, but the patient did not require to syringe his
nose more than once a week. In Dr. Lack’s case there was distinct
pus, though doubtless the patient’s sufferings had been greatly
relieved.

Dr. Herbert Tilley was surprised to hear (for the first time)
that the case he showed at the last meeting was not a complete cure,
and he ventured to think that Dr. Thomson had some other case in
his mind. Dr. Lack had spoken of his case as a cure, and in spite of
dissenting opinions the speaker was inclined to agree with him if
the word was not too rigidly applied. In the case referred to, no pus
came from the sinuses, but one or two ethmoidal cells were not clear
from disease, and they would probably cause little trouble. This led
to the question asked by one member, “ When is a surgeon justified
in advising an external radical operation upon a chronic frontal sinus
empyema ? ” Dr. Tilley thought the answer mainly turned upon the
patient’s views on the subject, and cited a case under his care for the
last two years of a young engineer, who was just beginning to get on
in his profession. This patient had applied to him on account of
nasal obstruction, purulent discharge, a chronic headache, and
inability to concentrate his mind on his work. The nostrils were f ull
of polypi, and pus flowed freely from both frontal sinuses. On
irrigation by the right fronto-nasal canal the fluid returned from the
left nostril, demonstrating a septal perforation allowing free com¬
munication between the sinuses. In due course all the polypi were
removed, also the middle turbinals on both sides, and a quantity of
the ethmoidal cells. The patient (who was seen six weeks ago) says
he is “ cured ” because his headaches have gone, he feels quite well,
the discharge has “ practically ceased,” and he only uses one hand¬
kerchief a day. Examination of the nasal cavities reveals a drop of
pus at the lower end of each fronto-nasal canal, and the speaker
thought that he was not justified in advising a radical operation under
such circumstances, for the patient was really in very little danger.

79

and not inconvenienced by his condition. The speaker thought that
in such cases the nose should be merely cleansed once or twice daily,
and nothing else done. Contrariwise, if the individual was of a
nervous disposition, and could not tolerate the occasional appearance
of a streak of pus from the nose, he then explained the nature of the
operation, its chances of success, the possibility of a small scar, etc.,
and left the patient himself to settle which course he would pursue.

Sir Felix Semon said Dr. Tilley had raised a very grave and
important question, which he was very glad had been brought for¬
ward. The question was, when ought one to perform a radical opera¬
tion in these cases ? Belonging to the seniors, he did not wish to be
considered as opposing the progress of the times. It was a great
achievement that they could diagnose these cases better, and so
treat them more successfully than in the past by these big radical
operations ; but, on the other hand, he looked back over a period of
twenty-five years, which had been devoted to special practice, and
within that period he had seen plenty of these cases, and, so far as he
knew, very few of them had come to grief prior to the discovery of
these modem forms of treatment. No doubt there were a few cases
in which threatening symptoms, such as severe headache, coma,
meningeal troubles, and other complications, had arisen from a mis¬
understanding of their original cause, and from want of radical
treatment; but how few were and are such cases! Looking at the
question from another point of view, he asked whether a really com¬
plete and lasting cure could be promised in every one of these cases
after a so-called radical operation ? He had seen a good many of Dr.
Tilley’s cases, and most heartily congratulated him on the results, but
he had also seen other cases—and he was not the only one who had—
in which after the performance of a radical operation suppuration
still continued; further operations had become necessary, and the
patient finally was not much better off than before. This fact had
been brought forward before in the Society. He was particularly
anxious not to be thought incapable of seeing anything good in things
new, but really, in his opinion, it was a matter deserving very great
consideration as to whether the discovery of a little pus coming from
the frontal sinus demanded radical operation in every case. He
thought the surgeon was bound to tell the patient that the big
operation occasionally left some deformity.

Dr. FitzGerald Powell had been much interested in this dis¬
cussion, which to a certain extent had somewhat relieved his mind, as
it appeared to him that the tendency of late was to rush to the per¬
formance of this rather serious operation as soon as pus was seen in
the nose. He had at the present time a case in his hands, in which it
had occurred to him that the radical operation should be done. The
patient was a young woman who had suffered from all the signs of
“ frontal sinusitus ” in a marked degree. He suggested to her the
radical operation, also putting before her the possibility of deformity.
As she was about to be married, she decided not to undergo the
operation. At several sittings he removed as much as possible of the
middle turbinate and freed the infundibulum, afterwards washing
out the sinus. The patient was now perfectly free from pain and

80

frontal headache. She used a nasal douche, and was quite comfort¬
able. Every now and then a small quantity of pus appeared in the
nose, which caused little or no inconvenience. This case fully illus¬
trated the safety and propriety of leaving the radical operation alone.

Dr. Donelan asked Dr. Lack what proportion of these cases under¬
went spontaneous cure. He had a case under his care about a year
ago, in which a young man aged twenty-four had distinct suppura¬
tion of the right frontal sinus, and arrangements were made to
operate. Before it could take place the discharge came away. He
washed out the nose, and the patient had remained perfectly well
since.

Dr. Vine ace wished to know how long would Dr. Lack wait, after
freeing the nostrils from polypi, before proceeding to undertake one
of these terrible operations.

Dr. Lack, in reply, said he thought Dr. Thomson a little hyper¬
critical. He saw no reason for continuing treatment, as the patient
was practically well and had ceased attending him for nearly a year.
The indications for external operation on the frontal sinus were rather
indefinite. He recommended operation whenever the disease caused
symptoms producing serious inconvenience. When the only symptom
was slight purulent discharge he thought the cases best left alone.
He always in the first instance adopted intra-nasal methods to the
extent of removing the middle turbinate, opening the anterior
ethmoidal cells, etc., and thoroughly clearing the approach to the
infundibulum, so as to allow the sinus to drain freely into the nose.
If this failed to give relief he operated externally, and always en¬
deavoured to obliterate the sinus, as he believed it the only certain
method of obtaining a cure. Personally he did not believe in the
possibility of making a definite diagnosis except by opening the sinus,
and thought many of the cases cured by intra-nasal operations, such
as opening up the anterior ethmoidal cells, were really cases of
ethmoidal cell disease, but this was only an additional argument for
carrying out thorough intra-nasal methods before adopting external
operation.

Papillomata removed from Larynx by Endolaryngeal

Method.

Shown by Dr. Herbert Tilley. The patient was a lad set.
years, who was brought on account of difficulty of respiration
and hoarseness. The former was so marked that the night
previous to operation the patient was nearly asphyxiated. It
was deemed advisable on account of the dyspnoea to perform a
preliminary tracheotomy. Four days after this the endolaryn-
geal operation was carried out. The patient was chloroformed
by Dr. Hewitt, and held in a sitting attitude ; it was then quite

81

easy to remove a few growths before the returning laryngeal
reflex and acts of swallowing rendered a further deepening of
the anaesthesia necessary.

By this means the growths were removed, and the voice
returned for six months, when increasing hoarseness necessi¬
tated a second operation. On this occasion only a few growths
were present, and were easily removed.

The speaker emphasised the ease with which the operation
could be performed when the anaesthetic was skilfully given in
the sitting position.

Case oe Epithelioma of Tonsil with Extensive Glandular
Involvement in a Middle-aged Man.

Shown by Dr. Dundas Grant. The typical epithelioinatous
ulcer extended over from the tonsil on to the soft palate and
anterior pillars, involving also the adjacent portion of the base
of the tongue. There is also a large hard mass of glands in the
neck. Dr. Grant presumed that the members of the Society
would agree that the case was beyond operation. A coloured
drawing by Dr. Mackintosh showed the characters and extent
of the ulcer most perfectly when first seen. Since then a mass
out of the centre of the growth had sloughed away, giving the
patient very great relief.

Sir Felix Semon remarked that, in his opinion, it was not a case
for operative interference.

Microscopical Portion of Vocal Cord removed by Means of
Jurasz’s Punch Forceps from the Vocal Cord of a
Gentleman m t. 61.

Shown by Dr. Dundas Grant. The patient was the subject of
liuskiness of the voice which commenced with influenza between
seven and eight months before he was seen, gradually increasing
in severity. On laryngoscopical examination there was seen in the
middle third of the left vocal cord a granular outgrowth of a red¬
dish-pink colour, internal to which was an excavation, the floor of

82

which was moist and of a yellowish colour. The larynx was other¬
wise normal, and there was no impairment of mobility of the vocal
cord. There was a history of primary specific inoculation in
youth, and of a consolidation of the apex of the right lung in
early middle age, the pulmonary trouble having apparently
completely subsided. An examination of the morning sputum
was made by a skilled bacteriologist, who in the first film found
two bacilli which stained like those of tubercle; numerous
subsequent examinations of the sputum were in that respect
entirely negative, and the bacteriologist came to the conclusion
that there was not sufficient evidence on which to found a
diagnosis of tubercle. Mercurial inunction and iodide of potas¬
sium were without the slightest effect, and the great probability
was, therefore, that the disease was epitheliomatous, although
the appearance was not absolutely typical. A highly skilled
confrere considered that the evidence pointed also in this direc¬
tion, and that the removal of a portion by endolaryngeal
methods or the opening of the larynx was called for. Dr.
Grant removed a large portion by means of Jurasz’s forceps,
but in none of the sections removed was there any appearance
in the least suggestive of epithelioma. The growth seems,
therefore, to have been entirely composed of inflammatory
tissue, and the patient at present suffers only from the inter¬
ference with his voice, which is due as much to the use of the
forceps as to the disease itself. He is rapidly improving.

Case of Glottic Spasm in a Young Woman ^t. 24 .

Shown by Dr. Dundas Grant and Mr. Mackintosh. Mr.
Mackintosh was called to see the patient on account of a suffo¬
cative attack, the onset of which had been quite sudden; there
was no previous hoarseness, but the patient had experienced
uncomfortable choking sensations in the throat; there was a
harsh brassy cough, the voice was husky, and there was occa¬
sionally stridulous inspiration. The suffocative attack rapidly
and completely subsided, but the slight huskiness of the voice
persisted. On laryngoscopic examination there was no oedema
of the framework of the larynx; the vocal cords were slightly

88

i

congested; the most marked feature was swelling of the lingual
tonsil, in which there were numerous patches of exudation ; there
was also a distinct enlargement of the thyroid gland. Next day
Drs. Grant and Mackintosh examined the patient together at
the Central London Throat and Ear Hospital. The larynx was
then free from any sign of inflammation; the swelling of the
lingual tonsil had considerably subsided, and there were elicited
such stigmata of hysteria as comparative hemianaesthesia of the
right side, and diminution of pharyngeal and nasal reflex. The
treatment ordered was bromide of potassium. The case was,
therefore, considered one of hysterical glottic spasm, the acute
lingual tonsillitis being a factor in the exciting causation.

Mr. Mackintosh called attention to the defective condition of
the teeth, the whole of the upper set being represented by a row
of foul blackened stumps which, in view of recent investigations,
he thought might act as a producing factor.

Sir Felix Semon was not convinced that the local cause excited
the spasm. He asked whether the lingual tonsil could be responsible
for hemianaesthesia and paralysis. From the symptoms he per¬
sonally would have great doubts as to the local cause.

Dr. Herbert Tilley related a case of glottic spasm in a parti¬
cularly healthy-looking man (a butcher) aged forty-two. During the
speaker’s examination of the patient’s throat a sudden suffocative
attack ensued, the patient fell from his chair, and seemed in im¬
minent peril of asphyxiation. A long-drawn inspiration terminated
the attack, and the patient was quite well again. It seemed probable
that the great irritability of the pharynx and larynx was due to ex¬
cessive cigar smoking, because while avoiding tobacco for two months
he had no attack. At the end of this period he had a similar attack
ten minutes after smoking his first cigar.

Case op Innocent Growth on the Right Vocal Cord.

Shown by Dr. Wm. Hill. The patient was a woman aet. 48,
with a small red, innocent growth, springing from the upper
surface of the right vocal cord near its anterior extremity, and
slightly projecting into the glottic space, thereby causing
hoarseness; this symptom had lasted about one year. The
larynx at present was extremely intolerant to intra-laryngeal
instrumentation. Unfortunately the patient was from the
country, and occupying a bed in hospital which should be placed

84

at the disposal of a more serious case; under the circumstances,
he wished to know the opinion of members as to whether he
could, with any confidence, send the patient back to her doctor
in the country (who was a skilled laryngoscopist), with the sug¬
gestion that the growth should and could be eradicated by
applications of salicylic acid (5 per cent, in alcohol). He had
no personal experience of the treatment, and hearsay evidence
as to its value had been conflicting.

Dr. Dundas Grant thought it a pediculated growth which
habitually lay underneath the vocal cord. During the action of
phonation it was forced up between the cords by the expiratory blast,
and it seemed to him that as soon as the patient drew a breath it
entirely disappeared. He thought that to apply salicylic acid or any
other chemical would be a waste of time. 'J he growth could be most
easily removed by operation.

Dr. Lack said he had never seen any good result from the use of
salicylic acid.

Dr. Bronner thought formalin much more efficacious than
salicylic acid, but in the present case the forceps should be used.

Dr. FitzGerald Powell said, in view of the intolerance of this
patient’s larynx to operative measures, he would recommend swab¬
bing the larynx with a solution of perchloride of iron as likely to
cause the disappearance of the growth, which was a very small one,
and appeared to him to grow from the upper surface of the cord, and
not from below. He had not infrequently seen these small growths
disappear under the systematic employment of this treatment.

Dr. Vinrace asked Dr. Hill if he thought it would be advisable to
nip the growth off.

Dr. Hill, in reply, was glad to get an expression of opinion on the
salicylic treatment. When the larynx had been educated to tolerance
the growth could be removed easily enough with forceps, but that
would take a long time, he feared, in this instance.

A Laryngeal Case for Diagnosis.

Shown by Mr. Atwood Thorne. The patient, a man set. 43,
came to St. Mary’s Hospital, on January 19th, in a very excited
condition, complaining that while drinking a cup of cocoa he
felt great pain in the throat, and he thought he must have
swallowed some broken china or something.

Owing to the patient’s excitement the house surgeon was
unable to get a good view of the larynx, but finding a slight
wound on the tip of the epiglottis was inclined to believe that

85

some sharp substance had been swallowed, or had entered the
larynx.

When seen on the 21st the cricoid cartilage was found to be
swollen, the left ventricular band much crumpled, and in the
arytaenoid space was found a collection of muco-pus, and on
removing this a gaping scar, as of a burst abscess, w r as visible.

There is no indication of tuberculosis in the lungs, but there
is a history of syphilis dating back twenty-two years.

The wound of the epiglottis may have been due to an over-
enthusiastic dresser passing a probang.

Dr. Dundas Grant said the man had occasional loss of voice.
Both vocal cords moved perfectly well, but there was an extraordinary
swelling of the left ventricular band. It was one of those cases in
which at times the swelling either acts as a damper by pressing on
the vocal cord, or interferes with the production of tone by getting
between the cords. If the trouble was sufficiently serious to justify
the introduction into the larynx of a cautery, he would recommend
cauterisation of the ventricular band.

Mr. Atwood Thorne said, in reply, that the ventricular band was
certainly much swollen. The interest of the case, however, lay in the
fact that the man had a pain in the throat directly after drinking a
cup of cocoa, and thought he had swallowed a piece of china, and on
examination two days after a recent scar was seen in the inter-
arytaenoid space.

Case of Supposed Epithelioma of the Larynx.

Shown by Drs. Dundas Grant and Wyatt Wingraye. J. C—,
male set. 53, a piano-maker, was first seen on December lltli,
1900, complaining of loss of voice of twelve months’ duration,
commencing with slight huskiness and gradually becoming more
marked; there had been no pain except on vocal effort; deglu¬
tition was normal; there was no cough, but lately occasional
dyspnoea, especially on exertion, accompanied by inspiratory
stridor. He had lost two stone within twelve months. There
was no personal history of syphilis or tuberculosis. His wife is
tubercular, and he has lost two children with phthisis. The
sputum is scanty, and no tubercle bacilli could be found, the
chest, beyond a slight emphysema, appearing to be normal. In
the larynx there was seen a granular fringe along the whole
length of the right vocal cord, and to a slighter extent below

86

the most anterior portion of the left cord. The right half of the
larynx was completely fixed, and some thickening was felt over
the right ala of the thyroid. The opinion of the exhibitors was
that it was a case of epithelioma, and they were desirous of
having opinions as to whether a portion of the growth should be
removed for examination, or the exploration effected by thyrotomy;
they hesitated about removing a portion without receiving the
patient’s consent to a partial or complete extirpation of the
larynx, should the diagnosis be confirmed.

Sir Felix Semon was not firmly convinced of its malignancy.
Exactly the same appearance might be produced by either syphilitic
or tuberculous infiltration. He certainly had seen malignant cases
where there was very little more evidence than in this case, but he
did not think the appearance absolutely typical. He would not feel
justified in removing the larynx, but he thought an exploratory
thyrotomy quite justifiable.

Hr. Dundas Grant said there was no evidence of tuberculosis in
the chest and sputum. The man had not been put upon iodide of
potassium, but there was no history of syphilis. Was it a case in
which one should remove a piece for examination, or do an exploratory
thyrotomy ? If it was malignant, and any operation was to be done,
the sooner the better. That was the position of the case.

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Sixty-fourth Ordinary Meeting, March 8th, 1901.

E. Cresswell Baber, M.B., President, in the Chair.

Ernest Waggett, M.B., “) Q ,

Charles A. Parker, F.R.C.S.(Ed,),) ecie aiies '

Present—30 members and 4 visitors.

The minutes* of the preceding meeting were read and con¬
firmed.

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

Wilfred Glegg, M.D., M.R.C.P.(Edin.), Throat Hospital, Golden
Square, W.

The following cases and specimens were shown :

A Case of Malignant Disease of the Larynx in a Man ,®t. 47,
treated by Thyrotomy and Removal of the Diseased Area,
shown Seven Months after Operation.

Shown by Sir Felix Semon. Mr. F. J. B—, aet. 47, was sent
to me on July 4th, 1900, by Dr. Maguire, of Stoney Stratford.
He had been suffering from hoarseness for several months past.
This was the only symptom.

FIRST SERIES-VOL. VIII.

5

88

On examination the right vocal cord was found to be much
tumefied in the middle part and ulcerated in front, the ulceration
extended into the subglottic cavity, and the mobility of the
cord was much affected; the left side was quite free. Iodide of
potassium failed to exercise any effect, and thyrotomy was
performed on July 16th, 1900. When the larynx had been
opened, it was found that the new growth was a good deal more
extensive than it had appeared from laryngoscopic examination.
It not only occupied the whole right half of the larynx, com¬
pletely destroying the right vocal cord, but also extended below
the anterior commissure to the front part of the subglottic
cavity, and attacked the front part of the lower surface of
the left vocal cord. On the other hand, it was well circum¬
scribed. When the growth was removed it was found that it
deeply infiltrated the thyroi,d cartilage, both on the right side
of the subglottic cavity and on the left side of the anterior
commissure. It was removed together with an area of appa¬
rently healthy tissue, and the parts were very energetically
scraped, so that everywhere healthy cartilage was visible.
Considering the condition just described, the chances with
regard to recurrence appeared rather doubtful. The parts
removed were examined by Mr. Shattock, who reported that the
growth was a typical squamous-cel led carcinoma. The patient
made an uninterrupted recovery, and returned home on July
26th, ten days after operation.

Four months later Mr. Cecil Powell, of Stoney Stratford,
reported for Dr. Maguire that the patient was getting on very
satisfactorily, his general health had much improved, he had
gained in weight, and the voice, which had been quite aphonic,
had slightly increased in strength.

When I saw him on Februai’y lltli, i. e. seven months after
operation, he was, as he is now, in excellent health, there
being not the least trace of recurrence, and the voice, although
still hoarse, had gained a good deal in strength since the
operation. On phonation the remnant of the left vocal cord
somewhat crossed the middle line, but only in front reached the
cicatricial ridge which replaces the removed right vocal cord.

The Pbesident, on behalf of the Society, congratulated Sir Felix

89

Semon on the success of his case; the result was most satisfactory,
and the patient had a wonderfully good voice.

Mr. P. de Santi asked Sir Felix Semon the percentage of absolute
recoveries in the cases on which he had operated. He knew the general
percentage, but it would be interesting to hear what were his indi¬
vidual figures.

Sir Felix Semon hoped the voice would continue to improve. His
experience was that the improvement continued up to the end of
the first year, and even after that in some cases. In reply to Mr. de
Santi, he said his last cases, namely those of the past eighteen months,
had not been tabulated, but excluding these his permanent cures were
83 3 per cent.

Specimen of Retention Cysts of the Lymphoid Follicles of the

Vallecula.

Shown by Mr. H. Betham Robinson. This specimen was
removed from a healthy man set. 25, who complained of a lump
in his throat and occasional pain in the neck.

On examination, both by means of the tongue depressor and
the laryngeal mirror, some whitish lumps were seen at the base
of the tongue, standing out above the level of the mucous
membrane, and situated about the outer margin of the vallecula ;
on the right side was a single large one, the size of a sixpence,
and on the left side were three smaller ones.

Under cocaine they were removed with scissors and forceps.

The histological examination of these growths corroborates
the clinical diagnosis. They consist of tonsillar tissue with
retained products in the follicles.

The specimen seemed to him worth bringing to the notice of
the Society, as he could not find any record of this condition.

Case of Chronic Laryngitis with Thickening over the Cricoid

posteriorly.

Shown by Mr. H. Betham Robinson. The patient, a man set.
44, complained of aching pain at the back of the neck and some
pain on swallowing. There was no history of tubercle or
syphilis; no cough, and no loss of flesh. His voice was husky
and weak. There was general chronic laryngeal catarrh, with

90

marked thickening of soft parts in the middle line posteriorly,
and also definite subglottic thickening of the true cords.

Under the application of chloride of zinc all the symptoms
and signs of catarrh had disappeared, with the exception of the
posterior thickening.

Two Cases of Recent Perforations of the Septal Cartilage.

Shown by Mr. H. Bf.tham Robinson. The first case was of
tuberculous origin, and occurred in a lad set. 20, who first
noticed both his nostrils blocked in January, 1899. After a little
while there was discharge from the right nostril, and later from
the left. There was no pain except when the nostrils were com¬
pletely blocked by crusts.

At the beginning of February, 1901, he was found to have a
circular perforation in the septal cartilage, with thickened
margins covered by grey watery exuberant granulations. These
were curetted away, and lactic acid, 20 per cent., rubbed in,
after which iodoform ointment was applied. He had very much
improved under this treatment.

The second case occurred in an engine-driver, get. 43, who
complained of discharge from right nostril.

When first seen there were black crusts on either side of the
cartilaginous septum, but no evidence of a perforation could be
discovered by means of a probe. On the left side there was a
small angular spur.

Over the right temple was a small indurated spot, and there
was enlargement of the pre-auricular and cervical glands, pro¬
bably secondary to the spot.

There was no history of tubercle, but a definite one of syphilis
eighteen years before.

When next seen, sixteen days later, there was an oval per¬
foration in the cartilage only, without any thickening of the
edges, and the glands in the neck were breaking down.

The question here was whether the perforation, limited as it
was to the cartilage, was induced by the trauma (picking), or
whether syphilis played any part in its production.

91

The President said that the first case was undoubtedly tubercular,
and that the other might be either a syphilitic lesion or a simple per¬
foration. The bone was not exposed, and the perforation was entirely
in the cartilage, which was in favour of its being of a simple cha¬
racter.

Dr. Dundas Grant asked if Mr. Robinson had seen the case at the
stage of the gumma.

Mr. Betham Eobinson said the patient referred to when first seen
had simply a black mass where the perforation was now situated,
which looked very much like necrosed cartilage. There was no hole
then, but when he next saw the case he found the perforation in its
present position. The septum broke down very i*apidly. The soften¬
ing glands in the neck might possibly be of syphilitic origin.

A Case op (?) Sarcoma of Tongue and Fauces.

Shown by Mr. H. Betham Robinson. The patient, a married
woman get. 49, was first seen on February 20th last, and then
gave the following history.. She had noticed no symptoms
before a month ago. Her throat then felt ulcerated, and some¬
thing seemed to burst; there was slight bleeding,but no matter.
The bleeding had not been repeated, and there was no pain or
dyspnoea, but with the increase in size of the tumour eating and
drinking had become difficult. Her appearance corresponded
with her acknowledged good health. There was no history of
syphilis or tubercle.

On examination over the left posterior half of the tongue
there was a somewhat circular swelling, the edge of which was
raised fully one eighth of an inch above the surface of the
tongue. It extended backwards and downwards, involving the
left tonsillar region by the side of the epiglottis. The tongue move¬
ments were remarkably free, and the growth, though extensive
superficially, evidently did not penetrate to any depth into the
substance of the tongue. The surface of the swelling did not
seem ulcerated, and (on February 20th) there was only one
slightly enlarged gland at the angle of the jaw.

Since the patient was first seen the glands on the left side
have become considerably enlarged and matted; this might be
1 explained by an attack of influenza during the past few days.

The pathologist considered the tumour to be a mixed sarcoma,
but Mr. Robinson thought that syphiloma was by no means
improbable. This view was to some extent borne out by the

92

following points :—the age of patient, her good health, the rapid
growth, the absence of pain, and the tardy involvement of
glands. On this supposition, iodide of potash had been given
for the past week with some improvement.

The President remarked on the interesting nature of the case.
Its character was doubtful. Antisyphilitic treatment ought to be
tried.

Mr. Spencer thought from the clinical appearance and from the
microscopical specimen that the case was one of gumma.

Sir Felix Semon asked if the painlessness was not in favour of
syphilis as against malignancy.

Mr. Betham Robinson, in reply, said the growth was called “ sar¬
coma” because this was the opinion expressed in the pathologist’s
report. He favoured syphilis himself.

Case of a Male .ft. 26 with the Left Vocal Cord in the
Cadaveric Position, Right Facial Palsy, and Paralysis
of the Right Genio-hyoglossus and the Left Half of
the Soft Palate.

Shown by Dr. Havilland Hall. T. I-—, set. 26, corporal 6th
Lancers. Has had five and a half years’ service in India. Has
since been in South Africa. Has not had fever. Acute rheu¬
matism in July, 1900. Admits gonorrhoea but no history of
syphilis.

Patient was on active service in the recent South African cam¬
paign. Two days after embarking for England from Cape Town
patient first noticed a difficulty in swallowing. This steadily
increased, and reached its maximum in fifteen days. Two days
after landing at Southampton he first noticed a difficulty in
speech, which is now so pronounced. This also gradually
increased, and became stationary in about nine days. This
period was also marked by the first appearance of the hacking,
brassy cough, which was very distressing on admission into
hospital. Patient had not noticed the right facial paralysis or
the weakness on the 'right side until they were pointed out to
him in the hospital.

There is no history of headache, fits, or vesical or rectal
trouble during the development of the present illness, and it is
remarkable that the patient has never had to lie up, or been in

93

any way incapacitated from going about while the symptoms
have been manifesting themselves.

Condition on Admissipn .—No headache, vomiting, or optic
neuritis; intellect clear; no aphasia; speech markedly affected.
Difficulty with labials and linguals to some extent, but great
hoarseness also.

Eyes react to light and accommodation ; no ophthalmoplegia of
any kind; no nystagmus; paralysis of whole of right seventh,
and deafness of right ear. Paralysis of right genio-hyoglossus.
Tongue cannot be deflected to left side. Palsy of left side of
soft palate; left vocal cord in cadaveric position.

Both sterno-mastoids and trapezii act equally well. Marked
weakness on right side of body (both limbs). Both knee-jerks
abolished; no ankle-clonus; plantar reflexes normal.

No sensory disturbance of any kind in body or limbs; some
blunting of sensation in fauces, palate, and posterior pharyngeal
wall.

A disseminated subacute polio-encephalitis is suggested as the
probable cause of the condition.

The patient has had iodide and mercury in full doses, but
without any apparent amelioration of his symptoms.

Case of Extreme Deflection of Septum to Right Side, caus¬
ing almost Complete Unilateral Oustruction, in a Male
^t. 20.

Shown by Dr. Pegler. In this case there was considerable
deviation of the right nasal bone with discoloration and thicken¬
ing. The patient sought advice more for the disfigurement
than for the obstruction to breathing or deadness of his voice.
There was a history of a fall at age of three. The case was
shown to elicit from members whether in such an extreme case
as this there seemed a prospect of a good result from a sawing
operation, or whether one of the methods of fracturing and
forcible straightening of the septum appeared preferable.

Dr. Herbert Tilley thought the best treatment would be to saw
off the projection in the right nostril. It was not a suitable case for
Asch’s operation, because the space in the left nasal cavity was already
none too large for breathing purposes, and the result of Asch’s

94

operation would be to still further occlude the left side without
making much difference on the right. The great thickening of the
nasal bone on the right side was interesting. According to the patient
this had been present since the fall which caused the septal deflection.
It would seem to be one of those cases of traumatic periostitis of the
bone, examples of which had already been shown to the Society at
previous meetings.

Dr. Pegler, in reply, thanked the members for their suggestions.
He should try the saw as suggested in the first instance, as he had
had on the whole better successes in these cases by that means than
by performing an Asch or one of its modifications. The careful use
of splints or adhesion preventers would be an important part of the
after treatment.

Case of Malignant Disease (Extrinsic) of the Left Side of
the Larynx in a Male 2et. 56.

Shown by Dr. Pegler. In this case there was also a ma¬
lignant involvement of some glands on the same side of the
neck. The case was shown to ascertain the feeling of members
as to question of performing complete extirpation, the patient
being willing to submit to any operation proposed for his relief.
The history only extended back four months; voice not affected.

Mr. P. de Santi was strongly of opinion that the case should be
left severely alone. The man had a large mass of glands on the left
side, which were very hard and fixed. There were sure to be other
glands deeper down, and it would be impossible to remove these,
and therefore impossible to remove the whole disease.

Case of Malignant Disease of the Tonsil.

Shown by Dr. Jobson Horne. The patient, a man aet. 60,
states that the symptoms of the throat affection from which he
is suffering are of not more than five months’ duration. At
first he experienced a soreness on the right side, more painful
on swallowing; this steadily increased, and now deglutition is
most difficult and painful.

There is considerable glandular enlargement on the right and
also on the left side, and obvious swelling about the angle of the
jaw, and under the chin there is a discharging sinus.

The jaw can be only partially opened, and the tongue cannot

95

be protruded. The right tonsil is enlarged, extending across
middle line, on the surface of which is an ulcer with thickened
edges. The ulceration is extending on to the soft palate.

Recently he has experienced pain in the region of the left
tonsil. There is no history of syphilis obtainable. He abstains
from spirits, and only smokes half an ounce of tobacco a week
in a clean pipe. Since February 26th he has taken thirty grains
of Pot. Iod. a day, and has experienced relief.

The case is shown in the hope of eliciting suggestions as to
aetiology, and for affording relief by either medicinal or opera¬
tive measures.

Case or Total Extirkation ok the Larynx.

Shown by Dr. Clegg for Mr. Harvey. When admitted to
hospital this patient, a man act. 48, was not in good general con¬
dition.

' On examination a sessile growth the size of a large bean was
seen situated on an intiltrated base just below the right arytacno-
epiglottidean fold, and running obliquely down over ventricular
band and hiding the anterior two thirds of vocal cord. The
right side of larynx was fixed, and the posterior third of the
vocal cord, which was alone visible, was seen to be motionless
and white. The left side of the larynx and the vocal cord
moved freely. There was an indefinite thickening on right side
of neck opposite the level of thyroid cartilage (enlarged gland ?).
The respiration was comfortable although there did not seem to
be very much room. The voice was hoarse. The patient could
only take fluids owing to obstruction to passage of solids, but
had no pain.

History .—Until six months before operation the patient never
had any trouble with the throat. About that time he had a little
difficulty in swallowing and a feeling of gurgling in the throat.
About two months before operation had pneumonia, temperature
reaching 105°, and suffered from great dyspnoea, so much so
that tracheotomy was contemplated. During the next two
months he was hoarse on and off, gradually getting worse ; there
was increased difficulty in swallowing, the cough was often

96

severe, and there was much phlegm in throat, and occasional
slight earache. He could swallow solids until two days before
admission. Had been a heavy smoker and also drank freely.
He had suffered from winter cough, and lately some wasting.
There was a history of syphilis twenty-five years ago; he had
been taking iodide of potassium without any benefit. A piece
of the growth was removed and examined microscopically, and
the diagnosis of epithelioma was confirmed.

On July 25th, 1900, the operation of total extirpation of the
larynx was performed by Mr. Harvey, and it was then found
that on the right side, at the level of the inferior cornu of
thyroid, the growth had perforated into the neck through the
posterior part of the crico-thyroid membrane.

The patient’s health remained good, and the local condition
satisfactory up to December, 1900, when he presented himself
for examination, and a large, hard, irregular gland was found
and removed from the sheath of the jugular above the level of
the great cornu of the hyoid on the right side. He has now a
Gluck’s artificial larynx, whereby a loud whisper can be pro¬
duced and conversation can readily be carried on, and his health
appears to be quite satisfactory.

Case of Extreme Elongation of Uvula.

Shown by Dr. H. J. Davis. This patient, a male set. 52, is the
subject of left hemiplegia and old nasal and laryngeal trouble.
He sought relief for stridor and dyspnoea associated with com¬
plete abductor paralysis of right cord.

The cords now move well, and there, is no stridor, and I am
simply showing him as a curiosity for another reason. He has
the longest uvula I have ever seen. It hangs like a pigtail
from his fauces, and when he protrudes his tongue—which
organ is also of unusual length—you can see without the help, of
a spatula the uvula lolling on to the epiglottis.

Dr. Davis, in answer to a. question, said the man had a slight
cough, but the physical signs in the chest accounted for it. The
patient did not wish to be operated upon ; there was slight anaesthesia
of the pharynx.

97

Sir Felix Semon said he thought the scarring would account for
the anaesthesia of the pharynx.

Specimens op Post-nasal Growths kemoved “ en Masse 5 ’

with a Curette.

Shown by Dr. 11. J. Davis. These specimens, besides demon¬
strating the size to which such growths may develop, show—

(1) Two lateral masses attached to median raphe.

(2) Another specimen of the same in which the growth is
studded with white specks, similar to that observed in follicular
tonsillitis.

(3) A mass at free border of which is an ulcerated area con¬
taining pus and calcareous matter. This was removed from a
child aet. 7, with enlarged cervical glands and probably tuber¬
cular.

(4) A central mass with a largish vessel entering upper
surface.

They have been preserved in spirit since last June, and are
therefore much shrunken, but the sulci and convolutions are
very well marked.

A Case oe Submucous H.emokrhage oe Soft Palate.

Shown by Mr. de Santi. This occurred in a man and was
the size of a walnut. It had appeared suddenly whilst eating
some crusts of bread, and was in all probability dtie to bruising
therefrom. He had had two similar attacks, once on the back
of the tongue and once underneath the tongue in the floor of
the mouth.

When first seen by Mr. do Santi there was an ulcer in the
right glosso-epiglottic fossa, on both sides of which there were
enlarged veins. The haemorrhage from the back of the tongue
had probably come from the right glosso-epiglottic fossa.

The man was not a “ bleeder.”

Unfortunately all traces of the haematoma had by now disap¬
peared, and also the ulcer already referred to.

98

Drawing of Congenital Fenestration of the Faucial Pillars.

Shown by Dr. W. atson W illiams. This was shown in refer¬
ence to the cases and drawings brought forward at the previous
meetings of the Society. It depicted another case of probable
congenital malformation.

Case of Fixation of the Left Vocal Cord and Empyema of
Right Maxillary Antrum.

Shown by Dr. Dundas Grant. Frances T—, set. 44, married,
came under my observation on February 14th, 1901, complaining
of hoarseness and dyspnoea on exertion, and a frequent catch in
the breathing. The hoarseness had been present to a slight
degree for from eighteen to twenty years, and had been gradu¬
ally getting worse. On examination the left vocal cord was
found to be absolutely fixed in the median position, its edge
being markedly concave. Both cords had lost their lustre, and
were distinctly congested. There appeared to be an abnormal
degree of fulness round the base of the arytsenoid cartilage in
the left hyoid fossa. There was slight movement of the left
eornicula. The movement of the right vocal cord was not quite
complete. There appeared to be a rounded fulness under the
left vocal cord, but this proved to be due to a shadow cast by a
vei’y dark greenish pellet of inspissated muco-pus adhering to
the lower surface of the right vocal cord. On inspection of the
naso-pharynx there was found to be a small collection of muco-
pus in the neighbourhood of the right middle turbinated body,
and on anterior inspection there was found a polypoid enlarge¬
ment of the middle turbinated body. On transillumination the
right antrum showed comparative opacity, and when it was
punctured a considerable amount of foetid muco-pus was washed
out. The frontal sinuses were perfectly translucent. There is
a slight flattening of the bridge of the nose, attributed to com¬
pression at birth.

She is the twelfth of a family of fourteen, of whom only two
others survive. The brother, two years older than herself, died

99

at fourteen of scarlet fever. Her father lived to very old age;
her mother died at forty-four of dropsy, probably from heart
disease. There are believed to have been several miscarriages.
The patient has had seven children, of whom two have died;
no miscarriages. She is somewhat anaemic, the palate is paretic,
the pupils contract to light, and the knee-jerks are normal. The
expulsion of the inspissated muco-purulent crusts in the larynx
has been greatly facilitated by the inhalation of turpentine in
warm water, and by the occasisnal injection of 10 per cent,
menthol in olive oil into the trachea, the voice having become
much clearer and the breathing much freer. She has been
washing out the nasal passages, and it is proposed to puncture
the antrum without delay. There is no evidence of abnormality
in the thorax, and the laryngeal affection is probably maintained
by the nasal suppuration.

Dr. de Havilland Hall thought it was an affection of the joint
rather than a paralytic one. There certainly seemed to be on com¬
parison with the right cord a difference in the shape, the left arytenoid
being more round and full.

Dr. Dundas Grant was glad to hear Dr. Hall’s confirmation of his
own opinion. The swelling was extremely small, and consequently
left room for a considerable difference of opinion.

Case of Tumour of the Vocal Cord in a Boy.

Shown by W. G. Spencer. This boy, mt. 12, has a tumour
obscuring the right vocal cord, also a swelling in the right leg
groin.

Huskiness in speech was first noticed a year ago, which has
increased, until now he is very hoarse.

The swelling in the right leg began five years ago, after a
blow from a stone. It disappeared, to return six months ago.
The patient presents no other evidences of inherited syphilis.
In the larynx there is nothing abnormal except a tumour, which
obscures the right vocal cord. The swelling is red in colour,
has a smooth glistening surface, and shows no sign of ulceration
or hasmorrhage. When the glottis closes it seems to come in
contact with, and then to pass somewhat over, the left vocal
cord. But the right vocal cord vibrates freely during vocalisa-

100

tion, as shown by the fact that the vocal fremitus to be felt in
the crico-thyroid space seems to be equal on the two sides.

The swelling in the leg involves the upper and inner surface
of the tibia; the skin is discoloured; two apparently periosteal
nodes are to be felt on the tibia, from which extend backwards
to the popliteal space an induration of the skin and subcutaneous
tissue. The swelling is tender, and there is pain, especially at
night. The femoral glands below and the iliac glands above
PouparPs ligament are a little enlarged, but soft and discrete.

Dr. de Havilland Hall asked if any one would have suggested
that the laryngeal condition was of syphilitic origin from the local
appearances without reference to the tumour in the leg. To his
mind the cord gave no suggestion of a specific lesion. He thought
.that it was a tumefaction rather than a distinct tumour, and he
should have had no idea of suspecting syphilis unless he had seen the
leg.

Dr. Lambert Lack thought that some members might remember a
similar case shown to the Society by Dr. W. H. Kelson. In this case
also there were no definite signs of inherited syphilis. The indefinite
outline of the swelling on the ventricular band and the fixation of the
cord pointed to its being of an inflammatory origin.

Dr. StClair Thomson said there was nothing in the appearance of
the laryngeal condition indicative of a specific lesion. It agreed with
what was commonly described as prolapse of the ventricle, but which
was really inflammatory hypertrophy of the ventricle of Morgagni.
Perhaps the case might be treated first with antispecific remedies to
see what the result would be before resorting to surgical or other
treatment.

Dr. Bond did not think it was specific, and he doubted whether the
leg was, for there was a distinct history of injury at the beginning.

Mr. Spencer, in reply, said the cord was not fixed; vocal fremitus
was obtained equally on both sides. He thanked Dr. Lack for re¬
calling the case of Dr. Kelson to his mind. This might be a gum¬
matous infiltration. With regard to Dr. Bond’s remarks to the effect
that the tumour in the leg might be due to the stone which injured
the boy five years ago, it was rather a long time for a traumatic
osteitis to be gradually going on. The injury might have localised
the gumma in that particular position. He would treat the case with
Pot. Iod., and show it again in a month’s time.

A Laryngeal Case for Diagnosis.

Shown by Dr. Permewan. The patient, a man oat. 55, was
sent to him four weeks ago suffering from dysphagia.

On examination a small circular white tumour about the size

101

of a sixpence, low down on the back of the pharynx, could be
seen on depression of the tongue. Laryngoscopicallv there was
swelling of both arytanio-epiglottic folds, and behind the right
arytsenoid cartilage there was a whitish, granular-looking poly¬
poid swelling. The left side of the larynx and left vocal cord
were quite immobile, there being apparently fixation of the cord
very near the median line.

The small growth was removed with a snare, and on examina¬
tion was pronounced by a pathologist to be “inflammatory.”
The patient was ordered iodide of potassium. Three weeks
afterwards the patient was seen again, and there was some appa¬
rent recurrence of the pharyngeal growth, but otherwise the
appearances were unchanged. Dr. Permewan desired the
opinions of the Society on the nature, prognosis and treatment
of this case.

Sir Felix Semon would not commit himself definitely, but he was
inclined to think that the various projections in the pharynx on the
left and right side originated from one and the same general infiltra¬
tion, which also caused the fixation of the left half of the larynx.
He thought the whole thing was malignant.

Mr. Spencer thought that it might be syphilitic, but if not that it
was most likely malignant. He had shown a large number of cases
to Dr. de Havilland Hall at the Westminster Hospital, in which
malignant disease of the lower part of the pharynx had gone un¬
noticed for a long time. The primary growth in that situation was
exceedingly small. In this connection he instanced the case of a man
who had a growth for a long time not quite as large as a threepenny
piece, and indurated glands on each side of the neck. He had seen
six cases in two years of malignant growth of the lower portion of
the pharynx, and in one or two there were indurated glands in the
neck, these latter having been sent to him with the request to take
away the glands ; in none could he see any chance of doing good
by surgery.

Dr. Dundas Grant brought before the Society about a year ago a
man with an extremely small growth in the wall of the pharynx,
similar to that seen on the left side in Dr. Permewan’s patient. His
case was made easier in diagnosis by the involvement of the glands.
There was room for some doubt as to whether or not it was malignant
so far as its appearance was concerned, but the extreme hardness on
palpation made it pretty evident what the real nature of the case was.
Eventually the man died in the Cancer Hospital of malignant disease.
He was disposed to think the present case one of malignant disease.
It was certainly singular to have a large growth on one side and the
cord fixed on the other.

Dr. Bond was disposed to think it malignant, though one might be

102

led astray by the pathological report on the piece removed, which was
reported to be of an inflammatory nature. Evidently there was ex¬
tensive mischief. It was very uncommon to see two separate patches
of apparently malignant growth, but the intervening tissue was no
doubt quite infiltrated. Commonly, when one examined masses of
this nature with the fingers, one made out very evident hardness and
induration of the growth and surrounding parts. In this case the
growth was quite soft. He showed such a case some three years ago.
He thought this case a similar one, and that it was malignant.

Dr. Fitzgerald Powell remarked that, with all due deference to
the distinguished opinions which had been given, he could not help
having a strong suspicion that the case might prove to be specific in
character; he had elicited the fact that the man’s wife had had three
miscarriages, and he certainly thought that he should be treated by
antispecific remedies.

Dr. Permewan, in reply, agreed on the probable malignant cha¬
racter of the case. He would, however, give iodide of potassium
freely, and report the result to the Society. He thanked Dr. Bond
for the suggestion as to palpating these growths as well as examining
them laryngoscopically.

A Laryngeal Case for Diagnosis.

Shown by Dr. Bennett. P—, male yet. 31, a teacher, was first
seen in September, 1900, on account of hoarseness of one
month’s duration. Examination of the larynx revealed the
presence of what appeared to be a small granulating surface
immediately below the anterior commissure of the cords, and
involving to a very slight degree the anterior inner margin of
the left vocal cord. On two or three occasions this surface was
curetted and a small amount of granulation tissue removed.
Nothing had been done to it for the last three months. The
voice is now better, though not clear. There is still a small
swelling visible, and the opinion of members of the Society is
invited as to the nature of the condition.

Dr. StClair Thomson had perhaps not listened attentively to Dr.
Bennett’s description of his case, but he had obtained a very complete
view of the whole length of the cords, and on phonation no thicken¬
ing was visible in the anterior commissure. On phonation a slight
thickening was seen in the anterior subglottic region. This was not an
uncommon condition; it did not interfere with the action of the
cords, and he therefore thought that the cause of any impairment of
voice must be sought for elsewhere.

PROCEEDINGS

OF THB

LARYNGOLOGICAL SOCIETY OF LONDON.

Sixty-fifth Ordinary Meeting, April 12 th , 1901.
E. Cresswell Baber, M.B., President, in the Chair.

Ernest Waggett, M.B.,

Charles A. Parker, F.R.C.S.(Ed.)

| Secretaries.

Present—31 members and 4 visitors.

The minutes of the preceding meeting were read and con
firmed.

The ballot was taken for the following gentleman, who was
elected a member of the Society :

Wilfred Glegg, M.D., M.R.C.P.(Edin.), Throat Hospital, Golden
Square, W.

The following cases and specimens were shown :

Case of Tumour of Right Yocal Cord with a Swelling on

the Leg in a Boy.

Shown by Mr. Spencer. This case was shown at the last
meeting. Since then the patient had taken 15 grs. of iodide of
potassium daily, and Ung. Hydrargyri had been applied to the
leg every night.

first series—vol. vm.

e

104

Both swellings had largely subsided, tending to show that
both had origin from the same cause, namely, inherited syphilis.

Mr. Spencer proposed to increase the dose of iodide of
potassium, in order to obtain their entire disappearance.

Man a:t. 33 with Chronic Laryngitis and an Ulcer on one

Vocal Cord.

Shown by Dr. StClair Thomson. The patient presented
himself for hoarseness, and a constant desire to clear the throat,
which had commenced about six months ago. When he was first
examined there was general subacute laryngitis, the cords were
congested, irregularly thickened and rounded. On the anterior
third of the left vocal cord there was an oval, boat-shaped
ulcer, covered with a greyish slough. A thickening on the
opposite cord appeared to fit into this ulcerated depression
on phonation.

His temperature was 98'8°, pulse 86 ; there were no symptoms
suggestive of tuberculosis, and nothing was found in his chest.
There was no definite history of lues, but he was put on 10 grs
of iodide of potassium three times a day. On a subsequent
occasion I examined his nose, and found each middle meatus
covered with dirty greenish crusts. He was given a cleansing
lotion, and at his last visit no crusts were visible; his left nose
was clear, but there was some pus in the right middle meatus
and in the right choana. In spite of the improvement in his
nose the hoarseness was w r orse. This was a fortnight ago, and I
have not seen him since, but show him to-day, before further
treatment is carried out, to see if members agree that the
chronic laryngitis and ulcer are both due to infection from the
nose.

Sir Felix Semon thought it was a simple case of chronic laryngitis,
and was not tubercular or specific.

The President said he was not sure of the presence of ulceration
in this case.

Dr. StClair Thomson, in reply, said that at first the idea of
, tubercle had occurred to his mind whilst diagnosing the case; but the
temperature was normal, the pulse not hurried, and though repeated
examinations of the chest were made, no signs of pulmonary tuber-

105

culosis were detected. There was no history of syphilis. Iodide of
potassium was given, but this did not improve the patient, in fact
the drug made him much worse. There was nothing definite about
the nose, but there was a good deal of catarrh. He decided in favour
of chronic laryngitis, possibly of nasal infection.

Case of Infiltration of Right Cord of Three Months’
Duration in a Man jet. 40.

Shown by Dr. StClair Thomson. This man has been hoarse
since early in January. It will be seen that the posterior two
thirds of the right cord is represented by an even, red infiltra¬
tion. The cord moves freely. There is some general hyper¬
trophic laryngitis. The cavum is clear; some polypi have been
removed from each nostril. He has had some treatment with
iodide of potassium, although there is no history of lues. Rest
to the voice and abstinence from tobacco and spirits do not
appear to have improved him.

Dr. Jobson Horne considered that the changes to be seen in the
larynx suggested pachydermia diffusa.

Dr. StClair Thomson, in reply, agreed with the remarks put
forward by Dr. Jobson Horne, and thought the case more like one of
pachydermia diffusa. ' The patient had been watched for some time.
He was suspected of being addicted to alcohol.

Case of Infiltration of the Right Vocal Cord of Six
Months’ Duration in a Man a-:t. 56.

Shown by Dr. StClair Thomson. This patient has been hoarse
since September, 1900. The central portion of the right cord is
rounded, red, and infiltrated. As to the movement of the affected
cord I have been considerably puzzled. At times it has appeared
to move freely, but on other occasions I have felt convinced that
it was slow and partially tethered in its excursions. The rest of
the larynx is normal. He presents no changes in nose, pharynx, or
chest. There is no history or suspicion of lues, but he has been
given iodide of potassium up to 15 grs., three times a day, without
any result. His weight is 12 st. 91 lbs., and does not vary. Feeling
that the appearances were uncertain and suspicious, I asked Sir
Felix Semon to see the patient, which he kindly did about four

106

months ago, ami his conclusion was that there was not then
sufficient evidence to justify a diagnosis of malignancy. Two
months ago the patient was seen by Mr. Butlin, who wrote to
me as follows:—“I do not think it is a new growth. It is too
smooth, and there is too free movement of the cord. Also, his
voice is not so badly affected as I should expect it to be with a
malignant tumour of that size and character. On the other
hand, I do not think that so definite and limited a swelling of
the cord is likely to be due to any ordinary chronic inflamma¬
tion. It is not like tubercle, not quite like syphilis, not like any
of the ‘ infective ’ group of tumours. I have twice opened the
larynx for somewhat similar tumours, under the impression that,
if the disease was not malignant, it was too suspicious to be left.
In one case I found in the centre of the rounded swelling a little
mass of what appeared to be coagulated blood, in the other
something of the same kind, but not so dark-coloured. One of
the patients was a clergyman, the other a commercial traveller,
therefore they both used their cords a good deal. I cannot
help suspecting that this may be a case of a similar kind, in an
agent who talks a good deal. In both my cases there was the
same redness of the affected cord. I do not know whether you
can get rid of the tumour without incising it or carefully
cutting it away, taking the greatest care not to injure the cord
itself in doing so. To do this may necessitate the opening of
the larynx from the neck.”

Both my patients are voice users; this one is a commercial
traveller, while the former one is a shop assistant.

One of Mr. Butlin’s cases is described by Sir Felix Semon in
an article on “ Blood-clots simulating Neoplasms in the Larynx,”*
and the description there given certainly suggests a similarity
to the present case.

Case op Laryngeal Neoplasm occurring on the Posterior
Wall, and accompanied by Paresis of Left Vocal Cord in
a Man mt. 49. For Diagnosis.

Shown by Dr. Scanes Spicer. The only symptom had been
hoarseness of gradual onset, commencing over four years ago.
* ‘ Annale* d$s maladies <Je VOreille,’ etc., xxv, 1899, No. 8.

107

The growth was sessile, and attached to the posterior wall. A
portion was curetted off, and reported by a pathological expert
to be tubercular. Six weeks later a further portion was removed,
and was deemed, after examination by the same expert, to be
malignant. There had been no pain, haemorrhage, or emacia¬
tion, and there are no enlarged glands; no purulent infection
from sinuses or nasal stenosis. There are no history or signs of
syphilis or tuberculosis, and nothing to suggest excessive or
perverted use of voice, or special exposure to dust in occupation.
The patient had been on potassium iodide (gr. v, t. d. s.) for two
months with no effect on his condition. Dr. Spicer inquired
whether the Society considered that the clinical appearances
were so suggestive of malignancy as to demand laryngo-fissure.

Sir Felix Semon feared the growth was malignant. Seeing that
it was so very small, he advised an exploratory thyrotomy to aid the
diagnosis, which was certainly difficult.

In reply, Dr. Scanes Spicer said that, as there was a conflict be¬
tween the evidence of the histologist and that of the history of the
case, and as the clinical appearances were equivocal, he welcomed the
remarks that had fallen from Sir Felix Semon. He had not seen the
section himself, but clinically he doubted the malignant theory.

A Case op Laryngitis with Marked Subglottic Hyperplasia
OCCURRING BELOW THE ANTERIOR COMMISSURE IN A MAN ^T. 36.

For Diagnosis.

Shown by Dr. Scanes Spicer. The illness commenced with
hoarseness four months ago. The patient is anaemic, but there
is no evidence of tuberculosis, there being no emaciation, night
sweats, haemoptysis, or cough, and there is no history of any
other disease. The treatment for the last month had been a
spray of chloride of zinc and small doses of iodide of potassium.
Dr. Spicer thought the case was not at all plain, and seeing that
the patient was a corn dealer, he inquired whether it was possible
that a husk had become imbedded in the larynx. Occasionally
the epiglottis and aryepiglottic folds became oedematous.

Dr. Dundas Grant thought it was a case of tuberculosis.

Dr. Pegler said, had not the evidence against tubercular disease
of the lungs been confirmed, he would Lave regarded the laryngeal

108

disease as tuberculous, to judge from a casual inspection. In testi¬
mony of how deceptive appearances sometimes were, he would mention
a case very recently under his care, which was brought to his mind by
a remark of Dr. Spicer’s, that the oedema in this case might have
been caused by the irritation of a husk swallowed by the patient. A
middle-aged woman came to the hospital stating that she had swal¬
lowed a fish bone a week previously, and still felt it sticking in her
throat. Examination of the larynx failed to reveal the bone, but a
very marked oedematous swelling was seen occupying the left arytenoid
region, and obscuring the glottis and both vocal cords, except quite
the anterior portion of the right one. As this oedema might be due
to one of several sources of irritation, a portion of tissue was removed
for examination by Mr. Lake, who saw the case with the speaker. No
bone was found, but the swelling began to subside, and a week later
the patient brought a comparatively large plaice bone to the hospital,
which she had hawked up. After this the oedema rapidly dis¬
appeared.

Mr. Lake felt very much inclined to recommend the use of mercury
in some form.

A Specimen of a Larynx from a Case of Primary Laryngeal

Diphtheria.

Shown by Dr. Logan Turner. The case was of interest from
the fact that the disease was confined entirely to the larynx,
that it occurred in a strong vigorous adult, and that it ran a
rapidly fatal course. Frequent attacks of severe dyspnoea
necessitated tracheotomy. Post-mortem examination showed the
mucous membrane of the larynx to be covered with diphtheritic
membrane, which extended from the apex of the epiglottis to
the cricoid cartilage. Bacteriological examination demonstrated
the presence of the Klebs-Loffier bacillus and streptococci.

A Specimen of a Larynx for Diagnosis.

Shown by Dr. Logan Turner. The larynx was removed from
a boy set. 8 years, who had died suddenly during the night from
asphyxia, resulting from the drawing of vomited matter into
the larynx and bronchi. All the organs of the body were
healthy.

The mucous membrane of the larynx and upper part of the
trachea was studded with a number of small white points,
varying in size from a half to one millimetre or more in diameter

109

and resembling small miliary tubercles. The posterior surface
of the epiglottis was almost completely covered by a large white
patch of a similar kind. There was no evidence of ulceration
or swelling.

The microscope showed that each patch appeared to consist
of a small area of lymphoid tissue, lying beneath the epithelial
layer, and infiltrating between the glands of the submucous
layer. There was a small communication with the surface.
There were no giant-cells or other evidence of a tuberculous
condition.

Dr. Jobson Horne said he had examined the larynx, and also the
microscopic section ; he did not consider the minute nodules to which
attention had been directed had any pathological significance. By
the epithelium having been destroyed, the underlying structure had
become more obvious.

A Case of Destruction of the Nose caused by a Ferret.

Shown by Mr. Walsham. The patient is now 24 years of age.
At the age of three months a ferret was found gnawing her face.
The whole of the nose, part of the skin of the forehead, and a
large part of the middle of the upper lip were destroyed. She
has had eighteen plastic operations, the most successful being
done by Sir Thomas Smith in 1887, when the skin was taken
from the arm, the arm then bound to the face for three weeks to
fashion the nostrils, and the lip was repaired. The lip was very
successful, and the left nostril fairly so. She has had the Indian
operation done also, but it was a failure.

Right nostril was open, but closed up after last operation in
1899.

The President said that he agreed with Mr. Walsham that nothing
further should be done. He added that he understood from Mr.
Walsham that the introduction of cartilage in this case had been tried
without success.

A Case of Epithelioma of the Larynx.

Shown by Dr. Jobson Horne. The patient, a man set. 69,
stated that in August, 1899, he had “ influenza” which was
followed by some impairment of voice, and which had gradually

110

increased; he had experienced no pain or discomfort, and had
not troubled about medical advice. Excepting an occasional
cold, he considered his general health had been good.

The growth occupied the anterior two thirds of the right
vocal cord, and appeared to be confined to this region. The
greater part of the growth was a papillomatous mass filling the
anterior third of the glottis. Being partly concealed under the
ventricular band of the opposite side it could only be fully
brought into view on deep inspiration. The right vocal cord
was motionless. The left was not affected. There was some
general congestion of the larynx, but this was not more marked
on the right than left. No glandular enlargement had been
made out.

Thirty grains of iodide of potassium had been taken daily
during the previous fortnight without any material change
being noted. The case was shown to ascertain opinions as to
diagnosis.

The President said it looked like malignant disease. There was
want of action on the right side of the larynx.

Sir Felix Semon was of opinion that there could hardly be any
doubt as to the malignancy. There should be no hesitation in per¬
forming thyrotomy and removing the growth.

Dr. FitzGerald Powell said he had seen the patient in January
last, and had advised operation, thinking there was no doubt as to the
malignancy of the growth. The patient had declined operation, and
he had not seen him again until now. Though still thinking it
malignant, he was struck by the fact that the tumour had not grown
or altered very much since January.

Dr. Jobson Horne, in reply, expressed his thanks for the opinions
that had been given, which he also shared.

Case of Tubercle of the Larynx in a Man mt. 18.

Shown by Dr. FitzGerald Powell. The patient states that he
has suffered from gradually increasing hoarseness and difficulty
of breathing for the last four years, accompanied by cough and
attacks of suffocation at night. Five years ago he had ery¬
sipelas of the face and head, and twelve months ago the
eruption, now apparent, on his nose and face appeared. He
complains of pain in swallowing.

On examination the epiglottis, arytaenoids, ventricular bands
and as much of the larynx as can be seen are found to be pale

Ill

and much swollen, and there appears to be very little room for
respiration. The swelling in parts is covered by superficial
erosions.

He had applied a 5 per cent, ointment of salicylic acid to the
nose and face, which had caused some improvement, and he
proposed curetting the larynx and applying lactic acid.

Specimens from Recent Cases illustrating the Two Chief
Classes of Intra-nasal Papillomata.

Shown by Dr. Wyatt Wingrave. 1. The squamous variety
regionally belonging to the vestibule, and histologically identical
with an ordinary cutaneous wart. 2. The columnar or cylin¬
drical variety only growing on mucous membrane, and therefore
never found in front of the lumen vestibuli.

This latter may grow from the septum, floor, or turbinals, and
is often referred to as a “moriform growth.” Histologically
it presents digitations of myxoedematous tissue covered with
columnar or “ palisade ” epithelium, ciliated and smooth, resting
upon a hyaloid basal border.

Warts on the mucous membrane may, however, be covered
with squamous epithelium, a heterologous feature which is due
to irritation causing retrograde changes, as seen in atrophic
rhinitis, and often in slowly growing polypi.

One specimen is that of a “ bleeding tumour.” It is a
squamous papilloma, which grew from the septum about half an
inch behind the lumen vestibuli and above the floor. The
“ core ” consists of numerous blood-vessels with very thin walls,
which run into the digitations. Nests are found, but not of the
“ horny ” variety so characteristic of the vestibular and cuta¬
neous variety. The surface epithelial laminae are also thinner.

Bleeding tumours other than malignant and granulomatous
most frequently are of one of these two types of papillomata.

Drawings of (1) Cyst in the Floor of the Nose; (2) Pachy¬
dermia Laryngis (Tubercular).

Shown by Mr. Richard Lake.

The President congratulated Mr. Lake on the excellent drawings
he had shown to the Society.

112

A Case of Pharyngo-mycosis in a Female.

Shown by Mr. Attwood Thorne.

Dr. Scanes Spicer said the question to be considered was whether
these cases should be actively treated or not. When the patients were
worried by symptoms such as a sensation of a foreign body, scraping,
discomfort, sourness of breath, unpleasant taste, and flatulent dys¬
pepsia, he would recommend active treatment, such as the free and
regular use of alkaline antiseptic washes, the application of per-
chloride of mercury solution to the crypts, or the insertion of the
galvano-caustic point into three, or four, or six of these at a time. He
usually found that these cases were very obstinate, and that even long
holidays, alternating with periods of active treatment, by no means
guaranteed freedom from recurrence. Patients suffering from
mycosis were not as a rule content to be left alone.

Dr. Pegler inquired whether a bad taste in the mouth was com¬
plained of, as in a case of his own at present under treatment this
was the principal symptom, and it was one to which some text-books
gave prominence.

Dr. FitzGerald Powell advised scraping with a sharp curette
once or twice a week, and the application of a solution of nitrate of
silver, twenty to thirty grains to the ounce.

Dr. Wyatt Wingrave emphasised the importance of differential
diagnosis between true leptothricia and keratosis of the tonsils. The
latter appeared as hard papillary projections from the lacunae, not
easily removable, and showing under the microscope typical horny
epithelium with few or no leptothrices. He had found a saturated
solution of salicylic acid (well rubbed in) the best treatment for
keratosis, while true pharyngo-mycosis yielded to sulphurous acid and
antiseptics.

Mr. Parker thought that the most important point to be remem¬
bered in the treatment of cases of mycosis was that in the early
stages of the trouble the fungus was very firmly adherent and very
difficult to remove or destroy, but that if it was left alone for a few
months—some placebo being given to the patient in the meanwhile—
the fungus growth generally became quite loose, and it could then be
easily wiped away. He therefore recommended that such cases
should be left until the growth became loose.

Sir Felix Semon said that in discussing the treatment of
pharyngo-mycosis, the Society was going over old ground, as the
same subject had only recently been discussed by the members. At
the former discussion every one who spoke recommended this or that
remedy as giving excellent results, and there was, altogether, a great
variance of opinions. Personally, he found that these cases, whether
of the leptothricial type, or a true keratosis, always occurred in people
very much below par, and if they were ordered change of air, tonics.

113

rest, open-air exercise, etc., they would, in his opinion, get well with¬
out any other treatment, medicinal or operative. In his experience
a bad taste was not at all usually present in the mouth.

Mr. Attwood Thoene, in reply, said that the patient complained
of no bad taste in the mouth. Personally, he was inclined to avoid
any active treatment.

Cask ok Antral Suppuration with Marked Distension of the

Inner Antral Wall.

Shown by Dr. Herbert Tilley. The patient is a boy aet. 16,
who came under treatment for inability to breathe through the
right nostril and a purulent nasal discharge, associated with
feelings of languor and general depression.

Examination of the right nasal cavity showed a large swelling
of the inner antral wall, which touched the septum opposite.
On pressing it outwards with a probe a crackling sensation and
noise were produced. A ridge of bone traversed the swelling
from above downwards, and at first sight the appearance closely
resembled that of a swollen middle turbinal, but the latter bone
could be seen in its normal position above.

The bony ridge referred to was undoubtedly the uncinate
process of the ethmoid, and immediately in front of this the soft
bulging could be easily penetrated by an ordinary surgical
probe.

The right second upper bicuspid, which was carious, was re¬
moved, and for three months the patient had been irrigating
the antrum twice daily with various antiseptic washes. As long
as these were continued the discharge practically ceased, but if
the irrigation was interrupted for two or three days, then the dis¬
charge reappeared. The question arose as to whether any radical
operation, such as removal of the bulging inner wall, or even a
more radical procedure, should be adopted. The patient’s father
was very averse to any operation unless it was absolutely neces¬
sary for the cure of the case.

The President said that Dr. Tilley’s motive in showing the case
was to receive suggestions for treatment. It seemed as if the inner
wall of the antrum was very much bulged, but, to make certain of
this, examination of the parts with a fine probe was necessary. He
would not advise a radical operation being done at present. The

114

opening had only been made in January last, and the discharge, accord¬
ing to the patient, was slight in quantity, therefore he thought syring¬
ing should be continued for a time.

Dr. FitzGerald Powell said that if it was a fact, as he under¬
stood was the case, that there was no discharge at all, he did not think
it was necessary to do a radical operation on the chance of discovering
polypi.

Dr. Scanes Spicer saw no objection to waiting a little longer
before resorting to further operative measures, but in his opinion
something more radical would have to be done, either through the
nose or through the canine fossa, for the reason that the discharge
through the ostium maxillae was an irritating one, and was keeping up
ethmoiditis and inflammation of the uncinate body, producing the
appearance which had been described as “ cleavage.”

Case of Cyst of the Thyroid.

Shown by Dr. Pegler. The patient was an elderly woman
under the care of Dr. Frederick Spicer, for whom the exhibitor
had offered to show her to the Society. An operation was
contemplated next day, and Dr. Spicer would be glad of sug¬
gestions.

The swelling was the size of an orange, tense, fluctuating,
and having a history of about eighteen months’ duration. There
were pressure symptoms, which had increased latterly, and the
larynx was considerably displaced.

The President said that he was always doubtful as regards the
cystic nature of these growths. He had had a large experience of them,
and he was of opinion that without puncturing it was not possible to
say whether they were cystic or not. This, he believed, had not been
done in this case ; probably not one, but several cysts would be found.
With regard to treatment, the shelling out of these cysts could usually
oe accomplished without much difficulty; but in those cases where it
could not be done, he had adopted the plan of opening the cysts and
sewing the wall to the edge of the skin, allowing the cavity to granu¬
late up. It took a longer time, but gave good results. He had been
in the habit of puncturing goitres for exploratory purposes for many
years, but had had an unusual experience lately. Immediately after
puncturing a moderate sized goitre in a woman aged 25, and evacuat¬
ing only a few drops of blood, the gland swelled up slightly, and a
few days afterwards he heard from the medical man that an extensive
ecchymosis had come out, extending down to the nipples. This soon
subsided, and the gland returned to its previous size. Some tachy¬
cardia was present in this case, but no exophthalmos.

Dr. Dundas Grant asked if other members of the Society had had

115

good results from tapping and then injecting perchloride of iron, as
formulated by Sir Morell Mackenzie, lie had several cases in which
this procedure answered well. He was guided beforehand by the
degree of collapse that the cyst underwent after tapping, and previous
to injecting with iron.

Sir Felix Semon could answer Dr. Grant’s question. Some fifteen
or twenty years ago he had a veiy lively controversy in the ‘ British
Medical Journal’ on the injection treatment of goitres. He then
quoted a number of cases showing that the injection of iodine occa¬
sionally was very dangerous. Since then he knew of another case in
which injection of iron after puncturing a cyst had been followed by
inflammation of the gland, sepsis, and death. In former years he
himself had used injections a good deal in his cases, and had never
personally had any bad result, but he had now completely given up
this method of treatment. The surgery of the thyroid gland had
made such advance that one ought not to have recourse to such expe¬
dients as injections now, when one could remove the whole thing more
simply and surgically.

The President agreed with Sir Felix Semon that the injection of
iron was not satisfactory. It might produce an abscess, and give rise
to a great deal of trouble.

Dr. StClair Thomson thought that in modern surgery the method
of tapping and injecting cysts had gone out of practice. It was simply
done in the pre-antiseptic days from fear of opening these cavities, but
now they might be opened perfectly harmlessly.

Dr. FitzGerald Powell said he thought the best treatment was
removal of the tumour. He considered that there was a good deal
more danger in tapping and injecting these cysts than in shelling
them out. He referred to a case in which he witnessed a well-known
surgeon introduce needles for treatment by electrolysis. The patient
died within half an hour.

Case op Rhinolith ? in a Child.

Shown by Mr. R. Charsley.

Mr. Attwood Thorne considered that the case was one of foreign
body, and expressed a wish that a further report of the case be made
at the next meeting.

The President would prefer to call it a case of foreign body rather
than rhinolith; he had used a probe, but could feel no solid body.
There was either a growth or a foreign body obstructing the nostril.

Dr. Charsley could obtain no information of any foreign body
having been put in the nostril. The body was white, hard, and very
moveable, but he was puzzled to know exactly what it was. He saw
the patient for the first time on the previous day.

N.B.—The day after the meeting the boy was anaesthetised, and a
block of white india-rubber, one inch long by half an inch broad, was
removed from the nostril. •

Ilf)

Case of Unusual Tumour on the Posterior Wall of the

Larynx.

Shown by Dr. Lambert Lack. The patient is a female,
married, aet. 39, who for fifteen years has had occasional diffi¬
culty in swallowing. This has been worse for the last three
months, and the voice has been weak. The patient is thin, but
not wasting, and there are no enlarged glands in the neck. On
laryngoscopic examination a large, nodular, pale tumour is seen
projecting from the posterior surface of the arytsenoids on the
right side. It is soft to touch, and grows apparently from the
posterior surface of the cricoid cartilage. The growth is almost
certainly not epithelioma, and appears to be either simple or
possibly sarcomatous. Suggestions as to diagnosis and treat¬
ment are asked for, since as far as the exhibitor’s experience
goes the case is quite unique.

Sir Felix Semon considered it a very interesting and rare case.
Of one thing he felt sure, and that was that it was not carcinomatous,
and he was very strongly of opinion that it was not a sarcoma. If it
were a malignant growth, there would be by now secondary infection
of the lymphatics, and there would also be deficiency of movement of
the vocal cord on the affected side, from myopathic disability of the
posterior crico-arytenoid muscle. Both these signs being absent here,
he was convinced of the innocent nature of the growth. He advised
that the growth should be removed by the snare internally, and
should be submitted to microscopical examination, and he would be
guided in the future treatment of the case by the result of that exa¬
mination.

Dr. StClair Thomson thought it should be described as an oeso¬
phageal growth. It seemed to him to be a simple growth, and he
agreed with Sir Felix Semon’s remarks. Sir Felix and he had seen
a similar case in consultation together. The patient was a lady from
the Cape, who had a suspicious-looking growth behind the larynx, and
they had come to the conclusion that there was an abscess in connection
with it, which of course there was not in Dr. Lack’s case; but the
tumour was like the one in the present case. His own patient
returned to the Cape two or three years ago, and he had since heard
that she had remained perfectly well. She was an elderly woman;
the glands were not enlarged. No operative treatment was carried
out.

Dr. Jobson Horne, referring to the remarks made by the previous
speaker, said he thought the growth sprang primarily and mainly
from the arytenoid region, and he regarded t as a laryngeal and not
as an oesophageal growth.

117

Cases op Lupus op the Septum and Widening of the Dorsum
op the Nose in a Young Girl.

Shown by Dr. Dundas Grant.

Case op Pachydermia op toe Vocal Processes in a Middle-

aged Man.

Shown by Dr. Dundas Grant. The patient, whose employ¬
ment necessitated the use of his voice in directing the work at
a large railway station, had for one year been becoming gradu¬
ally more and more hoarse. On the vocal processes there were
found extremely typical pachydermic swellings. He was being
treated by means of weekly applications of salicylic acid, and
was improved as regards voice, although no change in the
pachydermic swellings was obvious.

Case op Specific Perforation op the Palate and Ulceration
op the Larynx ok Tuberculous Appearance in a Middle-
aged Woman.

Shown by Dr. Dundas Grant. The perforation of the palate
was typical of tertiary syphilis, and there was indii’ect evidence
(miscarriages, etc.) of specific infection. In the larynx the
epiglottis was thickened and ulcerated all over in a manner
resembling tuberculosis, but without any increase of secretion.
Dr. Grant asked whether this appearance had been met with by
other members in pure cases of syphilis; he was himself of the
opinion that the process in the larynx was of tuberculous nature,
and that, in fact, the case was one of mixed tuberculosis and
syphilis. (Coloured drawings of the appearances in the pharynx
and larynx by Dr. Mackintosh were exhibited.)

Dr. Scanes Spicer said that this case had been under his care
some time ago. He regarded the present condition of the epiglottis
as a tubercular one, for the appearances differed from all the syphilitic
ulcerations he had seen. The epiglottis was really very similar to
that in Dr. FitzGerald Powell’s case. When he had the case there
was no laryngeal involvement at all, but the palate presented the
typical perforation and distortion of tertiary syphilis—just as seen
now.

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Sixty-sixth Ordinary Meeting, May 3rd, 1901.
E. Cresswell Baber, M.B., President, in the Chair.

Ernest Waggett, M.B.,

Charles A. Parker, F.R.C.S.(Ed.),

| Secretaries.

Present—30 members.

The minutes of the preceding meeting were read and con¬
firmed.

The following cases and specimens were shown :

Case of Large Laryngeal Growth shown at a Previous

Meeting.

Shown by Dr. Barclay Baron. There was, on the previous
occasion, some difference of opinion as to the nature of the
growth, but it was generally agreed that it was attached by
some sort of pedicle, and that its removal through the mouth
would be easy. At the operation it was found quite impossible
to remove it in this way, as the growth was a widely infiltrating
epithelioma with no pedicle at all, the epiglottis and other struc¬
tures of the larynx being implicated.

first series—VOL. VIII.

4

120

The patient is still living, the glandular infection being very-
considerable ; he has declined to submit to a total extirpation of
the larynx, which would be necessary to eradicate the tumour.

A Man jet. 61, from whose Left Vocal Cord a Large Epi¬
thelioma was removed by Endo-laryngeal Operation in
1886 AND AGAIN IN 1887, SINCE WHICH THERE HAS BEEN NO
Recurrence.

%

Shown by Mr. Mark Hovell. R. P—, set. 46, a stoker at some
gas-works, came to the Throat Hospital, Golden Square, on
March 17th, 1886, suffering from severe dyspnoea, caused by a
large growth of a whitish colour, which almost filled the larynx.
He looked pale and anxious, and perspired freely on the least
exertion.

On March 20th, after a solution of cocaine had been sprayed
into the larynx, nearly the whole of the growth was removed

The growth as seen before operation.

through the mouth with cutting forceps. Free haemorrhage
occurred, but it quickly subsided. The growth came away
easily, and after its removal was found to have been attached to
the inner border and under surface of the left vocal cord for
almost its whole length. Subsequently two or three small pieces
were removed as before with cutting forceps, and when the
patient left the hospital, on April 5th, not a trace of the growth
remained.

After the operation the patient gave the following history:

In the summer of 1884, whilst making up the fire, he suddenly
experienced, for the first time, difficulty in breathing. The
subsequent attacks of dyspnoea, which as time went on became

121

more severe, used to come on suddenly and last for a few
minutes. They came at irregular intervals, sometimes two or
more in a day, and at other times only one or two during the
week. In consequence of the attacks increasing in frequency
and severity, he went to the Westminster Hospital at the begin¬
ning of 1885, and there saw Dr. de Havilland Hall, who wished
him to become an in-patient; but he refused to do so, and did
not consent to this proposal until April, by which time the
difficulty in breathing had considerably increased. He remained
in the hospital three months, during which time some pieces of
growth were removed by Dr. Hall. He was taken by Dr. de
Havilland Hall to see Dr. Felix Semon at St. Thomas’s Hospital,
who attempted to remove the remaining portion of the growth.
He left the hospital, but was subsequently taken by Dr. Hall to
see Dr. Semon again, who then recommended the removal of the
portion of the larynx to which the growth was attached. To
this treatment the patient refused to submit.

He returned home and resumed work, and remained at it for
three weeks or a month. The difficulty of breathing then
became so great that he was obliged to seek further advice, and
he went to St. George’s Hospital, with the hope that relief could
be obtained there without an operation being performed. He
saw Dr. Whipham, and was made an in-patient. When he had
been in the hospital about a week, he learnt that it was proposed
to perform tracheotomy before an attempt was made to remove
the growth through the mouth. He declined to have tracheo¬
tomy performed, and left the hospital. He then again returned
to work, and remained at it until the end of 1885, when his
breath was too short to enable him to continue at it any longer.

On March 17th, 1886, he came to the Throat Hospital as
before mentioned.

After leaving the Throat Hospital the patient was not seen
again until May 2nd, 1887, on which date he returned, and was
found to be in a condition similar to that which existed when
admitted the previous year. On examining his larynx a growth
was visible almost identical in appearance, as regards size,
colour, and macroscopic texture, to that previously removed.
Subsequent to the second operation he told me that on leaving
the hospital on April 5th, 1886, he resumed work, and felt no

122

discomfort until about January, 1887, when his breathing
became a little short. The dyspnoea steadily increased, and
about the middle of April he was obliged to discontinue work.

As the patient still refused to allow any extra-laryngeal
operation, it was decided to again remove the growth with
forceps. A solution of cocaine having been sprayed into the
larynx, the growth was removed as before with cutting forceps.
It was tougher than that of the previous year, and had a much
larger base, being attached not only to the under surface and
inner edge of the left vocal cord, but also to its upper surface
and to the left ventricular band. At the first operation, on May
9th, although the haemorrhage was greater than it had been on
the former occasions, sufficient growth was removed to enable
the patient to breathe with comfort. Another piece was removed
on May 17th, and the patient left the hospital on May 20th.
The last piece was removed on June 15th, after which no trace
of the growth was visible, and the surfaces from which it had
been removed soon healed. The long intervals between the
operations were made to suit Mr. HovelFs convenience, and
were not caused by any unfavourable symptoms having occurred.
On June 30th slight congestion of the larynx still remained; the
left vocal cord moved but little, but the movement of the right
cord was normal. His voice was strong and distinct, but
slightly husky in consequence of the congestion.

The patient was examined on August 13th, 1887, and there
was no trace of the growth. The movement of the left vocal
cord was impaired, but with the exception of slight general con¬
gestion of the larynx, and slight thickening of the interarytae-
noid fold, the result of chronic laryngitis, no abnormal condition
was visible. The patient’s voice was clear and strong, and there
was no dyspnoea. The patient had been employed at the gas
works for twenty-one years, and the dusty work during this
period would account for the chronic laryngitis.

The following microscopical report of the growth removed in
1886 was kindly made by my colleague, Mr. Frederic Eve :

“The growth removed in 1886 was an epithelioma with a
markedly papillary surface. The papillae were very long and
filiform. The base of the growth, under the microscope, showed
prolongations downwards of the surface epithelium. These were

123

cylindrical, and terminated in a well-defined rounded or sub¬
divided end. In some parts tbe growth of epithelium was more
confused, and composed of tortuous columns or cylinders, which
here contained numerous cell-nests; but these also existed in
smaller numbers in other parts of the growth. The submucous
tissue was nowhere present in the parts removed, but the
epithelial columns forming the growth were so well defined that
I do not suppose there was any diffuse infiltration of the mucosa
with young epithelial cells.

“The growth removed in 1887 differed from' that of the
previous year in that it contained very few cell-nests, and these
of small size. The epithelial columns were more confused, and
their margins less well defined. Some shreds of mucosa were
attached to its base. These were composed of small spindle-
cells and fibrous tissue, containing elongated nuclei, and many
small round or * indifferent ’ cells. Looking at the matter solely
from a histological point of view, I have no hesitation in express¬
ing my opinion that the growth was an epithelioma. This is
based on the extensive and characteristic ingrowth of epithelium,
the presence of cell-nests, and the general appearances of the
neoplasm.

“ P.S .—I have formed an impression that epitheliomata are
less highly malignant if distinctly warty or papillary on the
surface; whilst, when the opposite condition exists and the
surface is flat or ulcerated, the infiltration below is wider and
more diffused, and the growth more malignant. As examples
of comparatively lowly malignant warty epitheliomata, I may
mention chimney-sweep’s cancer of the scrotum, and the epi¬
thelioma following ichthyosis of the tongue. This may account
in some measure for the successful issue of your case.”

Mr. Hovell, in conclusion, said that, although the attempt to
remove an epithelioma from the larynx by means of forceps was
not a procedure which in an ordinary case would be enter¬
tained, or, if undertaken, would in the large majority of cases
have any chance of success, yet exceptional cases must be dealt
with in an unusual manner.

In the present case the man was fortunate to have got rid of
the disease by the measures adopted; but, although in his case
a cure had been effected, it was to be hoped that other patients

124

would not persistently refuse to have the affected region
exposed and efficiently dealt with, or decline to have even a
preliminary tracheotomy.

Mr. de Santi said that he was extremely interested in the history,
the line of treatment, and the result of this case. What one had to
consider in the matter was, firstly, the microscopic appearances of the
sections submitted to the meeting; and secondly, the clinical features
presented by the history given. Mr. de Santi had very carefully exa¬
mined the microscopic sections, and must state that he could not find
in their appearance anything whatever pointing to epithelioma. The
drawing shown was a very artistic one of a perfect epithelial cell-nest,
but in no part of the sections could he find anything even like an im¬
perfect cell-nest. Moreover, cell-nests might occur in growths that
were not epitheliomatous. He felt certain that as regards the micro¬
scopic appearances the diagnosis of epithelioma must be considered
non-proven. Again, looking to the clinical aspect of the case, the
time over which it had extended, together with the great size of the
growth, as shown by the drawing, was quite unlike any epithelioma
he had ever seen or heard of. If the growth had been malignant and
had existed as long as stated, there must have been extensive infiltra¬
tion at its base, and no endo-laryngeal operation could possibly have
eradicated the disease as the disease had been eradicated in this
instance. Neither, therefore, did the clinical features or the micro¬
scopic appearances warrant the diagnosis of epithelioma, and in Mr.
de Santi’s opinion this conclusion was more than supported by the
result obtained by the removal of the growth by endo-laryngeal
forceps. In his opinion the growth had been of an innocent nature
throughout.

Sir Felix Semon declared his entire agreement with the remarks
of Mr. de Santi. It would not be expected of him, after the lapse of
fifteen years, that he should recollect the case, and indeed he frankly
confessed that he had no recollection whatever of it. What he was
going to say would be based only on the drawing which Mr. Ho veil
had shown to the Society, on the microscopical appearances, on the
clinical features of the case, and finally on the present appearance of
the patient’s larynx. From all these points of view he could not help
confessing that the case was a mystery to him. To begin with, he
could not reconcile the idea of malignancy with the clinical ap¬
pearance as now presented. We were taught—and his own experience
corroborated it,—that the difference between a benign growth and a
malignant growth was that a non-malignant growth sprouted from
the surface, while the malignant infiltrated the tissues. How then
could an infiltrating growth be removed so thoroughly that no recur¬
rence had taken place, whilst the larynx, as at present seen, showed
not the least trace of any operation having ever been performed ? He
did not wish to be misunderstood, and he wished to say distinctly
that he did not deny the possibility of removing a malignant growth
from the larynx by endo-laryngeal operation. Quite a number of
cases of that sort were now on record. Perhaps some of the older

125

members of the Society might remember a letter which he had written
to the ‘British Medical Journal’ on June 4th, 1887, in reference to
the case of the then German Crown Prince, for the purpose of warn¬
ing laryngologists against subordinating clinical apprehensions to the
report of the microscopical examination. But in that letter he him¬
self had described a case on which involuntarily he had performed a
radical intra-laryngeal operation. It was the case of an old gentle¬
man, aged seventy-five, who had a suspicious-looking wart on one
vocal cord. He had only wished to remove a piece for microscopical
examination. However, as every laryngologist of experience knew,
intra-laryngeal operations were after all more or less of a fortuitous
character, and by an exceptional piece of luck he found he had
removed the whole growth. Mr. Shattock made transverse sections
through the whole growth and its base, and it in part bore the
characters of a typical comifying epithelioma. The patient in
question was now alive, although more than ninety years of age, and
about six weeks ago he actually preached at a wedding! It was well
known to the Society that his friend, Professor Fraenkel, of Berlin,
had made himself the champion of the intra-laryngeal method of
removing a malignant growth in suitable cases, and there were now,
as he had said before, a number of well-authenticated cases on record
in which the proceeding had been successful. But he could not under¬
stand, in spite of this, how after removing an infiltrating growth from
the larynx, particularly of the size of the one shown in Mr. Hovell’s
drawing, it came about that one could not detect the slightest evidence
of its former presence and of its removal. Now there was no sign
whatever in the larynx of Mr. Ho veil’s patient to show that a large
epithelioma had been removed. If he were asked at the present
moment in a court of law to state on oath from which vocal cord the
growth had been removed, he would have to confess his inability to
tell, and he would have to say it looked as if nothing had been re¬
moved. So clinically he must confess the case beat him altogether.
Further, he had seen a good many cases in which there was for some
time a considerable arrest in the progress of a malignant growth, but
for this to happen for several years, during which there was practically
no progress observed in the size of the growth, surely was most un¬
usual. He was not one who did not believe in things for the mere
reason that he himself had not seen them; but he found it difficult to
understand an arrest of this kind. Again, from a careful examina¬
tion of Mr. Hovell’s own drawing of the growth, it looked to him
much more like a large papilloma springing from the anterior com¬
missure of the vocal cords than like a growth, benign or otherwise,
springing from one of the vocal cords. If this surmise of his should
be correct, then they would have a perfectly natural explanation of
the present appearance of the case. He had once himself removed a
very large papilloma looking exactly like the growth shown in Mr.
Hovell’s drawing from the anterior commissure of the vocal cords of a
lady aged forty-eight. The specimen was at present in the museum of
St. Thomas’s Hospital. With regard to the microscopical appearance,
he had looked very carefully, but could not see anything in the speci¬
men typical of epithelioma. He willingly admitted that it was an old

126

specimen, and therefore it might not be so characteristic as it origi¬
nally had been. He had asked Mr. Hovell if he would consent to
more pieces being examined by the Morbid Growths Committee. He
hoped it would be the general opinion of the Society that such an
unusual case should be submitted to this examination. In conclusion,
he wished to say that nothing had pleased him more than Mr.
Hovell’s final observations to the effect that this was an unusual case,
and therefore had to be dealt with in an unusual manner. If the
man absolutely refused to have the growth removed in the way which
was in accord with the progress of modern scientific surgery, i. e. by
external operation, then under such circumstances an intra-laryngeal
operation was permissible; but he strongly hoped that a case of this
sort would not be made the starting-point for further intra-laryngeal
operations in cases of suspected or proved malignancy. These remarks
were analogous to those he had made at the last meeting in the
discussion of the value of injections of iodine or iron in cases of
goitre. At a time when one had not a better, such methods were both
valuable and permissible, but the operator should keep pace with the
progress of surgery; and so he was particularly delighted to hear
Mr. Hovell say that under normal circumstances he would recom¬
mend the extra-aryngeal operation. With this sentiment he entirely
agreed.

The President, in commenting upon this interesting case, thought
Sir Felix Semon’s proposal of re-examination of the tumour by the
Morbid Growths Committee was a valuable one, and ascertained
from the meeting that it would be its wish to adopt it. He said the
larynx at the present moment showed so little change that it was
difficult to imagine that any malignant growth had been removed.

Mr. Vinrace wished to asked Mr. Hovell whether from first to last
he had observed any lymphatic enlargement in connection with this
growth ?

Mr. Mark Hovell, in reply, said he had not troubled the Society
with the full notes of the case, and therefore had not mentioned the
attachments of the growth at the time of the first and second opera¬
tions. At the first operation the growth was attached to the inner
border and under surface of the left vocal cord along its whole length.
At the second operation the growth was much tougher, and it had a
much larger base, being attached to the whole length of the under
and upper surface, and inner edge of the left vocal cord, and to the
left ventricular band. As regards the portions of the growth which
he exhibited, he should be very happy for the Morbid Growths Com¬
mittee to have a portion of each for further examination. He re¬
minded the meeting that Mr. Eve, who had made his own sections,
had definitely stated that the growth was an epithelioma. With
regard to the mobility of the left vocal cord, the movement was im¬
paired after the first operation, and had remained so since. In reply
to Mr. Vinrace, he did not recollect any lymphatics being enlarged.

127

Female mt. 15, with Absorption op the Cartilaginocs
Septum due to Pressure prom Nasal Polypi.

Shown by Dr. Frederick Spicer. The patient came under
observation some months ago with both nostrils completely
obstructed with polypi, on the removal of which the cartila¬
ginous septum was found to have been absorbed, and the nose
disfigured, but there was no perforation.

The case was shown in order to obtain the opinion of others
as to its causation; but Mr. Spicer ventured to describe it as
above, firstly, because he believed the usually recognised sources
from which this trouble arises have been eliminated; secondly,
on account of the history; and thirdly, because of the totally
blocked condition of the nose when first seen.

There was no family history of syphilis, and none of scrofula;
nor was there a history of any injury.

The first indication of anything wrong was the appearance
four years ago of what she called “ a pimple ” upon the bridge
of the nose, from which matter came ; this was accompanied by
a discharge of pus from the nostrils, and was of sufficient import
to require the assistance of a doctor. It only lasted a few days.

The President understood that this case had been brought for¬
ward with a view to eliciting an opinion as to whether the absorption
was really due to pressure from the nasal polypi. It was evidently a
case of nasal polypus with disease of the ethmoidal, and possibly of
other, sinuses. He should hardly say that absorption of the cartila¬
ginous septum was due to pressure, but more likely to some abscess
in the septum, and he would like to ask Dr. Spicer whether he had
observed at any time in this case an abscess in this position.

Dr. FitzGerald Powell had seen a case under treatment very
similar to Dr. Spicer’s, in which there had been an abscess of the
septum, which pointed, and was opened at the anterior margin of the
septum. The cartilage had entirely fallen away from the nasal bone.
There was considerable thickening or broadening of the latter, the
result of ethmoiditis. The exciting cause was said to be traumatism.
The case was improving, and if possible, and agreeable, he would
show the patient at a future meeting as an interesting comparison
with the present case.

Mr. Nourse thought that an interesting point in this case was the
actual cause of the falling in of the nose; was it due to the absorption
of the septal cartilage or to some further injury ? He recollected a
case he saw at the hospital a short time ago, where the only remain-

128

ing vestige of the division between the two nostrils was the little
columella; the septum, bony and cartilaginous, having entirely disap¬
peared, and yet the nose was perfectly straight and without deformity
externally. It struck him in this case that possibly, although there
had been disappearance of the triangular cartilage, the falling in was
due to the absorption of the lateral cartilages, with consequent break¬
ing of the cartilaginous arch.

Dr. Scanes Spicer thought that this was a case of old septal
abscess in which the upper lateral cartilages had been destroyed by
the suppuration, and that the deformity was characteristic of that
condition. In his experience, traumatism and syphilis were the
commonest forerunners of these septal abscesses.

Dr. StClair Thomson thought that Mr. Nourse’s explanation
might read entirely the other way. He agreed with the President
that the broadening was due to starting ethmoiditis, and that the
most likely explanation was that the patient had had an abscess of
the septum. He had made reference on a previous occasion to a case
in which an abscess in the septum—not traumatic—occurred in the
course of suppurative disease of the antrum. Of course they all
knew of cases like that mentioned by Mr. Nourse, where the whole
cartilage might be absent, and yet there was no falling in. But if the
cartilage was absent through an abscess, the consequent contraction
of the cicatricial tissue explained the dragging down of the bridge
and the deformity of the nose. In this patient, if the nose was
grasped from side to side and compared with one’s own nose, it be¬
came very evident that there was a large defect of the quadrilateral
cartilage of the nose.

The President thought Dr. Thomson’s explanation the correct one,
i. e. the occurrence of contraction of the cicatrix after absorption of
the cartilage.

Dr. F. Spicer thanked the various speakers for their remarks. He
had nothing more to add. He thought he must agree that the
absorption was due to abscess, and considered the abscess was
secondary to polypi and ethmoidal trouble.

Case of Unusual Laryngo-pharyngeal Tumour in a Woman,
with Microscopic Specimen of Growth removed.

Shown by Dr. Lambert Lack. This patient was shown at the
last meeting of the Society (see page 116). 'The advice given
on that occasion had been very carefully considered, but after
some hesitation the exhibitor had preferred to perform an
external operation, so as to thoroughly examine the growth and
its attachments, and to see exactly what steps were necessary to
completely extirpate it. An incision some four inches long was
accordingly made in the anterior triangle of the neck, the sterno-
mastoid muscle and the large vessels drawn outwards, and the

129

lateral pharyngeal wall exposed. A linear incision was then
made into the pharynx, and the larynx hooked forward so as to
thoroughly expose its posterior wall. The growth was soft and
nodular, about the size of a pigeon’s egg, and attached by a
broad base to the mucous membrane over the cricoid cartilage.
The mucous membrane was divided all round the growth, and it
was then dissected off the larynx. The wound in the mucous
membrane of the larynx was closed with a few catgut sutures.
The wound in the pharynx was then closed by a row of closely
placed fine sutures uniting the edges of the mucous membrane,
and the pharyngeal aponeurosis was also carefully stitched up.
A large drainage-tube was inserted into the wound in the neck,
and the skin wound closed by silk-worm gut sutures. Just
before opening the pharynx, a laryngotomy was performed as a
precautionary measure, but it was really not needed, and the
tube was removed next day. The after history was uneventful.
The patient swallowed easily the day after the operation, and
five days later could take solids more easily than before opera¬
tion. The wounds, except where the drainage-tube had been,
healed by first attention, and the patient is now able to attend
the meeting, on the sixteenth day after the operation. Exami¬
nation with the laryngoscope shows nothing abnormal.

Dr. Jobson Horne has made sections of the growth, which he
reports to be a mixed-cell sarcoma.

Sir Felix Semon suggested that this specimen should be submitted
to the Morbid Growths Committee. He did not pretend to be a great
histologist, but to him the section of the tumour looked more like
a fibroma than a sarcoma, and he would like to have the opinion of
the Morbid Growths Committee. Under all circumstances. Dr. Lack
must be congratulated on his most successful operation.

Dr. StClair Thomson asked if Dr. Lack intended publishing the
case in full in the ‘ Proceedings; ’ if not he would like to have a few
particulars as to whether it was necessary to put temporary ligatures
round any of the arteries; as to whether he had experienced any
difficulty with bleeding or breathing, and as to what steps were
necessary in turning round the lkrynx.

Dr. Lambert Lack said there was no difficulty with bleeding, as
the large wound exposed the whole field of operation to view. Con¬
sequently there was no necessity to put temporary ligatures round any
of the large vessels. Such a proceeding was only necessary when
operating in the pharynx through the mouth, where it would be
impossible to pick up any large vessel which might be cut.

130

The President having obtained from the Society an expression of
its desire that a specimen of the growth should be submitted to the
Morbid Growths Committee, Dr. Lack said he should be very pleased
to supply a portion of the growth for examination.

Specimen of Bony Occlusion of one Nostril.

Shown by Dr. Lambert Lack. The specimen showed a com¬
plete occlusion of one nostril at about its centre by a bony
septum. The nose was otherwise normal. The specimen was
obtained whilst dissecting, and no history was obtainable.

Specimen of Multiple Papilloma of Larynx.

Shown by Mr. H. W. Carson. The specimen was removed
post mortem from a female child aet. years, who had died sud¬
denly of asphyxia. There was a history of orthopncea and
dysphonia from birth. The specimen showed well-marked
papillomatous growths in the region of the vocal cords, and a
subglottic extension on the anterior wall. There was some
oedema in the arytaenoid region.

Mr. Carson wished to ascertain the views of members of the
Society on the question of prognosis, more especially as regards
recurrence after thyrotomy.

The President said this subject had been under discussion at the
Society on previous occasions. They knew that recurrence often did
take place. There was the celebrated case in which thyrotomy was
performed seventeen times.

Case of Pachydermia Laryngis.

Shown by Mr. Charles A. Parker. This patient had been
shown to the Society about two years ago, when it was thought
by some to be of a tuberculous nature. Since then the chest
had been frequently auscultated, and the sputum examined from
time to time, but no evidences of tubercle had been discovered.
The local condition was practically unchanged, in spite of various

131

methods of treatment, both at Mr. Parker's hands and at the
hands of others, for the patient had sought relief at other hos¬
pitals. Mr. Parker would be glad to know if anything further
could be done for the patient.

The President said he understood that the condition had existed
for three or four years without much improvement.

Dr. Jobson Horne considered the condition was typical of pachy¬
dermia laryngis verrucosa, and agreed with Mr Parker that tubercu¬
losis was not a factor in its causation. Dr. Horne was not in favour
of any local treatment of a surgical nature.

Mr. de Santi was of opinion that in this case the line of treatment
now should be to leave the man quite alone.

Mr. Parker, in reply, said he showed the case chiefly because on the
former occasion it was thought by some members to lie tubercular,
and he was then asked to bring it forward again. He did not think
there had ever been any evidence of tubercular disease. For the last
nine months no treatment had been attempted.

A Case of Tumour of the Base of the Tongue in a Young

Female.

Shown by Dr. Dundas Grant. This case was shown with the
object of gaining from the members of the Society opinions as
regards both diagnosis and treatment.

Mr. de Santi considered this case to be one of extensive sarcoma of
the base of the tongue. The feel of the tumour, its irregular surface,
the absence of ulceration, the age of the patient, and the history, all
pointed strongly to its malignant nature. Moreover, a large piece of
the growth had been removed a year ago (unfortunately he understood
this piece had been lost, and therefore not submitted to microscopic
examination), and had been followed by a rapid and considerable
extension of the tumour. The patient he noticed had enlargement of
the submaxillary glands, and this was far from uncommon in
sarcomata of this neighbourhood. A piece of the growth should be
removed and submitted to a skilled pathologist for microscopic exami¬
nation, and the case dealt with surgically.

Dr. Lambert Lack had under his care at the present time, a young
girl set. 19, presenting some* features very much like this case. The
tumour was a smooth one with large vessels coursing over it, and he
was under the impression that the growth was a thyroid tumour. He
would not, however, like to give that diagnosis in the present case,'
unless some of the ulceration seen was due to the removal of pieces by
Dr. Grant.

The President said with regard to thyroid tumours at the base of

132

the tongue, he had had one case which he had shown to the Society,
but this case presented a different appearance. It was more irregular
and more like a malignant growth.

Dr. FitzGerald Powell said that the tumour looked like a
carcinoma to him, though the woman’s age was against its being so;
anyhow a portion should be removed and examined microscopically
before anything further was done.

A Case op Ulceration op the Tip op the Tongue in a
Man mt. 52. For Diagnosis.

Shown by Mr. Attwood Thorne. The patient had complained
of some pain for the last year. Mr. Thorne only saw the patient
ten days ago, and he then at once put him on iodide of potas¬
sium, grs. 10 three times a day. There was, if anything, a
slight improvement. Hs asked whether it was epithelioma,
syphilis, or tubercle ? The tongue was slightly fixed.

The President advised that the iodide of potassium be pushed.

Mr. Mark Hovell suggested that a piece should be removed and
submitted to the microscope.

Dr. StClair Thomson said syphilitic disease was certain, and
malignant possible. In all cases where there was any doubt it was
the rule to treat the case on anti-syphilitic lines. He had once had a
patient who was condemned to have his tongue removed by a leading
authority on syphilis. That patient was afterwards shown as having
been cured of cancer by Mattei’s remedies. Mr. Thorne would be
well advised to take no further measures until inunctions of mercury
had been given a good month’s trial.

Mr. de Santi considered this case to be epitheliomatous rather
than syphilitic. There was marked induration at the base of the
ulcer; the ulcer itself was raised and warty, not depressed and punched
out, and it rubbed distinctly over the lower incisor teeth. There was
a little limitation of movement, and some slight fulness in the sub¬
maxillary region. It was an uncommon situation for a gumma, but
not so uncommon for epithelioma.

Dr. Lambert Lack said that Dr. Thomson had exactly stated his
views when he said it was certainly syphilis and quite likely epithe¬
lioma, but he disagreed entirely with his suggestions as to the course
to be pursued. Dr. Lack thought it was very wrong to put a case of
suspected epithelioma in such an accessible region on a course of
iodide of potassium, and more especially to give him a month’s course
of treatment by mercurial inunction, when the diagnosis could be
immediately made by removing a small piece of growth for micro¬
scopical examination. Should the case be malignant, the danger of
such a long delay was obvious.

138

Mr. Vinrace wished to ask whether Mr. Thorne had noticed any
fixation in the tongue. He thought the patient had considerable
difficulty in putting it out, and its movement was impaired. He
asked if there were any infiltrations, other than those of a malignant
nature, which impaired the movements of the tongue.

Mr. Thorne, in reply, said that he would remove a small portion
for examination, and would order mercurial inunctions, and hoped to
report on the case at a future meeting.

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Sixty-seventh Ordinary Meeting, June 7th, 1901.
E. Cress well Baber, M.B., President, in the Chair.

Ernest Waggett, M.B.,

Charles A. Parker, F.R.C.S.(Ed-),

Secretaries.

Present—32 members and 3 visitors.

The minutes of the preceding meeting were read and con¬
firmed.

The following cases, specimens, and instruments were shown :

Case of Ulceration of the Larynx (? Tuberculous) in a

Male ast. 48.

Shown by Dr. de Havilland Hall. The patient was first seen
on April 30th, 1901, when he complained of hoarseness. He
was in the army thirteen years, and has been in India, Canada,
Egypt, and South Africa. The only previous illness he has had
was enteric fever in 1882. No history of any venereal disease
can be obtained. The patient lost his voice twelve months ago,
hut he had no treatment until last April. He has had a cough
and some expectoration, but no haemoptysis. He has lost weight,
FIRST SERIES VOR. VIH, 8

136

There has been thickening and' ulceration of both vocal cords
and interarytenoid commissure. There has also been some
ulceration on the laryngeal aspect of the epiglottis. There are
physical signs of consolidation with rales at both apices, and
a few tubercle bacilli have been found in the sputum.

Under the inunction of blue ointment and the administration
of potassium iodide—20 grains three times a day—there has
been considerable subjective improvement, but very little objec¬
tive alteration in the larynx.

