of a foreign body in the larynx, according to the site and size of the tumour. But these functional derangements are very deceptive, while the information given by the laryngoscope is at once precise and sufficient. This fact was illustrated in the first of the cases I have to bring before you to-night. The patient suffered from frequently recurring attacks of loss of voice and laryngeal catarrh for thirteen years. His age now is 41. He was treated for laryngitis by every physician into whose hands he came, till at last he was referred to Dr. Joseph Coats, about a year ago, who at once diagnosed a papilloma growing from the under surface of the left vocal cord. This tumour was considerably larger than the average. being about the size of a horse bean. Dr. Coats succeeded in removing a considerable part of the tumour by forceps inserted through the mouth, and gave the patient so much relief, that he was able to resume his employment as a sailmaker on board ship, and take a voyage to Australia and back. On his return home, however, he felt a renewal of his symptoms, and again came to see Dr. Coats, who, on examining him, saw that the tumour had grown still larger than before, and was pressing upwards the left vocal cord, especially in front. It was sessile, and from its extent, Dr. Coats did not think it could be removed per vias naturales. The patient was, however, very anxious to have something done. His voice was completely gone, his occupation gone, and though he had not suffered from paroxysms of dyspnoea, yet from the situation of the tumour, these were very likely to happen, and, besides, Dr. Coats was afraid that the tumour might develop an epitheliomatous tendency. He therefore asked me to see the case with him, with a view to removing the tumour by some extralaryngeal method. This I did, and agreed to operate.

I may here say that there are two methods of operating in such a case as this. (1.) Laryngotomy or tracheotomy is performed, and after a few days a pair of canula forceps are passed through the opening thus made into the interior of the larynx, and the tumour torn away piecemeal. This method is perhaps the safest and simplest; but it is obviously the most difficult practically, and you cannot be certain that the tumour is eradicated. You are working totally in the dark, grabbing at a tumour in a very confined space, and will probably require to repeat your operation three, four, or even six times, as some of the most experienced operators have done before complete removal is effected. (2.) The other method of operating is more heroic certainly, but you work in the light, and the manual difficulties are reduced to

a minimum. I refer to thyrotomy. This consists in slitting up the thyroid cartilage, laying the larynx open, and removing the tumour in the most thorough manner possible. This operation has proved very successful as regards the removal of the tumour, but it has one great disadvantage: in the majority of cases (53 per cent, according to P. Bruns) the voice is lost or much impaired. This was a serious matter in the present case, where the operation was necessitated chiefly by the loss of voice. Guided, however, by the dictum of Bruns in relation to such operations, "that everything depends (so far as restoration of function is concerned), on the question whether the operation can be performed without the division of the thyroid (i.e., the anterior commissure of the vocal cords)," I devised the following operation, which consists of laryngotomy combined with partial thyrotomy, and I have every reason to be satisfied with the result, as it has been, so far as I know, a complete success.

Assisted by Dr. Coats and Dr. Dickson of Paisley, I performed the operation on 17th September last. Tracheotomy was first performed above the isthmus, and then this tampon,

made for me by Mr. Hilliard, was introduced into the trachea to prevent blood passing downwards. The tampon is a very simple affair. It is merely a large tracheotomy canula, with a thin piece of india-rubber tied round the lower end about in. from the margin. This is inflated by blowing through a fine silver tube (portion of No. 1 catheter), which runs along the inner surface of the canula to an opening beneath the

rubber. There is no complicated mechanism about it; it is easy of insertion, and is quite efficient. The rubber, being distended, fills up the trachea, and so prevents the passage downwards of blood. The late Dr. Foulis used in his cases a piece of lead tubing, the short arm of which he inserted into the trachea, but this necessitated the having several sizes beside you, so as to get one to fit, or one had to do as Mr. Lister did, in a case reported by him-roll a ribbon of elastic tissue round the end of the tube till the proper size was reached. I did not care to perform these experiments, and so adopted the tube I show you. I may say the only precaution necessary in using the tampon is in blowing up the bladder-not to make it too large, so as to distend the trachea, or reflex spasms are at once set up which interfere greatly with the operation. They subside, however, by slightly reducing the pressure. A notch, which you see in the upper edge of the shield of the tampon, is intended to allow of the insertion of the knife, if necessary, into the tracheotomy wound when about to make the next incision.

There was, as usual after tracheotomy, a good deal of coughing, but not more than in an ordinary case. When this subsided I proceeded to clear the anterior surface of the cricoid and thyroid cartilages, and the crico-thyroid membrane in the middle line. I then cut these structures through from below upwards with a short, strong, slightly curved and probe-pointed knife. I did not cut through the thyroid completely, but left the upper third with the anterior commissure of the cords intact. This, of course, hindered to some extent my view of the interior, but the section of the cricoid amply made up for this. The sides of the larynx were now held apart by retractors and the tumour came partly into view. A small mirror was then placed in the lower part of the wound and thus the tumour became completely visible. I removed it with small curved scissors. It was somewhat larger than a horse bean, sessile, and attached firmly to the left vocal cord and the commissure. After careful examination with the mirror to see that nothing was left, the mucous membrane was cleaned, and the cartilages were allowed to fall together. This they did very perfectly, no deep sutures being required. The integuments were then stitched together in the usual way, the tampon removed, and a large tracheotomy tube substituted, and the patient removed to bed.

His after progress was most favourable. For the first two days he could not swallow anything without great difficulty, as, owing to the inflammatory swelling about the glottis,

fluids trickled down into the larynx and set up violent coughing. There was also some slight pain and tightness about the chest, and a good deal of coughing for two or three days, but these subsided under the use of poultices, and without leaving any bad results whatever. The coughing set up some surgical emphysema by forcing the air through the wound in the thyroid under the integument, but this never was of any consequence, and subsided spontaneously in a few days. The tube was removed on the third day, and the wound healed rapidly, except the lower part, which did not close for nearly four weeks, when the patient left for his home in England. Before he left he had almost completely recovered the use of his voice; he still had a little hoarseness, due, as Dr. Coats stated in his report, to inflammatory swelling, but he felt quite comfortable and in as good health as ever he had been A fortnight after he went home he wrote me saying that his voice was still improving, although he had caught a little cold in the journey, which had delayed his progress slightly. Before he left Glasgow, Dr. Coats examined him laryngoscopically, and reported that "the cords were not represented by silvery bands as in the normal condition, being red and obviously still somewhat inflamed, but they moved into the middle line quite in the normal fashion during vocalisation."

With regard to the performance of tracheotomy in such cases, either some time before, or simultaneously with the thyrotomy, I see that Mackenzie and Bruns, the two chief writers on the subject, say that it is not at all required. Curiously enough, however, both of these surgeons speak of the danger to life from hemorrhage as one of the risks of the operation, and mention several cases where patients nearly died from suffocation with blood during the operation. My own experience in this case showed that tracheotomy was amply justified both at the time of the operation and afterwards. There was not a great deal of hæmorrhage at the time of the operation, but there was enough to have caused a good deal of coughing, and it was necessarily very difficult to stop it till it did so of itself. But it was especially after the operation that the tracheotomy was justified, when, owing to the swelling of the vocal cords, and the parts above them, the difficulty of breathing would have been such that I consider my patient would have been in great danger but for the tube in his trachea.

As regards the question of recurrence there are no large data to found upon. Mackenzie and other writers are agreed that when the tumour is solitary there is much less tendency

to return than when it is multiple. Mackenzie gives five similar cases to mine, in which thyrotomy was performed with only one recurrence. In 31 solitary tumours, where laryngotomy was performed, there were 24 cures and 7 recurrences. On the other hand, when the tumours are multiple, there are nearly as many recurrences as cures under either operation.

Lastly, unless further experience of the operation I have now described should bring presently hidden dangers to light, I think I may claim in the meantime for it the following advantages.

1. It leaves the vocal cords completely undisturbed.

2. It renders sutures through the sides of the thyroid cartilage to keep them in position unnecessary, and thus diminishes the risk of perichondritis.

3. It gives easy access to the interior of the larynx, and allows therefore of the rapid and complete removal of new growths at one operation.

4. As a corollary from the above, it is especially valuable in cases of multiple growths, which may by this method be removed almost as easily as solitary ones. For I do not think that thyrotomy has as yet received fair play in the matter of statistics, having been hitherto reserved for the very worst cases. If it were more frequently performed, and at an earlier period, I believe its results would be better than those of either operation as hitherto performed.

Epithelioma of Larynx.-The next specimen I have to show you is an example of the most common kind of malignant growth in the larynx-viz., Epithelioma. The patient was under the care of Dr. J. A. Dickson, of Paisley, by whose kindness I was enabled to see him before death, and from whom also I received the specimen. The history of the case, as given me by Dr. Dickson, is shortly as follows.

John B., æt. 26, miner, was admitted to the Glasgow Royal Infirmary on 2nd December, 1881. He stated that, four years before, he caught cold working in a damp mine. The cold went away, leaving a stiffness in the chest which gradually increased up to time of admission. His voice also became affected, and he had a short dry cough, worse at night. He had considerable pain on speaking, coughing, or swallowing solid food. This pain was present more or less throughout, and radiated upwards and outwards to the parotid region. On the night of the 21st January, 1882, he became suddenly dyspnoeic and seemed about to suffocate. Tracheotomy was therefore performed to the entire relief of the symptoms.