Dr. StClair Thomson was of opinion, from an inspection only of
the larynx, that it was a case of tuberculous ulceration in a syphilitic
subject, who had probably had pachydermia, and had now contracted
tuberculosis of the larynx.

Dr. de Havilland Hale said this was precisely the view he took
of the case when it was in hospital, though he was unable to obtain
any history of syphilis. In spite of inunctions of mercury and iodide
of potassium internally, there had been very little alteration in the
appearance of the larynx as seen by the laryngoscope. At the present
time, however, the patient breathed much more comfortably than he
did when first seen.

Case op Malignant Laryngeal Growth in a Man j^t. 52.

Shown by Dr. StClair Thomson. This patient complains of
hoarseness coming on slowly for the last two and a half months.
He attributes it to repeated colds since January, so that we may
take it that the laryngeal affection dates from at least five
months ago.

His voice is now reduced to a hoarse whisper. The anterior
four-fifths of the right cord is occupied by an oblong growth
with an irregular mammillated surface ; the tips of some of these
excrescences present the white snow-like surface which has been
referred to at previous meetings of the Society in connection
with the question of malignant disease. The anterior third of
the left cord is also infiltrated, and shows one or two of these
white-tipped mammillae. The posterior pavt of the same cord
appears as if indented by the larger growth on the right cord.
Both cords move, but while the left moves freely, the right is
decidedly limited in its excursions.

There is nothing in the patient’s history to arouse a suspicion

137

of lues. He has ho cough, expectoration, or haemoptysis. The
temperature is normal, the pulse is not hurried, and the chest
sounds are normal. He has taken 5 grains of Iodide of Potas¬
sium with some Liquor Hydrargyri Perchloridi since May 25th
without any apparent effect.

Dr. Thomson inquired whether the condition was due to
malignant disease, whether the diagnosis could be made with
sufficient certainty without recourse to removing a portion for
microscopic examination, and whether the case was suitable for
operation by laryngo-fissure ?

Mr. Spencer thought it was malignant and now bilateral owing to
infection from the opposite side. In his opinion it required early
and extensive operation.

Mr. Waggett asked Dr. StClair Thomson if he contemplated per¬
forming thyrotomy, and if so, would he bring the case before the
Society when he had done so. He presumed thyrotomy should be
undertaken as an exploratory measure.

Dr. StClair Thomson said he thought of performing a thyrotomy,
and he wished to know whether members present thought the diagnosis
could be positively made without recourse to the excision of a piece
of the growth. He himself thought removal of a portion was unneces¬
sary, for if the examination was negative it would not alter their
present opinion. Before proceeding to a thyrotomy he should like to
know how freely one might remove the parts when both cords were
affected ? Of course,' one might scoop out very freely the whole of
one side of the interior of the larynx. Could one be as free on the
other side without fear of stenosis Y He had had one case in which
the whole of one of the cords right up to the arytenoid was removed,
and the anterior fourth of the opposite cord as well, but in the present
case it seemed to him that not only the whole cord originally affected,
but two thirds of the opposite cord required removal; if at the explora¬
tory operation he found this was so, would it be safe to carry it out ?

Sir Felix Semon said that he had several times found it necessary
to excise both vocal cords, and that no subsequent stenosis had
resulted. He did not think that such an event was to be feared. He
quite agreed with Mr. Spencer that in all probability there was
secondary disease of the left vocal cord, owing to auto-infection.
Probably, however, it would be found sufficient to simply excise the
left vocal cord, if this suspicion should turn out to be justified, with
curved scissors.

138

A Cask of Frontal-Sinus Suppuration Fourteen Months
after External Operation,

Shown by Dr. StClair Thomson,
and

Three Cases Demonstrating the Results of External Opera¬
tion on the Frontal Sinus,

Shown by Dr. Herbert Tilley.

Dr. Thomson's Case. This case was shown to illustrate the
completeness and permanence of the cure of nasal suppuration,
due to frontal sinusitis, and also to demonstrate that the external
scar was trifling and had not increased with time.

The ordinary external operation was performed on April 10th,
1900. A photograph was shown of the scar three months later,
and by comparison with the patient's actual condition, it would
be seen that this had not increased.

The patient still has suppuration in the antrum, which is
drained through a tooth socket. She had, however, been in¬
structed not to syringe this out for forty-eight hours, and as she
had not had occasion to wash her nose out since the date of
operation on the frontal sinus it would be allowed that the free¬
dom of the nose from all trace of pus was both genuine and
complete. She now never requires more than one handkerchief a
day, and states, that were it not for aesthetic reasons, two a week
would suffice.

Dr. Herbert Tilley's Cases. These cases were shown to
demonstrate that if the radical operation was effectually carried
out, there was no reason why a recurrence of the discharge
should take place with lapse of time, as he understood Dr.
McBride to have suggested at one of the recent meetings of
the Society, and that there was nothing terrible about the
operation. These cases had been operated on fourteen months,
nine months, and six months ago respectively, and there was
still no trace of purulent discharge into the nostrils. Two of
the cases also illustrated how slight a deformity is caused by a
somewhat radical operation.

Dr. Vinrace confessed to having used the word terrible in connec¬
tion with these operations, as he considered them both formidable and

139

of a serious nature. He laid stress on the importance of freeing the
inferior meatus or breathing channel of the nose from all obstruction,
and of giving that a fair trial before proceeding to the radical operation.
He gathered from the patients that this had not been done in the cases
before them. He also considered that it seemed more rational to en¬
large per nares the natural communication between the frontal sinus
and the nose, namely tbe infundibulum, than to perform an external
operation.

Dr. Fitzgerald Powell asked the exhibitors to give the Society *
some detailed information as to the methods adopted in the operative
treatment of these cases. He would like to know firstly what amount of
bone was removed, whether the whole of the anterior wall of the sinus
or only a portion of it. Also, if the opening from the nose to the
sinus was enlarged and kept open by a tube, either solid or hollow, for
purposes of drainage ; and secondly, as to the method of packing, and
general treatment. They seemed to him to be very excellent results,
upon which the operators should be congratulated.

Mr. Spencer asked Dr. Tilley to give some information with regard
to the comparative frequency of unilateral and bilateral affection of
the frontal sinuses. Dr. Tilley seemed to meet with unilateral cases
chiefly; was it that these cases were more frequent ? At one time,
very nearly fifty per cent, of, cases of frontal-sinus empyema were
found to be bilateral, but he had noticed Dr. Tilley showed fewer bi¬
lateral than unilateral cases. Was this due to the fact that by doing the •
radical operation on one side early he prevented the empyema from
becoming bilateral F

Dr. McKenzie Johnston said that, generally speaking, he thought
the antrum of Highmore a much simpler thing to treat than a frontal
sinus. In several of these cases, however, the antrum had been
opened, and from the fact of the patients still wearing a tube, he
presumed that in these cases, as far as the antrum was concerned, the
termination of the case was not yet reached. He would like to know
when it was proposed to remove the tubes, and whether the “ cure ”
was considered complete before the antrum was in a satisfactory con¬
dition.

Dr. Furniss Potter asked Dr. Tilley what symptoms he con¬
sidered necessitated the operation. Would he do the operation in
every case in which he had reason to suppose that pus came from the
frontal sinuses ?

Dr. Peglbr said it was just worth remarking with regard to Mr.
Yinrace’s remarks that there was much difference of opinion as to
which really was the “ breathing channel ” of the nose.

The President said the main point of interest was what should
be the exact radical operation undertaken. The treatment should be
as short as possible, and leave as little scar as possible. On these two
points the Society would be glad to hear the remarks of Dr. StClair
Thomson and Dr. Tilley. He thought it was clearly settled, as had
been mentioned by Dr. Tilley, that before operating on the frontal
sinus it should if possible be washed out from the nasal cavity. It
was usually also necessary to first remove the anterior end of the
middle turbinated body.

140

Dr. StClair Thomson said that with regard to the severity of the
operation, the temperature chart showed this not to be the case. His
patient was out of bed on the foui*th day after the operation, and on
the seventh was up for the whole day, and in about a fortnight left
the hospital. So at any rate it was not such a “ terrible ” operation
as regards the time the patient had to remain in bed. This woman
had the operation done because the discharge was such that she
averaged six to eight handkerchiefs a day, and sometimes in the
• twenty-four hours she might require eighteen. The symptoms were
pain over the left eye and neuralgia. She had had discharge for ten
months. The disease was evidently brought to a head by an attack
of influenza, which made her frontal-sinus condition much worse.
There was plenty of room in her nose to admit of proper breathing
when it was not obstructed by pus. When the frontal sinus was
opened it was found full of pus, and entirely lined with degenerated
polypoid mucous membrane. The anterior end of the middle turbinate
was removed sixteen days before the operation, which evidently had
given sufficient room for drainage, since for some two months after
the operation the patient was able to blow air from the hole in the fore¬
head. fa]ven now, if one put the hand on the forehead when the patient
distended her nose, one could feel the scar bulge. Several members
had noticed this. With reference to the suggestion of treating the
frontal sinuses from within the nose, the matter had been considered
by the Society on a previous occasion. In this patient, knowing that
unsatisfactory results had been obtained, and that fatal cases had
been put on record, he determined to keep the wound open for a long
time. He operated on April 10th, and did not allow it to close till
June 80th. This was one of the factors in the treatment of his case.
Another was that he cleared out the fronto-nasal duct, but left no
drain into the nose. His patient had, as Dr. Johnston mentioned,
still empyema of the antrum. He had thought it might simply be a
reservoir for the frontal sinus, and so he left it alone, hoping it would
spontaneously heal when it ceased to be filled from above. But the
antrum was still secreting pus, though in very small amount. At
some future time he intended operating on the maxillary sinus.

Dr. Tilley, in answer to Dr. Vinraee, observed that removal of nasa
polypi was a purely temporary measure, and did not relieve the head¬
aches for which the operation had been performed in the cases ex¬
hibited. One of his patients had been having his polypi periodically
removed for seventeen years at different hospitals. He also pointed
out that other questions raised by Dr. Yinraee and Dr. Potter would
be found answered in the Proceedings of the Society for February,
1901, p. 78. In reply to Mr. Spencer, Dr. Tilley said that in twenty-
three cases of frontal-sinus empyema with which he had had to deal,
ten cases had been bilateral.

Two Cases of Thykotomy for Malignant Disease of Vocal

Cords.

Shown by Dr. Herbert Tilley. In these two cases the opera¬
tion *had been performed five and three and a half years ago
respectively. The patients had enjoyed perfect health since,
and in the second case the voice was quite good. In the
first case the left vocal cord and arytasnoid cartilage had been
removed, and a few weeks after the operation a large granulation
appeared in the anterior commissure, which was still present in a
cicatrised form. Had this not been carefully watched it might
have been regarded as a recurrence. Sir Felix Semon had con¬
firmed the opinion of the nature of the case before it was
operated on. Full details of both cases may be found in the
‘ British Medical Journal/ October 22nd, 1898.

Mr. Wagoett had seen Dr. Tilley do the operation in one case. He
remembered that a fortnight after the operation they found some large
suspicious-looking granulations in the anterior commissure. These,
however, disappeared without treatment.

Case of Infiltration on Left Cord in a Man ,et. 28.

Shown by Dr. Fctrniss Potter. This patient, a railway
porter, whose duties entailed very considerable use of the voice,
had recently come under observation complaining of huskiness
and a feeling of irritation in the throat, which had troubled him
for the last six months.

On examination the uvula appeared to be somewhat elongated,
and the left cord was seen to be reddened and infiltrated in its
whole length, and it presented an uneven granular appearance.
Its mobility was not impaired. The arytenoid region was unduly
red, but otherwise the larynx was in normal conditibn.

The chest had been carefully examined, but no sign of
pulmonary mischief had been detected. There was no cough
or expectoration, and no loss of flesh or strength, the patient
stating that he felt perfectly well, and able to do his work.
There was no history of syphilis, and the family history was
free from evidence of tuberculous taint.

142

The President thought the case might be tubercular, but he
understood there was no evidence of tubercle in the lungs. There was
no want of movement of the cords.

Dr. Furniss Potter thought it was tubercular.

Specimen prom a Case op Sarcoma op the Tonsil, with

Microscopic Slide.

Shown by Dr. McKenzie Johnston (Edinburgh). L—, male, aet.
28 years, a farm servant from Shetland, was sent to me at the
Royal Infirmary about the beginning of December, 1900, on
account of a tumour in his throat. He stated that he had only
been aware of its presence for about six weeks, but on inquiry it
was found that his friends had noticed for about three months
that his speech was thicker than usual. He had no pain or
discomfort, and had nothing to complain of except the fact
that he felt a lump in his throat, although, latterly, he noticed
that when swallowing liquids they were occasionally regurgitated
through the nose.

On inspecting the throat, the left tonsil was seen to be enor¬
mously enlarged, extending inwards for some half inch beyond
the middle line, and also well down into the pharynx. In
colour arid appearance it appeared much like an hypertrophied
tonsil, only somewhat softer and more vascular. Nothing else
abnormal could be seen. Several friends to whom I showed
it were inclined to think that the condition was a simple in¬
flammatory swelling. I ordered a course of iodide of potassium,
but it was soon evident that in spite of this the growth was
rapidly increasing, and that glands underlying it were also
enlarging. I then removed the greater part of the projecting
mass with the electro-cautery, and Dr. Gulland, who kindly
examined it for me, pronounced it to be a rapidly-growing
round-celled sarcoma. It was therefore evident that if it was
to be removed the operation should be undertaken as soon as
possible.

On January 3rd, 1901, my friend Mr. David Wallace operated,
and I am further indebted to him for the following notes of the
steps of the operation. The remains of the tonsil and tissue
between the pillars of the fauces and the pillars themselves

143

were removed, together with two enlarged glands situated pos¬
teriorly and below the angle of the lower jaw. An incision
corresponding to the posterior part of Kocker’s normal incision
was made behind and below the angle of the jaw, the enlarged
glands removed, and a ligature placed on the external carotid
artery. The jaw was exposed in front of the masseter muscle
and divided obliquely, in a line from above downwards and
forwards, and the two portions widely separated. This, after
opening the mouth, exposed the region of the tonsil very
freely, and allowed excision of the diseased tissues to be readily
carried out. There was practically no bleeding. The jaw was
united by silver suture, a drainage-tube inserted through the
opening into the mouth, and the posterior part of the wound
completely closed. The patient made an excellent recovery,
and at the present date remains perfectly well.

The President said this was a very interesting case, and the
Society was much indebted to Dr. McKenzie Johnston for coming so
great a distance to show this specimen.

Specimen op a Cheesy Mass pound in an Adenoid Growth

after Removal.

Shown by Dr. McKenzie Johnston. The cyst appeared to
be about size of half an almond, and was filled with a cheesy
material. *

Dr. StClair Thomson did not think these cases were very rare.
One often saw them in acute adenitis of Luschka’s tonsil, but in the
chronic cases they were more rarely visible in the mirror. He had
had a case sent to him at the Throat Hospital for recurrent attacks
of laryngitis, tracheitis, and bronchitis. The patient had adenoid re¬
mains, which were removed, and all present were struck by the sicken¬
ing smell of the caseous matter in the adenoid growths. It was quite
possible that from time to time it gave rise to infection, spreading
downwards. He did not think Dr. Johnston looked upon this condi¬
tion as being of rare occurrence, but showed his specimen as being a
good example of these cases. They occurred more often than was
suspected.

Dr. Johnston agreed with Dr. Thomson’s remarks. He did not
think the case extremely rare, but he had not met with such a good
specimen before, nor one in which the secretion was so deeply situated;

144

the specimen, of course, did not exemplify the condition so well as when
it was at first removed. Small, somewhat seedlike, masses were often
seen, but such a cyst he did not remember to have seen before in this
situation.

Sketch of an Aneurism of the Aorta in which Paralysis of
the Left Vocal Cord was the only Physical Sign during
Life.

Shown by Dr. Donklan. This patient, an Italian man aet. 39,
was admitted into the Italian Hospital on February 14th,
complaining of loss of voice, slight dyspnoea, and some numb¬
ness and pain in the left arm. He had become slightly hoarse
two months before, and had complete aphonia for fifteen days
before admission.

There was no history of syphilis. No physical signs could be
elicited by the stethoscope. On the 15th, at the request of
Cavaliere Naumann, under whose care he was, I made a
laryngoscopic examination, and found the usual evidences of
paralysis of the left recurrent nerve.

The diagnosis made was paralysis of left recurrent from intra-
thoracic tumour, probably an aneurism.

On the following morning the patient was suddenly seized
with symptoms resembling those seen in angina pectoris, became
rapidly collapsed, and died within two hours of the seizure.

The post mortem showed a healthy state of all the organs
with the important exception of the aortic arch, where a small
oval aneurism was situated on the postero-superior aspect, and
immediately outside the origin of the left subclavian. The
tumour overlapped and compressed the left recurrent nerve in
the manner shown in the rough sketch exhibited.

Case of Separation of the Upper Lateral Cartilage of the

Nose in a Male ast. 25.

Shown by Dr. Fitzgerald Powell. On May 1st of this year
this patient consulted me, complaining of considerable nasal ob¬
struction, discharge, and deformity of his nose. He stated

145

that on June 15th, 1900, he received a blow on the nose, which
was followed by bleeding.

In November, 1900, he had an attack of influenza, which left
him with much nasal obstruction, and in December he consulted
a specialist, who did not find much the matter in his nose.

In January, 1901, a swelling suddenly appeared on his
septum, which was opened, and contained pus ; a drainage-tube
was put in. From this time his nose began to sink and broaden.

When I saw him last May his nose had sunk in at the
junction of the cartilages and the bones. The nasal bones were
thickened, and the nose widened. The septum was deflected to
the left, was swollen, and had an opening of a sinus, which was
discharging. The upper lateral cartilages had become separated
from the nasal bones.

At the present date he has much improved, the nose is more
natural in shape, not so thick and wide, though the depression
remains. The sinus is closed; there is no discharge, but he
says he sometimes has attacks of epistaxis.

•

The President understood that portions of cartilage had come
away, the result being that the cartilaginous arch had fallen in.

Dr. Fitzgerald Powell said he showed this case as he thought it
would be of interest as a comparison with a somewhat similar case
shown by Dr. Frederick Spicer at the last meeting of the Society. Dr.
Spicer thought that the condition in his case arose from the pressure
of polypi, but the general opinion of the members was that it was due
to abscess of septum, probably arising from traumatism. In the case
now before them the man had received a blow on his nose on June
15th, and as late as seven months afterwards an abscess formed in his
septum, which was opened and drained, and from that time the falling
in of the nose took place from the separation of the cartilages. The
sinus was discharging up to a month ago, but was now healed, some
necrosed cartilage came away, but no bone was observed. The shape
of the nose appeared to be improving.

t

A Case of Chronic Ulcer of the Septum (? Tuberculous).

Shown by Mr. Walter Spencer. This occurred in a girl set.
18, who worked with dusty woollen goods. The ulcer was
situated on the left side of the septum, and had been present for
a year, during which time there had been some healing at its

146

lower part, but some extension upwards. There is now an ulcer
about h cm. in diameter covered by granulations, which easily
bleed. The cartilage is not exposed. She has a ringing cough,
but there is no evidence of lung or laryngeal disease, nor have
tubercle bacilli been found with sputa. The treatment applied
has been simple, only alkaline douches and ointments.

Dr. McKenzie Johnston said from the view which he had obtained
there seemed nothing to favour the idea of tuberculosis. He con¬
sidered it of a simple nature, and recommended the application of
chromic acid, and at the same time of some simple ointment to prevent
the secretions from becoming too hard. He had no doubt it would
heal in a short time.

Mr. Parker looked upon the case as one due to dry rhinitis. The
ulcer was situated just at .the spot where excoriation occurred from
dust, etc., impinging on the septum. He did not thiuk there was any
evidence of tubercle.

The President thought there was an absence of evidence of tuber¬
culosis in this case.

Mr. Spencer would apply some chromic acid, and recommend to
the patient the use of a douche.

An Apparatus for Vibratory Massage.

Shown by Dr. A. Hudson. Dr. Hudson considered that this
instrument afforded a useful method of applying vibratory
massage by means of an electromotor. It could be so regu¬
lated that any kind of massage could be employed from the
faintest stroking to the coarsest hammering. Many thousand
vibrations could be obtained a minute, and consequently there
was great power of penetration, as the exhibitor had proved by
experiments with water enclosed in an india-rubber bag. He
had obtained markedly beneficial results in diseases of the eye
and ear, and suggested that it was equally suitable for nose and
throat troubles, especially for bringing about absorption of
inflammatory thickening, and for the stimulation of muscles in
cases of paralysis. He had also found it useful for relieving pain
and inducing sleep.

Dr. Vinrace asked if any motor power could be used to work
the instrument.

Dr. Hudson replied that a continuous current was necessary.

147

Three Cases of Bilateral Abductor Paralysis in Tabes

Dorsalis.

Shown by Sir Felix Semon. (The notes of these cases were
very kindly prepared for the demonstration by Dr. M. Douglas
Singer, Senior House Physician to the National Hospital for
Paralysis and Epilepsy, Queen Square, Bloomsbury, of which
the three patients were then inmates.)

Case I.—G. B—, toy-maker, aet.51 (under Sir William Gowers).
Syphilis twenty-five years ago. No secondary symptoms.

Present illness began three or four years ago with pains and
pins-and-needles in legs and feet, and some difficulty in walking.
Quite from the beginning he had “ choking attacks ” at night.
Stridor at night first noticed about three years ago, and during
last three months has been present also in the daytime if he
exerts himself at all. Has also had transient diplopia and a
girdle sensation. Hesitant micturition for two years. No in¬
continence.

Status, April 26th, 1901.—Pupils R. > L., Argyll-Robertson
type. Partial bilateral ptosis. All deep reflexes absent. Super¬
ficial reflexes brisk. Marked ataxia of legs. Well-marked
Rombergism. Well-marked analgesia of trunk, ulnar borders
of arms and legs.

Larynx, May 3rd.—Marked double abductor paralysis, almost
complete. The left cord is a little better abducted than the
right, but even then the maximum width of the glottis in inspi¬
ration is only 1| to 2 mm. Subjective and objective dyspnoea
is considerable.

4th.—Tracheotomy performed by Mr. Ballance.

31st.—The glottis is a little wider than it was four weeks ago
during inspiration.

In remarking on this case. Sir Felix Semon said he wished to
draw particular attention to the fact that since the performance
of tracheotomy, the inspiratory inward movement of the vocal
cords had ceased. This fact was held to be important in
connection with the question whether such inspiratory inward
movements were due to a purely mechanical cause, viz. to the

148

rarefication of the air below the stenosis during inspiration—a
view held by the older laryngologists, and by the speaker,—or
whether it represented an active inward movement of the vocal
cords due to the fact that during respiration both abductors and
adductors were simultaneously innervated, and that the ab¬
ductors having been paralysed, the innervation of the adductors
alone prevailed. This view had been advocated by Rosenbach,
Burger, and pthers. If it were correct, one would naturally
expect the inspiratory movement to continue even after the
performance of tracheotomy. The disappearance of the move¬
ment in the present case was held to point strongly in favour of
the mechanical theory.

Case II.—C. L—, barman, aet. 32 (under Dr. Bastian).
Syphilis fourteen years ago. Temperate in alcohol, non-smoker.

Present illness began three years ago with a heavy feeling in
his feet and sudden giving way at the knees. Soon after he began
to have lightning pains. Two years ago he was told that he
snored very much at nights, a thing which previously he did not
do ; this snoring has continued ever since. Sixteen months ago
began to have difficulty in walking, which has steadily increased.
About five months ago first had choking attacks at night, and
on one occasion lost consciousness in one of these attacks. No
bladder trouble.

Status, May 13th.—Pupils small, R. > L., Argyll-Robertson
type. Knee and Achilles jerks absent. Elbow and wrist jerks
diminished. Superficial reflexes brisk. Marked ataxia of legs,
with extreme Rombergism. Some analgesia of legs.

Larynx, May 31st.—The larynx shows abductor paralysis on
both sides with paresis of the internal thyro-arytenoid and the
inter-arytenoid muscles. The glottis in front on deep inspiration
forms a small ellipse, the vocal processes of the arytenoid carti¬
lages almost touch one another; behind them a comparatively
large triangular gap remains.

Case III.—T. W—, smith’s labourer, set. 30 (under Dr. Bas¬
tian). Father of patient died of “ religious mania.” Syphilis
fourteen years ago. No secondary symptoms.

Present illness began with gastric and rectal crises two and a

149

half years ago, and have recurred at intervals ever since. Ten
months ago began to have also difficulty in walking and light¬
ning pains. About the same time first had choking attacks at
night, and soon after noticed a change in his voice. Has had
also girdle sensation and precipitate micturition.

Status, March 1st.—Pupils L. > R., Argyll-Robertson type.
Double ptosis. Knee jerks absent. Slight ataxy and Romberg-
ism. Analgesia of ulnar borders of arms and of lower part
of trunk.

Larynx, March 8th.—Considerable bilateral and asymmetrical
abductor paralysis with slight paresis of the internal tensprs.
On phonation the cords come promptly together, and only a
very small elliptic gap remains in the middle part of the glottis.
On deep quiet inspiration the cords are never separated more
than about 2J mm. in the broadest part of the glottis; their
inner borders are slightly excavated, and a small triangular gap
remains in the cartilaginous part of the glottis. The speaking
voice has a slightly forced mournful character. Patient states
that he has lost several notes in the upper register.

The President remarked on the great interest of these cases, but
at such a late hour of the meeting he thought it would be impossible
to enter upon a full discussion of the subject. The case in which
tracheotomy had been performed was, he thought, of especial interest.

Dr. Fitzgerald Powell asked Sir Felix Semon when in his
opinion it was necessary to perform tracheotomy in such cases.

Mr. Waggett asked what Sir Felix thought of the plan of early
tracheotomy in such cases as these, the ordinary cannula being replaced
by a solid plug. This measure would relieve the patient of danger
from sudden and fatal dyspnoea, while at the same time avoiding tbe
disadvantages of permanent respiration through a cannula.

Sir Felix Semon said that at this late hour it was impossible to
fully enter upon the discussion of the points which had been raised by
the various speakers. With regard to Dr. Fitzgerald Powell’s ques¬
tion, he wished to say that this subject had been discussed quite
recently in the Society, when he had stated the principles which now
guided his action as to the performance of tracheotomy in cases of
bilateral abductor paralysis in tabes. It was a very difficult question
indeed, and the decision must be made dependent upon the degree of
stenosis, and the question of serious choking fits supervening, whilst
a full explanation of the situation ought to be given to the patient,
and the decision in doubtful cases be left to him. The occurrence of
paralysis of the interarytenoid muscle, which as a rule followed the
original abductor paralysis somewhat later than the paralysis of the
internal tensors, was a blessing in disguise to the patient, as the greater

150

opening of the glottis resulting from this paralysis greatly diminished
the danger of suffocation. As to the permanent wearing of a tube,
he thought that the dangers and discomforts it was said to entail were
more theoretical than real. He had a patient, a stockbroker, on whom
he had performed tracheotomy twenty-one years ago for bilateral
abductor paralysis, who was fully able, whilst still wearing his tube,
to follow his occupation, and he had never suffered from bronchial
or pulmonary affections.

INDEX.

PAGE

Abductor paralysis, bilateral (J. B. Ball, M.D.) .64

--in tabes dorsalis (Sir F. Semon, M.D.) . 147

Address to His Majesty the King . . . .67

Adenoid growth: cheesy mass found in adenoid growth after removal

(R. McKenzie Johnson, M.D.) .... 143

Aneurysm of aorta: paralysis of left vocal cord only physical sign

during life (J. Donelan, M.B.) .... 144

Angiofibroma (recurrent) involving ventricular bands and vocal cords

(E. Furniss Potter, M.D.) . . . . .61

Antrum, epithelioma, alveolar (J. Dundas Grant, M.D.) . . 7

--(microscopic specimen shown by V. Wyatt

Wingrave for J. Dundas Grant, M.D.) . . .11

- right maxillary, empyema, with fixation of left vocal cord

(J. Dundas Grant, M.D.) . . . . .98

- suppuration, with dissension of inner antral wall (H. Tilley,

M.D.) . . . . . . .113

Aorta: aneurysm; paralysis of left vocal cord only physical sign

during life (J. Donelan, M.B.) .... 144

Baber (E. Cresswell), discussion on the treatment of nasal polypus 26, 43
Ball (J. B., M.D.), case of bilateral abductor paralysis . .64

Baron (J. Barclay, M.B.), case of laryngeal growth in a man set. 49 . 5

- case of large laryngeal growth shown at a previous meeting . 119

Bennett (F. W., M.D.), a laryngeal case for diagnosis . . 102

Bond (J. W., M.D.), discussion on the treatment of nasal polypus . 40

Bridge of nose: see Nose.

Bronner (Adolph, M.D.), cutting trephine for operating on spurs and

deviations of the nasal septum . . . .72

Cadaveric position of left vocal cord in man set. 26 (F. de Havilland

Hall, M.D.) . . . . . .92

Cancer of oesophagus causing complete laryngeal paralysis (W. G.

Spencer) . . . . . . .2

Carson (H. W.), specimen of multiple papillomata of larynx . 130

Cartilage.- separation of upper lateral cartilage of nose (H. Fitzgerald

Powell, M.D.) ., . . . . . 144

Charsley (R.), case of rhinolith (?) in a child . . .115

Cheek: swelling of left cheek and eyelid (H. J. Davis, M.D.) . 60

Cheesy mass found in adenoid growth after removal (R. McKenzie

Johnson, M.D.) ...... 143

Council: list of officers and council, 1901 . . .45

- report of council, 1900 . . . .45

FIRST SERIES—VOL. VIII.

9

152

Cricoid cartilage : thickening over cricoid in case of chronic laryngitis
(H. B. Robinson) ......

Curette in removal of post-nasal growths “en masse” (H. J. Davis,
M.D.) .......

Cyst, dermoid, (P) specimen of (Fitzgerald Powell, M.D.)

- in floor of nose: drawing (R. Lake)

-of thyroid (L. H. Pegler, M.D.) . . . .

- retention cysts of lymphoid follicles of vallecula (H. B.

Robinson) ......

-serous, of inferior turbinated and floor of nose (H. J. Davis,

M.D.) .

Davis (Henry J., M.D.), bilateral webbing of the fauces

- case of enlarged thyroid cured by iodide of potassium

- a case of swelling of left cheek and eyelid .

- case of serous cyst of inferior turbinated and floor of the nose .

- case of extreme elongation of uvula

- - ■ specimens of post-nasal growths removed “ en masse ” with a

curette .......

Deformity in case of nasal polypi (J. Donelan, M.B.)

Dermoid: specimen of cyst (P dermoid) (Fitzgerald Powell, M.D.)
Diagnosis, cases for: laryngeal case (W. Permewan, M.D.) .
-(F. W. Bennett, M.D.)

- -laryngeal case for diagnosis (P tubercular) (StClair

Thomson, M.D.) ......

-laryngeal neoplasm on posterior wall accompanied by

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

-laryngitis with marked subglottic hyperplasia below

anterior commissure (Scanes Spicer, M.D.)

ulceration of tip of tongue in man set. 62 (Atwood

Thome)

specimens for diagnosis:

larynx (Logan Turner)

Diphthena (laryngeal) specimen of larynx from case of primary laryn¬
geal diphtheria (Logan Turner) ....
Donelan (James, M.B.), discussion on the treatment of nasal polypus

- a case of nasal polypi with marked deformity

- a fatal case of exophthalmic goitre

- sketch of an aneurism of the aorta in which paralysis of the

left vocal cord was the only physical sign during life

Empyema of right maxillary antrum with fixation of left vocal cord
(J. Dundas Grant, M.D.) .....

- of frontal sinus, chronic, cured by Kuhnt’s radical operation

(H. Tilley, M.D.) ......

Epithelioma of maxillary antrum and nose, alveolar (microscopic
specimen shown by V. Wyatt Wingrave for J. Dundas Grant,
If.b.) .......

—-alveolar, of ethmoidal cells and antrum (J. Dundas Grant, M.D.)

-- of larynx (W. Jobson Home, M.B.)

-removed from left vocal cord by endolaryngeal opera¬
tion in 1886 and 1887; no recurrence (T. Mark Hovell) .

■ - . - squamous (microscopic specimen shown by V. Wyatt

Wingrave for J. Dundas Grant, M.D.) . .

——- - ■ ■ - supposed (J. Dundas Grant, M.D., and V. Wyatt Win¬
grave, M.D.) ......

-- of tonsil and glands in neck: operation; recovery (H. Lambert

Lack, M.D.) ......

-with extensive glandular involvement in a middle-aged

man (J. Dundas Grant, M.D.) .

PAGE

89

97

66

111

114

89

74

56

58

60

74

96

97
68
66

100

102

12

106

107

132

108

108

33

68

69

144 '

98

62

11

7

109

120

11

85

55

81

153

Ethmoid cells: cutting forceps for (P. Watson Williams, M.D.)

-alveolar, epithelioma of (J. Dundas Grant, M.D.)

Eyelid: swelling of left oheek and eyelid (H. J. Davis, M.D.)

Fauces : congenital fenestration of faucial pillars (P. Watson Williams,
M.D.) .

-congenital symmetrical gaps in both anterior pillars of the

fauces with complete absence of the tonsils (Sir F. Semon, M.D.)

- ? sarcoma (H. B. Robinson) ....

- webbing, bilateral (H. J. Davis, M.D.)

Fenestration, congenital, of faucial pillars (P. Watson Williams, M.D.)

Ferret causing destruction of nose (W. J. Walsham)

Fixation of left vocal cord with empyema of right maxillary antrum
(J. Dundas Grant, M.D.) .....

Follicles, lymphoid, of vallecula: see Vallecula.

Forceps : ethmoidal cell-cutting forceps (P. Watson Williams, M.D.)

- Jurasz’s punch forceps in removal of microscopical portion of

vocal cord (J. Dundas Grant, M.D.) ....

Fracture of larynx (E. B. Waggett) ....

Frontal sinus: see Sinus (frontal).

Genio-hyoglossus (right), paralysis of (F. de Havilland Hall, M.D.) .
Glands in neck, epithelioma of (H. Lambert Lack, M.D.)

Glandular involvement, extensive, in case of epithelioma of tonsil (J.
Dundas Grant, M.D.) .....

Glegg (Dr.), case of total extirpation of the larynx (shown for Mr.
F. G. Harvey) ......

Glottis, spasm of (J. Dundas Grant, M.D., and Mr. Mackintosh)
Goitre, exophthalmic, fatal case (J. Donelan, M.B.).

Grant (J. Dundas, M.D.), case of probable primary specific ulceration
of the tonsil ......

-case of alveolar epithelioma of the ethmoidal cells and antrum

- case of sarcoma of thyroid gland; extirpation, fatal result

- case of malignant disease of the larynx

- (1) squamous epithelioma of larynx; (2) alveolar epithelioma

of maxillary antrum and nose; (3) sarcoma of thyroid gland
(microscopic specimens shown by V. Wyatt Wingrave) .

-- discussion on the treatment of nasal polypus

-case of epithelioma of tonsil with extensive glandular involve¬
ment in a middle-aged man .....

- microscopical portion of vocal cord removed by means of

Jurasz’s punch forceps from the vocal cord of a gentleman set. 61.

- case of fixation of the left vocal cord and empyema of the right

maxillary antrum ......

-case of lupus of the septum and widening of the dorsum of the

nose in a young girl .

- case of pachydermia of the vocal processes in a middle-aged

man .......

■ - - case of specific perforation of the palate and ulceration of the

larynx, of tuberculous appearance, in a middle-aged woman

- a case of tumour of the base of the tongue in a young female .

- and Mackintosh (Mr.), case of glottic spaBm in a young woman

rot. 24

-and Wingrave (V. Wyatt), case of supposed epithelioma of

the larynx ......

Growth, innocent, on right vocal cord (G. William Hill, M.D.)

-laryngeal (J. Barclay Baron, M.B.)

- - in man at. 49 (Barclay Baron, M.B.)

PAGE

6

7

60

68

73

91

56

98

109

98

6

81

13

92

55

81

95

82

69

6

7

9

10

11

39

81

81

98

117

117

117

131

82

85

83

119

5

154

PAGE

Growth (post-nasal), specimens of post-nasal growths removed “en

masse” with a curette (H. J. Davis, M.D.) . . .97

-of right (vocal) cord in a man set. 35 (W. H. Kelson) . 63

Haematoma, bilateral, of septum following progressive sinking of

bridge of nose (W. G. Spencer) . . . .3

Haemorrhage of vocal cords (C. A. Parker) .. . .14

- submucous, of soft palate (P. E. W. de Santi) . . 97

Hall (P. de Havilland, M.D.), discussion on the treatment of nasal

polypus . . . . . . .41

- case of a male aet. 26 with the left vocal cord in the cadaveric

position, right facial palsy and paralysis of the right genio-
hyoglossus and the left half of the soft palate . . .92

- case of ulceration of the larynx (? tuberculous) in a male

set. 48 ....... 135

Harvey (F. G.), case of total extirpation of the larynx (shown by Dr.

Glegg) . . . . . . .95

Hill (G. William, M.D.), discussion on the treatment of nasal

polypus . . . . . . .38

- case of innocent growth on the right vocal cord . . 83

Horne (W. Jobson, M.B.), case of malignant disease of the tonsil . 94

-a case of epithelioma of the larynx . . . 109

Hovell (T. Mark), a man set. 61, from whose left vocal cord a large
epithelioma was removed by endolaryngeal operation in 1886, and
again in 1887, since which there has been no recurrence . . 120

Hudson (A.), an apparatus for vibratory massage . . . 146

Hyperplasia, subglottic, below anterior commissure (Scanes Spicer,

M.D.) . . . . . . .107

Infiltration of vocal cord (right) (StClair Thomson, M.D.) . . 105

——— on left cord in a man set. 28 (Fumiss Potter, M.D.) . . 141

Iodide of potassium curing enlarged thyroid (H. J. Davis, M.D.) . 58

Johnson (E. G.), lupus of the larynx (shown for Mr. E. Lake) . 64

Johnston (E. McKenzie, M.D.), specimen from a case of sarcoma of

the tonsil, with microscopic slide .... 142

- specimen of a cheesy mass found in an adenoid growth after

removal ....... 143

Jurasz’s punch forceps in removal of microscopical portion of vocal

cord (J. Dundas Grant, M.D.) . . . .81

Kelson (W. H.), growth of right cord in a man set. 35 (patient and

specimen) . . . . . .63

King (The) : Loyal Address to His Majesty the King . . 67

Kuhnt’s radical operation in treatment of chronic frontal sinus; opera¬
tion (H. Tilley. M.D.) . . . . .52

Lack (H. Lambert, M.D.), discussion on the treatment of nasal

polypus . . . , . . 18,41

- case of epithelioma of the tonsil and glands in the neck;

operation; recovery . . . . ,55

- case of mucocele of the frontal sinuses , . .75

- case of persistently recurring nasal polypus with suppuration

in frontal and ethmoidal sinuses; operation; result . . 77

- case of unusual tumour on the posterior wall of the larynx . 116

- case of unusual laryngo-pharyngeal tumour in a woman with

microscopic specimen of growth removed . . .128

- specimen of bony occlusion of one nostril . , 130

155

PAGE

Lake (Richard), lupus of the larynx (shown by Mr. R. G. Johnson) . 64

- drawings of (1) cyst in the floor of the nose, (2) pachydermia

laryngis (tubercular) . . . . .Ill

Laryngitis, chronic, with thickening over the cricoid posteriorly (H. B.

Robinson) . . . . . .89

- with ulcer on one vocal cord (StC. Thomson) . . 104

- with marked subglottic hyperplasia below anterior commissure

(Scanes Spicer, M.D.) ..... 107

Larynx: clonic spasm (Sir F. Semon, M.D.) . . .49

-epithelioma (W. Jobson Home, M.B.) . . . 109

--- removed from left vocal cord by endolaryngeal opera¬
tion in 1886 and 1887; no recurrence (T. Mark Hovell) . . 120

-supposed (J. Dundas Grant, M.D., and Y. Wyatt Win-

grave) . . . . . . .85

-squamous (microscopic specimen shown by V. Wyatt

Wingrave for J. Dundas Grant, M.D.) . . .11

- extirpation, total (case shown by Dr. Glegg for Mr. F. G.

Harvey) . . . . . . .95

- fracture (E. B. Waggett) . . . .13

- growth in man set. 49 (J. Barclay Baron, M.B.) . . 5

- growth of (J. Barclay Baron, M.B.) . . .119

- laryngeal case for diagnosis (Atwood Thome) . 84

-(F.W. Bennett, M.D.) .... 102

-(W. Permewan, M.D.) .... 100

- malignant disease (J. Dundas Grant, M.D.) . . 10

-(extrinsic) of left side (L. H. Pegler, M.D.) . . 94

-treated by thyrotomy and removal of diseased area

(Sir F. Semon, M.D.) . . . . .87

-growth (StC. Thomson, M.D.) . . . 136

- neoplasm occurring on posterior wall (Scanes Spicer, M.D.) . 106

- pachydermia laryngis (C. A. Parker) . . 130

-(tawing of (R. Lake) . . .111

- papillomata, multiple (H. W. Carson) . . . 130

-(Y. Wyatt Wingrave) . . . .11

-removed from larynx by endolaryngeal method

(H. Tilley, M.D.) . . . . . .80

-paralysis, complete, caused by cancer of oesophagus (W. G.

Spencer) . ... . . .2

- polypus, mucous (W. R. H. Stewart) . . .2

- specimen for diagnosis (Logan Turner) . . . 108

-from case of primary laryngeal diphtheria (Logan

Turner) ....... 108

-tubercle of (FitzGerald Powell, M.D.) . . , 110

- tuberculosis of: laryngeal case for diagnosis (? tubercular)

(StClair Thomson, M.D.) . . . . .12

- tumour of (H. Tilley, M.D.) . . . .6

-unusual, on posterior wall (H. Lambert Lack, M.D.) 116, 128

- ulceration, of tuberculous appearance (J. Dundas Grant, M.D.) 117

--(? tuberculous) (F. de Havilland Hall, M.D.) . 135

- swelling on leg in patient with tumour of right vocal cord

(W. G. Spencer) ..... 99,103

Librarian: report of librarian, 1900 . . . .47

Lupus of septum of nose (J. Dundas Grant, M.D.) . . . 117

Mackintosh (Mr.) and Grant (J. Dundas, M.D.), case of glottic spasm

in a young woman set. 24 . . . .82

Malignant disease of larynx (J. Dundas Grant, M.D.) . . 10

-treated by thyrotomy and removal of diseased

area (Sir F. Semon, M.D.) . . . . .87

-(extrinsic) of larynx (L. H. Pegler, M.D.) . . 94

9 §

156

PAGE

Malignant disease of tonsil (W. Jobson Horne, M.B.) . . 94

-of vocal cords, thyrotomy for (H. Tilley, M.D.) . 141

- growth in larynx (StClair Thomson, M.D.) . . .136

Massage, vibratory, apparatus for (A. Hudson) . . . 146

Mucocele of the frontal sinuses (H. Lambert Lack, M.D.) . .75

Mucous patch on the tonsil (V. Wyatt Wingrave) . . .71

Neck: epithelioma of tonsil and glands in neck; operation; recovery

(H. Lambert Lack, M.D.) . . . . .55

Nose: absorption of cartilaginous septum due to pressure from nasal

polypi (F. Spicer, M.D.) ..... 127

- cutting trephine for operating on spurs and deviations of the

nasal septum (A. Bronner, M.D.) . . . .72

- cyst in floor of: drawing (R. Lake) . . . Ill

-serous, of inferior turbinated and floor of nose (H. J.

Davis, M.D.) . . . . . *74

- destruction caused by a ferret (W. J. Walsham) . . 109

- epithelioma, alveolar (microscopic specimen shown by V. Wyatt

Wingrave for J. Dundas Grant, M.D.) . . .11

- growth (post-nasal) removed " en masse ” with a curette (H. J.

Davis, M.D.) . . . . . .97

-lupus of septum and widening of dorsum (J. Dundas Grant,

M.D.) . . . . . . .117

- (obstruction), extreme deflection of septum to right side

causing almost complete unilateral obstruction (L. H. Pegler,
M.D.) . . . . . .93

- papillomata, intra-nasal (V. Wyatt Wingrave) . . Ill

-perforations, recent, of septal cartilage (H. B. Robinson) . 90

- (polypus), nasal polypi, recurring (P. E. W. de Santi) . 62

--with marked deformity (J. Donelan, M.B.) . 68

-nasal polypus, treatment (discussion opened by H.

Lambert Lack, M.D., and E. Cresswell Baber, continued by W. G.
Spencer, C. Parker, J. Donelan, Scanes Spicer, M.D., P. de Santi,

H. Tilley, M.D., StClair Thomson, M.D., Fitzgerald Powell, E. B.
Waggett, William Hill, M.D., Dundas Grant, M.D., J. W. Bond,
M.D., Y. Wyatt Wingrave, F. de Havilland Hall, M.D., H. Lambert

Lack, M.D. (reply), E. Cresswell Baber (Veply) ) . 18—13

- progressive sinking of bridge of nose following bilateral hsema-

toma of septum (W. G. Spencer) . . . .3

- separation of upper lateral cartilage (H. Fitzgerald Powell,

M.D.) . . . . . . .144

-ulcer of septum, chronic (? tuberculous) (W. G. Spencer) . 145

Nostril: bony occlusion, specimen (H. Lambert Lack, M.D.) . . 130

Occlusion, bony, of one nostril, specimen (H. Lambert Lack, M.D.) . 130

(Esophagus, cancer of, causing complete laryngeal paralysis (W. G.

Spencer) . . . . . . .2

Pachydermia laryngis (C. A. Parker) .... 130

- - drawing (R. Lake) .... Ill

- of vocal processes (J. Dundas Grant, M.D.) . . . 117

Palate : clonic spasm (Sir F. Semon, M.D.) . . .49

- perforation, specific (J. Dundas Grant, M.D.) . .117

- (soft), haemorrhage, submucous (P. E. W. de Santi) . . 97

-paralysis of left half (F. de Havilland Hall, M.D.) . 92

Palsy, right facial (F. de Havilland Hall, M.D.) . . .92

Papilloma (intra-nasal): two chief classes of intra-nasal papillomata

(V. Wyatt Wingrave) ..... Ill

- (laryngeal), multiple papillomata (H. W. Carson) . . 130

- - papillomata of larynx (V. Wyatt Wingrave) . . 11

157

PAGE

Papilloma (laryngeal): papillomata removed from larynx by endo-

laryngeal method (H. Tilley, M.D.) . . . .80

Paralysis, abductor, bilateral (J. B. Ball, M.D.) . . .64

-in tabes dorsalis (Sir F. Semon, M.D.) . 147

- of larynx, complete, caused by cancer of oesophagus (W. G.

Spencer) . . . , . . .2

- right facial palsy, paralysis of right genio-hyoglossus and left

half of soft palate (F. de Havilland Hall, M.D.) . . 92

- of vocal cord (left) only physical sign of aneurysm of aorta

during life (J. Donelan, M.B.) .... 144

Paresis of left vocal cord accompanying laryngeal neoplasm on posterior

wall (Scanes Spicer, M.D.) ..... 106

Parker (Charles Arthur), case of haemorrhage of the vocal cords . 14

- discussion on the treatment of nasal polypus . .31

- case of pachydermia laryngis .... 130

Pegler (L. H., M.D.), case of extreme deflection of septum to right

side, causing almost complete unilateral obstruction, in a male set. 20 93

- case of malignant disease (extrinsic) of the left side of the

larynx in a male set. 56 . . . .94

- case of cyst of the thyroid . . . .114

Perforation of palate, specific (J. Dundas Grant, M.D.) . .117

Pbrmewan (W., M.D.), a laryngeal case for diagnosis . . 100

Pharyngomycosis in a female (Atwood Thome) . . .112

Pharynx: clonic spasm (Sir F. Semon, M.D.) . . .49

- tumour, unusual laryngo-pharyngeal (H. Lambert Lack, M.D.) 128

Polypus, mucous, of larynx (W. R. H. Stewart) . . .2

- (nasal): case of nasal polypi with marked deformity (J.

Donelan, M.B.) . . . . . .68

- - persistently recurring, with suppuration in frontal and

ethmoidal sinuses (H. Lambert Lack, M.D.) . . .77

-pressure from nasal polypi causing absorption of car¬
tilaginous septum (F. Spicer, M.D.) . . . 127

-*- recurring nasal polypi (P. R. W. de Santi) . . 62

-treatment (discussion opened by H. Lambert Lack, M.D.,

and E. Cresswell Baber; continued by W. G. Spencer, C. Parker,

J. Donelan, Scanes Spicer, M.D., P. de Santi, H. Tilley, M.D.,
StClair Thomson, M.D., Fitzgerald Powell, E. B. Waggett,
William Hill, M.D., Dundas Grant, M.D., J, W. Bond, M.D., V.
Wyatt Wingrave, F. de Havilland Hall, M.D., H, Lambert Lack,

M.D. (reply), E. Cresswell Baber (reply) ) . . 18—43

Potassium, iodide of: see Iodide of potassium.

Potter (E. Fumiss, M.D.), recurrent angiofibroma involving ventricu¬
lar bands and vocal cords . . . . .61

- case of infiltration on left cord in a man set. 28 . . 141

Powell (H. Fitzgerald), discussion on the treatment of nasal polypus 37

- specimen of cyst (P dermoid) . . . .66

-case of tubercle of the larynx in a man aet. 18 . .110

-- case of separation of the upper lateral cartilage of the nose

in a male set. 25 . . . . . . 144

Rhinolith (?) in a child (R. Charsley) .... 115

Robinson (H. Betham), case of chronic laryngitis with thickening

over the cricoid posteriorly . . . . .89

- specimen of retention cyst of the lymphoid follicles of the

vallecula. . . . . . .89

- two cases of recent perforation of the septal cartilage . 90

- a case of (?) sarcoma of tongue and fauces . . .91

de Santi (Philip R. W.), discussion on the treatment of nasal polypus 35
-recurring nasal polypi . . . .62

158

PAGE

de Santi (Philip E. W.), a case of submucous haemorrhage of soft palate 97
Sarcoma of thyroid gland; extirpation; fatal result (J. Dundas Grant,

M.D.) . . . . . . .9

-(microscopic specimen shown by V. Wyatt Wingrave

for J. Dundas Grant, M.D.) . . # .11

- of tongue and fauces (H. Betham Eobinson) . . 91

- of tonsil; specimen with microscopic slide (E. McKenzie John¬
son, M.D.) . . . . .142

Semon (Sir Felix, M.D.), clonic spasm of palate, pharynx, and larynx

in a woman aet. 30 . . . . . .49

-congenital symmetrical gaps in both anterior pillars of

the fauces with complete absence of the tonsils . .73

-a case of malignant disease of the larynx in a man

aet. 47, treated by thyrotomy and removal of the diseased area,
shown seven months after operation . . . .87

-three cases of bilateral abductor paralysis in tabes

dorsalis ....... 147

Septum: see Nose .

Sinus (ethmoidal), suppuration in case of persistently recurring nasal

polypus (H. Lambert Lack, M.D.) . . . .77

- (frontal), empyema, chronic, cured by Kuhnt's radical operation

(H. Tilley, M.D.) . . . . . .52

-mucocele of the frontal sinuses (H. Lambert Lack,

M.D.) . . . . . . .75

-suppuration fourteen months after external operation

(StC. Thomson, M.D.) ..... 138

-suppuration in case of persistently recurring nasal

polypus (H. Lambert Lack, M.D.) . . . .77

-results of external operation on frontal sinus

(H. Tilley, M.D.) ...... 138

Sinusitis, maxillary (double), ethmoidal, and frontal, cured (StClair

Thomson, M.D.) . . . . . .52

Spasm, clonic, of palate, pharynx, and larynx in a woman set. 30 . 49

- glottic (J. Dundas Grant, M.D., and Mr. Mackintosh) . 82

Spencer (W. G.), specimen of cancer of the oesophagus causing com¬
plete laryngeal paralysis . . . . .2

-case of progressive sinking of the bridge of the nose

following bilateral heematoma of the septum . . .3

-discussion on the treatment of nasal polypus . . 30

-case of tumour of the vocal cord in a boy . . 99

-case of tumour of right vocal cord, with a swelling on

the leg, in a boy ...... 103

-a case of chronic ulcer of the septum (? tuberculous) . 145

Spicer (Frederick, M.D.), female set. 15, with absorption of the cartila¬
ginous septum due to pressure from nasal polypi . . 127

Spicer (E. H. Scanes, M.D.), discussion on the treatment of nasal

polypus . . . . . . .33

- case of laryngeal neoplasm occurring on the posterior wall,

and accompanied by paresis of left vocal cord in a man set. 49;
for diagnosis ...... 106

- a case of laryngitis with marked subglottic hyperplasia

occurring below the anterior commissure in a man set. 36; for
diagnosis....... 107

Stewart (W. E. H.), a case of mucous polypus of the larynx . 2

Suppuration of antrum with distension of inner antral wall (H. Tilley,

M.D.) . . . . . . .113

- of frontal sinus: case fourteen months after operation (StC.

Thomson, M.D.) . . . . # . 138

-results of external operation on frontal sinus (H. Tilley,

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

138

159

TAGS

Suppuration of frontal and ethmoidal sinuses, in case of persistently

recurring nasal polypus (H. Lambert Lack, M.D.) . . 77

Swelling of left cheek and eyelid (H. J. Davis) . . .60

- on leg in patient with tumour of right vocal cord (W. G. Spen¬
cer) ...... 99,103

Syphilis: probable primary specific ulceration of tonsil (J. Dundas

Grant, M.D.) . . . . . .6

- specific perforation of palate and ulceration of larynx of tuber¬
culous appearance in middle-aged woman (J. Dundas Grant, M.D.) 117

Tabes dorsalis, bilateral abductor paralysis in (Sir F. Semon, M.D.) . 147

Thomson (StClair, M.D.), laryngeal case for diagnosis (? tubercular) . 12

-discussion on the treatment of nasal polypus . . 37

- case of cured maxillary (double) ethmoidal and frontal

sinusitis . . . . . . .52

- man set. 33 with chronic laryngitis, and an ulcer on one vocal

cord ....... 104

- case of infiltration of right cord of three months' dura¬
tion in a man set. 40 . . . . . 105

- case of infiltration of the right vocal cord of six months'

duration in a man set. 56 . . . . 105

- a case of frontal sinus suppuration fourteen months after

external operation...... 136

- case of malignant laryngeal growth in a man set. 52 . . 136

Thorne (Atwood) a laryngeal case for diagnosis . . . 84

- a case of pharyngo-mycosis in a female . . . 112

- a case of ulceration of the tip of the tongue in a man set. 52;

for diagnosis ...... 132

Thyroid gland, cyst of (L. H. Pegler, M.D.) . . . 114

-enlarged, cured by iodide of potassium (H. J. Davis,

M.D.) . . . . . . .58

-sarcoma, extirpation, fatal result (J. Dundas Grant,

M.D.) . . . . . .9

-(microscopic specimen shown by Y. Wyatt

Wingrave for J. Dundas Grant) . . . .11

Thyrotomy and removal of diseased area in treatment of malignant

disease of larynx (Sir F. Semon, M.D.) . . .87

- for malignant disease of vocal cords (H. Tilley, M.D.) . 141

Tilley (Herbert, M.D.), case of laryngeal tumour . . .6

- discussion on the treatment of nasal polypus . . 36

- chronic frontal sinus empyema treated by Kuhnt's radical

operation. . . . . . .52

- papillomata removed from larynx by endolaryngeal method . 80

- case of antral suppuration with marked distension of the inner

antral wall ...... 113

- three cases demonstrating the results of external operation on

the frontal sinus ...... 138

-two cases of thyrotomy for malignant disease of vocal cords . 141

Tongue (?) sarcoma (H! Betham Robinson) . . .91

- tumour of base of tongue (J. Dundas Grant, M.D.) . . 131

- ulceration of tip of tongue in man set. 52 (Atwood Thome) . 132

Tonsil: congenital symmetrical gaps in both anterior pillars of the
fauces with complete absence of the tonsils (Sir F. Semon,

M.D.) ....... 73

-epithelioma with extensive glandular involvement in a middle-

aged man (J. Dundas Grant, M.D.) . . . .81

-malignant disease (W. Jobson Home, M.B ) . . 94

- mucous patch on (V. Wyatt Wingrave) . . 71

- sarcoma, specimen with microscopic slide (R. McKenzie Johnson,

M.D.) . . . . . . .142

160

PAGE

Tonsil: ulceration, probable primary specific (J. Dundas Grant, M.D.) . 6

Treasurer, report of, 1900 . . . . . 46

Tubercle of larynx (FitzGerald Powell, M.D.) . . . 110

Tuberculosis of larynx: laryngeal case for diagnosis (P tubercular)

(StC. Thomson, M.D.) . . . . .12

-- ulceration of larynx of tuberculous appearance (J. Dundas

Grant, M D.) ...... 117

Tumour of larynx (H. Tilley, M.D.) . . . .6

- of larynx; unusual tumour on posterior wall (H. Lambert

Lack, M.D.) . . . . .116, 128

- of base of tongue (J. Dundas Grant, M.D.) . . . 131

-— of (right) vocal cord in a boy (W. G. Spencer) . 99, 103

Turbinate bone: serous cyst of inferior turbinated and floor of nose

(H. J. Davis, M.D.) . . . . .74

Turner (Logan), a specimen of a larynx for diagnosis . . 108

-a specimen of a larynx from a case of primary laryngeal

diphtheria ...... 108

Ulcer of septum, chronic (P tuberculous) (W. G. Spencer) . ' . 145

- of vocal cord (left) (StC. Thomson, M.D.) . . . 104

Ulceration of larynx of tuberculous appearance (J. Dundas Grant,

M.D.) . . . . . . .117

- (? tuberculous) (F. de Havilland Hall, M.D.) . 135

-of tip of tongue in man set. 52 (Atwood Thome) . . 132

-- of tonsil, probable primary specific (J. Dundas Grant, M.D.) . 6

Vallecula: retention cysts of lymphoid follicles of vallecula (H. B.

Robinson) . . . . . .89

Ventricular bands involved by recurrent angiofibroma (E. Furaiss

Potter, M.D.) . . . . . .61

Vocal cord: haemorrhage of vocal cords (C. A. Parker) . . 14

-thyrotomy for malignant disease of vocal cords (H.

Tilley, M.D.) . . . . . .141

-vocal cords involved by recurrent angiofibroma (E. Fur-

niss Potter, M.D.) . . . . . .61

-(left) epithelioma removed from, by endolaryngeal

operation in 1886 and 1887; no recurrence (T. Mark Hovell) . 120
- --fixation, with empyema of right maxillary an¬
trum (J. Dundas Grant, M.D.) . . . .98

-in cadaveric position (F. de Havilland Hall,

M.D.) . . . . . . .92

--infiltration on (Fumiss Potter, M.D.) . 141

-microscopical portion of, removed by Jurasz’s

punch forceps (J. Dundas Grant, M.D.) . . .81

-paralysis of, only physical sign of case of aneu¬
rysm of aorta during life (J. Donelan, M.B.) . . . 144

- - - paresis of, accompanying laryngeal neoplasm on

posterior wall (Scanes Spicer, M.D.) .... 106

-ulcer (StC. Thomson, M.D.) . . . 104

-- (right) growth in man ffit. 35 (W. H. Kelson) . 63

-- innocent, on (G. William Hill, M.D.) . 83

-infiltration (StC. Thomson, M.D.) . . 105

—— -tumour (W. G. Spencer) . . 99, 103

Vocal processes, pachydermia of (J. Dundas Grant, M.D.) . . 117

Waggett (E. B.), case of fracture of the larynx . . .13

-discussion on the treatment of nasal polypus . . 38

Walsham (W. J.) : a case of destruction of the nose caused by a ferret 109
Webbing of fauces, bilateral (H. J. Davis, M.D.) . . .56

161

PAGE

Williams (P. Watson, M.D.), ethmoidal cell-cutting forceps . 6

- drawing of congenital fenestration of the faucial pillars . 98

Winobaye (V. Wyatt): case of laryngeal papillomata . .11

- 1. squamous epithelioma of larynx. 2. Alveolar epithelioma

of maxillary antrum and nose. 3. Sarcoma of the thyroid gland
(microscopic specimen shown for J. Dundas Grant, M.D.) . 11

-- discussion on the treatment of nasal polypus . . 40

- specimen of mucous patch on the tonsil . . .71

- specimens from recent cases illustrating the two chief classes

of intra-nasal papillomata . . . .111

- and Grant (J. Dundas, M.D.) case of supposed epithelioma of

the larynx . . . . .85

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

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY

OF

LONDON.

VOL. IX.

1901 — 1902 .

WITH

LIST OF OFFICERS, MEMBERS, ETC.

LONDON:

PRINTED BY ADLARD AND SON,

BARTHOLOMEW CLOSE, E.C.

1902 .

OFFICERS AND COUNCIL

✓

OF THB

Ifarpgoltigital JSotiet]) of ^Unbon

ELECTED AT

THE ANNUAL GENERAL MEETING,

JANUARY 10th, 1902.

^rtsibmi.

E. CRESSWELL BABER, M.B.

Dite-|)Mgibint6.

E. CLIFFORD BEALE, M.B., F.R.C.P. F. W. BENNETT, M.D.

DUNDAS GRANT, M.D.

ftreasttrtr.

WILLIAM STEWART, F.R.C.S. (Edin.).

librarian.

StCLAIR THOMSON, M.D., F.R.C.S.

Srcrttarits.

CHARLES A. PARKER, F.R.C.S. (Ed.). JAMES DONELAN, M.B.

ComuiJ.

F. DE HAVILLAND HALL, M.D., F.R.C.P. RICHARD LAKE, F.R.C.S.
SIR FELIX SEMON, M.D., F.R.C.P. ERNEST WAGGETT, M.B.

H. LAMBERT LACK, M.D., F.R.C.S. J. BARCLAY BARON, M.B.

PRESIDENTS OF THE SOCIETY

ELECTED

1893

1894-6

1897-8

1899-1900

{From its Foundation.)

Sir George Johnson, M.D., F.R.S.

Sir Felix Semon, M.D., F.R.C.P.

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

F. de Havilland Hall, M.D., F.R.C.P.

1901-2

E. Cresswell Baber, M.B.

i

PROCEEDINGS

OP THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Sixty-eighth Ordinary Meeting, November let , 1901.
E. Cresswell Baber, M.B., President, in the Chair.

Ernest Waggett, M.B.,

Charles A. Parker, F.R.C.S.(Ed.),

| Secretaries.

Present—46 members and 2 visitors.

The minutes of the preceding meeting were read and con¬
firmed.

>

The following report of the Morbid Growths Committee was
read:

Mr. Lake’s specimen of laryngeal growth (Slide No. 20), see
‘Proceedings/ March, 1900, page 71. The section presented
shows the structure of a glandular carcinoma.

Dr. Potter’s case of growth in the region of the left tonsil
(Slide No. 21), see ‘Proceedings,’ May, 1900, page 114. The
section submitted for examination shows the structure of a large
round-celled sarcoma.

Mr. 1 Mark Hovell’s case of laryngeal growth (Slides 22, 23,
and 24), see ‘ Proceedings,’ May, 1901, page 120. Fresh sections
were cut by Dr. Horne from fragments removed in 1886 (Slides
first series—VOL. ix. 1

2

22 and 23) and 1887 (Slide 24). The Committee are of opinion
that the histological structure of the specimens submitted to
them is that of a benign papilloma.

Dr. Lambert Lack’s case of laryngeal tumour (Slide 25), see
‘Proceedings,’ May, 1901, page 128. The Committee consider
the case to be one of mixed cell sarcoma.

The following cases, specimens, and drawings were shown:

Case op Tertiary Syphilitic Laryngeal Stenosis treated by
Laryngofissure without Tracheotomy (Re-exhibited).

Shown by Mr. W. Gr. Spencer. The patient, a potter, was
operated upon in March, 1899, for severe dyspnoea, not relieved
by large doses of iodide of potassium and mercury.

Tough, irregular masses of inflammatory sclerosed tissue
covered the ventricular bands and partly the vocal cords, which,
however, moved fairly, and the cartilaginous framework was
not involved. Much of the obstructing tissue was excised,
including part of the right vocal cord. The patient has
remained well and at work, breathing freely as well by night
as by day. He has a hoarse but thoroughly audible voice.
The inflammatory hypertrophy of the cord on one side now
crosses the middle line so as to meet the remaining portion of
the excised cord. When exhibited, soon after recovery, the
opinion of the meeting was strongly in favour of tracheotomy
for such cases, and it was thought that this patient would soon
require it (see vol. vii, page 62).

The case shows that tracheotomy is not always best, but that
in selected cases, especially where the cartilages are not
involved, success is to be obtained by thyrotomy and excision.

The President congratulated Mr. Spencer on the successful result
obtained, for there was no contraction of the wound in this case. The
man had a very fair amount of voice and was certainly more comfort¬
able than he would have been if he had had tracheotomy performed.

Mr. P. de Santi said the case he had intended to show was of the
same nature as Mr. Spencer’s but was one where tracheotomy had
been performed, and the man’s life was a burden to him. He
was unable to do any work, and ready to have any operation whatever

3

done bo long as lie could get rid of the inconvenience caused by the
tracheotomy tube. If tracheotomy could have been avoided with a
result equally as good as in Mr. Spencer’s case, it would have been a
great advantage to the patient.

Dr. Herbert Tilley said that the case referred to by Mr. de Santi
had recently been operated on by the speaker at the Golden Square
Hospital. The patient was very anxious to dispense with the tube,
and laryngoscopic appearances seemed to indicate that if the left
ventricular band and vocal cord were removed sufficient room would
be provided for natural respiration. Thyrotomy was performed, but
it was found that the cicatricial tissue extended below the larynx and
was particularly marked in the cricoid region. Hence little good
could be expected from removal of the left vocal cord and ventricular
band.

Mr. W. G. Spencer said the Germans had been trying grafting
skin and turning the flap in as a means of checking the stenosis.
Perhaps Dr. Tilley and other members would try this flap method.
It had apparently been attended with some suocess, especially as
regards getting rid of the tracheotomy tube.

An account of some cases in which this operation had been per¬
formed would be found in the Centralblatt fur Chirurgie.

A Series of Specimens, Photographs, and Drawings, illus¬
trating the Inflammatory Diseases of the Nasal Foss.®
and Accessory Cavities.

Shown by Mr. F. Westmacott. One dry preparation showed
a marked frontal projection of the anterior ethmoidal cell.
Another a very large sphenoidal cavity coming far forwards
and with very thin walls.

Several photographs and drawings taken from specimens in
ZuckerkandePs Museum in Vienna presented some abnor¬
malities in size of Highmore’s cavity and of the ethmoidal and
frontal sinuses, and also hypertrophies of mucous membrane in
the nasal fossae.

Two Molar Teeth showing Healthy Crowns, but Evidences
of Caries in the Palatal Root—in each case there

EXISTED AN EMPYEMA OF THE CORRESPONDING ANTRUM.

Shown by Dr. Herbert Tilley, who pointed out that although
the crown of a tooth might appear healthy it did not prove

4

that the roots were not diseased and the cause of antral
suppuration; hence in a given case of antral suppuration the
healthy aspect of the corresponding molar teeth should not at
once lead to the inference that such an empyema was due to
intra-nasal causes. If the patient experienced pain or dis¬
comfort in a tooth, which was coincident with an increase of
the antral symptoms, such a tooth should be regarded with
suspicion, no matter how healthy its crown might appear.

In one of the cases referred to, the abscess around the
palatal root had free access to the antrum; in the second, a
small abscess was situated in the recess at the root of
the fangs.

Mr. Parker asked Dr. Tilley whether there were any signs of
pyorrhoea alveolaris, because otherwise he did not see how caries and
suppuration could occur at the roots of the teeth, unless it was
secondary to the sinus disease. The only conditions which could
account for it would be either ordinary caries proceeding from without
inwards, or else pyorrhoea, and if there was no pyorrhoea in these
cases he should look upon the caries of the fangs as being secondary
to, rather than the cause of, the sinus suppuration.

Mr. Waggett wished to say in contradistinction to the previous
speaker that Tomes, in his ‘ Dental Surgery ’ (Ed. iv, page 389), points
out that one may meet with necrosis of the pulp without any external
wound of the tooth whatever, an abscess forming from pus escaping
through the apex of the fang.

Mr. Nourse was of opinion that there was a small area of caries on
the crown of one of the teeth.

Mr. Westmacott said that this question of an apparently sound
tooth with an abscess at the root had recently come under his con¬
sideration in the case of a doctor, who had, when he first saw him,
antral suppuration on the right side. Apparently the set of teeth on
that side was perfect. He noticed a symptom which to him was new,
and he had not found any confirmation of it elsewhere. By trans¬
illumination with a strong lamp in the right side of the mouth, the
first molar was opaque, the other teeth being perfectly transparent.
From the experience of a previous case he came to the conclusion that
the first molar was “ dead,” and advised its removal. An abscess
was found at the apex of the palatine root leading into the antrum,
and which was apparently the cause of the empyema. The same
thing had, within the past month, been again brought to his notice in
the case of a gentleman who applied to him with marked irritation at
the front of the hard palate. Nothing could be found to account for
this until, by means of trans-illumination, it was discovered that the
right central incisor was opaque. On removing it, an abscess was
found at the root of the tooth. After extraction all the symptoms
disappeared.

Dr. StClair Thomson said he had just been reading an old book—
Spencer Watson’s hook on ‘ Diseases of the Nose,’ and found the
following on page 161: “ It may happen that the teeth are all
apparently sound, and yet one of them may be the cause of the
purulent collection within the antrum in consequence of the death of
the fang, the symptoms of which are not by any means easily detected.
The skilful dentist, however, is sometimes able to get information on
this point by striking the crowns of the teeth in succession with a
metallic rod until one of them is found to be more sensitive than the
rest, and he then proceeds to test the condition of the pulp cavity of

the suspected tooth.” Dr. Thomson was sorry that

they could not consult with dentists on this subject, because
he had had cases in which the patients had insisted on having
certain teeth extracted, which were found to have diseased fangs
when there was nothing to be detected in the crown. He could
not say whether in these cases the tooth was the cause, or
whether it was secondarily infected. He believed he had read that the
Rontgen rays were being used for the purpose of detecting diseased
roots of teeth. He did not know if any member had come across
this in the literature on the subject, or if anyone skilled in dentistry
could tell them about the procedure.

Case of Laryngeal Syphilis with Fixation of Left Vocal

Cord.

Shown by Dr. Donelan. The patient, a man set. 52, had
contracted syphilis sixteen years previously. Three weeks ago
there was a large foul ulcer occupying the left side of the larynx
and involving the left arytenoid, vocal cord, ary-epiglottic
ligament, and extending past the middle line on the posterior
surface of the epiglottis with several unhealthy granulations.
There was complete fixation of the left vocal cord. There had
been remarkable improvement under antisyphilitic treatment so
far, but in view of the unilateral character of the affection, and
the existing appearances, he desired the opinion of members as
to whether there was not malignant disease as well.

Mr. Spencer thought the antisyphilitic treatment might be
continued for some time, as it looked likely to be successful.

6

Man, j?t. 33, shown at the Meeting in April last (vide

. ‘ Proc..’ p. 104) with Chronic Laryngitis and an Ulcer
on one Vocal Cord. Now seen to present marked
Lupus Infiltration and Ulceration of the Epiglottis.

Shown by Dr. StClair Thomson. This patient has now
complained of hoarseness and a constant desire to clear his
throat for about a year. When shown to the Society six months
ago the author raised the question as to the ulcer on one cord
and the general thickening and congestion of both cords being
due to tubercle, but he abandoned it in the absence of any
confirmatory signs, and also because some purulent rhinitis was
thought to be a sufficient explanation of the condition. Several
members expressed their opinion that it was only a case of
simple laryngitis, and some even thought that the man’s hoarse¬
ness was to a great extent functional.

On June 1st last it was noticed that no ulcer was visible
on the cords, which were simply thickened, catarrhal, with
granulations along their attached border. For the first time
the epiglottis was then noticed to be red, velvety, and infiltrated
with slight vertical fissures (? commencing ulceration) on its
laryngeal surface. He did not come under observation again
until October 20th, when the epiglottis presented the condition
which may now be observed. It has lost much of its contour,
being thickened, red, congested-looking, and with marked loss
of substance and tubercular infiltration of the floor of the
ulcers. There is no marked dysphagia. The voice remains
hoarse and painful.

The President asked whether there were any symptoms or history
of syphilis in this case, and also whether tubercle bacilli had been
found.

Dr. Job son Horne did not know why it should be regarded as a
case of lupus. To him, it seemed a fairly straightforward case of
tuberculous disease.

Dr. StClair Thomson said, in reply to the President, that there was
no distinct history of syphilis in this case. He had been put on ten
grains of iodide of potassium, but it had made him rather worse; this, of
course, tended to confirm the suspicion of tuberculosis. There was a
great clinical difference between tuberculosis and lupus in the larynx,

a point which he had previously raised before the Society. He
thought this distinction assumed its greatest importance in regard to
the question of treatment, because if this was a case of lupus of the
epiglottis, it was a form of disease most amenable to treatment; but if
it was a tuberculous epiglottis, it was one of the most malignant of
laryngeal affections.

Cask of ? Congenital Fenestration op the Anterior Pillars

op the Fauces.

Shown by Dr. E. Waggett. The case was a well-marked
example, occurring in a woman aet. 43, of the condition of which
several instances had been exhibited at meetings during
the past year. History of ulceration was completely wanting,
but the patient had scarlet fever at an early age.

Dr. Clifford Beale said that considerable interest was attached
to this case, in association with cases previously shown to the Society,
because the question was raised whether such fenestration could be
due to scarlet fever. It struck him at the time that there was not
very much evidence generally forthcoming to show that scarlet fever
was followed by such fenestration. Since then he had looked up the
literature of the subject and seen what the authorities had to say in
this matter. The result was that he found several recent editions of
present text-books had quoted from one another, and that finally the
quotations came from one source—a paper by Goodall, in 1894, re¬
cording a short series of cases where there was definite fenestration
after scarlet fever. No one else appeared to have brought forward
such cases. He had the personal evidence of physicians at the fever
hospitals to the effect that it is almost outside their experience to meet
with palatal fenestration after scarlet fever. One physician had told
him that he had come across one case where perforation had followed,
but otherwise he had never seen it. That is to say, although ulcers
of the soft palate follow scarlatina—they are, indeed, fairly common—
they do not usually end in fenestration, but in recovery.

Dr. Donelan referred to the recent literature of this subject, par¬
ticularly to the cases of Monro, of Glasgow, and Koenig, of Paris, as
showing that perforations of this kind were liable to be due to so
many varieties of infection that the question whether a given case was
congenital or otherwise was attended by increasing difficulty. In
Monro’s case, which appeared in the October number of the ‘ Glasgow
Medical Journal,’ the bacteriological evidence appeared to show clearly
that the erosive action was due to the pneumococcus.

Dr. FitzGerald Powell thought that there was very little
doubt that this was a case of perforation resulting from ulceration.
The openings, it would be observed, were certainly surrounded by

8

bands of white cicatricial tissue, which showed that there had been
ulceration, whether scarlatinal or not in origin he could not say.

Some time ago he showed a case of malformation of the fauces,
which he thought was due to developmental causes, and which looked
much more like it than the present case,, but the general opinion was,
on that occasion, that it was due to scarlatinal ulceration.

He thought Mr. Waggett had, on previous occasions, shown cases
which confirmed this opinion.

Mr. Waogett, in answer, agreed with Dr. Powell in thinking that
scarring was present, and that the condition was probably, in this
case, due to ulceration.

A Series of Living Cultures of those Bacilli which simu¬
late Bacillus Tuberculosis by their Staining Reaction.

Shown by Mr. St. George Reid. Each culture was supple¬
mented by a microscopical drawing of the organism. They
included besides Koch’s bacillus tuberculosis, the bacillus tuber¬
culosis of fish, Dubard, by inoculation; and the following
organisms isolated by Moeller: the bacillus tuberculosis from the
blindworm, a bacillus from manure, the Timothy grass bacillus,
and grass bacillus I and II—five different bacilli isolated
from butter by Maria Tobler; those isolated from butter by
Rabinowitsch and Grassberger; Korn’s bacilli Nos. I and II,
also from butter, and Marpmann acid fast bacillus from the urine.

Mr. St. George Reid explained that all the microscopical
preparations from these, cultures had stood a prolonged soaking
in 15 per cent, acid solution, and in acid-alcohol without yielding
up the carbol-fuchsin stain; but that the cultures themselves
showed how extremely they differed in their manner of growth
from that of Koch’s bacillus. Under the microscope, while
some organisms simulated exactly bacillus tuberculosis, others
showed a very distinct variation from that bacillus, as shown
when it was obtained from fairly recent cultures.

Case of Growth (probably Papilloma) on the Left Yocal
Cord in a Man ^t. 32, a Porter by Occupation.

Shown by Dr. FitzGerald Powell. The patient stated that
in February this year he began to suffer from hoarseness and
difficulty in singing, which had gradually got worse. There had

9

been no pain or dyspnoea. On examination, an irregular sessile
growth is seen arising from the anterior three-fourths of the left
vocal cord. It is nearly white in colour and shows slight papillary
projections on the surface. The growth is most probably a
papilloma, containing some fibrous tissue. It is interesting to
note in these cases of benign neoplasms of the larynx arising
from the cords, even when of considerable size, the slight
amount of interference with the breathing in adults.

Dr. Clifford Beale asked whether a papilloma of such a very
white colour was not very uncommon ? He suggested that such an
excellent case should be recorded by means of a coloured drawing.

Dr. Law wished to point out that the late Dr. Whistler showed a
case to the Society some years ago in which the growth was even
much whiter than the present one.

The President remarked on the whiteness of the growth.

Case of Epithelioma of the Epiglottis in a Man mt. 58.
Shown by Dr. Dundas Grant.

Mr. Butlin said he believed Dr. Grant did not so much raise the
question of diagnosis as that of operative interference, and from that
point of view he would not regard the case as a favourable one. He
bad never operated on a case in a similar condition to this, and he
was doubtful as to which was the best way of exposing the growth.
Seeing that the man had a gland on the right side and that the gland
was movable, he thought it would be best to cut down on it and make
an extensive incision on the right side, getting to the base of the
tongue and epiglottis, and then to make a thorough examination. At
Dr. Grant’s request he had put his finger down onto the back of the
tongue as far as the epiglottis, which was very hard. The base of the
tongue was also indurated, but not to the extent he had anticipated,
taking into consideration the visible thickening. There seemed to be
little infiltration. Those cases that one saw, not very uncommonly, of
malignant disease in front of the epiglottis spreading along the base
of the tongue and backwards into the epiglottis, he had never yet
ventured to attack by operation, the disease was so deep-seated and
extensive ; but he had often thought that he would expose the growth
from the outside when a suitable case came before him, although he
doubted whether it would be successful. Here he would expose the
growth from the side and remove the glands at the same time, if he
were going to operate from the outside.

Dr. Lambert Lack agreed that the case was quite unsuitable for

10

operation. Not only the larynx but so much of the adjacent parts of
the anterior wall of the pharynx and tongue would have to be removed
that it would be quite impossible to close the wound. In early cases
of epithelioma spreading from the tongue to the epiglottis, it was
sometimes possible to remove the disease without removing the
larynx, and in these cases he had seen very good results.

Case of Nasal Stenosis occurring in a Man ast. 43, in which
the Symptoms seemed to be chiefly Subjective.

Shown by Dr. Dundas Grant.

The President said it seemed to him that the patient had a good
deal of objective inspiratory obstruction; in addition to the very
irregular septum, the collapse of the alee on inspiration made it diffi¬
cult for the man to inspire.

Dr. Pegler noticed some constriction of the folds of the limen
vestibuli which might contribute to the general stenosis. He hoped
Dr. Grant would show the case again after the objective conditions
had been treated.

Dr. FitzGerald Powell thought the symptoms were chiefly
objective ; there was also some superficial ulceration about the anterior
nares which rather suggested a specific taint, and he would suggest
putting the man on anti-specific treatment.

Case of ? Tubercular Disease of the Epiglottis.

Shown by Mr. H. M. Ramsay. The patient, a girl set. 19, an
envelope sorter, complains of cough and hoarseness. She states
that she was quite well till eight months ago, when she noticed
an alteration in her voice, and began to be troubled by a cough.
On examination, she has extensive thickening and lumpiness
of the epiglottis and ary-epiglottidean folds. It is difficult to
see the cords, but they seem to be very little affected and to
move freely. The patient has no pain. The chest is normal,
and no tubercle bacilli have been found in the sputum. The
case is shown with a view to diagnosis.

Dr. StClair Thomson thought this case was, clinically, a very
typical example of lupus. There was the greatest difference between
that and tuberculosis of the same extent in the larynx. If this girl
had no mischief in her lungs, it was one of the most favourable cases

11

for local treatment, and it was quite possible to make a cure of it.
He had recently seen such a case, in which the disease, apparently
quite as extensive as in this girl, was completely arrested by the use
of the galvano-cautery in one of his colleague’s hands. He mentioned
this because he had heard in the Society many expressions of opinion
against the use of the galvano-cautery in the larynx. The case he.
referred to was one of extensive lupus, not only of the epiglottis, but
also of the ary-epiglottic folds, and treatment with the cautery resulted
in complete arrest.

- Mr. Butlin said that with regard to the use of the galvano-cautery
in the larynx, a well-marked case of lupus was once handed over
to him. The patient was in the hospital. He applied the cautery
very freely indeed, and in the end succeeded in getting the disease
cured. But he was bound to admit that on one occasion the patient
nearly died, and certainly would have died had he not instantly
performed tracheotomy in the ward. Anybody who was going to
apply the cautery in the larynx in the case of lupus unaided should be
prepared for such a contingency.

Case op Laryngeal Swelling.

Shown by Dr. Bond. The patient, a boy set. 14, has had a
peculiar voice since infancy. On the left side the cord is
masked by a swelling, especially in front and low down, red
in colour, slightly granular and moving with phonation.
Occasionally a small portion of base of cord can be seen.
The boy is unable to obtain work because of his peculiar voice.
Suggestions as to treatment of the condition will be welcomed.

Dr. Law would suggest as a possible, but very improbable, explana¬
tion of the condition, the impaction of a foreign body. He remembered
when he was House Surgeon at Golden Square a patient coming to the
hospital for four or five months presenting a very similar appearance
in the larynx to this patient. He heard a year or two afterwards that
a piece of rabbit bone was one day extracted which had not been
visible during the previous year’s observation.

PBOCEEDINCtS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Sixty-ninth Ordinary Meeting, December 6th, 1901.

E. Cresswell Baber, M.B., President, in the Chair.

Ernest Waggett, M.B., la ,

Charles A. Parker, F.R.C.S.(Ed.)J SecretaneF -

Present—85 members and 5 visitors.

The minutes of the preceding meeting were read and con¬
firmed.

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

Arthur Stanley Green, M.B., B.S.Lond., 9, West Parade,
Lincoln.

The following cases and specimens were shown :

Perforation of Left Faucial Pillar.

Shown by Dr. Furniss Potter. This case was exhibited
chiefly because it presented a considerable contrast to the case
shown by Mr. Waggett at the last meeting of the Society, and
PIE8T SERIES - VOL. IX. 2

14

also because of Dr. Clifford Beale’s remarks on that occasion,
who stated that from inquiry he had learned that perforation as
the result of scarlet fever was almost outside the experience of
physicians at the fever hospitals.

The patient, a single woman set. 24 years, stated that she had
scarlet fever when she was four years of age, at which time she
had “a very bad throat and mouth.” No history of syphilis
was obtainable. On examination a slit-like opening about
three quarters of an inch long was seen in the left anterior
faucial pillar, through which a probe could easily be passed.
In the right posterior pillar there was the appearance as of a
perforation, but a probe could not be passed through. There
was considerable cicatricial tissue in the pharynx, and the right
posterior pillar was partially adherent to the pharyngeal wall.
The angles of the mouth were scarred. There were no signs of
tonsils. As a result of the scarring there was considerable
deformity and interference with distinct articulation, the patient
speaking in a manner somewhat resembling that of a case of
cleft palate.

Dr. Clifford Beale said that on looking at the case one could not
help having rather a doubt as to its causation. There were scars on
the edges of the lips and elsewhere in the mouth, which were, in his
opinion, most probably due to infantile syphilis. He thought it
hardly fair to label the case as being definitely and entirely due to
scarlet fever. If scarlatinal ulceration was a common cause of
perforation more cases would have been noted, since scarlatinal
patients were always kept under observation for some weeks after the
cessation of the fever.

Sir Felix Semon did not quite know for what purpose the case
had been shown. Was it merely to show the occurrence of perfora¬
tions in the palate, or was it brought forward as' a counterproof
against the possibility of a congenital formation of such clefts in the
palate ? He thought the case was an excellent illustration of the
fact that faucial webbing might be developmentallv explained. He
could not think of a better illustration showing the difference between a
congenital defect and one of ulcerative agency, for in the congenital
cases there was absolutely no trace of cicatricial tissue at the edges of
the clefts, whereas in this case the cicatricial tissue was most marked.

Dr. F. de Havilland Hall suggested that possibly scarlet fever
might have had something to do with the condition by depressing the
patient’s vitality, and allowing the poison of hereditary syphilis to
act.

Dr. Ftjrniss Potter said, in reply, that with regard to Dr. Clifford
Beale’s remarks as to syphilis acting as a cause, he had carefully

Proceedings of the Laryngological Society of London,
December 6th, 1901.

Process reproduction of a photograph of a larynx removed, July 18th, 1898,
from a woman aged 23, a subject of Hodgkin’s disease.

The larynx has been opened to show an ulcer on the posterior part of the
left vocal cord ; the adjacent lymphatic glands are considerably enlarged. No
evidence of tuberculosis was found in the lungs.

To illustrate Dr. Jobson Horne’s communication on a “ Path of Infection in
Hodgkin’s Disease.*’

To face page 15, f'ol, IX .

/I (Hard Son, hup.

15

questioned the girl, but could not elicit any history leading him to
suppose that she or her family had been affected by syphilis. The
patient stated that she suffered at the time of having scarlet fever
from very severe ulceration of the throat and mouth, the ulceration,
in fact, extending to the mucous membrane inside the cheeks, and to
the lips. This would, he supposed, account for the scars at the angles
of the mouth.

With regard to Sir Felix Semon’s question, he showed the case
because he thought it was in sharp contrast to the one shown by
Mr. Waggett at the November meeting, and also because it would be
of interest after Dr. Clifford Beale’s remarks on that case in
November.

Macroscopic and Microscopic Specimens op the Larynx prom
Cases op Lymphadenoma, Lympho-sarcoma, Tuberculous

Lymphadenitis, etc.

Show n by Dr. Jobson Horne. Dr. Jobson Horne exhibited and
demonstrated these preparations, and said that upon them he had
based his opinion that the diseases generally grouped under the
name of Hodgkin’s disease were due to infection, and that one
manner of entry of the infecting agent was through ulceration in
the larynx. An account of the work he had done on this subject
would be found in the ‘ Journal of Laryngology ’ for December,
1901. Dr. Horne mentioned that in one of the cases (micro¬
scopic sections of which were exhibited) he had found tubercle
in a gland which presented the structure of lymphadenoma, and
which was adjacent to the ulcer in the larynx; this, he con¬
sidered, raised the question whether the ulcer in such a case
and in the absence of tubercle in the lungs should be regarded
as evidence of primary tuberculosis of the larynx.

Dr. FitzGerald Powell thought he understood Dr. Jobson
Horne to say lymphadenoma was due to tubercular infection; he
should like this explained.

In reply to Dr. FitzGerald Powell’s question as to whether
lymphadenoma and tuberculosis were to be regarded as one and the
same disease, Dr. Horne said it was a point on which it was difficult
to make himself clearly understood, for this reason: that tuberculosis
was an entity, and lymphadenoma might also be one, but at present,
no two people in discussing lymphadenoma seemed to be quite agreed
upon what should be regarded as lymphadenoma. Dr. Horne said
he recognised a distinct histological structure as characteristic of
lymphadenoma; in that structure he had at times observed distinct

16

histological tubercle with giant-cells and tubercle bacilli; whether the
lymphadenoma structure had been developed through the presence of
tubercle, or whether the tubercle had been added to the lymphadenoma,
there was not sufficient evidence at present upon which to base an
answer.

Case and Specimen of Tubercular Rhinitis in a Man jet. 35,

TREATED WITH RONTGEN RAYS.

Shown by Mr. L. Lawrence. The patient, a road surveyor, had
been troubled with discharge from the nose for rather more than
a twelvemonth. Some months ago he was treated with douches,
first of boiacic acid, and later of an alkaline lotion with some
apparent benefit. Later the discharge returned, and on September
21st last the following condition was noted :—The whole septum,
both sides and also both sets of turbinate bones were, as far as
visible, greatly inflamed and covered here and there with yellow
patches. The mucous membrane in many places was polypoid.
In the floor of the nose on both sides the septum and inferior
turbinals were pressing against each other. There was abun¬
dant offensive discharge from the nose. A piece of polypoid
mucous membrane was removed for microscopic examination,
and well-marked tubercle (exhibited) was shown. The man’s
general health had been good all along, but he had had severe
supra-orbital neuralgia and some pain in the eyeballs. Treat¬
ment by exposure to Rontgen rays had been tried since
September. The patient had had twenty-one applications,
varying from seven to ten minutes each. His symptoms had
considerably abated, and there was much less swelling in the
nose than formerly. The pain also had gone from eyes and
forehead, and the patient now expressed himself as feeling
more comfortable.

Dr. Hugh Walsham explained the technique of the treatment
of such cases with Rontgen rays.

Dr. Herbert Tilley wished to suggest in connection with this
case that if after twenty-three applications of the Rontgen rays,
administered by such an expert as they knew Dr. Hugh Walsham to
be, the improvement was not more marked than it appeared to be in
this case, it was high time to proceed to other and more drastic

17

measures of treatment. He suggested thoroughly curetting the
ulcerated surface under general anaesthesia, followed by the
rubbing in of pure lactic acid. The application of the Rontgen
rays was a very interesting form of treatment which one would
like to see more often applied to difficult cases of lupus of the
inside of the nose, especially in the earlier stages of the disease. He
could conceive that it might produce good results, similar to those
obtained in lupus of the skin. He did not know how bad this case
was when it was first seen before the rays were applied, but it was
obvious that it must have been an exceedingly bad one if the present
condition of things was supposed to be one of great improvement.

Mr. de Santi had recently had two such cases under his care in the
out-patient department; they were both tubercular affections of the nose.
One was treated by the Rontgen rays and the other he was treating
with urea (ten grains to the ounce of water). He was bound to admit
that the latter treatment had been much more effective than the former.
The urea was taken internally, and local treatment was also applied to
the interior of the nose of the nature mentioned by Dr. Tilley
(scraping, lactic acid, etc.). He had also had very satisfactory results
in cases of tubercular glands of the neck treated by the internal
administration of urea.

Dr. StClair Thomson suggested that as primary tuberculosis of
the septum was very rare, Mr. de Santi should put his cases on record.
There were only seven cases in British literature bearing on the subject.
Six of these were reported by Mr. Steward, of Guy’s Hospital,* and
the seventh by himself, t His authority for this statement was
Renshaw of Cambridge, who searched the literature in connection
with some animal experiments in which tuberculous matter was
inoculated into the nose (‘ Journal of Pathology,’ vii. No. 2, 1901,
p. 142). These seven cases did not include lupus. His owU case 'was
shown at the Clinical Society, and he had watched it for four years.
The treatment had, to a great extent, been palliative, and its condition
was now much better than the one they had just seen in the adjoining
room. The treatment in his own case consisted of cleanliness, with a
little curetting, the use of lactic acid, and general hygiene. The
patient objected so strongly to the curette, and was so positive that she
was better without it, that he had not pressed it. The same patient
was treated by Dr. Watson Williams at the Bristol Infirmary with
tuberculin, to which she reacted violently according both to her own
account and that of Dr. Watson Williams, and she was no better for
it. He had not seen the patient now for a year, but the progress of
the disease was extremely slow, and at that time her condition was
very comfortable.

Mr. de Santi, in reply to Dr. Thomson, said his cases were not
primary tuberculosis of the nose, but cases of lupus, which he included
in the designation “ tubercular.”

The President regarded the case as one of chronic tuberculosis of
the nose; such cases were not uncommon. As regards the light

* ‘Guy’s Hosp. Rep,/ vol. liv.

t StClair Thomson, * Clin. Soc. Trans./ October, 1897, and February, 1900.

18

treatment, he had had a case of this description which he saw in the
spring, in which the patient received eighteen applications of Finsen’s
light treatment for spots of lupus outside the nose, and twenty
applications of X rays. The former seemed to do some good, (if
the X rays he could not speak so decidedly ; if they had any effect at
all in this case, which had been previously treated by curetting, lactic
acid, etc., it was in making the parts look more glazed and drier. As
regards the internal administration of urea, he mentioned that his
colleague, Mr. Buck, had obtained good results from it in lupus of the
skin. He himself had tried it in one case of tuberculosis of the nose,
and had given it for about four months. The nasal mucous membrane
had been previously curetted and treated with lactic acid, and the patient
expressed herself as very satisfied with the urea treatment; at any
rate, no re-growth had occurred, although there had been no scraping
for some months, only applications of lactic acid. It was impossible,
of course, to draw any conclusions from a single case of this character;
a large number would require to be treated before an estimate of the
value of urea given internally could be formed, and it should, if
possible, be tried on cases that had not been submitted to local
treatment. With regard to the case under discussion, he thought
thorough curetting was necessary, or else a further course of the
Rontgen rays. Personally he would advise the former, and then
apply lactic acid in the usual way. The Society were much indebted
to Mr. Lawrence for bringing forward such an interesting case, and
also to Dr. Hugh Walsham for explaining the method and technique.

Mr. Lawrence said: “ As regards the treatment of the case, of
course the obvious thing at present would be to curette it and rub
in some lactic acid. I think, looking to the fact that the Rontgen rays
have done considerable good, and that there is really no great urgency
in the case, and that it is improving slowly, it is worth while trying the
rays for a little longer, especially as Dr. Walsham is willing to go on
with the treatment to see how it answers. On a future occasion I will,
if you will allow me, bring the patient before you again.’'

Case of Complete Loss of Internal Framework of the Nose

in a Girl aot. 22.

Shown by Dr. Cathcart. The patient was quite healthy up to
the age of thirteen. She then contracted scarlet fever, followed
by inflammation in the nose, which resulted in complete loss of
all the internal nasal structures. The bridge of the nose had
fallen in, and Dr. Cathcart would like to have the opinion of
any member who had had experience of the subcutaneous
injection of paraffin as to whether this was a suitable case for
such treatment.

19

Dr. Scanes Spiceb had had one case in which he had injected
vaseline under the skin of the nose for a very similar deformity. The
only disadvantage which followed was that some of the paraffin
worked its way into the upper eyelid. He had shown the casts of
the nose before and after treatment, and photographs at the meeting
of the British Medical Association at Cheltenham this year. Within
the last few weeks he had handed over the patient to the ophthalmic
department to see if it were practicable to remove the paraffin from
the subcutaneous tissue of the lid; but having made an incision, Mr.
Keeling had not been able to improve matters, and so the puffiness of
the lids remained. He hoped to show the photograph and the patient
at the January meeting of the Society if possible. The technique for
inserting the paraffin into the nose was rather troublesome. He used
just such a small syringe as used to be used for tuberculin injections.
He heated the paraffin in a water-bath, and had the patient standing
near. Having sterilised the skin with alcohol and sublimate solution,
he injected three or four syringefuls of the paraffin into the sub¬
cutaneous tissues over the middle of the nasal bridge, and moulded
the mass up with the fingers to the shape of a normal nose. The
point of injection was sealed with collodion. In future he would
inject only a small amount at one time, and repeat as necessary, and
he would press down the skin at root of nose on to the subjacent
tissues, so that nothing could escape, at all events at time of injection.
He thought Dr. Cathcart’s case was a suitable one, because the skin
was so freely moveable, and a bolster of paraffin between the skin and
the bridge would make a presentable nose. The paraffin in his own
case had now been in situ six or seven months, and it was really
wonderful how well it filled up the depression which had previously
existed in the bridge. Before commencing treatment the condition
was quite as bad as that now seen in Dr. Cathcart’s case, whereas
now there was really quite a decent bridge, though the feature was
not of an ideally refined type.

In reply to Dr. Tilley, Dr. Spiceb stated that the paraffin used
melted at 105° or 106° F., and was sterilised. It was a mixture of lard
and soft paraffin, as first recommended by Dr. Gersuny of Vienna.

Dr. StClair Thomson asked if there were not some doubt as to
this case being the result of scarlet fever. He saw the words used to
describe the case were “after scarlet fever.” Did the history point
indubitably to this destruction being the result of scarlet fever?
Perhaps members with a greater experience than he possessed would
tell the Society whether it was ever a recorded occurrence for the
bony framework of the nose, or even part of it, to be destroyed by
scarlet fever.

Dr. S. Snell thought that the patient had been the subject of
interstitial keratitis ; there was also scarring at the right angle of the
mouth, and he was therefore of opinion that this was a syphilitic
lesion, perhaps lighted up by the scarlet fever.

Dr. Cathcart was much obliged to Dr. Scanes Spicer for the
description of the technique he had given, and for the results of his
experience, and if he decided to inject paraffin he would take advantage
of the latter, and try and prevent the paraffin going into the lids.

20

With regard to what Dr. StClair Thomson had said in reference to
the aetiology, according to the description given him, the affection
came on immediately after or during an attack of scarlet fever.

With reference to a specific origin, there was a small leucoma on the
corneal periphery below, in the right eye, but it was confined to one eye
and was not interstitial keratitis, but a leucoma following an ulcer.

Case of Mal-development of the First and Second
Branchial Clefts.

Shown by Dr. Cathcart. The patient, a boy set. 8, has mal-
development of the first and second branchial clefts on the right
side. There is a rudimentary auricle, slight facial paralysis,
and a sinus halfway down the anterior border of the right
sterno-mastoid. There is also marked hydrocephalus.

Case of Epithelioma of the Epiglottis in a Middle-aged Man.

Shown by Mr. E. Waggett. This was a case of slow-growing
epithelioma involving the cervical glands. It was brought
forward as one in which divergent opinions might be expressed
as to the possibility of radical operation.

Sir Felix Semon did not think this a case suitable for operation.
The disease was very extensive, and had infiltrated the pharyngeal
wall on both sides; there were also large glands on both sides. Even
if it were possible to remove the disease entirely, which he doubted,
rapid recurrence would be unavoidable.

Mr. de Santi fully agreed with the remarks of Sir Felix SemoD.
He did not think in that particular case it would be possible to get
away the whole of the disease. It should be left entirely alone.

Case of Cicatricial Stenosis of the Pharynx in a Young
Woman, the Sequel of Cut Throat inflicted Eighteen
Months previously.

Shown by Mr. Waggett. Deglutition and respiration were
embarrassed by a firm web binding the epiglottis to the posterior
wall of the pharynx. A cutting operation through the mouth
had been followed by some dyspnoea, and it was now proposed
to perform laryngofissure.

21

Case of Paralysis of the Left Vocal Cord in a Woman
AST. 42, PROBABLY OF SPECIFIC ORIGIN.

Shown by Mr. de Santi. The patient had suffered from
embarrassed breathing for from three to four months; she had also
had a bad cough during the last six months. There were well-
marked tertiary scars about both legs, and her last baby, born
live years ago, had had snuffles, etc. Examination of the larynx
showed well-marked paralysis of the left vocal cord, otherwise
the larynx was normal. There was no swelling in the neck to
be discovered, and examination physically of the chest had been
negative. The case looked, however, like one of thoracic
aneurysm with pressure on the left recurrent laryngeal nerve,
and this would tally with the history of syphilis. (Subsequent
to the meeting the thorax was examined by the rays, and a
dilatation of the arch of the aorta easily made out.)

Case and Specimen of Fibroma of Nasal Vestibule.

Shown by Mr. W. H. Kelson. The patient, a man, came to
hospital complaining of a tumour which blocked the left side
of his nose and produced considerable deformity. He had
noticed it for about ten years. It looked and felt like a cyst.
An incision was made through the skin of the vestibule, where
the growth appeared to take origin, and it was enucleated.
The tumour, which was about the size of a small hem’s egg, was
solid, and microscopically was seen to be a fibroma. Patient
had had one or two similar tumours removed from other parts
of his body. The side of the nose previously blocked was now
pervious, and the deformity had quite disappeared.

Case of Sublingual Dermoid Cyst in a Male act. 17.

Shown by Dr. Wyatt Wingrave. The symptoms were chiefly
discomfort in deglutition and speech of about two month s*
duration. The swelling was visible on each side of the fraenum

lingua' of a somewhat purple colour. It projected below the
mandible, fluctuated, and was painless.

It was opened nine days ago on the left side of the foramen,
releasing at first a small quantity of clear thin fluid with 9 , few
white flakes. On digital pressure about two ounces of white pasty
matter, resembling German yeast, was evacuated. This mass
was not foetid, and consisted microscopically of amorphous fat
granules and epithelial squames.

Part of the capsule, which was deeply situated and very thick,
was excised, and the cavity, which extended under the tongue
between the genio-hyoglossal muscles, was scraped and swabbed
out with pure phenol.

The foramen caecum was not well marked, and although the
cavity extended closely to it, no actual communication could be
made out.

The contents conformed in every respect with cholestea-
tomatous cysts of the auricle.

A similar case was recently under his care in private, in the
person of a young athlete aet. 22 . The history, anatomy, and
treatment were exactly like the present case, but it healed without
suppuration, and had caused no further trouble, there being no
signs of its existence eight months after operation.

Case of Tubercular Larynx with Fixation of the Left Cord.

Shown by Mr. C. A. Parker. The patient, a man aet. 29, com¬
plained chiefly of hoarseness. On examination there was found
to be some general chronic laryngitis, but the more marked
pathological changes were confined to the left side of the larynx.
The left cord was infiltrated, ulcerated, and fixed, and there was
a red fleshy swelling springing from the left ventricular band.

The patient had been losing flesh slightly, and there were
signs of commencing phthisis at the left apex.

Just before coming to the meeting Mr. Parker had learned
that the case had previously been brought before the Society by
Dr. Fumiss Potter in June last.* There were then no signs of
phthisis, and the cord was freely moveable.

* See * Proceedings/ vol. viii, p. 141.

23

Dr. Clifford Beale stated that when he examined this case he
certainly thought that the left cord moved as well as could be
expected in a patient the subject of that amount of disease. He did
not think it was fixed when he saw it. It quite fell into one’s ordinary
experience of unilateral tubercular disease in the larynx when
comparatively acute. Sometimes in such conditions the cord worked
well and sometimes not. Very often in consultation one had a little
indecision in these cases as to whether the cord was fixed or not, but
after observing it for a short time one generally came to the conclusion
that the damaged cord moved very much like an arm when damaged,
i. e. sometimes better than at other times, but at all times badly and
stiffly. With regard to the question of fixation as the result of tubercular
disease, he thought it would be better to exercise care in reporting
and describing these cases if there was a doubt as to the absolute
fixation. Such a case as the one under discussion, if so described,
would make it appear that the Laryngological Society of London
recognised fixation of the cord as one of the natural sequences of
tubercular disease of the larynx. He ventured to say that the Society
would not give their assent to that opinion. He had not yet seen any
case put on record to prove that fixation of the cric'o-arytsenoid
joint did occur as a direct result of tubercular disease.

Mr. C. A. Parker said in reply that he quite agreed with Dr.
Clifford Beale that there was not absolute fixation of the cord ;
“ impairment of movement ” would have been a more correct
description. At times, however, he thought the cord refused to act
at all.

Cask of Re-growth of Malignant Disease in a Man jet. 52,
after Partial Removal by Laryngofissure.

Shown by Dr. StClair Thomson. This patient was shown to
the Society in June last [vide ‘ Proceedings/ vol. viii, p. 136), with
a growth involving the anterior four fifths of the right cord, and
the anterior third of the left. It was then generally agreed by
members that the growth was malignant and suitable for
thyrotomy. This operation was undertaken on June 18th, and
as soon as the skin incision had been carried down to the front
of the larynx it was seen that the disease was much more
extensive than any one had suspected. The glands in front of
and alongside the larynx were infiltrated and the muscles even
were affected, while the thyroid cartilage itself had broken
down in the middle line. It was noteworthy that no one who
had seen the case beforehand had suspected this malignant
perichondritis, though possibly it was indicated by a red fleshy

24

granulation below the cords in the anterior commissure. (This
was indicated in a drawing handed round, made by an artist
the day before the operation.)

In spite of the extension of the disease beyond the confines
of the cartilaginous voice box it was thought desirable to give
the man any benefit of doubt, and all the soft parts inside of
the thyroid cartilage were widely removed, the cartilage being
left bare on each side and the cords removed right back to the
arytaenoids. The infiltrated parts of the cartilage in front were
cut away.

One interesting point was to note how well the patient stood
the operation. That evening his temperature was 100*8°, but
the next day it was only 99*4°, and it never rose higher. He
swallowed water on the evening of the operation. The next
day he sat out of bed for four hours, and forty-eight hours
after the operation he was swallowing solid food, such as eggs
and bread and butter.

The neck wound healed well, and he gained a fair whispering
rough voice from the development of cicatricial tissue in the
larynx into pseudo-vocal cords. At the end of July he
appeared fairly well.

He did not come under observation again until November 30th,
when the growth was seen to have re-grown on the right side,
where an enlarged gland is to be felt.

The growth removed was reported by the pathologist to be
epithelioma.

The patient now weighed fifteen stone and had remained these
six months in the enjoyment of good general health, and no
local discomfort beyond the diminished voice power.

Sir Felix Semon would make a further attempt, for it seemed to
be a pity that nothing more should be done. The disease still
appeared to him limited enough, so that a second operation of the
same sort might be more lastingly successful than the first one had
been.

Mr. de Santi understood from Dr. St Clair Thomson that when
operating enlarged glands were found, and also some glands which were
not usually described, namely, one or two in the front of the larynx—
the praelaryngeal glands. It would be interesting to find out whether
these glands, which were removed at the time of operation, were
infiltrated with epitheliomatous disease. If so—and it was presumable
they were involved—one would not get any really good results from a

25

second operation, as recurrence would undoubtedly take place rapidly.
Moreover the disease was very extensive, and it was a question
whether its limits could be at all defined. In his opinion, therefore,
it was not a suitable case for secondary operation.

Dr. Lambert Lack did not think further operation advisable. The
growth had spread to the arytenoid and anterior wall of the pharynx.
If operation were decided on, the case required total extirpation of
the larynx and part of the pharynx as well.

Sir Fklix Semon said he should like to know why extirpation of
the whole larynx was recommended by the last speaker. There was
no evidence of the return of the disease on the left side. In other
respects the man was in a good state of health. If he personally was
in this man’s unfortunate position, he would rather undergo a second
operation than go certainly downhill, as must otherwise be the case.

In reply to Sir Felix Semon, Dr. Lack said the chief point in favour
of extirpating the whole larynx was that the mortality of cases in
which half the larynx had been removed was very much greater than
that of cases in which entire removal had been done. He further
thought that total extirpation would give a better chance of freedom
from recurrence.

Dr. StClair Thomson said he had not seen the patient since the
end of last summer until a few days ago, but after some discussion of
the case in the next room the history came back to his memory. He
was speaking now without having recently looked up his notes. When
he made the first incision at the operation, he came down at once, as
Mr. de Santi had mentioned, upon some glands in the neck which
were distinctly infiltrated. They were situated over the crico-thyroid
membrane. The thyroid cartilage itself was also involved, and was
ulcerated so much that he resected portions of it, and clipped away a
lot of muscle which appeared to be infiltrated. The pathologist
reported that the growth was epitheliomatous. The disease had
spread very much more than was suspected before operation. He
agreed with Dr. Lack that it seemed to him the disease had spread
through the arytenoid, and very possibly to the side of the pharynx
quite close to the tongue, and so he thought an operation of any sort
was almost hopeless, especially when one bore in mind the extra-
laryngeal conditions found at the laryngofissure six months ago.

Case of Complete Paralysis of the Right Vocal Cord

in a Man mt. 33.

Shown by Mr. E. W. Roughton. The patient had well-marked
physical signs of phthisis and a small deep-seated swelling in
the right side of the neck, which Mr. Roughton thought was a
mass of tuberculous glands involving the recurrent laryngeal
nerve.

20

Dr. Clifford Beale had some doubt as to the absolute paralysis
of the right cord here, for he saw it move to a certain extent.

Dr. FitzGerald Powell said there did not appear to be any
tubercular disease in the larynx, but he thought the cord was quite
paralysed; it was suggested that this was a case of fixation or paralysis
of the cord from enlarged tubercular glands in the neck pressing on
the recurrent laryngeal nerves, and this he thought to be the case.

Dr. Scanes Spicer thought the condition one of immobility from
paralysis of nerves rather than organic fixation. He could not detect
any movement whatever in this case, whereas he agreed with Dr.
Clifford Beale as to the previous case shown as paralysis of cord that
there was now considerable movement.

In reply Mr. Houghton said he did not think there had been any
tubercular disease of the larynx at all.

Case of Hoarseness in a Child .et. 1 year and 10 months.

Shown by Mr. E. W. Roughton. In this case Mr. Roughton
had been, unable to obtain a view of the larynx.

Dr. Scanes Spicer considered that this was a very suitable case
for trying the method of general chloroform narcosis with simul¬
taneous local application of cocaine. He continued to find this
combined anaesthesia invaluable in a large number of cases of
laryngeal trouble in children in which it was essential to examine or
operate on the larynx.

The President would advise trial of an examination with cocaine,
using a tongue depressor and small laryngeal mirror. During
respiration a momentary view of the glottis might be obtained.

Dr. Lambert Lack thought it would be quite easy to examine the
child with the aid of his tongue depressor without using either
chloroform or cocaine.

The President said he knew Dr. Lack’s method, but had not
always found it successful.

Growth in Larynx in a Case of Syphilis (for Diagnosis).

Shown by Dr. H. Lambert Lack. This patient, a woman aet. 37,
has been under treatment for a month with ulceration of the left
vocal cord, fixation of the left side of the larynx, and a fleshy
growth springing from the anterior commissure. There is
extensive scarring of the palate attesting former syphilis. In
spite of large doses of potassium iodide (gr. xxv ter die) the

27

laryngeal growth is increasing rapidly. The case is shown for
suggestions as to diagnosis and treatment.

Dr. StClair Thomson said that pieces of the growth had been
punched out, and so it was impossible to say clinically what it might be.
He would like to hear the microscopist’s report, as it might be
tubercle, syphilis, or almost anything. At present it was only an
ulcerated thickening.

Case of Swelling of Left Side of Nose (for Diagnosis).

Shown by Dr. Furniss Potter. The patient was a woman
set. 49, who stated that the swelling in her nose had been
developing for the last four years. She had had pain at times,
and some discharge. There was no history of syphilis. On
examination the left side of the nose was seen to be considerably
swollen externally, the mucous membrane of the left nasal fossa
was swollen, and bled very readily on being touched. The
septum was much thickened and presented two perforations,
one behind the other.

Dr. FitzGerald Powell said he thought that this was a case of
breaking-down gumma or tubercular abscess, but the perforation of
tbe septum led one to suspect a specific origin. On making firm
pressure on the swelling outside, pus was distinctly seen coming from
a sinus on the inside of the nose.

Dr. StClair Thomson thought the condition of the septum
suggested tuberculosis much more than syphilis, and that a portion
of the hypertrophy might be removed and examined microscopically.
It was a sort of thickening that could not be easily described, and was
similar to the tuberculous case he had referred to earlier. The patient
under discussion had had for four years a thickening of the skin on
the nose, and he did not think it likely that a node could remain in
statu quo as long as that.

The President agreed with Dr. StClair Thomson in believing the
swelling looked more like tuberculosis. A piece should be scraped off
and examined under the microscope.

Dr. Furniss Potter would act on the suggestions made, and obtain
a scraping from the nose and have it examined microscopically.

Case of Stenosis of the Pharynx.

Shown by Mr. C. A. Parker. The patient, a woman set . 37,
stated that when ten years old she had an abscess in the neck

28

followed by trouble in the throat which caused her to talk thickly.
She was then and for many' years afterwards under the care of
the late Sir Morell Mackenzie. There was no history of scarlet
fever and there were no definite signs of hereditary syphilis.

On examination, the tonsils and posterior pillar of the pharynx
were seen to be bound down to the posterior wall of the pharynx;
lower down the epiglottis was adherent to the pharynx, leaving a
small circular opening not much bigger than a threepenny piece.
On strongly depressing the tongue the opening could be seen by
direct vision as a narrow vertical chink about half an inch long
and an eighth of an inch wide. The patient had no difficulty
in respiration and but little in deglutition; she could swallow
solids, but occasionally fluids “ go the wrong way.”

The President said this case reminded him of one he had shown
some years ago at the Society—a young person with stenosis of the
lower part of the pharynx (see ‘ Proceedings,’ vol. i, p. 9).

PROCEEDINGS

OP THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Annual Meeting, Friday, Janvary 10 th, 1902.

E. Cresswell Baber, M.B., Pi-esident, in the Chair.

Present—18 members.

The minutes of the last Annual Mooting woro read and con¬
firmed.

Drs. H. Sharman and Braine-Hartnell were appointed scru-
tineers of the ballot, and the following officers were appointed
for the year :

President. —E. Cresswell Baber, M.B.

Vice-Presidents —E. Clifford Beale, M.B., F.R.C.P., and F. W.
Bennett, M.D., and Dundas Grant, M.D.

Treasurer .—William Stewart, F.R.C.S.Edin.

Librarian .—StClair Thomson, M.D., F.R.C.S.

Council. —F. de Havilland Hall, M.D., F.R.C.P.; Sir Felix Semon,
M.D., F.R.C.P.; H. Lambert Lack, M D., F.R.C.S.; Richard Lake,
F.R.C.S.; Ernest Waggett, M.B., and J. Barclay Baron, M.B.

Secretaries .—Charles A. Parker, F.R.C.S.Edin., and James
Donelan, M.B.

The report of the Council was then read and unanimously
adopted.

Report op Council.

The past year has been marked by the deep sorrow of the Society
at the lamented death of Her late Majesty Queen Victoria, the
respectful expression of which was graciously acknowledged by His
Majesty King Edward.

The Council has the pleasure to report that the Society continues
in all respects in a most prosperous condition.

At the last Annual Meeting the rules, as revised by the late
Council, were unanimously adopted. These rules include special
FIR8T SERIES — VOL. IX. 3

30

provisions with regard to the qualifications for membership of the
Society, and in consequence only five new members have been elected
during the year.

The meetings have been well attended and the clinical material has
been both interesting and abundant. By the exclusion of academic
matter from the first section of each meeting the transaction of
business has been facilitated.

The following report of the Treasurer was read and adopted :

During the past year the Society’s receipts from all sources amount
to £143 17#. lOd. Several members have neglected to pay their
subscriptions for 1901, but most of the outstanding subscriptions
referred to in the Financial Report of last year have now been paid in.

The total expenses have amounted to £140 10#. 10d., thus leaving
an excess of income over expenditure of £3 7#. for the year. To this
has to be added the balance brought forward from last year, viz.
£216 11#. Id., making a total credit balance on January 1st, 1902, of
£219 18#. Id. Of this amount £200 has been placed on deposit with
the Society’s bankers during the past year.

The Balance Sheet, duly audited and found correct by the auditors,
Dr. FitzGerald Powell and Mr. L. A. Lawrence, is appended.

BALANCE SHEET, 1901.

Income.

£ s. d.

7 Entrance Fees ... 770

113 Subscriptions . . . . 118 13 0

10 „ (1900) . 10 10 0

1 „ (1899) .110

Sale of ‘ Proceedings/ Read¬
ing-cases, etc., per Hon.

Librarian.2 2 0

Interest on Deposit ... 4 4 10

Cash on De¬
posit . . . £200 0 0

Balance brought
forward from
1900 ... 16 11 1
Balance Jan.

1st, 1901 . . 3 7 0

Total Credit

Balance . 219 18 1

£143 17 10 i

Expenditure.

£

S.

d.

Rent.

31

10

0

Adlttrd—Printing ....

68

15

6

Reporting.

16

16

O

Baker—Microscopes . . .

1

18

0

Pulman—Binding ....

3

6

O

Annual Dinner .....

10

2

0

Clarke—Indexing ....

1

10

0

Mathew (porter) ....

2

0

0

Tongue-cloths.

0

12

6

Carbolic acid, etc.

0

7

3

Hon. Secretaries* Expenses .
Hon. Treasurer's Expenses

1

6

6

and petty cash payments .

1

4

6

Bank charges.

1

2

7

Total Expenditure for 1901.

140 10 10

Balance.

3

7

0

£143 17 10

Dec. 31 st, 1901.

Audited and found correct,

E. CLIFFORD BEALE, Treasurer.

/ H. FITZGERALD POWELL.
I L. A. LAWRENCE.

The Librarian’s report was then read and adopted.

31

The following “ Exchanges ” have been regularly received during
1901:

Journal of Laryngology.

The Laryngoscope.

Revue Hebdomadaire de Laryngologie, d’Otologie, et de Rhinologie.

Annales des Maladies de TOreille, du Larynx, du Nez, et du Pharynx.
Monatsschrift fur Ohrenheilkunde.

Archiv fur Laryngologie.

Archives Internationales de Laryngologie, d’Otologie, et de Rhinologie.
Archivii Italiani di Laryngologia.

Bollettino delle Malattie-delF Orecchio, etc.

Archivio Italiano d’Otologia.

Arrangements have been made for the exchange with the French
journal ‘ La Parole,’ edited by Dr. Marcel Natier.

The following works have been added to the library during 1901:

Presented bv Dr. de Havilland Hall .

\s

Frankel. Prof. Dr. B. Adenoide Vegetatiouen. (Separat-Abdruck aus der Real-

Encyclopadie der gesammten Heilkunde.)

„ „ Angina. (Separat-Abdruck aus der Real-Encyc., etc.)

„ ,, Die Demonstrationen des laryngoskopischen Bildes. (Son-

derabdmck aus Thcrapeiitische Monatsschrift-heraus-
gegeben von Dr. Oscar Liebreich.)

Lange, Victor. Sur Peraploi de la Methode galvano-caustique dans le Nez et le
Pharynx. Remarques pr£sent£s k la sous-section de laryngologie dans la 7e
session du Congr^s International des Sciences Medicales (Londres, aout 1881).
Mygind, Dr. Med. Holger. Die angeborene Taubheit. Beitrag zur Aetiologie und
Pathogenese der Taubstummheit.

Scheppegrell, Wm., A.M., M.D. Congenital Occlusion of the Posterior Nares.

The following have been presented by their authors:

Bar, Dr. Louis. De la Tricophyte du Conduit auditif externe. (Extrait des
Annales des Maladies de FOreille, etc.). 2 copies.

Downie, Walker, and Kennedy, Robert. Two Unusual Cases of Stricture of the
(Esophagus.

Downie, Walker. Four Cases illustrative of the Local Lesions resulting from the
swallowing of Liquid Ammonia.

,, „ Two Examples in Men of severe and prolonged Attacks of

Asthma, associated with, and apparently dependent upon,
the presence of Nasal Polypi, extirpation of which resulted
in complete Immunity from Asthmatic Symptoms.

Hall, Dr. de Havilland, and Tilley, Dr. Herbert. Diseases of the Nose and Throat.
Joris, Dr. Alois. Ueber die Anwendung des Menthol-Jodols in der rhino-laryngo-
lischen Praxis.

Krieg, Dr. Robert. Atlas der Nasenkrankheiten von Hofrat. (Specimen contain¬
ing Tafel VI.)

Gougenheim, A., and Lombard, E. de Paris. Indications operatoires dans le Cancer
du Larynx. (Extrait Annales des Maladies de 1’Orielle, etc.) 2 copies.

Natier, Dr. Marcel. Syphilis tertiaire du Nez chez une jeune Fille: Infection au
cours de Pallaitement par la nonrrice; sequestres et polypes muqueux. (Avec
4 figures dans le texte.) 2 copies.

Ropke, Dr. F. Three cases operated on for Otitic Abscess of the Temporal Lobe,
with Fatal Result.

Williams, Dr. Watson. Diseases of the Upper Respiratory Tract. (Fourth edition.)
„ „ The Therapeusis of Gonorrhoeal Urethritis, with special

reference to Gonal (published by F. Williams and Co.).

32

Williams, Dr. Watson. The Treatment of Tuberculosis and Catarrhal Conditions
of the Respiratory Organs by the Isovalerianic Acid Ester of Creosote and
the Eosolate of Quinine (published by P. Williams and Co.).

The following Proceedings of Societies, etc., have also been
added:

Jahrbiicher der Gesellsclmft der ungarischen Oliren- und Kelilkopfarzte (Dr.
Ludwig Polyak).

Sitzungsberichte der Gesellsclmft der ungarischen Oliren- und Kehlkopfarzte (Dr.

Hugo Zwillinger), 1901. No 1 (2 copies) and No. 2.

Sitzungsberichte der Wiener Laryngologischen Gesellsclmft, 1900.

Transactions of the 22nd Annual Meeting of the American Laryngological Associa¬
tion, 1900.

Brighton and Sussex Chirurgical Society, 1900-1.

Niederlandische Gesellsclmft fur Hals-, Nasen-, und Ohrenheilkunde, Arnheim, 1901.
Catalogue of Accessions to the Library of the Royal College of Physicians of London,
1901.

Fourteenth Congr&s International dc Medecin—Rules.

British Congress on Tuberculosis—Programme.

Socidte Fran<jaise d'Otologie efc de Laryngologie, Reunion annuelle, mai, 1901.

At an informal mooting consisting of the ex-librarians, Dr. de
Havilland Hall and Dr. Clifford Beale, the outgoing librarian,
Dr. Dundas Grant, and the nominate librarian, Dr. StClair
Thomson, with Sir Felix Semon, inspected the unbound material
in the library of the Society and a number of papers which
had little or no bearing upon the work of the Society were
laid aside for elimination. The librarian trusts that the Society
will approve of their recommendation being carried into effect.

The library has now attained such dimensions that the
accommodation for it at the rooms of the Royal Medical and
Chirurgical Society is quite inadequate. In order to relieve sub¬
sequent librarians of the necessity of finding space for it, the
present librarian recommends that some arrangement should be
made for its accommodation. He would also advise that a
catalogue should be printed and placed in the hands of the
members of the Society, and spaces or leaves introduced on
which they could add the names of whatever additions are made
from time to time; he is convinced that in this way the use of
the library would be much greater than it is at present.

The meeting then adjourned.

33

Seventieth Ordinary Meeting, January ltith, 1902.
E. Cresswell Baber, M.B., President, in the Chair.

Ernest Waggett, M.B.,

Charles A. Parker, F.R.C.S.(Ed.),

| Secretaries.

Present—34 members and 1 visitor.

The minutes of the preceding meeting were read and con
firmed.

The ballot was taken for the election of the following candi¬
dates, who were unanimously elected :

As Honorary Member :

Thomas James Walker, M.D.Lond., of Peterborough.

As Ordinary Members:

A. Stanley Green, M.B., B.S., 9, West Parade, Lincoln.

James M. Browne, M.B., 27, Wellington Road, Cork.

The following cases and specimens were shown:

Specimen op a Pedunculated Angeioma op the Larynx.

Shown by Dr. Bronneu. The patient, a strong, healthy man
aet. 63, was seen in June, 1901. For the last twenty years the
voice had been slightly hoarse, and he could not speak for any
length of time with comfort. Five months ago the voice
suddenly became very hoarse, and had remained so ever since.
There was no dysphagia or dyspnoea. A large red raspberry¬
shaped .growth was seen in the glottis, about the size of a
marble ; only a small part of the vocal cords was visible. A
piece of the growth was removed for examination. The Clinical
Research Association reported: “ This seems to be a nmvoid
growth in the mucous membrane, which is ulcerated in the
centre and become consolidated with fibrin and exudation.

34

The vascular channels in the deeper tissues are large and
numerous.”

The growth was removed by Frankel’s forceps. There was
now a small red swelling in the anterior part of the left vocal
cord, but otherwise the larynx seemed to be normal. The voice
was better than it had been for twenty years, and up to the
present there had been no recurrence.

Mr. P. de Santi said that from the general appearance of the
growth under the microscope there was, in his opinion, no doubt that
it was a tumour of the nature of nsevoid tissue, and that the case was
one of “ pedunculated angeioma.” He understood that Dr. Bronner
wanted to know if the Society agreed with his diagnosis.

Case of a Female whose Saddle Nose had been Treated by
Subcutaneous Injection of Yaselin (Paraffin), with Casts
and Photographs Taken Before and After Treatment.

Shown by Dr. Scanes Spicer. The patient, set. 25, had
applied for treatment for nasal suppuration and fcetor, which had
lasted from childhood. There was a negative history as to
traumatism or acquired syphilis, but some doubt as to evidences
of congenital taint. She had a well-marked tip-tilted saddle
nose and stunting of the nasal framework. Crescentic wrinkles
from eye to eye over the bridge of the nose were well marked,
as seen in Cast No. 1, taken the day before injection (May 6th,
1901). In addition to ordinary methods of treatment for nasal
suppuration, the speaker suggested improving the shape of her
nose by injecting sterilised vaselin as first described by Gersuny
of Vienna. He had obtained the result indicated by Cast No. 2
and Photo. No. 2 (taken end of July, 1901).

The paraffin used was a mixture of hard and soft paraffin
made to meet at 40° C. (105° F.), previously sterilised and kept
in sealed bottles. The skin of the nose, etc., was cleansed first
with alcohol and then with Liq. Hydrarg. Perchlor. The syringe
and needle were cleansed and boiled in the steriliser, which was
also used as a water bath to heat the paraffin. A German
glass hypodermic syringe was used, like that for injecting
tuberculin. Ten to twelve syringefuls were injected, some

35

downwards over nasal bends, some upwards from the sides of the
nose into the depressed gap, and the injected matter was moulded
by an assistant’s fingers so as to shape the part before setting.
The skin was again cleaned and the points of injection sealed up
with collodion. The syringe was removed for refilling from the
socket in the needle, which, when once in situ , was allowed
to remain there until it was judged that enough vaselin had
been injected at that spot. There was no pain, though the nose
looked a little tense and brawny. No paraffin passed into the
eyelids apparently at the time. There was afterwards no pain
nor inflammation, but in a few days the upper eyelids became
somewhat cedematous. This had varied in amount from day to
day ever since, and in left upper eyelid was a little nodule the
size of a large shot. This had been cut down on, but it did not
appear possible to get it out.

The result, as far as the appearance of the nose went, was
very palpable, the skin over the bony bridge of the nose being
bolstered up, produced a very decent-sized organ. As it was
done eight months ago and now remained in the same state as
when first injected, it might be regarded, as far as could be seen
at present, as permanent. It was certainly a great improvement
to her appearance, and the patient states that her mother was
“ proud of her in her altered condition.” The patient indeed
alleged that there had been an improvement in her general health
and nasal suppuration since, but that was doubtless due to the
general tonics and nasal washes she had used. The passage of
a nodule of paraffin into the upper eyelid was disappointing, and
so was the oedema of the lids. The former was not improbably
due to the physiological action of the pyramidalis nasi, which
would tend to shift movable bodies upwards and into the orbit.
The latter might be due to a blockage of lymphatic vessels by the
paraffin, some of which had probably got divided up into a mole¬
cular condition. It should be remarked, however, that the upper
lids were inclined to be puffy before the injection. There was
no oedema elsewhere in the body. In any future case Dr.
Spicer thought still more care should be taken to put pressure
on the root of the nose at time of injection, and he suggested
that repeated injections of smaller quantities would in all
probability be better than doing all at once. The method

36

appeared to offer many advantages over plastic operations for
this class of case. Gersuny injected cocaine before injecting the
vaselin, but this, he thought, could be hardly necessary in nasal
cases, as the only pain was the prick of the needle. In some of
his cases of filling up cavities or formation of an artificial
protuberance the effect produced by the vaselin had remained
unaltered in shape or size for many months, the paraffin
apparently having become encapsuled.

The President thought it a very interesting case, and would like
to hear if anyone else had experience of the method. The paraffin
injection seemed worth trying in such cases, provided precautions were
taken to prevent the paraffin from running into neighbouring parts.

Mr. P. de Santi suggested that in treating these cases a piece of
lead sheeting should be applied over the parts adjacent to the root of
the nose, and firm pressure exerted on it during the injection of the
paraffin. This method he bad used successfully for removal of cirsoid
aneuiysm of the scalp. Such a piece of lead, properly cut and shaped,
and applied round the neighbourhood of the root of the nose would,
in his opinion, prevent the particular accident that had taken place in
Dr. Scanes Spicer’s case. If this were done he would also be in favour
of not removing the lead for some little time after the operation. As
he understood from Dr. Spicer that the infiltration into the eyelids had
not taken place immediately after the injection of the paraffin, but
some time afterwards, it would also be easy to keep up the pressure
on the parts by means of the lead sheeting and bandaging. He
congratulated Dr. Scanes Spicer on the fine nose he had made in this
case.

Dr. Bronner inquired if the paraffin had always been as soft as it
was at present. He thought that by pointing the syringe downwards
one would get over the particular difficulty that had arisen in this
case. In a case of his own, which was similar to this, the nose waa
very much harder than that of the patient they had just seen, and his
own difficulty was that immediately the paraffin was injected it
assumed a certain shape, and retained that shape to such an extent
that one could not mould it. Two or three weeks after the operation,
in his own case, some inflammation set in. There was no pus, but the
nose became red; in a few days, however, it settled down again to its
normal state.

Dr. Milligan asked what kind of paraffin had been used by
Dr. Scanes Spicer, and what was the temperature at which it had been
injected. It evidently was a very mobile paraffin.

Dr. Lambert Lack thought it might be possible to raise the skin
and make a small cavity into which to inject the paraffin, instead of
injecting it at random into the subcutaneous tissues. He thought the
result in Dr. Spicer’s case was excellent.

Dr. Donelan said that with regard to preventing the rapid cooling
of the paraffin, it might be possible to model a series of noses varying

37

from the most aristocratic and refined to the most vulgar in type, and
have them made on the principle of the Loiter’s coil, with a double
chamber, so that the temperature might be maintained at that of the
injection, and the nose given any desired shape.

In reply. Dr. Scanes Spicer said that he put the bottle containing
the paraffin and the syringe into a water bath and heated it till it was
just mobile. Such a small quantity as was injected must very soon
cool down to the body temperature. The paraffin described by
G-ersuny was described in the Austrian Pharmacopoeia as unguentum
paraffinum. It is said to melt at 40° C., i. e. 105° F. Rogers, of
Oxford Street, had prepared it for him (and from this firm it could
always be obtained) in hermetically sealed bottles. He was very
careful to ensure asepsis. There was not the slightest reaction of any
kind after injection in his case. The nose was possibly a little
tighter at first than it was now. About six drachms were required to
form the “ bolster.”

With regard to Dr. Lack’s remarks, he wished to say the paraffin
was not injected “at random.” The point of the syringe was put
down where the chief part of the bolster was required, and then the
paraffin was injected little by little and slowly, and the lump rose
before one’s eyes. But he thought that speaker’s idea of first making
an incision and then a kind of cavity with a blunt probe beneath the
skin a very good one, and if he had another case he would cautiously
try it.. He feared, however, that bleeding might interfere with the
operation. He tried to direct the shape of the bolster into that of a
kind of omelette underneath the skin, between the skin of the nose
and the bone. He had an assistant to help him while doing the
operation, but the patient did not mind a bit, and did not even sit
down for it.

Sequel to Case of Radical Cure of Multiple Suppurative
Sinusitis and Polypoid Disease of Nose; Previously Ex¬
hibited April 10th, 1895, and January 8th, 1896.

Shown by Dr. Scanes Spicer. The patient, a male aet. 21,
was first seen on November 4th, 1893, suffering from bilateral
nasal obstruction due to polypi, accompanied by profuse sup¬
puration. These conditions he had had for several years, for
which repeated forceps operations had been performed. Lately
he had lost 1 £ stones in weight. Empyema of right antrum was
indicated by symptoms, and corroborated by transillumination
and by exploration through the canine fossa and irrigation. A
day or two later the pus had collected near site of puncture and
formed an abscess, which had burst into the mouth. The

3§

38

polypi were thoroughly removed, and also the anterior end of
the right middle turbinated body and the polypoid masses about
the ostium maxillare were thoroughly curetted. The discharge
continued profuse. Radical operation, as described by the
speaker, was recommended and performed in St. Mary’s
Hospital on December 2nd, 1893. A two ounce bottlefull of
polypi, granulations, and cholesteatomatous debris were re¬
moved. There was severe febrile reaction afterwards, which
soon subsided, and patient left hospital in ten days, and gained
in first week at home 7 lbs. in weight. The polypi re¬
curred and the nasal suppuration continued, though clearly
not from the antrum, as when the patient blew through the
antrum from nose to mouth or vice versa no pus was seen.
Removal of polypi and bone and curettement of the ethmoidal
lateral mass under cocaine were persisted in on and off
until March, 1895, when the bone about the right frontal
eminence appeared swollen, and the skin over it tinged with an
erysipelatous blush the size of a shilling, together with con¬
siderable pain and malaise. He had been losing weight again,
and there was evening pyrexia. Retention of pus was diagnosed
in the right frontal sinus, and the left was possibly involved
also, though in a less degree. There were both polypi and pus
in the left nostril, which had been treated throughout the case;
the antrum on this side was translucent. Operation was recom¬
mended, and the frontal sinuses were opened on March 23rd,
1895. The patient had a very deep natural median furrow on
the brow, so this was used for a mid-line incision. A half-inch
trephine was used and applied centrally, its progress being care¬
fully tested with clean quills. As soon as the sinuses had been
entered on either side the crown was levered up from its attach¬
ment to the septum between the sinuses and detached. At once
a membranous sac containing gelatinous polypi and yellow pus
sprang from each sinus into the wound. Both sinuses were now
thoroughly curetted out,, passages made freely into the nose
with sharp spoons, the cavities swabbed out with chloride of
zinc, and a rubber drainage-tube passed through each sinus out
through the corresponding nostril, their ends tied loosely to¬
gether, and the skin incision sewn up. Warm boracic irriga¬
tions were used both through the tubes and in the nose, and

39

the tubes were slightly moved each day, and were finally re¬
moved about the tenth day. The patient was shown to the
Society on April 10th, and in the ‘ Proceedings/ vol. ii, page 74,
is simply mentioned by name, as a case of antral empyema. The
patient had gained eleven pounds in weight since the operation
seven days previously, and there was hardly any discharge, while
the skin wound had closed.

The patient was shown again at the annual meeting on
January 8th, 1896, as an instance of a radical cure. There had
been a gradual diminution of suppuration until it completely
stopped, and no recurrence of it or the polypi had recurred for
several months. The line of incision was almost invisible owing
to the deep natural furrow.

During 1896 the patient entered the Army Medical Service
and went to India on active work. He continued in the fullest
enjoyment of health and energy till he injured his leg during
prolonged riding on duty and developed phlebitis and throm¬
bosis of the left saphena. On returning home in 1901 he was
in St. Mary's Hospital. He then had not had any recurrence
of polypus or nasal suppuration for over 5£ years. Unfor¬
tunately, however, the phlebitis in the leg persisted with
relapses until, on October 3rd, he was considered to have re¬
covered and to be fit to return to duty. He returned to London
from the country with that view, when he was seized with
cerebral thrombosis, from which he died in three days.

Dr. Spicer considered the interesting points about the case
were its long duration, extensive diffusion, and obstinacy of the
intra-nasal disease. Before coming under his charge irrigations
only had been used, and removal of the larger polypi with
forceps. He underwent constantly repeated operations at his
hands for over li years before the intra-nasal disease was
finally eradicated, but in the end he was cured, and remained
so for 5.| years, dying of a quite independent affection. Fur¬
ther, there was a remarkable gain in weight after each of the
larger operations. Lastly, this was one of the first cases of
cured frontal sinus empyema to be demonstrated at the
Laryngological Society of London, and although the notes
had not yet appeared in the ‘ Proceedings/ he thought they
were of sufficient interest now the case is finally concluded.

40

A Case op Bony Thickening over and Polypi within the
Right Frontal Sinus in a Man act. 40; Operation ;
Recurrence op Bony Growth and Commencing Similar
Symptoms on the Opposite Side of the Face.

Shown by Dr. Scanes Spicer. The patient was first seen on
November 23rd, 1901. A month previously a swelling had
appeared over right frontal eminence with pain ; the upper
eyelid was oedematous and the palpebral fissure almost closed.
There was a long history of nasal catarrh. Trans-illumination
of the sinuses showed the most marked relative blackness over
the affected eyebrow, with unusual translucency elsewhere.
Dr. Spicer diagnosed intra-sinus disease with retention of fluid
and distension of the anterior wall, and recommended explora¬
tion of the sinus. This was done, and it was found that the
bone was unusually dense and thick, and a large amount of the
diffuse osteoma was chiselled and gouged away. On reaching
the sinus it was found to be filled with polypoid tissue; there
was no communication with the opposite side. The sinus was
gently curetted and washed out into the nose without difficulty,
and then packed with ribbon gauze, the end being brought
out through the forehead wound and the latter sewn up. The
gauze was removed on the fifth day, and the patient made an
uninterrupted recovery and was about within the week. Later
he returned with a new rounded bony swelling on the frontal
bone on the same side, which was slightly tender, and on the
left side the eyelid was oedematous, and the palpebral fissure
almost closed, and there was some ill-defined thickening of the
left supra-orbital ridge. He said he had knocked himself there
accidentally a few weeks before. He was ordered iodide of
potassium gr. v, t.d.s., and directed to show himself in the begin¬
ning of the year.

It appeared to Dr. Spicer to be an unusual case. There was no
history of rheumatism, gout, or any constitutional disease which
might throw any light on the case. At the present date he has
been taking the iodide for two months, the bony swellings had
diminished, and the eyelids and palpebral fissures were both
quite normal as well as the intra-nasal condition. The rapid

41

diminution of symptoms under Pot. Iod. suggests “ nodes ” of a
specific nature which, however, the extreme hardness of the
bony tumour that was cut into would appear to negative, but
opinions were invited as to the diagnosis of the case.

Specimen of Pharyngeal Lipoma.

Shown by Dr. Milligan. Mrs. H—, set. 37, had suffered from
her throat for from one to two years. She complained of slight
dysphagia, a feeling of fulness in the throat and considerable
amount of dyspnoea when lying down. Her general health had
also depreciated and she had lost a certain amount of weight.
On examination a large unilateral ovoid swelling was found
under the mucous membrane of the posterior wall of the pharynx
on the left side. The swelling extended upwards behind the
level of the soft palate and downwards behind the larynx,
where, indeed, the swelling was most prominent. To palpation
the swelling appeared soft and doughy. There was no pain, no
expectoration, and no temperature. Diagnosis lay between the
possibility of a chronic abscess or lipomatous tumour. The fact
that there was no indication of any bone disease present rather
negatived the idea of abscess. The patient was put under
chloroform with the intention of removing the growth through
the mouth, but it was deemed advisable, owing to its size and to
the dyspnoea from which she was suffering, during the chloro¬
form anaesthesia, to make a lateral incision and remove the
growth from the outside. This was accordingly done and the
growth was successfully removed. The patient made an
uninterrupted recovery, and was rapidly regaining her health
and her strength.

The President thought it a very interesting specimen.

Dr. Jobson Horne thought it would considerably add to the value
of the communication if Dr. Milligan would allow the Society to have
a section of the specimen. As the specimen was in a bottle it was
difficult to express an opinion as to its nature.

42

Microscopic Section of Fibro-Sarcoma of Right Vocal Cord.

Shown by Dr. Milligan. H. C —, male, set. 61, had suffered
from his throat for six months. He complained of slight pain
upon the right side, accompanied by progressive loss of voice.
There was no expectoration, no loss of weight, and no history of
any previous illness of any moment. When first seen there was
slight congestion of the right vocal cord, but no appearance of
any growth. When seen six months later the right vocal cord
was found to be deeply congested, almost immobile, and growing
from its upper surface, at about the junction of the middle
with its posterior thirds, there was a smooth rounded reddish-
looking growth about the size of an ordinary red marble.
There were no enlarged glands. The rapidity of the growth,
the almost complete fixation of the vocal cord, and the age of
the patient made it probable that the growth was malignant.
Its contour and its want of ulceration suggested a sarcomatous
process. Immediate operation was advised. In the first place
a tracheotomy was performed, and three days later the larynx
was split and the growth fully exposed. It was removed
entirely along with a considerable amount of contiguous mucous
membrane. An uninterrupted recovery ensued, and at the
present time, now nearly twelve months since the operation, the
patient was in excellent health and with no appearance of
recurrence.

Microscopically the growth had the structure and character¬
istics of a fibro-sarcoma.

The following is the report from the Clinical Research
Association :—“ On the free surface the specimen submitted
shows considerable activity, and has the structure of a sarcoma^
composed in the main of spindle cells, but also showing round
and branched cells. The central part of the tumour is composed
of fairly well developed fibrous tissue. From the appearances
presented I think the tumour should be regarded as a fibro¬
sarcoma. The epithelium covering the tumour shows active
proliferation, and at one spot there is irregular down-growth.
At this point it is a question whether some of the large cells
seen are not to be regarded as epithelial.” Mr. C. H. Wells

43

adds to this report: “I think, on tlie whole, that they should
be regarded as derived from the connective tissues and not
from the epithelium overlying them.”

Dr. Lambert Lack suggested that both the above specimens should
be referred to the Morbid Growths Committee. He thought there
was considerable doubt as to the diagnosis in both cases.

Dr. Milligan had not the least objection to the specimens being
referred to the Morbid Growths Committee. With regard to the
second, the piece shown was all he had, as the Clinical Research
Association had not sent him back the remainder.

On the President putting the question to the Society, it was
unanimously agreed to refer the two specimens—No. 5, specimen of
lipoma of the pharynx, and No. 6, specimen of fibro-sarcoma of vocal
cord—shown by Dr. Milligan to the Morbid Growths Committee for
report and examination.

X-Ray Photograph Showing Plate op Teeth Impacted in
Upper Laryngeal Orifice.

Shown by Dr. Milligan. M. C—, female, set. 32, swallowed
her teeth during sleep, the place of impaction being doubtful.
The X-ray photograph now exhibited was taken, from which it
would be seen that the plate was lodged in the upper laryngeal
orifice. By the help of a laryngoscope the plate was extracted,
and the patient made a good recovery.

Dr. Milligan also showed an X-ray photograph of a rubber
tube which had slipped into the maxillary antrum in a case
which had been operated upon for chronic maxillary antrum
suppuration, and one of an ordinary Eustachian catheter passed
into the frontal sinus of a patient suffering from chronic
suppurative frontal sinusitis.

Specimens of Papilloma of the Tonsil and of the Posterior

Pillar.

Shown by Dr. H. Shakman. The patient from whom these
specimens were taken was a boy set. 15, shown to the Society
nearly four years ago, May 11th, 1898 (see p. 86 of vol. v of
‘ Proceedings’).

44

He had a sessile papilloma of the left tonsil and a pedun¬
culated papilloma of the left posterior pillar of the fauces.

After the patient had been shown the tonsils were removed
and the pedunculated papilloma also.

A section of the left tonsil through the papilloma was cut by
Dr. Hewlett, and also a section through the papilloma of the
posterior pillar. Both were true papillomata, with finger-like
processes covered with stratified epithelium.

The interest of the specimens was that they showed that the
papilloma of the tonsil grew from the surface of the tonsil
proper (not from the interior of a lacuna), and that it apparently
lay quite behind and unconnected with the expansion from the
anterior pillar known as the “ plica triangularis.”

The slides have been presented to the Society.

A Self-Looping Nasal Polypus Snare.

Shown by Mr. Atwood Thorne. This snare was made by
Messrs. Meyer and Meltzer, and consists of a Y-shaped end-piece
fitted on to the usual Krause snare. The two upper ends of

the Y are joined by a slightly curved surface, and the polypus
is caught between the wire and this surface.

The loop is tightened in the usual way by approximating
the two finger plates. When the polypus is withdrawn from the
nose by simply separating the finger plates, the loop is re¬
formed without the usual fingering. As there is no knot or
sharp twist in the wire, it has not the usual tendency to
break.

45

In addition to its use for simple polypus, it is particularly
adapted for the removal of moriform growths from the posterior
end of the inferior turbinal, as the instrument can be passed
with the loop retracted, and when in its right position the loop
can be ejected, when it will take on any curve to which it has
been previously bent.

The instrument can be used for the larynx as well as the
nose.

Messrs. Meyer and Meltzer can supply the instrument com¬
plete or will make the addition to a Krause snare for a
small sum.

Mr. Bennett thought the instrument very ingenious, but doubted
whether its practical application would be very useful. He used
snares made on the same principle, though less perfectly finished than
Dr. Thorne’s snare. The objection was that a wire coiled round a
large surface did not cut through if the tissues were at all thick, and
then one had to tear the polypus off. In all tough growths this defect
would be found a serious one, for in such cases one would have to use
considerable traction.

Mr. Atwood Thoene had just heard that a similar device had
been shown in Berlin about a year ago, but this was news to him.
In the cases in which he had used it the results had been very good.

A Case of Nasal Obstruction in a Woman ast. 24.

Shown by Dr. Jobson Horne. The patient had recently come
under observation on account of symptoms attributed to nasal
obstruction. The history was that some six or seven years
previously she had suffered in a similar way, and had had
the inferior turbinated bodies removed. An examination of the
nose showed that the inferior meatus was very roomy, and there
was evidence of a “ spoke-shaving ” operation having been
performed, probably some years before. The middle turbinated
bodies on both sides were hypertrophied and the middle meatus
obstructed. The tonsils were somewhat enlarged, and there was
hypertrophy of the adenoid tissue in the post-nasal space.

Dr. Jobson Horne brought the case forward with reference to
two points. In the first place, the spacious inferior meatus with
free expiration, and the occluded middle meatus with obstructed
inspiration, supported the observations recently made by Mr.

46

Parker Journal of Laryngology, Rliinol., and Otol./ vol. xvi,
p. 345) on the directions of the air currents in the nose; namely,
that the current of inspired air passed upwards and backwards
through the middle and superior meatus, entirely missing
the inferior meatus, and that the current of expired air
passed chiefly through the inferior meatus.

In the second place, the hypertrophy of the mucous mem¬
brane covering the middle turbinated bodies raised the
question whether such hypertrophy could be consequent upon
the removal of the inferior turbinated bodies, for if so, what¬
ever the immediate result might be from inferior turbinectomy
with a view to reducing inspiratory obstruction, the ultimate
result might be the reverse to that anticipated, and most
disappointing.

Dr. Herbert Tilley was very interested in the case, because he
believed the nasal obstruction to be due, not to any of the intra-nasal
structures, but to collapse of the alse nasi. On asking the patient to
breathe without a speculum in the nostrils, the alee nasi on inspiration
were both sucked in, and on expiration a considerable noise was made.
But directly a speculum was inserted the patient breathed quite easily
and noiselessly. Under these circumstances he considered that to
carry out any operative treatment inside the nose would be both un¬
justifiable and unscientific. The possible and probable explanation of
the condition was that as a child the patient suffered from adenoids
or some form of nasal obstruction, and as a result of disuse the soft
parts at the entrance of the nostrils had not developed, with the result
which was evident in the case exhibited.

Dr. Bennett said there was another interpretation of the obstruc¬
tion beside that given by Dr. Tilley. In most patients a sense of
greater freedom was given whefi a speculum was inserted into the
anterior nares. In this particular case the obstruction was not so
much a real obstruction as a subjective obstruction. The patient
stated that the right side was fairly free, but that the left side seemed
blocked. Careful inspection showed that the anterior part of the left
middle turbinal was in contact with the septum. Such contact often
gives rise to a sense of obstruction. It can be cured by treatment
which prevents this contact. In some cases this can be effected by
the galvano-cautery, but the best method is to snare off a little of the
redundant tissue on the inner side of the turbinal body. It is un¬
necessary to remove any bony tissue. He had come to the conclusion
that it was very important in such cases to carefully distinguish
between what might be termed objective and subjective obstruction.

Dr. Scanes Spicer was glad to hear Dr. Tilley’s remarks in reference
to the collapse of the alae and the nasal vestibule as a factor in
obstruction. He did not remember to have heard any special reference

47

at this Society’s meetings made to this, and yet, in his opinion, a
great deal could be done for that factor in many cases of obstruction.
What was wanted in this case was to secure efficient action of the
dilatatores alae nasi so as to lift away the alee on inspiration. In
many cases this could be effected by conscious education of those
muscles by assiduous practice. In some of these cases this was much
facilitated by a good stretching of the soft tissues of the alae nasi with
a Hill’s dilator. This should be followed up by systematic lubrication
of the nostrils, and the wearing at night of a support such as the
celluloid nasal springs, or little pieces of red rubber tubing of the
largest calibre the nostril could accommodate and as shallow as
possible. Physical exercises also were adopted, which had the object
of re-establishing the normal co-ordinated action between the alae
muscles and the other inspiratory muscles. He had obtained markedly
good results in many of his own cases, and he did not think this
matter had been brought forward as prominently as its relative import¬
ance and efficiency demanded, though he had no doubt many members
used these measures. It was, however, undoubtedly true that in a
large proportion of cases the alar stenosis element was ignored.

Dr. Burt had seen a similar case, and did not think operative
interference would be of any use. By putting in a tube to force the
alae nasi to work well, some relief might be given. It was the only
way in which he had been able to give relief in a case of his own,
where the inferior turbinate body had been removed for some obstruc¬
tion and the alae nasi had collapsed. He did not think for a moment
from his experience that mechanical dilatation would give permanent
relief, for if the dilator were removed the alae would soon fall in again.

Dr. P. McBride asked Dr. Scanes Spicer in what way he thought
that forcible dilatation of the alae could possibly affect the collapse.
As far as he understood the cause, the collapse was due to paresis and
resulting flaccidity; how, then, could stretching of the alae possibly
permanently enlarge the opening ? He absolutely failed to see how it
could be done. He was quite aware that Moritz Schmidt had written
on the subject, and had come to the conclusion, after considerable
experience, that mechanical dilatation, as accomplished by wearing a
Feldbausch dilator, made the patients more comfortable, but he was
unable to see how forcible stretching could permanently affect a con¬
dition of this kind.

Dr. Scanes Spicer asked Dr. McBride what he desired to infer by
the term paralysis in these cases.

Dr. McBride said there was a dilator nasi, and he presumed the
term “paresis,” as applied to these cases, stood for paresis of the
dilator nasi. He asked if after these measures described by Dr. Spicer
patency was restored. What was the permanent outcome ?

Dr. Scanes Spicer could not admit a “ paralysis ” in the true sense
from nerve lesion. He thought that from long continued disuse (1)
the alar muscles were weakened and paretic; (2) that the soft tissues
of the alae were stiff, rigid, and often contracted, and that the
weakened muscles were unable to drag out the stiff tissues, especially
when the action of the inspiratory air current led to a fall of atmo¬
spheric pressure in the nose; then the external atmospheric pressure

48

drove in the alae. He would therefore describe the condition as one of
functional paresis of dilators from disuse, combined with a stiffness
or rigidity of cellular tissues from disuse, similar to what
occurred in an over-rested joint. He would therefore suggest,
as an explanation of forcible stretching of the alae, that
the resistance against which the muscles worked was lessened, and
they could overcome this lessened resistance in the same way that, after
a stiff joint had been mobilised under anaesthesia, it could be moved
after by its own muscles, and these could again recover good power by
practice. It had happened to him several times that in the course of
an operation under anaesthesia for complex intra- and post-nasal
stenosis, he had ended up with dilating the alae if collapsed and rigid,
when immediately they began to resume their normal inspiratory
rhythm, which was kept up afterwards by practice and tube supports.

Dr. McBbide thought it would be most interesting if Dr. Scanes
Spicer would show to the Society a case in which there was a collapse
and in which this “ mechanical dilatation ” treatment had been tried,
so that they could see if it was cured by that method.

Dr. Pegler said that with regard to the question raised by Dr.
Jobson Horne as to whether in this case the middle turbinates were
compensatorily hypertrophied, he did not think that these bodies were
liable to this change. Here there was no hypertrophy of the left
middle turbinate, but the right one showed signs of disease.

Dr. Milligan asked if there were any observations in the literature
of the subject on what the paresis of the dilators was really due to.
Had any microscopic examination of the muscle been made ? If there
was really an atrophy of the muscle, dilatation such as described
could not have any possible value. If the muscle was atrophied, and
it was dilated, would not the cicatricial contraction tend to narrow still
more the vestibule of the nose ? He was not aware of any observa¬
tions having been made on the subject, but it was certainly one which
might with advantage be investigated.

Dr. Jobson Horne, in reply, said he was glad to have heard so
many suggestions and remarks; at the same time, it was a little
difficult for him to accept the theory put forward by Dr. Tilley,
attributing the obstruction to collapse of the alee nasi. Dr. Horne
said he was of the same opinion as Dr. Bennett in that the respiratory
obstruction was caused by enlargement of the middle turbinated
bodies and consequent narrowing of the meatus. He had brought
the case forward mainly with reference to the two points stated in his
opening remarks, but inasmuch as the treatment had been discussed
he would mention that the patient had shown signs of commencing
myxcedema, and had been taking extract of thyroid gland with
beneficial results and subsidence of nasal symptoms. The case was
therefore of value in illustrating the advisability of looking further
afield for a cause in some cases of nasal obstruction, and of not over¬
looking the possibility of commencing myxcedema. He hacl no in¬
tention of suggesting further surgical treatment of the nose.

49

Case of Herpes of the Palate.

Shown by Dr. H. Snell. The patient, a butcher aet. 40, had
obviously been suffering from chronic laryngitis for the last
three months. On December 25th he awoke with severe pain
and feeling of choking in throat, which lasted badly for some
hours. Since that time he had had pain in throat. When seen on
January 4th there were several dark patches on the hard and soft
palate (limited to right side), and on the right side of uvula there
were two or three small, round, shallow ulcers. These appear¬
ances had now largely disappeared.

A Case of Syphilitic Laryngitis in a Man jet. 52.

Shown by Dr. Donelan. The case had been brought before
the Society on a previous occasion, since which he had been
energetically treated by anti-syphilitic remedies, but though
there had been improvement during the first few weeks, latterly
the ulceration appeared to be spreading. The fixation of the
left vocal cord was more marked than before, and he thought
there was now evidence of malignancy, but desired the opinion
of members.

Mr. de Santi thought it would be advisable to remove a piece of
the growth and examine it microscopically. He thought it of a
malignant nature. It certainly seemed to him to have altered a good
deal since he last saw the case, there being greater thickening,
ulceration, and fixity. But to clear up the diagnosis, recourse should
be had to the microscope, and the case dealt with accordingly.

Dr. Donelan would endeavour to carry out the suggestions made
by Mr. de Santi.

Case of Very Extensive Destruction of the Interior of the
Nose, due to Tubercular Ulceration, in a Woman aot. 31.

Shown by Mr. de Santi. The patient had been married seven
years and had had one miscarriage. There was no history of
acquired or congenital syphilis, and nothing to corroborate any
such condition, except the state of the nose. For some four years

50

the woman had suffered from chest trouble and haemoptysis,
and for three years she had been suffering from disease of the
nose and larynx. There were well-marked physical signs of
phthisis in both lungs, abundant tubercle bacilli in the sputum,
and the larynx showed tubercular disease with ulceration. The
main point of interest in the case was the very extensive
destruction of the nasal cavities; the whole of the bony and
cartilaginous septum had disappeared, and the greater part also
of the turbinals; there was consequently great external de¬
formity, due to falling in of the bridge of the nose. There was
still active ulceration going on in the nasal cavities and tuber¬
cular ulceration of the larynx.

Mr. de Santi had never seen such extensive destruction of the
nasal cavities follow on tubercular infection, and although there
was no doubt about the tubercular nature of the case he con¬
sidered there was a strong suspicion that syphilis played some
part in the causation, in fact, that the case was one of mixed
infection. As bearing on this question of syphilis, one could
see on looking at the pharynx that there was a fenestra in the
posterior pillar of the fauces on the left side; this was sugges¬
tive of syphilitic ulceration. Treatment so far had been entirely
of an anti-tubercular character, and had been fairly successful
in keeping the lungs and larynx from a rapid advance of the
disease. He, however, now proposed to try anti-specific treat¬
ment as well.

The President asked if the sphenoidal sinuses had been investi¬
gated. He understood there was no doubt as to the tuberculous
nature of the case, but something else besides tuberculosis seemed
required to produce the deformity, e. g. syphilis. Accessory sinus
disease might also be present.

Dr. FitzG-erald Powell thought the patient was undoubtedly
suffering from tertiary syphilis. He thought that there was not any
appearance typical of tuberculosis. In reply to Mr. de Santi he said
he had looked into the larynx, which appeared to him (from what was
necessarily a cursory examination) to be the seat of syphilitic disease.
With regard to the nose, he was quite convinced that the extensive
destruction of the soft tissues and bone was the result of syphilitic
ulceration. The same remark applied to the large perforation in the
faucial pillar. Notwithstanding the fact that tubercle bacilli had been
found in the nose, and that there was said to be tubercular disease in
the lungs, he maintained that the extensive destruction of the nasal
tissues was due to syphilis. This case presented very different

51

appearances to cases of mixed disease he had observed, and some of
which he had shown at a former meeting of this Society.

Mr. de Santi, in reply to the President, said he had not examined
the sphenoidal sinuses. He adhered to his decision that the case was
a tubercular condition; but he also considered it almost certain that a
mixed infection of syphilis and tubercle existed, for he himself had
never seen such extensive destruction of the interior of the nose from
tubercular disease alone.

Case op Ulceration op the Nasal Septum with Marked Pain.

Shown by Dr. Bennett. Miss H—, set. 22, came first under
observation in 1898. She was pale, tired, overworked, and
suffering from frequent gastralgia.

The right nostril was obstructed. The septum of the nose
was perforated, causing whistling respiration, and there was a
good deal of tenacious muco-purulent secretion in the naso¬
pharynx. There was marked pain in the nose, and especially
high up on the right side, where the tissues were considerably
swollen.

The pain and swelling gradually increased. Incision of the
swollen tissues and the application of ice during a period of
several days did little good. Soothing antiseptic ointments,
calomel fumigations, tonics, iodides, etc., were tried, but all
without good result.

In July, 1898, the swelling became very great and the pain
intense, so under ether some of the middle turbinal tissue was
removed and the septum curetted. For a few weeks there was
slight relief. The removed tissues were examined on more than
one occasion, but no light was thrown on the cause of the
ulceration.

During the last two years there had been gradual extension
of the ulceration until nearly all the cartilaginous septum had
been destroyed. There had been very frequent small and
occasional severe haemorrhages. The pain had apparently been
very severe on one or other side, and often it had been
accompanied by redness of the side of the nose. The swelling
of the septum had been very great, and it must have attained a
thickness of about one inch.

In March, 1901, she consulted Mr. Bond, who advised removal

52

of middle turbinal tissue so as to prevent the pain caused by the
pressure of the swollen tissue. In June I removed more of the
middle turbinals, and freely curetted the septal swelling.

Although there is relief as regards the nasal obstruction, the
pain still remains as severe as before.

Dr. Tilley said that the antra on both sides should be explored.
From the right antrum at about the position of ostium, there was a
small trail of yellow pus coming down. If there were pus in the
antra, as he thought possible, he felt sure that their drainage would
effect a considerable improvement in the condition of the nose. He
had recently seen in consultation the case of a lady addicted to the
cocaine habit, and who, under the influence of that drug, had picked
away the whole of the cartilaginous septum, so that the combined
nasal cavities were covered with a thin veneer of dried mucus and
scabs producing an appearance identical with that showed by Dr.
Bennett.

Dr. Dundas Grant considered it a tuberculous condition of the
septum. It might be lupus. It was too extensive for any form of
simple perforating ulcer.

Dr. Scanes Spicer asked whether the ulceration commenced on the
cartilage or on the bone. If the former he thought it was lupus, if
the latter, syphilis. He had had a similar case, and showed it at the
Society some three years ago. It had remained practically the
same.

Dr. Milligan thought it might be traumatic and the result of
picking the nose followed by extensive ulceration. Was there any
history to corroborate this view ?

Dr. Lambert Lack suggested it might be a case of syphilis. He
had never seen sinus suppuration cause a progressive destruction of
the septum, whilst in cases of nasal syphilis, sinus suppuration was
often seen.

Dr. Bennett, in reply, said there was no disease of the ethmoidal
or sphenoidal sinuses, and he should be astonished if the antra
proved to be affected.

ERRATUM.

69th Ordinary Meeting.

Page 19, paragraph ii, line 2, for “ lard ” read “ hard.”

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Seventy-first Ordinary Meeting, February 7th, 1902.
E. Cresswell Baber, M.B., President, in the Chair.

Charles A. Parker, F.R.C.S.(Ed.),)
James Donelan, M.B., /

Secretaries.

Present—37 members and 3 visitors.

The minutes of the preceding meeting were read and con¬
firmed.

The ballot was taken for the election of the following candi¬
dates, who weVe unanimously elected as Ordinary Members :

Arthur Roberts, F.R.C.S.Edin., M.R.C.S.Eng., Reading.

Herbert Elwin Harris, M.B., F.R.C.S., 13, Lansdown Place, Clifton.

The following report of the Morbid Growths Committee was
read:

1. On Dr. Milligan's case of fibro-sarcoma of the right vocal
cord. Shown on January 10th, 1902.

“ After examination of the specimen submitted, the Committee
report that they can find no sufficient evidence upon which to
base a diagnosis of fibro-sarcoma or malignant disease. The
bulk of the growth consists of fibrous tissue. The Committee
first series—VOL. ix. 4

54

suggest that the structures observed are the outcome of a slow
inflammatory process.”

2. On Dr. Milligan’s case of pharyngeal lipoma. Shown
on January 10th, 1902.

“ The microscopic examination confirms the diagnosis.”

The following cases and specimens were shown:

Case op Tuberculosis op the Larynx with marked Swelling
op the Thyroid Cartilage in a Man mt. 37.

Shown by Mr. Kichard Lake. The patient had been sent into
the Mount Vernon Hospital at the end of 1898, where he
remained for three months, during which period at least forty
pieces were removed from his larynx. The lung was only
slightly affected, and, as far as physical examination went, this
was entirely cured when the patient left the hospital. His
larynx also was cured, and remained so for about eighteen
months. During the latter half of 1901 he complained of
occasional swelling of his thyroid cartilage; this, however, went
down with a small amount of treatment, the interior of his
larynx never showing any signs of recurrence.

He was not seen again until about three weeks ago. The
condition was then much what was seen now : the thyroid
cartilage was enormously thickened, was rather hard, and
inclined to be uneven on its surface. Internally there was a
pointed or conical projection forwards of the right ventricular
band. He appeared to be more anaemic and thinner than he had
been three months previously. His voice was much worse than
it was; in fact, he could only make himself intelligible with
great effort, which effort was accompanied by pain.

The case was brought before the Society for an expression of
opinion as to the nature of, and best form of treatment fbr, the
disease of the thyroid cartilage.

Dr. Dundas Grant thought the condition looked like tuberculous
perichondritis of the thyroid cartilage, but the progress was certainly
rather slow. He had seen this in a case of laryngeal phthisis,
eventually resulting in an abscess, but, if he recollected the case

55

aright, its course was much less indolent than that of Mr. Lake’s case
As regards treatment, he suggested that the right course would be
to open it, and having explored, to drain and inject with iodoform.
It would be unfortunate if the whole thyroid cartilage were to come
away as a sequestrum, since the obstruction following that would be
very severe.

Mr. E. Lake said he last saw this patient only a fortnight ago, and
until then he had not seen the man for some time. The swelling was
not then so extensive, but much harder. Four months ago when he
saw him there was some temporary perichondrial trouble He showed
the case because he wanted suggestions as to what was to be done.

Case of Rhinorrhcea of some years’ duration in a Woman

mt. 38.

Shown by Mr. L. A. Lawrence. The patient had had discharge
of a clear fluid from the nose for many years. This followed an
attack of general oedema at the age of 20, probably of acute
renal origin.

The rhinorrhoea, from being occasional and fairly profuse, is
now nearly constant, except when the patient has cold, during
which time it stops almost entirely.

In 1895 she was seen several times by Dr. Edward Law, when
the nose was fairly clear and dry at the back. Her sense of
taste and of smell in those days was perfect.

Now she had largely lost these senses. Her nose on the right
side showed deflection of the septum to the right, and some
enlargement of the inferior turbinate bone, and a polypoid
condition of the mucous membrane covering the middle turbinal.

On the left side the same sort of condition existed, but the
turbinal swelling was more marked. The rhinorrhoea was more
marked on the right side, and was excited by any kind of
stimulus—draught, shutting a door suddenly, etc. Patient had a
very large appetite, and slept abnormally well during an attack.
She had had some vaso-motor disturbances about her fingers,
and analgesia of thighs and hips and upper arms, which was
more or less transient.

Local treatment for the nose had been tried—chromic acid
and alkaline douches, and the cautery—without avail. Internal
remedies—iron, arsenic, and strychnine—seemed to have done

56

more good; supra-renal extract had also been tried, but none of
them had given any certain relief.

The President suggested in reference to the question of treatment
that a trial might be given to the method he had employed in a case
he had shown to the Society three or four years ago, where the
rhinorrhcea was arrested by the application of the continuous current
externally to the nose. He looked upon the condition as a vaso-motor
neurosis.

Dr. Herbert Tilley thought the symptoms were the outcome of
some obscure local vaso-motor neurosis, but that failure to give
relief in this case should not be assumed until certain obvious patho¬
logical defects within the nose had been relieved. In the left middle
meatus was a polypus the size of a horse-bean, and similar chronic
inflammatory changes could be seen in the right nasal cavity, although
the exact definition of such changes was obscured by a very prominent
deflection of the septum towards the right side. It was highly
probable that the removal of such obvious pathological changes would
give at any rate partial relief to the symptoms.

Dr. H. Lambert Lace agreed with the last speaker as to the
condition of the middle turbinates, and considered the case just one
of those in which local disease in a neurotic subject was responsible
for the rhinorrhcea. The same local conditions in another patient
might not cause such symptoms. He thought that both middle
turbinates should be partially removed.

Mr. F. H. Westmacott said that the part which at first sight
looked like a polypus, having a glazed translucent appearance, was,
he thought, really due to some of the discharge having dried upon it.
On looking carefully one might see a condition of lobulated
hypertrophy of the middle turbinate bone. He had had a good many
of these cases, and had been struck with the advantage accruing from
removal of one or more of these protrusions of the mucous membrane
and applying pure carbolic acid every day for about a fortnight. As
carbolic acid was an anaesthetic, the application was painless, except
for a little momentary smarting. Patients stated that the anaesthetic
effect of the acid remained for quite twelve hours, and in some cases
for twenty-four hours. He found this treatment effected a consider¬
able diminution in the rhinorrhcea, and if, as in this case, the inferior
turbinals were not so much affected, a good deal of improvement took
place. As regards the mode of application, this was done by means
of cotton wool wound round the end of a wire probe; the wool was
dipped into the acid and then applied the whole way round the edge
of the middle turbinate bone.

Dr. Peqler said that no mention had been made of the deflection
of the septum to the right side, which was a source of trouble in con¬
tinually keeping up contact with the outer wall. The polypi of the
middle turbinate might be attributed to the general sodden state of
the mucous membrane. Glacial acetic acid would be a good
application to try in this case, but the result was not reliable.

Dr. Dttndas Grant said that the correction of the septal deviation

57

either by straightening or by removing a projecting part would be
very advisable for the purpose of manipulation of the deeper parts of
the nose. He did not think it likely that the septal defection was
directly one of the elements in the production of the trouble. The
attacks of so-called cold seemed to be almost daily, and answered very
much to the description of hypersesthetic rhinitis. He asked whether
adrenalin had been tried.

Dr. FitzGerald Powell was of opinion that this case represented
what was understood as hypertrophic rhinitis. The middle turbinate
was enlarged, and the inferior turbinal slightly so, and there was a
distinct spur on the septum. He thought that the only chance of
getting much relief would be to remove in some way portions of the
middle turbinate, either by shaving them off or by the use of the
cautery. Local application of washes, etc., in his opinion, would have
no effect until the abnormal portions referred to were removed.

Mr. L. A. La whence said that adrenalin had been tried, but with¬
out benefit. He was much obliged for all the suggestions that had
been made, but they were all offered with the idea of relieving the
nasal obstruction. With regard to that, he supposed that most of
them would agree that the nasal obstruction should be removed, but
was the nasal obstruction the cause of the rhinorrhoea ? That was
the important point. Many people had a deflected septum, or an
enlarged turbinate, or polypoid masses, but they did not suffer from
rhinorrhoea as a consequence. The patient was of an extremely neurotic
tendency. He was afraid if he followed all the advice given there
would not be much left of the interior of the nose. He wanted to
hear if there was any experience of cases of this nature having been
treated otherwise than by removal of obstructions and portions of the
turbinates, etc., and would welcome any suggestions of that sort.

Case of Lupus Nasi.

Shown by Mr. F. G. Harvey. The patient, a man set. 24, had
suffered from an obstruction to breathing in the right side of
the nose ten years ago. A swollen condition of the right inferior
turbinal was noticed at that time, and the disease had since
successively implicated the skin of the tip of the nose, the
posterior choana and pharyngeal roof on the right side, and the
epiglottis. The region of the inferior turbinal and the skin of
the nose had been cured by the use of the curette, but the
disease remained active in the roof of the naso-pharynx.

Mr. Parker said that this case had been under his care for many
years. He first saw the patient in 1894, when he came to the
hospital suffering from nasal obstruction of three years’ duration.
There was apparently, then,, an ordinary hypertrophic outgrowth from

58

the inferior turbinal. This was removed. Instead of healing the
wound became ulcerated, and assumed the characteristics of a tuber¬
culous ulcer. The chest was then examined, and well-marked signs
of phthisis discovered. It was an interesting point as to whether the
outgrowth originally removed was a tuberculoma or whether it was
hypertrophic, and whether, if the latter, the resulting wound had been
infected from the lungs. The ulceration had extended and affected
the pharynx, and in May, 1895,* the case was shown here as one of
“ tubercular ulceration of the nose and pharynx.” After this date
the patient developed typical lupus in the skin of the nose, and a
little later the epiglottis became affected. Meanwhile the condition
of the lungs improved, and then became quiescent. Whilst under
his care Mr. Parker had tried both local and general treatment, but
the only thing which did him any real good was a very severe attack
of erysipelas, after which he was very much better for a long time.
The speaker had last seen the case about three years ago, and he
thought the present condition was ver/ much as it was then.

Case op Partial Membranous Occlusion op the Right
Posterior Choana.

Shown by Dr. Lambert Lack. The boy, aet. 18, had thin
crescentic bands passing from the roof of the naso-pharynx down
towards the base of the nasal septum attached along the outer
side of the space, almost completely hiding the choana on the
right side, and less prominent on the left side. There was a small
perforation of the septum, and the boy said he had had a dis¬
charge of thick matter from the nose some years ago, but no
reliable history could be obtained.

The President had made a careful examination, but did not think
the partial occlusion was on the choana itself, but behind it. It was
a band extending up from the Eustachian cushion, and looked like a
cicatrix, but he was unable to obtain any history of an operation.
There was also perforation of the septum.

Dr. Scanes Spic er agreed with the President as to the membrane
being posterior to the choana and in the naso-pharynx; the band
extended upwards from the right Eustachian cushion to the adenoid
tissue at the apex of the right choana, and it had the appearance of a
cicatricial band, as frequently seen here.

Dr. Dundas Grant thought the case presented a great many
points of interest, and it would be valuable if Dr. Lack would
describe the history more thoroughly. The patient said that at one
time a mass of some sort came away from the back of the throat. It
was crumbly in consistence. After that he was able to breathe

* See ‘ Proceedings/ vol. ii, p. 83.

59

through the nostrils, although previously he was unable to do so
owing to the great obstruction. He thought that these partial web-
formations were cicatricial, but felt some difficulty in surmising as to
what it was which had come away. It might be simply some
inspissated cholesteatomatous matter, which was sometimes seen in
the nose, or it might be a soft rhinolith or a sequestrum. From the
deformity of the part he thought it quite possible that a small
sequestrum had come away.

Mr. Spencer thought the diagnosis turned on the question of the
septal perforation. The cicatrix seemed rather far back to have been
the seat of operative interference. The perforation was probably due
to inherited syphilis. Perhaps a sequestrum had come away, which
would explain the history given. There also had to be taken into
account the facial aspect and the eye symptoms.

Dr. StClair Thomson thought he could throw some light on the
perforation of the septum. He inquired of the man if he had had
an operation performed. He had. The patient had performed it
himself! He had in his pocket a horse-nail, which he had once
pushed up his nose. Dr. Thomson felt so sure on examining the
cicatrix that it was traumatic in origin that, when there was no
history of any operation by a surgeon, he cross-questioned the man
with the result stated. When he once had some nasal obstruction
the man pushed the nail up to relieve the obstruction; he then felt
something come away; this was followed by profuse haemorrhage.
From the appearance and the situation of the perforation, which was
not in the bony septum, but at the back of the cartilaginous part, he
thought the patient’s own explanation was a very probable one. He
would like to hear from Dr. Lack if he had put nis finger into the
choana, because he (Dr. Thomson) could not say from inspection of
the case that it agreed with the description of “ membranous occlu¬
sion.” It was situated entirely on a posterior plane, and there was
a somewhat similar condition on the other side. The occlusion really
extended from the cushion of the Eustachian tube up to the roof of
the pharynx. Such an occlusion was not uncommonly left by adenoid
remains.

Dr. FitzGerald Powell said it would be rather interesting to
get a portion of the band away and have it examined under the
microscope to make out the exact construction of the tissue. It
might be, as suggested, cicatricial tissue, but it was difficult to
explain exactly how it came to exist there. Whether it was a develop¬
mental growth and had always been there or whether it was a growth
of adenoid tissue arising in the fossa of Rosenmuller which had
become attached to the cushion of the Eustachian tube was doubtful.
If there had been nasal obstruction, and this was cleared up by some¬
thing coming away, it was probably a large crust.

Mr. Spencer doubted whether it was possible for the patient to
have pushed such a nail through a healthy septum. To have done so
there must have been previous ulceration or softening. He probably
pushed away a crust or sequestrum which was obstructing the nasal
passage.

Mr. Westmacott thought that a man could easily injure the

60

septum with a nail of that size. It was well known how easily an
ulceration in the septum following traumatism did spread through to
the other side and leave a typical perforation such as they had now-
before their notice.

Dr. H. Lambert Lace, in reply, regretted that the history was
incomplete and unreliable. He should say that the mass which was
said to come from the post-nasal space was probably a sequestrum.
He had put his finger into the space and had found a very definite
band with a concentric margin, which was quite different to anything
he had ever felt before in the adhesions which occurred in a man with
adenoids. He did not think it was due to adenoid growth, but more
likely to congenital syphilis.

Case of (Edema of the Larynx for Diagnosis.

%

Shown by Dr. Lambert Lack. The patient, a man aet. 40 r
had been in the London Hospital for three months suffering
from hoarseness and slight dyspnoea. The voice had been
affected now for nearly six months. There was no difficulty in
swallowing and very little expectoration. There was some
wasting, but the patient felt well and strong. There were no
physical signs of phthisis, and no tubercle bacilli had been
detected in the sputum.

On examining the larynx the right arytaenoid region was seen
to be an immense cedematous swelling, smooth and not ulcerated.
The oedema extended slightly to the right side of the epiglottis.
The left arytaenoid appeared normal, but was partly hidden b}’ the
swelling on the right side. The interior of the larynx could not
be seen.

Mr. W. G. Spencer thought the diagnosis of this case very-
interesting. It looked almost as if it were a malignant condition,
but there were no glands in the neck, and in epithelioma in that
particular region the glands in the neck were so early enlarged; in
fact, very often the glandular enlargement preceded the discovery of
primary epithelioma. The disease could not very well be tuberculous
owing to the length of the history and the absenoe of glands in the
neck. He was therefore of the opinion that it must be of syphilitic
origin.

Dr. StClair Thomson had shown a very similar case to the Society
about a year ago. It ran a very erratic course. Several members
thought it might be malignant. He watched the patient and had to
perform tracheotomy later on. Very soon afterwards the patient’s
health broke down, and he died of tuberculosis, bacilli having been

61

found previously. Dr. Horne had possession of the larynx. The
post-mortem examination was confirmed by sections.

Dr. H. Lambert Lack .said he brought the ease forward because
he could not arrive at a diagnosis. The case had been thoroughly
treated with iodide of potassium and mercury, and he had been kept
in bed in hospital for three months. There were no tubercle bacilli,
and further, if the case had been tubercular in nature, it would
probably have got markedly worse under iodides. The man was
wasting. He did not know if sarcoma was a possible diagnosis, but
it might have to be taken into account.

Case of (?) Syphilitic Ulceration of Soft Palate occurring
during a Course of Antisyphilitic Treatment.

Shown by Mr. Atwood Thorne. The patient, a man rnt. 23,
contracted syphilis in May, 1901, since when he had been
treated with mercury, and latterly with mercury and potassium
iodide by the mouth. After eight months’ continuous treatment
he was found to have deep ulcers on the soft palate, and despite
active local treatment with silver nitrate the patient had got
worse and lost his uvula and a part of the soft palate; he looked
exceedingly ill and was very feeble. He complained that he
had lost a great deal of flesh, and had some difficulty in swallow¬
ing. On examining the throat, the uvula and part of the soft
palate adjacent to it were now missing, the edge of the remaining
portion being covered with a dirty white slough, and on the
posterior wall of the pharynx and on the posterior edge of the
septum nasi there was a yellowish thickened exudate. Crepita¬
tions wei*e heard at both apices, but no tubercle bacilli could be
found in the sputum. Antisyphilitic remedies had been stopped,
and every endeavour made to feed up and strengthen the patient.

Mr. Thorne asked for the opinions of the members on the
nature of the case; personally he took it to be at any rate due
partly to syphilis, but was surprised that the condition should
commence while the patient was being actively treated for
syphilis.

Dr. StClair Thomson would like to hear again what treatment
the man was having. He looked very cachectic, and as if he would
not stand very much. He regarded the case as one of syphilis only.

Dr. Dtjndas Grant thought there was a tubercular element in

4 §

62

this case. They knew that occasionally in secondary syphilis ulcera¬
tion and destructive lesions occurred, but they were very uncommon.
The very extreme ulceration occurring so soon in the course of the
disease, together with the general characteristics of the patient, made
one ask if there were any further evidence of tuberculosis.

Mr. Spencer said it might be a “ mixed ” case of tubercular-syphilitic
infection. If the iodide were continued the man would certainly die.
He recommended keeping the patient in bed and putting him on the
“ tonic ” treatment; very little mercury should be given.

Mr. E. Lake thought it was a perfectly straightforward case of
syphilis without any question of tuberculosis. He did not think twelve
months so very short a period for even such extensive lesions as were
present in this case, for ulceration might commence early and be
followed by severe destruction of tissue when a case was going to be
really severe.

Dr. Lambert Lack agreed with the previous speaker’s remarks.
It was purely a case of syphilis, and if the man were treated by being
put to bed and fed on plenty of milk and eggs, with a little anti¬
syphilitic treatment, in a month he would be practically well.

Dr. FitzGerald Powell thought that large doses of iron and
strychnine were very necessary in such a case as this. He had found
that iodide of potassium and mercury in cases where a man was in an
anaemic condition were worse than useless. If it were possible he
would send this man to the seaside, and as he improved in health, in
addition to the iron and strychnine, he would give him just a little
iodide of potassium and mercury; under this treatment he would
soon get better.

Mr. Atwood Thorne, in reply, said that on examining the chest,
he found distinct evidence of phthisis, but there were no bacilli in the
sputum. While the man had the chancre, he was put on mercury,
but during the last month a small amount of iodide had been added.
He thought it was a mixed case and would feed the man up and give
him small doses of iodide and mercury.

Case of Myeloma of the Nose in a Woman .et. 30.

Shown by Mr. Waggett. The patient, previously quite
healthy, began to notice nasal obstruction in June, 1901, three
months after confinement. Obstruction increased until, at the
time of* her first visit, in October, the right side had become
completely blocked, and epistaxis was frequent.

On examination the right nostril was found to be filled by a
large dark red growth, with an intact smooth surface, feeling
elastic to the touch, and bleeding readily. The right eye was
more prominent than the left. Under an anaesthetic the large

tumour, which completely filled the nose, was removed piece¬
meal and without serious haemorrhage. The tissue was dark in
colour, of firm consistence, and contained a sponge-work of bony
trabeculae.

Microscopic examination showed the structure to be typical
of myeloma, containing numerous giant-cells (specimen ex¬
hibited). During the operation it was found that the growth
had created a smooth-walled pressure cavity encroaching upon
the orbit. Proptosis disappeared within two days of operation.
In consequence of the microscopical diagnosis of tumour of only
a local malignancy, a more radical operation was undertaken a
few days later.

The seat of origin of the growth seemed to be in the region of
the middle turbinate or of the unciform process. Rouge’s
operation was therefore performed, the anterior wall of the
antrum and part of the septum were cut away, and the greater
part of the inner wall of the antrum and of the inner wall of
the orbit was removed.

The exact anatomy of the parts, deformed by encroachment
of the tumour and obscured by free haemorrhage, could not be
determined, but apparently a thorough removal was made of all
suspicious tissue. Free access could not be obtained until
laryngotomy had been performed and the gag removed from the
mouth. Apart from the effects of orbital luemorrhage the
patient did not suffer much from the operation, and healing took
place within the nose very rapidly. This process was accom¬
panied by so marked and rapid a diminution in the size of the
cavity that suspicion was aroused that the restriction was due
not merely to cicatrisation, but to recurrence of the growth.
Opinions were invited upon this question. Against the diagnosis
of recurrence were the healthy appearance of the mucous mem¬
brane, the absence of epistaxis and want of any noticeable
change during the last six weeks. The operation was performed
early in November. The general health was excellent apd pain
absent.

9

Mr. W. G. Spencer would not say that the growth had recurred,
he would wait till it bled continuously, for these tumours were very
vascular. The nose required to be kept very clean as in atrophic
rhinitis.

64

Dr. H. Lambert Lack asked if the nose was still gradually closing,
because if that were so it might be due to recurrence. He did not
think it would be possible to do any more if a recurrence took place.

Mr. E. B. Waggett said, in reply to Dr. Lack, that he thought the
contraction took place during the first month, and that it was not
contracting now. Three months had now elapsed since the operation.
The contraction was especially noticeable in the region of the right
choana where the septum seemed to pass away into the outer wall
of the nose, which was precisely the part not affected, so that he
was in hopes that the structures were cicatricial and not evidences
of regrowth.

Tertiary Syphilis of the Pharynx and Larynx ; Phonation
with the Ventricular Bands.

Shown by Dr. H. J. Davis. The patient, a groom set. 31, had
laryngeal ulceration when the subject of secondary syphilis three
years ago. He was admitted into the Middlesex Hospital two
years ago for urgent dyspnoea, the swelling of the right ven¬
tricular band being so great as to almost occlude the glottis.
Ulceration followed and stenosis had resulted.

His present condition showed ulceration of palate, which had
a peculiar worm-eaten appearance, fixation of the true cords,
phonation being accomplished by the ventricular bands.

Laryngeal Tuberculosis, with Granulation Tissue between

the Cords.

Shown by Dr. H. J. Davis. The patient, a woman ast. 25,
had pulmonary tuberculosis in the quiescent stage, and well-
marked signs of the same disease in the larynx. She had lately
undergone an open-air treatment, and had benefited materially.

At present, where there had originally been ulceration, a
granulating mass extended downwards between the cords, Avhich
were thickened and fringed with granulations. On phonation
the cords encountered the obstruction, the muscles failed to
overcome it, and the cords quivered and then sprang apart.

The voice varied from a deep croak to a mere whisper, but the

65

patient stated that in wet weather the voice was always improved.
Pallor of the palate was well marked.

Dr. Jobson Horne said the appearance of the larynx in this case
was interesting and rather unusual. The tissue between the cords
was described as granulation, but he would like to ask whether any
member might feel disposed to speak of it as a tuberculoma.

Dr. H. J. Davis said there had previously been ulceration in the
same position, and lactic acid had been rubbed in, but during the
time the woman had been away undergoing the open-air treatment
granulation tissue had grown on the surface of the ulcer.

Case of Abeyance of Nasal Breathing in a Female a^t. 23;

Nasal Passages Free ; Hysterical Aphonia ; Rhinalgia.

Shown by Dr. Peglek. The patient had been shown in 1899
for functional aphonia and recurrent apsithyria, which still
persisted. Soon after that occasion she had developed mouth
breathing, and her speech, though aphonic, became “ clipped/’ a
defect known as Rhinolalia clausa. There being a pad of
adenoids and considerable turbinal hypertrophy in both
chambers, these impediments to nasal breathing had been
radically eliminated, but instead of the patient gaining any
benefit, the above-named symptoms grew worse, and so they
remained. Rhinalgia had been much complained of, especially
recently ; the mouth was always open, and the breath was
peculiarly disagreeable, possibly owing to this fact. Before
speaking, with a view, perhaps, to getting some use of her nose,
she made a clicking kind of sound with her palate. The velum,
on inspection, appeared paretic, but the exhibitor had no
hypothesis to offer, especially in the light thrown upon this case
by the next one, except that the nasal breathing and resonance
were shut off by spasmodic contraction of the soft palate.

The photograph marked 1 showed this patient before her
various hysterical symptoms set in, and when she was teaching
in a school; the mouth was closed, and the expression highly
intelligent. No. 2 photograph had been taken recently, and
showed a very marked deterioration in this respect, with open
mouth and dilated alae nasi.

66

The President thought it a “ hysterical ” case. One had seen
such cases, in which people occasionally talked without using their
noses although there was no obstruction, and were unable to pro¬
nounce “ ni ” and “ n,” and converted these letters into “ b ” and
“d.” He put down similar cases he had seen to neurosis of
the palate. Dr. Pegler thought that in his case there was a
spasm of the palate, but whether that was proved or not he was not
aware.

Dr. Scanes Spicer thought this case a very important one. Dr.
Pegler had quite satisfied him personally that there was now no
organic obstruction, and yet, when the mouth was closed, no air
entered on the patient attempting to inspire. After a time, unable to
do without air any longer, she opened the mouth and violently
inspired. The explanation appeared to be a functional spasm of the
soft palate and pharynx—a hysterical contraction at a time when
normally there should be a relaxation or yielding to the incoming air-
current. It might otherwise be regarded as a hysterical holding of
the breath by the soft palate. There was evidence of hysteria in the
adductor laryngeal paralysis, so that apparently there was in this
palatal spasm another instance of perverted respiratory rhythm'
parallel to what was occasionally seen in the larynx in hysterical
•subjects. The case demonstrated without doubt the abeyance of
nasal respiration without any organic obstruction in the nasal
passages to compel such abeyance. He thought the patient would be
benefited by treatment of the causes of obstruction he had pointed
out. Perhaps stretching the soft tissues of. the alae, followed by the
use of rubber dilators at night, and education of the dilator muscles,
would be ample. As to the soft palate in this case, he thought it was
paretic rather than spastic.

Mr. Waggett suggested that the woman should be treated like a
hysterical person with aphonia, namely, by forcing her to breathe
through her nose by shutting the mouth and tying it up.

Dr. FitzGerald Powell said that as the patient could blow out a
spirit lamp held under the nose whilst her mouth was closed, there
could be no real obstruction. Apparently the soft palate seemed to
suffer from some neurosis just in the same way as the cords suffer
from neurosis in functional aphonia. There was a greater or less
degree of post-nasal catarrh with a good deal of mucus coming down
from behind, and probably the palate was in a more or less rigid
condition. He hoped to be able to show a similar case at a future
meeting suffering from functional obstruction to the breathing. The
nose had been cleared of all objective causes of obstruction, but
nevertheless the breathing had become worse.

Dr. William Hill thought that in this case there was a want of
co-ordination between nasal inspiration and the muscular actions of
the palate and pharynx.

Mr. Atwood Thorne said that as the patient had a good current
of air up and down both nostrils, he would advise breathing exercises
with a forcibly closed mouth, and the usual general treatment for
hysteria.

Dr. Dundas Grant said that in this case there was a condition of

67

anaesthesia ; as the patient did not. feel the air which passed through
the nose, she therefore did not think it did pass.

Dr. Jobson Horne inquired whether the possibility of tuberculosis
had been entirely excluded as a factor in the aphonia.

Dr. PEGiiER agreed with Dr. Hill, and thought the term hysterical
inco-ordination of the muscles of the soft palate and pharynx would
supply what was wanted in that regard. It was remarkable that
since the nasal operations the symptoms had been aggravated; this
might be due to the influence of auto-suggestion.

Cask of Abeyance ok Nasal Breathing, the Passages being
Free, Palate and Faeces Hyi’Er.esthetic.

Shown by Dr. Pegler. A. G—, a?t. 81, came to the Metro¬
politan Ear, Nose, and Throat Hospital a few days ago complain¬
ing of her speech. (“ Her bother said there bust be subthig
the batter with her throat because she always spoke through
her dose.”) Patient dated the defect from November last, when
she was sent to the North-Eastern Hospital as a case of supposed
diphtheria. On her return she states that in drinking fluids
returned through her nose. Dr. Cuff, however, assured the
exhibitor that the case was one of tonsillitis only, and that three
separate cultures failed to disclose any Klebs-Loeffler bacilli.

The mouth is kept open constantly. Examination of the nose
and naso-pharynx gives a negative result in so far as explaining
the total absence of nasal breathing and resonance were con¬
cerned. The pharynx was so irritable that repeated cocainisa-
tion was necessary in order to gain a satisfactory inspection of
the post-nasal space. There was no nasal anaesthesia, but pain
was complained of over the bridge. There was paraesthesia of
the pharynx in the form of a pricking sensation in the throat,
and the patient was constantly “ clicking ” and “ hemming.”
Following the suggestions made in Dr. Lermoyez’s paper on a
similar case, Dr. Pegler closed the patient’s mouth with his hand,
when she held her breath till cyanosis set in, but after a violent
effort the patient respired through the nose. Suspecting that
palatal spasm was operating here as in the last case, Lermoyez’s
other experiment was tried, and the palate tied up by a tape
passed through the nose, naso-pharynx, and mouth, the two ends
being secured over the upper lip. After a slight effort the patient

68

breathed comfortably through the nose, her mouth being closed.
The (moral) effect of this treatment was permanent, for the
speech defect was now nearly absent. The photograph marked
A shows this patient prior to her throat attack; the mouth is
closed and the features natural. B shows the patient taken
previous to treatment the other day, and is in obvious contrast
to the former one.

Dr. Scanes Spicer took exception to Dr. Pegler describing the air-
passages in this case as being entirely free, since insufficiency was
proved by marked collapse of right ala on inspiration. There were
three objective causes of obstruction : (1) the right nostril was a slit,
and the ala collapsed on that side on attempting inspiration ; (2) the
septum was deflected, the. deviation being sigmoid; (3) there was
enlargement of the right middle turbinate with dry crusts. Certainly
this case could not be placed in the same category as the previous one.

Dr. Vinrace said that regarding the doubt as to whether this
patient had had diphtheria, he would like to point out that the
regurgitation of fluids through the nose after the attack was, to his
mind, stronger evidence in favour of diphtheria than the failure to
find bacilli was against it. He would like to know whether this
condition was or was not the result of diphtheria.

In reply to Dr. Vinrace, Dr. Pegler said he was content to accept
Dr. Cuff’s assurance with regard to the absence of diphtheria, besides
which no point was made supposing the disease had existed; there
might have been a paretic palate in the first instance, but the speech
and breathing defect pointed to the opposite condition of spasm.

Dr. Vinrace remarked that if one searched for the bacillus and
failed to find it, it did not follow that the patient had not had
diphtheria.

Dr. Pegler, replying to Dr. Scanes Spicer, said he was sorry that,
he could not persuade that gentleman to regard the case in the same
light as he did. The unilateral insufficiency was not of a kind that
he should treat by operation, seeing that an armed probe passed
comfortably through the narrower chamber, whereas in the companion
one he was able to discern the pharyngeal wall easily without the aid
of cocaine. As in the previous case, he looked to the vagaries of the
tensor and levator palati muscles for an explanation of the pheno¬
mena, and thought the simple experiment of tying up the palate was
conclusive in its result. Kyle alluded in his book to spasmodic
affections of the palate, and in this case there were other evidences of
choreic or spasmodic action in the upper air-passages. The inspection
of the larynx showed contraction of the ventricular bands on phona-
tion, which perhaps explained the hoarseness of the voice.

69

Case of Progressive Ulceration of the Nose.

Shown at the last meeting by Dr. Bennett. It had been
suggested at the last meeting that the ulceration of the septum
might have been due to antral suppuration. Dr. Bennett had
therefore explored, but found no discharge.

Case of (Edema of the Larynx with Thickening of Palate,
Uvula, and Fauces in a Boy jet. 10.

Shown by Mr. F. Hunter Tod. This case was under the care
of Dr. Percy Kidd at the London Hospital. The boy’s mother
had noticed that for two years he had breathed through his
mouth, and was very noisy in his sleep. Between October and
December, 1900, he had had four operations on the tonsils and
the back of the throat, but without relief. There had been
wasting and day and night sweats, and difficulty in breathing at
night.

At the present time the patient was thin, pale, and pigeon¬
chested. There was slight bronchitis, but no signs of pulmonary
phthisis. The temperature was normal. No bacilli had been
found in the sputum. There were no signs of congenital syphilis.
There was laryngeal stridor, which was much worse at night,
accompanied by retraction of the chest, but cyanosis had never
occurred. Examination of the larynx showed enormous enlarge¬
ment of the epiglottis, which was smooth and of a pale colour,
and prevented a view of the interior of the larynx being seen.
The tips of the arytaenoids could be seen, both, but especially
the left which seemed fixed in the middle line, being pale and
much swollen. No ulceration was visible. The condition had
remained unchanged since admission to the hospital four weeks
ago. The uvula was much enlarged and oedematous, and there
was considerable thickening of the palate and fauces. Mr. Tod
suggested that the diagnosis rested between tubercular laryngitis
and congenital syphilis, and that the patient should be fed well
and given antisyphilitic treatment, and that tracheotomy should
be performed if it should become necessary.

70

The President said the condition reminded him of congenital
syphilis.

Mr. Spencer said this was an interesting case, but he did not
know what its origin was. There was some danger of his dying of
suffocation suddenly one night. Something ought to be done to avoid
this; for instance, tracheotomy combined with rest for a time, and
careful treatment on the same lines as those proposed by Hunter
Mackenzie for laryngeal growths in children. One might, in addition,
remove the tonsils, and the lower pharynx, including the epiglottis,
might be lightly scarified, and astringents rubbed in or cauterised.

Dr. Dundas G-rant asked if any albumin had been found in the
urine. He had shown a case (March, 1897) to the Society of a boy
who had had scarlet fever, with subsequent albuminuria, in which the
oedema persisted very much as it had done in Mr. Tod’s case,
although he had some suspicion that the boy was the subject of
inherited syphilis. He asked whether tuberculosis had been excluded
in Mr. Tod’s case. Tuberculin might afford information in a case of
great doubt.

Dr. Powell considered it a case of hereditary tertiary syphilitic
infiltration, and would like to hear if the boy had been put on anti¬
syphilitic treatment. If not, he suggested that the boy’s general
health should be attended to by tonics, and that then antisyphilitic
treatment should be employed. If there was any danger of laryngeal
spasm tracheotomy ought, of course, to be done. At present there did
not seem to be any spasm.

Mr. Lake said he would give the boy Hyd. c. Creta. 1

Mr. Hunter Tod said that Dr. Percy Kidd was inclined to think
that it was a case of tubercular laryngitis, although there was 1

no sign of pulmonary phthisis nor tubercle bacilli in the sputum.

He had not been put on antisyphilitic treatment because he wished ^

to see the effect of good diet and tonics. On admission there was so
much laryngeal obstruction that tracheotomy was nearly performed,
but at present there was no danger of suffocation as the boy could sit
up all day quietly, and could sleep all night in the recumbent
position.

Ethmoidal Suppuration in a Man complaining op Excessive

Pain.

Shown by Mr. Waggett. The patient had been under treat¬
ment for some years. The greater part of the ethmoidal cell
region had from time to time been removed. Both frontal
sinuses had been opened and found healthy. Very severe
frontal and vertical pain was complained of, and suggestions for
treatment were- asked for. A marked neuropathic element was
present.

71

Dr. Vinbace wished to know what were the indications for the opera¬
tive treatment of the frontal sinuses which had been resorted to twice
in this case, and what were the beneficial results which were claimed
after each of these two operations. Further he did not see why the
left side had been interfered with when it was the right side on which
there was the nasal obstruction. In the first instance it seemed that
vertical headache was the prominent symptom, and in the second
instance there was supra-orbital pain on the left side; and subse¬
quent to the second operation, new symptoms had been introduced,
and he would like to know if these were to be attributed to the second
operation. As far as he could ascertain the sight had been affected
and the patient was very giddy. It was very gratifying to him to
hear of such good results following these operations, but the perplexing
point was that, according to the account of the patient, when the first
operation was done, the only pain he had was that of vertical headache,
there being an absence of symptoms in the region of the frontal sinuses.

Dr. Lambert Lack thought the mau had now had sufficient done
to the nose, and the results of the operations were good. The man
was now suffering from neurasthenia.

Dr. Jobson Hobne said that this man was under his care for some
few weeks after being under the care of Mr. Waggett, but he could
find no sufficient cause for operating, and he thought that was the
reason why the patient left him. The patient seemed to attach too
much importance to his symptoms, and he advised him to undergo no
further treatment for a while.

Dr. FitzG-ebald Powell said that this man had also visited him.
He came to him after leaving Mr. Waggett, but he had only seen the
man once; he did not recommend active enough measures. It was
evident that there must be some considerable amount of pain in the
frontal sinuses or forehead, whatever might be the cause of it, or he
would not be so persistent in complaining of it. He suggested to Mr.
Waggett putting in a seton, as in some cases frontal headache had
been considerably relieved thereby. If the patient had remained under
his care, he would have put in the back of the neck an ordinary tape,
which might have had the effect of removing the pain to some extent.
He would like to hear whether the frontal sinuses had been obliterated
by operation.

Mr. F. H. We8Tmacott asked whether it was not an experience
quite commonly found after operation in cases of frontal sinus disease
that the patient did very well lor a time; the discharge ceased and
the patient became apparently well. But after a time there was a
periodical recurrence of the symptoms as regards the pain, etc., and
yet on looking into the nose there was nothing, or very little, to
account for the recurrence. In one or two such cases he had given
considerable relief by simply passing up a cannula into the infundibu¬
lum and inflating the frontal sinus, after which the pain went away
instantly. If in two or three weeks the patients again complained of
their pain he repeated- the process and with the same temporary suc¬
cess. He had come to look upon this state of affairs as very largely
due to neurotic causes. There might be some foundation for the pain
no doubt in local congestion.

72

Mr. Waggett said that this man had in the first place ethmoidal
suppuration, and in the second place he was undoubtedly a hypo¬
chondriac of the worst type. He had treated him according to the
rules of rhinology, with the exception that he had not yet explored
the sphenoidal sinuses. The frontal sinuses were explored as severe
frontal pain and tenderness were experienced, and the ethmoidal cells
in the neighbourhood were suppurating.

Case of Subjective Nasal Obstruction.

Shown by Dr. Dundas Grant. Miss E. E—, set. 34, was first
seen by Dr. Dundas Grant on Feb. 6th, 1902, when she com¬
plained of a feeling of suffocation and inability to breathe
through the nose. The right nasal passage was almost normally
free, and the left one patent to an abnormal degree. There was
considerable atrophy of the left inferior turbinated body, the
posterior wall of the pharynx and the “ arcade ” of the posterior
choana being visible to a considerable extent. There was a very
slight tendency to alar collapse, but not sufficient to interfere
with breathing. The mucous membrane was abnormally tolerant
of manipulation with the probe, and in fact there was a con¬
siderable degree of anaesthesia. The exhibitor attributed the
subjective obstruction to this anaesthesia. The patient did not
feel the air passing through the nose, and had consequently
acquired a fixed idea that it did not do so, and that she could
therefore only breathe through the mouth. Dr. Grant said
that this was the mechanism of many cases of subjective nasal
obstruction.

Dr. Scanes Spicer was of opinion that there was marked in¬
sufficiency of passages in this case, due to stunted evolution of the
nostrils, and there was collapse on inspiration. He thought the
insufficiency would be overcome by dilation, wearing rubber tubes, and
re-establishment of normal action of nasal inspiratory muscles. When
this was done he believed, from his experience of similar cases, that
the patient’s sense of stuffiness would disappear.

Dr. Dundas Grant said the patient was a very highly neurotic
subject, and there was some, though not very great, tendency to
collapse of the alee. The left nostril, in his opinion, was at all
events abnormally patent, and there was ample room for breathing
purposes if only she were conscious that the air could go through.

73

Considerable anaesthesia of the nasal mucous membrane was present
on both sides, and he believed this was a large factor in many of
these cases.

A Specially Constructed Glass Tube for the Inhalation of
Medicinal Powders into the Larynx.

Shown by Dr. Dundas Grant. A glass tube of about 6 inches
in length is bent at one end into a crook of about \ inch, while
inches of the other extremity are bent downwards at an
obtuse angle. The short crook, lying downwards, is pushed by
the patient to the back wall of the pharynx, and the opposite
extremity is allowed to dip into a small quantity of light powder
in a watch-glass or plate; the patient then closes his lips and
draws in his breath rapidly through the tube so as to inspire
some of the powder. This, following the inspiratory blast, finds
its way, according to the inventor of the method, into the larynx.
It is a method of great simplicity, and has the advantage that it
can be carried out by the patient himself under the direction of
his medical adviser. Its inventor, Dr. S. Leduc, of Nantes,*
strongly recommends the use with it of the powder known as
di-iodoform, and he deprecates the employment of crystallines
such as those of ordinary crystallised iodoform. Dr. Dundas
Grant had used with it orthoform and resorcin, and had seen by
the laryngoscope the powder adhering to the interior of the
larynx. It had given great relief to several patients with
laryngeal phthisis to whom he had given it.

Mr. A. J. Hutchison said that these tubes were not new, for he
had known of them for four years. They were brought out first on
the Continent, either in France or Germany. To the small extent he
had employed them he had found them very useful.

Wooden Probes and Cotton Carriers.

Shown by Dr. StClair Thomson on January 10th, 1902. Dr.
Thomson had met with these wooden probes in a throat clinic in
* See * La Gazette medicale de Nantes,’ 16 novembre 1901.

74

Germany last summer. There was nothing particularly novel
in them beyond the fact that they were remarkably cheap and
reliable. They were cheap because they were originally manu¬
factured wholesale for use in the making of sausages, and were
known as “ Wurststabchen,” and were carefully sterilised under
Government control. They could be cut in suitable lengths, and
were useful as probes for applying caustics, as cotton carriers,
and for other purposes. When cotton-wool pledgets had to be
left in the nose, it was much easier for the patient to remove
them if the cotton were first wound round a wooden probe which
was then cut off flush with the orifice of the nostril. These
wooden probes were kept in stock by Messrs. Mayer and Meltzer,
and by Mr. Rogers, of Oxford Street.

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Seventy-second Ordinary Meeting, March 7th, 1902.
E. Cresswell Baber, M.B., President, in the Chair.

Charles A. Parker, F.R.C.S.(Ed.),l 0
James Donelae, M.B., 'Secretaries.

Present—34 members.

The minutes of the preceding meeting were read and con¬
firmed.

The following cases, specimens, and instruments were shown :

Case of Complete Recurrent Laryngeal Paralysis in a Male

JET. 24 WHICH HAD REAPPEARED AFTER A PERIOD OF RECOVERY.

Shown by Dr. FitzGerald Powell. This patient was first seen
on December 30th, 1901, complaining that he had lost his voice
quite suddenly on December 28th. He could give no explanation
as to the cause, unless it were strain from singing.

He further stated that in February or March of 1901 he had
lost his voice quite suddenly in the same way. At this time he
was not feeling very well, and three or four days after the voice

FIRST SERIES-VOL. IX.

o

76

became affected he had a severe cold, with rise of temperature,
which was considered by his doctor to be due to influenza.

On this occasion he was under treatment by Dr. Bronner,
of Bradford, and after three months his voice returned com¬
pletely, and had kept quite strong until December 28th last, when
he again lost it.

There was no history or evidence of syphilis, and nothing
abnormal could be found in the chest. He complained of
periodic headache and attacks of supra-orbital neuralgia. He
had a spur on the right side of the septum nasi and a polypus
causing nasal obstruction.

The most careful examination and investigation of his case
failed to give the slightest explanation of the cause of what was
found in the larynx, viz. complete paralysis of his left vocal cord,
which hung in the cadaveric position, the inner edge of the cord
being curved with the concavity towards the median line.

So far as could be observed there was an entire absence of
the usual causes which produce this paralysis.

As regards treatment, the spur on the septum had been
removed and the polypus snared, and he was placed on iodide of
potassium up to twenty grains three times a day, and strychnine
had been administered.

On February 19th the paralysis was still complete, but on
March 5th there was some movement in the cord, and the patient
stated that on February 22nd his voice had suddenly improved
and was now much better, though still hoarse and weak.

The same treatment is being continued.

Sir Felix Semon suggested that the most likely explanation of the
occurrence of the paralysis in such a case was peripheral neuritis.
The history in this case of influenza would be quite sufficient to
account for the occurrence of the first paralytic attack. The nerve
being afterwards left in a weakened state, recurrence of the paralysis
on slight provocation was no unlikely sequel; some extra vocal effort
on the part of a patient or a cold would be sufficient to produce such
a recurrence. It was now becoming a general opinion that peri¬
pheral neuritis was a rather frequent cause of laryngeal paralysis.
He had lately read a very interesting monograph by Cahn, of
Strassburg, endeavouring to establish that the most frequent cause
of laryngeal paralyses in tabes was peripheral neuritis. At any rate,
it was a subject well worth any one’s while to follow up.

Dr. FitzGerald Powell thanked Sir Felix Semon for his remarks

on the causation of the alternating condition of this case, but he
would like to hear from lijm what was the cause of the peripheral
neuritis. Did he look on influenza as the cause, although there was no
definite history of the patient having had it previous to the first
attack, and he certainly had not had it on the last occasion of the
paralysis ?

Sir Felix Semon said, in reply to Dr. Powell’s question, he regarded
the toxin of influenza as the cause of the peripheral neuritis.

Case of Hematoma of the Vocal Coed in a Female et. 29.

Shown by Dr. FitzGerald Powell. The patient was first seen
on March 4th, complaining of hoarseness and loss of voice,
which came on suddenly in February of this year. On examina¬
tion of the larynx the left vocal cord was seen to move very
sluggishly on phonation, and an extravasation of blood was seen
in its whole length, forming w r hat he might describe as a
“ haematoma of the cord.” The nose, pharynx, and larynx
were the seat of chronic inflammation. The patient had lost her
voice three years ago, but it returned after six months’ treat¬
ment.

Dr. F. de Havilland Hall asked if the attack of haemorrhage
coincided with the menstrual period, or whether there was any
catamenial disturbance, because most of these cases occurred in women,
and either coincided with or preceded the catamenia, or else some
menstrual disturbance.

Dr. Dun das Grant said it would probably be within the memory
of some of the original members of the Society that he had showed a
case identical with Dr. Powell’s case at one of the earliest meetings,
in which the heematoma recurred on several occasions. To the best of
his recollection it was associated with menstruation, but he had not
had an opportunity of looking up the notes, and would not therefore
speak with certainty on this point. The case was reported in the
‘ Proceedings ’ of the Society.* Ultimately a small angeioma near
the junction of the anterior and middle third developed on the upper
surface of the left vocal cord. The patient had gone to South Africa,
aud he did not know what had happened since.

Dr. J. Donelan thought the case was the result of influenza, from
which the patient was still suffering; she had the characteristic eye.
He had had two cases under his care—both the patients were men—
in whom the haematoma had followed influenza and severe coughing.
Some of the subglottic veins were enlarged, and from these tracheal
haemorrhage had also taken place.

* See vol. i, p. 2.

78

Dr. FitzGerald Powell regretted to say that though he had
promised to inquire with regard to the menstrual periods he had
forgotten to do so, but he would ask the patient the next time he saw
her. So far as influenza was concerned, he supposed the last speaker
hardly wished to infer that influenza was the cause of the extravasation
of blood otherwise than by causing trauma from coughing.

A Modification of Mackenzie’s Laryngeal Forceps for
Removal of Growths in the Anterior Commissure and
Drills for draining Maxillary Antrum through Tooth
Socket.

Shown by Dr. FitzGerald Powell. The forceps were simply
Mackenzie’s laryngeal forceps with the cutting ends turned
forwards. He found that they were useful in removing growths
from the anterior commissure, and he thought others might find
them useful in cases where there was a difficulty in removing
these growths with the straight forceps. At the same time he
did not claim any “ proprietary rights ” in the instrument, which
Avas Mackenzie’s with the slight alteration mentioned. The chief
point of interest in the drills was their size, the largest being
the size of a No. 14 silver catheter; these drills, he thought,
provided a means of curing the great majority of cases of
empyema of the antrum. They made a large opening through
the tooth socket, after extraction of the first molar or second
bicuspid, through which a tube could be introduced, and through
which the antrum could be freely curetted and washed out. He
thought there were only a few cases in which what is known as
the radical operation was required.

The President thought that unless more than one tooth was
extracted the drill and tube were rather large to get in without
damaging the teeth at the sides of the socket.

Dr. StClair Thomson presumed that the exhibitor, in claiming that
the majority of cases of empyema of the antrum might be radically
cured by drainage through the tooth socket, included only those cases
in which none of the other cavities were affected. At one time he
himself was inclined to enlarge the alveolar opening, but he came to
the conclusion that it was not the size of the opening that was of
importance in effecting a cure, because when one had had consider¬
able experience in opening antra, one found that there were many
cases in which a large drainage through the alveolar border would

79

never overcome the difficulties. He referred to those cases with
dissepiments from the floor, or with the mucous membrane in so
altered a condition that suppuration was liable to be started again by
the first fresh infection. Perhaps Dr. Powell did not mean that the
cases were 'permanently cured.

Dr. Dundas Grant, in referring to the alveolar perforation, said
he generally made use of a hollow trephine, the advantage of which
was that it cut out the piece of bone which one removed instead of
sending it or the bone-dust into the antrum. On one occasion, how¬
ever, when he fancied he must have used almost excessive speed with
it, there was actually a sequestrum of a little piece of bone around
the trephining hole. Others had observed this fault as well, but he
did not know the cause of its appearance. He thought it might be
due to the intense heat generated; he did not use an electric motor,
but a foot-drill.

With regard to the forceps, he thought the variation a most ex¬
cellent one. If criticism a priori were permissible, he would say that
the vertical shanks were rather too long; the upper angle would im¬
pinge upon the hard palate in a good many cases. Otherwise the in¬
strument was an admirable one.

Dr. Herbert Tillet said that an almost precisely similar for¬
ceps had been in use for the last two years at the Throat Hospital,
Golden Square, and was introduced there by Dr. Lack.

Dr. Lambert Lack said the forceps very greatly resembled some
he had had made, and which had been in use at the Throat Hospital
for over three years. In addition to the curve at the tip his forceps
had an obtuse angle, which he thought a great additional advantage,
as it held the epiglottis out of the way.

Dr. FitzGerald Powell, in reply to the President’s remarks on the
drill, said that it would be clearly seen in the example which he showed
them, where the hole was made by the largest instrument, which was
bigger than that of a No. 14 silver catheter, that the teeth were not
impinged upon in any way. Cases were occasionally met with in
which the teeth were so close together that there was some difficulty
in this respect, but in the vast majority of cases one obtained a good
large opening in the way he advocated, through which drainage could
be thoroughly effected, and through which the antrum could be curetted.

In reply to Dr. StClair Thomson, he said that if the ethmoidal
sinuses were affected, it would be necessary to curette the sinuses at
the same time that the antrum was being opened. One came across
cases occasionally in which it was necessary to open the anterior wall
and curette the sinuses very freely, but in all ordinary cases—which
constituted the great majority—the measures he recommended
were sufficient to effect a cure. With regard to Dr. Tilley, he
only wished to emphasise that the forceps he showed were Mackenzie’s
laryngeal forceps, modified bv having the cutting point turned for¬
ward, and they were absolutely and totally different from Dr. Lack’s
forceps, which were short and very light, with an obtuse angle instead
of the right angle of Mackenzie’s, and were practically only suitable
for children.

In using Mackenzie’s forceps he had found some difficulty in re-

80

moving growths in the anterior commissure, and it occurred to him if
the points could be turned forwards the growths could be more easily
reached. Hence the forceps he now showed.

Case of Paralysis of the Left Vocal Cord.

Shown by Dr. Willcocks. The patient, a postman get. 45,
had complained of cough and huskiness of the voice since last
Christmas. On examination the left vocal cord was found to be
completely paralysed, both cords were white, and there was no
local swelling in the larynx. There was no history of syphilis,
and no signs of any source of intra-thoracic pressure, such as
aneurysm or tumour.

Dr. de Havilland Hall said that though they must remember the
possibility of peripheral neuritis in this case, yet there was less
evidence of it than there had been in the case of Dr. Powell’s patient.
At the age of forty paralysis of the left vocal cord indicated very
possibly the existence of an aneurysm. He called to mind a case of
Dr. Fincham’s at the Westminster Hospital, where the only sign of an
aneurysm for many months—in fact, nearly a year—was the cadaveric
position of the cord. Eventually the patient developed well-marked
physical signs of aneurysm, from which he died. In this case there
might be no physical signs of aneurysm for many months to come,
but they must still bear in mind the possibility of its being
aneurysmal.

Mr. P. de Santi had shown a similar case to the Society only two
meetings ago, in which, if he remembered correctly, Sir Felix Semon
had considered there was an aneurysm in spite of the absence of the
physical signs. The patient, a woman, was skiagraphed, and a well-
marked dilatation of the arch of the aorta was easily made out; since
then he believed the patient had been under the care of Dr. de
Havilland Hall.

Sir Felix Semon had seen comparatively often the production of
laryngeal paralysis in cases in which the aneurysm was so small that
there were practically no physical signs to be obtained. The
absence of physical signs of aneurysm in the chest was certainly no
proof of its non-existence. He recollected a case which would serve
as a very apt illustration. Many years ago the head-master at one of
the big public schools consulted him on account of frequent fatigue of
the voice. On examination of the throat he found paralysis of the
left abductor. He then examined the chest, and thought there was
possibly a very little dulness over the lower part of the sternum.
Barring this dulness, there were no physical signs whatever; still, he
suspected the presence of aneurysm. The patient was induced to see
Dr. Ord, of St. Thomas’s Hospital, who found the same condition and

81

agreed entirely with the speaker as to the probable existence of
aneurysm. The patient was at the time just about to start for a tour
in Switzerland, where he intended spending the holidays. Both Dr. Ord
and he advised him to go home and rest, and undergo a course of
Tufnell’s treatment. Dr. Ord knew the family medical attendant,
and wrote to him expressing their joint opinion as to the case, in
reply to which he received a letter saying that the writer wished
devoutly there were no consultants in London, for they only needlessly
frightened patients, and that lie had strongly advised the patient to
proceed with his arranged plans and go to Switzerland. This was
done, and the patient died four weeks afterwards from haemorrhage,
caused by the bursting of a small aneurysm, which had, indeed, been
present. The moral was obvious.

Dr. Donelan said, in reference to the remarks just made by Sir
Felix Semon, he had shown to the Society in .Tune, 1901, a sketch of an
aneurysm of the aorta in which paralysis of the left vocal cord was the
only physical sign during life. The patient was an Italian man
aet. 39, whom he had been asked to examine. He considered that the
paralysis was probably due to an aneurysm. On the morning of
the day following this examination the patient was suddenly seized
with what seemed to be angina pectoris, became rapidly collapsed,
and died within two hours of the seizure. The post-mortem showed
a small oval aneurysm on the postero-superior aspect of the aorta,
immediately outside the origin of the left subclavian, compressing the
recurrent nerve.

Dr. Willcocks had no further remarks to add, except that he was
glad of the hint given by Mr. de Santi with regard to the X-ray
examination. He had not taken a skiagram yet, but would do so.
He thought Dr. Hall was most likely correct in referring to the case
as of aneurysmal origin. He saw the case for the first time a month
ago, when he had examined the man very carefully with that view in
mind, but he had been totally unable to satisfy himself as to the
existence of an aneurysm ; he had shown the case to some of his
colleagues at Charing Cross, and they were all of opinion that at
present there was no obvious sign of aortic dilatation.

Case of Laryngeal Stenosis due to Cicatricial Contraction

in Intkrarytjenoid Region.

Shown by Mr. H. Betham Robinson. The patient, a young
man set. 20, was brought to him on account of the difficulty in
breathing on exertion.

According to the history he had had a severe attack of what
was stated to be diphtheria some years ago ; after it he had had
no voice, but this had come back very slowly. Eight months

82

ago the voice was only a squeak, but recently there had been
great improvement, so that now there was only huskiness.

Examination showed a very large perforation of the nasal
septum, involving both bone and cartilage, and loss of the
uvula. In the larynx there was slight catarrhal reddening of
the vocal cords, but the marked feature was the loss of abduc¬
tion of the cords on deep inspiration with some stridor. On
phonation the cords came together to the mid-line, except
between the arytsenoids. This laryngeal condition was due to a
cicatricial web passing between the arytaenoids, evidently the
result of previous inflammation. Although no history could be
obtained, syphilis explained the three lesions mentioned.

The President said the question was whether the cause of the con¬
dition was syphilis or diphtheria; the nasal trouble might, he thought,
be caused by the latter, and possibly the laryngeal trouble also. He
suggested that the man ought to have tracheotomy performed as soon
as possible.

Sir Felix Semon drew attention to the adhesion between the pos¬
terior ends of the vocal cords in the very small part just visible above
the interarytsenoid fold. Supposing the cicatrix had been a little bit
lower, everybody would have looked on it as a case of bilateral
paralysis of the glottis openers. This case reminded him of the well-
known case of Sidlo’s, of Vienna, in which a similar diagnosis was
made, and after death a cicatrix was found on the posterior wall of
the larynx. The case to which he referred was extremely interesting
as showing how careful one had to be, if the cords were lying close
together, not to rush to the conclusion that the condition must needs
be of nerve origin, and to remember the possibility of a mechanical
origin. As to the particular case under discussion, he thought the
perforation in the nasal septum and the absence of the uvula would
make him very sceptical in regard to the diphtheritic origin of the
case ; there was, on the contrary, strong evidence in favour of syphilitic
mischief.

Dr. Dundas Grant thought it was very likely a case of peri¬
chondritis, such as occurred in typhoid fever; there was decubital
ulceration from the pressure of the cartilages against each other. If
the man were left in statu quo he was in considerable danger, but he
did not consider that the operation for the relief of these cases was
very satisfactory.

Dr. StClair Thomson said that in the absence of reliable history
the evidence in favour of syphilis was not more than a suspicion. If
the perforation in the nose occurred when the man was not having
any treatment, it was very usual to find retraction afterwards causing
some falling in of the nose, and even retraction round about the
perforation, just in the same way as was found with the soft palate
and uvula in inherited syphilis. It might be a coincidence that the

$3

syphilitic process in the larynx took place exactly in the middle line,
but he thought it more likely to be of diphtheritic origin. He agreed
with the President in thinking that tracheotomy was urgently called
for.

Mr. Robinson, in reply, thought all the lesions were due to
syphilis, and could not agree with the diphtheria explanation put
forward. Of course, if they wanted to explain the condition by two
causes, diphtheria and syphilis would do, but such was unnecessary
when one common cause was sufficient. With regard to the question
of operation, the lad was a pupil-teacher, and the whole matter had
been put clearly before him and his parents, explaining the risks he
ran. They were, however, unwilling, bearing in mind that he was
dependent on his voice for his living, to have anything whatever done,
and there the case must rest.

Sections of Tuberculous Growth of Mucous Membrane of
Right Middle Turbinal in a Man act. 50.

Shown by Dr. Adolph Bronner. The patient from whom this
growth was removed was first seen on June 20th, 1901. lie had
had nasal obstruction off and on for some years, with discharge
into throat; he could never smell well, but taste was fairly
good. He gave a history of an ulcerated throat one year
previously. The nose had been worse for some weeks, with pain
over the bridge. He had noticed a rather offensive smell from
the right nostril for two or three weeks.

The apex of one lung was affected. Both nostrils were
blocked by swollen mucous membrane of lower turbinals. This
was removed by a snare and galvano-cautery.

On July 25th the right middle turbinal was much enlarged,
and on it a large patch of ulcerated mucous membrane. A
piece was removed by snare for examination. Trichloracetic
acid was applied, and aristol insufflations were ordered.

On September 24th there had been very little discharge or
bad smell or pain for three to four weeks, and the nares were
patent. The right middle turbinal was still enlarged, but the
ulceration had healed.

The Clinical Research Association reported : “ This growth
consists of tuberculous granulation tissue in which are many
miliary tubercles with large giant-cell systems.”

§

84

Dr. StClair Thomson suggested that Dr. Bronner be invited to
give a specimen to the museum, because, as far as his recollection
went, it was extremely rare to see a specimen of tuberculosis of the
middle turbinal. The best article he knew on primary tubercle in the
nose was that written by Mr. Steward in the ‘ Guy’s Hospital Reports,’
vol. liv, where it was pointed out that primary tubercle in the nose
generally attacked the septum, and that next in frequency came the
inferior turbinal, but that the middle turbinal was very rarely subject
to tuberculosis.

Case of Tertiary Intra-nasal Syphilis in which the Right
Frontal Sinus hXd been opened twice with Negative
Results, in a Married Woman jet. 48.

Shown by Mr. P. de Santi. The patient was first seen five
weeks ago, complaining of great pain at the back of the nose
and head, also of a foul discharge from the nostrils and
occasional discharge of pieces of bone.

She had been married seventeen years, and had had three
miscarriages and one seven months child born dead.

Nine years ago she first noticed a discharge of small hard
lumps of a greenish colour from the left nostril, also occasional
swelling at the root of the nose; soon afterwards a similar
discharge occurred from the right nostril, and the discharge, -
which had included frequently pieces of bone, had continued
ever since, and had got worse and worse. Three and a half
years ago she had had paralysis of left facial nerve, which came
on suddenly, and cleared up entirely after about eighteen
months* time.

In 1901 the patient was an in-patient at University College
under Mr. R. Johnson for nasal discharge and headache.
There was pain over bridge of nose and right frontal sinus,
slight diminution to tactile sensation over left side of body,
and slight apparent weakness of facial muscles on the left
side. The right frontal sinus and maxillary antrum were
explored, and found to be healthy.

The patient left the hospital unrelieved, and on September
25th, 1901, was admitted into Charing Cross Hospital, under
Mr. Waterhouse, and the right frontal sinus was opened, a
little purulent material exuding; the mucous membrane was

85

in a thickened and catarrhal condition. An attempt to pass a
small rubber tube down the infundibulum was unsuccessful, and
a strip of gauze was substituted. The frontal sinus was packed
with iodoform gauze, and the usual dressing applied. After the
third day a No. 2 catheter was passed down infundibulum, and
this was done daily, the parts being washed out with boracic
solution. The fcetor became less, and after a few days’ treat¬
ment the patient passed a large mass of necrosed bone, which
consisted of a part of the lateral mass and ethmoidal cells.
The frontal wound was gradually allowed to heal. Patient was
discharged on October 10th, 1901, unrelieved. She now com¬
plained of intense headache, loss of sleep, diarrhoea, and a half-
choking sensation. The pains in the head appeared to be
referred to the b*ack of the nose and frontal regions.

Examination of the nose showed large greenish-black sloughs
in the posterior region of the intra-nasal cavity; there had been
extensive destruction of the bony lateral masses, but the septum
was intact.

The patient’s condition, in Mr. de Santi’s opinion, was due to
syphilis, and she had had large doses of iodide of potassium, but
without benefit. Suggestions as to operative treatment were
invited.

Dr. Dundas Grant said the woman seemed to be in a very serious
condition. He strongly suspected tertiary changes were taking place
in the sphenoid, and probably there was a sequestrum at the junction
of the sphenoid and the vomer; he thought Mr. de Santi might
explore this region with his finger. He had had a similar case to this
under treatment, which consisted in taking the patient into hospital
and giving her the good feeding up which her circumstances at home
rendered impossible. He was giving her inunctions of mercury with
iodide of potassium and opium internally. He recommended the same
treatment to Mr. de Santi's patient.

Dr. Herbert Tilley agreed with Dr. Grant as to the possibility
of deep-seated bone mischief in the sphenoidal region, and cited a
similar case which died of basal meningitis after temporary improve¬
ment by mercurial inunctions and constant nasal douches. The pus
between the middle turbinal and the septum, the pain on the top and
at the back of the head, together with deep-seated pain in the right
eye and frequent disturbances of vision, were all symptoms very
suggestive of suppuration in the sphenoidal sinus.

Dr. Yin race said he thought that before any further operation was
proposed in this case, it might be desirable to review very briefly what
had been done. He had, on a previous occasion, asked what were the

86

indications for opening the frontal sinus, and what were the benefits
claimed for it; and the answer he received was that the operation
was performed in accordance with the best canons of rhinological
surgery, and that the patient was very much better for it. This
answer only left him to speculate in what details the benefits accrued.
In this particular case he would like to know why it was that the
frontal sinus was opened. It was opened for the first time about
two years ago, but nothing of a morbid character was found.
Twelve months afterwards it was opened for the second time, and
he believed it was stated that a little pus was found in it. Now
what he wished to know was exactly what benefit had followed the
surgical measures adopted in these two operations. As far as he
could gather from the patient, she had been in trouble for nine years, but
never in serious trouble till the operations were performed. To use
her own words, she had a “ dirty nose ” for several years. After
the first operation was performed, as he gathered from her, she was
worse in health and new symptoms arose; even ,after the second
operation, the patient admitted that her symptoms were very much
aggravated. Having regard to these reports from the patient, he
thought very great care should be exercised before any further opera¬
tion was done. Assuming that when the first operation was done the
patient was suffering from active syphilis, one of the last things that
it would have occurred to him to do would have been to operate on the
nose in the extravagant way in which it had been done in this case.
He did not wish to put any member in the position of an oracle pro¬
nouncing judgment upon this question, least of all the exhibitor, since
the surgical interference referred to had been carried out before the
patient came under his care, but if any member could enlighten him
upon the points he had raised he would indeed be grateful.

Mr. de Santi, in reply*, said the first point to be mentioned was in
regard to the diagnosis which was raised by Dr. Grant. There could
be no doubt that the woman was suffering from tertiary syphilis of
the nose, and that the disease had penetrated as far back as the region
of the sphenoid bone. Nor was there any doubt that her condition
was a somewhat serious one, and that she must undergo some further
operation. She should, he thought, be examined thoroughly under an
anaesthetic, and the posterior nares be carefully explored with the
finger, and, of course, what might be done afterwards depended on
what might be found. If the sphenoid bone were necrosed and firmly
fixed, it would not be safe or wise to try and get the necrosed bone
away, unless it would come away with the exercise of very little force.
If a sequestrum had formed, as he feared, its removal might be quite
easy, or, on the other hand, difficult and dangerous.

With regard to Dr. Vinrace’s remarks, he had to say that when the
patient first went to University College Hospital, and was under the
care of Mr. Johnson, she had very intense headache, and there was
considerable pain over the bridge of the nose and the right frontal
sinus. The patient localised most of the pain in the head on the right
side of the frontal bone, and the area of tenderness to pressure was
over the right frontal sinus, and he supposed these were the reasons
why 1 right frontal sinus was opened. Moreover there was a nasal

87

discharge consisting of thick greenish pus, and this was seen mostly
in the middle meatus. He could not go further than that as to the
reasons which probably prompted Mr. Johnson to operate on the right
frontal sinus. Later the patient was at Charing Cross Hospital,
complaining of similar symptoms, only they were aggravated. It was
only fair to Mr. Waterhouse to say with regard to the second opera¬
tion on the frontal sinus, that although the woman now denied it, it
was against his advice that the operation was undertaken. The
patient insisted on Mr. Waterhouse doing it, and it was done under
protest. One of his colleagues at Charing Cross, Mr. Bloxam, felt
certain there was nothing the matter with the right frontal sinus
before it was operated on again by Mr. Waterhouse, but was of
opinion that there was a mass of dead bone at the back of the nose.

He could not go further into the subject of the indications for and
advantages of the frontal sinus operation, but as regards this particu¬
lar case, the reason for operation was the pain referred to the right
frontal sinus, which was constant and excessive before the sinus was
opened.

A Case of Angioneurotic (Edema of Right Hand with

RECENTLY DEVELOPED ATTACKS OF DIFFICULTY IN BREATHING.

Shown by Mr. P. df, Santi. The patient, a married woman
aet. 26, was in the London Hospital four years ago with swelling
of the right hand and forearm, and angioneurotic oedema
was diagnosed. The treatment consisted in elevation of the
limb.

Since then she had had several further attacks, always of the
right hand. The attacks began with a feeling of tightness in
the hand, rapidly followed by great swelling of the fingers, hand,
and forearm, the fingers becoming almost black in colour, and
the rest of the affected parts bluish red. The attacks lasted a
variable time, and then the parts returned to the normal. There
was no particular periodicity in the attacks, and no family
history of similar conditions. About six weeks ago the right
side of the face became swollen, and for three weeks the patient
was, unable to open the mouth properly, having to live on
slops. Then followed suffocative feelings in the throat, which
occurred both by day and night, the patient feeling as if the
throat were being tightly gripped. The attacks were slightly
relieved by adopting the sitting posture. The hand had not
been affected for four months.

88

Examination of the larynx revealed no oedema or abnormal
condition. The case was brought forward as, in these cases of
angioneurotic oedema, of which Mr. de Santi had seen two,
sudden oedema of the larynx proving fatal might occur.

Osier had knowledge of one family extending to five genera¬
tions in which twenty-two various members had been attacked
by angioneurotic oedema, and in which two had died of oedema
of. the larynx. This disease was characterised by the sudden
onset of local oedematous swellings, more or less limited in
extent and of transient duration. The parts attacked were
usually the face, back of the hands, the buccal or pharyngeal
mucous membrane, or the larynx. Mr. de Santi would be glad
if any members could inform him if they had had any experience
of throat trouble in these cases of angioneurotic oedema—other¬
wise called Quincke's disease.

Dr. de Havilland Halt, thought this an extremely interesting
case. He had a case under his care which he saw from time to time,
* the patient being a lady of forty-four or forty-five years of age, who
was subject to attacks of angioneurotic oedema of the neck and
buccal mucous membrane, and as she had had on one or two occasions
great difficulty in breathing he inferred that the symptoms extended
to the larynx. Unfortunately he had never been able to see the larynx
affected; but usually he saw the buccal mucous membrane in an
oedematous condition. This patient was undoubtedly a gouty subject,
and she had derived most benefit from a course of treatment directed
to the gout, and from alkalies. She was formerly a patient of his
late colleague, Mr. Bond, who had been treating her with bicarbonate
of potash and bark with considerable benefit, and occasionally doses
of blue pill. He had not seen the patient now lor three or four
months, but he had heard that the attacks were getting less frequent.
He sent her to Llandrindod Wells for a course of treatment, and she
had come back very much better. He had seen another case in a
boy who had no throat complication, but who was subject to attacks
of angioneurotic oedema, which were located in the back of the left
hand and wrist. It was an interesting case, as the patient had
developed cyclic albuminuria. When in the recumbent position there
was no albumen in the urine, but on gettingup and about a trace was
found. He thought this combination of the two conditions—angio¬
neurotic oedema and cyclic albuminuria—in the same patient a matter
of some interest.

Dr. Edward Law thought that some of the members might remem¬
ber that five or six or seven years ago he had brought before the
Society a case of well-marked Quincke’s disease.

Mr. de Santi, in reply, said he should be pleased to adopt the
treatment mentioned by Dr. Hall.

89

Case of rapidly recurring Papilloma of the Larynx.

Shown by Dr. Lambert Lack. The patient, .a Swiss waiter
set. 21, had suffered from hoarseness for four months. When
first seen six weeks ago there was what appeared to be an
ordinary fairly large papilloma on the anterior part of the right
vocal cord.

This was at once removed under cocaine. Subsequently there
was considerable congestion of the vocal cords, which increased
during the following three weeks until both cords appeared red,
thickened, and irregular, resembling the “ fleshy granulating ”
cords often seen in tubercular disease. The patient was “run
down,” and had considerable cough and expectoration. He was
now much better, and the local condition had cleared up, but on
examining the larynx it would be seen that the growth had
recurred, and there were at least two distinct fresh growths on
the other cord.

Mr. Lake said he could not help thinking that in this case if Dr.
Lack removed the growth, the careful bacteriological examination of a
portion of such a rapidly growing papilloma might throw some light
on its causation ; micro-organisms that were found might serve as an
important aid.

The President, from a cursory examination, thought the case was
suitable for the application of the galvano-cautery.

Case of Traumatic Tracheal Obstruction.

Shown by Dr. Dundas Grant. Edith C —, set. 22, was first
seen on February 13th, 1902, complaining of difficulty and
loudness in breathing, especially when hurrying. These sym¬
ptoms had existed since an accident at three years of age, when
she fell on the blade of a knife and punctured her windpipe.
She had no difficulty in breathing at night, but the dyspnoea had
been getting worse during the last six months. It was worse
after food. There was no indistinctness in her speech, but a
slight apparent effort. The left vocal cord was completely fixed,
and without doubt the left recurrent laryngeal nerve must have

90

been injured. The extremely late period at which the narrow¬
ing had more strongly asserted itself was difficult to explain ; it
was hardly likely that there was anything in the way of a poly¬
poid granulation, but more probably cicatricial contraction.
Dr. Grant had advised that she should come into the hospital
for a more thorough examination, and if possible for the intro¬
duction of a tube into the trachea for direct inspection.

Case of Rhinorrhcea in a Girl mt. 9.

Shown by Dr. Cathcart. Since the patient was two years old
she had had a thin watery discharge from both nostrils, which
caused excoriation of the upper lip. During the last six years
she had twice been operated on for adenoid growths, and on
four other occasions the nose had been examined under an anaes¬
thetic and either curetted or cauterised with nitrate of silver or
the electro-cautery.

Everything in the way of drugs had been tried, both internally
and locally, but the discharge still continued.

The President said information was desired as to the treatment to
be pursued.

Dr. de Havilland Hall had had a case at Westminster Hospital,
and on measuring the fluid he found it amounted in the twenty-four
hours to nearly a pint. The fluid was clear and limpid, and came
undoubtedly from both nostrils, and not from any other part. At
that time he had thought the case due to a vaso-motor condition.
His patient had derived most benefit from mustard foot-baths with
morphia and atropine. He had originally been under his care sixteen
or seventeen years ago, and he had seen him quite recently—during
last week,—and he had now nasal polypi. When he felt the attacks
coming on he put his feet into the mustard foot-bath and took a dose
of 1 minim atropine and 5 of solution of hydrochloride of morphia.
In Dr. Cathcart’s case he would feel inclined to try a weak spray of
adrenalin solution.

Dr. StClair Thomson said it was very rare to find this condition
of uncomplicated nasal hydrorrhoea in a patient so young as nine
years. The cases which had come under his observation had been
much older. As to their treatment, speaking from personal expe¬
rience, he thought it extremely unsatisfactory. By giving placebo
treatment many cases would undergo a temporary spontaneous cure,
but the symptoms were quite likely to come on again at any time.
Yet a certain number of cases seemed to be relieved by the use of

91

atropine, particularly if it was combined with Liq. Strychnia, as
suggested by Lermoyez, whose contention was that the atropine
checked the glandular secretion, and that the strychnine was beneficial
to the vaso-motor paresis. He had given a pill containing extract of
belladonna, quinine, and extract of nux vomica. The results were
uncertain from the use of adrenalin, for cases were published in
which the adrenalin, instead of being beneficial, made the patients very
much worse. He had heard of a city man who particularly wanted to
attend a public meeting, and had adrenalin administered to him in
order to tide him over the meeting, with the result that he was so
much worse that he was unable to go at all, whereas without the
adrenalin he could have got through with two or three handkerchiefs.
He would like to hear from other members what results, even if
negative, had followed the use of adrenalin in their hands. In
more than one case in which he had explained the condition of affairs,
and refrained from local treatment, the patients had gone elsewhere,
and had a great deal of the galvano-cautery, but with what results he
did not know. General treatment and that of hydrotherapy at
different health resorts had at the least an elevating effect.

The President said he could only suggest the same treatment he
had recommended for Mr. Lawrence’s patient at the last meeting—
the application of the continuous current externally to the nose. He
wrished to add that adrenalin required to be used carefully; if it was
applied too strong it might produce prolonged sneezing. He em¬
ployed a solution of 1 in 10,000 of adrenalin chloride to contract the
nasal mucous membrane.

Sir Felix Semon said he had lately frequently used adrenalin in
view of the many recommendations bestowed upon that remedy, and
he found that for about an hour or two after its administration it
produced a stoppage of secretion and feeling of absolute dryness in
the nose, followed by infinitely greater discharge than previous to its
use.

Mr. "Waggett considered that it was worth while to make trial of
the treatment of Lermoyez in its entirety, for he had had three or
four lady patients under his care who had taken the trouble to pursue
the treatment regularly, and had obtained complete relief of hydror-
rhcea. Whether or no this was to be permanent he was unable to
say. The syrup used contained strychnine and atropine (vide
4 Journal of Laryngology,’ vol. xv, p. 442).

Dr. Law, replying for Dr. Cathcart, said that adrenalin had been
tried, but without success, also many other remedies.

Dr. Bbonneb asked if any member had tried the desiccated supra¬
renal extract, which was in the form of a powder, and was used as a
snuff. He thought it acted better than the solution of adrenalin.
It was used 1 in 10 with boric acid and a little menthol.

92

Case op Atrophic Rhinitis in which Melted Paraffin had been

INJECTED INTO THE INFERIOR TURBINATE BODIES WITH GOOD

Results.

Shown by Mr. G. Lake. The patient, a woman set. 25, had
been afflicted with foetid atrophic rhinitis for many years.
Crust formation had been got under by the usual treatment, but
the patient was dissatisfied, as she felt no air passing down the
nose. This suggested to him the idea of contracting the passages
by making an artificial inferior turbinate by means of submucous
injections of paraffin.

The injections were made under the posterior surface of the
remnant of the inferior turbinate, about m v each time with
intervals of one week. The total increase of length obtained
was not great, but the relief was most satisfactory to the patient.

The needle required was one of fair calibre, three inches in
length, and attached to the syringe by means of a screw. The
syringe employed was one with metal bands connecting the
metal ends and worked with a screw piston to overcome the
friction caused by the long needle.

The President asked Mr. Lake if the patient had benefited as far
as the symptoms were concerned.

Dr. Dundas Grant said that the turbinated bodies looked an ex¬
cellent size at present. He asked whether a local anaesthetic was
required, and whether cocaine was contra-indicated, owing to the fact
that the contraction it would produce would militate against the
successful injections.

Mr. Waggett thought the most remarkable point about the case
was the colour of the inferior turbinals, which was now practically of
a normal tint. He had closely questioned the patient, and from her
replies he had gathered she must have enormously improved. He
heartily congratulated Mr. Lake on his very ingenious new method of
treatment.

Dr. Lambert Lack said that although the patient herself was
positive that she had derived great benefit, the treatment seemed to
him utterly irrational and against the modern ideas of the pathology
of the disease. He thought much more evidence was required before
this treatment could be accepted.

Mr. Lake, in reply, said he had used cocaine, and that it answered
very well. With regard to the symptoms, the girl bothered him after
the crust formation ceased because she could not blow her nose ; she
had plenty of room, but she could not feel air pass down the nose.

93

He was pleased to hear Dr. Lack’s strictures, because it was a
question of some considerable interest as to what was the pathology
of the disease. People talked of the destruction of the turbinals as
if this were part of the disease, but why did they disappear ?

In the present case the patient expressed herself as more comfort¬
able with the substituted inferior turbinals, which merely relieved the
symptoms. He did not feel so confident in the present pathology of
atrophic rhinitis as described in the text-books to quite accept the
explanations given by them as correct.

Papillomatous Growth ox the Posterior Edge of the Vomer.

Shown by Dr. Herbert Tilley. The patient, an adult male,
had been under treatment for almost complete nasal obstruction
in the left nostril. In the course of examination a small whitish
growth the size of a yellow pea was seen by posterior rhinoscopy
situated on the posterior edge of the vomer about the middle of
its length. The growth was dead white in colour, contrast¬
ing very markedly with the normal redness of surrounding
structures.

The growth had not been touched by finger or instrument,
and hence the exhibitor could say nothing of its feel or consis¬
tence. He had once seen a definite papilloma growing from that
spindle-shaped mass of mucous membrane so often seen on the
posterior edge of the vomer, but had never met with a condition
similar to that in the case exhibited. He regarded it as a
harmless curiosity.

The President said in regard to this case of growth on the edge of
the vomer, he would not like to say without feeling it with his finger
whether it was papillomatous or cartilaginous in character. He
thought the growth different from the ordinary swellings seen near
the posterior margin of the vomer.

Sir Felix Semon said that in that part of the vomer one often saw
little symmetrical thickenings. This growth might simply represent
an excess of the ordinary thickening.

94

Case o.f Syphilitic (?) Disease op Larynx simulating
Malignant Disease.

Shown by Dr. Herbert Tilley. The patient was a well-
proportioned man set. 28. For six weeks he had complained of
“ hoarseness,” and for the past week of pain on swallowing,
which shot from the throat towards the right ear.

The irritation in the throat caused a cough, but at no time
had he expectorated blood. The patient had syphilis about five
years ago.

The larynx was uniformly congested, but the right vocal cord
was motionless on phonation, and there was considerable, but
uniform, swelling of its posterior half. Below the level of the
cord for about half an inch in a vertical direction well-marked
ulceration was seen; there were no prominent edges or projec¬
tions from the surface of the ulcer. The right arytasnoid
cartilage moved on phonation. A hurried examination of the
chest had been made, but so far as it went no evidences of
tubercular mischief were obtained. The appearances in the
larynx simula/ted malignant disease, but at present the patient
was being treated on the hypothesis that the lesion was a
syphilitic one.

Dr. FitzGerald Powell did not quite catch whether or not the
chest had been examined. It seemed to him, from the appearance of
the condition, it was much more likely to be tuberculosis than either
syphilis or malignant disease. The larynx was pale in colour, there
was present to a fairly large extent cough and expectoration,
according to the man’s own account. He seemed to have been having
night sweats, and showed other symptoms of tubercle; under these
circumstances he thought that until the sputum had been examined,
and they knew the condition of the chest, it was almost impossible to
come to a definite conclusion with any certainty as to the condition,
but be believed it to be tubercle.

PKOCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Seventy-third Ordinary Meeting, April IMA, 1902.
E. Cresswell Baber, M.B., President, in the Chair.

Charles A. Parkier, F.R.C.S.(Ed.)
James Donelan, M.B.,

* | Secretaries.

Present—32 members and 1 visitor.

The minutes of the preceding meeting were read and con¬
firmed.

The following gentleman was nominated for election:

Woods, Robert Henry, 39, Merrion Square East, Dublin.

The following cases, specimens, and instruments were shown :

Case of Laryngeal Growth in a Man jet . 50.

Shown by Dr. Wyatt Wingrave. The patient was a dock
labourer, and when first seen, about two months ago, complained
of hoarseness of twelve months’ duration, with some dyspnoea on
exertion for past four months. He admitted having a “ chancre ”
twenty years ago, but without any sequelae.

FIRST SERIES-VOL. IX.

6

96

On laryngoscopic examination, two smooth opalescent swellings
were seen overhanging the right half of the glottis. The cords
were normal in appearance and texture. He was ordered
sedative inhalations, and carefully watched. The symptoms
considerably improved, but the swellings distinctly increased in
size, a third one appearing just above the left capitulum.

Fourteen days ago considerable oedema of uvula and palate
appeared.

The voice was at the present time very good, and there was
very little dyspnoea on exertion.

He had not lost weight, and felt quite well. There were no
enlarged cervical glands.

Case of Tumour of Larynx.

Shown by W. H. Kelson. The patient, a woman aet. 74,
came to hospital suffering from hoarseness of nine months’
duration. On examination, there was seen to be a rounded
greyish coloured tumour, about the size of a marble, lying on
and concealing the anterior part of the left vocal cord, and
apparently originating from the left ventricle. It was firm
when touched with a probe; the cords moved well, but were
prevented from coming into apposition by the growth.

He thought it was probably a cystic fibroma.

Dr. Scanes Spicer thought the tumour was a cyst. It was white,
and shaped like a pearl.

The President also thought of its possibly being a so-called
prolapse of the ventricle, but it did not look solid enough for that.

Dr. Jobson Horne said he could not be quite sure from inspection
alone whether the growth lying on the left vocal cord were solid and
dependent from the roof of the ventricle, and therefore similar in its
pathology to one he had described (vide * Proceedings,’ vol. v, p. 98), or
whether it were of a cystic nature, and formed by the prolapsed lining
of the ventricle. Its appearance, he thought, was suggestive of the
latter.

Dr. StClair Thomson had seen a similar case in a small boy. On
being punctured a fluid came out, and the whole thing collapsed. A
fortnight later the patient returned to hospital with the growth filled
up again. It was removed with forceps, and found to he a cystic
fibroma.

97

Sir Felix Semon was of opiniou that this was a cystic fibroma.
The surface was too granular for a simple cyst.

Dr. Kelson himself thought it was a cystic fibroma. He had cocain¬
ised the larynx and felt it with a probe, and it seemed to be rather firm.

Case of Tuberculous Disease of Larynx.

Shown by Dr. W. H. Kelson. This occurred in a woman
set. 42, who came complaining of loss of voice for two months
and loss of health for two years. There was swelling and loss
of movement of the left arytsenoid, and a pink granuloma pro¬
jecting from the left ventricle and overlapping the left cord.
There were indications of phthisis at both apices. A very few
bacilli were to be found in the sputa.

Dr. Grant said it seemed a very pretty case of what was sometimes
described as prolapse of the ventricle, which was supposed to be an
eversion of the mucous membrane, whereas really it was just a growth
of granulation tissue—possibly tubercular—from the ventricle.

Case of Syphilitic Laryngitis, possibly Complicated with

Tuberculosis.

Shown by Dr. StClair Thomson. The patient presented fixa¬
tion and ulceration of one cord. There was also ulceration of
one faucial pillar, and some ulceration on the posterior pharyn¬
geal wall. This assisted in the diagnosis of syphilis, and the
condition improved considerably under specific treatment. Still,
in spite of large doses of iodide of potassium the condition did
not entirely clear up, and, while the cord improved, there seemed
to be more infiltration in the inter-arytaenoid region. There
were no constitutional symptoms of tuberculosis, and the tempera¬
ture was always subnormal. The man had gained in weight.

Dr. Permewan asked why Dr. Thomson thought this was possibly
a case of tubercle. To him it seemed that there were no marked tuber¬
cular symptoms, and that it was simply syphilitic.

Dr. StClair Thomson, in reply, thought the case tubercular be¬
cause of the intra-arytcenoid thickening, which had slightly increased,
though the patient had improved with regard to the fixation and
ulceration of the cord.

98

Case of Congenital Absence of the Front of the Nose with
Occlusion of the Antekior Naees.

Shown by Mr. Arthur H. Cheatle. The infant was six weeks
old. It was the mother's first child, and was born at full time.
There was no history of syphilis; the nasal bones were present,
but the framework of the nose in front of the nasal bones was
absent. The palate was normal, and no other deformities were
present.

The President considered this a highly interesting case. Whether
it was due to intra-uterine syphilis or not was the only point which
might be raised.

The case showed that a person could sleep perfectly quietly when
the nose was completely obstructed. Though with polypus of the
nose causing partial obstruction there was often great difficulty in
breathing and noise during sleep, yet when there was complete
obstruction the patient might after a time sleep comfortably.

Dr. FitzGerald Powell said it was a very interesting point
whether this was congenital or whether it was due to intra-uterine
syphilis, but one would expect to find some other evidence of syphilis
in the child if this was a case of intra-uterine syphilis. He should
think it would be a case for a plastic operation in later years.

Dr. William Hill asked exactly what was meant by describing the
condition of occlusion of the nares as congenital. Did those who em¬
ployed the term here mean a closure from an inflammatory process
occurring during intra-uterine life ? Looking at the matter from a
purely developmental point of view, the term “congenital” was
usually applied rather to a defect of closure from arrested develop¬
ment ; in this case the nares, formerly patent, had obviously been
closed up later by an active inflammatory process in utero.

Specimen of Rhinolith.

Shown by Mr. Arthur H. Cheatle. This specimen was
removed from a woman set. about 50 years, who had been
troubled with the right side of her nose for twenty years. From
the prescription she brought the origin was syphilis. The fcetor
was extreme. The rhinolith, which had to be broken before it
could be extracted, weighed 140 grains. The nucleus apparently
was a portion of necrosed inferior turbinal, as the configuration

99

of the largest portion of the stone demonstrated. After removal
the inferior turbinal was seen to be absent.

Mr. Jackson, of King’s College, reported that the stone was
composed of calcium phosphate and carbonate in almost equal
proportions, together with a trace of organic matter.

A New Form of Laryngeal Forceps.

Shown by Dr. Lambert Lack. These forceps were mentioned
at the last meeting. They were similar to Mackenzie’s well-
known forceps, hut the blades formed an obtuse angle with the
shaft, and thus, when in the larynx, held the epiglottis out of
the way. The forceps were also thus removed from the direct
line of vision, and enabled a better view of the growth to be
obtained at the moment of seizing it; for this reason, also, the
blades were much more slender than Mackenzie’s. One pair of
the forceps were curved forwards at the tip of the blades to
enable a growth in the anterior commissure to be more easily
reached. The forceps had been used for over three years by
various members of the staff at Golden Square, and had been
found useful.

Dr. FitzGerald Powell again produced the forceps he had
shown at the March meeting, and pointed out how they differed
from Dr. Lack’s.

A Case of Thyrotomy for Tuberculosis of the Larynx.

Shown by Dr. Lambert Lack. The operation had been per¬
formed for what at the time was diagnosed as epithelioma of
the larynx, and Dr. Lack thought the case presented many
features of interest.

The patient, a finely made, robust man get. 66, was an old
soldier, and, apart from wounds, had never had a day’s illness.
He was first seen in April, 1901, for hoarseness, which had
commenced three months previously and was gradually increas¬
ing. On examination an ulcer with raised edges and some
surrounding thickening was seen occupying the centre of the

100

right vocal cord, the movements of which were considerably
impaired. The rest of the larynx was of normal colour and
contour. The patient had some cough and expectoration, which
he stated was not unusual to him during the winter. Examina¬
tion of the chest showed signs of bronchitis. The sputum was
examined for tubercle bacilli with negative result; the patient
was otherwise in good health, and no enlarged glands could be
felt. The diagnosis pointed so strongly to epithelioma, and the
case was so eminently suitable for operation, that thyrotomy was
advised and immediately carried out. The entire right vocal
cord was removed in the usual way, and the patient's recovery
was uninterrupted.

The growth macroscopically looked like an epithelioma, but
Dr. Horne, after microscopical examination, reported it as
tubercle.

The patient made good progress until the commencement of
August, 1901, when enlarged glands were noticed in the neck.
In September there was a hard lump under the upper part of
the right sterno-mastoid about the size of a walnut, and rather
fixed. Immediate removal was advised and at once performed.
The operation involved removal of part of the sterno-mastoid
muscle, of the spinal accessory nerve, and of the internal jugular
vein. Some of the mass of glands, which was removed entire,
were found to be breaking down, and looked suspiciously like
suppurating tubercular glands. This opinion was confirmed by
microscopical examination, and there was no doubt but that this
case was really one of tuberculosis throughout. The patient had
since remained in his usual state of good health, but had no
voice, the cicatricial band which usually takes the place of a
removed cord not having formed. The left cord moved freely,
but had an apparently hollow space opposite to it. This case
seemed a remarkable one for the following reasons :

1. The laryngoscopic appearances of the localised growth on
the vocal cord, the normal condition of the rest of the larynx,
the patient’s age and vigorous health, the absence of signs of
tubercle in the chest, the absence of tubercle bacilli in the
sputum, etc., all pointed to a diagnosis of epithelioma. (This
was confirmed by my colleague, Mr. Parker.)

2. Even after the pathologist’s report an error was suspected.

101

especially when enlarged, hard, fixed glands appeared in the
neck.

3. The good result of the operation, although performed for
tuberculosis.

4. There were no signs of the presence of phthisis even now.

5. The failure of the formation of the cicatricial band which
usually takes the place of the removed cord, and the consequent
continuance of aphonia.

Sir Felix Semon thought the case very interesting from many
points of view. First of all from Dr. Lack’s description of the case,
i. e. from the clinical appearances, there seemed to be hardly any doubt
that it was a case of malignant disease. When the microscopic exa¬
mination disproved that, he could quite understand that Dr. Lack
was very much inclined to disbelieve the microscopist in this particular
instance.

Then came the glands in the neck, which would help to increase
the belief in the malignant nature of the disease. Nevertheless this
view was again disproved and the case ultimately shown to be one of
tuberculosis.

Thirdly, there was a fact to which Dr. Lack had drawn his particu¬
lar attention. They knew that usually in cases of thyrotomy under¬
taken for malignant disease of the larynx, a ridge formed correspond¬
ing to where the diseased vocal cord had been removed, and that the
voice materially improved, usually up to the end of the first year, but
in this case there was a complete absence of such a ridge, and it was
impossible to say why.

He was most interested, too, in the appearance of the left vocal cord
during phonation. In the latter part of phonation one saw quite
distinctly the arytenoid cartilage not merely move inward but make
quite a quarter-tttm inwards, so that its vocal process pointed directly
into the glottis, and the vocal cord assumed a completely triangular
form instead of its usual linear outline. He had never seen this
before, and, again, it was practically impossible to say why it should
be so. It was, of course, due to the action of the lateralis muscle,
but why this should contract in this exaggerated way it was difficult
to see, unless a sort of subluxation had been produced by all possible
energy being put into the action of the remaining vocal cord in the
effort to get a better voice.

Dr. Pebmewan had also noticed this appearance of the left vocal
cord with some interest, and it struck him as a sort of rotation or
turning on itself which might be due possibly to the fact that the
anterior end of the cord might have been cut across. He asked
whether the thyrotomy had been only unilateral or whether the ex¬
cision had extended to this side as well.

Mr. Pabkeb had seen this case with Dr. Lack from the first, and
from the clinical appearances when he first saw the patient he quite
agreed with Dr. Lack that there was little doubt as to the malignant

102

nature of the disease and that the proper treatment was immediate
operation.

Dr. Scanes Spicer said this case raised to his mind the question
whether resort should not be had in certain cases of tuberculosis of
the larynx to the external operation and the removal of the affected
area, more especially in those cases in which the tubercular process
was definitely localised.

Dr. Jobson Horne said he was the pathologist and microscopist
referred to. He had expressed the opinion that the disease was
tuberculosis, and not epithelioma, and, as Dr. Lack had stated, he
had not departed from that opinion, notwithstanding the surprise the
result of the examination had occasioned, for it was not the first time
he had microscoped a vocal cord believed to be the seat of epithelioma,
and had found tuberculosis. He considered that the statistics had
been enriched by Dr. Lack having published this case. It went to
show how fallacious and misleading statistics must be which did not
include negative cases. To obtain trustworthy statistics of operations
for epithelioma of the larynx, Dr. Horne said, there were at least two
essentials ; the first was to have a microscopic examination made in
every case of the parts removed by the operation, and the result of
the examination appended; the second, which was, perhaps, more
important, was to have the name of the microscopist also stated.

Referring to the suggestion made by Dr. Scanes Spicer, that the
result of the case opened up a field for further operations of the kind
for tuberculosis of the larynx. Dr. Horne said the results rather
disproved than supported the theory. The cord itself presented
under the microscope the appearance of chronic, quiescent, and, oue
might say, arrested tuberculosis. Tour months later some glands
were removed from the same side of the neck, which doubtless
would have been removed at the same time as the thyrotomy was
done had they been sufficiently affected. The sections of the glands
showed recent and more active tubercle, and suggested a lighting up
of old disease with a reinfection, consequent upon the disturbance of
the old tuberculous focus in the larynx itself. Dr. Horne expressed
himself desirous of showing the sections to the Society at the next
meeting.

Mr. W. G-. Spencer did not quite agree with the last speaker. He
thought this case ought to be classed with those of senile tuberculosis,
which had been mentioned by surgeons. They were more common in
connection with the bones, but there were other forms of senile
tuberculosis occurring in old people, who otherwise had no connection
with the disease—no family history— and who had not shown tuber¬
culous lesions in earlier life. All these cases of senile tuberculosis
were progressive forms of the disease, and he thought, that the
operation in this case was amply justifiable, and would contribute to
their knowledge of other cases of senile tuberculosis in different
positions. As to the frequency of such cases, it might possibly be
greater in the larynx, but even here must be very rare. He thought
it was of further interest, pathologically, in connection with the
question that had been raised of carcinoma of the larynx, i. e. whether
in old age or towards old age there was a diminished resistance

103

against the pathological lesion causing epithelioma. Here some
chance tubercle bacilli getting on to the patient’s cord, and he possibly
having less resistance against the attack than in early life, tuber¬
culous disease had developed.

Dr. Lack said the case was such an exceptional one that he did not
think it afforded any reasons for operating in other cases of laryngeal
tuberculosis. • Thyrotomy and even tracheotomy were generally disas¬
trous in these cases. He did not think this could be called an
arrested growth, as the hoarseness was of only three months’ duration
and was increasing. Nor did he think complete excision of a focus
of disease likely to spread the infection to the glands.

Specimen op Cystic Growth op the Septum and Microscopic

Section.

Exhibited by Dr. Pegler. The tumour was removed from a
male patient aet. 30, who came to the hospital January 31st,
1902, complaining of what he thought was a polypus in the nose,
creating obstruction. On examination a pendulous body was
seen occupying the left middle meatus, bluish grey in colour,
and resembling a polypus to all intents and purposes, though
less flattened and rather more opaque. A distinct attachment
to the left side of the septum was traced by the probe, at about
the region of the tubercle or a little higher. Dr, Clayton Fox
also examined the case, and an oedematous septal polypoid
hypertrophy was diagnosed. It was removed with a Mackenzie
snare with the usual antiseptic precautions, and neither bleed¬
ing nor serous fluid escaped. The after-appearance of the
middle meatus was peculiar, the septum showing a marked
indentation, and the anterior half-inch of the middle turbinal
being strongly deflected outwards at the site occupied by the
growth, which might therefore be presumed to be either of
congenital origin or, at all events, to have existed for a long
period. It proved on inspection to be a cyst with a short,
hollow pedicle. The patient wrote three days later excusing
himself from keeping his appointment at the hospital on account
of “ a bad influenza cold,” and did not subsequently return.
For full notes of the after-history the exhibitor was indebted to
the patient’s private medical attendant, who was called in on
February 7th. At this time the patient was found to be

§

104

suffering from shiverings, pains in the limbs, and headache, with
a temperature of 100°. There being three other cases of influenza
in the house, this disease was diagnosed. After a temporary
improvement the case took an unfavourable turn, and by
February 9th symptoms of meningitis had developed. The left
arm and leg became paralysed, coma set in, and the eyes were
drawn to the left. Later, large twitchings and convulsions
invaded the right side of the body, arm, and leg, and the
patient died on February 15th. The report states that the
initial symptoms indicated right-sided brain trouble, but that
the patient had no local signs drawing attention to the nose
during the illness, neither swelling, pain, tenderness on pressure,
nor discharge, and on this account the exhibitor had not been
communicated with. The tumour, which had been placed in
spirit immediately after removal for subsequent examination,
was handed over to Mr. Bland-Sutton, as there seemed reason,
in the light of what had followed, to suspect meningocele. That
gentleman had carefully examined it, both macro- and micro¬
scopically, but thought “ the source of the cyst was a matter for
conjecture.” The micro-sections showed two distinct zones of
tissue; the outer consisted of nasal mucous membrane; it was
surrounded by columnar, non-ciliated epithelium, and contained
racemose glands, but no sinuses. The inner zone was much
thicker in certain situations than others, and was made up of
connective tissue containing many elastic fibres, but did not
appear to have a definite squamous epithelial lining. The
appearances were well shown in the drawing handed round.
The specimen had been mounted by Mr. Pollard, of Middlesex
Hospital, who also made the micro-sections.

Dr. Dttndas Grant thought they all ought to express their
indebtedness to Dr. Pegler for bringing forward the case. When a
case ended fatally, as this had, the interest was enormously increased,
and its instructiveness was increased, perhaps, in geometrical propor¬
tion. If Dr. Pegler had only mentioned to them at the outset that
the case had terminated fatally, they would have been able to follow
his minute description of what seemed rather small details with much
greater interest. But he thought the points brought before them
showed that the diagnosis he had made as to the site of the tumour
was correct, and no doubt he wished to eliminate any possible idea of
its being a tumour connected with the meninges, such as a menin-

105

gocele. The case was a very interesting one, and there was always
the possibility of such a coincidence occurring in any one’s practice
which had to be kept in mind when carrying out even minor opera¬
tions during a period of epidemics. Many of them had been much
distressed by rashes occurring which turned out to be scarlet fever,
and the patients suffered considerably, and they themselves were
subject to grave anxiety. He thought Dr. Pegler’s description should
be accepted as correct.

Dr. Wingeave said that the evidence of the histology rather
showed that whatever central connection the swelling had, it consisted
to a great extent of distension of some of the lymph or connective
spaces of the periosteum. One could see very clearly the normal
mucous membrane covered with what appeared to be the olfactory
cells in a somewhat fragmentary state. Underneath that one found a
very thick connective-tissue layer with elastic fibres conforming very
thoroughly to the description of periosteum. In that deep periosteal
layer one would find large distended spaces, so that it was quite
possible that it might have been a cystic distension of the periosteal
layers, and even possibly that it might have been a continuation of
the dura mater. In the absence of a definite statement as to where it
was removed from, and in the absence of any histological evidence of
meningeal structure, it was a pure assumption to say that it was directly
connected with the cranial cavity. Certainly the cyst was not lined with
any kind of epithelium suggestive of subdural continuity, or that
could be differentiated from the connective-tissue cells themselves.

Dr. Hill suggested that the specimen and sections be referred to
the members of the Morbid Growths Committee, who should have
power to add other clinicians to their number in order that the
questions raised might be thoroughly investigated. The clinical
history did suggest very forcibly to many present that this was a case
of meningocele. If one removed a polypus from the nose of a patient
who soon after died from meningitis, and if it were then found that
the presumed polypus was a cyst, and came from the septum of the
nose, a strong case was made out in favour of its being a meningocele.
Of course, the remarks of both Drs. Pegler and Wingrave went to
show that the tumour was not like a meningocele histologically, but
then they all knew that congenital abnormalities often underwent
alterations in structure. The case was almost unique, and the refer¬
ences in medical literature to the subject were very vague. Whether
it turned out that one really had to deal with a genuine cystic tumour
of the septum or a meningocele, an important case would have been
elucidated and added to their records.

Dr. StClair Thomson suggested that the possibility of a congenital
meningocele should not be dismissed without such a full investigation
of the subject as Dr. Hill had proposed.

In investigating the literature of the subject in connection with
cerebro-spinal rhinorrhcea, it was suggested by one authority—and it
seemed to be a working hypothesis—that some of these cases of
spontaneous cerebro-spinal rhinorrhcea might be congenital meningo¬
celes which had spontaneously ruptured. He found amongst the
literature that many cases had been put on record of patients who,

106

sooner or later, became infected through the nose, and a great many of
them died with meningeal symptoms.

The importance of the nature of this tumour being definitely
settled was so great as to merit the investigation of the Morbid
Growths Committee.

The President thought the Society was much indebted to Dr.
Pegler for bringing forward this interesting case.

Dr. Pegler said, in reply, that on receiving the report of sub¬
sequent events, his first impression, supposing any connection between
the removal of the cyst and the meningitis existed at all, was that the
growth had been a meningocele. He had since been led to relinquish
that suspicion as a result of the microscopic investigation over which,
in addition to Mr. Bland-Sutton, he had the assistance of Dr. Wyatt
Wingrave.

The microscopic appearances certainly tallied with his recollection of
the attachment of the pedicle. He was anxious that the sections
should be referred to the Morbid Growths Committee, but he feared
that, there having been no necropsy, a great deal in connection with
the case would have to remain conjectural. Anyhow he had brought
it forward as a matter of duty, as well as on account of its unique
interest, for he had found but little in the literature of septal tumours
that had thrown light upon this case. It was stated by unequivocal
authorities that cystic growths of the septum and also meningoceles
under certain conditions should be excised.

On a show of hands it was unanimously decided to accept Dr..
Pegler’s offer to refer the specimen and sections to the Morbid
Growths Committee.

Case op Epidermolysis Bullosa in a Woman, associated with
Mouth and Throat Lesions.

Shown by Dr. William Hill.

Dr. Vinrace asked Dr. Hill if he proposed to adopt any treatment,
and whether he had acquainted himself with any line of treatment
which had been acted on in the past in the many hospitals this patient
had atttended.

Dr. Hill, in reply to Dr. Vinrace, said that no treatment did any
good in these cases as regards the skin lesions.

Case op Tumour of the Right Vocal Cord formed during
Influenza, in a Man ast. 50 (for Diagnosis).

Shown by Dr. Donelan. The patient had attended the
Italian Hospital two months ago, suffering from influenza. The

‘ Laryngolooical Society’s Proceedings,’ Vol. IX.

Dr. Pegler’s Case of Intra-nasal Cyst ( pp. 103—114).

107

paths of infection appeared to have been the pharynx and larynx,
as there were well-marked symptoms of true grippe. The
larynx was intensely congested; there was, however, no growth,
and the patient had a clear voice up to the time of attack. Seen
again two days ago, a growth about 4 mm. long by 2 mm. wide
projected backwards and inwards from about the middle of the
right vocal cord. Apart from the hindrance to approximation
of the cords due to the growth there appeared to be also some
paralysis of the arytaenoid muscles.

Dr. StClair Thomson did not altogether follow the description
of this case, but there seemed to be some ulceration on the left vocal
cord and a good deal of inter-arytaenoid thickening. The man had
lost weight, the pulse was quick, and he had night sweats. He
thought the subject of tuberculosis ought to be borne in mind in
connection with this case, for it frequently developed rapidly after
influenza.

Dr. Donelan, in reply, said he had seen the patient only at an
interval of a month or five weeks, and as the growth had developed
only during the last nine weeks he had not had much opportunity of
studying the case. The patient had syphilis twenty years ago, which
might alter the view taken as to the diagnosis.

Specimen of Fibroma removed from Left Maxillary
Antrum of Male mt . 18.

Shown by Dr. FitzGerald Powell. This patient came under
observation complaining of nasal obstruction. On examination
his septum nasi was seen to be deflected to the left, preventing
a good view of the nostril from in front, but on examination of
the posterior orifice with a mirror a small growth was observed
filling the upper half of the left choanae; the appearance was
that of a polypus or enlarged turbinate. An effort was made to
snare it under cocaine, but only a small portion could be
removed by the snare. The patient was put under a general
anaesthetic, and an attempt made to remove the growth from
behind with Howell's adenoid forceps, but in attempting to
seize the growth it slipped out of reach, and on pushing the
finger in after it a considerable soft mass was felt lying in the
left maxillary antrum, through an opening in the posterior third
of the inner wall.

108

Keeping the finger on the growth, a long-handled, sharp
spoon was pushed in through the nostril from in front, and
using considerable force the growth was freely curetted from
its attachment to the under surface of the floor of the orbit
and scooped into the nostril, where it was seized by the
adenoid forceps pushed up the nostril from in front and drawn
out.

It was found to be a dense fibroma about the size of a small
kidney. Haemorrhage was very free during the operation, but
stopped when the growth was removed, and the patient was at
present doing very well, and had not had a bad symptom since
the operation, which was done a week ago.

The President thought it was difficult to extract such a large
tumour through the nose so as to be sure of its complete removal.

Dr. Powell said that nobody was more surprised than he was
when the tumour came through the nose entire. When he put his
finger into the post-nasal space and felt the mass in the left maxillary
antrum, he had no idea that it was of the size it turned out to be.
It seemed to have grown from underneath the floor of the orbit.
There could not have been a very wide attachment to it, and from the
general contour of the tumour he thought that it had come away
entirely, though, of course, he was not absolutely certain.

If one had known the size of the tumour it would have been
advisable to open the antrum from the front and remove it, or else
remove the jaw. But as it came out as it did he was very well satis¬
fied with the result. The case was being kept under inspection to
see if there was any recurrence.

Case op Malignant Growth in the Nose op a Male Patient

MT. 61, PROBABLY OF THE NATURE OP ALVEOLAR EPITHELIOMA.

Shown by Dr. Dundas Grant. John C—, set. 61, presented
himself at the Throat and Ear Hospital a week ago on account
of complete obstruction of the right nostril and partial obstruc¬
tion of the left. The right nostril was completely filled with a
polypoid growth of a pinkish colour but irregular in shape, and
rough over the greater extent of the surface. The irregularities
were interspersed with small masses of shiny myxomatous
growth. The soft part of the external nose was bulged out-

109

wards, but there was no displacement of the nasal bones and no
bulging of the superior maxilla. There exuded from the nostril
a sanious discharge which irritated the margins, and the nose
emitted a peculiar heavy smell suggestive of putrefying flesh,
and distinct from the odour of ozaena or simple polypus or antral
suppuration. Dr. Grant had observed this smell in connection
with sarcoma, syphiloma, and epithelioma, and was disposed to
think it of some diagnostic value. By posterior rhinoscopy there
was seen to be a large mass blocking up the right choana and
extending over the back of the left one; it was of the same
nature as what was seen in the front, and after palpation showed
marks of haemorrhage. There was no distension of the antrum
in any direction, and on transillumination it was found to be
perfectly translucent. The trouble dated from the earlier part
of last year. In May he spat up some blood which did not
appear to come from the lungs; in June and July the back of
the throat became somewhat obstructed, and in August a fleshy
lump dropped down from the back of the nose into the pharynx,
about the size of a small shelled walnut and of a dark colour.
During the later months of the year numerous polypi were
extracted, but apparently without effecting a complete clearance.
In March of this year an endeavour was made to clear the nose
through the nasal passages by a surgeon of the highest ability,
who considered the growth to be malignant, and although a
large quantity was removed, recurrence had taken place by the
time he came under Dr. Grant’s care.

The case now presented the characters of malignant disease
growing from some portion of the nasal cavity, but in all pro¬
bability not the antrum. There was no enlargement of glands.

A small portion of the growth had been removed and examined
microscopically by Dr. Wingrave, who found it to consist of
a stroma formed of densely packed fusiform cells and enclosing
irregular alveoli which were filled with epithelial cells; the
surface epithelium was stratified, the deepest portion consisting
of columnar cells covered by nucleated spheroidal cells ; this epi¬
thelium invaded the stroma, filled the alveoli, and expanded
irregularly to become cystic; the cells in the alveoli fell out
during preparation. Dr. Wingrave considered that the epi¬
thelium had invaded both from the surface and from the glands;

110

he considered it probably malignant, but the opinion of members
was invited as to the nature of the specimen. It might be
stated that there was no history of specific infection, and that
the patient had of late been gaining flesh, although he had lost
it to some degree during the later part of last year.

Dr. Grant suggested an external operation, making an incision
round the side of the nose and through the upper lip, to which
could be added one below the orbit if excision of the upper jaw,
completely or in part, should seem necessary.

Mr. Spencer thought this a very malignant case, and that it was
the worst form of burrowing epithelioma or carcinoma of the antrum,
and would require removal of the upper jaw. The glands were
beginning to enlarge under the jaw which, if taken away at a second
operation, might prolong the patient’s life a little, but he was afraid
the results in these cases were always bad, and hardly any cases with
this particular form of growth were cured. Although the section
shown was rather thick, yet the chief element was distinctly cylindrical
epithelium arranged in alveolar masses, and not sarcoma.

Mr. Robinson thought it doubtful if it was a case of carcinoma at all.
In the main it appeared to be sarcomatous with the normal glands
embedded in this structure. It certainly was not the usual type of
alveolar or glandular carcinoma, such as would arise from the lining
membrane of the antrum. Transillumination, which had been done,
might here assist, as the antrum appeared to be free. The growth
seemed rather to spring from the nasal wall.

Dr. Wingrave said that one of the specimens was somewhat thick,
yet clearly showed its epithelial nature, which, he thought, was strongly
suggestive of “ duct cancer.”

Dr. Lack said the section was not a satisfactory one, and hoped the
specimen would be referred to the Morbid Growths Committee.

Dr. Dun das Grant expressed his willingness to have the growth
submitted to the Morbid Growths Committee, but thought it would be
undesirable to postpone the operation on that account.

Case op Paralysis op Left Vocal Cord in a Female .et. 27.

Shown by Dr. Wyatt Wingrave. The patient had complained
of hoarseness and shortness of breath for fourteen months, also
slight deafness since childhood.

There was a history of two attacks of acute rheumatism.

The voice was weak, and there was dyspnoea and palpitation
on the slightest exertion or excitement.

Ill

She stated that the voice suddenly changed after a bad cold,
and had remained more or less hoarse and weak.

Laryngoscopy showed complete fixation of the left cord in
extreme abduction.

There was a double basic systolic murmur, with cardiac dulness
extending to supra-sternal notch, associated with thrill and
pulsation, although the pupils were equal and radial pulses were
equal in volume and synchronous.

The evidence was strongly in favour of an aneurysm involving
the left recurrent.

Dr. Permewan said he was rather surprised to hear Dr. Wingrave
in his description say that the cord was in extreme abduction. This
would be a very unusual condition of things. To him the position of
the cord was just the ordinary cadaveric position. He suggested it
was a case of recurrent paralysis with a certain amount of swelling of
the ventricular band concealing the cord.

Dr. Wingrave mentioned the fact that the left cord was extremely
abducted when first seen, being completely hidden by the ventricular
band. To-day one could see a little of it, but at the same time he
felt that it was somewhat external to the cadaveric position.

A Case of Bulbar Paralysis in a Female xt . 23.

Shown by Dr. Wyatt Wingrave. The patient sought relief
for “ a lump in the throat and difficult breathing ” of fourteen
years* duration, but much worse lately.

The voice was weak and articulation imperfect; she spoke in¬
distinctly, as if her mouth were full. She suffered frequently
with dyspnoea on the slightest exertion, but worse during sleep.
Deglutition was normal. The pupils are equal and react to light
and accommodation. The tongue was deeply fissured, red, and
slightly tremulous, and its action feeble. There is well-
marked facial palsy ; knee-jerks are exaggerated.

The larynx showed both cords fixed in a position somewhat
mesial to the cadaveric, leaving but a very narrow aperture.
Tension was fair, but other movements wanting, with the excep¬
tion of slight abduction in the right cord. There was a prominent
sarcous-looking projection in the posterior commissure, and
some slight periarytaenoid swelling.

112

The mother’s story was that she had enjoyed fair health, but
that fourteen years ago a piece of slate pencil was removed from
the right ear under chloroform, which was followed by face
paralysis (right side).

She had five healthy brothers and sisters, and neither syphi¬
litic nor tuberculous history could be obtained.

Mr. Tod said that the growth between the cords suggested fixation
of the cords rather than paralysis.

The case had been under Mr. Hovell at the London Hospital, and
there were some notes to the effect that there had been some disease
of the crico-arytcenoid joint. This referred to some years back.

Mr. Parker said he had seen this case at the Throat Hospital,
Golden Square, some three months back. He then formed the opinion
that the facial paralysis was probably traumatic, due to injury by a
slate pencil in the ear; at any rate the paralysis was first noticed
immediately after its removal under chloroform, when the patient was
between seven and eight years old. Shortly after this the voice began
to change, which led the mother to seek the advice of the late Sir
Morell Mackenzie, since which time the patient had been taken to
various laryngologists and various hospitals.

Dr. Lack said that one point of interest about the case was that
the patient slept perfectly quietly, although she had dyspnoea when
walking about. He did not think she required tracheotomy.

He had seen a case of paralysis and wasting of the arm immediately
following the administration of chloroform for a simple operation,
and wondered if the history in the case afforded any support to a
similar origin.

Dr. Wingrave said that the history of the patient was somewhat
involved and unreliable.

She undoubtedly had facial palsy and weakness and tremor of the
tongue, but the palate moved perfectly well.

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Seventy-fourth Ordinary Meeting, May 2nd, 1902.
E. Cresswell Baber, M.B., President, in the Chair.

Charles A. Parker, F.R.C.S.(Ed.),
James Donelan, M.B.,

}

Secretaries.

Present—35 members and 5 visitors.

The minutes of the preceding meeting were read and con¬
firmed.

The following gentleman was unanimously elected as an
Ordinary Member of the Society :

Robert Henry Woods, B.A., M.B., B.Ch.Dublin, F.R.C.S.I.,
39, Merrion Square East, Dublin.

The following report of the Morbid Growths Committee was
read:

On Dr. Dundas Grant’s case of malignant growth in the nose
(vide ‘ Proceedings ’ for April, 1902, p. 108).

The report on this case was postponed for the purpose of
examining further sections of the growth.

FIRST SERIES—VOL. IX.

7 •

114

On Dr. H. Pegler’s case of cystic growth of the septum (vide
‘ Proceedings * for April, 1902, p. 103).

After examination of the specimen and sections submitted,
the Committee report as follows:

1. The cyst was evidently of old standing, there being dis¬
placement and atrophy of the septum nasi and middle turbinate.

2. The wall of the cyst is composed of the fibrous layer of
the periosteum covered with mucous membrane normal to the
parts.

3. There is insufficient evidence on which to speak definitely
as to the nature of the lining membrane of the cyst. If it was
endothelial, no cells now remain.

4. There is no evidence of any embryonic tissue, e. g. naevoid.

5. Meningoceles have generally been seen in the middle line,
and usually connected with other congenital deformities.

6. The Committee suggest the possibility of a cyst arising in
a dilated lymph space of the nasal periosteum, which, perhaps,
had a communication with the subarachnoid lymph space.

The following cases, specimens, and sections were shown :

Sections op a Large Recurrent Papilloma, which seemed to
grow from the Left Maxillary Antrum.

Shown by Dr. Bronner. The patient, a woman aet. 40, was
seen November 14th, 1901. She had had left nasal obstruction
for over one year, and for five or six weeks had noticed a
purulent and offensive discharge from the left nostril. A large
grey mass completely blocked the nostril. This was removed
by the snare. There was slight haemorrhage. A fortnight
later there was recurrence. The nostril was scraped, and a
large smooth cavity could be felt with the finger, corresponding
in position to the antrum, but much larger in size. There had
been slight recurrence of the growth, which was removed by
the snare. There was now very little discharge, and it was no
longer offensive, and there had never been much pain or

115

external swelling or haemorrhage. The symptoms at first
seemed to point to epithelioma, but microscopical examination
showed the growth to be papilloma. The fact that there had
never been much haemorrhage or pain or external swelling,
and that the growth had practically disappeared, also seemed
to point to papilloma, from a clinical point of view.

Specimen of Sarcoma of Right Tonsil.

Shown by Dr. Walker Downie. The patient, a woman aet. 58,
when first seen on August 17th, 1899, complained of a swelling
of the right tonsil, which had been slowly increasing in size
since the beginning of that year. It had come on without any
apparent cause, and at first gave her only slight discomfort.
This discomfort, however, persisted, so she consulted a doctor in
March, 1899, who informed her that the tonsil was inflamed and
ulcerated. The tonsil was at this time evidently enlarged, and
she had some difficulty in swallowing, but there was no marked
pain. During the next three months the affected tonsil slowly
increased in size, and the patient lost flesh and strength.

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 increased so much in size
in that interval that he had deferred operation, and on August
17th sent the case to Dr. Walker Downie. At this time there
was no doubt as to the nature of this new growth. Her tem¬
perature was normal. She appeared to be in moderately good
health, though complaining of weakness and exhaustion on
slight exertion. Her speech was somewhat thick, and she
complained of pains shooting up 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 barely the size of an average
walnut; it had the form of an enlarged tonsil, and was of a
deep red colour, with several greyish patches of superficial
erosion distributed over its surface. It was firm to the touch,
non-fluctuant, and palpation caused no pain. The faucial pillars

116

were not adherent to the tumour, which was, as a consequence,
freely moveable, and the lymphatics in the neighbourhood were
unaffected.

She was admitted to the infirmary with the least possible
delay, and on August 23rd the tumour was removed under
chloroform. This was effected through the widely opened
mouth, and the growth was enucleated by the finger-nail and
scissors. Firm pressure over the raw surface checked what
bleeding there was. Ice was given frequently for the first few
hours after operation, and thereafter small doses of dilute
hydrochloric acid were administered several times daily until the
parts were healed.

Swelling and ecchymosis of the faucial pillars on the right
side followed the operation, but this rapidly subsided, and the
patient was dismissed on September 2nd with the parts
completely healed.

On microscopic examination the tumour was seen to be a
spindle-celled sarcoma. The entire tonsil had been replaced by
tumour growth. Towards the surface of the tonsil, however,
there was a layer of well-formed connective tissue, covered by
the epithelial investment of the tonsil. This latter (not complete
in the sections) presented no evidence of invasion by the growth.
The tumour, however, in other parts had reached the surface.
A spindle-celled sarcoma might, as was known, remain encap-
suled for a considerable period, and the glands remain unaffected,,
and if recognised and enucleated whilst still encapsuled, there
was every hope that the operation would effect a cure. Such
being the conditions in the present case, this result was hoped,
for. The patient was not seen again till October, 1901, two
years and two months after operation.

On examining the mouth, a small smooth rounded projection
about the size of the tip of the little finger was seen springing
from the soft palate at a level of the upper border of the right
anterior pillar, and close to it. On palpation this projection
and the surrounding parts of the palate and fauces were found
to be the seat of an infiltration—hard, nodular, and firmly
fixed.

Externally there was a fulness just behind the angle of the
right lower jaw. On palpation this was found to be hard and

117

fixed, and to nearly fill the space between the angle of the
lower jaw and the tip of the mastoid process.

The woman's health was still fairly good; she was stout and
florid, and the local manifestations had increased but slowly,
the only additional complaint being that of pain and throbbing
in the right ear, aggravated by lying down.

Specimen op a Fibrous Growth removed from the
Naso-pharynx of a Boy a:t. 14.

Shown by Dr. Walker Downie. The patient, who was first
seen on February 21st, 1901, had complete obstruction of the
right naris for many months, and latterly the left naris had
been similarly affected.

This obstructive difficulty was accompanied by frequent
tickling cough, shortness of breath on slight exertion, and dis¬
turbed sleep, with loud snoring and suffocative attacks. There
were several mucous polypi in the right naris. The naso-pharynx
was very completely occupied by a large bluish-grey growth,
the lower portion of which, rounded and smooth on the surface,
projected below the level of the free border of the soft palate for
fully half an inch during respiration, and during deep inspiration
a much larger portion of the growth was exposed to view. The
movements of the tumour were restricted by the completeness
with which it filled the naso-pharynx. This growth was removed
by means of a cold wire snare introduced through the mouth.
Its removal, though carried out slowly, and by torsion rather
than by cutting, was followed by a very profuse haemorrhage.
This was checked by pressure exerted by long strips of lint,
packed firmly into the naso-pharynx through the mouth and
through both nares.

On microscopic examination the tumour was found to be a
richly vascular and very cedematous fibroma, consisting of a dense
reticulum of curling fibres, and comparatively few cellular
elements.

The operation was followed by continued improvement in the
boy's health, and, so far, there had been no recurrence.

118

Specimen op a Fibrous Growth removed from the
Naso-pharynx op a Boy .et. 11.

Shown by Dr. Walker Downie. The patient had had
difficulty in breathing' through the nose for years, and for at
least eighteen months he had snored loudly while asleep; he
complained of dry mouth, of occasional frontal headache, and
some deafness.

The naso-pharynx, on examination, was found to be com¬
pletely occupied by a large fleshy growth which bled readily
on manipulation.

By digital examination, under chloroform, the growth was
found to spring from the vault of the pharynx. Its extirpation
was attempted by means of a chain ecraseur passed through
the nose, but this instrument broke while crushing through the
firm fibrous pedicle. It was latterly removed by torsion, while
firmly grasped by a curved wire rope ecraseur. This was on
November 12th, 1892. Twelve months later the left superior
maxilla began to swell, and the left naris became obstructed.
The left upper jaw, which was then found to be the seat of a
sarcoma, was excised, and the result had been subsequent
immunity.

Microscopic examination showed this tumour to be a dense
fibroma, in which, however, the cellular elements were compara¬
tively numerous.

The tumour was the seat both of haemorrhage centrally and
inflammatory changes along its external aspect.

Specimen op Sarcoma of the Fauces.

Shown by Dr. Walker Downie. The specimen consisted of
the soft palate, fauces, pharynx, larynx, and gullet. The patient,
a man aet. 33, had been first seen on February 26th, 1901. He
then complained of sore throat, pain on deglutition, and
huskiness of some three months’ duration. On examination
the fauces were seen to be in a state of deep congestion, and the
left faucial pillars and the greater part of the buccal pharynx

119

ulcerated. The ulceration, though extensive, was superficial,
and was considered to be a late secondary manifestation of
syphilis. He was anaemic, emaciated, and feeble, conditions
which favour the rapid extension of syphilitic lesions.

Chromic acid solution was applied to the raw surfaces, and
mercury with iodide of potassium was prescribed. He improved
very greatly up till the end of June, when, without any
apparent cause, his cervical glands became enlarged, and he
again experienced difficulty in swallowing.

On August 17th, 1901, he was admitted to hospital, and the
local lesion was found to have extended very considerably, both
in area and in depth. Not only were the left faucial pillars and
the buccal pharynx ulcerated, as when first seen, but the whole
naso-pharyngeal cavity was raw, and the ulceration had ex¬
tended down to the opening of the gullet. At the lowest part
of the pharynx the mucosa was undermined, and a pocket with
gaping mouth was found on the left side, into which food
entered, and, to further complicate matters, the posterior wall of
the larynx—the arytsenoids, and interaryteenoid membrane—was
greatly swollen. He was, as a consequence, quite unable to
swallow any food (in attempting to swallow food it returned
through his nose), and a bougie could not be passed into the
gullet. It was therefore necessary to resort to rectal feeding,
which was maintained till death. The odour of the discharge
secreted by and covering the raw surfaces was not only foul,
but loathsome.

On admission to hospital his palate had been swollen and
inflamed. A few days thereafter liquefaction occurred in the
centre of a reddened swollen area to the right of the middle
line in the soft palate. The small perforation which resulted
steadily increased in size, and at death readily admitted the little
finger.

On September 20th he was pale, cachectic, and exhausted, as
much from septic absorption as from insufficient food. His pulse
was rapid and feeble. In the afternoon he had two attacks of
syncope, and early on the following morning he died.

On admission to hospital the cervical glands on the right side
formed a swelling considerably larger than a duck’s egg, and
this swelling slowly increased in size till four days prior to

120

death, when it very rapidly shrank, and at death was scarcely
perceptible.

The man was married. His wife had had no miscarriages,
and he was the father of a healthy child of seven months. Up
till about twelve months ago he had enjoyed good health, with
the exception of frequent attacks of sore throat, which, from
his description, appear to have been of the nature of simple
.acute tonsillitis. He was an iron-turner, of temperate habits,
and he denied having contracted any form of venereal disease.

The foregoing lesions were considered to be due to late
.secondary syphilis. During the earlier course of the illness the
ulcers had tended to heal under treatment, and in the lateir
stages the swelling of the palate, which ended in perforation,
followed the usual course of a syphilitic infiltration of the
palate.

The results of the post-mortem examination were wholly
unexpected. The extensive ulceration of the palate, fauces,
and pharynx, accompanied by swelling which resembled inflam¬
matory oedema, might well have passed for a syphilitic lesion.
But on proceeding further new growths were found in the
lungs, the liver, and the kidneys, in all of which the essential
features presented were those of round-celled sarcoma.

Case op Laryngeal Stenosis in a Man .®t. 50, resulting prom
a Large Syphilitic Ulcer op Left Side op Larynx.

Shown by Dr. Donelan. Patient was shown at November
and January meetings on a question of diagnosis, as there was
some suspicion of malignant disease. No decided opinion was
given, but the exhibitor was advised to continue the mixed anti¬
syphilitic treatment under which improvement had taken place.
The ulcer was almost healed, but the patient was shown now on
account of the stenosis which appeared to be increasing, and in
evidence of the fact that even extensive syphilitic disease of the
larynx might be successfully treated without any local measures.

Dr. StClair Thomson suggested punching out pieces of the
syphilitic infiltration. He had under his care a ’bus driver for four

121

years whom at times he had threatened with tracheotomy, but on
punching out the infiltration of the interarytaenoid space and per¬
severing with antisyphilitic treatment, and trying to persuade the
patient to drink and smoke less, the man was able to return to his
work for a few months.

Case op Syphilitic Contraction of Posterior Pillars of the

Fauces in a Man act. 44.

Shown by Dr. Donelan. This might appear a misdescription
without the history. The patient was admitted to the Italian
Hospital last September, suffering from pneumonia and a large
tertiary ulcer, involving the naso-pharynx, posterior aspect of
vomer, and back wall of pharynx. He was in an extremely
debilitated state, but, notwithstanding, was given a course of
twenty-five inunctions of 3 ] of blue ointment, with iodide of
sodium internally. The naso-pharynx was regularly sprayed in
the first few weeks with pcrchloride of mercury (1 : 5000),
and the patient steadily improved. During his subsequent
mixed treatment as an out-patient contraction of the cicatrix
gradually took place, and the posterior pillars were gradually
drawn together until they are as might be seen now.

Complete Occlusion of Right Nasal Vestibule in a Man

act. 32.

Shown by Dr. Herbert Tilley. The condition followed the
insertion of a strong styptic which was applied to check severe
bleeding during an attack of pneumonia. The cartilaginous
portion of the septum deviated very markedly to the right, and
it was thought probable that the occlusion was the result of
cicatrisation of the two closely apposed surfaces, the ulceration
of which had been induced by the styptic. The exhibitor, at
the express desire of the patient, purposed to remove the scar
tissue, and at the same time to perform A sell’s operation 011 the
septum.

The President said that there was so much deflection of the
septum that a cicatrix might easily form across from one side to

7 §

122

the other. There appeared to be no evidence that the case was con¬
genital in character.

Dr. Watson Williams thought it was an interesting point that
this condition should have followed immediately upon an attack of
acute pneumonia. The question of pneumococcal ulceration was so
new, and so few cases were known of or described, that it was im¬
possible for him to do more than throw out a suggestion that some of
these cases of ulceration might be due to pneumococcal infection.

Advanced Destruction of Intra-nasal Structures associated
with Suppuration of the Right Maxillary Sinus.

Shown by Dr. Herbert Tilley. The patient, a man aet. 42,
had had syphilis six years ago, and the intra-nasal structures had
been extensively destroyed. A portion of the vomer alone
remained of the septum, and the right middle turbinal was
absent. The mucous surface was covered with a thin veneer of
dry blood-stained muco-pus. In several features the case
resembled that shown by Dr. Bennett at a recent meeting, but
in that instance no history of syphilis was present, neither was
there any pus in the antra.

The exhibitor wished for the opinion of the Society as to
whether such a condition might not arise independently of
syphilis, and as a result septic infection of the nasal mucosa.

The President suggested that this might be a case of syphilis; it
looked very much like it.

Dr. Pegler said that Dr. Bennett, who was unable to stay to the
discussion, requested him to say that he did not see any parallelism
between his case and Dr. Tilley’s. In the present one there was not
nearly so much perichondrial thickening, nor was there any pain,
and in every essential point he thought the two cases quite different.

Case of Great Symmetrical Thickening of the Upper and
Anterior Part of the Nasal Septum.

Shown by Dr. Lambert Lack. The patient, a man aet. 33, had
been under treatment for the past twelve years for nasal obstruc¬
tion. This apparently depended upon a very marked thickening
in the neighbourhood of the tubercle of the septum. This

123

thickening was so great that the case had been diagnosed as a
cyst of the septum. It had been cut away and cauterised many
times, but had always recurred after a few months or a year.
Dr. Lack first saw him about a month ago, and with snare and
cutting forceps removed the growth from one side, which is now
clear, but the curious growth can still be seen on the other. If
this swelling was simply an exaggeration of the boggy thicken¬
ing of the septum often seen in this region, it was by far the
most marked example he had ever met.

Mr. Waggett asked if pus, as at the present time, was always to
be found in the nose, and whether there was any possibility of this
being a case of perichondritis and suppurative disease of the septum
itself.

The President asked whether there was any suppurative disease
in the left maxillary sinus. He had noticed pus in the left nasal
cavity.

Dr. Hill thought that there was some suppuration present, but he
imagined that that was not the point which Dr. Lack intended to
emphasise in connection with the case; it was rather the recurrence of
the large thickening of the septum after it had been freely cut off in
large portions with, presumably, a knife. He had had the same diffi¬
culties and disappointments himself, and he had almost come to the
conclusion that there was a tendency in all soft thickenings of the
septum to recurrence after removal, and sometimes even in hard
structures also.

Dr. Pegler had had an almost exactly similar case under his care.
He operated two or three times upon the swollen septum and then
the patient ceased attending, probably only slightly benefited. He
thought these cases were probably syphilitic in origin.

Sir Felix Semon suggested that on some future occasion this very
important question which had just been raised by Dr. Hill should be
made a subject of general discussion. He was glad to hear he was
not the only unfortunate person with regard to these cases. It had
so often struck him after operations on the septum that the difficulty
one had in subduing the subsequent swelling was very great, and
literature afforded hardly any assistance as to the after-treatment of
these cases.

Dr. Lack regretted that the appearance of this case had completely
changed since he last saw it. There was then no pus. The discharge
the patient said had commenced during the last week. Dr. Lack was
surprised to hear there was often difficulty in preventing recurrence
after operations for thickened septum. He had small expei'ience in
cases of this kind, but in bony thickenings of the septum he had
found no recurrence after operation.

124

Case op Inherited Syphilis of Nose, Pharynx, and Larynx,
with Complete Occlusion op Anterior Nares.

Shown by Dr. Lambert Lack. The patient was a boy who had
come under observation three weeks ago with complete occlusion
of the left nostril and a red granulating ulcer of the right
nostril, with nearly complete atresia of this side also. The soft
palate was infiltrated with small nodular patches, and in places
there was slight ulceration and scar tissue. The upper part of
the larynx was similarly affected, the epiglottis being partially
destroyed, and the stump greatly thickened and distorted.
Under treatment with potassium iodide internally, and mercury
ointment locally, the ulceration of the right nostril had healed,
and there was now complete atresia of both anterior nares, with
remarkably little sign of loss of tissue or of scarring.

Sir Felix Semon doubted from the appearance of the larynx
whether this case was due to syphilis alone, though that disease
might in part be the cause. He would think lupus a more probable
explanation of the condition, and had no hesitation in saying that the
appearance of the epiglottis was almost typical of lupus. Of course,
the nose made the diagnosis doubtful, as did the result of the treat¬
ment. He thought some tissue ought to be removed and examined
for tubercle bacilli. He drew attention to the fact that whilst
there was complete occlusion of the nose, there was no deafness.

Dr. Lack would remove a piece for the microscope. He admitted
that the condition of the palate and larynx strongly resembled lupus,
but considered the favourable result of treatment pointed strongly to
syphilis.

Case op Large Laryngeal Growth in a Woman.

Shown by Dr. T. W. Bond. Patient, a married woman, had
had some huskiness of voice for thirteen months. She had had
no cough, no difficulty or pain in swallowing, no night sweats,
and her temperature was normal. There was no history of
syphilis. She had had one severe attack of stridor. There were
no enlarged glands.

On right side of larynx there was a large red mass, firm to

125

palpation, extending from below cord to level of tip of epiglottis.
The right arytaenoid and the ary-epiglottic fold were merged in
the mass. The case was shown for the purposes of diagnosis.

Dr. Dun dab Grant took the growth to be a sarcoma, and wished
to know whether Dr. Bond had also come to this conclusion.

Dr. Lack said some members might remember a somewhat similar
case he had shown to the Society in February (see vol. ix, p. 60).
This patient had marked cedematous infiltration of one side of the
larynx, and especially of the arytaenoid, and had been under observa¬
tion for three months, and taking iodide of potassium without any im¬
provement, and without developing any sign of phthisis. Quite lately,
however, tubercle bacilli had appeared in the sputum, and Dr. Lack
considered that the large majority of doubtful cases of this kind
proved, ultimately, to be tuberculous. He thought this should be the
diagnosis of Dr. Bond’s case.

Mr. R. Lake thought there was a difference between this case and
the one Dr. Lack had shown them in February last, for the latter was
a large smooth growth and not nodular, whereas in this patient the
growth was very nodular. He thought the growth here looked as if
it had been palpated, and he would like to know whether the redness
was due to injury by a finger.

Dr. StClair Thomson said that this case reminded him of a
case he had shown to the Society of a growth in a similar situation in
R man about fifteen months ago. The patient was somewhat older
than Dr. Bond’s patient, being forty-five. It was, when shown, taken
by the Society to be a malignant growth, the patient at the time
being without any symptoms of tuberculosis. Some two or three
weeks after showing him his health broke down, and tubercle bacilli
were found. Tracheotomy had to be performed, and the man died of
tuberculosis. He thought he had previously mentioned that Dr.
Horne had possession of the larynx, which was distinctly tubercular.

Sir Felix Semon said that in such cases he thought it was much
better not to speak at once of a “ tumour ” or a “ growth,” but rather
of an “ infiltration ” or a “ swelling,” in order not to prejudice one’s
own diagnosis. Personally, he preferred to call the “ growth ” in the
larynx of this patient an “ infiltration.” For there was a general
infiltration, a little nodular, as Mr. Lake had said, of the right half
of the larynx. As soon as one spoke of a “ tumour,” or a “ growth,”
one’s thoughts were immediately directed to the formation of a new
growth, and left out the other alternative which had been mentioned
by Dr. Lack, with whom he agreed in thinking that this would turn
out to be tubercular.

Dr. Bond said that, in his opinion, in the present condition of the
case, he did not think anyone had a right to diagnose it, although one
might be permitted to suspect tuberculosis of the larynx. But there
were several points against the tubercular supposition; so far as he
could learn from the husband, there was no loss of weight, no night
sweats, and no cough. When he himself took the temperature for
the first time it was normal. To-day, at the end of the examinations,

126

it was 100°, but as she was at present suckling an infant of four months
this rise could easily be explained.

It was a firm feeling growth, but he had not palpated it that day.
He did not know whether anyone had done so. He saw the woman
six days ago, when there was a red patch on the surface of the
tumour. It was open to all to say that it might be a sarcoma,
for there was some justification for this opinion. But there were
no glands enlarged, and there was a history dating back thirteen
months. In such a case one might on operating find the glands
enlarged, although they could not be made out as enlarged from
a surface examination. He intended to watch the patient, and
would be glad to give a further report later on. Probably he would
examine a small piece of the growth microscopically.

Glosso-labio-laryngeal Paralysis, with Complete Paralysis op
one Vocal Cord and Abductor Paralysis op the other.

Shown by Dr. StClair Thomson. The case was specially
interesting, as the progress of the laryngeal paralysis had been
watched from an early stage. The patient had complained of
thickness of speech for some twelve months. In November last
there was only paresis of the abductor muscles. A month ago
Dr. Thomson had tried to bring the case before the Society as
one of complete double abductor paralysis. Since then the
affection had made further progress, for it would be noted that
the left cord was completely fixed in the cadaveric position,
while the right cord failed entirely in abduction, and on phona-
tion crossed the middle line in its attempt to close with the life¬
less left cord. In other words, the only action to be found in
the cords was that of adduction in one—the right.

The patient’s speech was so thick and indistinct that the poor
fellow had been taken up by the police for drunkenness when he
was quite sober, and he had great difficulty in earning a living.

Phonation was unimpaired. The vowel sounds were successfully
produced, but there was distinct failure of some of the consonants,
both labials and dentals. There was conspicuous speech defect
owing to failure of co-ordination, yet it was difficult to detect any
appreciable paresis of the muscles of the lips; the tongue could
be protruded with apparent facility and without tremor, and the
soft palate showed no failure in its reflex movements. He could

127

inflate his cheeks, but could not whistle. There was no dysphagia,
but occasional spasm and coughing on drinking. The reflexes
and pupils were normal.

The President said an important question in this case was whether
or not tracheotomy should be performed, and it would be valuable to
have the opinion of members on that point. There was scarcely any
interval between the cords. He inquired as to whether there was much
anaesthesia of the larynx.

Dr. Watson Williams suggested that as the paralysis had
developed so rapidly, the probability was that before very long, there
being already complete paralysis on one side, there would be complete

r *alysis on the other side also. The danger of asphyxia would then
greatly lessened. Any operation might only still further compli¬
cate the case, and add a new danger.

Dr. StClaib, Thomson asked whether tracheotomy was in any way
contra-indicated from the existence of anaesthesia of the larynx, which
was often present in these cases. Should he be hastening on a fatal
termination by doing tracheotomy by reason of the food going down
the trachea, which it already showed some signs of doing? The
patient was in a rather pitiable state. He was at present able to earn
his own living and talk a little, and when it was explained to him
that even if operative measures were taken he would be able to talk
no better than before, and would probably not be able to continue
earning his living, he did not naturally seem inclined to undergo any
operation. If anyone had any experience of a case of this sort in
which tracheotomy had been performed, he would be very glad to hear
of the results.

In reply to the President, Dr. Thomson said the anaesthesia, though
present, was not very marked.

Case op Excrescences or Incrustations or Chalky Deposits

LOW DOWN IN THE TRACHEA.

Shown by Dr. Edward Law. The patient, a lady set. 36,
came under observation three days ago. She brought a letter
from her doctor in South Africa, stating “ she has suffered from
ozsena, and has, to a great extent, recovered under various
methods of treatment. She knows her ailment, and is anxious
to get quite well if possible; she has recently lost her sense of
smell.”

She had first noticed nose trouble as a child with an occasional
disagreeable odour from the nostrils. She had employed various
nasal solutions with a syringe or douche, but gave those methods

128

up some years ago on account of the discomfort which they
caused at the back of the nose and throat. For some years she
had sniffed the nasal solution through the nose. Formerly the
voice was very husky and hoarse, but not recently. She now
complained of a constant short, hacking cough, loss of smell, in¬
different taste, and a slight discharge from the nostrils. There
was no history of a foreign body, no dyspnoea nor expectoration,
and the general health was satisfactory. An uncle died of
cancer of the throat. On examination no atrophic changes were
found in the nose, pharynx, or larynx, and nothing abnormal
beyond some little catarrhal trouble and a small crust in the
neighbourhood of Luschka’s tonsil, thus verifying her doctor’s
statement that she had to a great extent recovered from the
ozaenic trouble. Low down in the trachea a number of papillo¬
matous excrescences, or crust-like or cretaceous deposits, were
seen, a large one with ragged edges on the right side, and a
number of smaller ones dotted in an annular or crescentic
arrangement around the trachea. There was little or no irrita¬
tion of the tracheal mucous membrane, but pressure over the
windpipe, just above and behind the upper border of the
sternum, caused slight pain and discomfort.

The diagnosis was, in Dr. Law’s opinion, very uncertain. He
had thought of papillomatous excrescences, ozaenic incrusta¬
tions, herpetic crusts, keratosis, ulcer, enchondromata, and chalky
deposits.

Dr. Law and the members had to thank Mr. Waggett for his
very interesting drawing of the case. Suggestions were
solicited in reference to the aetiology, diagnosis, prognosis, and
treatment.

Dr. Wm. Hill said that to see this case well a better light was
necessary than that afforded, and he suggested that as the paucity of
light was so frequent a source of complaint, some steps should be
taken with a view to remedying this very serious defect.

Mr. Waggett .had had an opportunity of looking at this case for
an hour under a very strong light when making the drawing, and he
said that with regard to the presence or absence of crusts, a point
upon which considerable doubt existed, he was persuaded that there
were no crusts, and for the reason that the upper part of the trachea
was perfectly healthy in appearance, and in the texture of its mucous
lining. On the other hand, those little excrescences had very definite
forms ; there was the larger mass of a trilobed shape, and there were

129

about fourteen other little masses which were arranged in an annular
manner corresponding to the rings of the trachea; and although the
drawing which they had seen might not be absolutely correct, it
erred in the omission rather than in the fictitious introduction of
masses which were not to be seen with a good light—a strong electric
light and a four-inch condenser. He ventured to make a diagnosis that
these excrescences were of a papillomatous nature, although he knew
opinions on that point differed very widely. There was no true
atrophy of the intra-nasal structures. He thought it might be of
some interest to add that these little masses did not move during
respiration, and that their appearance was absolutely identical now
with what it had been twenty-four hours previously.

The President asked Dr. Law whether there was any history of a
foreign body having been in the trachea at any time.

Dr. Lack suggested that the growths in the trachea might really
be crusts, a view also expressed by other members. The fact that the
appearances had not changed in twenty-four hours, in his opinion, in
no way militated against this view. They might remain stationary
for a week. He suggested that Dr. Law might clear up the diagnosis
as to this important point by syringing or spraying the trachea.

Sir Felix Semon added his own opinion to the same effect. What
induced him to take this view was the co-existence of crusts in the
naso-pharynx and (what could not be seen well with the light at their
disposal in the adjoining room, but could very well with an oxygen
light) the greenish colour of the little protrusions in the trachea,
which was quite different from anything with which he was acquainted,
either of tracheal excrescences or of a papillomatous nature. As to
remaining stationary for twenty-four hours or a week, he would like
to mention a little experience of his own. When in statu pupillari he
observed on a certain occasion an extraordinary (as he thought)
excrescence on the right vocal cord of a patient in the Throat Hospital
which he could not account for, and so after having it under observa¬
tion for about a week, he took the patient to Sir Morell Mackenzie,
and asked his opinion about this extraordinary growth. Sir Morell
Mackenzie, after examining it for a moment, took a dry laryngeal
brush, introduced it into the patient’s larynx, and having withdrawn
it, invited him (the speaker) to look again. He looked, and there
was no growth to be seen.

Dr. Law, in reply to the President, said there was no mention of
the presence of a foreign body at any time in the trachea. He would
like to suggest that the Council should make some arrangement by
which members might be provided with a better light at their
meetings for the examination of tracheal cases, for every member who
had looked at his case had told him it was almost impossible to do so
properly because of the wretched light. With reference to the
diagnosis, he was sorry it was still a matter of doubt, as the patient
came from South Africa, and was leaving London the following day.
He would try and persuade her to return to town for the next
meeting. Having carefully examined the condition, he was somewhat
opposed to the diagnosis of ozsenic crusts. At first the impression
made upon him—and he did not at first see the excrescence or deposit

130

with ragged edges on the right side, but only the somewhat annular
arrangement of a number of the projections which were whitish in
colour—was that they were a sort of chalky deposits. Afterwards he
thought of papillomatous excrescences, of keratosis, of a possible
herpetic condition, of ozsenic crusts, of an ulcer. But he considered
the diagnosis very doubtful. Dr. Thomson had suggested there
might be a breach of surface due to an ulcer; he would point out
there was some tenderness over the affected part of the trachea.

Case of Removal of Epiglottis for Tuberculous Disease.

Shown by Mr. R. Lake. The patient, a man aet. 30, was sent
to him by Dr. Bennett, of Leicester, with the following history :—
He was working in a laboratory when the next man, in performing
some experiment, produced a very thick cloud of nitrous vapour
which irritated the patient’s throat. A few days later, as he
was suffering with dysphagia, he consulted Dr. Bennett, who
diagnosed laryngeal tuberculosis, and found slight crepitations
in one apex. He came as an in-patient to Mount Yernon
Hospital two weeks later, and after being treated for a week and
getting worse, his epiglottis was removed with the galvano-
cautery snare. The stump is quite healed and healthy, but the
arytaenoid regions are still slightly swollen. His lungs now are
apparently healthy.

Tuberculous Perichondritis; Case shown at the Society’s
Meeting, February 7th, 1902.

Shown by Mr. R. Lake. In this case the larynx had been
exposed by a large flap incision on March 8th, and on incising
the perichondrium a yellowish-white semi-transparent mass was
found separating the perichondrium from the cartilage ; it was
roughly of an inch in thickness. This was carefully
removed, and a small spot of disease was found in the mid-line
of k the cartilage, which was cleared out. Mr. Lake said, had it
not been for the advice of his colleague, Mr. F. Spicer, he would
have excised the larynx, but he was glad he did not, the man
being now in good health and working at his trade, that of a
baker. The mass removed was an organised product of inflam¬
mation, and was full of giant-cells, with bacilli in most of them.

131

Case of Geographical Tongue.

Shown by Dr. Pegler. This patient was a boy set. 4, and he
had been subject to “ wandering patches ” on the tongue since
birth. They were more or less circular, and varied in size from
a quarter of an inch to an inch in diameter. At present they w'ere
fewer and less marked than usual; they often disappear alto¬
gether for a few days, and then a fresh set succeeded them.
The centre of each patch was red and raw-looking, the edges
raised, reddish yellow towards the centre, and white at the
periphery. The boy was brought to the hospital for nasal
obstruction, which turned out to be due to membranous rhinitis.
A quantity of the membrane was removed from the septum in
the left fossa under an anaesthetic, with considerable benefit,
but traces were still visible.

Case of Syphilitic Necrosis of Intra-nasal Structures, expos¬
ing to View the Opening of the Sphenoidal Sinus on

EACH SIDE, AND OF THE POSTERIOR ETHMOIDAL ON THE LEFT.

Shown by Mr. Hunter Tod. The patient was an old woman,
who came to the London Hospital Out-patients, complaining of
headaches and dimness of sight. The hose was filled with
crusts, removal of which showed present condition. The eyes
were reported by the ophthalmic surgeon to be normal.

Dr. StClair Thomson said that no doubt the openings led into
the sphenoidal sinus, but he thought it was quite open to question
whether they were the natural ostia sphenoidalia. They appeared
to him to be on too low a plane altogether, for the natural openings
were more commonly higher up, and it was rare for them to be close
against the septum. The natural opening in this case was occluded
by granulation and cicatrisation tissue higher up, and the opening
now seen was due to the front wall having partly necrosed away.

Dr. Hill said that he had measured the distance of these ostia
from the vestibule in this case, which was not more than 2| inches,
and he thought that was one inch anterior to the real sphenoidal
openings and lower down. He had seen a similar case in which he
had made the mistake of thinking he was dealing with the sphenoidal
sinuses when he was not. On measuring he found openings too far
forward, and he attributed the abnormality to the formation of

i

132

adhesions, but why they should form in this region and simulate
the sphenoidal ostia was most curious and inexplicable.

Dr. Watson Williams took the same view of this case as Dr. Hill,
and did not think that these were openings into the sphenoidal sinuses.
Without measuring it was, of course, difficult to judge distances, but
it certainly seemed to him that they were too far forward, and he
thought that there was no doubt that the syphilitic changes, which
evidently had been very pronounced indeed, occurring in the posterior
portion of the nasal passages, would be quite enough to distort the
posterior ethmoidal cells and to produce the conditions in this case.
Under the existing circumstances it would be very difficult indeed
without actual measurement to make up one’s mind whether they
were ethmoidal cells or sphenoidal sinuses. These openings did not
appear to be natural openings, being too large and not situated in the
normal situation.

The President regretted he had not seen this case. He did not
think there was usually difficulty in recognising the opening into the
sphenoidal sinus when it was visible.

Mr. Tod, in reply, said he certainly thought that they were
sphenoidal sinus openings, as they were very symmetrical and so
central. On the left side they could pee above and behind the middle
turbinate bone an opening which he took to be the posterior ethmoidal
cells. On feeling with a probe between the openings it was quite hard
to the touch, but around the openings it was membranous. He was
able to pass in a probe on the right side nearly an inch; on the left
to a less extent. When the patient first came to hospital he passed a
cannula into the openings and pus was washed out, and it came out
from each opening separate, showing absence of communication
between the two sinuses. He agreed with Dr. Thomson the openings
led into the sphenoidal sinuses, although the anterior wall had
probably become necrosed and been replaced by membrane.

Cystic Adenoma op Pyramidal Lobe op the Thyroid.

Shown by Mr. Waggett. This occurred in a woman aet. 43,
who first noticed a lump in the neck six years ago. A fortnight
ago it had become painful, and increased to double its former
size. At the present time a firm tumour, the size and shape of
a bantam’s egg, occupied the subhyoid region of the neck a
little to the left of the middle line. Evidently a haemorrhage
had occurred in a cyst.

Dr. Grant considered this a cyst connected with the thyro-lingual
duct.

Mr. Waggett said he thought Dr. Grant and himself merely
differed on the question of terms. The pyramid lobe of the thyroid
gland was the lower part of what was called the thyro-lingual duct.

/

/

/

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Seventy-fifth Ordinary Meeting, June Qth, 1902.

E. Cress well Baber, M.B., President, in the Chair.

Charles A. Parker, F.R.C.S.(Ed.),l g , .

James Donelan, M.B., Secretaries.

)

Present—25 members and 3 visitors.

The minutes of the preceding meeting were read and con¬
firmed.

The President called upon Mr. Charters J. Symonds to open the
discussion on

THE DIAGNOSIS AND TREATMENT OF MALIGNANT
STRICTURE OF THE (ESOPHAGUS.

Mr. Symonds said—

Mr. President and Gentlemen,

To put the subject of this debate briefly, it may be said
that the diagnosis of malignant stricture of the oesophagus
resolves itself into the passage of a bougie to ascertain the

FIR8T SERIES—VOL. IX. 8

134

presence of an obstruction, and the treatment in deciding the
best way to introduce food. One sees, however, so many cases
treated for dyspepsia that it is necessary to consider a few of
the early symptoms. In speaking to an audience of experts, I
will limit myself to what appear to me to be essential points, and
endeavour not to weary you with unnecessary details.

A gradually increasing dysphagia is the common history in
most cases. In by no means a small number the onset is sudden,
e. g. at a particular meal; a man choked over a mouthful of meat,
and from that moment had difficulty. Another, after shouting
himself hoarse in welcoming the men from the Powerful in the
City, had choking the same evening, and developed cricoid
obstruction. In one instance a loathing for food, so great as to
require feeding by a tube, was the leading sign for some weeks.
In another the man complained of pain as the food passed the
centre of the gullet.

I have seen one instance where there was no dysphagia; the
man was anaemic and was thought to have cancer of the stomach,
and when his evacuations were black this view was strengthened.
At the autopsy we found the greater portion of the oesophagus
occupied by an ulcerating carcinoma, which had enlarged and
not constricted the lumen at any point.

Before a bougie is passed a good many patients are treated
for dyspepsia, and much valuable time may be lost. One sees
such patients losing flesh, not so much on account of inability
to swallow, but because the diet has been restricted, on the view
that the disease was gastric. It must be remembered that so-
called “ dyspepsia,” i . e. loss of appetite, “ tightness at the chest,”
water brush, some pain and distension, with irregular bowels,
may be the result of oesophageal obstruction. The restricted diet
usually prescribed tends to increase the symptoms. A diagnosis
can generally be made by asking the patient to swallow
liquid. This when marked is characteristic; he makes one
ordinary effort, followed by one or more smaller ones; these
are accompanied by certain peculiar movements of the neck.
Then he brings up a little gas, often hits his chest, and says
now it has gone. Kussmaul’s sign, viz. listening to the back to
hear the fluid arrested at the stricture and then trickling
through, is always interesting, and when the observer does not

135

pass a bougie is sometimes valuable. I am sure from what I
see that an unnecessary fear exists in the minds of many as to
the danger attending the use of a bougie. Provided that a fair
size be employed, and no force used, and especially that no
pressure be made when the patient strains to extrude the instru¬
ment, there is no danger. The bougie should be advanced in a
deep inspiration or on an act of deglutition, held still on any
expulsive effort, and again advanced on inspiration. That there
are dangers with fine bougies, and in advanced disease, one
cannot deny. In passing the cricoid one must wait for the in¬
spiration which follows the first glottic closure, or make the
patient regurgitate by passing the left forefinger far back on
the tongue. To press at this moment in close cricoid stricture
may send the bougie into the trachea. Once more it may be
added that in impermeable cricoid obstruction, where the patient
is particularly tolerant, there is special risk of entering the
trachea. It is remarkable to note how a patient will bear the
presence of a large bougie in the windpipe for some time with¬
out coughing. In any doubt we must pass the bougie not more
than twelve inches, and examine its position with a laryngoscope.
These special points refer rather to treatment; it seemed but
right to refer to them here.

With these general remarks, I will next ask you to consider
the diagnosis of the disease as it affects the three situations,
viz. the upper third and cricoid orifice, the lower end and
gastric orifice, and the central region.

1. Upper third .—Stricture at the cricoid or beginning just
below the ring is, in my experience, always malignant. It
begins at 84 to 9 inches from the teeth, and usually involves 2
or 3 inches. The chief peculiarity is the tendency to cicatrise
and contract; so marked is this feature that a specimen may be
indistinguishable to the naked eye from a chronic syphilitic or
other ulcer. If the margin, however, of such a specimen be
examined microscopically, squamous epithelial growth will, I
believe, always be found. The contraction is irregular, so that
a bougie in passing may have to turn several corners. In the
diagnosis of disease at the cricoid I have found three conditions
give rise to confusion:

a. The one most closely resembling organic disease is

136

dysphagia, occurring in elderly people. In the first instance
that came under my notice, the patient was a woman set. 70;
there was dysphagia for solids, and fluids caused trouble; a
bulb passed with difficulty, there was a streak of blood, and
altogether I thought gravely of the case, and gave a serious
prognosis. The symptoms soon disappeared, and the patient,
after some years, is still well. A similar instance came before
me again in a woman over 70, and another in a man over 80.
In the persistence, in the indefinite obstruction to a bougie, and
in the age of the patient, there is sometimes a close resemblance
to malignant disease. There is also an absence of the nervous
symptoms seen in younger people. The condition suggests
some organic change, giving rise to temporary interference with
deglutition. I have thought that possibly an excessive cricoid
ossification, or some bony outgrowth interfering with movement,
might explain these cases.

6 . The nervous form, especially when occurring in men,
and in medical men above all others, can only be settled by
time. Suddenly such a patient has difficulty at a meal over a
mouthful of food, and later cannot swallow a pill or a crust of
bread. He has to be more careful in eating than before. It is
well known that such is often the history of the early stages of
malignant stricture. The passage of a bougie is not easy, a
little blood may result to further confuse the issue, or one may
fail to pass the bougie beyond the cricoid without undue force.
Where such symptoms occur in a man of forty-nine or fifty, the
diagnosis is not easy. In both affections the freedom of swallow¬
ing varies, in both soft solids are better dealt with. I would say,
however, that in malignant disease the patient almost always
permits the passage of a bougie, and that there is found
irregularity of the surface indicating disease of some standing.
Practically in the majority there is no great difficulty, but in a
few cases—especially if they happen to be medical friends—it
may give rise to no small anxiety. In most cases it is best, 1
believe, to give a positive opinion as to the simplicity of the
case and wait with your own secret fear.

c. The third condition is that of a pharyngeal pouch. When
well marked, the symptoms of this complaint are so defined as
to quickly clear up any difficulty. The subject has been so well

137

dealt with before this Society that I need only refer to Mr.
Butlin’s communications.

Malignant disease of the lower end of the pharynx, in¬
volving the arytamoids, cannot be excluded from a discussion
upon oesophageal stricture, and as the same treatment is
required, I must refer to it here. The main distinctions are the
pain accompanying dysphagia; the voice early has the peculiar
sound produced by the presence of cedematous aryttenoids;
again, the growth can usually be seen in the early stages. It
appears first as a pale cushion below the arytaenoids, and
gradually advances, giving rise to early oedema of one or other
arytaenoid. These patients often continue to swallow fairly well,
and can, so far as I have seen, always be relieved by a soft tube.
The direct extension to the larynx is the special feature of
disease in this situation. Those who have seen many of these
cases will have observed the greater frequency in women, and in
many at an age nearer thirty than forty. I may add that in
one instance—a woman also—the early mass seen below the
arytamoid disappeared under iodide of potassium. I have not
myself encountered syphilitic disease lower than the pharynx.
I have one patient with slight obstruction just above, or at the
cricoid, who had originally—some thirty years ago—syphilitic
ulceration involving the larynx.

2. In the middle third a sarcoma and a myoma may occur, and
give rise to obstruction. In one of my cases a sarcoma was
found as a localised tumour, but clinically it was indistinguish¬
able from the ordinary carcinoma. With such rare exceptions
as these, all obstructions of any moment in this section of the
oesophagus are due to carcinoma. It is very noticeable that
aneurysm and mediastinal growths rarely give rise to serious
dysphagia. Once only have I passed a bougie in a case of
aneurysm, and the sensation communicated to the hand was, I
thought, diagnostic of the disease. The case was sent to me
with a diagnosis that mediastinal pressure was absent. The
bougie passed over a convexity and smoothly descended without
any difficulty.

(Esophageal pouches occurring in the middle and lower
sections are sometimes very difficult to detect. In one patient*
set. 72, symptoms of obstruction had existed for several years; a

138

bougie was arrested 14 inches from the teeth; on one
occasion it slipped past, and there seemed abundance of room.
Under chloroform, the largest bougie was several times guided
past the orifice. At this time he regurgitated a good third of
his food. For another two years he went on much the same,
and died somewhat suddenly from another malady. There was
no doubt a pouch in this case. The,long duration was a strong
point against malignant stricture; the second, that he could
always take solids.

In another instance a man was sent to me for pyloric
vomiting; without going at length into his case, I may say
that the symptoms pointed to obstruction low in the gullet, and
the large quanity of food retained to the existence of a pouch.
He was fed by a tube, and the vomiting ceased. I thought it
better that the man should learn to feed himself in this way
than undergo a gastrostomy. After a year of such treatment,
he is in good health and able to do his work.

3. The lower end, i. e. a point 15£ inches to 17 inches from the
teeth, is, in my experience, the only locality where we find a
simple obstruction. One is justified in saying that, as the obstruc¬
tion is in this situation, the cause may be simple, and that the
mechanical difficulty being overcome, the future carries more
hope than does obstruction in any other situation. I have notes
of five such cases, two with pathological evidence, while three
are clinical. In the first two the symptoms were those of
obstruction only, and they died unrelieved. One of the three
living cases has had symptoms for some years, and is relieved
from time to time by the passage of a coude bougie; another
has swallowed well since a gastrostomy was performed over a
year ago, never having required to use the artificial opening;
while the third has had symptoms for twenty years, and requires
a bougie from time to time. I will again refer to the use of the
coude bougie in obstruction at the lower end; let me here, in
referring to diagnosis, insist upon its great value. When a
small, straight bougie will not pass, a large coude may slip
through easily. The two specimens referred to showed a simple
fibrous thickening, allied, no doubt, to that seen in the pylorus.

Slighter degrees of obstruction occur in this situation, which
nmy be called spasmodic. I have seen only one marked case, a

139

lady aet. 30, who, when I saw her, had had obstruction for
twenty-four hours. A bougie encountered resistance, which
yielded as would a tight sphincter. The obstruction was
definite, not a purely nervous form. This brings one to the
whole question of “ spasmodic stricture,” so called. Personally
I must express a disbelief in such a complaint, apart from the
hysterical cases. Of these latter, the two worst occurred, the one
in a boy aet. 7, and the other in a man aet. 35, both hospital patients,
and both greatly .emaciated. The boy was cured by the tempta¬
tion of a penny currant bun, the man took a pair of the largest
bougies. All the cases brought to me for spasm, except the
hysterical, have a basis of malignant growth. I have mentioned
before that in a growth in any situation there may be, in the
early stages, much difficulty from added spasm and varying
mechanical alterations in the growth itself, permitting the taking
of solids on one day, and of fluids only with difficulty on
another.

When the stomach is infiltrated by malignant disease, and so
reduced as to hold but a couple of ounces—the so-called leather-
bottle stomach—the resemblance to obstruction at the cardiac
end of the gullet is very close. In one instance the patient
could retain about 1£ ounces, any larger quantity being re¬
jected. But this amount, taken frequently, was retained, and
the diagnosis thus established. This was confirmed by opera¬
tion.

In another, with obstruction at the cardiac orifice, I found, on
performing gastrostomy, only a small portion of the stomach
free and available for establishing a fistula. I have no doubt
that we had entered the stomach through the oesophagus, and
that the inability to retain fluid was due to the reduced capacity.
After the operation wo were never able to introduce more than
two ounces at a time.

Of oesophagoscopy I have no personal experience. Its value
was recently demonstrated to me by Professor Mickulicz, of
Breslau, who showed me a case of actinomycosis recognised by
this method. A piece of growth was removed by forceps and
examined.

I may summarise the diagnosis in the following way :

1. Among early symptoms we may base so-called “ dyspepsia,”

140

nausea, and repulsion for food; pain alone when the central
district is affected.

2. That the passage of a bougie is the only way to clear up
the case, and that its employment need not be feared.

3. That extra-oesophageal disease rarely gives rise to serious
dysphagia.

4. That spasmodic obstruction, apart from the hysterical form,
has always, when decided, an organic cause, and that this would
be better called intermittent dysphagia.

5. That with regard to the three special districts it may be
said—

a. That all organic obstruction in the upper third is malig¬
nant, and has a special tendency to cicatrise.

b. That in the central half of the gullet, a sarcoma or a
myoma, both rare diseases, may cause fatal obstruction; that
here, also, a pouch may give rise to difficulty in diagnosis, but
can generally be excluded.

c. That in the lower end alone does simple stenosis occur, and
that here there may be difficulty in distinguishing from cancer
of the stomach causing great reduction of the cavity (leather-
bottle stomach).

Finally, that in estimating the extent of the disease, the
special value of the steel bulb is noted, and also the use of the
coude bougie in obstruction at the lower end.

Treatment. —Speaking generally, it may be said that we can
relieve by mechanical means only, and that two methods are
available, one to overcome obstruction by inserting a tube of
some kind, and the second to open the stomach below the
obstruction, i. e. perform gastrostomy.

I would put the general question of treatment in the follow¬
ing way, as applying to all cases :

1. While the patient can swallow fluids and semi-solids, and
while a bougie can be passed and plenty of nourishment taken,
he may be left, so long as—

а. He can swallow well;

б . A small bougie, No. 12 (catheter gauge), can be passed.

2 . If the dysphagia increases, even though a bougie can be
passed, then a tube must be inserted or gastrostomy performed.
These conditions are seen in the soft fungating forms.

141

3. If a bougie cannot be passed, or goes with difficulty, then
the same course must be followed, as wo know that complete
closure may occur at any time.

4. If both conditions arise, i. e. the patient cannot swallow
and a bougie cannot be passed, then immediate mechanical
treatment is required.

Probably most have summarised their treatment in some such
fashion. ,

I have not advocated the passage of bougies with a view of
dilating the stricture. It is injurious in that it irritates and
leads to increase of obstruction ; it may split a hard stricture
and set up rigor and fever from absorption. In my own
practice I have abandoned this method in all malignant cases.
The object of the small bougie to which I have referred is
simply to secure the route so that at any time a tube can be
passed for feeding purposes, or the time fixed for gastrostomy.
More than this has, in my experience, proved injurious. As
applying to all cases, I would here again refer to the advantage
of attempting the passage of a tube after a night’s rest and a
dose of opium.

Turning next to each region, in the upper third we have to
note the great tendency to rapid closure and to the certainty of
complete obstruction sooner or later. Two methods are available
here: (a) the long feeding-tube, and ( b ) gastrostomy. Though
I have successfully employed a short tube, it does not, as a
rule, rest comfortably unless the highest part of the stricture be
at least 1£ inches below the cricoid. Of the long tubes, the best
is that made from rubber drainage-tube, introduced by the
whalebone director. When this cannot be passed, the retention
of a silk-web tube for a few days will so enlarge the passage as
to enable the other to be inserted, or an ordinary urethral
catheter will answer, and sometimes the coude variety will pass.
If the patient be fairly tolerant, the method is a useful one.
The tube will last a long time, so much as nine months. If it
comes out, it can always be replaced if the attempt be made at
once. Should the tube, when rejected, be soft and have lost its
elasticity, then a fresh piece must be used. It should never be
removed for cleaning, as re-insertion may be difficult. I have
conducted many cases to the end with this tube; the main

§

142

objection is that saliva cannot as a rule be swallowed, though
some patients will sip fluid by the side of the tube.

Another objection is that it does require some dexterity,
perhaps, to insert in difficult cases, and much patience, but not
more of either than does the passing of a catheter in stricture
of the urethra. The form I have for many years used is, as you
see, somewhat roughly made, the end of a piece of ordinary
No. 10 drainage-tube .being sewn up with silk, and a big eye
cut above. Note that the end of the introducer is passed into
the eye, and a small plug of wool is inserted into the closed end
to prevent the introducer slipping through. The proof that
the thinnest walled rubber tube would keep a malignant
stricture dilated was first pointed out by Mr. Berry. We must
contrast this method with gastrostomy, and I would say that
where the patient is low and unable to bear abdominal section
it is our only plan. As an alternative, I find it has sustained
life in comfort equal to the most successful gastrostomy, and
greater by far than when the stomach contents escape and
cause excoriation. When the patient is intolerant and objects,
then we can offer only gastrostomy. The longest time I have
known one of these rubber tubes remain unchanged was
thirteen months. The obstruction was at the cricoid, and great
difficulty was encountered in passing the first long feeding-tube.
The rubber form was easily introduced after a few days'
residence of the silk-web tube. From time to time small
pieces of the rubber tube had to be removed, as it split near the
silver cannula. The patient died with the original tube in
position. Others have worn it for varying periods. In two
cases patients have also worn tracheotomy tubes. One now
under treatment has had a rubber tube in eleven months and a
tracheal tube four and a half months. The same method
answers admirably in disease of the pharynx. In this form
the obstruction to a bougie is never very great, and I have
had cases fed by a member of the family three or four times a
day. Its application is limited. After many trials, I have no
doubt that the best tube is the gum-elastic silk-web, with a
closed end and two large eyes, and that the best sizes are
Nos. 10, 12, and 14; smaller ones are of little use for permanent
wear, and dilatation up to 12 is best conducted by the long

143

tube. The vulcanite pattern introduced by Renvers I have
found of no value ; it is too hard and too short. The most suit¬
able cases for this method are those where the stricture is short,
and has a tendency to contract; then a four-inch tube answers
admirably. The position and length of the stricture are ascer¬
tained by a steel bulb. As the disease progresses it may be
necessary to use a six-inch tube.

In the central •portion , i. e. for obstruction occurring from a
point 10 inches from the teeth to 141 inches, we can use a short
tube in addition to the long one. When introducing this
method in 1884* I said I hoped it would give relief in a certain
number of cases, and it has fulfilled this forecast and no more.

The experience published in two former paperst represents
very well the use and value of the short tube, and later experience
has confirmed it. Of recent cases I may cite the following:

A man set. 55. Dysphagia began early in 1898.

February 24th, 1899.—A short tube was inserted, the stricture,
a short and contracting form, being 14 inches from the teeth.

April 21st.—The tube removed at patient’s request; great
difficulty in inserting another.

May 2nd.—A tube inserted.

July 28th.—A new tube introduced by Mr. Steward.

March 3rd, 1900.—The tube was still in and acting well, i. e.
over seven months.

Some time later he showed signs of extension to the lung, and
died on June 3rd, 1900.

Duration before tubage, twelve months; duration under tubage,
sixteen months. Of these certainly thirteen were passed in
comfort; and he attended to his business.

In another case the short tube acted perfectly up to the time
of death, the treatment covering a period of more than a year.

Disease involving the lower end and cardiac orifice I have
found difficult to treat by tube. I admit that occasionally one
has been successful with a short tube or a long one, but as a
rule it is rejected on account of the contraction of the dia¬
phragm. Early gastrostomy seems to me the best advice. I
advise that this be done while the patient’s general condition is

* ‘ Clin. Soc. Trans.,’ vol. xviii.

t ‘ Brit. Med. Journ.,* April, 1887 ; * Lancet,’ March and April, 1889.

144

good. One very strong point in favour of this course is that, as
I have said earlier in this paper, simple stenosis may occur in
this situation. Given, therefore, a successful gastrostomy, life
may be indefinitely prolonged. Moreover it may be possible,
especially with the coude bougie, to dilate the obstruction after
the gullet has had a rest. We may at least auticipate some
return of swallowing.

Of course, as in other situations, operation would not be
undertaken so long as a bougie could be passed and the patient
could swallow freely.

Early gastrostomy applies especially to malignant disease in
this situation.

I must mention one remarkable case referred to before. A
woman with great dysphagia, emaciation, and obstruction at
the lower end. A coude bougie could be passed. As she lived
in the country, and as dysphagia was increasing, I performed
gastrostomy. From that moment the power to swallow returned,
and the second stage of the operation was completed. It has
not been necessary to use the stomach opening. The woman
remains so well—now more than a year from the operation—
that I think the case must have been one of simple obstruction.
Dilatation could not have been effected by suturing the stomach
to the abdominal wall, and the only other suggestion one can
offer is that a tortuosity has been straightened.

In view of the occasional occurrence of simple stenosis at the
cardiac orifice, it seems to me our duty to press operation upon
our patients when the dysphagia is marked.

The use of chloroform to facilitate the introduction of a tube
is a question for discussion. Personally I have always had an
objection to it, but I must admit that in cricoid strictures it has
been of great service, and deserves a wider employment. So
easy is it, however, to pass a small bougie or tube into the
trachea, that I make it a rule, after passing a tube for 12
inches, to examine with the laryngoscope to see that it is really
in the oesophagus. In one case, when this precaution was
omitted, after waiting some time and there being no spasm or
cough, milk was poured down and passed into the lung with
disastrous consequences.

In another the tube passed through a tracheal fistula.

145

Reviewing tlie whole question of treatment and contrasting
tubage and gastrostomy, one may say as regards the latter that
it at once disposes of all difficulty as regards swallowing; that
in obstructions at the cardiac end it should be performed early;
that in ail patients intolerant of the tube and bougie, time
should not be wasted. In advanced cases, where leaking can be
prevented and immediate feeding undertaken, the operation
may be successful, and there is reason to expect that such a
method has been found.

Unfortunately, many cases among the poor are obtained in too
advanced a stage for operation to be considered, and there are
others who decline operation. It, therefore, is necessary to
perfect, as far as possible, the alternative method of tubage.
With regard to cricoid strictures and disease in the lower part
of the pharynx, I am quite satisfied with the rubber tube, and
believe it to be superior to gastrostomy. We want a tube so
constructed that it will not easily be regurgitated, and I believe
this will be produced. Once a tube has been retained it is never
wise to dispense with it, even for a day. I have several times
yielded to the patients’ wishes in order that they may enjoy the
luxury of a solid meal and been unable to re-insert another tube.
The insertion of the new tube should immediately follow the
withdrawal of the old one, be it a short or a long tube.

The short tube has, as I said, a limited use, being of little
service in disease of the two orifices. But in the central
section I still find it valuable. It is open to the objection that
it is liable to get blocked, and that, again, some skill is required
to insert it. With cases where there is no cough I have known
it remain unchanged for ten months, and in another three
months. There is no necessity to remove these tubes for cleans¬
ing purposes; the silk, protected as is now done by fine rubber
tubing, will last for months, and the security of the silk is the
only anxiety.

When cough arises from extension of growth, or haimorrhage
occurs, the tube will get blocked, and then a long feeding-tube
must be used—either a silk-web or a rubber. It is unnecessary
on this occasion to go into details, so I will put the question of
tubage thus:

The short tube is useful in strictures occurring from a point

146

10 inches to a point 14 inches from the teeth. It is no use
when there is cough on swallowing, indicating perforation. It
is of little value when the growth occupies a long stretch of the
gullet. It is seldom of use in strictures involving the cardiac
orifice, and cannot, as a rule, be borne in disease involving the
cricoid level.

In suitable cases it has, however, given good results up to the
time when perforation occurs, and then, as a rule, a long feeding-
tube answers for the few weeks that remain.

A word must be said as to the dangers of intubation. One
has had accidents, fortunately in only one was life much
shortened. In one case a tube was passed, under chloroform,
through a perforation into the trachea. This showed the danger
of chloroform.

In another a soft and ragged oesophagus was perforated, the
man being in the last stage of the disease.

In another a tube in the tight cricoid stricture passed into the
trachea; the man did not cough, and gave no sign that such an
accident had occurred until signs of pneumonia developed.

These accidents occurred some years ago, when one was
endeavouring to improve the method of treatment. Since one
has systematically used the laryngoscope to ascertain the position
of the tube in cricoid strictures, several similar accidents have
been avoided. It is essential to use this check when operating
under chloroform.

Summary of Treatment.

1. In cricoid obstruction the long rubber tube gives excellent
results. When not well borne, gastrostomy, if selected, should
be performed early.

2. In disease of the central portion the short tube is service¬
able in a fair number of cases, and, when it acts well, is superior
to any other method. It must be replaced by the long feeding-
tube when pulmonary symptoms arise.

3. In disease of the cardiac orifice tubage is so .uncertain that
gastrostomy should be performed when dysphagia becomes

serious.

147

Dr. Herbert Tilley : I think that most members will agree with
me that the term “ classical ” is one which might well be applied to
the address that Mr. Symonds has given us on the subject of the
diagnosis and treatment of malignant stricture of the oesophagus.
His experience in this class of cases is so unique that anything which
others may say on the matter can only lie in the nature of accentuat¬
ing facts which Mr. Symonds has already brought forward. I will not
attempt to do more than this. I wish only to bring before the notice
of the Society two cases which seem to illustrate the apparent simple¬
ness of some of the symptoms which are so easily overlooked in the
early stages of malignant stricture of the oesophagus, and to which
Mr. Symonds has referred in the early part of his address.

The first case was seen some four years ago in University College
Hospital. A middle-aged man was admitted to a medical ward
suffering, or supposed to be suffering, from ulcer of the stomach.
The patient had been brought in complaining of acute pain in the
stomach, and on three or four occasions he had vomited large
quantities of blood. He was very anaemic, and in the absence of
any physical signs in the chest or stomach, it was very difficult to
say what organic lesion was present. He took food well, and had no
difficulty in swallowing ; these were puzzling features of the case.
I was given an opportunity of examining the patient, and found that
although the voice was fairly clear, yet the left vocal cord was
paralysed. Of this, there were no symptoms so far as the voice was
concerned. On further examination I saw, about three inches down
the trachea, a small, pale, nodular mass projecting into the lumen of
the trachea. On the strength of this observation I made the diagnosis
of malignant disease, probably of one of the mediastinal glands, the
enlargement of which had obstructed the trachea. As to whether
that gland was a secondary growth no one could say, for the simple
reason that there was no evidence of any primary growth in the
oesophagus or elsewhere. In the course of a few days the man
died from another attack of severe haemorrhage. At the post-mortem
examination a malignant ulceration of the lower end of the oesophagus
was found, which, as already stated, at no time had caused any
obstruction, and the gland I had seen projecting into the trachea was
a secondarily infected mediastinal gland. The case is extremely
interesting as illustrating (1) how frequently such symptoms may
mislead as to the true nature of the case, and (2) the light which may
be thrown on an otherwise obscure case by means of a laryngoscopic
examination.

The second case was seen about two months ago. The patient, a
man aged fifty-one, had lost his voice for two months, and complained
of certain stomach symptoms, e. g. flatulence, anorexia, inability to
swallow solid food, because it immediately induced sickness, etc., and
his illness had been attributed to “ gouty oesophagitis,” whatever that
might mean. For some twelve months he had been complaining of a
feeling of sickness after taking food. On examining the larynx, I
found complete bilateral recurrent paralysis; the patient could only
speak in a whisper, and had a very distressing and ineffectual cough.
On examination of the chest, no evidence of aneurysm could be found.

148

Attempts were made to pass oesophageal bougies, but the smallest
one could not be passed beyond the level of the lower end of the
manubrium sterni. I therefore took this to be a case of malignant
disease of the oesophagus. A fortnight later I saw the patient again,
and on further examination found above the manubrium sterni and in
the region of the left lateral lobe of the thyroid a stony hardness, and
many small enlarged cervical glands above the clavicles. The patient
died a few days after the consultation, and unfortunately no post¬
mortem was obtainable, and it was therefore impossible to be sure as
to the situation of the primary growth, i. e. whether it was in the
thyroid gland and involved the gullet, or vice versa.

These two cases illustrate the fact that sometimes one may get
invaluable information as to the cause of the patient’s symptoms by the
use of the laryngoscope. In both the cases briefly outlined, the suspicion
raised by finding the vocal cords paralysed was the main factor in the
formation of a correct diagnosis. My experience has been very much
in accordance with that of Mr. Symonds with reference to an apparent
oedema of the upper end of the oesophagus, which occurs most com¬
monly in young females suffering from malignant disease of the
oesophagus in the neighbourhood of the cricoid cartilage. I remember
seeing two young women, one aged twenty-one, the other aged twenty-
eight, in which this curious oedema of the upper end of the oesophagus
was followed very shortly afterwards by death from malignant disease
in the situation referred to.

Sir Felix Semon : I am sorry I was prevented from being present
at the beginning of Mr. Symonds’ admirable paper, and, therefore, do
not know whether he referred to two points, the absence of which
rather struck me. In speaking of the differential diagnosis between
malignant and other forms of oesophageal obstruction, I heard him
say nothing about laryngeal paralysis, nor about the question of the
enlargement of the cervical lymphatics. Both these points I have
often found to be of considerable importance with regard to the
diagnosis of doubtful cases. Dr. Tilley has j nst quoted a case in which
the discovery of a laryngeal paralysis gave the first reliable sign of
existence of organic obstruction. I may say that I have seen quite
a number of similar cases, and more than once have I found that
patients who came to me for laryngeal symptoms, apparently limited
to that organ, such as hoarseness and loss of voice, later on developed
the ordinary symptoms of malignant disease of the gullet.

In connection with this point, I should like to say that oedema of the
neighbouring arytsenoid cartilages, if the disease is situated in the
cricoid region, is by no means the only laryngeal symptom of oeso¬
phageal cancer in that situation. When malignant disease affects the
posterior aspect of the cricoid cartilage, it eats its way by no means
rarely into the substance of the posterior crico-arvtsenoid muscles, and
causes a true myopathic paralysis of one or both of these muscles.
The symptoms resulting from this when the disease affects both sides
are stenosis of the glottis and great respiratory difficulty, often
enough of greater urgency than the difficulty of swallowing.

I need hardly mention that laryngeal paralysis is by no means
I’'!ted to cases of cancer of the oesophagus when the latter is situated

149

in the cricoid region, but that it may also accompany instances of that
disease occurring much further down,—that is, one or both recurrent
laryngeal nerves are caught in the furrow between the trachea and the
oesophagus by a new growth starting from the latter.

With regard to the enlargement of the cervical lymphatic glands,
this sign has several times been of considerable value to me, particu¬
larly enlargement of those glands which one can feel on pressing hard
immediately behind the clavicle when standing behind the patient; btit
one has to press sometimes very low down to feel these glands
enlarged.

With regard to the treatment, I speak with considerable diffidence,
for I think we may say we all sit at the feet of Mr. Symonds, who has
shown not only this country, but the whole world, how to treat a
number of these cases, particularly by the employment of the smaller
tubes which he has introduced. In Germany the credit of this is
often given to Professor Eenvers, although the last-named gentleman
himself, when first introducing the method into Germany, acknowledged
his indebtedness to Mr. Symonds. Personally I must confess I have
not much opportunity of trying the short-tube treatment, and I have
been rather unfortunate in those few cases in which I have tried it,
for my patients were quite intolerant of the tubes for any length of
time, and I had, therefore, to remove them; but in several cases
which, later on, I sent to Mr. Symonds considerable relief was given,
in two of them for a long time, by the employment of this method.

Should gastrostomy be required, I entirely agree with Mr. Symonds
that the operation should not be performed at too late a stage of the
disease.

Concerning the introduction of bougies, I have learnt from expe¬
rience the wisdom of his advice to give in difficult cases the patients a
night’s rest and a dose of opium previous to the introduction of the
tubes. One may succeed by following this simple advice where one
has previously failed. Should an anaesthetic be indispensable, the
dangers of chloroform in such cases should not be under-rated. I
have had a very sad experience of this. About a year ago a lady con¬
sulted me on account of difficulty in swallowing. She was thirty-four,
and in otherwise excellent state of health, but had lost flesh in conse¬
quence of this difficulty. There were no signs of organic disease
anywhere in the chest or in the throat, but when I proceeded to intro¬
duce a bougie, I did not succeed. The same difficulty was encountered
by Mr. Makins, whom the patient had also been advised to consult.
He and I agreed that it was desirable to repeat the examination under
chloroform. A few days later this was done, the anaesthetic being
administered by one of our most experienced and most skilful
anaesthetists. When the patient was deeply under the influence of the
drug—as in a case of this sort ought to be the case, to exclude all
reflex action—I endeavoured to introduce a big bougie, but without
success, nor did Mr. Makins have any better fortune. I then tried a
smaller one and still failed, and Mr. Makins’ attempt met with the same
result. The bougie having been withdrawn, the patient showed signs of
coming to. The chloroformist said, “ Let me give her a whiff more,”
and proceeded to do so, when the patient died suddenly. Every effort

150

was made to resuscitate her but all was fruitless. No post-mortem
examination took place, and to this day I do not really know what
was the nature of the disease, but both Mr. Makins and myself
concurred in the belief that it was organic.

A propos of the distinction between organic and functional stricture
of the oesophagus, I remember having seen two or three quite distinct
cases in which, after some iuitial difficulty, the bougie could be passed
quite easily, and in which, after this had been repeated two or three
times, the stricture was found to have disappeared. I cannot say that
these were not examples of “ hysterical ” stricture, but then, what is
hysterical stricture ? Is it not what one would usually call spasmodic ?
I do not think the existence of such a form of oesophageal stricture
can be denied.

In conclusion, I wish to congratulate the Society upon having had
so excellent an expose of an important and difficult question as that to
which we have just been listening.

Dr. Clifford Beale : I should like to make one small contribu¬
tion to this debate, and it is in reference to the question of diagnosis
by the means of the X rays. The opportunities have not occurred
very frequently since more powerful apparatus was introduced, but a
good many cases have been examined, and my friend, Dr. Hugh
Walsham, handed to me this afternoon four plates which he has
made of such cases, two of them being confirmed by a post-mortem
examination, and these two show certain definite characteristics which
may ultimately turn out to be trustworthy in diagnosis, but, of course,
with the evidence so slight as it is at present, one can only take
things as one finds them. But the important point is this, that in
these cases of oesophageal cancer there is a very well-defined shadow
thrown on both sides of the normal mediastinal shadow, whereas in
the case of enlarged glands at the root of the lungs, the shadow,
although something similar in form, is undefined at its edges. As
one would expect, a well-defined morbid growth will give a sharp
shadow, and a mass of glands with inflammatory thickening round
about them will be represented by indefiniteness. [The plates were then
shown.] One point with regard to this method of examination by the
Rontgen rays is that it gives us more information as to the amount
of thickening and growth that may be present. I think we shall
all bear out Mr. Symonds when he says that it is the bougie which
masks the diagnosis after all; but the bougie only tells us that
there is an obstruction and not how extensive the cause of obstruction
may be.

As regards the treatment, one cannot help being struck with the
fact that cases are recorded (and Mr. Symonds has mentioned one)
where, after gastrostomy has been performed, and where, presumably,
the patient has been kept quiet for a few days and fed per rectum , it
is found that the power of swallowing is perfectly restored. In the
cases in question that I have heard of—for I have not yet come across
one myself—the power of swallowing is apparently as good as ever.
Now, when one comes to think of what it is that gastrostomy does for
the patient, one finds that it is nothing more than freeing the growth
from irritation, and giving it absolute rest. Therefore, this leads one

151

to think that in the early stages of such a condition one might do a
good deal in the same way by keeping the cesophagus as free as
possible from irritation, and by giving it rest. I have carried out
this idea in the case of a patient who is under treatment now. By
getting him to swallow a certain amount of hot water after every
meal to wash down the oesophagus, and at the same time giving a
small amount of sticky mixture of opium, i. e. Liquor Morphiae com¬
bined with glycerine and gum acacia, the result is altogether satis¬
factory, affording, as far as one is able to judge, both cleanliness and
rest. I can also quite confirm what Mr. Symonds says as to the
absence of dysphagia in cases where there is pressure from intra-
thoracic growth and aneurysm. I think the absence of dysphagia
may sometimes be a rather striking feature in certain cases of cancer
of the cesophagus where the stricture is not complete. As an old
Guy’s man, I rather expected Mr. Symonds to tell the story that was
in vogue there in our student days, of Astley Cooper, who after going
through the medical wards at Guy’s to see some special cases, had his
attention called to an old man, sitting up in bed, whose face, so far as
appearances went, was obviously suggestive of cancer. Astley Cooper
•was told that none of the physicians could find out what was the
matter with the old man, and he instantly replied, “ Then he must
have cancer of the cesophagus; he obviously has cancer, and this form
of it is the only one which may give no symptoms.”

Cases crop up like this every now and then, which are proved by
post-mortem examination to have extensive malignant ulceration of the
oesophagus, and yet during life, though these patients obviously have
cancer somewhere, there is no regurgitation, no difficulty in swallow¬
ing, and nothing to call attention to it. I do not know how frequent
such cases may be, but still one must always bear in mind the possi¬
bility of their occurrence.

Mr. H. B. Robinson : I should like to emphasise a point which
was made by Sir Felix Semon, and that is, the great importance of
the enlargement of the cervical glands in the diagnosis of malignant
stricture of the cesophagus. Its importance struck me forcibly in a
case I saw a little time ago. The patient was a man I saw in private
practice, who had a mass of enlarged glands just above the right
clavicle; he had great pain down the arm, but there was no suspicion
whatever of his having any oesophageal disease at all, but when one
went into the question and made a few inquiries and passed a bougie,
there was undoubted contraction of the oesophagus. His oesophageal
symptoms had been of so slight a character that the enlargement of
the glands had never been thought to be in any way connected with a
growth in the oesophagus.

Another interesting case of oesophageal obstruction which is worth
bearing in mind perhaps, although the obstruction was not in the
cesophagus itself, but was caused by pressure outside it, was that of
a man sent to me with very marked dysphagia. He was about forty-
five. The only thing one could see that probably had relation to the
dysphagia was the fact that there was some enlargement of the left
lobe of the thyroid gland; but still, from what one was able to feel,
one did not at the time think it could exert any great pressure on the

152

oesophagus, though it was the only apparent cause of the difficulty in
swallowing. Thinking there might be something deeply placed
exerting pressure, I operated and found in the deep paid; of that
gland a cystic adenoma, which was pressing right down between the
trachea and the (esophagus and indenting the anterior wall of the
oesophagus. I removed it by shelling it out, and the man did
perfectly well and has had no further symptoms of dysphagia from
that day to this.

Dr. J. Donelan : I should like to ask Mr. Symonds whether he
regards as absolute strictures those in the neighbourhood of the
stomach, in the lower part of the oesophagus, where it is impossible to
pass a tube and keep it in position for any length of time. I
remember the very first case I ever saw of this kind as a qualified
man was a case which illustrates the point brought forward by Sir
Felix Semon, namely, the early occurrence of laryngeal paralysis. It
was a case under the care of a distinguished specialist here in
London, and laryngeal paralysis had existed for six months. After
a time I saw the patient, who said that four days previously he
suddenly lost the power of swallowing and had had no food since. I
remember I tried to pass several kinds of bougies, but without
success, and the only thing I was able to pass was the third string of
a violoncello, which is very small, much smaller than any sound.
This served afterwards as a guide for the passage of a straight
feeding-tube. I kept this in position for some days; the obstruction
was sixteen inches from the teeth. The tube I used for this man was
a thin one—I don’t know now whose name was attached to it—but it
was a French tube and very fine; it was much the shape of a
Symonds tube, but much thinner. During the six months that the
patient lived afterwards it was retained in position. It was taken
out on one occasion and there was very great difficulty in putting it
back, but ultimately it was replaced and remained in position until
the death of the patient. The second introduction was facilitated by
the use of cocaine, by passing the tube down as far as possible and
then pouring a little cocaine solution through it.

I should like to ask Mr. Symonds whether the similar use of a
solution of adrenalin might not be of some use in reducing the
turgescence and facilitating the passage of a bougie or tube.

We have lately had some three or four cases examined by means of
the Rontgen rays, but in these the lower part of the oesophagus was
the seat of disease, and whether in that situation it will be possible to
arrive at any more definite conclusion than that already afforded by
the passage of a bougie must be a doubtful matter on account of the
greater size and number of the intra-thoracic structures that are
present. It does not appear to me that the Rontgen rays in this
situation can throw more light on the subject than the bougie.

Dr. Dundas (xbant : I should like to add my tribute of indebted¬
ness to Mr. Symonds for the way in which he has marshalled so many
points. I have selected from my memory some of the difficulties
which I have experienced.

The following occurred very early in my experience of general
practice. The patient was a man of middle age who had increasing

difficulty in swallowing. This difficulty varied a little in its intensity.
The man was certainly getting thinner. I had then a consultation with
the late Sir Andrew Clarke, who asked me to pass an oesophageal bougie,
which I did without any very great difficulty; but he discovered the
presence of malignant disease in the abdomen.

In another similar case which I have had more recently under
observation, the patient had all the appearances of cancer of the
oesophagus. I was unable to pass a bougie through it. Without
examining the patient very much further I handed him over to a
general surgeon who was anxious to perform gastrostomy. On
examining him with a view to that operation he found carcinoma
of the liver. In these two cases the contraction of the oesophagus
seems to have been reflex in origin; perhaps my experience with regard
to these cases has been very exceptional, but I put it forward, and I
shall be glad to know whether this is a frequent condition simulating
carcinoma of the oesophagus. Again, whether in this second case of
mine the administration of chloroform would have helped to clear up
the difficulty is an important question, because if it would, I think it
is a great argument in favour of administering an anaesthetic in these
cases. There was under my care some time ago a patient on whom
X failed entirely to pass an oesophageal tube. He was fortunate
enough to come into the hands of Mr. Symonds, and I understand that
it was under an anaesthetic that he succeeded in introducing a tube,
which gave the patient very great comfort for some time. Naturally
the objection to chloroform is the risk incurred by its use, and this is
a serious factor which has to be reckoned with. I should suppose
it was a coincidence in this particular case of Sir Felix Semon’s, which
had such an unfortunate termination. But whether some involve¬
ment of the cardiac nerves makes chloroform more dangerous in
cases of cesophageal cancer is a point on which I think there is room
for reflection.

In another case I was able to pass a large bougie with perfect
facility, and ventured to give the opinion that there was no disease of
the oesophagus, but the patient died a few months later, and was
reported to me to have been certified as dying from carcinoma of the
oesophagus. In another case, which I showed to this Society as one
of primary malignant disease of the thyroid gland, there was a
general consensus of opinion that it was such. The patient died
afterwards at Reading Hospital, and on post-mortem examination
was found to have extensive disease of the oesophagus certified as
carcinoma of the oesophagus, though, indeed, this may have been
secondary to the disease of the thyroid gland.

With regard to those cases of spasmodic stricture of the oesophagus,
I have seen several cases where a considerable amount of dysphagia
has arisen from defective dentition, and I remember well the case of
an old gentleman (a medical man) who came to me on account of
what he thought to be carcinoma of the oesophagus. On examina¬
tion, I found that he had lost almost all his teeth, and I recommended
him to get some artificial substitutes. Within a few weeks’ time
after obtaining them there was complete recovery of the power of
swallowing.

154

With regard to the Rontgen rays, I saw a case some little time ago
in which a radiograph was taken; the question for decision was
whether there was by any chance aneurysm, but there was no pulsa¬
tion as reported by Dr. Mackenzie Davidson, who made the
radiogram. A few weeks afterwards the patient died from a sudden
enormous haemorrhage, and at once the question arose whether this
was not after all a mistaken diagnosis, death resulting from rupture
of an aneurysm. I do not think it a very rare thing for oesophageal
cancer to end fatally from haemorrhage, but I should be glad to know
what is the experience of members with regard to that.

There is one little therapeutic point which I have never had an
opportunity of carrying out, but in case it should have its value, I
venture to reproduce it for consideration. It was invented by the
late Michael, of Hamburg, and is a kind of Hahn’s tampon tracheo¬
tomy tube, in which the sponge is covered with very thin india-rubber,
and some glycerine is introduced between the rubber and the sponge,
so that it may dilate and be kept for a long time in the trachea
without its getting sodden and soaked with decomposing foods. He
states in a paper of his that for a year a patient with a fistula
between the upper part of the trachea and the oesophagus was kept
alive after the introduction of this tube into the trachea. It
remains to be questioned whether in a case of a fairly obvious
fistula of this kind it is not a good treatment to. do a tracheotomy,
and introduce some such dilating tampon cannula.

Mr. President and Gentlemen, I have purposely selected my most
unsatisfactory results, and I should be glad to hear how I may
avoid them for the future.

The President : Gentlemen, I am sure we are all very much in¬
debted to Mr. Symonds for the able way in which he has brought
before us our subject of discussion. His experience of the treatment
of these cases of malignant stricture of the oesophagus is, of course,
much larger than ours has been. There are one or two points, how¬
ever, to which I would like to refer. He has mentioned “ cesopha-
goscopy.” I do not know, and I should doubt, whether it is of any
particular value from the diagnostic point of view, but there is no
difficulty in introducing a straight metal tube fitted with a rubber
point down to the obstruction. Before using the tube I am in the
habit of letting the patient sip some solution of cocaine. Cocaine
' thus applied also facilitates the introduction of bougies.

In regard to the Rontgen rays, I had a case a short time ago under
my care in which a skiagraph was taken, but, unfortunately, the rays
did not give any very definite information. The case was confirmed
post mortem as one of malignant oesophageal stricture.

The dangers of anaesthetics in these cases have been mentioned by
Sir Felix Semon and Dr. Dundas Grant; I cannot help thinking that
there is some peculiar danger in this class of case from anaesthesia.
I remember a case a good many years ago where I was giving chloro¬
form for gastrostomy and the patient very nearly died. Fortunately,
we were able to bring him round, but the operation had to be
stopped. I think possibly there may be some special liability to

danger in these cases, or the danger may be doe to the weak and ex¬
hausted state of the patient at the time of operation.

I should like to ask Mr. Svmonds if he has any experience of
radical treatment in cases of disease of the upper portion of the
oesophagus. What are the results of cesophagectomy ? Mr.
Symonds, in bringing to our notice the subject of cancer of the upper
part of the oesophagus, has included the same disease of the lower
portion of the pharynx. There was a case under my care recently, a
woman set. 52, who came to the Brighton Throat and Ear Hospital.
On depressing the tongue, the top of a growth the size of a walnut
could be seen at the lower back part of the pharynx. On examina¬
tion with the finger, the growth appeared to be pedunculated.
Thinking it a suitable case for external excision, I passed her on to
Mr. Buck, at the Sussex County Hospital. Under chloroform,
laryngotomy was performed and the growth was ligatured round the
pedicle and came off easily. It was found to be a squamous-celled
epithelioma. Subsequently an external operation was performed on
the left side, the pharynx exposed, and the growth excised with
scissors, all the disease apparently being removed. The growth was
found to extend just to the left ary tamo-epiglottidean fold. The
patient did perfectly well, and except for a slight attack of bronchitis
after the operation there were no complications. The wound healed
admirably, but since her discharge from hospital she developed on
the right side of the epiglottis a further deposit of epithelioma, which
did not spread from the original growth but started as an entirely
fresh nodule. The patient declined further operation.

I have not had a large experience of the use of tubes, but I feel
more inclined to employ them since hearing Mr. Symonds* very
elaborate description of the method of employment. I should have
been glad to hear from him a few more particulars about the risks
of gastrostomy. Patients always ask what are the risks involved
in this operation.

Mr. C. J. Symonds, in his reply, said: I am much obliged for the
kind attention the Society has accorded my paper. I have to thank
Dr. Tilley and Sir Felix Semon for raising the question of laryngeal
paralysis and its value as an early diagnostic sign of oesophageal
stricture. On collating my experience for this paper, I found in most
of my cases I was able to settle the question of diagnosis in other
ways, but I have seen cases, though not similar to those related by
Sir Felix Semon, where laryngeal paralysis has helped in diagnosis,
and has been the symptom from which the patient has sought relief.
I am much interested in the cases referred to by members, and by
Mr. Robinson’s especially, though certainly I have not come across a
case similar to his. Of course, I may have missed them, but I do not,
speaking off-hand, recall any case where the enlargement of cervical
glands has led me to diagnose malignant stricture of the oesophagus,
and I am glad to learn of this case.

The only point of opposition I have had relates to the “ spasmodic ”
type of case. And here let me explain that as I was opening a dis¬
cussion, I purposely spoke somewhat positively, as I thought it would
increase the interest of the debate. The only case I have had which

156

resembled Sir Felix Semon’s was that of a woman who had had
obstruction for some hours when I saw her, and it was only on several
similar occasions that she experienced it, and in her there was a
distinct spasm of the sphincter at the lower end of the oesophagus. I
wanted to ask Sir Felix Semon at what part of the oesophagus he
found his cause of obstruction. [Sir Felix Semon : “ Middle.”]
That I certainly have never found.

With regard to the X rays I have no experience whatever to offer,
and I was glad to hear Dr. Beale’s answer to my suggestion, which
confirms me in my experience that intra-thoracic diseases do not give
rise to this trouble.

I would suggest to Dr. Grant, who has asked for any means of
assistance which would help him to clear up the difficulties which he
has formerly experienced, that he should use the steel bulb. I most
certainly would have missed more than one case of malignant disease
of the oesophagus if I had not used it. This form* I introduced some
years ago for my own convenience more than anything else, and
for use in the out-patient room. It answers, I find, very well indeed
in diagnosing those soft strictures which will certainly hardly give
any signs of their presence to the ordinary conical bougie.

I was glad to hear Dr. Donelan refer to cases of stricture at the
lower eDd of the oesophagus. The position I hold in regard to these
cases I put very strongly, because I have been so disappointed with
the treatment usually adopted. A long tube such as he described
will answer the necessary purpose. Solis Cohn sent me an interesting
paper giving a successful case of treatment by short tubes in a
stricture at the lower end of the oesophagus, but it is unsatisfactory
so far as my experience goes; and so I advise such patients to have
gastrostomy done early.

With regard to the President’s case of epithelioma, that was
not quite what I was referring to. I referred to cases where your
only view of the epithelioma is as it creeps up below the arytaenoids
directly in the middle line. It is so characteristic, being quite differ¬
ent from cases of pharyngeal carcinoma, which begin on one side and
creep round in the epiglottic folds. I doubt whether it is worth while
excising these growths; they are very unsatisfactory, as they always
recur. I think the patient has a better chance if he is left alone.
Although I have done these very big operations, one’s experience tends
to make one put them on one side.

The coude tubes are passed in the ordinary way; they are most
valuable for stricture at the lower end.

As to the question of the danger of gastrostomy which I am asked
to answer, I am not prepared to do so at the present time. If
performed at an early stage, it should involve very little risk indeed.
I have been trying a plan lately, but whether or not it is going to
prove sufficiently valuable I do not know yet. My object is to make a
better sphincter out of the rectus.

* The elastic stem form with vulcanite bulb at each end was exhibited.

PAGE

Adenoma, oystic, of pyramidal lobe of thyroid (E. B. Waggett) . 132

Angeioma of larynx, pedunculated (A. Bronner, M.D.) . . 33

Angioneurotic oedema of right hand, with recently developed attacks

of difficulty in breathing (P. de Santi) . . .87

Antisyphilitic treatment: (?) syphilitic ulceration of soft palate occur¬
ring during course of antisyphilitic treatment (Atwood Thome) . 61

Antrum: empyema of corresponding antrum in case of two molar
teeth with healthy crowns, but with evidences of caries in palatal
root (H. Tilley, M.D.) . . . . .3

-- maxillary, drainage through tooth socket by drills exhibited

(H. FitzGerald Powell, M.D.) . . . .78

-(maxillary, left), fibroma removed from (H. FitzGerald Powell,

M.D.) . . . . . . .107

-papilloma (large recurrent) apparently growing from

(A. Bronner, M.D.) . . . . .114

Aphohia, hysterical, in case of abeyance of nasal breathing (L. H.

Pegler, M.D.) . . . . . .65

Baber (E. Cresawell, M.B.), discussion on diagnosis and treatment of

malignant stricture of oesophagus . . . .154

Bacillus: living cultures of bacilli simulating Bacillus tuberculosis by

their staining reaction (St. G. Reid) . . . .8

Bacillus tuberculosis simulated by other bacilli by their staining

reaction (St. G. Reid) . . . . .8

Balance-sheet. . . . . . .30

Beale (E. Clifford, M.B), discussion on diagnosis and treatment of

malignant stricture of oesophagus . . . .150

Bennett (F. W., M.D.), case of ulceration of the nasal septum with

marked pain ..... 51, 69

-— case of progressive ulceration of the nose . . .69

Bond (J. W., M.D.), case of laryngeal swelling . . .11

-case of large laryngeal growth in a woman . . .124

Bony thickening over right frontal sinus (Scanes Spicer, M.D.) . 40

Branchial clefts, mal-development of first and second (G. C. Cathcart,

M.B.) . . . . . . .20

Breathing, difficulty in: attacks developing in connection with angio¬
neurotic oedema of right hand (P. de Santi) . . .87

-(nasal), abeyance of: nasal passages free (L. H. Pegler, M.D.) 65, 67

Bronner (Adolph, M.D.), specimen of a pedunculated angeioma of

the larynx . . . . . .33

— ■ » sections of tuberculous growth of mucous membrane of right

middle turbinal in a man set. 50 . . .83

-— sections of a large recurrent papilloma, which seemed to grow

from the left maxillary antrum . . . 114

FIRST SERIES-VOL. IX.

9

158

PAGE

Caries in palatal root of two molar teeth with healthy crowns; em¬
pyema of corresponding antrum (H. Tilley, M.D.) . . 3

Cathcart (G. C., M.B.), case of complete loss of internal framework

of the nose in a girl set. 22 . . . . .18

-case of mal-development of the first and second branchial clefts 20

-case of rhinorrhoea in a girl set. 9 . . . .90

Chalky deposits, or excrescences, or incrustations, low down in trachea

(E. Law, M.D.) ...... 127

Cheatle (Arthur H.), case of congenital absence of the front of the

nose with occlusion of the anterior nares . . .98

-specimen of rhinolith . . . . .98

Choana, right posterior, partial membranous occlusion of (H. Lambert

Lack) . . . . . . .58

Cicatricial contraction in interaryteenoid region causing laryngeal

stenosis (H. Betham Robinson) . . . .81

Commissure, anterior, removal of growths in, by modification of

Mackenzie's laryngeal forceps (H. FitzGerald Powell, M.D.) . 78

Cotton carriers (StC. Thomson, M D.) . . . .73

Council, report of . . . . .29

Cut-throat followed by cicatricial stenosis of pharynx (E. B. Waggett) 20
Cyst, dermoid, sublingual (Y. Wyatt Wingrave) . . .21

Cystic growth of septum (L. H. Pegler, M.D.) . . 103,114

Davis (H. J., M.D.), laryngeal tuberculosis with granulation tissue

between the cords . . . . . .64

-tertiary syphilis of the pharynx and larynx; phonation with

the ventricular bands . . . . .64

Dermoid cyst, sublingual (Y. Wyatt Wingrave) . . .21

Diagnosis, cases for: growth in larynx in case of syphilis (H. Lambert

Lack, M.D.) . . . . . .26

-oedema of larynx (H. Lambert Lack, M.D.) . . 60

-swelling of left side of nose (Furniss Potter) . . 27

-tumour of right vocal cord formed during influenza in man

aet. 50 . . . . . . 106

Donelan (James, M.B.), case of laryngeal syphilis with fixation of

left vocal cord . . . . . .5

-a case of syphilitic laryngitis in a man aet. 52 . . 49

-case of tumour of the right vocal cord formed during influenza

in a man aet. 50 (for diagnosis) .... 106

-case of laryngeal stenosis in a man aet. 50, resulting from a

large syphilitic ulcer of left side of larynx . . . 120

-case of syphilitic contraction of posterior pillars of the fauces

in a man aet. 44 . . . . . 121

-discussion on diagnosis and treatment of malignant stricture

of oesophagus ...... 152

Downie (J. Walker, M.B.), specimen of sarcoma of right tonsil . 115

-— specimen of a fibrous growth removed from the naso-pharynx

of a boy aet. 14 . . . . . 117

-— specimen of a fibrous growth removed from the naso-pharynx

of a boy aet. 11 . . . . . 118

-specimen of sarcoma of the fauces . . . .118

Drills for draining maxillary antrum through tooth socket (H. Fitz¬
Gerald Powell, M.D.) . . . . .78

Empyema of antrum corresponding to two molar teeth with healthy
crowns, but with evidences of caries in palatal root (H. Tilley,

M.D.) . . . . . . .3

Epidermolysis bullosa associated with mouth and throat lesions

(William Hill, M.D.) ..... 106

Epiglottis, epithelioma of (J. Dundas Grant, M.D.) . . 9

159

PAGE

Epiglottis, epithelioma of : case in middle-aged man (E. B. Waggett) 20

-removal for tuberculous disease (R. Lake) . . .130

-? tubercular disease of (H. M. Ramsay) . . .10

-ulceration, with marked lupus infiltration in case formerly

shown, with chronic laryngitis and ulcer on one vocal cord (StC.
Thomson, M.D.) . . . . . .0

Epithelioma (alveolar) : malignant growth in nose, probably of nature

of alveolar epithelioma (J. Dundas Grant, M.JD.) . . 108

— - of epiglottis (J. Dundas Grant, M.D.) . . .9

- -in middle-aged man (E. B. Waggett) . . 20

Ethmoid: suppuration in case of complaint of excessive pain (E. B.

Waggett) . . . . . .70

Ethmoidal sinus : see Sinus (ethmoidal).

Excrescences, or incrustations, or chalky deposits, low down in trachea

(E. Law, M.D.) . . . . . .127

Fauces: hyperaesthesia of palate and fauces in case of abeyance of

nasal breathing, the passages being free (L. H. Pegler, M.D.) . 07

-(pillar of left) perforation (Furniss Potter, M.D.) . . 13

-pillar, posterior, papilloma of (H. Sharman, M.D.) . . 43

- (pillars): ? congenital fenestration of anterior pillars of fauces

(E. B. Waggett) . . . . . .7

-pillars, posterior, syphilitic contraction (J. Donelan, M.B.) . 121

-sarcoma of, specimen (J. Walker Downie, M.B.) . .118

-thickening in case of oedema of larynx (Hunter F. Tod) . 69

Fenestration, (?) congenital, of anterior pillars of fauces (E. B.

Waggett) . . . . . .7

Fibroma of nasal vestibule (W. H. Kelson) . . .21

-removed from left maxillary antrum, specimen exhibited (H.

FitzGerald Powell, M.D.) ..... lo7

Fibro-sarcoma of right vocal cord, microscopic section (W. Milligan,

M.D.) ...... 42, 53

Fibrous growth removed from naso-pharynx: specimens exhibited

(J. Walker Downie, M.B.) . . . . . 117, 118

Fixation of left vocal cord in case of tubercular larynx (C. A. Parker) 22
Forceps (laryngeal): modification of Mackenzie’s laryngeal forceps for
removal of growths in anterior commissure (H. FitzGerald Powell,
M.D.) . . . . . . .78

-new form of (H. Lambert Lack, M.D.) . 99

Fossa (nasal): inflammatory diseases of nasal fossae and accessory cavi¬
ties (F. Westmacott) . . . . .3

Framework, internal, of nose, case of complete loss (G. C. Cathcart,

M.B.) . . . . . .18

Geographical tongue (L. H. Pegler, M.D.) . . . 131

Glass tube: see Tube (glass).

Grant (J. Dundas, M.D.), case of epithelioma of the epiglottis in a

man set. 58 . . . . .9

-case of nasal stenosis occurring in a man aet. 43, in which the

symptoms seemed to be chiefly subjective . . .10

-case of subjective nasal obstruction . . .72

-a specially constructed glass tube for the inhalation of medi¬
cinal powders into the larynx . . . .73

-case of traumatic tracheal obstruction . . .89

-case of malignant growth in the nose of a male patient aet. 61,

probably of the nature of alveolar epithelioma. . .108

--discussion on diagnosis and treatment of malignant stricture

of oesophagus . . . . . .152

Granulation tissue between vocal cords in case of laryngeal tuber¬
culosis (H. J. Davis, M.D.) . . . . .64

160

PAGE

Growth in larynx in case of syphilis (for diagnosis) (H. Lambert

Lack, M.D ) . . . . . .26

-— of larynx (V. Wyatt Wingrave) . . . .95

---large (J."W. Bond, M.D.) .... 124

■ — (probably papilloma) on left vocal cord (H. FitzGerald Powell,

M.D.) ....... 8

■ : see Cystic growth.

-: see Fibrous growth.

-— : see Malignant growth.

Growths in anterior commissure, modification of Mackenzie’s laryn¬
geal forceps for removal of (H. FitzGerald Powell, M.D.) . 78

H©matoma of left vocal cord (H.* FitzGerald Powell, M.D.) . 77

Hand, right, angioneurotic oedema of, with recently developed attacks

of difficulty in breathing (P. de Santi) . . .87

Harvey (F. G.), case of lupus nasi . ! . .57

Herpes of palate (S. H. Snell, M.D.) . . . .49

Hill (G. William, M.D.), case of epidermolysis bullosa in a woman

associated with mouth and throat lesions . . . 106

Hoarseness in child ©t. 1 year and 10 months (E. W. Houghton) . 26

Horne (W. Jobson, M.D.), macroscopic and microscopic specimens of
the larynx from cases of lymphadenoma, lympho-sarcoma, tuber¬
culous lymphadenitis, etc. . . . . .15

- a case of nasal obstruction in a woman set. 24 . .45

Hypersesthesia of palate and fauces in case of abeyance of nasal

breathing, the passages being free (L. H. Pegler, M.D.) . . 67

Hysteria: see Aphonia (hysterical).

Incrustations, or excrescences, or ohalky deposits low down in the

trachea (E. Law, M.D.) ..... 127

Inflammation: inflammatory diseases of nasal foss© and accessory

cavities (F. Westmacott) . . . . .3

Influenza, tumour of right vocal cord formed during (J, Donelan,

M.B.) . . . . . . .106

Interaryt©noid region, cicatricial contraction in, causing laryngeal

stenosis (H. Betham Robinson) . . . .81

Kelson (W. H.), case and specimen of fibroma of nasal vestibule . 21

- case of tumour of larynx . . . .96

- case of tuberculous disease of larynx . . .97

Lack (H. Lambert, M.D.), growth in larynx in a case of syphilis (for
diagnosis) ......

- case of partial* membranous occlusion of the right posterior

choana .......

-- case of oedema of the larynx for diagnosis .

- case of rapidly recurring papilloma of the larynx

- a case of thyrotomy for tuberculosis of the larynx .

- a new form of laryngeal forceps .

- case of great symmetrical thickening of the upper and anterior

part of the nasal septum .....
case of inherited syphilis of nose, pharynx, and larynx, with

26

58

60

89

99

99

122

124

complete occlusion of anterior nares
Lake (R.), case of atrophic rhinitis in which melted paraffin had been

injected into the inferior turbinate bodies with good results . 92

- case of removal of epiglottis for tuberculous disease . .130

■ case of tuberculosis of the larynx with marked swelling of the

thyroid cartilage in a man ©t. 37 . .54, 130

-tuberculous perichondritis: case shown at the Society’s meet¬
ing, February 7th, 1902 ..... 130

161

PAGE

Laryngeal forceps: modification of Mackenzie’s laryngeal forceps for
removal of growths in anterior commissure (H. FitzGerald Powell,

M.D.) . . . . . . .78

-new form of (H. Lambert Lack, M.D.) . . .99

Laryngitis (chronic) : case, formerly shown, subsequently presenting
lupus infiltration and ulceration of epiglottis (StC. Thomson,

M.D.) . . . • • • .6

-syphilitic, case of (J. Donelan, M.B.) . . .49

-possibly combined with tuberculosis (StC. Thomson,

M.D.) . . . . . .97

Laryngo-fissure: regrowth, after partial removal by laryngo-fissure, of

malignant disease (StC. Thomson, M.D.) . . .23

-without tracheotomy in treatment of case of tertiary syphilitic

laryngeal stenosis (W. G. Spencer) . . . .2

Larynx : angeioma, pedunculated (A. Bronner, M.D.) . . 33

- growth in larynx in case of syphilis (for diagnosis) (H.

Lambert Lack, M.D.) . . . . .26

-growth of (V. Wyatt Wingrave) . . . .95

— . .large (J. W. Bond, M.D.) .... 124

— - - inhalation of medicinal powders into larynx by specially con¬

structed glass tube (J. Dundas Grant, M.D.) . . .73

- macroscopic and microscopic specimens of larynx from cases of

lymphadenoma, lympho-sarcoma, tuberculous lymphadenitis, etc.

(W. Jobson Home, M.D.) . . . . .15

-oedema of, case for diagnosis (H. Lambert Lack, M.D.) . 60

-with thickening of palate, uvula, and fauces (Hunter F.

Tod) . . . . . . .69

-orifice of, upper, plate of teeth impacted in (W. Milligan,

M.D.) 43

-papilloma of, rapidly recurring (H. Lambert Lack, M.D.) , 89

-paralysis, complete recurrent (H. FitzGerald Powell, M.D.) . 75

-stenosis due to cicatricial contraction in interarytsenoid region

(H. Betham Robinson) . . . . .81

-resulting from large syphilitic ulcer of left side of

larynx (J. Donelan, M.B.) ..... 120

■ -tertiary syphilitic, case treated by laryngo-fissure with¬

out tracheotomy (W. G. Spencer) . . . .2

-swelling of (J. W. Bond, M.D.) . . . .11

■ -syphilis of nose, pharynx, and larynx, with complete occlusion

of anterior nares (H. Lambert Lack, M.D.) . . . 124

-syphilitic (?) disease of larynx simulating malignant

disease (H. Tilley, M.D.) . . . . .94

-(tertiary) of pharynx and larynx: phonation with

ventricular bands (H. J. Davis, M.D.) . . .64

---- with fixation of left vocal cord (J. Donelan, M.B.) . 5

-tuberculosis of (W. H. Kelson) . . . .97

-removal of epiglottis for (R. Lake) . . . 130

-thyrotomy for (H. Lambert Lack, M.D.) . . 99

-with fixation of left cord (C. A. Parker) . . 22

-with granulation tissue between cords (H. J. Davis,

M.D.) . . . . . . .64

--with marked swelling of thyroid cartilage (R. Lake) 54, 130

-tumour of (W. H. Kelson) . . . .96

-see Paralysis (glosso-labio-laryngeal).

Law (Edward, M.D.), case of excrescences, or incrustations, or chalky

deposits low down in the trachea .... 127

Lawrence (L. A.), case and specimen of tubercular rhinitis in a man

set. 35, treated with Rontgen rays . . . .16

■ -case of rhinorrhoea of some years’ duration in a woman eet. 38 . 55

Librarian, report of . . . . 30, 31, 32

162

PAGE

Lip: see Paralysis (glosso-labio-laryngeal).

Lipoma of pharynx (W. Milligan, M.D.) ... 41, 54

Lupus: ease of chronic laryngitis and ulcer on one vocal cord subse¬
quently presenting lupus infiltration and ulceration of epiglottis
(StC. Thomson, M.D.) . . . . .6

-of nose (F. G. Harvey) . . . . .57

Lymphadenitis (tuberculous), macroscopic and microscopic specimens

of larynx from cases of (W. Jobson Horne, M.D.) . . 15

Lymphadenoma, macroscopic and microscopic specimens of larynx

from cases of (W. Jobson Home, M.D.) . . .15

Lympho-sarcoma, macroscopic and microscopic specimens of larynx

from cases of (W. Jobson Home, M.D.) . . .15

Mackenzie's laryngeal forceps, modification of (H. FitzGerald Powell,

M.D.) . . . . . . .78

Mal-development of first and second branchial clefts (G. C. Cathcart,

M.B.) . . . . . . .20

Malignant disease of vocal cords; regrowth after partial removal by

laryngo-fissure (StC. Thomson, M.D.) . . .23

-simulated by syphilitic (?) disease of larynx (H. Tilley,

M.D.) . . . . . . .94

-growth in nose, probably of nature of alveolar epithelioma

(J. Dundas Grant, M.D.) ..... 108

-stricture of oesophagus, diagnosis and treatment (C. J. Sy-

monds) ....... 133

Medicinal powders: see Powders (medicinal).

Milligan (W., M.D.), specimen of pharyngeal lipoma . . 41

-report on, by Morbid Growths Committee 54

-microscopic section of fibro-sarcoma of right vocal cord . 42

-report on, by Morbid Growths Committee . 53

-X-ray photograph showing plate of teeth impacted in upper

laryngeal orifice . . . . . .43

Morbid Growths Committee, reports of . .1, 53, 113, 114

Mouth, lesions of, associated with epidermolysis bullosa (William

Hill, M.D.) . . . . . .106

Mucous membrane of right middle turbinal, sections of tuberculous

growth of (A. Bronner, M.D.) . . . .83

Myeloma of nose (E. B. Waggett) . . . .62

Nares: see Nostril .

Naso-pharynx, fibrous growth removed from ; specimen exhibited (J.

Walker Downie, M.B.) .... 117, 118

Necrosis, syphilitic, of intra-nasal structures, exposing to view opening
of sphenoidal sinus on each side and of posterior ethmoidal on left
(H. Tod) . . . . . . .131

Nose, breathing through, abeyance; nasal passages free (L. H. Pegler,

M.D.) . . . . . . 65,67

-destruction, advanced, of intra-nasal structures associated with

suppuration of right maxillary sinus (H. Tilley, M.D.) . . 122

-fossae, inflammatory diseases of (F. Westmacott) . . 3

- framework (internal), case of complete loss (G.C. Cathcart, M.B.) 18

- front of, congenital absence, with occlusion of anterior nares

(A. H. Cheatle) . . . . . .98

-interior, extensive destruction due to tubercular ulceration

(P. de Santi) . . . . . .49

- lupus of (F. G. Harvey) . . . . .57

- malignant growth in, probably of nature of alveolar epithelioma

(J. Dundas Grant, M.D.) ..... 108

- myeloma of (E. B. Waggett) . . . .62

- obstruction (W. Jobson Horne, M.D.) . . .45

-- subjective case (J. Dundas Grant, MJ).) . . 72

163

PAGE

Nose: polypoid disease with multiple suppurative sinusitis; sequel

to case of radical cure previously exhibited (Scanes Spicer, M.D.) 37

- (septum), gTeat symmetrical thickening of upper and anterior

part of (H. Lambert Lack, M.D.) .... 122

-ulceration with marked pain (F. W. Bennett, M.D.) 51, 69

- (stenosis), symptoms chiefly subjective (J. Dundas Grant,

M.D.) . . . . . . .10

- swelling of left side: case for diagnosis (Fumiss Potter, M.D.) 27

- syphilis of nose, pharynx, and larynx, inherited, with complete

occlusion of anterior nares (H. Lambert Lack, M.D.) . . 124

- syphilis, tertiary, intra-nasal (P. de Santi) . . .84

- syphilitic necrosis of intra-nasal structures, exposing to view

opening of sphenoidal sinus on each side and of posterior eth¬
moidal on left (H. Tod) ..... 131

- ulceration, progressive (F. W. Bennett, M.D.) . . 69

-tubercular, causing extensive destruction to interior of

organ (P. de Santi) . . . . .49

- vestibule: complete occlusion of right nasal vestibule (H.

Tilley, M.D.) . . . . . .121

-fibroma of (W. H. Kelson) • . .21

- see Polypus snare (nasal).

- see Saddle-nose.

Nostril: occlusion of anterior nares with congenital absence of front

of nose (A. H. Cheatle) . . . . .98

Nostrils: anterior occlusion, complete, in a case of inherited syphilis

of nose, pharynx, and larynx (H. Lambert Lack, M.D.) . . 124

Obstruction, nasal (W. Jobson Horne, M.B.) . • .45

-subjective case (J. Dundas Grant, M.D.) • • 72

- traumatic tracheal (J. Dundas Grant, M.D.) . . 89

Occlusion of anterior nares, complete, in case of inherited syphilis of

nose, pharynx, and larynx (H. Lambert Lack, M.D.) . . 124

- of anterior nares with congenital absence of front of nose

(A. H. Cheatle) . . . . . .98

- (membranous, partial) of right posterior choana (H. Lambert

Lack, M.D.) . . . . . .58

-of right nasal vestibule, complete (H. Tilley, M.D.) . . 121

(Edema, angioneurotic, of right hand with recently developed attacks

of difficulty in breathing (P. de Santi) . . .87

-of larynx: case for diagnosis (H. Lambert Lack, M.D.) . 60

-with thickening of palate, uvula, and fauces (Hunter F.

Tod) . . . . . . .69

(Esophagus, malignant stricture of; diagnosis and treatment (C. J.

Symonds) ...... 133

Pain, excessive : ethmoidal suppuration in man complaining of (E. B.

Waggett) . . . . . .70

-marked, in case of ulceration of nasal septum (F. W. Bennett,

M.D.) . . . . . . 61,69

Palate, herpes of (S. H. Snell, M.D.) . . . .49

-hyperaesthesia of palate and fauces in case of abeyance of

nasal breathing, the passages being free (L. H. Pegler, M.D.) • 67

-thickening in case of oedema of larynx (Hunter F. Tod) . 69

— - (soft) ulceration (? syphilitic) occurring during course of anti¬
syphilitic treatment (Atwood Thome) . . .61

Papilloma: growth (probably papilloma) on left vocal cord (H. Fitz¬
Gerald Powell, M.D.) . . . . .8

-large recurrent, apparently growing from left max i llary an¬
trum (A. Bronner, M.D.) ..... 114

-of larynx, rapidly recurring (H. Lambert Lack, M.D.) . 89

1G4

PAGE

Papilloma of tonsil and of posterior pillar (H. Sharman, M.D.) . 43

-papillomatous growth on posterior edge of vomer (H. Tilley,

M.D.) . . . . . . .93

Paraffin, melted, injected into inferior turbinate bodies with good

results in cases of atrophic rhinitis (R. Lake) . . .92

-subcutaneous injection of vaseline (paraffin) in treatment of

saddle-nose (Scanes Spicer, M.D.) . . . .34

Paralysis, bulbar, case of (V. Wyatt Wingrave) . . *. Ill

-glosso-labio-laryngeal (StClair Thomson, M.D.) . . 126

-r of larynx, complete recurrent (H. FitzGerald Powell, M.D.) . 75

-of left vocal cord (F. Willcocks, M.D.) . . .80

-(V. Wyatt Wingrave) . . .110

-complete, with abductor paralysis of right vocal

cord (StC..Thomson, M.D.) . .... 126

-probably of specific origin (P. de Santi) . 21

-of right vocal cord, complete (E. W. Roughton) . . 25

Parker (C. A.), case of tubercular larynx with fixation of the left

cord . . . . . . .22

-case of stenosis of the pharynx . . . .27

Peglkr (L. H.,M.D.), case of abeyance of nasal breathing in a female

aet. 23; nasal passages free; hysterical aphonia; rhinalgia . 65

-case of abeyance of nasal breathing, the passages being free;

palate and fauces hyperaesthetic . . . .67

«■ specimen of cystic growth of the septum and microscopic

section ....... 103

-report on, by Morbid Growths Committee . .114

-case of geographical tongue .... 131

Perforation of left faucial pillar (Fumiss Potter, M.D.) . . 13

Perichondritis,.tuberculous (R. Lake) ... 54, 130

Pharynx, lipoma of, specimen (W. Milligan, M.D.) . . 41, 54

-stenosis of (C. A. Parker) . . . .27

-cicatricial, sequel of cut-throat (E. B. Waggett) . 20

-syphilis of nose, pharynx, and larynx, with complete occlusion

of anterior nares (H. Lambert Lack, M.D.) . . . 124

-(tertiary) of pharynx and larynx; phonation with .

ventricular bands (H. J. Davis, M.D.) . . .64

Phonation with ventricular bands in case of tertiary syphilis of

pharynx and larynx (H. J. Davis, M.D.) . . .64

Pillar of fauces (left), perforation (Fumiss Potter, M.D.) . . 13

-posterior, papilloma of (H. Sharman, M.D.) . . 43

Pillars of fauces, (?) congenital fenestration (E. B. Waggett) . 7

-posterior, syphilitic contraction (J. Donelan, M.B.) . 121

Polypoid disease of nose with multiple suppurative sinusitis: sequel

to case of radical cure previously exhibited (Scanes Spicer, M.D.) 37

Polypus (of frontal sinus) : bony thickening over, and polypi within

right frontal sinus (Scanes Spicer, M.D.) . . .40

Polypus snare (nasal), self-looping (Atwood Thome) . .44

Potter (E. Fumiss, M.D.), perforation of left faucial pillar . . 13

-case of swelling of left side of nose (for diagnosis) . . 27

Powders (medicinal) inhaled into larynx by specially constructed glass

tube (J. Dundas Grant, M.D.) . . . .73

Powell (H. FitzGerald, M.D.), case of growth (probably papilloma)

on the left vocal cord in a man set. 32, a potter by occupation . 8

-case of complete recurrent laryngeal paralysis in a man set. 24,

which had reappeared after a period of recovery . .75

-case of heematoma of the vocal cord in a female set. 29 . 77

--a modification of Mackenzie's laryngeal forceps for removal of

growths in the anterior commissure, and drills for draining maxil¬
lary antrum through tooth socket . . , .78

165

PAGE

Powell (H. FitzGerald, MD), specimen of fibroma removed from

left maxillary antrum of male set. 18 107

Probes (wooden) and cotton carriers (StC. Thomson, M.D.) . . 73

Bamsat (H. M.), case of (?) tubercular disease of the epiglottis . 10

Beid (St. George), a series of living cultures of those bacilli which

simulate Bacillus tuberculosis by their staining reaction . . 8

Bhinalgia in case of abeyance of nasal breathing (L. H. Pegler, M.D.). 65

Bhinitis, atrophic: melted paraffin injected into inferior turbinate

bodies with good results (B. Lake) . . . .92

-(tubercular) : case treated with Bontgen rays (L. A. Lawrence) 16

Bhinolitli, specimen of (A. H. Cheatle) . . . .98

Bhinorrhtea: case in girl a?t. 9 (G. C. Cathcart, M B.) . . 90

- case of some years' duration (L. A. Lawrence) . . 55

Bobinson (H. Betham), case of laryngeal stenosis due to cicatricial

contraction in interarytsenoid region . . . .81

- discussion on diagnosis and treatment of malignant stricture

of oesophagus .. . . . . . 151

Bontgen lays in treatment of case of tubercular rhinitis (L. A.

Lawrence) . . . . . .16

-photograph showing plate of teeth impacted in upper laryngeal

orifice (W. Milligan, M.D.) . . . . .43

Boughton (E. W.), case of complete paralysis of right vocal cord in a

man ©t. 33 . . . . . .25

-case of hoarseness in a child ©t. 1 year and 10 months . 26

Saddle-nose: case treated by subcutaneous injection of vaseline (paraf¬
fin) (Scanes Spicer, M.D.) . . . . .34

de Santi (Philip), case of paralysis of the left vocal cord in a woman

set. 42, probably of specific origin . . . .21

-case of very extensive destruction of the interior of the nose

due to tubercular ulceration in a woman set. 31 . .49

-case of tertiary intra-nasal syphilis, in which the right frontal

sinus had been opened twice with negative results, in a married
woman set. 48 . . . . .84

-a case of angioneurotic oedema of right hand with recently

developed attacks of difficulty in breathing . . .87

Sarcoma of fauces, specimen (J. Walker Downie, M.B.) . .118

-of right tonsil (J. Walker Downie, M.B.) . . . 115

Semon (Sir Felix, M.D.), discussion on diagnosis and treatment of

malignant stricture of oesophagus .... 148

Septum, cystic growth of (L. H. Pegler, M.D.) . . 103, 114

-(nasal) : see Nose (septum).

Sharman (H., M.D.), specimens of papilloma of the tonsil and of the

posterior pillar . . . . . .43

Sinus, ethmoidal, posterior, exposed to view on left side by syphilitic

necrosis of intra-nasal structures (H. Tod) . . . 131

-frontal: bony thickening over, and polypi within right frontal

sinus (Scanes Spicer, M.D.) . . . .40

-right, opened twice with negative results in case of

tertiary intra-nasal syphilis (P. de Santi) . . .84

-maxillary, right, suppuration of, associated with advanced

destruction of intra-nasal structures (H. Tilley, M.D.) . . 122

-(sphenoidal): opening of sphenoidal sinus on each side exposed

to view by syphilitic necrosis of intra-nasal structures (H. Tod) . 131

Sinusitis: sequel to case of radical cure of multiple suppurative sinus¬
itis and polypoid disease of nose previously exhibited (Scanes
Spicer, M.D.) . . . . . . 37

-multiple suppurative, with polypoid disease of nose: sequel to

case of radical cure previously exhibited ^Scanes Spicer, M.D.) . 37

166

PAGE

Snell (S. H., M.D.), case of herpes of the palate . . * 49

Spenceb (W. G.), case of tertiary syphilitic laryngeal stenosis treated

by laryngo-fissure without tracheotomy (re-exhibited) • • 2

Sphenoidal sinus : see Sinus (sphenoidal).

Spicer (E. H. Scanes, M.D.), case of a female whose saddle-nose had
been treated by subcutaneous injection of vaseline (paraffin), with
casts and photographs taken before and after treatment . 34

-sequel to case of radical cure of multiple suppurative sinusitis

and polypoid disease of nose, previously exhibited April 10th, 1895,
and January 8th, 1896 . . . . ,37

-a case of bony thickening over, and polypi within, the right

frontal sinus in a man set. 40; operation; recurrence of bony
growth and commencing similar symptoms on the opposite side
of the face . . . . .40

Stenosis of larynx due to cicatricial contraction in interarytsenoid

region (H. Betham Eobinson) . . . .81

-of larynx due to a large syphilitic ulcer of left side of larynx

(J. Donelan, M.B.)...... 120

-- tertiary syphilitic (W. G. Spencer) . . .2

-of nose, symptoms chiefly subjective (J. Dundas Grant, M.D.). 10

-of pharynx (C. A. Parker) . . . .27

-cicatricial, sequel of cut-throat (E. B. Waggett) . 20

Stricture, malignant, of oesophagus; diagnosis and treatment (C. J.

Symonds) ...... 133

Suppuration, ethmoidal, in case of complaint of excessive pain (E. B.

Waggett) . . . . . .70

-of right maxillary sinus, advanced destruction of intra-nasal

structures associated with (H. Tilley, M.D.) . • . 122

Swelling, laryngeal (J. W. Bond, M.D.) . . . .11

-of nose (left side): case for diagnosis (Fumiss Potter, M.D.) . 27

-of thyroid cartilage in case of tuberculosis of larynx (E. Lake) 54,130

Symonds (Charters J.), the diagnosis and treatment of malignant

stricture of the oesophagus .... 133—146

Discussion, pp. 147—156. Dr. Herbert Tilley, Sir Felix Semon,

Dr. Clifford Beale, Mr. H. B. Eobinson, Dr. J. Donelan, Dr.
Dundas Grant, Mr. E. Cresswell Baber (President), Mr. C. J.
Symonds (reply).

Syphilis: growth in larynx in case of syphilis, for diagnosis (H.

Lambert Lack, M.D.) . . . . .26

-laryngitis (syphilitic) (J. Donelan, M.B.) . . .49

-possibly complicated with tuberculosis (StC.

Thomson, M.D.) . . . . . .97

--(of larynx), syphilitic (?) disease of larynx simulating malig¬
nant disease (H. Tilley, M.D.) . . . .94

--with fixation of left vocal cord (J. Donelan, M.B.) . 5

-of nose, pharynx, and larynx, inherited, with complete occlusion

of anterior nares (H. Lambert Lack, M.D.) . . . 124

--paralysis of left vocal cord, probably of specific origin (P. de

Santi) . . . . . . .21

-syphilitic contraction of posterior pillars of fauces (J. Donelan,

M.B.) . . . . . . 121

-necrosis of intra-nasal structures (H. Tod) . . 131

•-uloer of larynx causing laryngeal stenosis (J. Donelan,

M.B.) . . . . . . .120

-ulceration of soft palate occurring during course of anti¬
syphilitic treatment (Atwood Thorne) . . .61

-(tertiary) : case of tertiary syphilitic laryngeal stenosis (W. G.

Spencer) . . . . . . .2

-intra-nasal (P. de Santi) . . . .84

-- of pharynx and larynx; phonation with ventricular

bands (H. J. Davis, M.D.) *

64

167

Thomson (StClair, M.D.), man, set. 33, shown at the meeting in April
last with chronic laryngitis and an ulcer on one vocal cord; now
seen to present marked lupus infiltration and ulceration of the
epiglottis .

-case of regrowth of malignant disease in a man ®t. 52 after

partial removal by laryngo-fissure ....

-wooden probes and cotton carriers....

-case of syphilitic laryngitis possibly complicated with tubercu¬
losis .

-glosso-labio-laryngeal paralysis, with complete paralysis of one

vocal cord and abductor paralysis of the other.

Thobne (Atwood), a self-looping nasal polypus snare

-case of (?) syphilitic ulceration of soft palate occurring during a

course of antisyphilitic treatment

Throat, lesions of, associated with epidermolysis bullosa (William
Hill, M.D.) . . . /

-see Cut-throat.

Thyroid : cystic adenoma of pyramidal lobe of (E. B. Waggett)
Thyroid cartilage: swelling in case of tuberculosis of larynx (R. Lake)

Thyrotomy for tuberculosis of larynx (H. Lambert Lack, M,D.)
Tilley (Herbert, M.D.), two molar teeth showing healthy crowns but
evidences of caries in the palatal root; in each case there existed
an empyema of the corresponding antrum

- papillomatous growth on the posterior edge of the vomer

- case of syphilitic (?) disease of larynx simulating malignant

disease ......

- complete occlusion of right nasal vestibule in a man aet. 32

- advanced destruction of intra-nasal structures associated with

suppuration of the right maxillary sinus

- discussion on diagnosis and treatment of malignant stricture

of oesophagus . . . . .

Tod (Hunter F.), case of oedema of the larynx with thickening of
palate, uvula, and fauces in a boy set. 10

-case of syphilitic necrosis of intra-nasal structures, exposing

to view the opening of the sphenoidal sinus on each side, and of
the posterior ethmoidal on the left ....
Tongue, geographical, case of (L. H. Pegler, M.D.) . '

- sublingual dermoid cyst (V. Wyatt Wingrave) . *

- see Paralysis (glosso-labio-laryngeal).

Tonsil: papilloma (H. Sharman, M.D.) .

-(right), sarcoma of (J. Walker Downie, M.B.)

Tooth: teeth impacted in upper laryngeal orifice: X-ray phototrranh
(W. Milligan, M.D.) . . . . .

- (molar): two molar teeth, healthy crowns; caries in palatai

root; empyema of corresponding antrum (H. Tilley, M.D.)
Tooth-socket: drills for draining maxillary antrum through tooth-
socket (H. FitzGerald Powell, M.D.) ....
Trachea : excrescences, or incrustations, or chalky deposits low down in
(E. Law, M.D.) ......

- obstruction in, traumatic (J. Dundas Grant, M.D.) .

Tracheotomy not performed in case of laryngo-fissure for tertiary
syphilitic laryngeal stenosis (W. G. Spencer) .

Traumatic tracheal obstruction, case of (J. Dundas Grant, M.D.)
Treasurer, report of

Tube (glass): specially constructed glass tube for inhalation of
medicinal powders into larynx (J. Dundas Grant, M.D.) .
Tuberculosis (?) of epiglottis (H. M. Ramsay) . . *

-of larynx (W. H. Kelson) *

-removal of epiglottis for (R, Lake) .

PAGE

6

23

73

97

126

44

61

106

132

64,

130

99

3

93

94
121

122

147

69

131

131

21

43

115

43

3

78

127

89

2

89

30

73

10

97

130

168

PAGE

Tuberculosis of larynx, thyrotomy for (H. Lambert Lack, M.D.) * 99

-with fixation of left cord (C. A. Parker) . . 22

-with granulation tissue between cords (H. J. Davis,

M.D.) . . . . . . .64

-with marked swelling of thyroid cartilage (R. Lake) 64, 130

-: sections of tuberculous growth of mucous membrane of right

middle turbinal (A. Bronner, M.D.) . . . .83

-syphilitic laryngitis possibly complicated with (StC. Thomson,

MJD.) . . . . . . f 97

-ulceration, tubercular, of nose causing extensive destruction of

interior (P. de Santi) . . . . .49

-see Bacillus tuberculosis.

-see Lymphadenitis (tuberculous).

-see Perichondritis (tuberculous).

-see Rhinitis (tubercular).

Tumour of larynx (W. H. Kelson). . . . .96

-of right vocal cord formed during influenza (J. Donelan, M.B.) 106

Turbinal, right middle, tuberculous growth of; sections (A. Bronner,

M.D.) . . . . . . .83

Turbinate bodies, inferior, injected with melted paraffin with good

results in case of atrophic rhinitis (R. Lake) . . .92

Ulcer of larynx, syphilitic, causing laryngeal stenosis (J. Donelan,

M.B.) . . . . . .120

-- of vocal cord (left) with chronic laryngitis: case subsequently

presenting lupus infiltration and ulceration of epiglottis (StC.
Thomson, M.D.) . . . . . .6

Ulceration of epiglottis with marked lupus infiltration in case for¬
merly shown of chronic laryngitis and ulcer on one vocal cord
(StC. Thomson, M.D.) . . . . .6

- of nasal septum with marked pain (F. W. Bennett, M.D.) 61, 69

- of nose, progressive (F. W. Bennett, M.D.) . . 69

-tubercular, causing extensive destruction of interior of

organ (P. de Santi) . . . . .49

- of soft palate (? syphilitic) occurring during course of anti¬
syphilitic treatment (Atwood Thome) . . .61

Uvula : thickening in case of cedema of larynx (Hunter F. Tod) . 69

Vaseline (paraffin), subcutaneous injection in treatment of saddle-nose

(Scanes Spicer, M.D.) . . . . .34

Ventricular bands: phonation with ventricular bands in case of

tertiary syphilis of pharynx and larynx (H. J. Davis, M.D.) . 64

Vestibule, nasal: see Nose (vestibule of).

Vocal cord: granulation tissue between vocal cords in case of laryngeal

tuberculosis (H. J. Davis, M.D.) . . . .64

- malignant disease of vocal cords; regrowth after partial

removal by laryngo-fissure (StC. Thomson, M.D.). . . 23

- (left): fixation in case of laryngeal syphilis (j. Donelan, M.B.) 5

--- in case of tubercular larynx (C. A. Parker) . 22

-growth (probably papilloma) on (H. FitzGerald Powell) 8

-hsematoma of (H. FitzGerald Powell, M.D.) . . 77

-- - paralysis (F. Willcocks, M D.) . . .80

- : -(V. Wyatt Wingrave) . • .110

--— complete, with abductor paralysis of right vocal

cord (StC. Thomson, M.D.) ..... 126

-paralysis probably of specific origin (P. de Santi) . 21

-; - plcer with, chronic laryngitis: case subsequently present¬
ing lupus infiltration and ulceration of epiglottis (StC. Thomson,

M.D.) . . .

6

169

PAGE

Vocal cord (right), fibro-sarcoma of, microscopic section (W. Milligan,

M.D.) ...... 42, 53

-paralysis, complete (E. W. Houghton) . . 25

-tumour of, formed during influenza (J. Donelan, M.B.) . 106

Vomer, papillomatous growth on posterior edge of (H. Tilley, M.D.) . 93

Waggett (E. B.), case of (?) congenital fenestration of the anterior

pillars of the fauces . . . . .7

-case of cicatricial stenosis of the pharynx in a young woman,

the sequel of cut-throat inflicted eighteen months previously . 20

-case of epithelioma of the epiglottis in a middle-aged man . 20

-case of myeloma of the nose in a woman set. 30 . .62

-ethmoidal suppuration in a man complaining of excessive pain 70

-cystic adenoma of pyramidal lobe of the thyroid . . 132

Westmacott (F.), a series of specimens, photographs, and drawings
illustrating the inflammatory diseases of the nasal fossae and
accessory cavities . . . . . .3

Willcock8 (F., M.D.), case of paralysis of the left vocal cord . 80

Wingrave (V. Wyatt), case of laryngeal growth in a man set. 50 . 95

-case of sublingual dermoid cyst in a male set. 17 . .21

-case of paralysis of left vocal cord in a female set. 27 . .110

-a case of bulbar paralysis in a female set. 23 . .111

Wooden probes : see Probes (wooden).

PRINTED BY ADLARD AND SON,
BARTHOLOMEW CLOSE, E.C. ; 20, HANOVER SQUARE, W. ;
AND DORKING.

PROCEEDINGS

OP THE

LARYNGOLOGICAL SOCIETY

LONDON.

VOL. X.

1902 — 1903 .

WITH

LIST OF OFFICERS, MEMBERS, ETC.

PRINTED BY ADLARD AND SON,
LONDON AND DORKING.

1903 .

OFFICERS AND COUNCIL

OF TUB

Ifargnjological £foactg of |!onion

ELECTED AT

THE ANNUAL GENERAL MEETING,

JANUARY 9th, 1903.

|)resii>rnt.

P. McBRIDE, M.D., F.R.C.P.Ed.

flice-|)rtinbmt6.

A. A. BOWLBY, F.R.C.S. J. DUNDAS GRANT, M.D., F.R.C.S.

PERCY KIDD, M.D., F.R.C.P. CHARTERS J. SYMONDS, M.S., F.R.C.S.

(Treasurer.

WILLIAM R. H. STEWART, F.R.C.S. (Edin.).

Tibrari ;in.

StCLAIR THOMSON, M.D., F.R.C.S.

Secretaries.

JAMES DONELAN, M.B. E. FURNISS POTTER, M.D., M.R.C.P.

Council.

SIR FELIX SEMON, M.V.O., M.D., F.R.C.P. W. PERMEWAN, M.D., F.R.C.S.
E. CRESSWELL BABER, M.B. RICHARD LAKE, F.R.C.S.

C. A. PARKER, F.R.C.S. (Ed ). L. A. LAWRENCE, F.R.C.S.

PRESIDENTS OF THE SOCIETY.

ELECTED

1893

1894-6

1897-8

1899-1900

1901-2

1903

{From its Foundation.)

Sib Geobge Johnson, M.D., F.R.S.

Sib Felix Semon, M.D., F.R.C.P.

H. Tbentham Butlin, F.R.C.S.

F. de Havilland Hall, M.D., F.R.C.P.

E. Cbesswell Babeb, M.B.

P. McBbide, M.D., F.R.C.P.Ed.

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Seventy-sixth Ordinary Meeting, November 7th, 1902.

E. Cresswell Baber, M.B., President, in the Chair.

Charles A. Parker F.E.C.S.(Ed.),| Secretariea ,
James Donelan, M.B., )

Present—35 members and 1 visitor.

The minutes of the preceding meeting were read and con¬
firmed.

The following gentleman was nominated for election as an
ordinary member of the Society:—Donnellan, John Nicholas,
M.B., B.Ch., R.U.I., Bromsgrove, Upperton Road, Eastbourne.

The following cases and apparatus were shown:

A Case of Tertiary Syphilis of the Larynx in a Man ,®t. 26.

Shown by Mr. de Santi. The man originally attended Mr.
de Santi’s Clinic in October, four years ago, with secondary
syphilis. At that time the patient had a well-marked rash and
the usual ulceration of the tonsils, soft palate, and buccal
FIRST SERIES-VOL. X. 1

2

mucous membrane. He also had a hoarse voice, and on
examination was found to have well-marked laryngitis, the
latter presenting the usual mottled discoloration of secondary
syphilitic laryngitis. He was put under mercury, and topical
applications made to the larynx. The patient attended irregu¬
larly for some nine months, and although the skin eruption and
ulceration of the tonsils soon disappeared, the laryngitis
remained obstinate. He had been advised to give up smoking
and over-use of the voice, but did not observe these instructions.

The patient was lost sight of until October, 1902, when he
again returned to the Westminster Hospital. He stated he had
always had a hoarse voice since October, 1898, and that he had
been under treatment at various hospitals, especially GTolden
Square. At the last-named institution he had been under Dr.
Powell, who had put him on iodide of potassium gr. 40 three
times a day, and had applied various paints and sprays to the
larynx. Dr. Powell had also on six or seven occasions tried to
use endolaryngeal forceps.

At present the patient complained of a hoarse voice, some
difficulty in breathing, and slight pain. Examination of the
larynx showed both cords chronically inflamed, especially the
left. On the left cord was a large, firm, red outgrowth or
excrescence; in the interarytenoid space was a large swelling
which presented cicatricial changes. The cords could not be pro¬
perly approximated owing to the growth on the left vocal cord.

The patient was brought before the Society on the question of
treatment. He had had a long course of large doses of iodide
of potassium, topical applications to the larynx, and even
attempts to remove endolaryngeally some of the outgrowth
from the cord, but without any apparent benefit. He was now
getting both pain and difficulty in breathing, and bearing in
mind the course these cases of tertiary syphilis of the larynx are
apt to follow, the question arose as to the advisability of per¬
forming a thyrotomy, and removing the diseased intra-laryngeal
area.

Dr. Dttndas G-bant said that this case presented the appearance of
pachydermia laryngis. There was an elevation on one side of the
larynx, which lay in a depression, and a swelling on the other side.
The growth was redder and somewhat more irregular than the very

3

typical pachydermia, though for all that he considered it to be of that
nature.

Dr. FitzGerald Powell said this patient had been under his care
for some time, when he thought there was possibly a syphilitic history,
although he diagnosed the case as one of pachydermia laryngis. He
endeavoured on one or two occasions to remove portions of the growth,
but he found them very tough, and they could only be taken away with a
considerable amount of force. 'The size of the growths was nothing like
that now seen. At the beginning of the case there was evidently
pachydermia laryngis, but the growth which was now coming out from
the ventricle looked of doubtful origin.

Dr. Lack thought that one of Mr. de Santi’s cases was an instance
of pachydermia laryngis. The other was a syphilitic overgrowth which
he thought might be treated by removing pieces through the mouth.

Dr. Milligan suggested the inunction of mercury. This course
was usually followed in primary and secondary conditions. Assuming
this to be tertiary syphilis of the larynx, he considered it might be
very advisable to put the boy through a course of inunction over the
larynx if this had not already been done.

Mr. F. J. Steward asked if a formalin spray had been used for this
boy, as he had had good results from its employment in a somewhat
similar case.

In answer to the remarks of Dr. Dundas Grant, Mr. de Santi
thought he was mixing up his first and second cases, the second case
being probably one of pachydermia laryngis. In answer to Dr. Powell,
Mr. de Santi was surprised that he should have put the patient whilst
under his treatment on such large doses of iodide of potassium if he
thought the case to be pachydermia. In answer to Dr. Milligan, he
agreed with his suggestion of inunction of mercury, but had already
tried it, and apparently without benefit. Altogether Mr. de Santi
was disappointed that members had not brought forward any sugges¬
tions as to treatment.

Case for Diagnosis: Man with Growth on Left Vocal Cord.

Shown by Mr. de Santi. This patient came to Westminster
Hospital Throat Clinic in May, 1902, with a history of hoarse¬
ness, sore throat, and pain in left chest anteriorly. He had
had these symptoms about six months. Dr. Hebb, Mr. de Santi’s
colleague, had examined the patient’s chest, but found no
physical signs of disease. Examination of the larynx revealed
marked thickening and reddening of the posterior third of both
vocal cords, and a tumour, pyramidal in shape, with its base
attached to the left vocal cord posteriorly; also a well-defined
swelling in the interarytenoid space. The cords moved freely,

6

examination of the chest, harsh breathing, prolonged expiration,
and increased vocal resonance were found over the left apex, but
no adventitious sounds could be heard. There was some
difficulty of deglutition, the patient being unable to take solids.

Subsequent to admission to hospital a tracheotomy had to be
performed for the relief of dyspnoea. The sputum was twice
examined for tubercle bacilli, with negative results, and a large
bougie was passed without difficulty, except that it seemed
gripped about the level of the cricoid. The inequality of the
pupils varied, for a few days the right being the larger, and
then for a few days the left. After tracheotomy deglutition
improved, the patient shortly being able to take solids.

Mr. Parker brought the case forward for diagnosis. At first
he had been doubtful whether it was a case of fixation or
paralysis of the cords, and, if the latter, whether it was due to a
central nervous lesion or to pressure on the recurrents by a
malignant growth of the oesophagus. At the present time the
arytenoids were more oedematous, and the condition suggested
tubercular mischief with fixation of the cords.

Case op Removal op the Epiglottis for Tuberculous Disease in

a Male .®t. 35.

Shown by Mr. Richard Lake. The prominent symptom in
this case had been intense dysphagia, for which reason the
epiglottis had been amputated over four weeks ago by means
of the galvano-cautery snare. When removed it was found
to be nearly half an inch thick where cut through, and
the posterior or pharyngeal surface was deeply ulcerated.
The rest of the larynx was diseased, and had not yet yielded
entirely to treatment, but the stump of the epiglottis was
soundly healed, and of normal thickness. Dysphagia ceased
immediately after the operation and did not recur. The general
condition of the patient was markedly improved since he had
been able to take his food in comfort.

7

PEDUNCULATED LARYNGEAL GROWTH, PROBABLY DATING PROM

Birth, in a Boy ,®t. 15 Years.

Shown by Dr. Donelan. There were two growths present.
The large one probably began as a papilloma arising from the
upper surface of the anterior growth of the left vocal cord, and
had, in the course of years, become fibrous and pedunculated.
The smaller tumour was sessile, subglottic, and situated imme¬
diately below the anterior commissure. The mother thought the
affection dated from birth, as from the first he had had a peculiar
hoarse cry, and in voice had always been hoarse. The large
growth and its peduncle in each inspiration were drawn through
the glottis, which they momentarily filled almost completely.
The influence of this respiratory obstruction acting through so
many years showed itself in the stunted and anaemic appearance
of this youth, while the other members of his family were
healthy and well grown.

The President thought the case looked like one of papilloma.

A readily Improvised Working Model to demonstrate the
Air Channels and Currents in the Nasal Cavities in
Normal and Impeded Nasal Respiration.

Shown by Dr. Scanes Spicer. This apparatus had been con¬
trived from objects which would probably be in the possession
of most rhinologists. It consisted of a Betz plaster model of
the half-head as seen on medial sagittal section, the septum nasi
having been removed; a soft, flexible, perforated metal Asch’s
nasal tube splint ; 12 inches of india-rubber tubing (finch in
diameter); some plasticine modelling composition; and a sheet
of clear glass 10 by 8 inches. The flexible metal tube was
moulded to represent accurately the form and dimensions of the
vestibule and rima naris, and then puddled on to the alar
region of the plaster model with plasticine; the rubber tubing
was similarly affixed to the lower end of the pharynx of the
model. A cord of plasticine, f inch in diameter, was then

8

accurately affixed to the margins of the nasal and naso¬
pharyngeal cavities of the model, and the sheet of glass pressed
down so as to allow no leak anywhere. The model was now filled
with smoke from a cigarette through the rubber tube.

On inspiring or expiring air through the rubber tube, the
passage of the entering or outgoing current of air through the
dense smoke could be easily traced. The normal inspiratory
current in quiet breathing was seen to issue from the rima and
spread out like a fan to impinge on the front part of the middle
turbinated body and adjacent parts. It then swept rapidly
round the roof of the nose and naso-pharynx, passing chiefly
through the upper two thirds of the nasal cavity. A vortex was
also seen to be formed by a current becoming detached from
the main stream just in front of the posterior nares, which
impinged downwards and forwards on to the floor of the nose,
and then curled round the front end of the inferior turbinated
body. The inspiratory current did not normally pass through
the inferior meatus.

The normal expiratory current in quiet breathing passed
chiefly through the lower two meatuses, and a vortex was formed
in the fore-part of the nasal cavity in a reverse direction to that
of the preceding.

The glass could be removed, and any pathological condi¬
tion, such as spurs, deflections, polypi, adenoids, etc., could be
represented in size and position by lumps of plasticine, and on
replacing the glass as before their effects in diverting the normal
currents could be easily studied and the conditions varied.

Mr. Spicer thought it might with reason be objected that the
anatomical conditions were not exactly reproduced, and that
the ala did not move as in normal respiration; but the approxi¬
mation must be fairly accurate, for it was remarkable how the
results agreed with Paulsen’s and Franke’s researches on the
cadaver, and Parker’s deductions from his lycopodium powder
experiments.

The full results of observations made would be deferred for a
future communication, but in the meantime, considering how
readily the apparatus could be arranged and worked, doubtless
many rhinologists would test it and compare the results with
their previous ideas on the subject.

9

Left Antral Empyema, followed by Abscess of Hard Palate

and of Septum Nasi.

Shown by Mr. Hunter Tod. The patient was a medical
student, who three months ago had had a severe attack of tooth¬
ache on the left side, followed, on the second day after the onset,
by swelling of the face, and, on the fourth day, of the hard palate
on the same side also. On the sixth day an abscess of the palate
had burst into the mouth; at the same time he had noticed his nose
had become swollen and obstructed. Two weeks after onset a
dentist extracted the second incisor, canine, and first bicuspid
tooth. The swelling of the face gradually diminished. Mr.
Tod saw him three days later. He then had an obvious ab¬
scess of the septum, which blocked both anterior and posterior
nares. The left antrum was dark on transillumination. The
abscess of the septum was incised; much offensive pus
escaped, and the nose was kept clean by a simple wash. A
month later the nose appeared healthy but for great thicken¬
ing of the septum, seen by posterior rhinoscopy; and there
was a drop of pus in the middle meatus of the left side of the
nose. The second molar was extracted, and the antrum, which
contained much pus, was drained through the alveolar arch.
The patient was now practically well. There was no necrosis
of bone, and no perforation of the septum.

The President suggested that the teeth had caused inflammation
on the palatal surface and inside the antrum, producing a palatal
abscess and an abscess on the septum, and at the same time one in the
antrum.

Mr. C. A. Parker said he had recently had a rather similar case, as
far as the septum was concerned, in a child seven years old. There
was a considerable amount of necrosis of the alveolar process above the
right central and lateral incisors, and a well-marked abscess showing
on either side of the septum.

Mr. Hunter Tod said the onset was so very sudden. He was not
sure whether the antrum was first affected or not, but the history of
the case had its commencement in tooth trouble.

If

Double Antral and Frontal Sinus Disease; Left Side cured
by Radical Operation ; Question op operating on the
Right Side.

Shown by Mr. Hunter Tod. The trouble in this case probably
dated from an attack of influenza in 1897, since which the
patient had suffered from headaches, gradually increasing in
severity, and had noticed much purulent discharge from right
side of the nose. The headaches had incapacitated him from
working since onset.

About Christmas, 1901, there was an abscess over the left eye.
This was scraped twice at a provincial hospital. On admission
to the London Hospital the left eye was nearly closed from
oedema and infiltration of the supra-orbital tissues, and there
was a tiny fistula leading into the frontal sinus. The nasal
cavity on that side was normal. The right side was filled with
polypi, and there was much pus. The anterior half of the right
middle turbinate and the polypi were removed. A week later,
after cleansing the nose, the antrum was explored with a fine
trocar; it contained pus. Similarly a cannula was passed into
the fronto-nasal duct, and pus was washed out of the frontal
sinus. Exploration of the left antrum proved it full of pus,
although the nasal cavity appeared normal.

A radical operation, consisting of removal of all the anterior
and inferior wall of the left frontal sinus, which was filled with
polypi and pus, was performed, and a passage made into the
nose. The patient was practically well on the seventh day, and
left the hospital on the tenth. A tube was worn in the fronto¬
nasal duct for two months. Since then there had been no
recurrence.

The antra were drained via the alveolar arch. The left side
was now cured. There was still pus in the right frontal and
antral sinuses, proved by repeated washing out of the sinuses.
The patient, however, since the operation on the frontal sinus,
had had no further headache, and felt and looked well. He
had not been seen for two months before being shown to the
Society. He had now so greatly improved that the question of

11

operation on the right side hardly arose. There was consider¬
able flattening over the right frontal sinus, but to this the
patient did not object.

The President said there seemed to be a free exit for the discharge
from the right frontal sinus, and as Mr. Tod was able to syringe it out
easily and the man had no particular symptoms, he thought it was
well to leave that sinus alone, save for syringing at regular intervals.
It would be useless operating radically on the right antrum till the
right frontal sinus was better, since it might be emptying itself into
the antrum.

Dr. Herbert Tilley congratulated Mr. Tod on the result of the
operation on the left frontal sinus, and thought that a similar opera¬
tion on the right side would be the only means of curing the headaches
from which the patient suffered, and which was obviously due to the
suppuration in that sinus. If the headaches were not very severe the
operation was not urgent, because very little pus was present in the
right nostril.

Mr. Tod said the patient was not subject to very severe headaches,
but only to occasional slight attacks which were removed by washing
out the right frontal sinus.

A Case op Obscure Lardaceous-looking Variable Infiltration
op the Uvula, Soft Palate, and Right Arytenoid Car¬
tilage in a Lady ,®t. 30.

Shown by Sir Felix Semon. The patient was first seen on
July 12th of the present year, with a history of long-standing
throat trouble, and occasional difficulty in swallowing. She
had been seen by various medical men, all of whom, according
to her statements, had considered the affection as rather serious,
but had apparently not known what to make of it.

On examination an almost lardaceous condition of the uvula
was seen; that was to say, the uvula and the adjacent parts of
the soft palate were considerably infiltrated, and at the same
time quite smooth to sight and touch, whilst the most character¬
istic point consisted in the peculiar yellowish colour of the
affected parts, reminding one of nothing so much as of the
appearance of a kidney which had undergone lardaceous de¬
generation. In the larynx there was a similar condition of the
mucous membrane over the right arytenoid cartilage. The left
looked slightly more cedematous, reminding one of the ordinary

12

pseudo-oedematous infiltration of tuberculosis; still, although
more transparent than its fellow, it had a similar yellow colour
to the right arytenoid.

There was no evidence of kidney trouble, but on examination
of the legs there was slight pitting on pressure, particularly
over the external malleoli.

Her voice was normal. There was no pain, and no difficulty
in breathing. The organs of the chest were normal.

The urine had been examined later, and found perfectly
normal. On July 14th, 1902, the local condition of both
pharynx and larynx was much better than three days previously.
The patient was given an arsenic and iron mixture.

On July 29th, 1902, the swelling both of the uvula and of the
right arytenoid cartilage was much more marked than on the
occasion of her last visit, and the colour was much more that
characteristic lardaceous yellow which had been observed on the
occasion of the first examination. The condition apparently
varied from day to day.

On November 6th, 1902, the patient was found to have been
distinctly better since last seen, and had only occasionally had
slight difficulty in swallowing. The uvula as well as the right
arytenoid cartilage now looked much less infiltrated than they
were in July.

Remarking on this case Sir Felix Semon said: “ This is the
third case of the kind which I have ever seen, and I am not
aware that the condition has ever been described.

“ My first case, which I saw very many years ago, occurred in
the wife of a practitioner in the Midlands; the lady’s age was
about thirty. In her case the condition was much more marked
and general than in the present one, and I at first thought that
it was a case of tuberculous infiltration, distinguished only from
the ordinary cases by the peculiar yellow colour of the affected
parts, as the infiltration involved not only the uvula and the
soft palate, but also the epiglottis and both arytenoid cartilages.
In that case the general discomfort and the difficulties in
swallowing were much greater than in the present case, and no
method of treatment had any effect whilst the patient was under
periodical observation, which extended over nearly two years.
I was, therefore, not a little surprised when again, about two

13

years afterwards, the patient called on me to show me that there
had been a return to perfectly normal conditions. There was as
little known cause for the restoration to health as there had
been for the original affection.

“The third case, which also occurred in a lady, set. about
40, I only saw once. In that case the conditions were very much
as in the patient now shown.

“I cannot make the least suggestion as to the pathology of
these cases, and bring my case forward with the double purpose
of giving the members of the Society the opportunity of seeing
these most unusual conditions, and of possibly obtaining some
help with regard to its pathology and treatment.”

The President asked if any member had seen a similar case; if so
it would be interesting to hear his experience.

Dr. FitzGerald Powell suggested that a portion of the uvula
should be taken off and submitted to microscopical examination.

Sir Felix Semon replied that he would follow Dr. FitzGerald
Powell’s advice if the lady consented.

A Case op Ulceration op the Left Tonsil with Acute and
Considerable Enlargement of Numerous Cervical Lym¬
phatic Glands on Both Sides op the Neck ; (?) Malig¬
nancy.

The patient, a clergyman, set. about 70, was first seen on
October 28th, suffering from ulceration of the left tonsil, which
had remained behind after an attack of what appeared to be
peritonsillitis about six weeks previously. There was no general
cachexia, and hardly any pain or discomfort in the throat.

On examination the left tonsil was seen to be moderately
enlarged, and in part superficially ulcerated. It was not exces¬
sively hard. Not only on the left, but also on the right side of
the neck, numerous enlarged cervical lymphatic glands were
present, those on the left side being particularly enlarged.
Almost all of them on both sides were slightly tender on
pressure. The interior of the pharynx, with the exception of
the ulceration of the left tonsil, was quite normal.

Whilst the occurrence of ulceration of a tonsil, coupled with
enlargement of the cervical lymphatic glands, in a man of 70,

pointed of course prima facie to malignancy (there being no
evidence whatever of tuberculosis or syphilis), the unusual
features in this case were—-

1. The very rapid development of the enlargement of the
cervical lymphatic glands;

2. The comparative smallness of the affected tonsil in propor¬
tion to the number and size of the affected glands;

3. And, above all, the fact that the cervical glands were
enlarged on both sides, whilst only the left tonsil was affected.

A piece had, therefore, been removed, on the exhibitor’s
advice, with punch forceps by the patient’s regular medical
attendant, and sent to Mr. Shattock for examination, whilst at
the same time iodide of potassium had been given internally,
and a thick belladonna paste applied externally.

Mr. Shattock’s report was as follows :—“ I have carefully
studied sections of the two pieces of tissue removed three days
ago by Dr. T—, one from the swelling of the tonsil, the other
from the anterior pillar of the fauces. They both show the same
changes. I regard the tissue as inflammatory, rapidly growing
granulation tissue. It consists of polyhedral connective-tissue
cells distributed amongst fibroblasts and capillaries, the last well
formed and distinct from the surrounding structures. A certain
number of polymorphonuclear leucocytes occur. The epithelium
over the pillar of the fauces is intact, but a considerable number
of leucocytes are migrating into it from the subjacent inflamma¬
tory tissue.

“ In the tissue from the tonsil considerable areas have under¬
gone necrosis. Tuberculosis may be excluded histologically, as
it may doubtless also clinically. I should not, therefore, class
the lesion as sarcomatous. You recollect the notorious swelling
of the tonsil that was cured by the violets, i. e. disappeared.”

When the patient was again seen to-day there was found to
be a decided diminution of the size of the cervical lymphatic
glands on both sides, but they were still somewhat tender, and
undoubtedly both the size and the ulceration area of the left
tonsil had not inconsiderably increased since the patient was
seen ten days ago. In spite, therefore, of the unusual clinical
features, and of Mr. Shattock’s favourable report, Sir Felix
Semon did not consider that all cause for anxiety was over, and

15

he had therefore brought the patient before the Society to hear
the opinions of its members.

Mr. de Santi looked upon this case as one presenting many diffi¬
culties as regards diagnosis. Looking at the age of the patient, the
general appearance of the tonsil, and the condition of the glands, he
considered the ulceration to be epitheliomatous. He had not felt the
growth with his finger, but the tonsil was probably hard to the touch.
The condition of the glands and the rapidity of their enlargement was
unusual in epithelioma, but in his experience one could never quite be
certain of the course lymphatic infection in malignant disease might
take in various individuals. He had seen glands secondarily involved
from epithelioma of the lip on the opposite side to the malignant
growth, and he had seen cases in which for some time no lymphatic
enlargement was noticeable, and then almost suddenly extensive
involvement of the glands had occurred. Of course the rule was to
get the glands affected on the same side on which the original growth
existed, though later the glands on both sides might and did become
involved. Although bearing in mind the pathological report, and that
it had been given by so eminent an authority as Mr. Shattock, Mr. de
Santi looked upon the case as malignant from its clinical aspects;
indeed, he could not see what else the condition could be. At all
events, if it were malignant he was strongly of opinion that it should
be left alone from an operative point of view. No operation with such
glandular involvement would be of any use or justifiable. He under¬
stood iodide of potassium was being given, and he would be very
interested to hear the subsequent history of the case.

The President understood that the appearance of the tonsil had
changed considerably since the piece referred to by Sir Felix Semon
was punched out.

Sir Felix Semon. —Yes.

Dr. Dun das Grant said that the removal of one of the glands
could be easily accomplished, and its examination might give further
valuable information.

Sir Felix Semon said he by no means fought against the possibility
of this being a case of malignant disease. It was, in truth, at first his
own idea of the case.

With regard to Mr. de Santi’s remarks, however, he would like to
mention the following points :—(1) The appearance of the tonsil at the
present time might be more suggestive of malignancy because only six
days ago a fairly big piece had been punched out by forceps, and there
was of course a good deal of inflammatory change following this
operation. (2) He quite agreed that one saw cases in which the
cervical glands were affected on both sides, but this, in his experience,
was as a rule only found in advanced stages of the disease. In the
present case, however, there was extensive enlargement of these glands
on both sides, whilst the whole duration of the disease, including the
peritonsillar inflammation, was only six weeks. This was certainly
most uncommon if the affection was really of malignant character.
(3) So competent an observer as Mr. Shattock had made a micro-

16

scopic examination and expressed a very decided opinion that the
changes were of inflammatory character, and not of the nature of new
growth.

He did not, in reply to Dr. G-rant, consider himself justified in
removing one of the enlarged cervical glands, for if the case after all
were malignant, as Mr. de Santi thought, this was certainly no case for
radical operation. In all probability it would be impossible to remove
all the enlarged glands, and even if one succeeded in this, recurrence
in no time would be practically certain.

He would not fail to report to the Society on the further course of
the disease, and would only add that, in spite of complete absence of
any antisyphilitic antecedents, antisyphilitic treatment had been tried;
the patient had had iodide of potassium for two weeks and perchloride
of mercury, but with little effect.

Case op Cyst op the Epiglottis in a Male act. 40.

Shown by Dr. FitzGerald Powell. The patient complained
of nasal obstruction and ear trouble, but had incidentally
remarked that he felt a “ stickiness in the throat,” which
had existed for about two years. On making an examina¬
tion of his throat with the laryngoscope, a bluish translucent
growth was seen on the upper surface of the epiglottis. It was
about the size of a marble, and vessels were seen coursing over
its surface.

Case op Epithelioma of Tongue in a Single Woman ,®t. 24.

Shown by Dr. Hamilton Burt. Patient first noticed a de¬
pression under the right side of tongue in February last, about
the size of a pin’s head. It appeared as though the part had
been punched or sucked in. On the flow of depression she
noticed a small white deposit. She took little or no notice of it.
It grew very slowly, and was painless. She sought advice
about three months ago, and was advised to have some stumps
and bad teeth in the vicinity of growth removed. This was
done, but no improvement was noticed. Dr. Burt had first seen
patient about four weeks ago; the growth was then the size of
a small cherry, and occupied the right side and upper part
of the middle of the tongue; the base was indurated, and the
surface smooth, not ulcerated, with a few tiny yellow spots

17

scattered here and there, out of which, when squeezed, a yellowish
fluid escaped. No enlarged glands could be felt. Taking into
consideration the age of the patient, the appearance of the
growth, and the absence of enlarged glands, she was put upon
iodide of potassium and mercury, the iodide being increased to
3 SS three times a day. Under this treatment the growth became
considerably reduced at first, but in spite of the increased doses
of iodide it had increased rapidly during the past ten days.
The patient had not lost flesh.

Mr. de Sakti considered the diagnosis to rest between malignant
disease, tubercle, and syphilis. The situation of the growth on the
side of the tongue, its hardness, the fact that it had arisen from irrita¬
tion of a tooth, its general appearance of infiltration, were all points in
favour of malignancy. On the other hand, the age of the patient was
only twenty-four, and the sex female. Moreover there was an absence
of glandular infection, and there was the history of almost total dis¬
appearance of the growth under iodide of potassium. Mr. de Santi,
however, had seen a case of epithelioma of the tongue very similar to
the case under discussion in a girl still younger, namely twenty-one ;
the ulceration was considered to be syphilitic though there was no
history or other symptoms past or present of that disease. The patient
for a short time improved under iodide, but eventually the ulceration
extended rapidly and the glands became involved. Eemoval of one half
of the tongue and of the enlarged glands was performed, but within
four months the patient died of a recurrence in the glands,—in fact, the
case was very rapid in its malignancy. Mr. de Santi did not think the
case one of tubercle, nor was it probably syphilitic; it did not resemble
a chancre, and it was almost certain that it was not gummatous ; he
had seen many gummata of the tongue, and they invariably affected the
dorsum in its mid-line. He would advise excision of a piece of the
growing margin and its examination microscopically. If malignant the
earlier the case could be dealt with radically the better.

Dr. FitzGerald Powell said in his opinion the growth was an
epithelioma, and was to be felt beginning to dip down deeply into
the floor of the mouth. He understood that the growth had almost
disappeared under antiseptic treatment, but had again grown rapidly,
the treatment having been continued. He thought no time was to be
lost before operating.

Dr. A. H. Burt said that under treatment by iodide of potassium
the growth had almost disappeared, but within the last five days it had
again come up suddenly and had spread very much more into the sub¬
stance of the tongue. He had come to the conclusion that it could be
nothing but malignant disease.

18

Case of Recurring Ulceration in Pharynx and Larynx,

THOUGHT TO BE HERPETIC, IN A WOMAN .ET. 56.

Shown by Dr. Furniss Potter. The patient had come under
observation about three weeks previously, and stated that she
had been troubled with attacks of “ ulcerated throat ” almost
continuously for the last six years, never having been free for
more than ten days at a time.

On examination two small erosions were seen, one on the right
posterior faucial pillar, punched-out looking and saucer-shaped;
the other between the left posterior pillar and the pharyn¬
geal wall, about a quarter of an inch in diameter and with a flat
surface. The voice was husky. During the time the patient had
been under observation the ulcer on the right anterior pillar had
completely healed, while the one on the left side had almost
disappeared. In the meantime several others had made their
appearance—one on the palate, another on the edge of the
epiglottis, and a third in the interarytenoid region.

The patient stated that the “ spots ” sometimes came on the
gums, and inner surface of the lips and cheeks. She said that
their appearance was generally preceded and accompanied by
pricking, burning pain, a feeling of malaise, and discomfort in
swallowing.

There was a history of four miscarriages and loss of hair.
Between the ages of sixteen and twenty-one she had suffered
from exactly similar attacks, and had been an in-patient at the
Westminster Hospital for “ ulcerated throat.”

The appearance of the throat when first seen, together with
the history, had led to a suspicion of the possibility of
syphilis; and mercury and potassium iodide had been prescribed,
but had been discontinued after ten days, since which the only
treatment had been a mouth-wash of boric lotion, and occasional
touching of the ulcers with a solution of chromic acid (30
per cent.).

Dr. Lack said he did not think this was herpes, as the individual
ulcers were much too large. To him it appeared more like pemphigus.

Dr. Milligan said that the same idea had struck him as to its being
pemphigus. The ulceration on the pharynx was rather large for herpes,

19

but, on the other hand, the traces of small isolated areas in the larynx
were rather suggestive of herpes. He asked the patient, when she first
noticed the rash, what the condition was, and she said the spots were
as big as the little finger-nail—which was rather against herpes.

Dr. Furniss Potter thought the size of the vesicles at the com¬
mencement was against the pemphigus theory ; they were quite small.
He had watched them from the beginning, and had observed that
the. surface of the ulcer was very much larger than the initial vesicle.
In pemphigus one would expect to see a large bleb or bulla, but in
none of these cases had there been any bleb corresponding at all to the
size of the fully developed ulcer. The ulcers spread till they covered a
patch about a quarter of the size of a postage stamp. They healed
with great rapidity, leaving no cicatrix.

Case of Vascular Naso-pharyngeal Fibroma of Extensive
Origin finally removed by a Combined Operation through
The Soft and Hard Palate, and Extensive Removal of
Anterior Wall of Left Super-maxillary Bone.

Patient and specimen shown by Dr. Herbert Tilley. F. S—,
male aet. 14, came to the hospital November 19th, 1901, com¬
plaining of complete nasal obstruction associated with a blood¬
stained discharge from the left nostril of five months' duration.
For the last three weeks the discharge had been offensive, and
for seven to eight weeks the right nostril had been completely
occluded. It was noted that the patient was weak and anaemic.
The lower half of the nose was much broadened, and the left
nostril distended by a grey sloughing mass which bled freely
when touched with a probe. The discharge from the left nostril
was very offensive, while the right was completely occluded by
marked deviation of the nasal septum. By posterior rhinoscopy
the left choana was seen to be filled by a reddish mass, which
passed insensibly on to the mucous membrane of the naso¬
pharynx. Digital examination revealed a smooth-surfaced
elastic swelling which seemed to spring from the basi-sphenoidal
and ethmoidal regions. There was no displacement of the left
eye. Transillumination showed opacity of the left antrum.

First Operation, November 20th, 1901.—Having made an
inverted U _s ^ ia P 0( i incision over the sides and root of the nose, the
nasal bones were divided in the line of incision with a saw and
the nose turned downwards on the face. This brought the
growth well into view, and procured easy access to the ethmoidal

20

region. The growth was seized in strong forceps and some half
of it torn and cut away, hut it was soon* obvious that the base
of the tumour was too extensive for removal through the open¬
ing. The haemorrhage was very profuse, and could only be
kept in check by compressed marine sponges forced into the
nasal cavity. Respiratory difficulties arose owing to blood
escaping into the larynx in spite of the post-nasal space having
been plugged.

The nose was finally replaced and sutured in position; it
healed by immediate union. Dr. Horne reported the growth to
be an angeiofibroma, and free from any elements of malignancy.
The iodoform gauze packing which was used to plug the nasal
cavity at the end of the operation was removed through the
nostril in forty-eight hours. The patient made a rapid recovery
from the shock of the operation, and three weeks later it was
determined to attempt the removal of the remainder of the
growth by a different method.

Second Operation , December 1th, 1901.—Having inserted a
laryngotomy tube and placed a sponge above the larynx, a
Whitehead’s gag was employed to keep open the mouth. With
the patient’s head hanging slightly backwards over the end of
the table, the soft palate was completely divided in the middle
line, the incision being carried forwards to the alveolar border,
immediately behind the incisor teeth. The mucous membrane
was stripped from the left half of the hard palate, and the latter
completely removed by chisel and mallet. The growth was thus
brought fully into view, and its base was seen to be attached to
the left basi-sphenoidal and ethmoidal regions. Its base was
seized in an ovariotomy clamp, and the greater part of the
growth removed by scissors. Other smaller portions were
removed by means of strong wire snares and cutting forceps.
The haemorrhage was free but under good control, and it was
checked by marine sponges on holders. As far as the eye
and finger could ascertain allthe tumour was removed. The
patient, although only thirty-five minutes under the anaesthetic,
had at the end of the operation a weak, rapid, and intermittent
pulse, which quickly recovered under the influence of a rectal
injection of 1^ oz. of brandy and strychnine gr. ^ administered
hypodermically.

21

The long strip of iodoform gauze which was packed into the
naso-pharynx at the end of the operation was removed in forty-
eight hours, and the nasal cavity subsequently irrigated three
times daily with a warm alkaline wash.

The patient made a rapid recovery, but after an interval of
three weeks the growth was seen to be recurring, and in the
course of six to eight weeks it was obvious that further inter¬
vention would be required.

March 15th, 1902.—A third operation, identical in all details
with the last, was carried out, but possibly a more thorough
clearance of the growth was made.

A month later recurrence was visible in the region of the
middle meatus, and every week during the months of May,
June, and July the patient attended as an out-patient, the treat¬
ment consisting of piercing the growth in many places with the
galvano-cautery. This seemed at first to retard its growth, and
produced a number of puckered scars, but latterly it became
increasingly obvious that the growth was increasing in size.
Towards the end of July it projected through the cleft of the
palate, and nasal obstruction again became complete. The lad
was anxious that yet another attempt should be made to eradi¬
cate the growth, a request which received some encouragement
from the report of the pathologist, viz. that there were no signs
of malignancy in the piece of tumour which he had examined
(vide supra). Since the recurrence seemed to spring from the
middle meatal region, and the left antrum was very opaque on
transillumination, it was decided to explore that cavity.

July 31s£, 1902.—With the preliminaries, as in the preceding
operations, an incision was made in the gingivo-labial furrow
from the level of the left molar tooth across the middle line to
the corresponding position on the right side. The cartilage of
the nasal septum was divided along its floor by strong scissors,
and the nose and soft parts of the face on the left side turned
upwards, so as to fully expose the anterior surface of the left
maxillary bone. The front wall of this was then completely
removed, and the antral cavity found to be filled with the
growth, which was very vascular and firmly attached to the
whole of the posterior and upper walls. To gain more room the
lower half of the ascending (nasal) process of the maxillary

22

bone was removed by means of strong bone forceps. The
portion of the growth extending into the mouth was then
removed by a strong wire snare, the remainder was seized in a
pair of powerful tonsil forceps and torn away from its attach¬
ments, leaving completely bare the left side of the basi-sphenoid,
ethmoidal, and maxillary antral regions. Haemorrhage was
checked by means of marine sponges. The after treatment con¬
sisted of syringing out the nose and left antrum three times
daily for three weeks with warm boracic lotion.

The patient made a rapid recovery, and left the hospital
fourteen days after the operation. At the present moment
(November 7th) there is no sign of recurrence, no nasal dis¬
charge, the parts appear perfectly healthy, and the patient is in
robust health, having grown two inches since the first removal
of the growth. It now only remains to close the cleft in the
soft palate.

The President wished to know if there were any signs of recurrence
when the young man was last seen. It was an extremely interesting
case.

Dr. FitzGerald Powell congratulated Dr. Tilley on the result of
his operations. He hoped he would be able to place the patient’s
mouth in a better condition, by bringing together the divided soft
palate. He understood Dr. Tilley to say this was the first case recorded
of a growth of this nature springing from the antrum, but he had
exhibited a patient at a previous meeting of the Society from whom he
had removed a fibroma through the nose which had arisen in the
antrum from the under surface of the floor of the orbit and the outer
wall. He had also exhibited the growth at the same meeting.

In answer to questions Dr. Tilley pointed out—(a) the great
value of a preliminary laryngotomy and the placing of a, sponge above
the larynx, in that these measures (1) prevented blood getting into the
larynx, (2) they relieved the anaesthetist from anxiety, and at the same
time placed that individual out of the way of the surgeon; (b) by
dividing the soft and hard palate these growths were brought splendidly
into view, and the free haemorrhage which occurred during their removal
was under absolute control.

Case of Complete Adhesion of Soft Palate to Posterior

Wall of Pharynx.

Shown by Dr. Lambert Lack. The patient was a woman aet.
about 30. There was complete union between the soft palate
and posterior pharyngeal wall; not even the finest probe could

23

be passed up from the mouth into the naso-pharynx. This was
evidently the result of tertiary syphilis, although it was the only
lesion, and there was no active disease. The patient had trouble
in swallowing at times, occasional shooting pain in the ear but
not severe, and much mucus collected in the post-nasal space,
and had to be syringed away through the nose. Dr. Lack
asked was operation for this condition successful, and would
this patient, in view of her slight symptoms, be well advised to
undergo one.

Mr. de Santi had had operative experience of two exactly similar
cases—cases quite as complete. In the first case there was considerable
pain in one ear and mastoid region, and his colleague, Mr. Spencer,
bearing in mind the fact that the ordinary operations for relief of this
condition were unsatisfactory, had separated the adhesions with a knif e
and passed stout silver sutures through the detached though short
remains of the soft palate, and sutured the soft palate to the muco-
periosteum of the hard palate. In fact, the stump of the soft palate
was sutured tightly up—rolled up—to the hard palate, and it was left
to nature to allow the sutures to cut their way out. The result was
good, although later a good deal of recontraction took place. There
was also very severe haemorrhage at the time of operation. Not long
after a quite similar case came under Mr. de Santi’s care, and he per¬
formed the same operation. In this case there was luckily but little
haemorrhage, and the eventual result was very good. Some years had
elapsed since the operation, and the patient remained well with a free
passage between the naso-pharynx and the oro-pharynx, and dilatation
was unnecessary. He could with confidence recommend the operation
to Dr. Lack.

Case of Persistent Epistaxis in a Man act.- 42.

Shown by Mr. Charles A. Parker. The patient com¬
plained of epistaxis, which had lasted over twelve months
and had entirely incapacitated him for work. During this
period there had been constant slight haemorrhage, and three
or four times a week most severe attacks of bleeding. The
bleeding came from first one nostril and then the other, but
more often from the right. When first seen, in August, 1902,
he was anaemic, breathless, and exhausted. On removing a plug
which had been inserted into the right nostril, blood spurted
from a small vessel on to the septum. The mucous membrane
covering both sides of the septum as far back as could be seen
was soft and boggy, and bled profusely on the slightest touch of

24

a probe. Since then the condition had been treated by the
constant use of the electric cautery, but without much success.
The haemorrhage could be controlled by its use for the time
being, but after a day or two it recurred from other spots, and
sometimes from the floor of the nose as well as the septum. A
blood-count has been kindly made by Dr. Emery, who reported
that the findings suggested a moderate grade of secondary
anaemia, which might be due to the repeated haemorrhages, and
did not raise the suspicion of a more serious form of anaemia.

Mr. Parker raised the question of the best method for further
treatment. He asked the members whether they would think it
a suitable case for trying the method recently recommended by
Mr. Hunter Mackenzie, namely, of denuding the septum of
mucous membrane; or whether, seeing that both sides of the
septum were affected, it would be justifiable to remove a portion
of the septum itself.

A Case op Paralysis op the Abductors op the Vocal Cords
and op the Palatal Muscles, and Slight Paresis op the
Tongue, in a Man .®t. 25.

Shown by Dr. Dundas Grant. J. W—, ®et. 25, was first seen
in March, 1900, on account of cough and groaning sound when
in bed. The condition had lasted two or three months, and had
come on after an attack of hiccough lasting on and off for about
ten days. He had had a cough on and off for about one year,
especially when drinking quickly. For six months he had occa¬
sional stridor on inspiration. Examination of the throat revealed
slight paresis of the right half of the palate, but no abnormality
in the movements of the tongue. The vocal cords approximated
during phonation, but on inspiration the vocal processes did not
move from the middle line. There was, however, an elliptical
slit between the cords. The case was obviously one of paralysis
of the abductors and internal tensors of both cords and paresis
of half the palate, and the lesion was, therefore, in all prob¬
ability one of the vagus nerves in or near the medulla oblongata.

In seeking for a cause, especially for any signs of syphilis,
there were found enlarged post-cervical glands of about six
months’ duration, and a flat ulcer on the scalp on the parietal

25

region, with slightly indurated edges. This was asserted to
have been in existence for nearly three or four months', but it
seems more probable that it preceded the enlargement of glands.
There was also general enlargement of the lymphatic glands
over the body. The pulse almost disappeared during inspiration;
the knee-jerks were normal. An antisyphilitic course of treat¬
ment was instituted, and when seen a fortnight later it was
reported that there was less noise in sleep since the second occa¬
sion on which the mercurial ointment was rubbed in ; the vocal
slit appeared to be rather wider during inspiration. There was
some degree of mercurial stomatitis.

The patient disappeared from the observation of the exhibitor,
but returned again a fortnight ago—namely, more than two
years after being first seen—on account of great difficulty and
marked inspiratory stridor, also such a degree of paralysis
of the palate that fluids usually regurgitated through the nose
when he drank, while his speech was so indistinct that he was
obliged to pinch his nostrils in order to make himself understood
at all. The protrusion of the tongue into the right cheek was
not quite so strong as into the left; he was unable to channel the
tongue, but was not aware of ever having been able to do this.
He stated that under the previous course of treatment he
recovered sufficiently .to be able to attend to his work as a
butcher; he was at present, however, unable to do so. He
was again placed on antisyphilitic treatment, and when seen a
week later reported slight improvement in the breathing and
greater ease in speaking. He yesterday drew attention to the
fact that he had a difficulty in raising his left arm, but he had
left the out-patient department before an investigation of this
symptom had been made. It remained to be seen whether or not
this was due to paralysis of the muscles supplied by the spinal
accessory. The reporter would be glad to have suggestions as
to the possible source of infection, as there was nothing to give
colour to the idea that it was hereditary, and there was no history
of genital infection. It seemed possible that the ulcer on the
head was developed at the site of the primary sore, but the
early development of the nervous symptoms would, in that case,
be remarkable. Dr. Grant hoped to show the case at the next
meeting of the Society.

FIRST SERIES-VOL. X.

2

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Seventy-seventh Ordinary Meeting, December 5th, 1902.

E. Cresswell Baber, M.B., President, in the Chair.

Charles A. Parker, F.R.C.S.(Ed.),\ „ , .

James Donelan, M.B., J ^secretaries.

Present—23 members and 4 visitors.

The minutes of the preceding meeting were read and con¬
firmed.

The ballot was taken for John N. Donnellan, M.B., B.Ch.,
R.U.I., and he was declared unanimously elected.

The following cases, specimens, and experiments were shown :

Case op Nasal Deformity in a Woman.

Shown by Mr.^W. R. H. Stewart. This case was shown to
the Society in February, 1894. She had then suffered from a
bad'smell from the nose for eight years, and more recently the
nose had become blocked and sore, followed by falling-in of the
sides of the nose. She had been treated by Mr. Stewart by
the application of an 80 per cent, solution of lactic acid and the

FIRST SERIES—YOL. X. 3

28

passage of bougies, which was followed by some improvement.
The patient then became pregnant and was lost sight of until
a month ago. At the present time the alae had quite fallen in,
and there was considerable contraction in the vestibule, and the
septal cartilage was bent over. The case was shown in the
hope of obtaining suggestions as to treatment, operative or
otherwise.

Case op Strumous Ulcers op the Mouth and TongtJe.

Shown by Mr. W. R. H. Stewart. The patient, a domestic
servant set. 30, had suffered from ulcers on the tongue, lips, and
cheeks for about four years, recurring at intervals and lasting
for three weeks to a month. She had been under treatment for
two years. Anti-specific treatment made them worse. For the
last twelve months she had been taking from one to two grains
of sulphide of calcium three times a day, and Angier’s petroleum
emulsion. At the present time she did not have so many ulcers,
and they did not last more than one week. Mr. Stewart wished
to know if anyone could suggest a better line of treatment.

Mr. W. Gk Spencer said he thought it was a pity to apply the
term “strumous” to the conditions here seen, for that term was
generally understood to mean tuberculous. They were herpetic ulcers
—or, rather, vesicles, for they could scarcely be called ulcers—and as
such kept on recurring. They were very easily treated by some strong
astringent. Mr. Butlin’s treatment was 10 per cent, solution of
bichromate of potassium, but even with this they reappeared in three
weeks. They were attended by stinging pains.

The causes were not known, but the condition was due to something
more active than nerve lesions and neuralgic pains.

Dr. Furniss Potter thought this case was like the one he had
shown at the last meeting, and he should accordingly feel inclined to
agree with the previous speaker in calling it a case of herpes. In his
own case he had tried touching the ulcers with a 20 per cent, solution
of chromic acid, but without any effect. He was of opinion that these
cases were identical with those mentioned by Osier as “stomatitis
neurotica chronica Jacobi.”

Specimen of Malformation op the (Esophagus.

Shown by Mr. F. J. Steward. The specimen was taken from
a baby who was admitted into the Hospital for Sick Children at

29

the age of five days with a history that, after taking the breast,
apparently the whole of the milk taken was regurgitated in
about five minutes.

Examination demonstrated a complete obstruction in the
oesophagus five inches from the gums.

Gastrostomy was accordingly performed, and feeding com¬
menced at once.

The child did well at first, but sank and died nine days after
operation.

The specimen would be seen to belong to the most common
variety of malformation of the oesophagus.

The upper portion of the oesophagus was dilated, and ended
in a blind extremity about one inch above the bifurcation of the
trachea. The lower portion of the oesophagus communicated at
its upper end with the trachea immediately above its bifurca¬
tion. The opening into the trachea admitted a No. 8 catheter.
The actual gap in the oesophagus would be seen to be about
half an inch in extent.

The other organs were healthy, with the exception of the
lungs, which contained some milk presumably regurgitated.

Laryngitis Hypertrophica in a Girl ^et. 21, following
Prolonged Nasal Trouble.

Shown by Mr. Hunter Tod. The patient had suffered from
nasal obstruction, due to continuous nasal catarrh, for five years.
For the last four years she had been hoarse, and had been
troubled with a severe cough and continued hawking up of
mucous secretion from the throat.

She came to the London Hospital three months ago, and was
found to have marked hypertrophic rhinitis, with much muco-pus
trickling down the pharynx into the larynx. The larynx
showed marked hypertrophy of the interarytenoid region, and
also of the vocal cords, which latter were very thick, irregular,
and of a red beefy appearance, and there was considerable
muco-purulent secretion to be seen.

The nose was first treated, the hypertrophic tissue being
removed by the snare. The nose and pharynx were now

practically normal; there was no longer any nasal obstruction,
and no muco-purulent secretion in the pharynx.

Mr. Tod said he brought forward this case in order to obtain
advice as regards the further treatment.

Dr. Herbert Tilley advised that the interarytenoid mass should
be removed by cutting forceps, and nitrate of silver frequently applied
to the cords. He had completely restored the voice in a similar case
by these means. The hoarseness was mainly due to the fact that the
heaped-up epithelium and subepithelial connective tissue formed a
wedge which prevented adduction of the vocal cords.

Mr. Steward said, u propos of Dr. Tilley’s remarks, that this girl
had been under his care for a great many months. He had removed
large masses on four or five occasions, and she had, as in Dr. Tilley’s case,
recovered her voice, but for a short time only, when the trouble had all
recurred. Therefore he would like to know whether Dr. Tilley’s case
had been watched for any length of time, and, if so, whether the
improvement had been permanent.

Dr. Tilley, in reply to Mr. Steward, said the case he had referred
to had kept free for five months.

Dr. FitzGerald Powell thought the condition might be very much
improved by daily washing the larynx with an alkaline antiseptic
solution, with a view to getting away the tenacious mucus. Possibly
the insufflation of alum in addition would be of benefit. The chronic
condition was possibly the result of nasal obstruction and^the septic
discharge from the nose.

Dr. Dun das Grant had described such cases as “ post-rhinitic
pseudo-pachydermia.” He remembered a case of old standing’in^which
rapid improvement was obtained by repeatedly washing out the nose
and applying a solution of salicylic acid to the laryngeal swelling.

Mr. Tod, in reply, said he would follow Dr. Tilley’s advice, and
remove the interarytenoid mass.

A Lantern Demonstration showing the Normal Fluctuations
of Air-pressure in the Upper Respiratory Tract, by Dr.
Scanes Spicer.

This demonstration was given to bring to the knowledge of
those members of the Laryngological Society present some of
the results of his recent investigations on the normal fluctuations
of air-pressure in the upper respiratory tract, and the effect on
these fluctuations of experimentally induced alteration in calibre
of the nasal channels in himself. He also showed charts
with observations automatically recorded on persons who
did not know what was expected of them, and he invited the

31

members present to repeat these experiments on themselves
there and then, and test the accuracy of his conclusions. He
suggested that a naturally wide rima, with the consequent
diminution of normal pressure fluctuations and lessened rhyth¬
mical stimulus to circulation in the blood-vessels, leading to
diminished nutrition of the walls, was the long-sought explana¬
tion of the origin of so-called atrophic rhinitis. His researches
would shortly be published in detail.

The President thought that the Society was much indebted to Dr.
Spicer for describing to them these experiments, which had extended
over so long a period. In order to criticise them one would need to lie
a physiological physicist as well as a rliinologist. He would like to ask
Dr. Spicer whether he had found the apparatus of any practical value
in the diagnosis, prognosis, and treatment of cases. He understood
Dr. Spicer to say that he was aide to determine by the results of these
experiments whether the patency of the nasal cavities was normal. He
would like to know how this was done. Dr. Spicer’s remarks as to the
causation of atrophic rhinitis were extremely ingenious and suggestive,
and lent themselves to discussion.

Dr. Dundas Grant said he thought there would be no great
difficulty in accepting Dr. Spicer's views, in so far as they related to
physical facts, even if some members might dispute his interpretations
of them. He thought the occurrence of negative pressure—if they
understood what each of them meant by the use of that term in
physical science—was beyond dispute. He himself was quite prepared
to accept these experiments exactly as Dr. Spicer had given them ; his
little knowledge of physical science would have led him to anticipate
such results. He suggested that they should be performed quietly
before the Society, either at a special meeting or before a specially
appointed sub-committee of the Society with power to add to its
numbers, and that, in order to make them still more convincing, they
should be carried out upon individuals who did not know what results
were expected or—might he go the length of saying—desired to be
obtained.

He had himself, with a roughly made manometer, tried a similar
experiment to those of Dr. Spicer. By watching the rise and fall of a
coloured liquid he had, in this rough way, obtained results which
confirmed those of Dr. Spicer. There was also during the moment of
swallowing a distinct dip in the manometer tube, much more marked
if the nose was obstructed at the same time. He had also made a
model in which were placed manometer tubes corresponding to the two
Eustachian tubes, and he found that, in the one on the side of the
nostril which he had blocked, there was, during inspiration, a more
distinct dip than in the other. He allowed, however, that it was
dangerous to apply to biology results derived simply from physical
materials. It had always seemed a little difficult to explain why
expiration did not exactly neutralise what was effected by inspiration;

32

this was made very clear by Dr. Spicer. In Donders’ experiment the
difference in the negative pressure during inspiration and in the
positive pressure during expiration was very marked, but he thought
Dr. Spicer had made it more clear to them when he showed them that
it was only when obstruction was present that the difference between
these two was so marked as Donders found it.

He hoped that these experiments would receive the careful attention
they undoubtedly deserved.

Dr. Lambert Lace thought Dr. Spicer’s experiments were quite
unreliable, and that his instruments would give any desired result.
That there was a negative pressure in the upper air-passages during
inspiration and a smaller positive pressure during expiration were
surely facts that needed no further proof. Of necessity also these
pressures were increased by any obstruction to the air stream. The
unreliability of the instrument or of the method of using it had been
demonstrated that afternoon by the fact that two observers found quite
different effects on the air-pressure resulting from the act of swallow¬
ing. Again, Dr. Spicer demonstrated that there was no variation at
all of the air-pressure in the nose when the nose was completely
obstructed and mouth breathing was resorted to, although a little
consideration would show that this result was absolutely at variance
with all the laws of physics. There must be a negative pressure
during inspiration, not only in the direct path of the air stream, but in
every column of air in direct connection with it. If this were not so
Dr. Spicer’s instrument would not record any variations at all.

Dr. HiLii thought the subject ought to be thoroughly discussed in
order that they might arrive at the general opinion of the Society as a
whole regarding it. Some members might discredit Dr. Spicer’s inter¬
pretation of the experiments, as Dr. Lack had done; others might
endorse his conclusions; and others, again, might think there was some
truth in Dr. Spicer’s position without exaggerating the clinical import¬
ance of negative pressure. They ought to endeavour to thresh the
subject out before the forthcoming discussion on nasal obstruction in
reference to some forms of middle ear disease.

Dr. Scanes Spicer, in reply to the President as to whether these
experiments would have any practical value, said he thought that in
doubtful cases the use of his naso-manometer, under the conditions he
had stated, would afford a test of the presence or not of obstruction,
and would so become a clinical stenosimeter. The apparatus afforded
absolute physical evidence of the normal fluctuations of air-pressure,
and also how these fluctuations were altered by obstruction. It was
not necessary even to insert the tubes in the nose, for readings taken in
the mouth—always, be it understood, with the precautions he had men¬
tioned—accurately indicated the pressure conditions in the nose, and
therefore whether the nasal passages were sufficiently patent, other con¬
ditions being similar. Fluctuations of the column in excess of the
normal indicated stenosis. Provisionally he would suggest + 7 mm.
and — 7 mm. of water as the limits of physiological fluctuations of
pressure for ordinary quiet breathing at rest, whereas the normal
appeared to be —5 and +4 respectively. Dr. Dundas Grant thought
that it was hardly necessary to have experiments and physical

33

measurements on these matters, for the clinical evidence of the ill
effects of nasal obstruction was so overwhelming. He quite agreed we
should be quite justified in all other practical work of life in acting on
much less conclusive evidence than we had in clinical proofs here, but
he thought that experiments and physical measurements were also
necessary to remove any shadow of doubt, and to place the subject on
a scientific basis. He had shown them a number of charts, the results
of investigation upon persons who had no idea of physics or physiology,
or what was expected of them, and the results in essentials were the
same as those in himself. With reference to Dr. Grant’s observations
on the effect of swallowing, and on the more marked fluctuations of
pressure if nasal obstruction were present, he had not observed these
phenomena; but had found that, in himself at all events, there was
no fluctuation of pressure in the naso-pharynx at the moment of
swallowing, but a positive fluctuation during the expiration which
followed. Dr. Lack would find that he could not manipulate the
results at will. If he would consent to be tested with the apparatus,
and allow the speaker to obstruct the former’s nose, he would soon find
the limits of voluntary and intentional manipulation.

A Series of Anatomical Preparations demonstrating the
Artificial Production of CEdema of the Larynx.

Shown by Dr. Logan Turner. Injections of carmine gelatine
were made into the loose submucous tissue in various situations
in fresh specimens of healthy larynges. In some cases moderate,
in others forcible injections under considerable pressure, were
made, and in this way both the amount of development and the
limitations of the loose areolar tissue were defined. The results
thus obtained closely simulated the conditions met with clinically.
The injection was allowed to cool and set, and the preparations
were then hardened in Jores’ fluid and preserved in glycerine.
In this way the spread of oedema from the tonsil and lateral
wall of the pharynx was demonstrated, also oedema of the
glosso-epiglottic fossa), ary-epiglottic folds and pyriform
sinuses, the false cords, true cords, and subglottic region.

Specimen of Abnormal Narrowing of Larynx and Trachea,

probably Congenital.

Shown by Dr. Logan Turner. This specimen was removed
poet mortem from a man aet. 70. He was markedly alcoholic,

34

but apparently suffered from no respiratory difficulty during
life.

The post-viortem examination, which was carried out by Dr.
Harvey Littlejohn, from whom the specimen was obtained,
showed the body to be well nourished; the thorax was markedly
and there was

cartilages. There was considerable emphysema of the lungs
and some old pleural adhesions. The pericardium was univer¬
sally adherent to the heart, the aorta was dilated, and there
was hypertrophy of the left ventricle.

There was no glandular or other enlargement in the neck or
mediastinum.

The specimen showed the epiglottis of the infantile type being
curved backwards, and there was considerable narrowing of the
upper laryngeal aperture. The trachea was flattened from side
to side throughout its entire length, the lumen of the tube being
considerably narrowed.

The two main bronchi presented a normal contour.

Mr. W. G. Spencer wished Dr. Turner to tell them about the thv-
roid, as the trachea was scabbard-shaped. He asked whether there
had been any hypertrophic change, followed by atrophy, which would
be likely to produce a result of this kind, the isthmus acting like a
strap between the two lobes.

Dr. Logan Turner, in reply to Mr. Spencer, said that at the time
of the post mortem examination there was nothing found in the neck
or the posterior mediastinum to account for the condition. There
were no enlarged thyroid or lymphatic glands.

Specimen op Malignant Stricture of the Upper End of the

(Esophagus.

Shown by Dr. Logan Turner. The patient was a woman aet.
58, with a history of pain and difficulty in swallowing for six
months before death. She refused any palliative operation, and
died after rapid emaciation. The case had additional interest
from the fact that it was one of three cases of malignant disease
of the oesophagus occurring in women and seen within a
comparatively short period of time.

The specimen showed a stricture measuring one inch verti¬
cally, and with a diameter of 2—3 mm., lying behind tha cricoid

drawing-in of the lower costal

barrel-shaped

cartilage and upper two rings of the trachea. There was a
chain of enlarged glands on the right side. The right recurrent
laryngeal nerve was involved in the tumour mass. The micro¬
scope showed the tumour to be a squamous-celled carcinoma.

Case of Advanced and Inoperable Epithelioma of Epiglottis
with Secondary Infection of Cervical Glands. Exhibited

TO ILLUSTRATE RELIEF OBTAINED BY REMOVAL BY “ MORCELLE-

ment ” of Primary Growth through the Mouth.

Shown by Dr. Herbert Tilley. The patient was a man set.
52. He sought relief for fits of suffocation at night, which had
become frequent and distressing. In addition he could only
swallow small quantities of liquid food, and even these often
caused violent fits of coughing, not uncommonly ending in
regurgitation of the food. His breath was very foul, and he
was losing weight rapidly. Examination revealed a fungating,
sloughy mass, the size of a small hen’s egg, occupying the lower
half of the pharynx.

The patient was seen in consultation with Mr. Symonds, who
agreed that a radical operation was inadvisable, and advised
removal of the primary growth through the mouth in order
to relieve symptoms.

This had been carried out in the course of several sittings
by means of Krause’s and Watson Williams’ cutting forceps.

The relief to symptoms had been extraordinary. The patient’s
breathing was perfectly easy, and he could eat any food without
the slightest difficulty.

His weight had increased since September (when the treat¬
ment was undertaken) by 1^ stones.

The President said that undoubtedly this man had greatly im¬
proved as regards swallowing by removal of a portion of the epiglottis.

Dr. Furniss Potter fully endorsed what Dr. Tilley had said as to
the desirability of “ doing something ” in inoperable cases of malignant
disease of the larynx where the epiglottis was involved and there was
distressing dysphagia. He had had a similar case under his care last
May, and he had removed about five sixths of the epiglottis with very
marked relief indeed; before this the patient had suffered greatly from
dysphagia, could only take liquids, and any attempt at swallowing
gave great pain. The operation was performed with the galvano-
cautery snare, and three or four days afterwards the man was able to

36

eat quite comfortably a meal of beef, potatoes, bread, etc. He would
like to ask Dr. Tilley why he preferred to punch out the epiglottis
(which necessitated a number of sittings) in preference to using a snare
and completing the removal by one operation. In the case he referred
to he had removed the epiglottis quite easily at one sitting.

In answer to Dr. Potter, Dr. Tilley stated that it was impossible
to remove the whole growth at once by a snare, because it was not
sufficiently pedunculated.

Case of Laryngeal Growth in a Man j£t. 50.

Shown by Dr. Wyatt Wingrave. This patient, a dock
labourer, aet. 50, was exhibited in April last, when there was
some hesitation in expressing definite opinions as to the nature
of the lesion. At that time he was somewhat hoarse, and had
suffered slight dyspnoea on exertion. There w r ere three
myxoedematous-looking swellings overhanging the right half of
the glottis, together with some slight oedema of the uvula.

During the interval his symptoms had greatly improved, but
the growths had distinctly increased in size. He had been
treated with Pot. Iodid., as he gave a dubious specific history.

He had no dyspnoea, no swallowing difficulty, and a good
.voice and no loss of flesh. The tendency to oedema had
prohibited the removal of portions for examination.

Case of Paralysis of the Abductors of the Vocal Cords in
a Youth (shown at Last Meeting).-

Shown by Dr. Dundas Grant. The patient’s palate was still
in a highly paretic condition, but somewhat less than before, and
in the larynx there could be now distinctly seen, during inspira¬
tion, a linear extension forwards and backwards of the elliptical
slit, which alone was present between the vocal cords on the last
inspection. This seemed to indicate a slight increase in the
action of the abductors.

The exhibitor thought it unlikely that this could be accounted
for by increasing paralysis of the internal tensors, although he
was convinced that only time would settle this question.

The patient was still under treatment by means of mercurial
inunctions and iodide of potassium internally.

37

It should have been added to the former report that sensation
on both sides of the body was practically normal, both for touch
and for temperature.

Dr. Grant would like to bring the case before the Society
again.

Mr. W. G. Spencer thought this case made an interesting com¬
parison with others of a similar character that had been shown to the
Society. The man’s heart-rate was very quick, being 120—130 ; he had
doubted whether it was in excess of its normal rate, for this patient did
not seem to be nervous under examination. He suggested that the lesion
in this instance was bilateral and in the fourth ventricle somewhere
underneath the inferior fovea on each side. He thought it was a local
lesion, and it might be syphilitic ; but it was also quite as possible that
it was an obscure lesion of progressive muscular atrophy. It corre¬
sponded to other cases of this disease shown to the Society. There was
no paralysis of the sterno-mastoid and trapezius belonging to the spinal
accessory' proper coming from the spinal cord, and there was, in
addition, no indication of any involvement of the hypoglossal with the
nerves which are usually involved about the base of the skull in
syphilitic inflammation round the foramina, nor was there any sign of
carious disease in the occipitals. He had not stripped the man, but
the patient had evidently a weakness of the left arm, caused by the
involvement of the serratus magnus, and so possibly this was a case of
progressive muscular atrophy.

Case of Comparative Hemianesthesia in a Young Female,
with Subjective Nasal Obstruction on the Affected Side.

Shown by Dr. Dundas Grant. The patient, a female, un¬
married, set. 30, was first seen a few days ago on account of pain
and noises in the right ear, attributable to chronic suppurative
otitis. She complained further of the air not passing through
her right nostril. On examination no obstruction sufficient to
occasion this symptom was present, but the mucous membrane was
found to be in a comparatively anaesthetic condition. There was
found to be diminished pharyngeal reflex, increase of knee-jerks,
comparative hemi-anaesthesia on the right side, and erroneous
localisation of spots touched, too low on the arm, too high on the
leg. Under these circumstances he looked upon the alleged
nasal obstruction as being purely subjective, explainable by the
patient (owing to the anaesthesia of the mucous membrane) not
feeling the passage of air through the nostril, consequently not

38

believing that it did pass. The foundation was probably
hysterical.

Dr. FitzGerald Powell said that frequently there was some
nervous trouble in these cases, and probably it existed in this woman.
This subjective obstruction might be due to a choreic or spasmodic
condition of the soft palate. Probably the opening was not sufficiently
large to allow the patient to breathe properly, the palate being drawn
up against the pharynx. When the patient exerted her will she could
breathe easily through the nose.

The President did not have an opportunity of seeing the nasal
cavity, but he would like to ask Dr. Grant on what grounds he based
the diagnosis of subjective nasal obstruction in this case.

Dr. Pegler said this was a case in which he should have hesitated
to apply the term subjective nasal obstruction, as on the right side
there was slight inspiratory insufficiency due to displacement of the
lower lateral cartilage and a narrow lumen.

Dr. Scanes Spicer thought that in this case the rima was ob¬
structed by the inferior turbinals.

Dr. Dttndas Grant said he had stated that there was really no
obstruction at all. The only obstruction was that which existed in the
patient’s own mind, and the term “ subjective obstruction ” was most
legitimately applied to such a case. Obstruction produced by con¬
traction of the palate was not “ subjective,” but “ objective; ” it might
be simply due to spasmodic action of the muscle, but then it became
objective obstruction, and the word “ subjective ” was not applicable.
He had first found out the subjective obstruction when asking the patient
if she could breathe freely through the nose; she answered that she
could not breathe with the right nostril, whereas in reality she was
doing so at the time.

Case op Increasing Dysphagia of Six Months’ Duration in a
Middle-aged Man (for Diagnosis) ; probably Pharyngeal
Epithelioma.

Shown by Dr. Dundas Grant. The patient, set. 35, was first
seen on November 20th, 1902, on account of difficulty in
swallowing, which had come on gradually during the last six
months. He stated that when endeavouring to swallow potato
or meat he could hardly get it down at all, and when lying
down in bed the saliva did not go down the throat. There was
no pain. He had a thickness of the voice like that of a person
with very large tonsils. On examination there was seen a
projection from the wall of the pharynx, which concealed the
posterior part of the ary-epiglottic folds with the cartilages of

89

Santorini. The growth was so far down that it was impossible
to reach it with the finger; it was seen to be bathed with a fluid
which was probably saliva. There was no tendency to con¬
sumption in the family. There was just a little doubt with
regard to the gland behind the left angle of the jaw, but practi¬
cally at the present time there were no enlarged glands. As
regards the question as to whether, by any possibility, it was a
tertiary specific affection, there was no history to bear that out,
but it was decided to try him with iodide of potassium, and since
taking it in 10-gr. doses thrice daily for a week, he expressed
himself conscious of some relief; there was, however, no change
in the objective appearance.

Dr. Donelan said there was some obstruction of the oesophagus,
the dysphagia was progressive, and there was now frequent regurgita¬
tion, even of fluids. He thought it a case of oesophageal stricture,
probably malignant. There was some enlargement low down on the
right side of the neck.

Dr. Dundas Grant said that in this case there was a projection on
the posterior wall of the pharynx just above the level of the posterior
margin of the larynx, which overhung the cartilages*of jSantorini. He
took it to be the upper margin of either an epitheliomatous or a
gummatous ulcer. It was situated in the lowest part of the pharynx,
not in the oesophagus.

PROCEEDINGS

OP THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Annual General Meeting, January 9th, 1903.

E. Cresswell Baber, M.B., President, in the Chair.

Present;—the Honorary Officers and 15 members.

The minutes of the last Annual General Meeting 1 were read
and confirmed.

Mr. H. B. Robinson and Mr. Dennis Vinrace were ap¬
pointed scrutineers of the ballot, and the following officers
were appointed for the year :

President. —P. McBride, M.D., F.R.C.P.Ed.

Vice-Presidents. —A. A. Bowlby, E.R.C.S.; J. Dundas Grant, M.A.,
M.D., F.R.C.S.; Percy Kidd, M.D., F.R.C.P.; Charters J. Symonds,
M.S., F.R.C.S.

Treasurer. —W. R. H. Stewart, F.R.C.S.Ed.

Librarian. —StClair Thomson, M.D.

Secretaries. —James Donelan, M.B.; E. Fumiss Potter, M.D.,
M.R.C.P.

Council. —Felix Semon, M.D.; E. Cresswell Baber, M.B.; C. A.
Parker, F.R.C.S.Ed.; W. Permewan, M.D., F.R.C.S.; Rd. Lake,
F.R.C.S.; L. A. Lawrence, F.R.C.S.

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

Report of Council.

The Council has the pleasure to report that the Society continues in
a most prosperous condition. During the year six new members have
been elected and seven members have retired, whilst the Council has
to announce, with great regret, the death of one honorary member,
Professor Gerhardt, and two ordinary members, Dr. F. A. N. Bate¬
man and Dr. Caldwell Stephen.

There has been an average attendance of thirty-two members, which
FIRST SERIES-VOL. X. 3 *

42

is exceptionally large, and there has been a very abundant supply of
clinical material.

The Ordinary Meeting on June 6th was devoted to a discussion on
“ The Diagnosis and Treatment of Malignant Stricture of the
(Esophagus,” introduced by Mr. Charters J. Symonds. There was a
good attendance and full discussion.

The Council has made arrangements for a fuller report of the
Society’s proceedings in the ‘ Lancet ’ and 4 Medical Press and Circular.’
They have also come to a most satisfactory arrangement with the
Royal Medical and Chirurgical Society with respect to the Society's
Library, a matter j which will be fully dealt with in the Librarian’s
report,.

The financial position of the Society continues satisfactory, as will
be seen from the Treasurer’s report.

The following report of the Treasurer Avas read and adopted:

Our receipts this year have been <=£161 17*. 6d. This, with
=£19 18*. Id., the balance brought forward from 1901, gives a total of
<£181 15*. Id. Our expenses have been £148 9*. 8 d. We thus have a
balance of £33|5*. lid.

The sum of £151 3*. has been received in subscriptions. Of this
amount, however, no less than £23 2s. has been paid for arrears, one
member not] having paid since 1898. All these back accounts have
now been collected, and only twelve members, all country ones, remain
who have not paid-for 1902.

The Balance-sheet, duly audited and found correct by the auditors,
Mr. H. B. Robinson and Dr. F. Willcocks, is appended.

BALANCE-SHEET. 1902.

Income. i

£ s. d. j

Subscriptions:

1902 . . £127 0 0 i

1901 . . 16 10 0

1900 ..440

1899 ..1 1 0 i

1898 ..110 1

1903 . . 1 1 0

- 151 3 01

Entrance Fees. 5 5 0 j

Sale of ‘ Proceedings ’ . . 19 3
Discount (Arthur’s) ... 072

Interest on Deposit . . . 3 13 1
Balance from 1901 ... 19 18 1

£181 15 7

Expenditure.

£ d.

Rent.31 10 0

Adlard—Printing ... . 77 18 2

Arthur—Tongue-cloths . . 118

Smith—Reporting.... 21 9 3

Baker—Microscope ... 1 15 0

Pulman—Binding .... 199
Clarke—Indexing .... 1 13 0

Annual Dinner.6 6 0

Bank charges.0 0 8

Receipt Book.0 7 6

Christmas-boxes (Porters) . 0 15 0

Mathew (Porter) .... 200

Secretaries’ Petty Cash . . 1 10 5

Treasurer.0 13 3

Balance. 33 5 11

£181 15 7

Deposit at Bank, £200.

Examined and found correct,

HY. BETHAM ROBINSON, \
FREDERICK WILLCOCKS,]

Auditors .

W. R, II. STEWART, Hon Treasurer

i

/

43

The Librarian’s report was then read and adopted :

Owing to the regrettable failure of health on the part, of our
librarian, Dr. StClair Thomson, I have, at his request, undertaken to
continue the duties of his office in the meantime.

I have to report to you that he has effected certain arrange¬
ments with the Royal Medical and Chirurgical Society, which our
Council have approved of and consider of great advantage to
our members. The terms of the arrangement are, that in return
for our according to the members of the Royal Medical and
Chirurgical Society the use of our library for consulting and borrow¬
ing purposes, our books, marked with distinguishing labels, are con¬
veniently placed on the shelves of the Royal Medical and Chirurgical
Society’s library. Their librarians will undertake the duty of giving
out and recalling our volumes, which can be borrowed whenever the
library is open. We have, however, had to meet the expense of
arranging and marking tin* books, and the Council has further
sanctioned the initial expense of a typed card catalogue. I have no
doubt you will authorise me to convey to Dr. StClair Thomson the
expression of your thanks for the excellence of the arrangements, for
which you are indebted to him. I am pleased to be able to state that
his health is improving, and I am sure I may be allowed to add to my
communication the expression of the hope on the part of all members
of the Society that he may speedily recover and again be among them.

I have only to add that the “ Exchange ” periodicals have come with
regularity, and that the work of binding the completed volumes is in
progress.

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

The Curator of the Morbid Growths Collection of the Society has
pleasure in presenting to the Annual Meeting a copy of the catalogue
of the microscopical preparations now in the possession of the Society,
and wishes to thank those members who have kindly assisted his
efforts to render the cabinet as representative as possible with reference
to the Society’s pathological work since the date of its formation. The
preparations cover a considerable field in the realm of laryngology and
rhinology, but many valuable slides of great importance are absent
from the collection, which it is to be hoped are yet available for its
enrichment. The catalogue is divided into two portions, the first and
most important of which consists of microscopic sections referred to
in the ‘ Proceedings,’ and many of which have been reported upon by
the Morbid Growths Committee. The second part consists of slides
bearing upon the normal and pathological histology of those regions of
the head and neck with which this specialty is concerned, and which
are therefore valuable for purposes of reference and comparison. A
list of the normal tissue preparations, together with one or two others,
was published by Dr. Dundas Grant in the January number for 1900,
vol. vii, of the ‘ Proceedings.’ These, for the most part, were con¬
tributed by the Curator in order to start the cabinet, and many others
have now been added. As at present constituted the cabinet contains

44

sufficient material to render a study of it worth the while of every
member who is interested in the fundamental science of the specialty,
and the Curator hopes the members will avail themselves of the oppor¬
tunities that obtain for so doing. Aided by efficient microscopes, a
complete set of the bound volumes of the ‘ Proceedings,’ and an amply
indexed catalogue containing full reference to the ‘ Proceedings ’ and
‘ Reports ’ of the Morbid Growths Committee in every instance, he
trusts the members will find an inducement for visiting the collection,
either at the Society’s rooms or at his own residence, as they may
desire.

Reference Catalogue of Pathological Sections in the Cabinet of the
Laryngological Society of London, chronologically arranged,
January, 1903.

I. Nose.

1. Papilloma of Septum, P. de Santi, November 18th, 1894, vol. ii, p. 13.

2. Regeneration of Inferior Turbinal, W. Hill, October, 1895, vol. iii, pp. 15, 42.

3. (M.G.C., No. 4.) Tuberculous Degeneration of Inferior Turbinal, W. Hill,

March, 1896, vol. iii, p. 70.

4. Lupus of Inferior Turbinal, W. F. Bennett, January, 1897, vol. iv, p. 82.

5. Recurring Degeneration of Inferior Turbinal, H. Pegler, April, 1897, vol. iv,

p. 75.

6. Lymphoid Hyperplasi® of Septum, H. Pegler, December, 1897, vol. v, p. 16.

7. (M.G.C., No. 11.) (2) Recurrent Fibro-angioma of Septum, Scanes Spicer,

December, 1897, vol. v, p. 19.

8. Papilloma of Septum, McL. Yearsley, April, 1898, vol. v, p. 78.

9. Hypertrophy of Septal Tubercle, A. Cheatle, November, 1898, vol. vi, p. 6.

10. Rhinoscleroma, D. Grant, April, 1900, vol. vii, p. 85.

11. Alveolar Epithelioma of Nose and Antrum, D. Grant, November, 1900, vol.

viii, p. 7.

12. Squamous Papilloma of Vestibular Septum, W. Wingrave, April, 1901, vol.

viii, p. 2.

13. (M.G.C., No. 28.) (2) Alveolar Epithelioma of Nose, D. Grant, April, 1902,

vol. ix, p. 108.

14. (M.G.C., No. 29.) Cystic Growth of Septum (? Meningocele), II. Pegh r,

April, 1902, vol. ix, p. 103.

II. Nasopharynx.

1. Naso-pharyngeal Cyst, A. Cheatle, November, 1898, vol. vi, p. 6.

2. Naso-pharyngeal Sarcoma, H. Pegler, January, 1900, vol. vii, p. 54.

3. (M.G.C., No. 30.) Columnar-celled Carcinoma, B. Baron, January, 1903,

vol. x, p. 54.

III. Mouth and Tongue.

1. Fibroma of Tongue, Morley Agar, November, 1897, vol. v, p. 4.

2. (2) Epithelioma of Tongue, November, 1902, vol. x, p. 16.

IV. Pharynx.

1. Growth from Supra-tonsillar Fossa, A. Cheatle, April, 1898, vol. vi, p. 78.

2. Papilloma of Left Faucial Pillar, H. Sharman, May, 1898, vol. v, p. 86.

3. Papilloma of Left Tonsil, H. Sharman, May, 1898, vol. v, p. 86.

4. Epithelioma of Tonsil, L. Lack, April, 1901, vol. viii, p. 55.

5. Round-celled Sarcoma of Tonsil, McK. Johnston, June, 1901, vol. viii, p. 142.

6. (M.G.C., No. 27.) Lipoma of Pharynx, W. Milligan, January, 1902, vol. ix,

p. 41.

7. Fibro-angioma of Tonsil, W. Wingrave.

8. (M.G.C., No. 31.) Inflammatory Growth from Tonsil, L. Lack, January,

1903, vol. x, p. 51.

45

V. Larynx .

1. Angioma of Larynx, P. Kidd, January, 1894, vol. i, p. 63.

2. (M.G.C., No. 6.) Spheroidal-celled Carcinoma of Larynx, W. G. Spencer,

November, 1896, vol. iv, p. 10.

3. (M.G.C., No. 5.) Carcinoma of Cricoid and Larynx, W. G. Spencer, November,

1896, and June, 1897; four slides, larynx, neck, lung and liver.

4. (M.G.C., No. 13.) Recurrent Growth of Larynx (? Epithelioma), J. W. Rond,

June, 1897, vol. iv, p. 104.

5. Malignant Growth of Right Vocal Cord, F. Potter, November, 1897, vol. v,

p. 35.

6. (M.G.C., No. 15.) Carcinoma of Epiglottis, W. G. Spencer, February, 1898,

vol. v, p. 49.

7. (2) Malignant Growth of Left Vocal Cord, C. A. Parker, January, 1899, vol.

vi, p. 43.

8. (M.G.C., No. 19.) Fibro-angioma of Left Vocal Coxd, F. Potter, November,

1899, vol. vi, p. 1.

9. Syphilitic Stenotic Mass from Larynx, W. G. Spencer, February, 1900, vol. vii,

p. 62.

10. (M.G.C., No. 21.) (2) Round-celled Sarcoma of Larynx, F. Potter, November,

1899, vol. vi, p. 1.

11. (M.G.C., No. 20.) Glandular Sarcoma of Larynx, R. Lake, March, 1900, vol.

vii, p. 71.

12. Squamous Papilloma of Larynx, W. Wingrave, November, 1900, vol. viii, p. 11.

13. (M.G.C., Nos. 22, 23, 24.) Benign Papilloma of Larynx, M. Hovell, May,

3901, vol. viii, p. 120.

14. Subglottic Polypus, W. G. Spencer.

VI. Thyroid Gland.

1. Fibrosis of Thyroid Gland, W. G. Spencer, October, 1894, vol. ii, p. 24.

2. Parathyroid Tumour, P. de Santi, June, 1899, vol. vi, p. 104.

3. Sarcoma of Thyroid Gland, D. Grant, November, 1900, vol. viii, p. 9.

It was proposed by Dr. Vinraee, and seconded by Dr. Donelan,
“ That this meeting give the Council permission to approach the Council
of the Otological Society with a view of the two bodies jointly nomi¬
nating a Committee'which shall practically investigate the question of
the results of intra-nasal operations in chronic non-suppurative middle
ear disease.” This was carried nem. con.

The meeting then adjourned.

Seventy-eighth Ordinary Meeting, January Vth , 1903.
K . Cresswell Baber, M.B., President, in the Chair.

Charles A. Parker, F.K.C.S.(Ed.),\
James Donelan, M.B., J

Secretaries.

Present—32 members and 2 visitors.

The minutes of the preceding meeting were read and con¬
firmed.

46

The following gentlemen were nominated as Honorary
Members of the Society :

Professor G. Killian, Freiburg-im-Breisgau.

Professor Lermoyez, Paris.

Dr. P. Schech, Munich.

Dr. E. Schmiegelow, Copenhagen.

As Ordinary Member:

Arthur Stanley Cobbledick, M.D., B.S.Lond., 402, Brixton Road, S. W.
The following cases, specimens, and instruments were shown:

Sequel to a Case of Ulceration of the Left Tonsil, with
Acute and Considerable Enlargement of Numerous
Cervical Lymphatic Glands on Both Sides of the Neck.
? Malignancy.

Shown at the Meeting on November 7th, 1902, by Sir Felix
Semon. The case was shown again as affording a valuable lesson
to the effect that not every ulceration of a tonsil in old people,
accompanied by enlargement of numerous cervical glands, must
be looked upon as necessarily malignant. It would be seen that
the ulceration of the left tonsil had quite disappeared, and the
tonsil itself had become much smaller, whilst the enlargement of
the cervical lymphatic glands on both sides of the neck had also
considerably diminished, even more so on the side corresponding
to the affected tonsil than on the opposite one. In all proba¬
bility septic influences had been at work. Malignancy, at any
rate, was now completely excluded.

The President congratulated Sir Felix Semon on the successful
result of this case.

A New Design for Sphenoidal Sinus Cutting Forceps.

Shown by Dr. Watson Williams.

Dr. Dundas Grant expressed his admiration for the instrument,
which he calculated would be extremely useful. It was for use in a
dangerous region, and accordingly extra care had to be exercised. He

47

had sometimes l>een aide to expose the region without removing normal
structures by means of long-bladed nasal specula. There was an
illustration of one of these in Mr. Baber's lx>ok: the pattern he himself
used was devised by Killian, with which, after one had forcibly pressed
the middle turbinal to one side, a view of the anterior surface of the
sphenoid, large enough for inspection and for the introduction of suit¬
able punch-forceps, was obtained. He had brought with him some
sphenoidal sinus cutting forceps, which he would show to the Society
and describe later on in the evening if time permitted. ,

Dr. Bronner thought quite as good results were to be obtained
with cutting forceps, and without the danger necessarily attached to
pointed instruments.

Dr. Lack considered these forceps very dangerous ; it was not safe
to open a sphenoidal sinus without a good view of the natural opening.
If the opening were first brought into view it could l>e enlarged quite
easily and safely, but any attempt to perforate the anterior wall of the
sinus without previously ascertaining its extent or even its existence
must be dangerous under any circumstances.

The President said that he was inclined to agree with Dr. Lack,
l>ecause if one could not see the natural opening it seemed dangerous
to push a sharply pointed instrument into the sphenoidal sinus. As
regards Killian’s specula, which Dr. Grant had mentioned, it occurred
to him that tliev were somewhat like Markusovsky’s speculum.

Mr. W. G. Spencer, continuing the line of argument brought
forward by Dr. Lack, suggested that it was much safer to operate
externally, as for the frontal sinus ; a curved incision should l>e made
round the inner angle of the orbit to just a little outside the nasal
duct. Then the soft structures should lie turned downwards and
outwards, when the thin orbital plate of the ethmoid would lx* exposed,
and so render it possible to do what the previous speaker had men¬
tioned, viz. see wliat was being done. This, in his opinion, was a far
safer method than that of opening the sphenoidal sinus as proposed by
Dr. Williams.

Dr. McBride asked Dr. Williams how often he had used these
forceps and with what result;—that was the important point.

Dr. Powell asked Dr. Williams what was the result from his
ex]x*rience of operations on the sphenoidal sinuses, and whether he had
had many cures resulting from operative interference in this locality.
Personally, he had a numlxr of cases coming into his hands which had
l>een operated on by other surgeons, where the sphenoidal sinuses had
l»een opened, and he could only say that their last state was con¬
siderably worse than their first.

Dr. Watson Williams, in reply, admitted that the instrument was
dangerous inasmuch as any operation on the sphenoidal sinuses was
dangerous. But it must be rememliered that sphenoidal sinus disease
was very dangerous also. Everything depended on the care with which
the forceps were used, and he presupposed that the remarks which had
l>een made started on those premises. He himself never used any
force in entering a sphenoidal sinus, and he did not consider these
forceps were dangerous if used with proper care. If an cqxming had
to be made into a sphenoidal sinus, it was easier and safer to make it

48

lower down than in the position of the natural orifice, and unless it
could readily be seen he never troubled about the natural opening. He
had only just recently designed this instrument, and had used it once
with entire satisfaction. It was an improvement on those he had been
in the habit of using in the few cases he had had under his care. If
the sphenoidal sinus did not exist in any case it was because that one
had a solid sphenoidal body. Therefore the non-existence of the
sphenoidal sinuses robbed such an instrument as this of any real
danger, providing care and gentleness were used. These forceps
slipped in with the greatest ease through the thin turbinated bone
which forms the anterior wall of the sphenoidal sinuses; and it was
through this very thin portion that he always entered the sinuses.

Drawing with Notes of a Case of Suppurative Ethmoiditis
and Frontal Sinusitis after Radical Operation for
Nasal Polypi.

Shown by Dr. Adolph Bronner. In the section of laryngo¬
logy at the Manchester meeting of the B.M.A., Dr. Bronner had
stated that, in his opinion, the so-called radical operation for
nasal polypi was not devoid of danger, and that he knew of
several cases which had been followed by meningitis and death.
He was not at liberty to give details of these cases, as he had
heard of them privately, and had no permission to publish them.
He was very sorry to have now to report a case of his own.

Miss K—, aet. 20, was seen on July 24th, 1900. Both nostrils
had been blocked for several years, and there had been a
copious, purulent discharge. No pain or special discomfort.
Both nostrils were completely filled with polypi and degenerated
mucous membrane of the lower turbinated bones.

On September 18th, 1900, both nostrils were scraped with
Meyer’s ring, and the mucous membrane of the lower turbinated
bones removed. Insufflations of iodoformogene and boric acid
were ordered. The patient was seen again in June, 1901.
There had been extensive recurrence of the polypi from the
upper turbinated bone. It was again scraped.

On August 14th the patient was seen again. Numerous
polypi were removed by the cold snare. There was, however,
rapid recurrence. On October 28th, 1902, Meyer’s ring was
again used under chloroform. Insufflations of aristol and boric
acid were ordered. The patient was seen on November 7tli and

20tli. There was no pain, but very slight tenderness over the
right frontal sinus. There had been no recurrence of the
polypi, but there was very slight purulent discharge from the
region of the frontal and anterior ethmoidal cells. On Decem¬
ber 2nd the patient was brought into the hospital. For nine
days she had intense pain in the nose and head, and there was
swelling of the nose and forehead. She was semi-comatose;
there was well-marked swelling of the centre of the forehead
and bridge of nose, extending into cheek, and slight paresis of
the right side. Temperature 104°.

On December 3rd an incision was made above the right eye¬
brow' ; much pus escaped, the bone was rough. The right
frontal sinus w r as found to be full of pus. The dura was
exposed and bulging; on incision there w r as no pus. The left
frontal sinus was opened; there w ? as very little pus. The dura
was exposed and opened, and a large quantity of pus escaped.
The opening w r as enlarged and free drainage established. The
patient was relieved for twelve hours, and then became more
and more comatose and died.

On post-mortem examination the anterior part of left frontal
lobe was seen to be necrosed, and evidences of purulent menin¬
gitis were seen commencing on the left side, extending back¬
wards on the base of the brain (well marked over the pons) as
far as the medulla. The lateral ventricles were full of sero-pus.
The whole of the ethmoid bone was necrosed and filled with
pus, and the crista galli was quite loose and detached.

In this case the infection evidently originated in the ethmoid
bone.

Sir Felix Semon congratulated Dr. Bronner on his courage in
bringing forward such a case, by which frank act one learnt more than
from any amount of mere hearsay reports.

Dr. Lack hoped that every one who had such cases would bring them
forward with details, so that they might all learn something from them.
He would not criticise this case until he had seen a full report of it.

Dr. Bronner said that the fact that there had been recurrence
proved that he had not used excessive force; recurrence would not have
taken place if he had removed the greater part of the cells. The
more one scraped away the greater was the danger of cerebral com¬
plications.

50

Case of Functional Aphonia in a Man with Unusual

Symptoms.

Shown by Dr. Lambert Lack. The patient, a male set. 58, had
lost his voice suddenly six months ago, and had never regained
it. He spoke now in a whisper, but with much strain. The
expiratory muscles were all tense, and the pulse became more
rapid during speech. On examining the larynx the parts
appeared to be normal, and the movements were normal until
attempted phonation, when the larynx appeared to be tightly
closed and to prevent all air escaping.

It was probably a case of spasm of the larynx, but the patient
was not able to say even one word in a loud voice, thereby
differing from most similar cases, in which one or more words
can be loudly uttered at the beginning of each sentence. On
the other hand, the patient could sing loudly and naturally.
Another point of interest was that he had a similar attack the
previous year, losing and regaining his voice quite suddenly.
He had not used his voice excessively, although he had shouted
at times. He had recently lost a sister with tubercular laryn¬
gitis. It was possible that suggestion had something to do with
his present condition.

Dr. McBride thought this case one of great interest. It was a
case of spastic aphonia. The abdominal muscles were tense when the
patient attempted to speak. The interesting point about the case was
that the false cords covered the true cords when phonation was
attempted. He had observed in certain voice users, who complained
of early fatigue of the voice, a similar condition, but to a less marked
extent. He wondered if other members had observed it also ? The
parts during rest were normal, but on attempted phonation there was
apparently hypertrophy of one or other, or of both false cords. Whether
this was to be looked upon as a “ missing ” or early stage of spastic
aphonia or dysphonia was a point which had interested him for
some years.

Sections of Ulcer of Tonsil Showing Tubercles, but which

HAD YIELDED TO ANTISYPHILITIC REMEDIES.

Shown by Dr. Lambert Lack. The patient, a female aet. 25,
had had a large ulcer with clean cut edges and sloughly irregular

51

base covering the right tonsil and posterior pillar of the fauces.
There was much dysphagia, and the patient was anaemic and
rapidly wasting. The glands were tender and enlarged. A
diagnosis of tertiary syphilis was made, and the patient placed
on large doses of potassium iodide. She had, however, seen
other specialists who had considered the case to be possibly
malignant or tubercular. By special request, therefore, a small
piece of the ulcer was excised for microscopical examination.
The sections showed that the mass of the ulcer consisted of
granulation tissue with newly-formed capillary loops, but at the
deeper part of the ulcer were tubercle-like nodules consisting of
giant-cells, surrounded by epithelioid and round cells. This
seemed to confirm the cautious diagnosis which had been
previously given in the case. In spite of it, however, the ulcer,
which at first was as large as a two-shilling piece, had diminished
to half its size in a week, and was completely healed in a fort¬
night under the iodide treatment alone. The patient three
months later remained perfectly well. Was the case to be
regarded as one of syphilis or of mixed infection ? There was
no history of syphilis to be obtained.

The specimen was referred to the Morbid Growths Committee.

Microscopic Section of Cyst of Ventricle of Larynx opened
when Operating on a Case of Malignant Disease.

Shown by Dr. Lambert Lack. The patient, a male, had
malignant disease of the right vocal cord, etc., for which an
operation was performed. Previous to operation a smooth, fixed,
hard swelling was noticed overlying and apparently attached to
the cornu of the hyoid bone. There were no enlarged glands.
On cutting across the ventricular band during the thyrotomy
there was a sudden gush of creamy fluid, nearly two drachms
escaping. The swelling over the hyoid bone disappeared. At
first it seemed as if an abscess had been opened, but after
consideration and exploration it was considered more likely
that the cavity was a cyst-like projection from the ventricle,
such as was normally present in certain apes, e.g. the orang-
outang, and was rarely met with in man. This diagnosis was

52

confirmed by sections of part of the wall which was excised,
and which showed that the cavity was lined by ciliated
epithelium.

Pathological Specimens.

Shown by Mr. Lake. 1. Section of new growth removed
from the posterior extremity of the inferior turbinate body
(right) of a man aet. 50. The history was one of nasal obstruc¬
tion of some years’ standing, increasing considerably just before
the operation. The patient has not been heard of since.

2. From a male shown by Dr. Pegler and Mr. Lake in 1900.
This was from a recurrence; both left inferior turbinate and
septum were involved.

3. Section of right inferior turbinate from patient set. 72, who
had been under Mr. Lake ten years ago for lupus n^si of thirty-
five years’ duration. This had been cured after it had pene¬
trated the right tear duct. Two and a half years ago some
swelling appeared at the site of the old infection of the tear
duct, with nasal haemorrhage. There was a small ulcer visible
on the upper surface of the inferior turbinate. Finsen’s rays
were employed for a year, when Mr. Lake saw him again. The
ulcer was larger, and there was apparently an invasion of the
tissues about the nasal bones by what looked like new growth.
The inferior turbinate (right) was removed, and pronounced to
be carcinomatous by a pathologist. The disease was considered
to be too extensive for operation by Mr. Arbuthnot Lane, but
X rays had kept the patient comfortable, and appeared to be
able to control the spread of the growth, though not to
absolutely “ cure ” it.

Dr. Pegler had pleasure in recommending that these sections,
and Dr. Barclay Baron’s (see page 54), which required careful study,
should be referred to the Morbid Growths Committee. Dr. Pegler
said he had only been able to give the sections under the microscope
a very cursory observation, and had not had an opportunity of
examining the patient. He had formed an impression that naso¬
pharyngeal sarcomata were in certain cases very loosely attached to the
surface from which they sprang, and might in early stages be easily
mistaken, as they gave little evidence of malignancy. Some three or

more years ago, a young man of twenty-five came lo his out-patient
department complaining of nasal obstruction, in whom the usual digital
examination detached several loose fragments of tissue feeling like
adenoid growths, which were expelled through the nostrils. A short
time since, this patient returned to the hospital, and on admission
his naso-pharynx and nasal chambers were found to be completely
obstructed by the disease. He was shown to the Society (‘ Proceed¬
ings,’ vol. vii, Jan. 7, 1890). The masses were removed as thoroughly
as possible under chloroform by forceps, and Mr. Lake, who assisted
in the operation, w r as to-day exhibiting sections of the growth.
Previous specimens showed all the characters of mixed-celled sarcoma ;
fortunately examples of those sections were in the cabinet. The
patient had been lost sight of since his discharge.

The specimens were referred to the Morbid(irowtlis Committee.

Case of Large Swelling of the Mucous Membrane in the Inter-
arytenoid Region (so-called Interakytenoid “Pachy¬
dermia.”)

Shown by Dr. Herbert Tilley. The patient, a male iet. 48,
had not been addicted to alchohol or excessive tobacco smoking.
He complained of hoarseness of two months’ duration.

The patient was a particularly robust-looking man. In the
interarytenoid region was a sessile, red, congested swelling,
about the size of a large horse bean, which prevented complete
adduction of the vocal cords.

Dr. FitzGerald Powell said he noticed that Dr. Tilley had a note
at the end of the title of this case to the effect that this was a case of
“ so-called interarytenoid pachydermia.” He presumed from that
that Dr. Tilley did not believe in the existence of interarvtenoid
pachydermia. He himself had always understood that the heaping up
of the epithelium and hyperplasia of the connective tissue on the cords
and in the interarytenoid space w’ould be looked upon as pachydermia.
Evidently it was not pachydermia in this case, or it would not have
disappeared so quickly, but probably just a general swelling of mucous
membrane simulating pachydermia.

Sir Felix Semon thought that the observation made by Dr. Powell
was perfectly justified. This was not a case of pachydermia. In
order to speak of pachydermia, metaplasia was necessary, i. e. a change
of the epithelium into an epidermal structure. The present case was
simply an instance of hvjierplasia.

Dr. Herbert Tilley, in reply, said that his reason for putting at
the end of the description of his case the words “ so-called inter-

54

arytenoid pachydermia ” was in order to enter a slight protest against
the loose way in which the word “ pachydermia ” was so often applied
to any form of hypertrophy of the mucosa in the interarytenoid, space.
He did not consider this a case of pachydermia, but a localised form of
chronic laryngitis. He thought one ought to confine the term “pachy¬
dermia ” to those cases in which there was an overgrowth of the
epithelium and subepithelial connective tissues, such as were most
often met with on the vocal cords, where a prominence on the one cord
seemed on adduction to apply itself to a corresponding depression on
the other cord. In this particular patient there was a very swollen,
congested condition of the interarytenoid mucous membrane, and he
proposed removing it with Watson Williams’ intra-laryngeal “ punch
forceps.”

Specimen of Large Naso-piiaryngeal Fibro-myxoma with
Prolongations extending to Anterior Nares.

Shown by Dr. Donelan. The patient, a youth aet. 18, had
suffered from marked nasal obstruction and defective speech
since his second year. When seen he appeared to have a large
mucous polypus in each nostril, and a growth about the size of
a walnut projected slightly below the soft palate, in pulling or
pushing which the polypi were moved. The large growth was
sessile, springing from the vault of the pharynx immediately
behind the vomer. It was seized with forceps and came away
together with the anterior prolongations, leaving the patient’s
nasal passages perfectly free.

Case of Naso-pharyngeal Malignant Disease.

Shown by Dr. Barclay Baron. The patient, a woman aet. 50
years, had complained of deafness, obstructed nostrils, and
discharge of blood and pus, for about eight months. Three
months ago a hard, irregular growth had been scraped out of
the naso-pharynx, with relief of all the symptoms. Now they
had all returned, and there was much pain in the jaw and temple,
especially on the right side, which was swollen. The naso¬
pharynx was filled with growth, which protruded into the
nostrils, especially the right one. It was hard and ulcerated.
The nature of the growth was uncertain, lympho-sarcoinatous

looking in parts, but with islands of ephithelial colls in others.
Dr. Baron asked for suggestions as to treatment ; he was not
inclined to curette again, but preferred either to leave it alone
or deal with it more radically.

The President said the disease seemed to affect not only the naso¬
pharynx, but also the nasal cavity on that side. Therefore, if any
operation of a radical character were performed, it would either have
to l>e through the palate, or an external operation.

Dr. McBride said this case seemed to him to be one of very great
interest. There was, to start with, the growth in the naso-pharynx and
also one in the right nostril. He had no doubt that the pathological
report was absolutely correct. The one point which struck him forcibly
was that in a malignant case one would have expected more marked
ulceration and sloughing than had taken place in this case after the
removal of the growth. Then another point arising in connection with
that just mentioned was that this was probably a lymplio-sarcoma; it
would lie worth while to trv large doses of arsenic. He had seen
several cases of lymplio-sarcoma disappear wonderfully quickly under
the influence of arsenic. He called to mind one case with a very large
tonsil, which was reduced almost to its normal size by this means. The
patient died of malignant abdominal disease within a relatively few
months afterwards in the north. She went to a home, but he was
unable to hear the details of the last illness, and there was no post¬
mortem. In connection with malignant disease, he might refer to a
case of extreme interest which he had to deal with some time ago.
The patient, a gentleman, came to him with a very large ulcer in front
of the epiglottis at the back of the tongue, while there was a large, fixed,
glandular mass in the neck. It looked specific, and he gave him iodide
of potassium and mercurial inunctions, but they had no effect at all.
He then tried him with large doses of arsenic, but this also was of no
use. He might say he wished to punch a piece out for microscopical
examination, but the patient refused to allow him. He went on with
the iodide and arsenic for a long time, but without much benefit.
Later the patient met a friend in Glasgow, who acted somewhat un¬
prof essionally, but nevertheless for the patient’s good. The patient’s
friend saw his prescriptions, and ordered him, instead of arsenic, cacody-
late of sodium—another arsenical preparation. In about five weeks’
time the patient was so much better that he said to him, “ Go and
show yourself to Dr. McBride.” He came, and was undoubtedly very
much improved. The ulcer had quite healed, but the cervical tumour
remained. Later on he died, but the speaker did not know from
what cause, and was unable to give any histological history of this
case.

Mr. Spencer said that cases of lympho-sarcoma differed from other
forms of malignant disease, inasmuch as a surgeon could operate on
them partly and remove a part of the growth with benefit to the
patient. He should advise removal piecemeal, or that a large portion
should be removed, and that this treatment should be followed by

56

giving arsenic and iodide of potassium, which drugs should give consider¬
able benefit for a long time. There were many cases of malignant
sarcoma—not only the most malignant and generally considered hope¬
less cases, but also those moderate forms of the disease—where one
could do a partial removal with benefit to the patient. As regards
arsenic, undoubtedly there were certain preparations of this drug which
were much more valuable than others in their action. He remembered
a case which he had seen with Dr. Hall, and in which he had taken
away portions of a large mass of lympho-sarcoma from the neck, where
they had considerable difficulty in finding the particular preparation of
arsenic which was most suitable to the case; in this case it was, so far
as he remembered, the hydrochloride. This might explain what had
been said of the new one, the cacodylate of sodium.

Dr. Tilley remarked that he had had the opportunity of putting
his finger into the post-nasal space, and he found its posterior and
upper parts were covered by a large, well-marked, ulcerated surface,
which was somewhat hard to the touch. No bleeding followed the
examination. He was rather inclined to doubt the probability of its
being a lympho-sarcoma. The feel of the ulcerated surface was sug¬
gestive of epithelioma. He would suggest that if operative treatment
were attempted, a laryngotomy tube should be first inserted, a sponge
placed above the larynx, the soft palate divided, and, if necessary, some
of the hard palate also removed. Such measures would give a full
view of the growth, and haemorrhage could be readily controlled.

Dr. Baron thought that the method mentioned by Dr. Tilley was
the only one likely to do any good. For a case like this a curetting
operation was of no value, since the disease was too deeply situated.
He had left a section with the Morbid Growths Committee, in case
they should care to make use of it.

A Case of Epithelioma of the Larynx in a Man jet. 60.

Shown by Mr. Attwood Thorne. This man w r as first seen at
the London Throat Hospital on December 16th. He had then
suffered from hoarseness for six months, and slight pain on
swallowing for a few days.

A view of the larynx (which was only obtained with difficulty)
showed that the left cord was fixed in the mid-line, and that
there was a growth involving the left arytenoid and extending
into the ary-epiglottic fold on that side. The larynx was
slightly tender when examined from without, and there was a
large gland just under the ramus of the jaw on the left
side. There was a good deal of pain referred to the left ear,
and restlessness at night. The man was of good physique, a

57

carpenter still pursuing his trade. He had two healthy grown-up
children, and denied having had syphilis.

He was put on fifteen grains of potassium iodide and a drachm
of Liq. Hyd. Perchlor., and for the last fortnight had been an
in-patient. With the exception that there had been temporary
swelling for a few days of the right arytenoid, there had been
little to note, except that the enlarged gland had somewhat
increased in size.

Mr. Thorne said he would be obliged by any suggestions as to
treatment. He personally did not think that any operation
would prolong the patient’s life, or add to his comfort.

Dr. Lack said there was no epithelioma in the larynx; but there
was a growth on the outer edge of the aryteno-epiglottic fold which he
should think was epitheliomatous. It would be extremely difficult to
remove it, and if an attempt was made, pharyngotomy, not laryngo-
tomy, was required.

Mr. Waggett had watched the case for some days. The left side
of the larynx was completely fixed, and the left arytenoid region and
ventricular band were considerably swollen. Below the level of the
vocal cord, which could not be distinguished, there was occasionally to
be seen a growth which appeared to be pedunculated. He had no
doubt that the disease had commenced within the larynx, both the
history and the clinical appearances pointing in this direction.
Dysphagia was absent. The question of making an exploratory
laryngo fissure in this case was an open one. He would be glad to
know the actual experience of surgeons who had performed this opera¬
tion in cases which proved on inspection to be beyond radical treat¬
ment. Did the laryngo fissure seriously compromise the subsequent
condition of the patient ?

Sir Felix Semon said that the left side of the larynx was completely
fixed, and this pointed to infiltration of the inside of the larynx itself.
The growth had probably commenced in the lower part of the larynx.
With regard to the question of operation, he would not directly oppose
an exploratory laryngotomy, but his experience was that in such cases
the disease was usually found to be much more advanced than had
appeared on mere inspection and palpation, and the results usually
were not gratifying.

Dr. Lack admitted that there was fixation and thickening of the
left side of the larynx, but considered this was due to spreading
inwards of a growth commencing on the outside in the pharynx. There
was no epithelioma in the larynx.

Dr. Grant remarked that the interior of the larynx seemed to him
to lie very definitely affected, and he also should feel disinclined to
advise any operation because of the large extrinsic mass.

Dr. McBride said that probably the disease began inside and passed
over the arytenoid.

58

Mr. Thorne, ill reply, said that hoarseness had come on about six
months ago. He himself had been of the opinion that it would be a
mistake to undertake any operation, and he was glad to have this view
confirmed. There was no pain on swallowing until three weeks ago,
when the man first came under his care.

Case of Infiltration of Pharynx and Post-nasal Space in a

Man jet. 45.

Shown by Dr. FitzGerald Powell. The patient had com¬
plained of inability to sleep with his mouth closed. He stated
about six months ago he found that he woke himself up with a
loud snoring ; this had gradually become more marked, occurring
more frequently. He said that since present trouble began he
could fall asleep at any time. He had no pain, and was gaining
flesh. There was no interference with deglutition or phonation,
and there was no history of syphilis obtainable.

On examination, the whole of the pharynx, more especially
the left lateral wall, and the post-nasal space were found to be
the seat for considerable infiltration and thickening, giving the
appearance of bulging. There was slight swelling of the edge
of the epiglottis on the left side.

The tongue was marked with deep fissures and cracks. The
uvula was attached along both its free borders to the posterior
pillars of the fauces. The arms and wrists and inside of foot
showed patches of eruption, apparently dry eczema.

He had been treated with iodide of potassium and mercury.

Case of Growth in Post-nasal Space appearing p.elow Soft
Palate in an Infant a;t. 18 months.

Shown by Dr. FitzGerald Powell. The mother stated the
child cried as if it “ had a stoppage,” and during sleep made a
whistling noise. She said that she had noticed it from the time
of the child’s birth, and that the noise Avas not any worse now
than it Avas then. There had been no discharge or haemorrhage
from nose. The child was flabby, and backward for its age.

On examination, a reddish-looking growth, a little lai*ger than
the uvula, Avas seen protruding beloAV the margin of the soft

59

palate. On seizing it with a pair of forceps and running the
finger up along the growth, it was felt to be elongated and
pedicle-shaped, growing from the vault of the pharynx.
Considerable traction was made on it with the forceps, but it
appeared to be tough and resisting.

Dr. Powell proposed putting the child under an anaesthetic
and removing it.

The President said that the edge of a growth could l>e seen behind
the uvula. An opinion as to its nature could not l>e given except after
palpation.

Eitlides on Symmetrical Swellings of Gum at the Posterior
Ends of the Alveolar Border in a Female .et. 37.

Shown by Mr. W. G. Spencer. The patient had worn a plate
for seven years, and had noted the swelling for one year, with
pain. The dental plate now worn reached back only to the
front of the swelling.

Mr. Vinrace ventured to suggest that this case lent itself to a very
simple explanation. It seemed to him to be due to a combination of
mechanical action and slow inflammatory process. He had ascertained
from the patient that she had worn a plate constantly day and night
for seven years, and it would be observed that the growth was im¬
mediately adjacent and in contact with the margin of the plate;
consequently he thought that whatever had been the cause of the
swellings, they were largely regulated by the presence of the plate.

Dr. Don elan asked Mr. Spencer if he considered symmetry an
essential characteristic of an epulis, because, from the title of the paper,
he inferred tliis to be the case. An epulis might be symmetrical, of
course, but it was not a necessary characteristic. He agreed with Mr.
Vinrace as to the possible effect of the pressure of the plate, but he
noticed that it was in those parts—both in front and behind—where
the plate did not press that these enlargements were present. The
swellings behind the plate which were described as epidides were
apparently caused by the pressure of food between the lower plate and
the upper gums producing a thickening of ordinary fibrous tissue. So
far as his recollection went, he was under the impression that an epulis
was connected with bone changes, and that there must be some inflam¬
matory disease of tlie bone to set up an epulis; but there was no
evidence of that in this case.

Mr. Waooett believed tliis to lie an exaggerated example of the
tuberous swelling of the posterior end of the upper alveolus which was
very frequently to be seen in the mouths of adults. His attention was

60

constantly drawn to these swellings in making sketches of the mouth
and fauces, and he believed them to be of no clinical importance.

Mr. Spencer said he thought the swellings of the gum were con¬
nected with the tooth-plate, either directly or indirectly. He did not
propose to do anything to the patient, unless suggestions were made
that she might get worse if he did not. He did not see the necessity
of taking away the swellings, which were simply fibrous hypertrophy;
he brought the patient to the Society to see if any member thought the
removal necessary. The case had been sent to him as one of epulis,
with a swelling of the gum.

Case of Nasal Tumour in a Man .et. 26.

Shown by Dr. Kelson. The patient had had a fibrous poly¬
pus removed eight years ago, and recurrence had now taken
place.

Case of Laryngeal Growth in a Woman.

Shown by Dr. Kelson. The patient (shown at a previous
meeting) had suffered from aphonia, due to a rounded growth
originating in the left ventricle which had prevented approxi¬
mation of the cords.

The growth had been removed, and specimens shown under
the microscope pointed to its being a fibroma undergoing mucoid
degeneration.

Case of Hereditary Specific Perforation of the Anterior

Pillar of the Fauces.

Shown by Dr. Dundas Grant. The patient, a boy, set. 15, was
seen for the first time on January 8th, 1903, onaccount of pain and
difficulty in swallowing. He was found to have an elliptical open¬
ing in the left anterior pillar, with thick congested edges covered
with a greyish-white slough. Behind it on the tonsil was also
a fairly circumscribed excavation with a sloughy floor. The
symptoms were of fourteen days’ duration, and there was well-
marked evidence of a hereditary specific dyscrasia. The
exhibitor brought the case before the Society because the open¬
ing was very similar to the congenital slit observed in several

61

instances by members of the Society. He thought it would
be interesting to observe at a later stage to what degree the
opening would resemble the congenital malformation.

The President considered it to be a case of inherited syphilis.
The perforation did not look at all as if it were congenital.

Dr. Grant said it was difficult to foresee what the appearance would
be after the gummatous disease had l)een cured. It would probably
be very much like wliat they had seen in the congenital cases (but not
symmetrical).

Case op Chronic Laryngitis with Inter-Arytenoid Pseudo-

PACHYDERMIC SWELLING, PROBABLY DUE TO PURULENT

Rhinitis.

Shown by Dr. Dundas Grant. The patient, a girl, aet. 20, was
first seen the week previous on account of hoarseness, which was
worst in the morning, and which had lasted for two months ;
similar hoarseness was present during the whole of the previous
winter, but had disappeared as that season passed off. There
were crusts on the vocal cords and on the summit of a sessile
swelling, which interfered with the apposition of the cords.
This swelling was irregular, and presented a white, sodden
appearance. The patient was the subject of muco-purulent
rhinitis, and the secretion tended to dry in the nose. There
was deviation of the septum into the right nostril, and the right
middle turbinated body was hypertrophied. The exhibitor con¬
sidered the laryngitic condition to be the result of the inhalation
of morbid secretion from the nose, and that the swelling in the
inter-arytenoid space, which simulated pachydermia, was the
result of proliferation and maceration of the superficial
epithelium. He had prescribed a simple nasal wash, and the
patient, presented at the Society, stated that the hoarseness had
very much diminished during the week that the nasal wash had
been employed. The swelling in the inter-arytenoid space had
become somewhat smaller.

PROCEEDINGS

OP THK

LARYNGOLOGICAL SOCIETY OF LONDON.

Seventy-ninth Ordinary Meeting, February 6th, 1903.
P. McBride, M.D., F.R C.P.Ed., President, in the Chair.

James Donelan, M.B.,

E. Furniss Potter, M.D.,

| Secretaries.

Present—30 members and 2 visitors.

The minutes of the previous meeting were read and con¬
firmed.

The ballot was taken for the following gentlemen, who were
unanimously elected as Honorary Members :

Professor G-. Killian, Freiburg-im-Breisgau.

Professor Lermovez, Paris.

Dr. P. Schech, Munich.

Dr. G. Schmiegelow, Copenhagen.

As Ordinary Member:

Arthur Stanley Cobbledick, M.D., B.S.Lond.

The following report of the Morbid Growths Committee was
read:

Dr. Barclay Baron’s specimen (vide ‘ Proceedings,’ January,
1903).—The Committee considered that it was a columnar-
celled carcinoma, showing the characteristics of the epithelium
of the place of origin. Between the infiltrating columns was a
large amount of round-celled infiltration.

FIRST SERIES-VOL. X.

4

64

Dr. Lack’s specimen—tonsil —[vide ‘Proceedings/ January,
1903).—The Committee considered that there was no sufficient
evidence of tubercle. A giant-cell was seen in a lymph-space,
and the whole specimen showed evidence of inflammatory change
without any special characteristics.

Dr. Dundas Grant’s specimen (vide ‘ Proceedings,’ April,
1902).—The Committee considered that it was a columnar-celled
carcinoma of the antrum, the appearance having been much
altered by small-celled infiltration following the operations, and
recurrences.

The following cases, specimens, and instruments were shown:

Microscopical Section of a Tuberculous Pachydermia from the

Processus Yocalis.

Shown by Mr. Lake. The epithelium was thickened, and the
subepithelial tissue consisted of a mass of small, round cells.

Case of Laryngeal Tuberculosis.

Shown by Mr. Lake. The right vocal cord was thickened and
covered with granulations, with ulceration at the junction of its
anterior and middle thirds. The left ventricular band was
ulcerated, and there was also moderate enlargement of the ary¬
tenoids.

Mr. R. Lake, in reply to a question by Dr. W. Hill, said that the
signs in the chest were not very marked, but there was involvement of
both bases. The patient was under the care of Dr. Weber.

Case of Paralysis of the Left Vocal Cord due to Lead-

Poisoning.

Shown by Mr. Charters Symonds. The patient, a girl aet. 18,
exhibited the usual paralysis of the limbs seen in this malady,
and besides had paralysis of many muscles of the trunk. A
blue line on the gums was marked. The left cord lay in the
cadaveric position, and did not move on phonation. The rarity
of the laryngeal affection was commented upon.

65

Sir Felix Semon said that the co-existence of abductor paralysis
with paralysis of the internal tensors was a very interesting feature in
this case. According to modem researches the form of paralysis
seemed to vary with every poison. In lead-poisoning, the abductors
were most frequently affected. It was well known that for this
reason horses working in lead-mills had frequently to be tracheo-
tomised.

Dr. de Havilland Hall thought that there was also paralysis
of the right internal tensor. It struck him that there was quite as
much tensor paralysis on the right as on the left side.

Dr. Dennis Vinrace asked whether this was an isolated case, or
whether there was an epidemic of lead-poisoning in the neighbour¬
hood.

Septotome for use in Moure’s and other Operations for

Deflection.

Shown by Dr. Pegler. The instrument was an adaptation of
existing patterns of the best design, and could be had in two
sizes, differing only, however, in the length of the cutting parts,
which measured 1*75 and 2’25 cm. (about £ and £ of an inch)
respectively. These blades were modified from those of
Moure’s scissors, but they were narrower, somewhat probe-
ended, for the protection of the limina vestibuli; their cutting
edges were all but parallel, and they were symmetrical. More¬
over their necks or shanks were much less curved or bowed,
and at the junction of the latter with the blades there was no
bending on the flat. The remainder of the instrument closely
resembled the straight-cutting pliers of Asch, but there was an
addition of two powerful springs. The result of the combina¬
tion was a simple and handy septotome, which worked well in
practice. The springs ensured the disengagement of the blades
after closure upon the septum, an action which expedited opera¬
tion, whereas strength and precision were secured by sym¬
metry, and the absence of angles in the shanks. Of the two
sizes, the smaller was probably the more generally applicable;
the slight increase in the length of the blade in No. 2 could
scarcely obviate the necessity for extending the primary
maxillary incision in osteo-cartilaginous deflections. The septo¬
tome was made for the exhibitor by Messrs. Mayer and Meltzer.

66

Case of Unilateral (Right) Swelling of the Thyroid Gland

in a Woman jet. 50.

Shown by Mr. de Santi. The tumour had been growing for
five or six years, and was an ordinary parenchymatous swelling
of the right half of the thyroid gland. The interest of the case
consisted in the very great displacement of the whole of the
larynx and trachea to the left side. The woman had been for
some months lately subject to bad attacks of dyspnoea, due to
the pressure on the displaced larynx and trachea, and on the
right pneumogastric nerve. Taking this fact into consideration,
Mr. de Santi was strongly of opinion that removal of the enlarged
half of the thyroid should be performed, and brought the case
forward for corroboration of this opinion.

Sir Felix Semon thought that the right lobe of the thyroid gland
should be removed, since it both pushed the larynx to the left and also
exerted pressure on the laryngeal nerves. This pressure might become
dangerous if the tumour were to suddenly increase in size, as by
internal haemorrhage.

Dr. Dundas Grant thought that the operation should be carried
out as soon as possible, for if delay occurred both the larynx and the
trachea might lose their resiliency.

Mr. P. de Santi said that he would advise the patient to undergo
the operation.

Microscopical Sections of Nasal Growths of the type of
“Bleeding Polypus of the Septum.”

Shown by Dr. Brown Kelly. 1 and 2. Bleeding polypi of the
septum. 3. Alar polypus. 4. Sarcomatoid tumour of the septum.

The four growths, sections of which were shown, were re¬
lated histologically, although they differed from the clinical
standpoint.

All four were composed of a connective-tissue framework
supporting fibro-cellular masses through which numerous blood¬
vessels coursed. Many of the blood-vessels were dilated to form
sinuses. In each case one or other constituent predominated and
gave the growth its special character.

1 and 2, The clinical features of these bleeding polypi were

6 ?

typical of this class of tumour. The structure of one was that
of a soft fibroma ; the other was rather that of an angio-fibroma.

3. The alar polypus was about the size of a hazel-nut. It
was attached to the left ala, near the anterior angle of the
vestibule, by a thin pedicle which sprang from the region where
the skin passes into mucous membrane. The microscopical
characters of the growth closely agreed with those of the
bleeding polypi just referred to.

This case was of interest on account of the unusual seat of
attachment. Only one case of bleeding polypus of the ala could
be found on record (Masip). The growth from which the section
now exhibited was taken had originated in much the same way
as a bleeding polypus of the septum; a small “ pimple ” had
been first noticed, this had bled readily, and after each severe
haemorrhage the tumour had seemed to become larger.

4. The sarcomatoid growth illustrated how a serious error in
diagnosis might arise. The patient, a man aet. 20, had com¬
plained of frequent epistaxis of four months’ duration, and of
subsequent, gradually increasing nasal obstruction. On exa¬
mination, a purplish sessile growth was found filling the
anterior part of the right nasal fossa.

The whole extent of the growth could not be determined, but
it seemed to originate from the bony as well as the cartilaginous
septum. In consequence of the pressure exercised by it, the
superior lateral cartilage was elevated, causing considerable
external deformity, and the cartilaginous septum was. deviated
so as almost to occlude the other nasal fossa. The tumour was
regarded as sarcomatous, and a portion was removed for micro¬
scopic examination.

After this the patient passed out of notice, and was not seen
again for two years. He then stated that the snaring of the
piece of growth had cured him, but having been put in prison
he had been unable to report himself earlier.

The only indication now apparent of previous disease in the
nose, was an extensive smooth scar at the former site of the
tumour, from which a delicate synechia crossed to the anterior
part of the inferior turbinate. The deviation of the cartilaginous
septum was much less, and the external deformity had altogether
disappeared.

68

Sections showed the removed portion of the growth to be of
a uniformly cellular character in its deeper part, an appearance
which, taken in conjunction with the clinical history and aspect
of the case, would naturally have led to a diagnosis of sarcoma.

Various writers and several members of this Society, par¬
ticularly Dr. StClair Thomson and Dr. William Hill, had referred
to the misleading histological characters of certain nasal tumours.
This case was reported to show that a benign growth of the
septum may assume macroscopically, as well as microscopically,
characters of malignancy.

In reply to Mr. Waggett, Dr. Brown Kelly said he should be
pleased to send the sections to the Morbid Growths Committee.

Case op Tabes with Early and Unusual Implication op
various Cerebral Nerves.

Shown by Sir Felix Semon. For the following careful
abstract Sir Felix Semon was indebted to Dr. T. Grainger
Stewart, House Physician to the National Hospital for Epilepsy
and Paralysis, Queen Square :

The patient was a stud-groom, set. 46, married.

Complaint. —Tightness round waist, difficulty in speech and in swallowing.

Duration of above symptoms, six months; has had lightning pains for two
years.

Family history. —Good; married for eighteen years ; six healthy children,
none dead, no miscarriages.

Previous health. —Good till twenty-four years ago, when he had some kind of
venereal disease ; denies any secondary symptoms. Never had any throat
affection.

Present illness. — Two years ago " lightning pains ” in lower extremities. Six
months ago “ tight feeling " round abdomen at level of umbilicus. Five months
ago he began to have trouble with his throat, which consisted of a difficulty in
swallowing solids; no trouble with fluids. Four weeks ago feeling of numbness
in inside of left cheek, which later changed into right; now quite free. Three
weeks ago voice began to get weaker. Two weeks ago his wife noticed that he
made a peculiar noise when he was asleep. He replied that he was going to
turn a “ roarer/ 1 One week ago right eyelid began to droop, and patient had
diplopia for one day. Three days ago some difficulty in starting micturition.

Never any loss of sight or hearing; no gastric or laryngeal crisis; no difficulty
in walking at daytime or night $ never any pains in tongue or throat.

Present condition. —A rubicund man with tortuous temporal arteries; general
health good; also mental.

Special senses. — Smell and hearing good. Taste slightly affected on left side of
tongue. Sight: Eight, £; left, -£. Fields not contracted. Optic discs: Left,
normal; right edge of disc soft, not blurred. Condition due to a retinal oedema

69

which causes a slight haze. Arteries suggestive of granular kidney, being
irregular and " silver-wired / 1

Cranial nerves .—III, IY, VI. Weakness of right internal rectus; drooping of
right upper eyelid; right pupil larger than left; right, no reaction to light;
left, faint to strong light. Both pupils react to convergence. V. Motor ,
normal; sensory, slight affection left side. VII. Slight weakness right side,
general, passing off. XII. Tongue deviates to right when protruded; other
movements all good. IX, X. Soft palate : Volitional movement abolished;
Reflex irritability completely abolished; tactile sensibility more affected than
four weeks ago ; slight touches not felt on either side ; forcible probing felt and
localised on right, not felt on left; touching on middle line felt on right.
Electrical reactions of soft palate : Faradism, no response to moderate current;
galvanism, twelve cells KCC greater than ACC ; no polar change.

Larynx: Vocal cords slightly excavated, being, in quiet respiration, 4 mm.
apart. On deep inspiration not further abducted. On phonation come promptly
together. On deep inspiration following phonation, right vocal cord is moved
outward a shade more than left; there are no ataxic movements of vocal cords.
During examination had an attack of coughing with characteristic laryngeal
stridor—inspiratory.

Motor system not affected; sensory system, slight analgesia ulnar sides of
both upper extremities, a band across chest, and some change in legs; girdle
sensation, numbness in tip of second fingers. Reflexes, deep, arm-jerks
diminished; knee - and ankle- jerks absent; plantars, indefinite, flexor; organic,
some trouble in starting micturition; swallowing solids difficult, fluids not
unless patient is in a hurry.

General health. —Aortic second sound accentuated; urine low sp. gr., with
trace of albumen ; no hypertonia, no Charcot joint, no perforating ulcer; nails
more brittle.

Bemarlcs .—The point of interest in the case was, as stated
above, the early and unusual implication of various cerebral
nerves. It was, of course, well known that laryngeal abductor
paralysis sometimes was one of the earliest, if not the earliest,
signs of tabes, and might even be present at the time when the
patellar reflexes were not yet lost. Sir Felix Semon had
demonstrated a case of that kind some years ago at the Laryn-
gological Society, but he had never seen a case in which so
complete a paralysis of the soft palate as that witnessed in this
case was amongst the early symptoms of tabes; and, indeed, he
did not remember, amongst the very many cases of tabes with
laryngeal complications which he had seen, a single one in
which paralysis of the soft palate had played any role.

The second point of interest was that, in spite of the complete
motor paralysis of the palate, swallowing of fluids did not
produce regurgitation through the nose when he drank slowly.

Thirdly, it was very remarkable that, seeing how complete the
paralysis of the palate was, the tongue should, until a few days
ago, have so completely escaped. As a rule, when there was
paralysis of the palate and the larynx, there was a triad, the

70

tongue being also, and often enough even preponderate^,
implicated.

Fourthly, it was remarkable that there were considerable
vacillations of the clinical symptoms, the paralytic phenomena
in the tongue, the palate, the larynx, and the eyelids being
distinctly more marked on some days than on others.

Finally, it might be observed that the patient had had no
laryngeal crises at any time of the illness, but that his breathing
now at nights was distinctly stridulous and sonorous.

The President said he would like to hear whether members had
seen anything approaching the bilateral paralysis of the pharynx. He
had had a case which he had shown to Sir Felix Semon in which there
were bilateral paralysis of the abductors, unilateral paresis of the
palate and tachycardia, without other bulbar symptoms. The condition
had remained stationary for years.

Case of Ankylosis of Left Crico-arytenoid Articulation in a

Woman .et. 23.

Shown by Dr. Donelan. This case was shown on account of
one of its less obvious features. The patient, a French lady aet. 23,
when twelve years old had been seen by Dr. Landouzy, of Paris,
who considered she was suffering from incipient tuberculosis.
She, however, had apparently recovered, and had remained in
good health until six years ago, when she had what appeared to
have been influenza with acute laryngitis. Previously she had
had an excellent speaking and singing voice, but at this time had
completely lost it for about three weeks, after which it had gradu¬
ally grown stronger. During the attack she had been treated by
her family doctor, but haemoptysis having occurred a consultation
had taken place, when the opinion had been given that the case
was one of pulmonary tuberculosis and chronic laryngitis. The
haemoptysis had continued at intervals for over a year, when it
had ceased, and except for her defective voice she had been
quite well since.

The most obvious symptoms were those of left adductor
paralysis. She produced her present voice by compensatory
approximation of the right vocal cord. There were no thoracic

71

signs, pulmonary, vascular, or glandular, and there were no
evidences of former pulmonary lesions or impairment. The
paralysis was complicated by ankylosis of the crico-arytenoid
articulation, as evidenced by the absence of displacement of the
affected cartilage on phonation, and by immobility on the applica¬
tion of a probe under cocaine.

The case was regarded as one of left adductor paralysis
occurring in the course of an acute laryngeal influenza, with
subsequent bleeding from the laryngeal or tracheal mucus mem¬
brane, and in which ankylosis of the inflamed joint had
supervened.

The patient had had no treatment of the larynx, except
during the acute stage, and as in her present employment a
better voice was very desirable, the opinion of the members was
asked as to whether at this distance of time it would be
advisable to attempt to set free the articulation, and try fara¬
disation.

The President thought that the left arytenoid seemed completely
immobile.

Sir Felix Semon thought there was hardly sufficient evidence to
show that ankylosis had supervened upon the paralysis. There was no
tumefaction about the base, nor enlargement of the immobile ary¬
tenoid cartilage. Whilst not contesting the possibility of the order
of events sketched by Dr. Donelan, he considered it “ not proven.”
Therapeutically, he thought electricity would be harmless, but, on the
other hand, it was not likely to be of any benefit. Surgical measures
did not appear justifiable to him.

Dr. Donelan, in reply, said that it was, of course, impossible for
him to offer more than a suggestion as to the sequence of events
which took place in a case which had occurred so long ago and was not
under his observation. As he had previously mentioned, he based his
diagnosis of ankylosis on the fact that the arytenoid of the affected
side was not disturbed by the impact of the other in phonation, and
also resisted attempts to move it with a probe. It seemed to him the
natural course that the development of ankylosis should follow, rather
than accompany, the changes due to the initial inflammation.

72

Case of Polypoid Tumour of the Nasal Septum in a Woman
AST. 33. Three Months’ Duration. Microscopical Section
Exhibited. Diagnosis (?).

Shown by Mr. Hunter Tod. The tumour grew from the
anterior part of the septum, on the left side, and almost pro¬
truded from the nostril. There had been several attacks of
severe bleeding. The growth was polypoid, with a sessile base.
Only a small piece had been removed, in order to obtain a
microscopic examination. There was considerable bleeding
after this small operation, the nose requiring to be packed for
some hours.

Mr. Tod desired particular attention to be given to the micro¬
scopic section. He presumed the growth to be of the class
known as “ bleeding polypus of the septum.” The section
showed very dilated vessels, around which was a definite
tumour formation of cells of the endothelial variety. Dr.
Bullock, pathologist to the London Hospital, had suggested
the name “ haemangio-perithelioma ” or “ perivascular endothe¬
lioma ” to describe the growth.

Mr. Tod wished to know if this growth should be considered
benign or not, and if mere snaring off the growth would be
sufficient, or would it be desirable to remove part of the septum
with it ?

The President had had a similar case. The tumour was com¬
pletely removed on two occasions. The first time it was pronounced
by an expert pathologist to be an adenoma. It recurred in a few
weeks and was again removed. On this occasion it was pronounced to
be a sarcoma, but had never returned.

Dr. Dundas Grant said it would be desirable that these specimens
should be submitted to the Morbid Growths Committee. He referred
to a similar case of his own, in which the report of a pathologist of
high repute had been entirely indefinite. Many of the growths origi¬
nating in the septum seemed to baffle the histologists.

Dr. Pegler remarked upon the puzzling character of many micro¬
scopical sections of tissue from the region of the septum, owing to this
so-called sarcomatoid character. A section which he had placed in the
Society’s cabinet, of a small growth from the vestibular septum, had
been pronounced to be a sarcoma by experts from its microscopical
appearance, and had been labelled as such, but had shown no evidence
of malignancy or recurrence.

73

Mr. de Santi stated tliat these simple-looking (from a clinical point
of view) tumours occurred not infrequently in the vestibule, and had
pathologically—or, at all events, microscopically—all the appearance
of sarcomatous tissue, but were absolutely benign in their clinical
behaviour.

The President proposed that the matter should be referred to the
Morbid Growths Committee. The motion was carried nem. con.

Mr. Hunter Tod, in reply, said he would remove the growth as
suggested, and would be pleased to submit sections to the Morbid
Growths Committee.

Case op Laryngeal Obstruction.

Shown by Mr. W. H. R. Stewart. The patieut had been
shown at the January meeting in 1897. She then had the
following history: — “ Breathing badly for eight or nine
months, rapidly becoming worse. No history pointing to
malignancy, tubercle, syphilis, or injury.” The opinions of
members at that meeting had varied considerably. One member
diagnosed the case as “ simple inflammation,” another thought
there was a foreign body, a third suggested albuminuria,
a fourth syphilis, and a fifth tubercle. Tracheotomy had to be
performed immediately she entered the hospital, and thyro-
tomy a few days after. According to the notes, a soft round
growth was removed from below the left vocal cord. Unfor¬
tunately the pathologist’s report had been mislaid, and its
import had not been remembered. The patient did well, though
there was some difficulty in getting the wound to heal. The
voice returned, and she remained well until a year ago, when
pain on breathing and shortness of breath came on, and the
voice became gradually worse. There was now some subglottic
growth on the right side of the larynx. She also complained
that when she coughed, something came up and blocked the
throat, and she could not breathe until it had gone back again.
A month ago she had had a bad attack of bronchitis, and when
seen two days ago the whole larynx was swollen and stiff, the
left side especially seeming hardly to move.

74

Case of Frontal Sinus Disease showing Marked Expansion.

Shown by Mr. F. J. Steward. Alfred G—, set. 36, was first
seen on January 23rd, 1903, and gave the following history:—
Towards the end of 1901 he had developed nasal obstruction,
and in December some polypi had been removed. In the
following May a swelling had formed on the left side of the
nose, close to the inner angle of the orbit; this had gradually
increased in size, and burst a month later, discharging yellow
pus. After about, a month the sinus had healed spontaneously.
The patient had beeti well until September, 1902, when the
present swelling of the frontal region had commenced and
steadily increased, without pain or any other symptom, except
occasional discharge from the left nostril.

When seen on January 23rd there was marked swelling in
the frontal region, clearly due to expansion of both frontal
sinuses, the most prominent part projecting fully one inch
beyond the normal surface of the bone. Pus was also seen in
the anterior part of each middle meatus. A few small polypi
were removed from the left side, and an attempt was made to
pass a cannula into the frontal sinus without success. During
the past fortnight free discharge had taken place from both
nostrils, and the frontal swelling had markedly diminished,
although it was still considerable.

The chief points of interest in the case appeared to be (1)
the great expansion that had taken place without perforation,
(2) the rapidity of the expansion, (3) the rapid diminution of the
swelling during the last fortnight, and (4) the fact that the dis¬
tension of the left frontal sinus did not lead to discharge

through the old sinus.

\

Dr. Dundas Grant said there seemed to be some softening of the
bone, apparently periostitis associated with the frontal sinus suppura*
tion. He should be disposed to treat it actively with antisyphilitic
remedies. Sometimes in this region one met with tuberculous disease
of the frontal bone, but in this case he should first think of syphilis;
as far as his experience went, when a frontal sinusitis was pointing to
the surface of the bone it did not select that region. He thought
there must be some specific condition present.

Mr. Steward, in reply, said that the patient had been treated with
antisyphilitic remedies, but with no appreciable benefit.

75

Case of Malignant Disease in the neighbourhood of the
Right Eustachian Tube in a Man jet. 69.

Shown by Mr. Waggett. The patient was a man of strong
physique complaining of pain and tinnitus in the right ear, of
two months’ duration. Nose and throat symptoms completely
absent. The drum membrane of the right ear was markedly
retracted, and its vessels injected. The right Eustachian
eminence was involved in a firm, infiltrating, new growth, which
extended behind the posterior wall of the naso-pharynx on the
right side. The whole mass was not much larger than the yolk •
of an egg. The history, evidence, and result of anti-specific
treatment negatived the probability of syphilis.

Mr. de Santi said that he had not been able to obtain a sufficiently
good view of the growth to enable him to make any accurate diagnosis;
if Mr. Waggett’s diagnosis of malignant disease were correct he did
not think any operation would be justifiable.

Case of Disease of both Frontal Sinuses in a Man aot. 29.

Shown by Dr. Furniss Potter. The patient had been under
observation for two and a half years, the only trouble com¬
plained of being discharge from the nose. This had not been
profuse—the patient not requiring to use more than two hand¬
kerchiefs a day,—but was increased by cold weather. The
drainage was ample, the fronto-nasal canals being especially
patent, a curved probe being able to be passed into either sinus
with great ease.

There was marked tendency to the recurrence of polypi in the
neighbourhood of the fronto-nasal canals, which had been
repeatedly removed by snare and curetting. The patient was
a soldier, and had been ordered to a station where it would be
impossible for him to remain under observation. The case was
shown as one in which the indication was not considered
sufficient to justify the performance of a “ radical ” operation.

Dr. Pegleb thought that, in spite of Dr. Potter’s asseverations as
to much having been done in the direction of clearing away granula-

76

ti on-tissue from the region of the hiatus, there was still much to be
done with the curette, after which a more satisfactory drainage would
probably render further radical treatment unnecessary.

Dr. Grant asked if the sinus had been irrigated. Dr. Potter had
evidently been passing a probe, and if he could pass a probe he could
introduce a cannula. He thought this plan of treatment might be
given a trial.

Dr. Furniss Potter, in reply to Dr. Pegler’s suggestion, said that
both sides had been curetted very freely indeed with Meyer’s ring-knife,
and there was still great tendency to recurrence. If the patient were
about to continue under his care, he should curette him again, and
repeat the operation as often as might be necessary. He had not
irrigated the sinuses, but he would like to have an opportunity of
adopting Dr. Grant’s suggestion. He did not agree with Dr. Hill that
the mischief was principally in the ethmoidal region. Having observed
the patient very carefully for two and a half years, he felt convinced
that the chief trouble was in the frontal sinuses; he did not think
there was any extensive ethmoidal disease. There was persistent
recurrence of polypi—in spite of frequent curetting—in the neighbour¬
hood of the fronto-nasal canals, the result of the irritation of the
discharge. Unfortunately the man had been ordered to a distant
station, and he was therefore unable to continue further treatment.

Case of Chronic (Edema of Larynx. ? Amyloid.

Shown by Dr. Dundas Grant. Mrs. I—, aet. 45, was first
seen January 8th, 1903, on account of difficulty in swallowing,
without pain. This had commenced about twelve months ago.
It had been associated with slight hoarseness, most marked in
the morning, and the voice had now the tone suggestive of a
swelling in the pharynx. The larynx was the seat of a pale,
somewhat solid oedema of the epiglottis and both aryepiglottic
folds, especially the left; the cords appeared to be normal and
mobile, though the left one (which was only partially visible)
was somewhat restricted in its excursions. There was no ulcera¬
tion anywhere, but the palate and pillars of the fauces, especially
the left one, were somewhat thickened. The patient had been
losing flesh for the last three years, and had become pale,
whereas she formerly had had a good colour. The urine was
scanty and free from albumen; there was no history of pro¬
longed suppuration; no suppurating gingivitis; no evidence of
tuberculous or specific infection; no enlargement of glands.
The swelling seemed rather solid for simple oedema, too inactive

77

for tuberculosis, and the suggestion occurred that it might be a
form of amyloid change; the spleen was perceptible, and
probably enlarged. The liver dulness was considerable, but,
pending examination by a skilled physician, the exhibitor
would not dwell upon this. He would be glad of suggestions
in the meantime as to diagnosis and treatment.

Sir Felix Semon said he was greatly interested in this case. It was
so recently that he had brought a similar case before the Society
(November, 1902), when he had also read notes of three other cases,
that many of those present would remember that the subject of his
first case, whom he saw many years ago, was the wife of a medical
practitioner who had come to him with a general infiltration of the uvula,
epiglottis, soft palate and larynx. At first sight no one would have
doubted but that it was a case of tuberculous disease. The only thing
which had struck him as being unusual had been the infiltration of the
pharynx and arches of the palate just mentioned. He had examined
the chest very carefully, but had found no evidence of tuberculous
disease. He had tried various remedies,’ local and general, for nearly
two years without effecting any improvement, and the patient had finally
left him. Two years later the patient had come back, and the infiltration
had disappeared, although she had been under no treatment in the mean¬
while. Hr. Dundas Grant had spoken of the case as one of amyloid
disease. He (the speaker) wished to emphasise that he had merely
spoken, when bringing his last case before the Society, of a lardaceous
appearance, as he had no proof that the affection was actually connected
with amyloid disease; the look of the parts merely reminded one most
of the appearance of a kidney which had undergone lardaceous degene¬
ration—this, they would agree with him, after having seen Hr. Grant’s
case, was a perfectly justifiable comparison. He hoped sincerely that
the sequence of events in this case would be the same as in his own,
but the spontaneous disappearance of the infiltration did not help
them in the least as to its pathology. Since he had shown his last
case he had read the original description of Quincke’s disease, and felt
sure the cases in question did not belong to that category. Following
the suggestion of Hr. FitzGerald Powell, he had removed with his
patient’s consent the uvula, and had submitted it for microscopical
examination to Mr. Shattock, who found no evidence of amyloid
disease; the only thing he had so far found at a preliminary examina¬
tion was an enormous infiltration of round-cells. He was now waiting
for a further report. He wished once more to express his pleasure that
the Society had had an opportunity of seeing a particularly interesting
instance of a hitherto-undescribed and certainly pathologically very
obscure case.

Hr. de Havilland Hall said that the laryngeal aspect of this
patient reminded him of the case of a man shown to the Society six or
seven years ago, the diagnosis of which had been very doubtful at the
time; some members suggested lupus, and others a chronic tuberculous
condition. The disease had made gradual progress, and some eighteen

78

months after showing the patient Mr. De Santi had performed trache¬
otomy. He had lived three years after this operation, enjoying a fairly
healthy life, but eventually had died of pulmonary tuberculosis. The
condition had therefore probably been a tuberculous infiltration; there
had never been any ulceration, simply a pale puffy swelling of the epi¬
glottis and aryepiglottic folds, and the mucous membrane covering the
arytenoid cartilages. The aspect had been, in fact, much the same as
in this patient, but in the case he was relating the pharynx and soft
palate had not been involved.

Dr. Brown Kelly had had a somewhat similar case, which he had
described two years ago in the ‘ Lancet ’ under the name of “ sclerotic
hyperplasia of the pharynx.” He thought the President had had an
opportunity of examining the case. The most marked change had
been in the pharynx. The uvula had been immensely enlarged, being
not only elongated but also generally increased in size; and the lateral
parts of the posterior pharyngeal wall had presented great and uniform
thickening. The roof of the naso-pharynx had undergone similar
changes. Treatment had had no effect on the condition. There was no
history of syphilis, and antisyphilitic remedies had given no benefit.
The last occasion on which he had seen the patient he had noticed that
there was a tendency for the whole condition to grow less. He had cut
off a large piece of the uvula and had examined it, but was, unable
off-hand to give details of the microscopical structure. These, however,
together with illustrations of the pharyngeal appearances, might be
found in the article referred to.

Dr. Grant, in reply, referred to several cases of amyloid changes in
the larynx described in an article in a recent number of ‘ Munchener
Medicinischen Wochenschrift.’ He was bound to say that the exami¬
nation of the rest of the body, which he had described to the Society,
rather contradicted the idea of amyloid disease, being negative as far
as that was concerned. He thought these cases extremely puzzling,
but no doubt as their experience of them accumulated they might be
less in the dark than they were at present. He felt very uncertain
about the real nature of this one. Quincke’s disease was a more
sudden thing, which passed off quickly.

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Eightieth Ordinary Meeting, March 6 th , 1903.

P. McBride, M.D., F.R.C.P.Ed., President, in the Chair.

James Donelan, M.B.,

E. Furniss Potter, M.D.,

| Secretaries.

Present—38 Members.

The minutes of the previous meeting were read and confirmed.

The following gentleman was nominated for election as
an Ordinary Member of the Society :

J. A. Knowles Renshaw, M.D.Cantab.

The following cases, specimens, and instruments were shown:

Specimen op Columnar-celled Carcinoma op the Naso-pharynx

prom a Man ,®t. 63.

Shown by Dr. Bronner. The patient was first seen in April,
1898, when he complained of nasal obstruction and discharge
from the nose. There was a good deal of hypertrophic rhinitis,
and a small, soft tumour could be felt in the naso-pharynx
growing from the roof and posterior wall. It bled freely on
touch. A piece was removed and examined by the Clinical
Research Association, who reported that “the growth from the
naso-pharynx is a very soft columnar-celled carcinoma, covered
with intact mucous membrane. The character of the growth
suggests an origin in the antrum.”

FIRST series—VOL. X.

o

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Insufflations and a formalin spray were used, and part of the
growth was removed every three or four months, until May,
1902. It was then rather larger than when first seen, but did
not project below the soft palate, and only slightly into the
posterior nares. From that time the growth spread rapidly,
and the patient died in October, 1902.

At the time of djeath there was well-marked exophthalmos
and optic atrophy, with cerebral symptoms. There had never
been much pain.

The case was of interest in many respects. Columnar-celled
carcinoma in the naso-pharynx was very rare; the growth,
although of the soft type, had only slightly increased in size in
four and a half years; was it possible that the application of
formalin had arrested its growth ? The absence of pain was
also very unusual.

Sir Felix Semon, in reply to Dr. Bronner’s question, said he did
not put much belief in the efficacy of the formalin injection; it was the
nature of these cases to be of long duration. It was, indeed, well
known that malignant disease in the nose took a much longer course
than malignant disease in many other parts of the body, and a
duration of three or four years for a case of malignant disease of the
nose was nothing very uncommon; he had seen several cases where it
had existed as long as that. He was not prepared to say off-hand that
columnar-celled carcinoma grew more rapidly than the squamous
variety, but in this connection he would mention the following case:—
He had now under his care a girl set. 21 years, with a soft growth in
the posterior part of the nose, and with enormous infiltration of the
cervical lymphatic glands on both sides of the neck. The patient had
been seen by various observers, and amongst others by Dr. Dundas
Grant, who would perhaps remember that the case had been almost
stationary for a period of more than six months; at the present time
it was making very little, if any, progress.

Dr. Bronner asked Sir Felix Semon if he had not noticed that the
soft columnar-celled carcinoma grew much quicker than the squamous
kind. The softer and the more vascular a carcinoma was, the quicker
was its growth in most cases.

A Case of Dislocation of Bones of Nose due to Polypi, in a

Man ast. 60.

Shown by Dr. Kelson. The patient had suffered from nasal
polypi for fifteen years, and nasal deformity for six years. The

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left nasal bone was separated from the frontal, ethmoid, and
superior maxilla, and was perforated from pressure. The patient
had no headache, and only very slight discharge (muco¬
purulent).

Case op Bleeding Polypus op the Nose in a Girl ,®t. 15.

Shown by Dr. Kelson. The growth originated below the
anterior extremity of left superior turbinate body, and was first
noticed four months ago. It had twice been removed, with tem¬
porary cessation of the haemorrhage. Microscopical examination
showed a similar structure to the ordinary mucous polypus, but
with more round-cell infiltration.

The President considered this a case of great interest, since,
though he had seen several cases with some distension of the nasal
bones, he had only seen one where, this feature was much more
marked than in the present instance. In the case he was referring to
he extracted quite an enormous number of polypi from the nose, and
eventually got the patient into a fairly good condition. With the
polypi some sequestra came away. What struck him in the case under
notice was the unusually large quantity of pus in the nostril. He
would suggest that there might be an affection of one or more of the
accessory cavities, and he thought in a case of this kind it would per¬
haps be a safer policy to have some tissue removed, and examined
microscopically, since the naked-eye diagnosis between polypus and
malignant growth was not always very simple.

Dr. Kelson said that trans-illumination had given no evidence of
pus in the antra, for both sides were fairly translucent. He would
make some sections of the polypi.

Case illustrating an Operative Procedure for the Relief op
almost Complete Adhesion op the Soft Palate to the
Posterior Pharyngeal Wall—the Result op Tertiary
Syphilis.

Shown by Dr. Herbert Tilley. Patient was a female ®t. 23,
in whom the soft palate was so completely adherent to the
posterior pharyngeal wall that only a small probe could be
passed from the oro- into the naso-pharynx. It had already been
twice operated upon before coming under the exhibitor’s care;

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in each case the adhesions had been divided, but no means had
been adopted to prevent re-adhesion. In the course of ten days
to a fortnight the original condition had returned. The symptoms
complained of were a collection of mucus in the nasal cavities
which tended to constantly flow from the anterior nares, inability
to breathe through the nose, snoring, and other local dis¬
comforts.

Operation .—In view of the possibility of free haemorrhage
occurring when the adhesions were divided, a preliminary laryn-
gotomy was performed. The soft palate was then completely
separated from the pharyngeal wall, and a strong silver wire
was passed from before backwards through the soft palate close
to its junction with the hard palate, and about half an inch from
the middle line. The distal end of the wire was then made to
re-pierce the soft palate close to its fore margin and from behind
forwards. By this means a short segment of the wire rested on
the posterior surface of the soft palate. The free ends of the
wire were then passed from behind forwards, one upon each side
of the root of the incisor tooth, firm traction exerted on the
palate, and the wires twisted upon one another and cut off short
in front of the tooth. A similar procedure was then adopted on
the other side of the palate.

One wire cut out in about ten days, the second in a fortnight;
but by this time considerable healing had taken place over the
raw surfaces from which the adhesions had been separated.

Every day for three weeks the house surgeon had passed his
finger into the naso-pharynx, and excited firm traction forwards
upon the soft palatal structures.

The operation was performed six weeks ago.

The President said the result appeared to be most excellent; it
seemed to him that it would be interesting if other members would
give their experiences of ultimate results in such cases.

Mr. P. de Santi said he had seen two of these cases. The first was
the original one operated upon by Mr. W. G\ Spencer and shown to
this Society, in which there was considerable haemorrhage at the time
of the operation. The second was a case of his own, which he had
shown to the Society. Both cases were of a much more severe type
than that of Dr. Tilley’s; they were cases of absolutely complete
adhesion; not even a fine probe could be passed into the naso-pharynx
previous to operation. Severe pain in the mastoid region was the
cause of operation in both cases. As regards the operation itself there

83

was nothing of fresh importance in Dr. Tilley’s case. With reference
to the point raised by Dr. ^Tilley of suturing the soft palate forward to
the teeth instead of to the muco-periosteum of the hard palate, he
thought one method was as good as the other; but it was more com¬
fortable for the patient to have the remainder of the soft palate
sutured (as Mr. Spencer and he had done) to the muco-periosteum of
the hard palate. As regards ultimate results in Mr. Spencer’s case,
which was in excellent condition when shown to the Society two
months after operation, within about two years’ time re-contraction had
taken place, but no re-adhesion, and for some time Mr. Spencer had to
pass his little finger in to keep the passage dilated, and when, finally,
that could not be done, he had to pass an instrument up. Mr. de Santi
had not seen the case now for two years, but when he last saw it, it had
contracted so considerably that there was but little, if any, space leading
into the naso-pharynx. In his own case, the condition was exactly the
same as it was five years after the operation, and if it were wished, he
would be pleased to bring it forward again; he had seen the case off
and on during these five years, and undoubtedly the result of operation
was excellent. With regard to the question of haemorrhage, though
Mr. Spencer had encountered in his one case a considerable amount of
haemorrhage, and though he had seen this particular case, Mr. de Santi
himself did. not think it necessary to do a preliminary laryngotomy in
his own case, and he was surprised at the very little haemorrhage. Of
these cases one naturally did not have a very extensive experience,'but
he saw no reason to fear excessive haemorrhage. He did not understand
from Dr. Tilley’s report whether there was severe haemorrhage in his
case to justify the laryngotomy. If he had another case to operate
upon he would not think it necessary to do a preliminary laryngotomy.
He thought the operation as described and carried out by Mr. Spencer
was the best; every other method had resulted in failure, re-adhesion
taking place. The result in Dr. Tilley’s case at the present time was
excellent, but he feared re-contraction would take place; he would be
interested to see the case again in two years’ time.

Mr. Cresswell Baber called to mind a case in which he had
operated some years ago. In order to prevent re-contraction he taught
the patient to use a White’s self-retaining palate retractor, which was
introduced every day, pulling the palate forcibly forward. By this
means contraction was for a time prevented, but he did not know
the ultimate result of the case. The chief danger was, he thought, sub¬
sequent contraction, and not adhesion soon after the operation.

In reply to Mr. de Santi, Dr. Herbert Tilley stated that there was
no particular haemorrhage during the operation, and that, as a matter
of fact, the laryngotomy was unnecessary; but he had performed it
because Mr. Spencer in one of his cases had found the haemorrhage
embarrassing; and had free bleeding occurred in the present patient the
laryngotomy would have obviated all trouble with regard to blood
entering the larynx. In his next case he should certainly not open the
windpipe, unless during the operation it appeared advisable to do so.
His reason for fixing the silver wires around the teeth was because they
gave such an excellent fixed point from which to secure a firm hold
upon the soft palate. The principle was, of course, that introduced by

84

Mr. Spencer, and this case only differed in a modification of the details
of the operation.

Case with Clonic Contractions of the Palate, Adductors
of the Vocal Cords, and certain other Muscles.

Shown by Mr. F. J. Steward. The patient, a married woman
aet. 52, with no children, and having had no previous illnesses,
was in good health until eighteen months ago, when she was
suddenly seized with difficulty in speech, and inability to walk
without assistance.

Since the onset the symptoms had become slightly worse, but
otherwise had not altered. At the present time the condition
was as follows :—There were constant slight nodding movements
of the head. Articulation was difficult and jerky, and speech
quickly resulted in the patient getting out of breath. On
looking into the mouth, the palate was seen to be constantly
moving, the movements consisting of alternating quick elevations
and slower depressions of the palate, the 'rate varying from
110 to 130 per minute. Laryngeal examination showed similar
movements of the vocal cords, which were sharply adducted
and more slowly abducted. On phonation, adduction of the
cords took place in a sudden spasmodic fashion. At times
similar, but slighter movements of the upper lip were present.

On placing the finger over the thyroid cartilage it was evident
that similar movements of the elevators of the larynx were
taking place, and again a like condition, although less marked
in degree, affected the diaphragm.

The gait was markedly ataxic, but there was no inco-ordination
of the upper limbs.

There was no loss of power, no spasticity, and no alteration in
sensation. The knee-jerks and plantar reflexes were somewhat
increased. The pupils reacted both to light and accommodation.

The clonic contractions mentioned, appeared to be constant
and continued during sleep; they were not altered by the position
of the patient, and were not increased by voluntary movement.

There was no headache, vomiting, optic neuritis, or other sign
of increased intra-cranial tension.

85

The President said this seemed a case of extreme interest, and one
which certainly deserved discussion, especially by those who were
interested in its neurological aspect. The fact that the movements
probably proceeded during sleep, as Mr. Steward had said, was also of
especial interest.

Sir Felix Semon said that one would only with very great timidity
venture to give an opinion on this case, but it seemed to him most
likely that it was a cerebellar tumour which caused the rhythmic move¬
ments. The condition might, of course, be due to a multitude of other
causes, such as disseminated sclerosis (of which Mr. Steward thought
in the first place), paralysis agitans, chorea, hysteria, and tabes.
One might think of the last-named in view of the -patient’s unsteady
gait, but against this view was the fact that the patellar reflexes were
completely preserved. On the other hand, the patient could not stand
with eyes closed without nearly falling, nor could she walk straight.
The gait, however, was not exactly of the ataxic type, but like that of
a person whose equilibrium was disturbed. Mr. Steward had told him
that the symptoms, according to the patient’s own statements, had
come on suddenly, and a belief in this seemed to be the main reason
why the possibility of there being a tumour had not been seriously
entertained. Personally, in all such cases he believed that the state¬
ments of the patient as to the suddenness of origin must be received
with great caution. One often heard, for instance, in cases of oesopha¬
geal carcinoma, that the difficulty in swallowing dated from one definite
occasion; whilst they all knew that it could not have originated in this
way, but that there probably had been some occasion on which the
patient first perceived that he had a difficulty in swallowing, and that
date was given as the definite starting-point of the onset of the disease.
To return to the present case, it was, of course, possible that at first
there had been haemorrhage into the substance of the cerebellum, and
then, of course, a sudden origin of the symptoms would be conceivable;
but he thought now there was more likely to be a cerebellar tumour
than anything else.

Mr. Charsley said he had seen a precisely similar condition in an
old lady, a patient of his, who for twenty years suffered from paralysis
agitans, and who lived to be seventy-four years of age. He was led to
examine her larynx by noticing the rhythmic movements of her soft
palate and tongue. Her phonation was natural in the cold weather,
but during hot weather she generally spoke in a whisper. In this case
there could be no question of the accuracy of the diagnosis, as there
seemed to be in the case under discussion.

Tumour op Vestibule op Nose. Microscopic Section.

Shown by Mr. Cresswell Baber. Beatrice S — , set. 26, applied
at the Brighton Throat and Ear Hospital on November 6th, 1902,
with a growth filling the anterior half of the right vestibule. It

86

was the size of a small bean, soft, solid, and slightly lobulated
on the surface, and attached by a very thin pedicle to the outer
wall of the vestibule, close to its anterior end, and about £ inch
from its external edge. It was easily detached by avulsion.
There was rather free haemorrhage, which was arrested with the
galvanic cautery point. The history was that the growth had
been coming for three or four months. There was no known
cause. It was said to bleed easily. There had been no return
of the growth (March 2nd). The nasal cavities were noted as
normal, except a ridge on the left side of the septum. The
report of the Clinical Research Association was that the
“ growth is composed of much young spindle-celled tissue
covered with skin. It is chiefly inflammatory in origin, and
traversed by numerous large lymphatic channels. There are no
signs of tubercle or malignant disease.”

Tongue-depressor for Exposing the Tonsil.

Mr. Cresswell Baber showed a modification of Jaenicke’s tongue-
depressor, which he had found useful for examining the tonsil
and the opening of the supra-tonsillar fossa, and for facilitating
manipulation in that region.

The President said that an instrument which had not been used
by any of them hardly lent itself to discussion, but it certainly seemed,
from inspection, a most ingenious modification.

Dr. Dundas GI-rant referred to a paper by Professor Killian, in
which he described a method of examining, the tonsil which he had
found very useful. It consisted for the left tonsil, in turning the
patient’s face somewhat to the left and letting him hold out his tongue
with the left hand. One could then, by retracting the right cheek
slightly, look at the left tonsil almost fully in the face and get a very
good view of the supra-tonsillar fossa and the crypts of the tonsil,
which one did not get if the head were kept in the middle line.

Dr. Watson Williams was interested in these depressors, yet,
although he thought it was very important to get a good view of the
supra-tonsillar fossa, he could not help thinking that the plan he had
adopted of introducing a rhinoscopic mirror, combined with the use of
an ordinary tongue-depressor, gave one a perfect image and answered
every purpose, without in any way distorting the parts.

The President thought that the advantage of Killian’s method
(which he had made great use of) over the “ mirror ” advocated by the
last speaker, was that one could easily introduce a probe—and also,
when necessary, a sharp hook with cutting edge—into the fossa and

87

open it out. This was more easily done directly than by the aid of a
mirror.

Mr. Cresswell Baber wished to say this depressor was of especial
advantage in examining the supra-tonsillar fossa. By its use the
tongue could be depressed and the anterior faucial pillar, or the plica
triangularis, be drawn forward with one hand, whilst with the other a
probe or any other instrument could be introduced into the fossa.

Case op Lupus (?) of Nose and Face.

Shown by Mr. Yinrace. Mrs. X—, set. 56, married at 22; nine
children, of whom six were living. All the children were healthy;
youngest was born seventeen years ago. Ten years ago Mrs. X—
was treated for diphtheria at Fever Hospital. Three months pre¬
viously a rash had appeared on her chest. The diphtheria was
immediately followed by ulceration of the skin generally, and
especially of the tongue, nose, and throat. The ulceration of
the soft tissues progressed very rapidly, but the bone was
unaffected, and at the end of three months, she was practically
in the condition as now. She was treated for sixteen months at
St. John’s Hospital, one month as an in-patient, and the
remainder of the time as an out-patient, and had since attended
various other hospitals. At the time the ulceration commenced
Mrs. X— was 46, her husband 57, and the youngest child 7 years
old. The husband died four years after the onset of the attack
from stricture of bowel (? syphilitic). At some of the hospitals
she had attended lupus had been suggested, but Mr. Yinrace was
inclined to suspect tertiary syphilis, masked by the diphtheria(?).
He would be glad of any comments as to diagnosis, and also for
suggestions as to treatment. The patient was unable to work
owing to the eruption on the face, and was anxious that, if
possible, the shape of her nose should be somewhat restored.
She had lost the tip of her tongue and had difficulty in protrud¬
ing that organ.

Dr. Wm. Hill remarked on the difficulty of pulling forward the
tongue in order to make a laryngoscopic examination, and said he had
elicited from the patient the fact that the tip of the tongue had
ulcerated away some years ago; this was strongly suggestive of
syphilis. On the other hand, the nodule or growth on the posterior
part of the tongue looked like lupus, and supported the view that it
was really a “ mixed ” case.

88

Dr. FitzGerald Powell thought there was very little doubt that
this was a case of tertiary syphilis; in addition to the manifestations
in the forehead and nose, the patient was suffering from chronic
indurated glossitis, and,- she had a scarred sulcus in the posterior half
of the tongue. If put on antisyphilitic treatment the patient would
probably improve.

Dr. Dundas Grant said that the appearance of the patient could be
very materially improved by means of an artificial appliance such as
he remembered seeing on a patient from the North, who was shown
before the British Laryngological Association some years ago. He was
a coach-painter, and in order to rectify his disfigurement he made a
hollow model of the nose in tin or aluminium, and coloured it himself
so perfectly that when it was stuck on to the stump of the nose without
the aid of spectacle frame or anything else, from a very little distance
it looked like a natural organ. This man now manufactured these
noses for others. He thought this case one of lupus, for one reason
that the disease seemed to have confined itself to the softer parts, and
the septum could be seen quite intact. Three months was certainly a
very short time for so great disfigurement to occur, but he did not
think that excluded the possibility of its being lupus.

Mr. F. H. Westmacott said that the maker of the artificial noses
referred to by Dr. Grant was Mr. H. Brook, of 28, Savile Parade,
Halifax.

Mr. Vinrace, in reply, said that as regards the suggestion of
tertiary syphilis made by Dr. FitzGerald Powell, he thought that this
was supported by the circumstance that a rash (? secondary syphilitic)
appeared three months before the supposed attack of diphtheria. Dp
to that date her health had been perfect. Four years afterwards her
husband died of stricture of the bowel, said to be due to the “errors of
his youth,” but possibly due to disease contracted about the time that
his wife had developed her malady. Against the syphilitic theory was
the fact that immediately on leaving the Fever Hospital Mrs. X—
went to St. John’s Hospital, where she received a perfect course of
antisyphilitic treatment without any material result. Dr. Hill had
noted that the tongue was deficient. The fact was that during the six
weeks of terrible ulceration, the tip of the tongue had fallen off, and
the tip of the nose also came away. He was not in a position to
express an opinion whether Dr. Grant’s suggestion of lupus or Dr.
Powell’s diagnosis of tertiary syphilis was the true solution, but he was
grateful to Dr. Grant for suggesting an artificial nose. Certainly an
improved appearance would enable her to obtain work more easily.

Case op Anosmia. (Fob Diagnosis and Suggestions as to

Treatment.)

Shown by the President. Mr. B—, aet. 39, was first seen on
June 13th, 1901. He stated that he had lost the sense of smell
for the last six months, but that at occasional periods he could

89

“ smell and taste a little.” He could appreciate the difference be¬
tween salt and sweet. On examining the nose anteriorly both
middle turbinals were seen to be large, the inferior fairly so.
On posterior rhinoscopy the right middle meatus appeared to
be blocked. The left side seemed to be fairly clear. He
was ordered to use a nasal spray of menthol and paroline.
On July 11th he was seen again, when he stated that five
days after his first visit, smell and taste had returned per¬
fectly for one day. This had been repeated several times,
but only between the hours of 1 and 7 p.m., excepting on
the first occasion. After the application of cocaine to the
middle turbinals, smell at once returned. On August 3rd,
1901, he could smell peppermint and nitrous ether. On this
occasion the application of cocaine was followed by disappear¬
ance of the sense of smell. On this and on the previous visits,
pieces of mucosa were removed from the middle turbinals. The
treatment was continued as before, with the addition of strychnine
internally. On October 2nd, 1901, he could smell occasionally.
A considerable piece of each middle turbinal was removed with
Griinwald’s forceps. After, this more of the middle turbinals was
removed, and eventually the greater part of the right was removed.
On January 2nd, 1902, he stated that he had had the sense of
smell for four or five weeks and then had gradually lost it. On
June 18th, 1902, he reported himself to be still improving. On
July 14th, 1902, he stated that he “ has had sense of smell
most days.” On January 7th, 1903, the sense of smell
was stated to be better in the right nostril, and during the
earlier hours of the day. Killian’s speculum was introduced
into the left olfactory cleft and dilated ; immediately his smell
improved, and continued for two or three days. On March 1st
he could smell turpentine, carbolic acid, and nitrous ether, but
expected it to go off in the evening. In the posterior nares
some hypertrophy was observed in the left choana (? cold), and
a small, polypoid-looking mass in the right. Anteriorly, the left
middle turbinal appeared to be enlarged; the anterior part of
the right was absent.

Mr. Babes thought the Society was much indebted to the President
for showing this interesting case, and for the careful way in which the
history was given. In his opinion it was a neurasthenic case, and he

90

should be very chary of doing any further operation. He suggested
the application of the continuous current externally to the nose, and
the administration of valerian internally, but he thought it doubtful
whether the patient would recover.

Dr. de Havilland Hall agreed with Mr. Baber. Most cases of
anosmia were secondary to influenza, and he had been trying to discover
from this patient if there was any history of influenza, but he denied it.
The attack came on with rather a severe cold, which suggested to him
hay fever; was this severe cold of an influenzal nature, he wondered ?
He particularly remembered one case of influenza in which the patient,
a man rather fond of the good things of this life, for over a year
suffered from almost complete anosmia and great loss of the sense of
taste, which was a source of great trouble to him. By persisting with
arsenic and strychnine—a thirtieth of a grain of each—in pill form,
taking two or three a day, the patient eventually made a complete
recovery ; he thought this combination of drugs the best for anosmia.
Some seven or eight years ago he had seen in the * Lancet ’ a paper
recommending the application of carbonic acid to the mucous mem¬
brane of the nose, but, as far as his experience went, he had never seen
results commensurate with the trouble involved in getting a stream of
acid on the parts. In almost all cases of anosmia associated with
influenza he had used a spray of menthol, which had a stimulating
effect on the nasal mucous membrane; he thought these cases, without
exception, eventually recovered; he could not call to mind at the
moment any case of anosmia and influenza which had not recovered
under a stimulating kind of treatment, including the tonic he had
suggested.

Dr. Dun das Grant said that unless cocaine had been already
applied to the pharynx in this particular case that day, the patient
seemed to have a remarkable diminution of pharyngeal reflex, which
was indicative of a neurasthenic condition. He thought there was
considerable evidence of neurasthenia being an element of importance.
One dictum expressed by the late Morel Mackenzie as the result of his
observations and experience, was that when anosmia had lasted
uninterruptedly for two years it was incurable ; he had never seen it
recovered from after that length of time. Personally, he thought he
had seen it in an hysterical case. With regard to the removal of
portions of the middle turbinate body, he thought the President
had probably been inspired by the same feeling that he himself
had—namely, that it was a very critical question how to remove
enough, and yet not to remove too much, because in removing large
portions of the middle turbinal one was also removing a good deal of
the distribution of the olfactory nerve, and it was quite possible to do
more harm than good to the sense of smell. The action of cocaine was
very peculiar. He remembered finding in a case of his own that its
application caused the sense of smell to return. This subject was
discussed in a paper in * Archiv fur Laryngologie ’ many years ago, the
observer finding the opposite result, i. e. that the application of cocaine
took away the sense of smell. The, fact was, that after the application
for a certain time, while the swelling of the mucous membrane was
reduced, the drug might allow of taste and the presence of smell

91

becoming perceptible, but after a longer time it paralysed the sense of
smell and thus caused the contradictory symptoms observed by the
President.

Dr. Donelan said he was interested in Dr. Hall’s remarks with
regard to the influenzal origin of so many of these cases of anosmia.
He had seen a good many of them at the Italian Hospital, which was
situated in a densely populated district. There, they seemed to have
a constant succession of cases of influenza even in the summer, and
there were a number of cases which he had had under observation
almost continuously for ten years. Some persons who had had con¬
secutive attacks of anosmia were clearly recovering from definite
influenzal symptoms. It would be in the experience of many members
that there were many people who, having once had an attack of
influenza, were liable afterwards on slight exposure to cold, or over¬
exertion, or from shock, to get an elevation of the temperature and
suffer from another attack of influenza. He had had the presumption
to form for himself the theory, that the spores of the bacillus were more
difficult to destroy than the germ itself, and that a slight elevation of
the temperature was sufficient to set them free and produce the dis¬
tinct symptoms of the disease. With regard to the menthol spray and
the treatment of influenza generally, about ten years ago Dr. Taylor (?)
wrote an article in the ‘ British Medical Journal ’ advocating the
internal use of carbolic acid, and another writer also wrote advocating
the use of the essential oil of cinnamon. He had been trying these
two remedies in combination in a great many cases—acute and chronic
—where the symptoms were attributable to influenza, and he had
found (using minim doses of each in combination with aromatic
spirits of ammonia, in water) the remedy had a remarkable effect,
so much so, that it might be regarded as a specific for the disease.
He had tried it in thousands of cases, with good results. In regard
to anosmia, by using the menthol spray recommended by Dr. Hall
and supplementing its action with carbolic acid at the beginning of
the treatment, this combination seemed to have a distinct beneficial
effect.

Dr. Watson Williams agreed with the general consensus of
opinion, i. e. that this was a case of neurasthenic anosmia; but in
addition there were associated with it certain vaso-motor phenomena in
the nose, which had resulted in swellings of the mucosa, which the
exhibitor had to a large extent obviated by removal, he presumed, of
the most prominent portions of the swollen middle turbinal. He
thought that the variations in the function of smell in this case were to
a large extent dependent upon the result of vaso-motor phenomena.
Slight swellings in the mucosa would sometimes cause the sense of
smell to be in abeyance, and this was observed in an ordinary nasal
catarrh, even when the nose was subjectively fairly free. Physio¬
logical investigations demonstrated how easily the sense of olfaction
was rendered inactive. The distribution of the olfactory nerve fila¬
ments was confined to quite the upper portion of the olfactory fissure,
and did not extend so far down as the middle turbinal; and he thought
that probably a comparatively slight swelling of the mucous membrane
of the superior turbinal, and of the upper portion of the mucous mem-

92

brane of the middle turbinal, would be sufficient to prevent olfaction
for the time being. Whether one ought to apply the cautery con¬
stantly, or other local applications to slight swellings, depended, in
some measure, upon the general condition of the patient, and one
should take this point into consideration before removing the
grosser results of the vaso-motor phenomena. Personally, he would
feel disposed to rely upon his favourite remedy of arseniate of
strychnine in this case, now that the hypertrophic tissues had been
successfully removed. He had been himself a sufferer from hay fever,
and so he could enter to a certain extent into the feeling of a patient in
whom the sense of smell was apt to come and go with great rapidity.

Dr. Donelan said that the treatment by carbolic acid and cinnamon,
to which he had referred, was used to commence with, and it was
followed up by giving tonics such as those mentioned.

The President was glad to hear that the general consensus of
opinion was not in favour of further operative measures. He might
mention as an interesting fact that practically the whole of the right
middle turbinal had been removed; now it was rather difficult to make
out exactly what had been done. The point raised by Dr. Hall touched
upon a matter of some importance. He had seen olfactory affections
following influenza, and in two forms—one in which the anosmia
existed permanently and remained; and the other in which it existed
for a time without intermission and then improved. The anosmia was
either constantly present for a time, or remained altogether. He had
never seen the intermittent form follow influenza. In this case the
anosmia was intermittent. He had employed menthol. The question
of carbolic acid was not a new one; it was mentioned in many works
which were published some years ago; he had referred to it in his own
book, the first edition of which came out more than ten years ago.
Alum, carbolic acid, and sulphate of zinc were long known to
permanently injure the olfactory nerve. It reminded him of an
instructive case in which a physician—not a member of this Society—
ordered a carbolic douche for a lady, with the result that she imme¬
diately and completely lost her sense of smell.

Case of Functional Aphonia.

(Previously shown at the January Meeting.)

Shown by Dr. Lambert Lack. This patient was the man with
spastic aphonia of functional origin, who, when shown at the
previous meeting (see page 50, vol. x, January, 1903), could sing
loudly, but could not speak above a whisper.

Under local applications of the faradic current and general
tonic treatment, the voice had returned, at first for an hour or
two daily, and gradually improved until it now lasted almost the
entire day. Examination of the larynx showed pachydermia of

93

the vocal cords, but the movements were now normal, both on
breathing and phonation.

The sequel to the case added an additional reason for con¬
sidering this case to be quite distinct from the ordinary spastic
aphonia. In his (Dr. Lack's) experience it was quite unique.

The President thanked Dr. Lack for bringing this case forward
again and thus giving the Society an opportunity of seeing it both in
a good and in a bad condition.

Dr. Dun das Grant said the interesting feature about the case
seemed to be the fact that the patient originally found it much easier
to sing than to speak. Singing required less effort on the part of the
nervous centres, and he supposed that was the reason of this state of
affairs. His brain had, perhaps, in the interval been gradually '
exercised and trained in some way; thus his recovery might be
explained.

Dr. de Havilland Hall said that stammerers often sang perfectly
well, in spite of their defective speech.

Mr. Lake said he had seen the case some time ago and thought
it one of syphilis. He heard that a long course of antisyphilitic
treatment had been adopted, but without benefit.

Case and Microscopic Sections op (Edematous Thickening of
Larynx and Palate in a Boy.

(Previously shown at the Society.)

Shown by Dr. Lambert Lack. This patient, now set. 11,
was shown to the Society in February, 1902, by Mr. Hunter
Tod (see ‘ Proceedings,’ vol.. ix, page 69). He was still under
the care of Dr. Percy Kidd, who kindly allowed him to be shown.
His further history was extremely interesting. He had had
signs of laryngeal obstruction for three years, and he had
certainly had stridor off and on, all the time he had been under
observation—now fourteen months.

The present condition was almost exactly the same as a year
ago. The boy was thin and pale, the temperature was normal,
there were no tubercle bacilli in the sputum, and no signs of
pulmonary phthisis. Enormous, smooth, pale, oedematous en¬
largement of epiglottis and arytenoids prevented a view of the
interior of the larynx. The uvula and adjacent part of the
palate was thickened. This description applied three weeks

94

ago. As no improvement had taken place Dr. Kidd wished to
have the epiglottis removed. This was done with Lake’s forceps
under general anaesthesia. A large piece of soft tissue in the
arytenoid region was also cut away.

The boy recovered rapidly from the operation without any
bad symptoms. The healed stump of the epiglottis could now
be seen, the arytenoids were not much swollen, the interior of
the larynx could be easily inspected, and the cords were seen to
be normal both in colour and movement. The boy had lost all
his stridor, etc.

Under the microscope the sections showed numerous roundish
nodules, deep under the mucous membrane, which strongly
resembled, but were not characteristic of, tubercle.

The case presented many points of similarity with, and some
of difference from, those shown recently by Sir. F. Semon and
Dr. Dundas Grant.

In spite of a year’s observation, the well-marked symptoms,
the microscopical sections, etc., the diagnosis still remained in
doubt.

Microscopic Sections op Mucous Patches pp Tonsils.

Shown by Dr. Lambert Lack. The tonsils were obtained from
an adult with well-marked secondary syphilis. The sections
showed great thickening of the epithelium in places, infiltrations
with round-cells, etc.

On the suggestion of the President Dr. Lack said that he would
hand the specimens to Dr. Pegler for the consideration of the Morbid
Growths Committee.

Case op Perforation op the Nasal Septum. ? Trauma or Syphilis.

Shown by Dr. Don elan. The patient, an Italian set. 42,
denied ever having had syphilis, but admitted having had
gonorrhoea about twenty years ago. He used to suffer from
bad headaches for about a year, and conceived the extra¬
ordinary idea that by “ punching ” his nose and making it bleed.

95

the headaches would be relieved. He said that this treatment
had been successful, but it unfortunately had set up a chronic
epistaxis, from which he had suffered almost every day for eight
years. During this period he used to pick his nose a good deal with
his fingers. The epistaxis continued until about a year ago, when
he was treated in Milan with a grey ointment, which was rubbed
on the outside of the nose. He was positive that it had not been
applied anywhere else, and that the epistaxis had ceased com¬
pletely in a few days. A purulent discharge with formation of
crusts* followed, and had continued until the present time.
There was a very large perforation in the septum, as well as
considerable depression of the lower third of the nose, and a
marked fold in the right ala. In spite of his assertion, taking
into account the nasal and pharyngeal appearances, as well as
the general aspect of the man, Dr. Donelan was inclined to
think the deformity due to syphilis.

The President was strongly inclined to think this a case of syphilis.

FIRST SERIES-VOL. X.

6

PROCEEDINGS

OP THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Eighty-first Ordinary Meeting, April 3rd, 1903.

J. Dundas Grant, M.D., F.R.C.S., Vice-President, in the Chair.

James Donelan, M.B.,

E. Furniss Potter, M.D.,

| Secretaries.

Present—34 Members, 2 visitors.

The minutes of the previous meeting were read and con¬
firmed.

The following gentleman was elected an Ordinary Member of
the Society:

J. A. Knowles Renshaw, M.D., B.C.(Cantab.), Beech Hurst,

Ashton-on-Mersey.

The Morbid Growths Committee reported on specimens
examined, as follows:

Mr. Lake’s specimen (No. 1) of new growth from inferior
turbinal (vide ‘ Proceedings,’ January, 1903, p. 52) was con¬
sidered to be “ a large round-celled sarcoma with a tendency to
an alveolar arrangement.” No. 2, of growth involving inferior
turbinal and septum (vide ‘ Proceedings,’ January, 1903, p. 52),
was considered to be a “ sarcoma with myxomatous degeneration
on the surface.”

first series—VOL. x.

6

98

Mr. Hunter Tod’s specimen (vide ‘ Proceedings/ February,
1903, p. 72) of bleeding polypus of the septum was considered
to be an “ angioma.”

Dr. Lambert Lack’s case (vide ‘ Proceedings/ March, 1903,
p. 93), section removed from epiglottis; “ no evidence of tubercle
was found in the specimen, the structure of which corresponds
with what is known as lymphadenoma.”

The following cases and specimens were shown.

Case op Laryngeal Disease.

Shown by Dr. Kelson. The patient, a man aet. 55, a
messenger by occupation, had suffered from loss of voice of
six weeks’ duration. There was no history of syphilis, no
wasting, nor could tubercle bacilli be found in his sputa, which
were scanty but yellow. Examination showed much swelling Of
the epiglottis, aryteno-epiglottic folds, arytenoids, and the right
ventricular band; the vocal cords were very difficult to see, but
appeared to be slightly swollen. The cervical glands were not
enlarged, and the lungs appeared to be normal. The man had
been attending hospital for two weeks, during which time his
voice had certainly improved. Opinions were asked for as to
diagnosis.

Sir Felix Semon said this was a very obscure case, and he spoke
with great hesitation, but the most likely explanation seemed to
be a very acute tubercular infiltration. The disease was so universal
in its attack upon the parts which he was able to see, viz. epiglottis,
right aryepiglottidean fold, arytenoid cartilages, but not the interior
of the larynx, that one might practically, for diagnostic purposes,
include anything of a similar character. It was too dense to be an
ordinary oedema of any kind.

Dr. Lack was under the impression that one could actually see
minute opaque caseating tubercles under the mucous membrane of the
anterior surface of the epiglottis.

Case op Swelling op Right Side op Larynx (for Diagnosis).

Shown by Dr. H. J. Davis. The patient, a man aet. 29, first
came to the Middlesex Hospital fourteen days ago. Six years

4

<)<)

ago the voice had become husky, and hoarseness had persisted
ever since. He had no other symptom.

The larynx was partially occluded by a red, tense, unilateral
globular swelling. The left cord only was visible, and appeared
normal.

The swelling was firm to the probe, though softer in parts.
It was unreduced by the application of a 20 per cent, solution
of cocaine, and when incised with a rectangular palate needle
haemorrhage was profuse. The swelling diminished somewhat
in size, but now, after ten days, it was as large as ever. The
points of punoture were represented by the two yellow lines
seen on the upper surface of the swelling. They had healed
rapidly.

There was no external thickening of the larynx and no
specific history.

At the apex of the right upper lobe posteriorly, there were
indefinite signs of early consolidation of the lung, and, in
consequence of this, the exhibitor was inclined to look upon the
case as tubercular, though he did not think that the appearance
of the larynx warranted such a conclusion.

The patient was a little pale, but his appetite was good; he
had no cough or expectoration, and seemed quite unaware of
his laryngeal occlusion.

The opinion of members was desired, first as to diagnosis,
and secondly, in the event of the disease being considered
to be malignant (sarcomatous), as to whether thyrotomy should
be performed at once.

The patient was spraying the larynx with 20 per cent, lactic
acid, was taking cod-liver oil, a teaspoonful night and morning,
and ten grains of potassium iodide three times a day.

Mr. Butlin came to the conclusion that Dr. Davis was probably
right in thinking this tuberculous. The swelling was very red on the
surface, and had not the appearance of a new growth, even malignant,
in that situation. He noticed several tiny yellow spots. If it were
tuberculous, he confessed he had never seen any case of laryngeal
tuberculosis quite like it. As to removing it, he thought if it caused
trouble it ought to be exposed by a thyrotomy, and then one could
ascertain its extent and nature, and be guided by this in the question
of removal.

Sir Felix Semon would not venture to give any definite opinion as
to the nature of this tumefaction. It might be anything. Sarcoma

100

was not impossible; tuberculosis extremely unlikely. It might be a
case of chronic perichondritis, or a case of exochondroma. Thera¬
peutically he agreed with Mr. Butlin, that the proper thing would be,
if it caused serious inconvenience, to do an exploratory thyrotomy,
and be guided in one’s further proceedings by what was found at this
preliminary operation.

Mr. E. B. Waggett had seen a case rather similar to this at a
meeting of the Society, which proved to be an adenoma, the glandular
tissue being that of the thyroid gland. The peculiarly rounded
contour on the inner aspect of the present swelling was rather unlike
that of an infiltration, and suggestive of a tumour or of a cyst.

Sir Felix Semon, in criticising the remarks of Mr. Waggett, said
the swelling followed too much the original outlines of the parts to be
a thyroid tumour. He believed really it was an infiltration of the
parts, since they were enormously enlarged and still showed their
original outline.

Dr. Davis said the case was first regarded as one of tuberculosis
owing to slight physical signs at the apex of the right upper lobe
posteriorly, but they were very indefinite. The note on percussion
was slightly impaired and expiration prolonged. Mr. Gould had
removed some tuberculous glands from the neck of the patient’s
sister. The patient was in excellent health, and except for the hoarse¬
ness, he did not know there was anything the matter with his throat
He first saw him a fortnight ago, when the swelling was so tense as to
have the appearance of a cyst. He felt it with a probe, and tried to
puncture it with a laryngeal lancet, but the lancet would not go in.
With some little difficulty he inserted a rectangular palate needle, and, to
his intense surprise, the blood spurted out as if an aneurysm had been
opened. The swelling diminished, and the patient said he could
breathe better. The haemorrhage soon ceased. Later he came back
as bad as ever; there were two little yellow spots to be seen—the seat
of the punctures.

He was inclined to think it a sarcoma, and that the larvnx should
be opened at once.

Dr. Grant thought Dr. Davis would now feel justified in the hesi¬
tation he felt in coming to a conclusion with regard to the diagnosis.
It would be to the advantage of the Society if he would bring the man
before them again at a later date. At present there did not seem any
immediate call for active interference.

Case op Singer’s Nodule (Left Vocal Cord).

Shown by Dr. Furniss Potter. The patient, a healthy-
looking man aet. 41, who sang in a village choir and taught in a
Sunday school, had suffered from slight huskiness for the last
twelve months, which had come on after an attack of influenza.
Impairment of voice was the only symptom complained of. On

101

examination a small nodule was seen on the edge of the left
cord in the anterior third. The cord in the immediate neigh¬
bourhood of the excrescence was very slightly reddened, but
there was no swelling of the cord itself.

Case of Chronic Empyema of both Frontal Sinuses and Maxil¬
lary Antra ; Radical Operations to illustrate the almost
Complete Obliteration of the Maxillary Sinuses following
the Radical Operation.

Shown by Dr. Herbert Tilley. Miss H —, set. 41, had
suffered from a purulent nasal discharge for about ten years.
It followed immediately upon an attack of typhoid fever.
During the past five years headache has often been sufficiently
severe to preclude her from following her duties as a pro¬
fessional nurse. Inability to concentrate her mind upon her
work has also been a more or less constant symptom. During
the last-mentioned period polypi have on several occasions been
removed from her nasal cavities.

When first seen last November patient would allow no
external operation to be performed, but was very anxious to
have any relief which might be obtained from internal treat¬
ment of the nasal cavities, e. g. curettage of ethmoidal region,
removal of middle turbinals, etc. This was strongly advised
against, but owing to the constant and urgent requests of the
patient, it was eventually undertaken. The removal by curet¬
tage of the anterior group of ethmoidal cells upon the right
side was immediately followed by haemorrhage into the eye
socket, causing protrusion of the eyeball. This followed the
most careful handling of the parts, which were in a very
advanced state of degeneration. During the following five
days it was evident that suppuration had taken place within
the orbit, and upon the sixth day (under “ gas ” anaesthesia)
two drachms of pus were evacuated by an external incision in the
large “ cleavage line ” of the lower eyelid. The patient rapidly
recovered, and eventually desired to have the external opera¬
tions performed as she had originally been advised.

Both frontal sinuses were operated upon by the radical

102

method (a modified Kuhnt’s operation) on January 12th. A
free communication was made with the nose in each case, but it
was allowed to close by granulation tissue as rapidly as possible,
so that in the course of ten days or so the sinus cavities were
shut off from the nose, and granulated up without further
trouble.

January 28th.—The radical operation was performed on both
maxillary antra. A large opening was made in the canine
fossa, the thickened, degenerated lining membrane scraped
away, the cavity disinfected with zinc chloride solution (grs. xl
ad Jj), and a light packing of cyanide gauze inserted for forty-
eight hours. The gauze was removed at the end of this period
and not reinserted, the antral cavities being only syringed out
with warm boracic lotion twice daily, carefully dried, and then
left alone. No opening was made into the nose.

Examination of the antra now would show that they were
practically filled with granulation tissue, it being only just
possible to pass a probe upwards through the fistulous track
through the original opening in the canine fossa.

Dr. Herbert Tilley maintained that in these cases, where the
radical operation was thoroughly carried out, cure was brought
about by the growth of granulation tissue from the internal
walls of the cavities uniting with the large mass of granulations
which sprouted into the cavity from the soft parts of the cheek
in the situation of the canine fossa. Eventually the original
cavity of the antrum was so reduced in size as to form merely a
slight extension of the outer wall of the nasal cavity.

Unfortunately the patient exhibited was suffering from an
acute nasal catarrh, which rather detracted from the healthy
appearance of the nasal mucosa, which now, under ordinary
circumstances, was absolutely free from a suspicion of pus.
Both sphenoidal sinuses could be seen opened in the upper and
posterior region of the nasal cavities.

Dr. Hall asked what was the effect of transillumination in these
cases.

Dr. Fitzgerald Powell thought Dr. Tilley was to be congratu¬
lated on the thoroughness of this operation so far as the frontal and
sphenoidal cavities were concerned. As regards the maxillary sinus,
he did not quite see the object of obliterating this cavity, even if it

103

was possible—a fact which he very much doubted. As the cavity was
deep and elongated, extending in an antero-posterior direction, he
doubted much whether, even if a large portion of the anterior and
lateral wall of the sinus were removed, one would get the soft tissues
falling in sufficiently to unite with the granulation tissue to destroy
the sinus altogether. On the other hand, he did not see the necessity
of practising this obliteration method and destroying the antrum.
There were much less formidable and simpler operations, such as
thorough drainage and washing of the cavity through a large opening
at its most dependent part, viz. through a tooth socket. He believed
that in 99 out of 100 cases if this were thoroughly done, and a large
enough opening made and large tubes were used, a perfect cure could
be obtained without destroying the cavity.

Mr. Waggett would not now enter into a discussion upon the best
method of attacking these cases, but he wished to state that the sinus
in all the cases operated on radically did not become filled up. He
had certainly met with several cases where, after removal of the whole
outer wall of the inferior meatus of the nose, a very large cavity
remained after complete healing had taken place. His own experience
led him to think that obliteration in these and in frontal sinus cases
depended on the amount of irritation which took place after operation;
in other words, on the length of time during which post-operative
packing was employed. If the outer wound were immediately sewn
up and a large opening made into the nose, and no packing employed,
he believed that the antral cavity did not by any means become
obliterated, but, on the contrary, was very little decreased in size as a
rule. That certainly was the case with the frontal sinus where, after
the Ogston-Luc operation, and with immediate closure of the external
wound, the cavity remained absolutely or very nearly the size that it
was before operation, as far as could be tested by the use of a long
probe. If, however, a frontal sinus were left open, and packing in
diminishing quantity employed for a prolonged period, the cavity
became filled up with a tough leathery growth of thickened peri-
ostium.

Dr. Lace agreed with Dr. Powell and Mr. Waggett in their remarks.
It was absolutely impossible for a normal antrum to fill up with
granulation tissue. To obliterate the antrum would require excision
of the upper jaw. If the inner wall of the antrum between it and the
inferior meatus were entirely removed, as in the usual radical opera¬
tion, these cases would get quite well; there was therefore no need to
obliterate the cavity.

Dr. Scanes Spicer agreed with Dr. Powell, Mr. Waggett, and Dr.
Lack. He failed to see the necessity for obliteration, even if possible.
The radical operation with which the names of Caldwell and himself
were associated was so very successful in curing these cases that he
could not see why one should wish to depart from a method which
had become classic. Luc’s modification (t. e. sewing up the bucco-
antral wound at once) was preferable to leaving it open, as saving
pain, irritation, and reinfection. In the present case he thought it
was too soon to say yet that the cavity was obliterated, or even that
the case was radically cured.

104

Dr. Grant said that he was sure Dr. Tilley did not advocate this
method of treatment, except for a comparatively small number of
cases of empyema of antrum in which milder measures had failed.
With regard to the obliteration of the antrum, there was no doubt it
was a more radical method; nor did he see why it should be impos¬
sible, more especially if a very forcible invagination of the nasal wall
of the antrum was carried out at the time of the operation. He
thought Siebenmann had described how it should be done, viz. by
putting a finger in the nostril right into the antrum, and forcing the
inner wall of the antrum outwards, thus bringing it into very close
contact with the soft tissues which grew inwards from the hole in the
canine fossa.

Dr. Tilley, in reply to Dr. Hall, said that the result of trans¬
illumination after operation for radical cure was that the antrum was
always dark. Whilst speaking on this point, he thought it somewhat
curious that if one transilluminated the antrum a week after the
radical operation, and after having curetted away the thickened
mucous membrane, the darkness was just as great as it was before
any operation had taken place at all. He had satisfied himself of this
fact many times, and he thought the darkness of the antrum in an
empyematous condition was due to the chronic inflammation in the
bony wall, and had nothing to do with the pus and mucous membrane
in the cavity.

With regard to Dr. Powell’s question, and the doubt as to the
possibility of obliteration, he did not wish to be understood as saying
that directly one met with a case of chronic empyema of the antrum
one advised a radical operation, for this was the last thing he would
think of advocating. One should always give the patient a description
of the two courses of treatment and let him take his choice. Natur¬
ally, to start with, every one chose the milder form of treatment.
Then, if not cured, the patient began to get tired of the everlasting
drainage and washing out; he found it a nuisance and a trouble, and
wanted to know if something else could not be done. Then, he
thought, one had a right to advise the radical operation, and hold out
a very good prospect of complete cure by it.

With regard to the remarks of Mr. Waggett on incomplete oblite¬
ration, and of Drs. Lack and Scanes Spicer, he had evidently been
misunderstood. He did not say the whole of the cavity could be
obliterated. Having removed a large part of the anterior wall and
the inner wall of the antrum at the radical operation, one found as
the result that granulation had sprung up over the remaining portion
of the antral wall; the epithelium spread in from the nose, and the
soft parts fell in through the anterior opening. All these formed a
certain amount of tissue in the original cavity of the antrum, which
attained such a size that the antrum was practically obliterated. On
looking into the nose six or seven weeks later and attempting to pass
a probe, one found it impossible to insert it further than half an inch,
therefore the cavity must be diminished to a very great extent, but
not totally. The cases which were cured were those in which the
greatest diminution of the size of the original cavity took place.

As regards the packing, to which Mr. Waggett had referred, in this

case he took out the packing forty-eight hours after operation, and
put in nothing else afterwards. He syringed out the antrum morning
and evening, and dried it afterwards each time. The advantage of a
large opening in the anterior wall, was that one could take a large
speculum and look inside, and apply a suitable antiseptic if one saw
any unhealthy point.

A Case op Clonic Spasm of the Muscles op the Palate and
Pharynx causing Entotic Tinnitus in a Lady *:t. 30.

Shown by Dr. Pegi.er. This and the following case were
brought to display certain features in contrast to, and yet
others in uniformity with, Mr. F. J. Steward’s case shown at the
last meeting. The latter case called forth an opinion that it
depended upon a severe organic nervous lesion, probably cere¬
bellar, whereas the present ones were almost certainly func¬
tional, and in fact fell into the second of the two classes into
which Dr. Lack had arranged the cases of clonic palatal spasm
described up to the time of his paper (‘ Laryngoscope/ vol. iv,
No. 6).

E. H—, aet. 30, complained of a clicking sound mainly in the
right ear, but occasionally in the left, rarely in both simulta¬
neously. Duration three months. The clicking was audible
with or without the aid of the diagnostic tube in the right ear,
and was associated in the patient’s mind with the right lateral
pharyngeal band (salpingo-pharyngeus). On examining the
throat it was observable that the sound was concurrent with
clonic spasm of the posterior pillars of the fauces. The rhythm
of the contractions was interrupted at intervals,—the rate per
minute, now slower than formerly, 42. The movements in the
throat were of two kinds: one, a high vertical upward con¬
traction of the velum and uvula, presumably due to spasms of
the levatores palati; and the other an approximation of the
posterior pillars, due to contraction of the palato-pharyngei,
the tubal slip of which apparently caused the sound complained
of by suddenly separating the walls of the Eustachian tubes.
Distinct movement at the mouth of the tube was visible through
the nasal meatus, and the two kinds of movement were not
always concurrent. There was a simultaneous adduction of the

106

arytenoids and vocal cords, ceasing on phonation. No distinct
causal relationship could as yet be affirmed, but there had been
simple erectile tumefaction of both inferior turbinals, which had
been treated by the galvano-cautery, and with much general
benefit, whilst the clicking sounds were now considerably
diminished in rate per minute. The patient had evidence of
functional nerve deafness and other interesting auditory sym¬
ptoms, which had been detailed elsewhere. She was slightly
neurotic, but had no other marked hysterical symptoms.

Clonic Spasm op the Soft Palate causing Objective Noises
in the Pharynx in a Woman mt. 20.

Shown by Dr. Pegler. As a matter of fact this patient also
had entotic tinnitus, but in her left and deafer ear. Duration
two months. The palatal movements were simple upward jerk-
ings of the uvula as in the last case, due to symmetrical con¬
traction of the levatores palati, but they had latterly increased
enormously in rapidity; the first notes taken stated them to be
10 or 15 to the minute, but they had since risen to 240 per
minute with scarcely any intermission.

Again, as in the last case, the adductors of the vocal cords con¬
tracted simultaneously, but every few seconds the cords remained
widely abducted for a second or so. The clicking was very loud
when the mouth was open, but when the sticky character of the
secretion was changed, as by the use of the cocaine spray, the
sound ceased entirely for a time. The naso-pharynx and
pharynx were clogged with mucus excreted by the very con¬
siderable pad of pharyngeal tonsil, which might here be held to
be the local exciting cause. After its removal, if there were
any manifest improvement, the case would be reported upon to
the Society again. The hysterical symptoms were not very
marked. No hemianaesthesia, but pain, “ pins and needles,” and
numbness were complained of on left side of face and head.
Mother stated the noises were not heard during sleep. Palatal
anaesthesia considerable, and when held forward firmly by the
palate hook the laryngeal movements went on as usual. Dr.
Pegler advised comparison with Sir F. Semon's (viii, 49) as well

107

as with Dr. Lack’s (v, -><S) and Dr. Bund’s cases (iii, 41), as
equally interesting studies in the hysteriology of the pharynx.

Case of Phakynueal anj» Laryngeal Lesions in a Woman

jet. 28.

Shown by Dr. Dun elan. The patient, a married woman with
three healthy children, had a severe attack of diphtheria seven
years ago. She says her throat was severely ulcerated at that
time, but that she recovered her voice. Her youngest child, a
fine boy, was born four months ago. Dr. Donelan saw her only
once, a week ago, when he found the uvula, velum, palate, and
both anterior pillars eroded. There was a large ulcer on the
epiglottis, and the laryngeal mucous membrane was much
swollen and ulcerated in patches. There was complete aphonia
and some dyspnoea. He put her on mercury and iodide with a
view to clearing up the diagnosis.

Dr. Hall asked how long an interval intervened between the attack
of diphtheria and the appearance of the lesions.

Dr. Donelan, in reply to Dr. Hall, said the patient had diphtheria
seven years ago. He saw her for the first time a week ago, and
immediately put her on antisyphilitic treatment. She was voiceless
when first seen, but was already greatly improved.

Dr. Hall approved of the antisyphilitic treatment adopted. The
case presented the characteristic appearance of tertiary ulceration of
the pharynx and palate. There was considerable destruction of tissue.
He thought a continuation of the antisyphilitic treatment would make
a great improvement in the condition. He doubted whether diph¬
theria had anything to do with the present affection, considering that
it was seven years ago since she had diphtheria.

Sir Felix Semon wished to make a general remark with reference
to what Dr. Hall had said. He really thought that they, as throat
specialists, ought to receive with the greatest scepticism all histories
of ulceration and cicatrisation—to however trifling extent—in the
throat, of such diseases as diphtheria and scarlet fever. He was by
no means inclined to attack the possibility of sloughing occurring in
exceptionally bad cases, but in the enormous majority of cases syphilis
was the cause of t he throat condition. They should be extremely
careful in taking for granted, on the strength of the patient’s state¬
ment, a history of such diseases.

*

Dr. Donelan said the history of diphtheria was given by the
patient. He tried to get her husband to come and see him, but he
would not. At first sight it presented the appearance of lupus.

108

Case of a Woman, mt . 37, with Ulceration of the Soft

Palate.

Shown by Mr. Lawrence. The palate was acutely inflamed
and very painful two months ago. Iodide of potassium was
given in, first, ten-grain, then fifteen-grain doses, three times a
day. In less than a fortnight the case was well. The condition
now remaining was one of extensive loss of substance between
tonsil and uvula, leaving only one thick strand of tissue uniting
palate and pharynx. No history could be obtained except the
very doubtful one of exposure to “ bad drains ” six months ago.

Dr. Don elan thought it was syphilitic.

Mr. Lawrence said that although the ulcer was in a most unusual
position he had little doubt that it was specific. The aspect of the
disease in its acuter stage was suggestive, and the action of iodide of
potassium in so quickly relieving the symptoms only added to the pro¬
bable correctness of the diagnosis. Although the patient could not or
would not give any history, he had been informed that her respect¬
ability was not above suspicion—another fact to be considered in
making the diagnosis.

Specimen and Section of Acute Tuberculosis of Left Tonsil

from a Man act. 32.

Shown by Mr. Westmacott. The disease commenced in
August, 1902. There was no family history or evidence of tubercle
elsewhere. Ulceration had spread to the soft palate since
removal. There had been great pain in the tonsil and neck on
the left side from the onset.

Drs. Wingrave and Lack agreed that the specimen exhibited did
not show evidence of tuberculosis in any form.

On the suggestion of Mr. Atwood Thorne it was decided that
the specimen be submitted to the Morbid Growths Committee.

Dr. Westmacott, in reply, said the only point of clinical import¬
ance was the absence of enlarged glands in the neck. The other
tonsil was perfectly healthy. There was a great deal of pain, and a
sort of excavation on the front of the left tonsil. He did not take
any steps to try and find bacilli in the sputum or discharge, as he
had seen the patient only a day or two before he removed the tonsil.
Since this operation the ulceration had spread to the soft palate, but
with the application of lactic acid and formalin this had ceased and

109

healed in about three weeks; the patient was now perfectly well.
Before he saw him, the patient had been treated by iodide of potassium
and mercury, but with no result.

Microscopic Section op Localised Psorospermosis of the
Mucous Membrane op the Septum NasL

Shown by Capt. O’Kinealy. The patient, a married male
Mahomedan, set. 22, came under observation at the Medical
College Hospital, Calcutta, on the 12th of May, 1894, on
account of a growth in his left nostril. He was a native of
Bihar, and had been working as a mason for the past two and a
half years, previous to which he had been employed in a hide
store for eighteen months. His appearance was healthy, and
his past history, including that of his family, was good.

About three years previously, while working in the hide
store, he first noticed the growth, which bled frequently, the
haemorrhage being worse in the hot than in the cold weather.
He went to a hospital, where it was removed with forceps, and
he suffered no further inconvenience for six months. After
this, however, the growth began to reappear, so he had recourse
to a native barber, who removed it a second time. He was
again relieved for a few months, but the tumour once more
recurred, accompanied by attacks of epistaxis, and he was
compelled to seek further relief. He was not aware of any of
those employed with him being similarly affected.

On examination a small vascdlar pedunculated tumour, about
the size and shape of a large pea, was seen projecting into the
vestibule of the left nasal fossa. It was a freely movable
painless growth with all the appearances of a papilloma, and
was attached by a short pedicle to the mucous membrane at the
anterior and upper part of the cartilaginous septum, being
entirely confined to that region. The remainder of the upper
respiratory tract was healthy, and no evidence was found of
any disease elsewhere.

The growth was easily and apparently completely removed
by forceps and the cold snare, though it was composed of
friable tissue which bled rather freely. The patient remained
under observation for nearly three weeks after the operation,

110

when lie ceased attending the hospital, and all trace of him was
unfortunately lost. By this time, however, there were definite
signs of recurrence, and on the 6th of June, 1894, the date on
which he was last seen, a small highly vascular pimple with a
red apex was seen at the site of removal.

The tumour was examined by Major J. C. Vaughan, I.M.S.,
then officiating Professor of Pathology at the Medical College,
to whom the exhibitor was much indebted for permission to put
the case on record, as well as for the specimen and the following
report.

Pathological Report by Major J. C. Vaughan, I.M.S.

“ The growth was removed from the septum narium by Captain
0\,Kinealy, and to the naked eye had the appearance suggestive of a
small papillomatous excrescence on the mucous membrane; but the
tissue was friable, and there was rather free bleeding in removing it.
The tissue removed was a piece about us large as a “ marrowfat ” pea.
It was hardened for three or four days in absolute alcohol, and then
embedded in paraffin and cut. The sections, placed first in turpentine,
were washed afterwards, first in xylol, then in chloroform, and then in
spirit. They were then transferred to water, and stained in picro-
carmine, and mounted in Farrant’s solution.

“ On microscopical examination the tissue removed seems to consist
of the following elements, disposed as described below :

“ The free surface of the tissue under examination is somewhat
irregular in its outline, and presents certain crypt-like involutions of
its surface, which is covered with a layer of squamous epithelium of
irregular thickness in different parts, aud which extends down into
and lines the free surfaces of the involutions above referred to; and
is also in some sections seen as isolated nodules embedded in the
general tissue. This surface epithelium is in parts clearly degenerated,
the cells having mostly run together into a colloid-looking mass, in
which no nuclei can be stained. In other, and more especially in the
deeper layer, the cell outlines can be clearly distinguished, and nuclei
stain fairly well.

“ The mass of the groundwork of what is above referred to as the
‘ general tissue ’ appears to consist of a coarse, irregular granulation
tissue, almost entirely of the nature of more or less organised granu¬
lation tissue, and, judging from its anatomical relationship to the
epithelium, is apparently the submucous or subepithelial tissue,
which has been the seat of a chronic slow inflammatory process, due
probably to the irritation set up by the presence of, and by the con¬
tinuous growth of, numerous cyst-like bodies which are seen scattered
throughout both the epithelial and subepithelial tissue. These cyst¬
like bodies form at once the most remarkable and, indeed, the central
feature to be described, and they occur in practically all stages of
their development.

Ill

“ Tlie fully dovel >ped cyst, examined under a Reichert’s T l . oil
immersion lens with a Zeiss No. 1 ocular, shows the following
structure:—Ir is seen to consist of a symmetrically rounded cavity,
bounded by a clear hyaline wall or membrane, and filled with small
cells or spore-like bodies. The tissue in which the cyst occurs is
condensed around the wall of the cyst. Where it occurs in the
epithelial parts of tin* tissues, the more or less polygonal epithelium
is Rattened out into cells, spindle-shaped on section. Where the cvst
is found in the subepithelial tissue, the fibres and cells of this tissue
form a dense zone immediately applied to the cyst wall. In these
dense zones, both in the epithelial and subepithelial areas, nuclei are
not readily made out. In the epithelial layer the cells in this zone
seem undergoing a colloid-like degeneration; in the subepithelial
area they seem to have become organised into a firm fibrous capsule,
which varies somewhat in thickness in different cases, as well as in
the density of its structure.

“ The hyaline cyst, trail is of pretty equal thickness throughout any
given cyst. It is a clear membrane, highly refractile, and under
oblique illumination shows a stnation of its substance, the striae run¬
ning nearly parallel to each other and being concentrically arranged.
There is no trace of cell structure observed in the membrane (or wall),
and it does not appear to have any cell lining, either on the inside or
on the outside, and both along its outer and inside edges it shows a
clear single-contour line. In almost every case it resists stain with
either carmine or picric acid or fuchsin, and is apparently quite
unaffected by acetic or osmic acid .1 per cent., or by Liq. Potassae up
to a strength of 30 per cent., even after some days in the case of this
last. The average observed thickness of the cyst wall varies from
•02 mm. to '01 nun. Where fully developed cysts in section are seen
to have been ruptured, the cyst, wall has either collapsed or is spread
out in the neighbouring tissue as a distinct and clearly defined band¬
like structure, and seems, from the position occupied under such
circumstances, to be possessed of some degree of elasticity. Cysts
measure across from T44 mm. to 2'24 mm.

“ The cyst contents, seen in the case of cysts which have been rup¬
tured.—These seem to be more or less symmetrically rounded or
ovoid bodies, of an average diameter of '005 mm. Each cell or sporule
consists of a granular central material surrounded by a delicate
bounding membrane, which under appropriate illumination gives a
double fine contour line. These bodies are likewise refractile, their
membranes darken slightly with per cent, osmic acid, and they seem
to clear up slightly with acetic acid and with 30 per cent. Liq. Potass a;.
The bounding membrane seems to be distinctly elastic, and where
these bodies are observed inside an unruptured cyst, they seem crowded
together, and apparently faceted to accommodate each other where
they come in contact with each other or with the cyst wall. Whether
there is any intervening substance or not it is difficult to say; but the
cells in any case tend to stick to each other after they are shed from
their cysts, and even to preserve their faceted appearance where they
remain in contact with each other. As seen in situ in the cysts they
stain slightly purple with piero-carmine, and also faintly but more

112

marked with acid fuchsin. When shed from a cyst they infiltrate
the tissue into which they are shed, retaining their characters as above
detailed. This infiltration appears to be purely a mechanical one, and
there is no evidence of the sporules undergoing, in the tissues into
which they are shed, any change suggestive of multiplication, or of
development towards the form of the complete cyst described above.”

Remarks .—This was, the exhibitor considered, a case of true
local psorospermosis, and he had been unable to find any record
of the disease occurring in the nasal mucous membrane, though
coccidia had of course been found in man in other situations.
The condition, as was well known, existed in some of the lower
animals, and he was therefore inclined to attribute its origin, in
this instance, to direct infection from the raw hides among
which the patient was working at the time he first noticed the
growth.

Captain O’Kinealy, I.M.S., in reply to Mr. Spencer, said he had
not the rest of the material. He had only one or two sections, which
were stained and mounted at the same time. He was indebted to
Major Evan for the specimen. He at first thought it was an ordinary
papilloma, and was greatly surprised when he saw the condition they
had seen in the specimen. He had reason to believe, though he did
not think they had been published, that similar cases had been met
with in Calcutta. He had not seen them. The late Major Evan,
Professor of Pathology, who died from plague, had seen some of these
cases, and they would have been published but for his untimely
death. So far as he knew, this was the only case on record of the
condition.

On the suggestion of Mr. Butlin it was decided that the
specimen be submitted to the Morbid Growths Committee, and
a drawing be made for publication in the * Proceedings/

Case of Ulcerating Growth of Left Tonsil, Side of Tongue,
and Anterior Faucial Pillar in a Man ^t. 52.

Shown by Dr. FitzGerald Powell. The patient came under
observation on the 9th of March, 1903.

He complained of pain in his throat when swallowing, and of
a pain extending up to his ears, which was worse at night. He
could not open his mouth or protrude his tongue. The pain in
the ears had existed for twelve months, and in the throat for
three or four months. He had been losing weight.

113

On examination his jaws were seen to be partially fixed, and
he could only open his mouth slightly. The tongue could not
be protruded. The left tonsil and the side of the tongue were
seen to be the site of an ulcerating growth, which was covered
with a greyish slough, and bled readily. This extended up on
to the left anterior pillar of the fauces.

No specific history could be obtained, and there was no
enlargement of glands in the neck.

The appearance of the disease was strongly suggestive of
malignancy, but bearing in mind that not infrequently disease
thought to be malignant in this situation cleared up under
iodide of potassium and mercury, it was decided to give him
twenty grains, with a drachm of the Liq. Hydrarg. Bichlor.^
three times daily.

Under this treatment he had improved very much; the
ulceration was less extensive, and the pain was less. He could
open his mouth wider and was gaining weight.

The ulceration had not, however, entirely disappeared, and
Dr. Powell expressed a desire for the opinions of members as to
the diagnosis and future treatment.

Mr. W. G. Spencer thought it was malignant. It was in an
awkward situation and difficult to remove, as it had spread back to
the inner side of the ramus of the jaw. It would need the L*shaped
incision of Langenbeck, with division of the jaw, to remove the
growth. He was doubtful whether it should be removed.

Large Papilloma of the Right Ventricular Band in a
Woman ast. 33, removed by Thyrotomy.

Shown by Mr. Waggett. The subject, drawings, macro- and
microscopical specimens were shown.

The growth, about the size of a small filbert, was attached by
a long base to the edge of the ventricular band. Although a
simple papilloma, it had appeared in life studded with points of
snowy whiteness. Intra-laryngeal manipulations under cocaine
were out of the question, owing to the nervous character of the
patient, and as neither the nature nor the extent of the growth
was certain, laryngofissure was performed.

114

The patient left the hospital on the eighth day, and the
larynx was now (nine months after operation) normal in appear¬
ance and in function.

Aphonia had existed for eighteen months before the opera¬
tion.

Sir Felix Semon said that, as he was originally responsible for the
statement as to “ white papilloma,” he particularly wished to observe
the second characteristic of these papillomata, which turned out to be
malignant. Not only were they distinguished by their snow-white
colour, but their excrescences were not rounded, but pointed as
ordinary papillomata.

Dr. Powell said it was an excellent result after thyrotomy. Was
it not possible to remove the growth interlaryngeally ?

Mr. Waggett said the woman was an exceedingly difficult subject,
so much so that a distinguished laryngologist thought she had tuber¬
cular ulceration. It was impossible to remove even a piece for
examination by the intra-laryngeal route.

Chronic Empyema op Sphenoidal Sinus ; Opened.

Shown by Mr. Waggett. He had employed in this case an
instrument resembling a Krause’s sliding attic chisel, inverted
and enlarged, which Dr. Lack had devised.

Case op Immobility of the Left Vocal Cokd, attributable to
Bronchocele, in a Young Woman ; Resection ; Extirpa¬
tion op Isthmus and Left Lobe.

Shown by Dr. Dundas Grant. Florence A—, set. 25, house¬
keeper, was first seen November 6th, 1902, complaining of
soreness of throat with occasional loss of voice, which had
developed during the previous three years. Although pre¬
viously she had been fond of singing, she was now unable to do
so, and occasionally she had complete aphonia; five years
previously she had had haemoptysis. The left vocal cord was
absolutely fixed, and there was slight swelling in the region of
the arytenoid cartilage. The left eyeball was slightly pro¬
minent, and there was firm general enlargement of the thyroid
gland, especially on the left side. For a considerable time she
was treated by means of internal administration of iodides, but

115

no change took place. On the 24tli March Dr. Grant excised
the isthmus and the left lobe of the thyroid, leaving, however,
a portion of this lobe behind, so as to avoid the risk of damaging
the recurrent laryngeal nerve. A few days after the operation
the patient’s voice was clearer. Healing took place without
any rise of temperature or other disturbance. The voice was
now clearer than before, and there was movement of the left
vocal cord for at least half its normal extent.

Dr. de Havilland Hall said there seemed to be more thickening
and enlargement of the left arytenoid than was accounted for by
pressure of the left recurrent. It was probably a joint case rather
than a paralytic condition.

Case of Paresis of both Recurrent Laryngeals and Left
Sympathetic in a Middle-aged Woman.

Shown by Dr. Dundas Grant. Mrs. A. H—, set. about 40,
was first seen on March 26th, 1903, on account of discomfort in
her throat, which she stated had come on suddenly three years
before. The voice was thick and seemed weak; she had a
tickling cough, and on swallowing liquids there was frequent
regurgitation through the nose. On examination there was
found almost complete paralysis of the palate, and both vocal
cords were nearly fixed halfway between adduction and abduc¬
tion. The left pupil was contracted and fixed, not acting either
to light or to accommodation. The left palpebral fissure was
diminished and the eyeball somewhat prominent. The left
eyebrow was drawn up in the endeavour to raise the left upper
eyelid. The left half of the forehead was moister than the
right. The movements of the tongue and lips were irregular.
The knee-jerks were exaggerated, and the pulse abnormally
rapid. There seemed to be a lesion in the medulla, and also
one in the cilio-spinal region of the spinal cord, and in all
probability specific in nature. It appeared that seven years
ago she suffered from a severe sore throat, accompanied by
falling out of the hair and a rash on the chest. Two children,
however, born since then—one aged five, the other twelve—
appeared to be in good health. She was ordered 10 grs. of

116

iodide of potassium thrice daily, and when seen a week later
expressed herself as feeling better and free from regurgitation
through the nose when drinking, the other symptoms being,
however, much the same as before.

Dr. Grant said that the laryngeal paralysis was certainly less than
when he first saw the patient, when paresis of both vocal cords was
well marked. The evidence of affection of the sympathetic was still
unmistakable. The improvement under iodide of potassium seemed
to confirm the diagnosis of syphilis.

Case op Disease op the Larynx op Twelve Months’ Duration,
PROBABLY EpITHELTOMA, IN A MAN ^IT. 50.

Shown by Dr. Dundas Grant. Mr. J. M—, set. 50, was first
seen on March 31st, 1903, on account of hoarseness and loss of
voice, which had developed rather suddenly and had been
steadily getting worse during the last twelve months. His
appetite was good; there was no pain in swallowing, and no
difficulty in breathing ; he was not getting thinner.

Laryngoscopic examination revealed an irregularly papillated
outgrowth occupying the whole of the area of the left vocal
cord, with some infiltration of the corresponding portion of the
vestibule, and diminished mobility of that half of the larynx.
There was irregularity and swelling of the anterior portion of
the right vocal cord, with some infiltration of the corresponding
ventricular band; no enlarged glands, and no apparent spread¬
ing of the thyroid cartilage. His medical attendant reported
that he had been treated freely with iodide of potassium and
mercury without any benefit. There was no sign of tuber¬
culosis in the chest and no history of haemoptysis. All possi¬
bilities of specific infection were denied.

The condition appeared to be one of extensive intrinsic
epithelioma of the larynx. The patient was apparently a man
of equable disposition, and otherwise in good health. The
exhibitor asked for suggestions with regard to treatment. In
view of the amount of infiltration and superficial extent of the
disease he was inclined to think that thyrotomy with removal
of the soft parts in the interior of the larynx would be in¬
sufficient, and that nothing short of complete excision of the

117

larynx would be of avail. Failing this he would only advise
tracheotomy, and would be inclined to place the issues before
the patient and leave the choice to him. As regards removing
a fragment for microscopical examination, he would be dis¬
inclined to do this unless the patient elected for radical opera¬
tion, in case of the diagnosis being confirmed.

Sir Felix Semon agreed with the diagnosis of epithelioma, and
saw no reason why a portion of the larynx should not be removed
from either side. He would throw out a suggestion to members
which he had found very useful in cases in which it was necessary to
cut clean across the vocal cord. When the anterior part of the cord
was affected it was advisable not to leave the posterior part alone, be¬
cause it projected afterwards like a tumour into the interior of the
larynx, but to stitch it with one or two stitches forward to the ventri¬
cular band. This procedure gave very good results, and astonishingly
good results, with regard to the voice.

Dr. Lack agreed with the diagnosis of malignant disease and
recommended thyrotomy. It might be possible to remove the whole
of the disease by an operation which stopped short of total extirpation,
but this point would best be decided after the larynx had been laid
open.

Dr. Grant asked what farther steps the members advised in the
treatment.

Sir Felix Semon advised thyrotomy, and either removal of the
soft parts or of half the larynx according to the depth of the infiltra¬
tion.

Dr. Grant said the disease had extended to the opposite side.

Sir Felix Semon said that made no difference. The larynx should
be split, and he would then be guided by what he found.

Case op Rapid Destruction op Nasal Septum, probably Lupus,

in a Male .et. 34.

Shown by Dr. Wyatt Winqrave. The patient, a well-
nourished male, a plumber, complained of a sore nose of six
months* duration. It commenced as a sore spot just inside the
nostril, which soon became a hole, and, melting away like glue,
ate its way on to the lip. He was in the habit of picking it
freely and pulling out hairs. There was now complete loss of
septum from before backwards, as far as the posterior limit of
the vestibule, with nodular ulceration of the upper lip on the
site of the philtrum, more or less covered with crusts. He gave
no history of syphilis or tubercle. The gums were healthy, but

*

118

he had some copper-coloured spots on the forehead. He had
been married twelve years and had four healthy children. His
wife had had no miscarriages. There was a submental enlarged
gland.

Dr. Grant said that the columella of the nose was eaten away
entirely by a curious circumscribed ulcer. Had any member seen a
similar case ? It was very difficult to decide whether it was a case of
primary syphilis, or of tuberculosis, or of epithelioma.

Mr. Atwood Thorne thought it was a remarkable case, of which
an illustration should be given in the * Proceedings.’ He was not
aware that such a case had ever been shown previously to the Society.

Mr. Spencer said that such a condition was more often seen in
inherited syphilis. One saw it coming on with great rapidity in
children called scrofulous.

Dr. de Havilland Hall remarked that scrofulous tumours were
mostly due to inherited syphilis; as a student he was taught to regard
the two as the same thing.

Dr. Wingrave, in reply to Dr. Powell, said that at present he had
adopted no treatment except the local application of boracic acid.
The local conditions were strongly suggestive of lupus, and the pro¬
cess seemed almost quiet now. When he first saw the case the area
affected was simply a mass of crusts.

Case of Exophthalmic Goitre.

Shown by Dr. Burt. Female aet. 18. First seen about a
year ago.

History .—Under treatment of family doctor for four years
for anaemia and palpitation, swelling Of thyroid not noticed, and
had grown gradually worse.

On examination patient was very anaemic. Temperature
normal, pulse 150, irregular. Hands very shaky. Very restless.
No exophthalmos. Left internal strabismus. Pupils normal.
Enlargement of thyroid, especially right lobe. Tongue large,
pale, and tremulous. The case was diagnosed and treated as
one of early exophthalmic goitre, giving first Ammon. Cit., Pot.
Iod., and Digitalis, introducing strychnine and arsenic. The
latter drugs did not apparently suit patient. In four weeks
patient was quite free from anaemia, and the pulse was regular
and normal. Hands still unsteady. Thyroid much smaller. In
about three months patient was able to resume her studies, and
could do her drawing, painting, and music with ease, which she

119

had not been able to do for over a year. Mixture stopped three
months ago. For past month, although free from anaemia, quick
and irregular pulse returned with hands very shaky, again
rendering it difficult for her to continue her painting, etc.
Right lobe of thyroid much larger, and extended higher up
beneath the sterno-mastoid. Placed under same treatment as
before, but patient disliked having to take medicine. Would
be glad to know if members could suggest further treatment, or
whether they thought operative treatment advisable.

Dr. Hall said the patient seemed to him to be going on satisfac¬
torily, but these cases lasted for years. As to the question of opera¬
tion, there was no reason for it. The pulse was only 92, and that
with the excitement of examination and strange surroundings. He
advised arsenic, strychnine, and digitalis, and rest—mental and
physical. He thought the iodide should be discontinued, for patients
with exophthalmic goitre did not seem to tolerate the drug well.

Dr. Burt said he had kept the patient perfectly quiet, had for¬
bidden tea, coffee, etc., all games, and everything tending to excite
her.

PROCEEDINGS

OP THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Eighty-second Ordinary Meeting, May 1st, 1903 .

P. McBride, M.D., F.R.C.P.Ed., President, in the Chair.

James Donelan, M.B.,

E. Furniss Potter, M.D.,

Secretaries.

Present—29 members, 1 visitor.

The minutes of the previous meeting were read and con¬
firmed.

The following gentlemen were nominated for election as
Ordinary Members of the Society:

John Aldington Gibb, M.B., C.M.(Aberdeen).

John Malcolm Farquharson, M.B., M.R.C.P.(Ed.).

/

The following cases and specimens were shown :

Case of Epithelioma of the Larynx (Shown at a previous

Meeting, January, 1903).

Shown by Mr. Atwood Thorne. When this patient was
seen in January last he had had hoarseness for six months and
dysphagia for a few days.

On examination the left cord was found to be absolutely
fixed, and there was a growth of the left arytenoid extending
on to the aryteno-epiglottidean fold.

He had been taking small doses of iodide of potassium and
mercury for three weeks without improvement. The dose of

FIR8T SERIES - VOL. X. 7

122

iodide was increased, with the result that the cord gradually
became more free, and the one continuous growth showed as
two with an intervening space.

The patient improved up to a certain point, which was reached
in the beginning of March, and the condition had remained
stationary since.

When last seen, a fortnight ago, the left cord moved fairly
well, the two growths remained distinct, there was no fcetor, no
dysphagia, and the gland at the ramus of the jaw was distinctly
smaller.

The improvement had certainly been very marked up to a
point, but the diagnosis of epithelioma was adhered to. When
now seen it was found that the left cord hardly moved, the
growths had both ulcerated, and it was not possible to show the
case (as had been hoped), as an “ epithelioma showing marked
improvement under treatment.”

Case of Lupus of Fauces.

Shown by Dr. Kelson. The patient was a girl set. 22, suffer¬
ing from whitish patches and red infiltration of the soft palate
and tonsils. She had been first seen five months ago, during the
whole of which time she had been treated with antisyphilitic
remedies without the slightest improvement. There were no
other signs of primary or secondary syphilis. The exhibitor
was now of opinion that the disease was lupus.

The President said that this case did not seem like previous cases
of lupus of the pharynx which he had seen; he would like to know
Dr. Kelson’s reasons for arriving at this conclusion.

Mr. Cresswell Baber asked whether antisyphilitic treatment had
been tried. He thought the case might be syphilitic in character.

Dr. Furniss Potter said that the appearance of this case sug¬
gested to him a condition typical of secondary syphilis. The patient
had volunteered the information that she had had some “ irritation ”
on the genitals for about three months, which had recently healed.

Dr. Kelson, in reply, said that the case was brought forward
because of its resemblance to secondary syphilis. When first seen, five
months ago, he had put it down to that disease, but he had altered his
opinion now on the ground, first of all, that for the past five months
she had been under antisyphilitic treatment, and till within the last
fortnight without the slightest improvement. A fortnight ago he

123

had changed the treatment and given arsenic, with the result that a
small improvement was already taking place. Secondly, there were no
other signs of syphilis. As regards the trouble complained of on the
genitals, there was nothing there of a syphilitic character. There was
no rash or falling-out of the hair.

Case op Ulceration op Tonsil.

Shown by Mr. Lake. The patient, a female set. 33, married,
complained of sore throat of five weeks’ duration. The right
tonsil was extensively ulcerated and covered with a thin slough;
the ulceration extended on to the posterior pillar of the fauces.
There was considerable dysphagia.

The President said that this case struck him as one the diagnosis
of which might well give rise to conflicting opinions. He would like
to know if Mr. Lake had removed a piece for microscopical examina¬
tion.

Dr. Pegler suggested syphilis. The eaten-out appearance in the
upper part extending to the soft palate, together with the coloration
of the border of the ulcer, seemed to him to indicate specific disease.

Mr. Charters Symonds had examined this case carefully, and
feared it was one of epithelioma. The edge was decidedly hard, and
there was a well-marked gland in the carotid triangle, which seemed
to him fairly characteristic. The short history might be misleading.
He was struck by the fact, that in this situation a patient might have
ulceration of an epitheliomatous nature for a considerable time with
little pain. His last case was a man of sixty-five with ulceration
involving the tonsil and soft palate, with a very short history indeed.
It was removed and found to be epitheliomatous. Taking into con¬
sideration the hardness, the depth, and the character of the ulceration,
and the presence of a gland, he greatly feared this case was malignant,
and not syphilitic. Ulcerating sarcoma had also to be remembered,
but the present case lacked the white appearance generally seen—an
appearance more closely resembling syphilis. And again, glands
occurred much latef.

Mr. W. G. Spencer was in favour of Dr. Pegler’s view, owing to
the extension of the ulceration over the posterior pillar of the fauces,
even so far as the posterior wall of the pharynx. This was rather a
wide-spread area. The gland in the neck was somewhat soft. He
would suggest in any case a course of antisyphilitic treatment for ten
days or a fortnight. It would not hurt to punch off the edge of the
tonsil where it was indurated for microscopical examination.

Mr. Cresswell Baber agreed with Dr. Pegler and Mr. Spencer as
to the syphilitic nature of this case, and recommended in the first
place antisyphilitic treatment.

Dr. H. Sharman said that one point which supported the syphilitic
theory was, that this patient had had two children, both of whom died

124

in infancy—one at the age of eight days, and the other when four
months old.

Dr. Lace thought they were all rather astonished to hear Mr.
Symonds’ views. Most members considered this an ordinary straight¬
forward case of tertiary syphilitic ulceration. The woman had, so
far, had no antisyphilitic treatment, so there was nothing to contradict
this view.

Dr. FitzGerald Powell proposed that Mr. Lake should show this
case at the next meeting.

Mr. R. Lake said he saw the patient for the first time only on
Thursday (the previous day), and he suggested the idea of removing a
piece for microscopical examination, but the patient did not wish to
have this done. He would give her antisyphilitic treatment and, if
anything worth reporting occurred in the further history of the case,
he would bring it before the notice of the Society.

Microscopic specimens. —(1) Large papilloma from posterior
aspect of cricoid cartilage, which was the apparent cause of
obstruction in a case of carcinoma of the upper end of oeso¬
phagus.

(2) Papilloma from region of inferior turbinal, with absorp¬
tion of internal antral wall.

Shown by Mr. Lake.

Mr. Spencer thought the appearance, under the microscope, of this
specimen (1) represented an epitheliomatous condition. He under¬
stood it came from a case of carcinoma of the pharynx and upper end
of the oesophagus. Surely Mr. Lake did not mean that the section
was from a papillomatous growth, and not an epitheliomatous. It
might be papillomatous in the clinical sense, but microscopically it was
a portion of epithelioma.

Mr. R. Lake, in reply to Mr. Spencer, did not consider this to be
epitheliomatous.

Case of Subglottic Thickening of Right Vocal Cord in a

Man AST. 27.

Shown by Dr. Donelan. The patient, an Italian open-air
singer, had had several attacks of laryngitis, and was now just
recovering from one which had lasted six weeks. On phonation
the edge of the anterior third of the right cord swelled up and
looked as if a subglottic thickening of the epithelium were pro¬
truding through the rima. There was some irregular thicken-

125

ing of the epithelium over the posterior parts of the cord,
? pachydermia.

Mr. Waggett wished to confine the term pachydermia to those
cases in which the mucous membrane overlying the vocal processes
was affected.

Dr. FitzGerald Powell did not think that the term should be
limited to those cases in which the vocal processes were alone the seat
of the hyperplasia. He could not accept such an arbitrary localisation
for a condition that was found on any part of the vocal cords, or more
often in the interarytenoid folds. He understood that the term pachy¬
dermia should be kept for the description of cases in which there was
a heaping-up of epithelium and a general thickening of the submucous
structures—a hyperplasia of the submucous connective tissue—and
not for cases of swelling of the mucous membrane, which were some¬
times brought forward as cases of pachydermia. This case seemed to
him, to be more of the nature of a swelling of the mucous membrane
than a true pachydermia.

The President did not think they could possibly accept the restric¬
tion of the term “pachydermia” to those cases mentioned by Mr.
Waggett, because if they did, they would do away with the fact that
one met with pachydermia in the interarytenoid spaces, fold, and
other parts.

Dr. Donelan in reply, remarked that the interesting point about
the case was that the right vocal process was distinctly enlarged and
thickened. For that reason he thought that the swelling about the
anterior third of the cord might be classed in the same category;
whether it was merely an increase of mucous membrane beneath the
cords, to which the term “ ballooning ” had been applied, he did not
know, but he suggested that it took part in the same process as con¬
cerned the rest of the larynx.

Case of Primary Turekcular Ulceration of Nasal Septum.

Shown by Mr. Waggett. A man set. 35, in failing health,
suffered a good deal of pain in the nose and frontal regions, and
exhibited an extensive superficial ulceration of the mucous
membrane of the left side of the nasal septum.

The area occupied was that opposite the anterior half of the
middle turbinate, and the posterior extremity of that body was
seen by posterior rhinoscopy to be enlarged, irregular in shape,
and yellow in colour.

The septal ulcer was fully an inch in diameter, and its base
was yellow and granular. The anterior edge alone was heaped

126

up, and a specimen taken from this portion had shown tuber¬
culous tissue with well-developed giant-cells. (Specimen
shown.)

Examination of the lungs showed merely increased vocal
resonance, over the right apex behind and in front. There was
no history of cough or haemoptysis.

For some two years the patient had been subject to pains
in the head with nasal discharge. The symptoms had increased
recently, and had been much exacerbated by taking potassium
iodide.

Evidence of special exposure to tuberculous infection was
wanting, but his trade entailed the inhalation of irritating fumes
and dust.

The President considered this case extremely interesting; the
only thing he regretted, and on which the patient congratulated
himself, was that there was so little of the original condition left that
one could scarcely see where the disease had been. He congratulated
Mr. Waggett on the thorough eradication.

Dr. Pegler had noticed a giant-cell in each specimen, but no true
giant-cell systems. He did not consider that the sections confirmed
the diagnosis of tubercle.

Mr. Oresswell Baber did not consider the appearance in this case
that of typical tuberculosis of the septum. He asked whether much
had been done to it.

Mr. Charters Stmonds thought the case was fairly characteristic
of tuberculosis. A very marked nodular line could be seen pretty high
up; it was yellowish and white in colour, and the fact remained that it
was seen in a good many cases of tuberculosis of nasal septum. He
had had recently a case in a clergyman who probably got it by infec¬
tion with his own finger from attending tuberculous patients. He
suggested that as a probable source of infection of the septum. His
late assistant, Mr. Steward, now in charge of the throat department at
Guy’s Hospital, had published six cases of primary epithelioma of the
septum, which they were able to confirm by microscopical examination,
and which, after free removal, sometimes with perforation of the
septum, got perfectly well. In the particular case now under his
care, to which he had just referred, the septum was quite free from
disease after free curetting, but the middle turbinal looked a little
suspicious in character, and he found it necessary to remove it,
because it was somewhat swollen. The disease was not quite so
uncommon as one was inclined to think, and in the present instance
there was a good deal more to be done for the patient. In one
instance the affection had spread to the lips and pharynx.

Mr. Waggett, in reply, said that under examination with powerful
illumination there was no sort of doubt as to the presence of a super¬
ficial ulceration fully as large as a penny. Its lower anterior edge was

127

heaped up and fairly thick, and this he had removed for examination,
but the main part of the ulceration had not been touched at all; it was
exactly as he had first seen it two or three weeks ago. The man was
very ill and suffered great pain in the forehead and nose, and he was
losing flesh. As to this ulcer being tubercular, he ventured to think
the specimens before them showed definite evidence of that disease.
More specimens, however, were being stained for tubercle bacilli.

Case op Swelling in Post-nasal Space (poe Diagnosis).

Shown by Dr. Furniss Potter. The patient, a man set. 40,
had come under observation two days previously complaining of
a sore throat for the last three weeks, with pain on swallowing.
During the last ten days the hearing had become considerably
impaired in the right ear.

On examination the right half of the soft palate was seen to
be paralysed, and in the post-nasal space there was an irregular
swelling projecting from the right side of the pharynx, and also
involving the posterior surface of the velum, which completely
obstructed the view of the right choana. The swelling was
covered with muco-pus and appeared to have an ulcerated
surface. On palpation it felt firm and fixed. A gland could
be made out below the lower jaw, but did not feel hard. The
patient admitted having had a “ sore ” twenty years ago, but
did not remember having any rash or other trouble which could
be regarded as evidence of systemic infection. It was not
possible to obtain any history of symptoms dating further back
than three weeks.

The case was shown with the view of obtaining the opinion of
members as to diagnosis.

The President said he could quite understand any hesitation in
arriving at a definite conclusion as to the nature of this case. He had
had the advantage of palpating it, and the diffusion of the growth
made him strongly suspect malignancy. On the other hand, it seemed
impossible to exclude a gumma. The only way of settling the matter
appeared to him to lie in the removal of a piece for microscopical
examination. This case was, he thought, worthy of detailed discussion.

Dr. Furniss Potter said he could not get the man to admit the
existence of any symptoms previous to three weeks ago. His own
opinion as to the diagnosis lay between malignant disease and gumma.
He proposed giving the patient a course of potassium iodide and
mercury.

128

Case op Chronic Laryngitis with Papillated Thickening op
the Vocal Cord and Chronic Rhinitis.

Shown by Dr. Dundas Grant. The patient was a middle-
aged woman, who for about ten years had suffered from loss of
voice, or, at all events, extreme dysphonia, almost amounting to
aphonia. When seen a week ago there were some green crusts
in the larynx. These were removed by brush after injecting
menthol and olive oil, and a white fringe upon the edge of the
left vocal cord was disclosed; it looked like one of those white
papillomata which have been supposed by some to be malignant,
and by others to be not necessarily so at all. During the week
she had been using a vapour with some turpentine in it, and
had been practising nasal irrigation (as he had always a sus¬
picion in these cases, that the crusts came from the drying up
of the secretion inhaled from the nose), with the result that the
crusts had disappeared to a considerable extent.

On looking at the patient to-day, the fringe-like appearance
on the left vocal cord was seen to be less than before, and a
good deal of the whiteness then visible, was due to the presence
of inspissated mucus on the surface. He did not think the
case was malignant, but it was a question what to call it;
whether to apply that much-discussed word pachydermia to a
portion of it. In any case it was a chronic laryngitis which he
attributed to nasal disease. He was anxious to have the opinion
as to whether it was a neoplasm of the vocal cord or simply an
inflammatory condition. He thought that, in any case, it was
not malignant.

Dr. FitzGerald Powell said he thought this was a case of simple
hypertrophic laryngitis consequent on an abnormal condition of the
nose and pharynx (rhino-pharyngitis sicca). The left cord was
swollen, and there was a small slough apparently on the edge of the cord.
He would like to know if any caustic paint had been applied to the
cord, as that would in all probability account for the white slough.

Mr. Cresswell Baber thought it looked more like thickening of
the vocal cord than papilloma.

The President said that his opinion of the case after examination
inclined him to take a more serious view of it than previous
speakers. There was no doubt a very distinct thickening of the left
cord as opposed to the right, and a certain amount of congestion. The

129

left cord moved freely, but at the same time he would be sorry to say
that the present condition was not the commencement of some malig¬
nant process. A maxim which experience had taught him to recognise
and act upon was, that where one had a localised thickening of one
vocal cord, one had usually the advent of some grave change, depending
either upon general disease such as tubercle or syphilis, or upon local
malignancy.

Dr. Dundas Grant, in reply, said it was difficult to understand why
it should be confined to one vocal cord. They did occasionally find
one vocal cord affected more than the other, particularly in cases of
papilloma. It was sometimes seen on one vocal cord where the
other was perfectly normal, but he did not know whether that was a
very serious question, although worthy of consideration. His own
opinion was, that it was simply a chronic laryngitis, and that the
papillfe of the mucous membrane had become exaggerated. The appear¬
ance of papilloma was, he thought, veiy much exaggerated just now
by the presence of inspissated secretion on the surface. He would
like to show the case again.

7 *

PROCEEDINGS

OF THE

LARYNGOLOGICAL SOCIETY OF LONDON.

Eighty-third Ordinary Meeting, June 5th, 1903.

P. McBride, M.D., F.R.C.P.Ed., President, in the Chair.

James Donelan, M.B., > Secretaries

E. Furniss Potter, M.D., $ aetrc “ ne8.

Present—28 members, 1 visitor.

The minutes of the previous meeting were read and con¬
firmed.

The ballot was taken for the following gentlemen, who were
unanimously elected :

John Aldington Gibb, M.B., C.M.(Aberdeen), London Throat
Hospital.

John Malcolm Farquharson, M.B.(Edin.), M.R.C.P.(Edin.),
2, Coates Place, Edinburgh.

The following cases and specimens were shown :

Large Post-pharyngeal Swelling in a Girl ^t. 9.

Shown by Mr. Waggett. The right side and posterior wall
of the oesophagus was pushed forward by a rounded mass the
size of a pigeon’s egg. A number of enlarged glands was
present below the angle of the jaw on the right side. The
PIR8T SERIES-VOL. X. 8

132

child had been quite well until attacked by measles three years
ago. Enlargement of the cervical glands was noticed soon
afterwards, and nine months ago the large pharyngeal swelling
had first been noticed, and this had latterly increased in size,
causing some difficulty in breathing during sleep. The child
appeared to be in good general health. No lesion was detected
in the lungs, spleen, or lymphatics elsewhere. No family history
of tubercle.

Dr. Foster Macgeagh thought it was a chronic retro-pharyngeal
abscess which had existed for some considerable time, probably tuber¬
cular in origin. Incision he thought would give relief.

Dr. Soanes Spicer thought that usually in a retro-pharyngeal
abscess there was a more gradual shading off of the swelling into the
surrounding tissues.

Dr. Herbert Tilley thought there could be no question as to the
. nature of the swelling; it seemed to possess all the characteristics of a
retro-pharyngeal abscess, and was probably due to suppuration of a
deep cervical gland, the pus from which had.found its way behind the
posterior pharyngeal wall. The gland in question might be tuber¬
cular or not. He had recently seen two such cases; the first super¬
vened within a week of the removal of tonsils and adenoids by the
medical attendant. High temperature and general symptoms of septic
infection characterised the case. At the operation the retro-pharyngeal
swelling was found to consist of an acutely inflamed gland, which
would probably have suppurated in the course of a few days. The
second case was under his care at present, and was noticed at the time
the operation for removal of adenoids was undertaken.

Dr. de Havilland Hall said that in most cases of retro-pharyngeal
abscess the swelling was in the centre, but this seemed to be rather on
one side.

Sir Felix Semon was not so certain that this was an ordinary
retro-pharyngeal abscess. It had not the usual smooth semi-globular
appearance of such a one, but there were dimples on the surface. It
might be a tubercular mass broken down in parts, or even a case of
sarcoma. As to the operation for the removal of adenoids being
followed by retro-pharyngeal abscess, in his own practice he had never
seen such a chain of events, but he had seen two cases in which there
was a co-existence of retro-pharyngeal abscess with enlarged tonsils
and adenoids; the abscess in these cases had, of course, to be
evacuated before performing the operation on the tonsils and
adenoids.

Mr. Charles A. Parker thought this was a case of retro¬
pharyngeal abscess. With regard to Dr. Tilley’s question, he had
seen one case of retro-pharyngeal abscess commencing one month
after the operation for removal of tonsils and adenoids; but in this
case the patient had developed measles a fortnight after the operation,
so that it was quite likely that the abscess was secondary to measles,
and not due to infection after the operation.

133

Mr. E. B. Waggett, in reply, said one could not lightly dismiss the
idea of a sarcoma, but he believed that the swelling was a large mass
of tubercular glands. The enlarged cervical glands were observed
three years ago after an attack of measles, while the pharyngeal mass
made its appearance much later. He proposed to attack the case by
an external operation.

Case of Swelling in Post-nasal Space (shown at Last

Meeting).

Re-shown by Dr. Furniss Potter. When seen in May last
there was a swelling occupying the right half of the naso¬
pharynx, and completely obscuring the right choana. Under
the administration of potassium iodide and mercury the in¬
filtration had completely disappeared. There was nothing
abnormal to be seen now, except that the right Eustachian
cartilage appeared to be somewhat larger and redder than the
left, and there was still slight drooping of the right half of the
soft palate.

Case of Sdpra-nasal Cyst in an Infant 15 Months old.

Shown by Dr. Wyatt Wingrave. The cyst was present at
birth, and had gradually increased in size with the infant's
growth. It was about the size of a small haricot bean, situated
in the middle line of the bridge of the nose. The base was
apparently attached to the periosteum of the nasal bones, but
not to the superjacent skin. No dimple or cleft in the osseous
suture could be felt, nor any evidence of intra-cranial con¬
nection. It did not vary in size, shape, or tension during
crying.

Dr. Wingrave considered it to be a^ simple dermal cyst,
and asked for opinions as to the expediency of dissecting
it out.

Case of Gumma of Epiglottis.

Shown by Mr. de Santi. The patient, a married woman
set. 32, attended the Throat Department of Westminster Hos-

134

pital on April 23rd, complaining of great pain in swallowing
and some dyspnoea. The symptoms had been coming on
gradually for six weeks, and latterly the patient had been
feeling very ill.

Examination of the larynx revealed a very large red, angry,
oedematous swelling of the whole of the epiglottis. No view of
the cords could be obtained. There was no history of cough,
and examination of the chest showed nothing abnormal.

The patient had been treated eight years previously for
syphilis.

A provisional diagnosis of gumma of the epiglottis was made,
and the patient put on iodide of potassium.

After a week’s treatment the swelling began to lessen, and
now there was scarcely any swelling to be seen, just a little
thickening remaining on the left side of the epiglottis.

Enormous Fibro-lipoma of Larynx.

Shown by Mr. P. de Santi. The specimen included the
thyroid bone, larynx, and first ring of the trachea. At the
posterior aspect of the larynx, to the left of the middle line,
was a large pendulous tumour measuring seven and a half
inches from above downwards. It was covered by the mucous
membrane of the pharynx. It consisted of three distinct parts—
two upper portions closely resembling each other, and separated
by a deep sulcus. The right one of these was continuous with
the left side of the epiglottis by a band of mucous membrane,
and it sent a prolongation into the upper aspect of the larynx.
It had been bisected. The cut surface looked like fat, but on
close examination bundles of fibrous tissue were seen passing
through it. The largest part of the tumour was rounded in
shape, measured rather over five inches in length, and was
connected with the two upper portions by mucous membrane.
Anteriorly, where it was attached to the wall of the oesophagus,
it was not covered by mucous membrane. Its cut surface was
similar to that of the portion already described.

History. —J. A—, set. 80, a robust man of active habit, had
been admitted into Westminster Hospital in 1853. About twelve

135

years before lie had suffered from occasional fits of choking,
especially marked when he became excited. This increased in
severity, and a swelling was noticed in the throat. Four years
before death, during vomiting, a large mass protruded from the
mouth, and the patient had to return it as speedily as possible
to prevent suffocation. Sometimes he could swallow solids
better than fluids; he was fairly comfortable if he took food
slowly. The voice was husky, and during excitement often
became inarticulate. The patient died suddenly whilst smoking,
and it was presumed that the fumes of the tobacco produced
sudden cough with displacement of the growth and suffocation.

At the post-mortem examination the viscera generally were
found to be healthy. In addition to the tumour preserved in
the specimen several small ones were noted in its immediate
neighbourhood.

Microscopic examination showed the growth to consist of fat,
arranged in part in layers separated by fibrous tissue. The
mucous membrane covering the growth was separated from it by
a capsule of connective tissue.

The President said that some years ago he had several cases of
fibro-lipoma of the larynx, and in one of them there was a recur¬
rence—a tumour the size of a bantam’s egg grew from the upper
surface of the epiglottis. This he removed, and after some months
recurrence took place, and he removed another tumour just as large.
What especially struck him about this case (and another which he
reported at the same time) was the very small amount of symptoms

{ )roduced in proportion to the size of the tumour. At the time the
iterature on the subject was very scanty, and he was sorry to say it
had not much increased even yet. He thought this subject of lipoma
of the larynx exceedingly interesting, and one which he fancied was
very little touched upon, owing to the fact that there were very few
cases on record, and that the material was insufficient.

Sir Felix Semon said that he had been informed that in the
‘ Transactions of the Pathological Society ’ for 1853 an illustration of
this specimen was published, but there it lay buried and little accessi¬
ble to specialists, both in this and other countries. He thought it
would be a good thing if permission could be obtained from the
Council of the Pathological Society to reproduce this illustration in
the ‘ Proceedings ’ of their own Society, where it would be welcome
abroad generally as well as to themselves. He therefore proposed
that they should approach the Pathological Society with this end in
view.

Dr. de Havilland Hall seconded the proposal of Sir Felix
Semon, which was carried nem. con,

8 §

136

Case op Infiltration op Soft Palate (? Cause).

Shown by Mr. F. J. Steward. George W—, aet. 39, steve¬
dore, came to Guy’s Hospital in August, 1902, suffering from a
quinsy on the right side. This was opened, and at first the
patient seemed to be doing well. A month later, however, the
soft palate was still infiltrated, and the uvula was somewhat
oedematous. This improved at times and again relapsed, so
that on the whole little change took place.

In January, 1903, some change in the voice was noticed, and
found to be due to paresis of the soft palate, which was still
infiltrated. As on inquiry the patient admitted having had
syphilis twenty years ago, he was given iodide of potassium in
increasing doses, and later mercury also. No improvement
took place, but rather the reverse.

In March, 1903, a small sinus was found opening in the right
supra-tonsillar fossa; this was opened up and quickly healed.

The present condition showed some infiltration of the soft
palate and uvula, and complete paralysis of the same parts.
The nose, naso-pharynx, and larynx were normal; the knee-
jerks were present; the pupils reacted normally, and there was
no evidence of paralysis in any other part of the body. There
was no complaint of headache or vomiting, the optic discs were
normal, and, in fact, no evidence of disease of the central
nervous system could be discovered.

Dr. Dundas Grant asked if Mr. Steward had described the con¬
dition found on palpation of posterior nares, or the post-rhinoscopic
appearance.

Sir Felix Semon said he thought it was a matter of regret that the
description of this case was so very brief, and he would like to mention
that the palate was absolutely motionless on phonation, and fluids
regurgitated. The infiltration was not a very prominent feature, and
additionally in his opinion there was a good deal of simulation in
this case. The patient plionated differently on different occasions,
uttering sometimes unearthly sounds, and at other times phonating
quite properly.

Mr. F. J. Steward said there was nothing abnormal to be made out
by post-rhinoscopic examination. In reply to Sir Felix Semon, he said
that the only reason he described it as a case of infiltration of soft
palate was that the infiltration appeared first. The palate moved well
at first, but in March last it became paretic.

Microscopical Section of Gumma of Nasal Septum.

Shown by Dr. Pegler. The patient was a gentleman aet. 30,
who complained of right nasal obstruction following what he
described as a “ cold in the head,” which had lasted long and
had not cleared up. The obstruction was of about three months’
duration, and at one time a fleshy substance, “half as big as a
marble,” had been blown into the handkerchief, attended by
bleeding. Inspection disclosed a red flattish mass in the right
nasal chamber, which, owing to a deflection of the septum to the
same side, was completely blocked. The growth was attached to
the septal cartilage, and considerably overhung its broad basal
attachment. It extended backwards somewhat indefinitely, and
reached upwards to the roof of the fossa. From its outer aspect
numerous fibrous adhesions extended over to the opposite in¬
ferior turbinal. The surface was slightly rough, and easily
penetrated by a probe.

The mass Avas removed under cocaine at one sitting Avith
septum knife aided by scissors and snare, exposing the tri¬
angular cartilage; a strong solution of chloride of zinc Avas
applied to all the remaining portions that could not be de¬
tached.

The patient was seen but once after this, having to rejoin his
company, but he wrote a short time afterwards saying that the
nasal passage had filled up again, and that a small and incon¬
spicuous nodule that had been pointed out in his hard palate
had broken doAvn and formed a huge sore. This fact went far
to justify a diagnosis of syphilis, which the very beautiful
section under the microscope, kindly made for the exhibitor by
Dr. Wingrave, seemed to confirm.

The section was that of “ a granuloma of the mucous mem¬
brane, the coniiecti\ r e-tissue frameAvork of which is infiltrated
Avith small round-cells, which abound especially towards the
circumference ; these granuloma cells exhibit a strong tendency
to develop into fusiform cells and sclerotic tissue. A few
groups of altered racemose glands remain, but there are no
giant-cells, and the periphery is enclosed by a limiting mem-

138

brane destitute of columnar or stratified epithelium. The most
characteristic feature of the specimen, however, is the activity
displayed by the endothelial layer of the connective-tissue cells
of the vascular sinuses and small vessels. The lumen of these
latter is in many instances completely blocked by these cell
masses, exhibiting in a remarkable manner the peculiar features
of endarteritis obliterans.”

Dr. Wyatt Wingrave said, with reference to the histology, that
the most characteristic feature of the section was the endoarterial
changes taking place. There was complete occlusion of some of the
blood-vessels, which was very suggestive of a process allied to syphilitic
conditions.

A Case op Laryngeal Fistula.

Shown by Dr. W. H. Kelson. The patient was a man aged
about 58,. who had cut his throat with a razor in November
last, dividing amongst other structures the thyro-hyoid mem¬
brane and stylo-pharyngeus, thyro-hyoid, omo-hyoid, and sterno¬
hyoid muscles, the result being that the larynx had fallen
downwards and forwards, and that he could not swallow or
speak in an audible voice, though the vocal cords moved per¬
fectly. Suggestions as to treatment were requested.

Mr. Waggett said that Dr. Kelson had allowed him to see the case
beforehand, and the man was very eager to have the fistula closed. It
seemed to him this would be quite the proper thing to attempt, and it
should not be very difficult. The dislocation of the larynx was one of
forward rotation rather than of depression. There was no scar tissue
holding the organ in its abnormal position, and he believed that after
section of the sterno-thyroid muscles it would be possible to bring it
up so as to obtain secure suturing to the base of the epiglottis and
closure of the pharyngeal fistula.

Dr. Lack was inclined to think it would be difficult to close the
fistula from the short examination he had been able to make that day.
He suggested that if it were found impossible to close it, it would be
well to allow the opening into the larynx to remain, but to sew up the
opening into the oesophagus. In this way the man would be able to
swallow perfectly, although he would continue to breathe through the
external opening.

m

Case of Thickening and Impaired Mobility of the Left

Vocal Coed.

Shown by Dr. Lambert Lack. The patient, a man aged about
58, had suffered from hoarseness off and on for the past nine
months. The hoarseness had increased lately, and he was now
almost aphonic. The man’s general health was good, and he
complained of no other trouble.

Upon examination both vocal cords were slightly thickened
and congested, but the left cord was more congested, slightly
more thickened, and it moved less than its fellow. The rest of
the larynx was normal.

The case was shown to elicit opinions as to diagnosis, the
suggestion being that the case was probably one of malignant
disease. The patient had been treated with iodides without
improvement. Was it advisable to wait or to perform an
exploratory thyrotomy at once ?

The President considered the case one in which doubt as to the
cause of defective movement was justifiable. The deficient mobility
seemed most noticeable when the patient laughed. The left cord
appeared to him thickened. Putting all the facts together, he was
inclined to suspect that possibly, if not probably, this might be the
commencement of a malignant process.

Sir Felix Semon agreed entirely with the President’s remarks.

Case of Multiple Sinus Suppuration, showing the Results of
Operation upon the Sphenoidal Sinus, with Demonstra¬
tion of a New Instrument.

Shown by Dr. Lambert Lack. The patient, a woman aet. 25,
had been under the exhibitor’s care for over two years with
suppuration in all the nasal accessory sinuses on the left side.
The antrum had been drilled through the tooth socket, and a
tube was still retained. The ethmoidal cells were then curetted,
and subsequently the frontal sinus was obliterated. Pus still
continuing to come into the nose, and to enter the post-nasal
space, further exploration was carried out, and it was found

140

that the sphenoidal sinus was full of pus. The opening of the
sinus had been brought well into view, as the result of the
removal of the ethmoidal cells. As washing out the cavity
through a cannula inserted into the ostium of the sinus failed to
cure the patient, the opening was enlarged with a HajeVs hook,
and the instrument now shown was then introduced, and the
entire anterior wall of the sinus was cut away. The operation
was easy, and was performed under cocaine anaesthesia without
much pain. The opening made was permanent, and allowed
free drainage of the sinus.

Dr. Herbert Tilley asked what treatment the patient was carry¬
ing out at present, as there still seemed to be some suppurating foci in
the left nasal cavity;

Dr. Dundas Grant said that the difficulty with regard to the
sphenoidal sinuses was not so much that of making an opening as of
keeping the opening, when made, from closing. He asked Dr. Lack
what method he had employed in this case, and whether he had any
difficulty in keeping the opening from contracting, and how long ago
it was since the opening was made.

Dr. Lack, in reply, said that the opening had been made some three
months ago, and showed little if any disposition to close. The only
precaution he took was the removal of the entire anterior wall of the
cavity. The sides and floor of the cavity still remained flush with the
edges of the opening.

Pedunculated Tumour growing prom the Region op the

Right Tonsil.

Shown by Dr. Herbert Tilley. The patient was a boy set. 6
years, in whom a freely movable pedunculated tumour the size
of a Tangerine orange was growing from the right tonsillar
region. It was first noticed two months ago, when the child
complained of choking fits while eating. Since this period the
growth had been twice removed by Dr. Williamson, of Earls-
field, but it had rapidly recurred. As seen at present the
tumour was freely movable, and could be projected towards the
anterior part of the mouth or partially swallowed. The surface
of the tumour was red, granular, and dotted here and there
with small superficial ulcers. It did not bleed when manipu¬
lated, neither had it done so when it had been accidentally bitten

141

by the patient, although, as a result of this, small portions of
the surface had sloughed off.

There was a small, hard, freely movable gland behind the
angle of the right jaw. Dr. Herbert Tilley could not state the
exact region from which the growth sprung, because the lad
was too nervous to examine without an anaesthetic. It was
proposed to remove the growth without delay.

The President would very much like to hear whether any member
had seen a similar case. He had not exactly. He had seen peduncu¬
lated growths, but none which recurred in the way this one did after
removal.

Sir Felix Semon said he spoke at the risk of being a false prophet,
but he was practically certain, from both the description of the
repeated rapid recurrences after operation and from the present aspect
of the tumour, that this was a malignant growth, and the only point
which seemed to be an obstacle to this diagnosis, viz. its pedunculated
nature, was, in reality, no obstacle at all. He might perhaps remind
the Society of a case published by him ten years ago in the ‘ Transac¬
tions * of the Royal Medical and Chirurgical Society; the specimen
was in St. Thomas’s Hospital. The case was one of malignant growth
of the thyroid gland which perforated into the trachea, and from the
moment it did so and met with no resistance it became pedunculated.
The specimen in the museum of St. Thomas’s showed a big mass, very
similar to that in Dr. Tilley’s case, in the trachea, and a smaller mass
besides, which was also pedunculated. In his remarks on the case
Mr. Shattock drew attention to the fact that there was a tendency for
malignant growths, if they perforated into a cavity where they met with
no resistance at all, to become pedunculated. Therefore, having
regard to the rapidity of recurrence and ulcerated appearance of the
growth in conjunction with this tendency, he had little doubt that Dr.
Tilley’s case was one of malignancy.

In answer to Sir Felix Semon, Dr. Herbert Tilley said that he
thought the growth would not turn out to be one of the most malig¬
nant forms of sarcoma, in spite of the fact that it had already
recurred twice after removal. Its non-vascular nature and free
mobility would suggest a preponderance of fibroid tissue rather than
the embryonic tissue associated with the more malignant forms of
sarcoma.

LARYNGOLOGICAL SOCIETY

OP

LONDON.

LIST OF MEMBERS.

1902 .

LONDON:

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

1902.

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, TT.S.A.
Walker, Thomas J., M.D., Peterborough.

DECEASED HONORARY MEMBERS.

Johnson, Sir George . . Died 1896.

Meter, Hans Wilhelm, M.D. . Died 1895.
StOrk, Professor.... Died 1899.

^argngolojical 3ocietj) of ^oubon

LIST OF MEMBERS,

JANUARY, 1902.

INDEX TO ABBREVIATIONS.

Indicating Past or Pretent Officers of the Society.

( P .) President. ( L .) Librarian.

( V.-P. ) Vice-President. ( S ’.) Secretary.

( T .) Tbeabueee. (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.Glasg., 56, Harley street, W.
1899 Agar, Morley, 76, Wimpole street, W.

1893 *Aikin, William Arthur, M.D., 14, Thurloe square, S.W.
1893 Ayres, Charles James, M.D., 55a, Welbeck street,
Cavendish square, W.

O.M. Ball, James Barry, M.D., 12, Upper Wimpole street,
W. C.

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. V.-P.

IV

Elected.

O.M. *Bond, James William, M.D., 26, Harley street, W. C.

V. -P.

O.M. Bowlby, Anthony Alfred, C.M.G., F.R.C.S., 24, Man¬
chester square, W. C. V.-P.

1900 Budd Budd, E. J., 73, South side, Clapham Common.

O.M. Butlin, Henry Trentham, F.R.C.S., 82, Harley street,

W. T. P.

1900 Carson, H. W., F.R.C.S., Craigholm, Upper Clapton, N.E.
1895 Cathcart, George 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., 55, Upper

Berkeley street

1899 Collier, M P. Mayo, F.R.C.S., 133, Harley street, W.

1894 *Cripps, Charles Cooper, M.D., 187, Camberwell grove,

S.E.

0 M. *Crisp, Ernest Henry, 43, Fenchurch street, E.C.

1899 Davis, Henry J., MB., 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., 6, Manchester square, 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 Fergusson, Arnold, F.R.C.S.Ed., 34, Canfield gardens,

Hampstead.

1901 Glegg, Wilfred, M.D., M.R.C P.Ed., Throat Hospital,

Golden square.

1896 Glover, Lewis Gladstone, M.D, 17, Belsize park,
Hampstead, N.W.

O.M. *Grant, J. Dundas, M.A., M.D., F.R.C.S., 18, Cavendish
square, W. C. L. V.-P.

O.M. *Hall, Francis de Havilland, M.D., F.R.C.P., 47, Wim-
pole street, W. L. V.-P. P. C.

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. C.

V

Elected.

1894 Hill-Wilson, A. E., 217, Goldhawk road, W.

O.M. Holmes, W. Gordon, M.D., 27, New Cavendish street, W.

1894 Horne, Walter Jobson, M.B, 4, Clement’s Inn, W.C.
O.M. Hovell, T. Mare, F.R.C.S.Ed., 105, Harley street, W.
1901 Hudson, A. A., M.D.Ed., 3, Ellerdale road, N.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., 16, Old Bur¬
lington street, W.

O.M. Kidd, Percy, M.D , F.R.C.P., 60, Brook street, Grosvenor
square, W. C.

1895 *Lack, Lambert Harry, M.D., F.R.C.S., 48, Harley

street, W. 8. C.

1893 Lake, Richard, F.R.C.S., 19, Harley street, W. C.

O.M *Law, Edward, M.D., 8, Wimpole street, W. C. F.-P.
O.M. Lawrence, Laurie Asher,. F.R.C.S., 9, Upper Wimpole

street.

1899 Lazarus, A. B., M.B., C.M.Edin., 77, Wimpole street, W.
O.M. Macdonald, Greville, M.D., 85, Harley street. C. F.-P.
1895 *Macgeagh, T. E. Foster, M.D., 23, New Cavendish street,

W.

1894 Mackenzie, Hector William Gavin, M.D., F.R.C.P., 34,

Upper Brook street, W.

1894 Mackern, George, M.D., c/o Dr. P. Kidd, 60, Brook

street.

1900 Mackintosh ,J. S., St. Ives, Platts lane, Hampstead.

1900 Nourse, Chichele, F.R.C.S.Ed., Abchurch House, Sher¬
borne Lane, King William street, E.C.

1897 Paget, Stephen, F.R.C.S., 70, Harley street, W.

O.M. Parker, C. A., F.R.C.S.Ed., 141, Harley street. S.

1893 *Pegler, Louis Hemington, M.D., 2, Henrietta 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., 49, Queen Anne 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.

VI

Elected.

1897 Ramsay, Heebeet, F.R.C.S., 85a, 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.

1893 Santi, Philip Robeet William de, M.B., F.R.C.S., 15,

Stratford place, Cavendish square, W.

1896 Schoestein, Gustave, M.B., F.R.C.P., 11, Portland place,
W.

O.M. # Semon, Sie Felix, M.D., F.R.C.P., 39, Wimpole street, W.
P. F.-P. C.

1894 Shaeman, Henet, M.D., Sedgmore, Arkwright road, N.W.
1898 Snell, Sydney, M.D., Trinity road, Wandsworth Common.

1893 Spencee, Waltee Geoege, M.S., F.R.C.S., 35, Brook

street, Grosvenor square, W. C.

1898 Spicee, Feedk., M.D., 17, Wimpole street, Cavendish
square, W.

O.M. Spicee, Scanes, M.D., 28, Welbeck street, Cavendish
square, W. 8. G. F.-P.

1895 Stephen, G. Caldwell, M.D., 54, Evelyn gardens, South

Kensington.

1898 Stewaed, Feancis J., M.S., F.R.C.S., 24, St. Thomas’s
street, S.E.

O.M. Stewaet, William Robeet Heney, F.R.C.S.Ed., 42,
Devonshire street, Portland place, W. 8. C. F.-P. T.

O.M. *Symonds, Chaetees James, M.S., F.R.C.S., 58, Portland
place, W. G. F.-P.

1894 *Thomson, StClaie, M.D., 28, Queen Anne street, Caven¬

dish square, W. 8. C. L.

1896 *Thoene, Atwood, M.B., 10, Nottingham place, W.

1893 Tilley, Heebeet, M.D., B.S., F.R.C.S., 89, Harley street,
W. S. G.

1900 Tod, Huntee F., M.B., London Hospital, E.

1990 Vineace, Dennis, 24, Alexander square, S.W.

1893 Waggett, Eenest Blechynden, M.B., 45, Upper Brook
street, Grosvenor square, W. 8. G.

VI1

Elected.

O.M. Walsham, William Johnson, M.B., F.R.C.S., 77, Harley
street, W. T.

1896 Whait, J. R., M.D., C.M., 124, Finchley road, Hampstead.
O.M. Willcocks, Frederick, M.D., F.R.C.P., 14, Mandeville

place, Manchester square, W.

1900 Willey, F. J. I., M.B., B.S.Dur., The Wych, Avenue road,
Highgate.

O.M. *Will8, William Alfred, M.D., M.R.C.P., 29, Lower
Seymour street, W.

1897 *Winorave, V. H. Wyatt, M.D.Dur., 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. P.

1895 Bark, John, F.RC S.Ed., M.R.C.P.I., 54, Rodney street,
Liverpool.

1895 Baron, Barclay J., M.B., 16, Whiteladies 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. F.-P.

1895 Brady, Andrew John, 3, Lyons terrace, Hyde park,
Sydney, New South Wales.

1901 Braine-Hartnell, J. C. R., Cotswold Sanatorium, Stroud,

Clos.

O.M. Bronner, Adolph, M.D., 33, Manor row, and 8, Mount
Royd, Bradford. C. V.-P.

1894 Brown, Alfred, M.D., Sandy croft, Higher Broughton,
Manchester.

1902 Browne, J. M., M.B., 27, Wellington road, Cork,

1898 Burt, Albert H,, 34, Montpelier road, Brighton.

VI11

Elected.

1893 Charsley, 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.

1900 D’Esterre, J. N., 11, Seaside road, Eastbourne.

1895 Downie, J. Walker, M.B., 4, Woodside crescent, Glasgow
1898 Foxcroft, F. W., M.B., 33, Paradise street, Birmingham.
1898 Frazer, Wm., Johannesberg, South Africa.

1902 Green, A. S., M.B., B.S, 9, West Parade, Lincoln.

1900 Hayes, George Constable, F.R.C.S., 22, Park Place,
Leeds.

1897 Herdman, Ronald T., M.B., C.M., Gw&o, Rhodesia,

South Africa.

O.M. Hodgkinson, Alexander, M.B., 18, St. John street,
Manchester. F.-P.

1894 Hunt, John Middi^emass, M.B., C.M., 55, Rodney street,

Liverpool.

1898 Hutchison, A. J., M.B., 84, Lansdowne street, Brighton.
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.

1990 Klemperer, Felix, M.D., 42, Dorrotheen Strasse, Berlin.

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.
O.M. *McBride, Peter, M.D., F.R.C.S.Ed., 16, Chester street,
Edinburgh. F.-P.

1898 Marsh, F., F.R.C.S., 95, Cornwall street, Birmingham.

1893 Milligan, William, M.D., 28, St. John street, Manchester.
C.

O.M. Newman, David, M.D., 18, Woodside place, Glasgow.

C.

1990 O’Kinealy, Capt., I.M.S., c/o Messrs. King and Co.
Calcutta.

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.

IX

Elected.

1899 Reid, St. George Caulfield, Thornton Heath, Croydon
1895 *Ridley, W., P.R.C.S., Ellison place, Newcastle-on-Tvne.

1895 *Sandford, Arthur W., M.D., M.Ch., 13, St. Patrick’s

place, Cork, Ireland.

1898 Scatliff. J., M.D., 11, Charlotte street, Brighton.

1900 Skelding, H., M.B., B.C.Camb., St. Loyes, Bedford.

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.
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.

1901 Yonge, E. S., M.D.Edin., 3, St. Peter’s square, Manchester.

X

LIST OF EXCHANGES.

Periodicals :

The Journal of Laryngology, Rhinology, and Otology (London).
Archiv fur Laryngologie (Berlin).

Revue Hebdoinadaire de Laryngologie, etc. (Bordeaux).
Archivii Italiani di Laringologia (Naples).

Annales des Maladies de 1’Oreille, du Larynx, etc. (Paris).
Bollettino delle Malattie dell’ Orecchio, etc. (Florence).

The Laryngoscope (St. Louis, U.S.A.).

Monatsschrift fur Ohrenheilkunde, etc.

Archivio Italiano di Otologia (Turin).

Archives Internationales de Laryngologie, Otologie, et Rhino-
logie (Paris).

La Parole (formerly Revue de Rhin., Otol., et Laryn.).

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.

Niederliindische Gesellschaft fur Hals-, Nasen-, und Ohren¬
heilkunde.

Laryngologische Gesellschaft zu Berlin.

Medical Society.

Brighton and Sussex Medico-Chirurgical Society.

INDEX

PAGE

Abductor paralysis, and paralysis of palatal muscles, with slight paresis

of tongue (J. Dundas Grant, M D.) . 24, 30

-double, with swelling of arytenoids (C. A. Parker) . . 5

Abscess of hard palate and of septum nasi following left antral em¬
pyema (Hunter Tod) . . . . . .9

Adductors of vocal cords, clonic contractions of (F. J. Steward) . . 84

Air channels and currents in nasal cavities in normal and impeded
nasal respiration demonstrated by working model (R. H. Scanes
Spicer, M.D.) . ... . .7

Air-pressure: lantern demonstration showing normal fluctuations of air-

pressure in upper respiratory tract (R. H. Scanes Spicer, M.D.) . . 30

Alveolar border: epulides or symmetrical swellings of gum at posterior

ends of alveolar border (W. G. Spencer) . . . .59

Amyloid disease: case of chronic oedema of larynx. P Amyloid (J.

Dundas Grant, M.D.) . . .76

Ankylosis of left crico-arytenoid articulation (J. Donelan, M.B.). . 70

Anosmia: case for diagnosis and suggestions as to treatment (P.

McBride, M.D.) . . . . . .88

Antrum, maxillary (disease of), double antral and frontal sinus disease;
left side cured by radical operation; question of operating on the
right side (Hunter Tod) . . . . .10

-empyema (chronic) of both frontal sinuses and maxillary

antra; obliteration of maxillary sinuses following radical operation
(H. Tilley, M.D.) . . .101

-(left), empyema of, followed by abscess of hard palate and

of septum nasi (Hunter Tod) . . . .9

Aphonia, functional, with unusual symptoms (H. Lambert Lack, M.D.) 50, 92

Arytenoid: interarytenoid pseudo-pachydermic swelling in case of

chronic laryngitis (J. Dundas Grant, M.D.) . . .61

-cartilage (right), infiltration with lardaceous-looking substance

(Sir F. Semon, M.D.) . . . . . .11

Arytenoids, swelling of, in case of double abductor paralysis (C. A.

Parker) . .5

Baber (E. Cresswell), extensive fenestration of the anterior pillars of

the fauces . . . . .4

-tumour of vestibule of nose . . .85

-tongue-depressor for exposing the tonsil . .86

Balance-sheet (1902) . . . . .42

Baron (Barclay J., M.B.), case of naso-pharyngeal malignant disease 54

Bones of nose : dislocation due to polypi (W. H. Kelson, M.D.) . . 80

Bronchocele cause of immobility of left vocal cord : resection; extirpation

of isthmus and left lobe (J. Dundas Grant, M.D.) . . 114

Bronner (Adolph, M.D.), drawing with notes of a case of suppurative
ethmoiditis and frontal sinusitis after radical operation for nasal
polypi .48

-specimen of columnar-celled carcinoma of the naso-pharynx from

a man set. 63 ,

79

144

Burt (A. Hamilton), case of epithelioma
set. 24

--case of exophthalmic goitre .

PAGE

of tongue in a single woman

. 16
. 118

Carcinoma of naso-pharynx, columnar-celled (A. Bronner, M.D.)

-section of right inferior turbinate body. ? Carcinomatous (R. Lake)

Cerebral nerves: see Nerves (cerebral).

Clonic contractions of palate, adductors of vocal cords, and certain other
muscles (F. J. Steward) . . • •

Clonic spasm of muscles of palate and pharynx causing entotic tinnitus
(L. H. Pegler, M.D.) ......

--of soft palate causing objective noises in pharynx (L. H.

Pegler, M.D.) .

Council: report for session 1902 .....

Crico-arytenoid articulation (left), ankylosis of (J. Donelan, M.B.)

Cricoid cartilage, papilloma (large) from posterior aspect of (R. Lake)
Cyst of epiglottis (H. FitzGerald Powell, M.D.)

_of ventricle of larynx, microscopic section (H. Lambert Lack, M.D.)

-supra-nasal, in an infant (V. Wyatt Wingrave, M.D.) .

79

52

84

105

106
41
70

124

16

51

133

Davis (H. J., M.B.), case of swelling of right side of larynx (for diagnosis) 98
Deflection (nasal): septotome for use in Moure’s and other operations for

deflection (L. H. Pegler, M.D.) . . . . .65

Diagnosis, cases for: anosmia (P. McBride, M.D.) . . . • 88

—-dysphagia, inclosing, in case of probable pharyngeal epithelioma

(J. Dundas Grant^w.D.) . • .38

-growth on left vocal cord (P. de Santi) . . .3

-polypoid tumour of nasal septum (Hunter Tod) . . 72

-swelling in post-nasal space (E. Furniss Potter, M.D.) . 127, 133

-of larynx on right side (H. J. Davis, M.B.) . . 98

Dislocation of bones of nose due to polypi (W. H. Kelson, M.D.) . 80

Donelan (James, M.B.), pedunculated laryngeal growth, probably dating

from birth, in a hoy set. 15 years . . . .7

-specimen of large naso-pharyngeal fibro-myxoma with prolongation

extending to anterior nares . . . . .54

_case of ankylosis of left crico-arytenoid articulation in a woman

set. 23 . • • • • .70

_case of perforation of the nasal septum. ? Trauma or syphilis . 94

_case of pharyngeal and laryngeal lesions in a woman set. 28 . 107

_case of subglottic thickening of right vocal cord in a man set. 27 . 124

Dysphagia, increasing, in case for diagnosis, probably pharyngeal epi¬
thelioma (J. Dundas Grant, M.D.) . . . .38

Ear: see Eustachian tube.

Empyema of left antrum followed by abscess of hard palate and of septum

nasi (Hunter Tod) . ... . . .9

-of sphenoidal sinus (chronic): opened (E. B. Waggett) . . 114

_(chronic) of both frontal sinuses and maxillary antra (H. Tilley,

M.D.) . • • • • • 101

Epiglottis, cyst of (H. FitzGerald Powell, M.D.) . . .16

__ epithelioma, advanced and inoperable: removal by “ morcellement ”

of primary growth through mouth (H. Tilley, M.D.) . . 35

_gumma of (P. R. W. de Santi) .... 133

-removal, in case of tuberculous disease (R. Lake) . . 6

Epistaxis, persistent, case of (H. Lambert Lack, M.D.) . . 23

Epithelioma of epiglottis, advanced and inoperable: removal by “ morcelle¬
ment ” of primary growth through mouth (H. Tilley, M.D.) . 35

-of larynx (Attwood Thorne) .... 56, 121

_disease of larynx of twelve months’ duration, probably epi¬
thelioma (J. Dundas Grant, M.D.) . . . 116

145

PAGE

Epithelioma of pharynx: increasing dysphagia in case of probable pharyn¬
geal epithelioma, for diagnosis (J. Dundas Grant, M.D.) . . 38

——— of tongue in single woman ret. 24 (A. Hamilton Burt) . 16

Epulides or symmetrical swellings of gum at posterior ends of alveolar

border (W. G. Spencer) . . . . .59

Ethmoiditis, suppurative, with frontal sinusitis following radical operation

for nasal polypi (A. Bronner, M.D.) . . .48

Eustachian tube (right), malignant disease in neighbourhood of (E. B.

Waggett) . . . .75

Face : lupus (?) of nose and face (D. Vinrace) . .87

Fauces, lupus of (W. H. Kelson, M.D.) .... 122

-(pillar, anterior), hereditary specific perforation of (J. Dundas

Grant, M.D.) . . . 60

-ulcerating growth of, involving also left tonsil and

side of tongue (H. FitzGerald Powell, M.D.) . 112

-pillars, anterior, extensive fenestration (E. C. Baber) . . 4

Fenestration of anterior pillars of fauces (E. C. Baber) . . 4

Fibro-lipoma of larynx, enormous (P. R. W. de Santi) . . 134

Fibroma of naso-pharynx, vascular, method of removal (Herbert Tilley,

M.D.) .19

Fibro-myxoma of naso-pharynx with prolongations extending to anterior

nares: specimen shown (J. Donelan, M.B.) . .54

Fistula of larynx (W. H. Kelson, M.D.) .... 138

Forceps : new design for sphenoidal sinus cutting forceps (P. Watson

Williams, M.D.) . . .46

Glands (cervical), secondary infection in case of advanced and inoperable

epithelioma of larynx (H. Tilley, M.D.) . . . .35

Goitre, exophthalmic, case of (A. H. Burt) . . .118

Grant (J. Dundas, M.D.), a case of paralysis of the abductors of the vocal
cords and of the palatal muscles, and slight paresis of the tongue in a
man set. 25 . - . . . . 24, 36

-case of comparative hemiansesthesia in a young female, with sub¬
jective nasal obstruction on the affected side . . .37

-case of increasing dysphagia of six months’ duration in a middle-

aged man (for diagnosis); probably pharyngeal epithelioma . 38

-case of hereditary specific perforation of the anterior pillar of the

fauces . . . . . . .60

-case of chronic laryngitis with interarytrenoid pseudo-pachydermic

swelling, probably due to purulent rhinitis . . .61

-case of chronic oedema of larynx. ? Amyloid . . .76

-case of immobility of the left vocal cord, attributable to broncho-

cele, in a young woman: resection j extirpation of isthmus and left
lobe . . . . . . .114

-case of paresis of both recurrent laryngeals and left sympathetic in

a middle-aged woman . . . . .115

-case of disease of the larynx of twelve months’ duration, probably

epithelioma, in a man ret. 50 . . . .116

-case of chronic laryngitis with papillated thickening of the vocal

cord and chronic rhinitis ..... 128

Growth in post-nasal space appearing below soft palate in an infant (H.

FitzGerald Powell, M.D.) . . . . .58

-involving left inferior turbinate and septum : recurrence (R. Lake) 52

-of larynx, case of (V. Wyatt Wingrave, M.D.) . . . 36

--pedunculated, probably dating from birth (J. Donelan,

M.B.) ....... 7

-on left vocal cord (P. R. W. de Santi). .3

(R. Lake)

52

146

PAGE

Growths, nasal, of type of “bleeding polypus" of septum (A. Brown

Kelly, M.B.). . . . . . .66

Gum: epulides or symmetrical swellings of gum at posterior ends of

alveolar border (W. G. Spencer) . . .59

Gumma of epiglottis (P. R. W. de Santi) .... 133

-of nasal septum, microscopical section (L. H. Pegler, M.D.) 137

Hemianaesthesia, comparative, with subjective nasal obstruction on

affected side (J. Dundas Grant, M.D.) . . .37

Herpes: case of recurring ulceration in pharynx and larynx, thought

to be herpetic (E. Fumiss Potter, M.D.) . . . .18

Infant: growth in post-nasal space appearing below soft palate in

infant (H. FitzGerald Powell, M.D.) . . . .58

-supra-nasal cyst in (Y. Wyatt Wingrave, M.D.) . . 133

Infiltration of soft palate. P Cause (F. J. Steward) . . . 136

-of pharynx and post-nasal space (H. FitzGerald Powell, M.D.) 58

-lardaceous-looking, of uvula, soft palate, and right arytenoid

cartilage in a lady set. 30 (Sir F. Semon, M.D.) . . .11

Instrument, new, for operation upon sphenoidal sinus (H. Lambert Lack,

M.D.) . . . . . . .139

Interarytaenoid region : large swelling of mucous membrane in interary¬
tenoid region (so-called interarytenoid “ pachydermia") (H. Tilley,
M.D.) . . . . . .53

Kelly (A. Brown, M.B.), microscopical sections of nasal growths of the

type of “ bleeding polypus of the septum " . . .66

Kelson (W. H., M.D.), case of laryngeal growth in a woman . . 60

-case of nasal tumour in a man set. 26 . . . .60

-a case of dislocation of bones of nose due to polypi, in a man set. 60 80

-case of bleeding polypus of the nose in a girl set. 15 . .81

-■ case of laryngeal disease . . . .98

-case of lupus of fauces ..... 122

--a case of laryngeal fistula ..... 138

Lack (H. Lambert, M.D.), case of complete adhesion of soft palate to

posterior wall of pharynx . . .22

-case of functional aphonia in a man, with unusual symptoms 50,92

-sections of ulcer of tonsil showing tubercles, but which had yielded

to antisyphilitic remedies . . . . .50

- microscopic section of cyst of ventricle of larynx opened when

operating on a case of malignant disease . . .51

-case and microscopic sections of cedematous thickening of larynx

and palate in a boy (previously shown at the Society) . . 93

-microscopic sections of mucous patches of tonsils . . 94

-case of multiple sinus suppuration, showing the results of opera¬
tion upon the sphenoidal sinus, with demonstration of a new instru¬
ment ....... 139

-case of thickening and impaired mobility of the left vocal cord . 139

Lake (Richard), case of removal of the epiglottis for tuberculous disease

in a male aet. 35 . . . . .6

-pathological specimens shown:—[(1) Section of new growth removed

from posterior extremity of inferior turbinate body ; (2) recurrence
of growth involving left inferior turbinate and septum; (3) section of
right inferior turbinate. P Carcinomatous] . . .52

-case of laryngeal tuberculosis . . . .64

-microscopical section of a tuberculous pachydermia from the pro¬
cessus vocalis. . . . . . .46

-- case of ulceration of tonsil ..... 123

147

PAGE

Lake (Richard), microscopic specimens: —(1) Large papilloma from posterior

aspect of cricoid cartilage; ( 2 ) papilloma from region of inferior turbinal 124
Laryngitis (chronic), case with interarytenoid pseudo-pachydermic swell¬
ing, probably due to purulent rhinitis (J. Dundas Grant, M.D.) . 61

--case with papillated thickening of vocal cord and chronic

rhinitis (J. Dundas Grant, M.D.) .... 128

-hypertrophica, following prolonged nasal trouble (Hunter Tod) 29

Larynx (disease of), obscure case (W. H. Kelson, M.D.) . . 98

-epithelioma of (Attwood Thorne) . . . 56, 121

-disease of larynx of twelve months* duration, probably

epithelioma (J. Dundas Grant, M.D.) . . .116

-fibro-lipoma, enormous (P. R. W. de Santi) . . . 134

-fistula of (W. H. Kelson, M.D.) .... 138

--growth of (V. Wyatt Wingrave, M.D.) 36

-(W. H. Kelson, M.D.) . . .60

-pedunculated, probably dating from birth (J. Donelan, M.B.) 7

—-lesions of larynx with pharyngeal lesions (J. Donelan, M.B.) . 107

-obstruction of (W. R. 11. Stewart) . . . .73

-oedema, anatomical preparations demonstrating artificial produc¬
tion of (A. Logan Turner, M.D.) . . .33

-chronic. ? Amyloid (J. Dundas Grant, M.D.) . . 76

- (stenosis), abnormal narrowing of larynx and trachea, probably

congenital (A. Logan Turner, M.D.) . . . 33

-swelling on right side—case for diagnosis (H. J. Davis, M.B.) . 98

-thickening (oedematous) of larynx and palate : case and micro¬
scopic sections (H. Lambert Lack, M.D.) . . . .93

-tuberculosis of (R. Lake) . . . . .64

--ulceration, recurring, considered herpetic (E. Furniss Potter, M.D.) 18

-(ventricle): microscopic cyst of ventricle of larynx (H. Lambert

Lack, M.D.) . . . . . .51

La^wbence (L. A.), case of a woman set. 37, with ulceration of the soft

palate . . . . . 108

Lead-poisoning, causing paralysis of left vocal cord (C. J. Symonds) . 64

Librarian, report for DK)2 . . . . . .43

Library of the Society, new arrangements regarding . . .43

Lupus of fauces (W. II. Kelson, M.D.) .... 122

-? of nose and face (D. Vinrace) . . . .87

-of septum: rapid destruction of nasal septum, probably lupus (V.

Wyatt Wingrave, M.D.) ..... 117

Lymphatic glands, cervical, acute enlargement on both sides of neck in

case of ulceration of left tonsil (Sir F. Semon, M.D.) . 13, 46

Malformation of oesophagus, specimen (F. J. Steward) . . .28

Malignant disease excluded in case of ulceration of left tonsil, with acute
enlargement of cervical lymphatic glands on both sides of neck (Sir
F. Semon, M.D.) . . . . . .46

-in neighbourhood of right Eustachian tube (E. B. Waggett) 75

-of naso-pharynx (J. Barclay Baron, M.B.) . . 54

Malignant stricture of oesophagus, upper end (A. Logan Turner, M.D.) . 34

McBride (P., M.D.), case of anosmia (for diagnosis and suggestions as to

treatment) . . . . . . .88

Model: readily improvised working model to demonstrate air-channels and
currents in nasal cavities in normal and impeded nasal respiration
(R. H. Scanes Spicer, M.D.) . . . . .7

Morbid Growths Collection, report of Curator . . .43

Morbid Growths Committee, reports . . . 63, 64, 97

" Morcellement ** of primary growth through mouth in relief of inoperable

primary epithelioma of epiglottis (H. Tilley, M.D.) . . 35

Moure’s operation for deflection, septotome for use in (L. H. Pegler, M.D.) 65

Mouth, strumous ulcers of (W. R. H. Stewart) . . .28

148

PAGE

Mucous membrane: large swelling of mucous membrane in interarytenoid

region (so called interarytenoid “pachydermia”) (H. Tilley, M.D.) . 53

Mucous patches of tonsils : microscopic sections (H. Lambert Lack, M.D.) 94

Muscles (palatal): paralysis, with paralysis of abductors of vocal cords and

slight paresis of tongue (J. Dundas Grant, M.D.) . . 24, 36

Naso-pliarynx, carcinoma, columnar-celled (A. Bronner, M.D.) . . 79

-fibroma, vascular, method of removal (Herbert Tilley, M.D.) . 19

-fibro-myxoma, with prolongations extending to anterior nares;

- specimen shown (J. Donelan, M.B.) . . . .54

-malignant disease of (Barclay J. Baron, M.B.) . . 54

-see also Post-nasal space.

Nerve (sympathetic) : paresis of both recurrent laryngeals and left sympa¬
thetic (J. Dundas Grant, M.D.) . ... 115

Nerves (cerebral) implicated early in case of tabes (Sir F. Semon, M.D.,

C.V.O.) . . . . . . .68

-(laryngeal) : paresis of both recurrent laryngeals and left sympa¬
thetic (J. Dundas Grant, M.D.) . . . . .115

Nose, bones of : dislocation due to polypi (W. H. Kelson, M.D.) . . 80

-(cavities) : working model to demonstrate air-channel^ and currents

in nasal cavities in normal and impeded nasal respiration (E. H.
Scanes Spicer, M.D.) . . . . . .7

-(deflection): septotome for use in Moure’s and other operations for

deflection (L. H. Pegler, M.D.) . . . . .65

-deformity, case of (W. E. H. Stewart). . . .27

-(growths): microscopical sections of nasal growths of type of

“bleeding polypus of septum” (A. Brown Kelly, M.B.) . . 66

-laryngitis hypertrophica following prolonged nasal trouble (Hunter

Tod) . . . . . . .29

-lupus (?) of nose and face (D. Vinrace) . . .87

-(obstruction) : subjective nasal obstruction on affected side in case

of comparative hemianesthesia (J. Dundas Grant, M.D.) . . 37

-polypus, bleeding (W. H. Kelson, M.D.) . . .81

-radical operation for nasal polypi followed by suppurative

ethmoiditis and frontal sinusitis (A. Bronner, M.D.) . . 48

-respiration through : see Respiration (nasal).

-(septum) : abscess of hard palate and of septum nasi following left

antral empyema (Hunter Tod) . . . . .9

-‘"bleeding polypus of” (A. Brown Kelly, M.B.) . . 66

-gumma; microscopical section (L. H. Pegler, M.D.) . 137

-localised psorospermosis of mucous membrane of septum

nasi (Capt. O’Kinealy) . * . . 109

---perforation due either to trauma or syphilis (J. Donelan,

M.B.) . . . . . . .94

-polypoid tumour of nasal septum (Hunter Tod) . .72

-rapid destruction, probably lupus (V. Wyatt Wingrave,

M.D.) . . . . . . . 117

-specimen of recurrence of growth involving left inferior

turbinate and septum (E. Lake) . . .. .52

-tubercular ulceration (primaiy) (E. B. Waggett) . 125

-tumour in (W. H. Kelson, M.D.) . . .* .60

-(vestibule), tumour of ; microscopic section (E. Cresswell Baber) . 85

-see Sinuses (nasal accessory).

-see Supra-nasal cyst.

Nostrils (anterior), prolongations of large naso-pharyngeal fibro-myxoma

extending to (J. Donelan, M.B.) . . . .54

(Edema of larynx, anatomical preparations demonstrating artificial pro¬
duction of (A. Logan Turner, M.D.) . . . .33

-of larynx, chronic. P Amyloid (J. Dundas Grant, M.D.) . .76

149

PAGE

(Esophagus, malformation, specimen (F. J. Steward) . . .28

- (stricture): specimen of malignant stricture of upper end (A. Logan

Turner, M.D.) . . . .34

Officers for session BK)3 . . . .41

O’Kinealy (Capt.), microscopic section of localised psorospermosis of the
mucous membrane of the septum nasi (with pathological report by
Major J. C. Vaughan, I.M.S.) .... UK), 110

“ Pachydermia,” interarytienoid, so-called (large swelling of mucous mem¬
brane in interarytamoid region) (H. Tilley, M.D.) . .53

-tuberculous, from processus vocalis; microscopical section (R.

Lake) . . . .64

Palate, clonic contractions of (F. J. Steward). . . .84

-cedematous thickening of larynx and palate ; case .and microscopic

sections (II. Lambert Lack, M.D.) . . . .93

-(hard): abscess of hard palate and of septum nasi following left

antral empyema (Hunter Tod) . . . .9

- (soft) adhesion, complete, to posterior wall of pharynx (II. Lambert

Lack, M.D.) . . . . . .22

--adhesion to posterior pharyngeal wall, operative procedure

for relief of (H. Tilley, M.D.) . . . .81

-clonic spasm of, causing objective noises in pharynx (L. H.

Pegler, M.D.) ...... 106

-clonic spasm of muscles of palate and pharynx causing

entotic tinnitus (L. H. Pegler, M.D.) .... 105

-growth in post-nasal space appearing below soft palate in

infant (H. FitzGerald Powell) . . . . .58

-infiltration. ? Cause (F. J. Steward) . 136

--with lardaceous-looking substance (Sir F. Semon,

C.V.O., M.D.) . . .11

-ulceration of (L. A. Lawrence) . 108

-see Muscles (palatal).

Papillated thickening of vocal cord in case of chronic laryngitis (J. Dundas

Grant, M.D.) . . % . .128

Papilloma from region of inferior turbinal (R. Lake) . 124

-large, from posterior aspect of cricoid cartilage (R. Lake) . 124

--- of right ventricular band removed by thyrotomy (E. B.

Waggett) . . . . . . .113

Paralysis, abductor, double, with swelling of arytenoids (C. A. Parker) 5

-of abductors of vocal cords and of palatal muscles, and slight

paresis of tongue (J. Dundas Grant, M.D.) . . 24, 36

-of left vocal cord due to lead poisoning (C. J. Symonds) . . 64

Paresis of both recurrent laryngeals and left sympathetic (J. Dundas

. Grant, M.D.) . . . . . .115

-of tongue, slight, in case of paralysis of abductors of vocal cords

and of palatal muscles (J. Dundas Grant, M.D.) . . 24, 36

Parker (Charles A.), case of double abductor paralysis with swelling of

the arytenoids in a man set. 38 . . . . .5

-case of persistent epistaxis in a man set. 42 . .23

Pedunculated laryngeal growth, probably dating from birth (J. Donelan,

M.B.) . . . .7

-tumour growing from region of right tonsil (II. Tilley, M.D.) 140

Pegler (L. H., M.D.), septotome for use in Moure’s and other operations

for deflection . . . . .65

-a case of clonic spasm of the muscles of the palate and pharynx

causing entotic tinnitus in a lady set. 30 . . . . 105

-clonic spasm of the soft palate causing objective noises in the

pharynx in a woman aet. 20 . . . 106

-microscopical section of gumma of nasal septum . 137

150

PAGE

Perforation of nasal septum: case due either to trauma or syphilis (J.

Donelan, M.B.) . . . . . .94

-(syphilitic): hereditary specific perforation of anterior pillar of

fauces (J. Dundas Grant, M.D.) . * . . .60

Pharynx : clonic spasm of muscles of palate and pharynx causing entotic

tinnitus (L. H. Pegler, M.D.) . . •. . . 105

-clonic spasm of soft palate causing objective noises in (L. H. Pegler,

M.D.) . . . . . .106

-(epithelioma), increasing dysphagia in case of probable pharyngeal

epithelioma—for diagnosis (J. Dundas Grant, M.D.) . . 38

-infiltration of pharynx and post-nasal space (H. FitzGerald Powell,

M.D.) . . . . . . .58

-lesions of pharynx with laryngeal lesions (J. Donelan, M.B.) . 107

-ulceration, recurring, considered herpetic (E. Furniss Potter, M.D.) 18

-wall of, posterior, adhesion of soft palate to: operative procedure

for relief (H. Tilley, M.D.) . . . . .81

-complete adhesion of soft palate to (H. Lambert

Lack, M.D.) . . . . . . .22

- see Post-pharyngeal swelling.

Pillar of fauces, anterior, ulcerating growth of, involving also left tonsil

and side of tongue (H. FitzGerald Powell, M.D.) . . . 112

-hereditary specific perforation of (J. Dundas Grant,

M.D.) ... . . . .60

Pillars of fauces, anterior, extensive fenestration of (E. Cresswell Baber) . 3

Poisoning: see Lead-poisoning.

Polypus (of nose), bleeding (W. H. Kelson, M.D.) . . .81

-dislocation of bones of nose due to polypi (W. H. Kelson,

M.D.) . . . . . .80

-radical operation for nasal polypi followed by suppurative

ethmoiditis (A. Bronner, M.D.). . . . .48

-(of septum): nasal growths of type of bleeding polypus of septum

(A. Brown Kelly, M.B.) . . . . .66

-polypoid tumour of nasal septum (Hunter Tod) . .72

Post-nasal space ; growth in post-nasal space appearing below soft palate

in infant (H. FitzGerald Powell, M.D.) . . . .58

-infiltration of pharynx and post-nasal space (H. FitzGerald Powell,

M.D.) . . . . . . .58

-swelling in: case for diagnosis (E. Furniss Potter, M.D.) . 127, 133

Post-pharyngeal swelling (large) (E. B. Waggett) . . . 131

Potter (E. Furniss, M.D.), case of recurring ulceration in pharynx and

larynx, thought to be herpetic, in a woman set. 56 . . .18

-case of disease of both frontal sinuses in a man set. 29 .75

-case of singer's nodule (left vocal cord) . . . 100

-case of swelling in post-nasal space (for diagnosis) . 127, 133

Powell (H. FitzGerald, M.D.), case of cyst of the epiglottis in a male

set. 40 . . . . . . .16

-case of growth in post-nasal space appearing below soft palate in

an infant set. 18 months . . . . .58

-case of infiltration of pharynx and post-nasal space in a man

S8t. 45 . . . . 58

-case of ulcerating growth of left tonsil, side of tongue, and anterior

faucial pillar. . . . . . .112

Processus vocalis, tuberculous pachydermia from; microscopical section

(R. Lake) . . . . . . .64

Psorospermosis, localised, of mucous membrane of septum nasi (Capt.

O'Kinealy) ....... 109

Respiration (nasal): working model to demonstrate air-channels and
currents in nasal cavaties in normal and impeded nasal respiration
(R. H. Scanes Spicer, M.D.) . . . • .7

151

PAGE

Respiratory tract (upper), lantern demonstration showing normal fluctuant

tions of air-pressure in (R. H. Scanes Spicer, M.D.) . . 30

Rhinitis (chronic), in case of chronic laryngitis (J. Dundas Grant, M.D.) . 128

-purulent, probably causing case of chronic laryngitis with inter-

arytenoid pseudo-pachydermic swelling (J. Dundas Grant, M.D.) . 61

De Santi (Philip R. W.), a case of tertiary syphilis in a man set. 26

- case for diagnosis : man with growth on left vocal cord .

-case of unilateral right swelling of the thyroid gland in a woman

set. 50 ......

-case of gumma of epiglottis .

- enormous fibro-lipoma of larynx ....

Sbmon (Sir Felix, M.D.), a case of obscure, lardaceous-looking, variable
infiltration of the uvula, soft palate, and right arytenoid cartilage in
a lady aet. 30

-a case of ulceration of the left tonsil, with acute and considerable

enlargement of numerous cervical lymphatic glands on both sides of
the neck ; ? malignancy .....

-sequel to case .....

-case of tabes, with early and unusual implication of cerebral

nerves .......

Septotome for use in Moure’s and other operations for deflection (L. H.
Pegler, M.D.) ......

Septum nasi: see Nose (septum of).

Singer’s nodule on left vocal cord (E. Furniss Potter, M.D.)

Sinus, frontal, disease : case showing marked expansion (F. J. Steward) .

---double antral and frontal sinus disease: left side

cured by radical operation; question of operating on the right side
(Hunter Tod) ......

-disease of both frontal sinuses (E. Furniss Potter, M.D.)

-empyema (chronic) of both frontal sinuses and maxillary

antra (H. Tilley, M.D.) .....

-(maxillary): see Antrum (maxillary).

-sphenoidal: case showing results of operation upon sphenoidal

sinus, with demonstration of new instrument (H. Lambert Lack, M.D.)

-empyema (chronic); opened (E. B. Waggett)

-new design for sphenoidal sinus cutting forceps (P. Watson

Williams, M.D.) ......

Sinuses (nasal accessory): multiple sinus suppuration ; case showing results
of operation on sphenoidal sinus (H. Lambert Lack, M.D.) .

Sinusitis, frontal, with suppurative ethmoiditis following radical operation
for nasal polypi (A. Bronner, M.D.) ....

Smell, loss of sense of: see Anosmia.

Spbncer (Walter G.), epulides or symmetrical swellings of gum at the
posterior ends of the alveolar border in a female set. 37
Spicer (R. H. Scanes, M.D.), a readily improved working model to demon¬
strate the air-channels and currents in the nasal cavities in normal
and impeded nasal respiration .....

-a lantern demonstration showing the normal fluctuations of air-

pressure in the upper respiratory tract ....
Steward (F. J.), specimen of malformation of the oesophagus

-case of frontal sinus disease showing marked expansion .

-case with clonic contractions of the palate, adductors of the vocal

cords, and certain other muscles ....

-case of infiltration of soft palate (P cause)

Stewart (W. R. H.), case of nasal deformity in a woman

-case of strumous ulcers of the mouth and tongue

-- case of laryngeal obstruction ....

Stricture, malignant, of oesophagus, upper end (A. Logan Turner, M.D.) .
Subglottic thickening of right vocal cord (J. Donelan, M.B.)

1

3

66

133

134

11

13

46

68

65

100

74

10

75

101

139

114

46

139

48

59

30

28

74

84

136

27

28
73
34

124

152

PAGE

Suppuration of nasal accessory sinuses (multiple sinus suppuration)

(H. Lambert Lack, M.D.) .... 139

Supra-nasal cyst in an infant (V. Wyatt Wingrave, M.D.) . . 133

Swelling in post-nasal space: case for diagnosis (E. Fumiss Potter, M.D).

127, 133

-interarytenoid, pseudo-pachydermic, in case of chronic laryngitis

(J. Dundas Grant, M.D.) . . . . .61

-(large) of mucous membrane in interarytenoid region (so-called

interarytenoid pachydermia) (H. Tilley, M.D.) . 63

-of arytenoids in case of double abductor paralysis (C. A. Parker) . 5

-of larynx (right side) : case for diagnosis (H. J. Davis, M.B.) . 98

-of thyroid gland, unilateral (right) (P. R. W. de Santi) . . 66

-post-pharyngeal (large) (E. B. Waggett) . . . 131

Swellings (symmetrical) of gum (epulidesj at posterior ends of alveolar

border (W. G. Spencer) . . . . .59

Symonds (Charters J.), case of paralysis of the left vocal cord due to lead¬
poisoning . . . . . . .64

Syphilis: hereditary specific perforation of anterior pillar of fauces

(J. Dundas Grant, M.D.) . . . . .00

-perforation of nasal septum; case due either to trauma or syphilis

(J. Donelan, M.B.) . . . . . .94

-sections of ulcer of tonsil showing tubercles, but which had yielded

to antisyphilitic remedies (H. Lambert Lack, M.D.) . . 50

-tertiary: case in man set. 26 (P. de Santi) . .1

-causing almost complete adhesion of soft palate to posterior

pharyngeal wall (H. Tilley, M.D.) . .81

Tabes : case with early and unusual implication of various cerebral nerves

(Sir F. Semon, M.D., C.V.O.) . . . . .68

Thickening, cedematous, of larynx and palate (H. Lambert Lack, M.D.) . 93

-of left vocal cord with impaired mobility (H. Lambert Lack, M.D.) 139

-papillated, of vocal cord in case of chronic laryngitis (J. Dundas

Grant, M.D.) ...... 128

-subglottic, of right vocal cord (J. Donelan, M.B.) . . 124

Thorne (Attwood), a case of epithelioma of the larynx in a man set. 60 56, 121
Thyroid gland : extirpation of isthmus and left lobe in case of immobility

of left vocal cord attributable to bronchocele (J. Dundas Grant, M.D.) 114

-swelling, unilateral (right) (P. R. W. de Santi) . .66

Thyrotomy in removal of large papilloma of right ventricular band (E. B.

Waggett) . . . . . . .113

Tilley (Herbert, M.D.), case of vascular naso-pharyngeal fibroma of ex¬
tensive origin, finally removed by a combined operation through the
soft and hard palate, and extensive removal of anterior wall of left
supermaxillary bone . . . . . .19

-case of advanced and inoperable epithelioma of epiglottis, with

secondary infection of cervical glands. Exhibited to illustrate relief
obtained by removal by " morcellement" of primary growth through
the mouth . . . . . . .35

-case of large swelling of the mucous membrane in the interarytenoid

region (so-called interarytenoid "pachydermia”) . . .53

-case illustrating an operative procedure for the relief of almost

complete adhesion of the soft palate to the posterior pharyngeal wall,
the result of tertiary syphilis . . . .81

-case of chronic empyema of both frontal sinuses and maxillary

antra ; radical operations to illustrate the almost complete obliteration
of the maxillary sinuses following the radical operation . . 101

-pedunculated tumour growing from the region of the right tonsil . 140

Tinnitus (entotic) caused by clonic spasm of muscles of palate and pharynx

(L. H. Pegler, M.D.) . . . . . .105

153

PAGE

Tod (Hunter F.)> left antral empyema, followed by abscess of hard palate

and of septum nasi . . . . . .9

-double antral and frontal sinus disease : left side cured by radical

operation ; question of operating on the right side . . 10

-laryngitis hypertrophica in a girl set. 21, following prolonged nasal

trouble . . . . . .29

-case of polypoid tumour of the nasal septum in a woman set. 33 ;

three months 9 duration ; microscopical section exhibited ; diagnosis (?) 72

Tongue : epithelioma in single woman set. 24 (A. Hamilton Burt) . 16

-paresis, slight, in case of paralysis of abductors of vocal cords and

of palatal muscles (J. Dundas Grant, M.D.) . . 24, 36

-ulcerating growth of side of tongue, left tonsil, and anterior faucial

pillar (H. FitzGerald Powell, M.D.) .... 112

-ulcers, strumous (W. R. H. Stew^art) . . .28

Tongue-depressor for exposing the tonsil (E. Cresswell Baber) . . 86

Tonsil, tongue-depressor for exposing (E. Cresswell Baber) . . 86

-ulcer of tonsil showing tubercles, but yielding to antisyphilitic

remedies (H. Lambert Lack, M.D.) .... 50

-ulceration (R. Lake) ..... 123

-(left) tuberculosis, acute; specimen and section (F. H. Westmacott) 108

-ulcerating growth, involving side of tongue and anterior

faucial pillar (H. FitzGerald Powell, M.D.) . . . 112

-ulceration, with acute enlargement of cervical lymphatic

glands on both sides of neck (? malignancy) (Sir F. Semon, M.D.,
C.V.O.) . . . . . . 13, 46

-(right) pedunculated tumour growing from region of (H. Tilley,

M.D.) . . . . . .140

Tonsils: mucous patches; microscopic sections (H. Lambert Lack, M.D.). 94

Trachea (narrowing) : abnormal narrowing of larynx and trachea, probably

congenital (A. Logan Turner, M.D.) . . . .33

Trauma: perforation of nasal septum; case due either to trauma or

syphilis (J. Donelan, M.B.) . . .94

Treasurer, report for 1902 . . . . . .42

Tubercles present in ulcer of tonsil, which yielded to antisyphilitic reme¬
dies (H. Lambert Lack, M.D.) . . . . .50

Tubercular ulceration, primary, of nasal septum (E. B. Waggctt) . 125

Tuberculosis: microscopical section of tuberculous pachydermia from pro¬
cessus vocalis (R. Lake) . . . . .64

-of larynx (R. Lake) . . . .64

-of left tonsil, acute; specimen and section (F. H. Westmacott) . 108

-removal of epiglottis in case of tuberculous disease (R. Lake) . 6

Tumour in nose (W. H. Kelson, M.D.) . . . .60

-of vestibule of nose, microscopic section (E. Cresswell Baber) . 85

-pedunculated, growing from region of right tonsil (H. Tilley, M.D.) 140

-polypoid, of nasal septum (Hunter Tod) . .72

Turbinal, inferior, papilloma from region of (R. Lake) . . 124

Turbinate body (inferior), section of new grow r th removed from posterior

extremity of (R. Lake) . . .52

-(left inferior): specimen of recurrence of growth involving left

inferior turbinate and septum (R. Lake) . . . .52

-(right inferior) ? carcinomatous section shown (R. Lake) 52

Turner (A. Logan, M.D.), specimen of abnormal narrowing of larynx and

trachea, probably congenital . . . . .33

-a series of anatomical preparations demonstrating the artificial

production of oedema of the larynx . . .33

-specimen of malignant stricture of the upper end of the oesophagus 34

Ulcer of tonsil, showing tubercles, but yielding to antisyphilitic remedies

(H. Lambert Lack, M.D.) . .50

Ulcers, strumous, of mouth and tongue (W. R. H. Stewart) 28

154

PAGE

Ulcerating growth of left tonsil, side of tongue, and anterior faucial pillar

(H. FitzGerald Powell, M.D.) . . . . .112

Ulceration in pharynx and larynx, recurring, considered herpetic (E.

Furniss Potter, M.D.) . . . . . .18

-of soft palate (L. A. Lawrence) .... 108

-of tonsil (R. Lake) ...... 123

-of left tonsil, with acute enlargement of cervical lymphatic glands

on both sides of neck (? malignancy) (Sir F. Semon, M.D., C.V.O.) 13, 46

-tubercular, primary, of nasal septum (E. B. Waggett) . . 125

Uvula, infiltration, with lardaceous-looking substances (Sir F. Semon,

M.D., C.V.O.) . . . .11

Vaughan (Major J. C., I.M.S.), pathological report on Captain O'Kinealy’s
case of localised psorospermosis of the mucous membrane of the
septum nasi . . . „ * . - 110

Ventricle of larynx : see Larynx (ventricle).

Ventricular band (right): papilloma (largp) of right ventricular band

removed by thyrotomy (E. B. Waggett) .... 113
Vinrace (Dennis), case of lupus (?) of nose and face . .87

Vocal cord (malignant disease), cyst of ventricle of larynx opened when

operating on (H. Lambert Lack, M.D.) . . . .51

-(left) growth : case for diagnosis (P. de Santi) . . .3

—-immobility attributable to br^nchocele (J. Dundas Grant,

M.D.) ...... 114

- -— papillated thickening- in case of chronic laryngitis (J.

Dundas Grant, M.D.) ...... 128

-paralysis, due to lead-poisoning (C. J. Symonds) . . 64

-•—'iinger’s nodule on (E. Furniss Potter, M.D.) . . 100

--thickening and impaired mobility (H. Lambert Lack, M.D.) 139

--— (right), subglottic thickening (J. Donelan, M.B.) . . 124

Vocal cords, clonic contractions of adductors of (F. J. Steward) . . 84

-paralysis of abductors of vocal cords and of palatal muscles, and

slight paresis of tongue (J. Dundas Grant, M.D.) . . 24, 36

m

Waggett (E. B.), case of malignant disease in the neighbourhood of the

right Eustachian tube in a man set. 69 . . .75

-large papilloma of the right ventricular band in a woman ret. 33,

removed by thyrotomy . . . .113

-chronic empyema of sphenoidal sinus, opened . . .114

-case of primary tubercular ulceration of nasal septum . 125

-large post-pharyngeal swelling in a girl ret. 9 . . 131

Westmacott (F. H.), specimen and section of acute tuberculosis of left

tonsil from a man ret. 32 . . . . . 108

Williams (P. Watson, M.D.), a new design for sphenoidal sinus cutting

forceps . . . . . .46

Wingrave (V. Wyatt, M.D.), case of laryngeal growth in a man ret. 50 . 36

-case of rapid destruction of nasal septum, probably lupus, in a male

ret. 34 ...... 117

-case of supra-nasal cyst in an infant 15 months old . . 133

9 .

J>RINTEI) BY ADLARD AND SON, LONDON AND DORKING.