TREATMENT OF BENIGN TIT3IORS.—In singers' nodes rest is the first requisite, talking especially being as much as pos sible avoided. The local use of astrin gent solutions is generally useless. The local application of chromic acid with a suitable instrument and by an expert, or g,alvano-cauterizations, or, again, the use,. for sufficiently large growth, of the laryn geal forceps, alone affords satisfactory results.
In the cases of all other benign growths removal is also necessary. In small ses sile growths this may sometimes be ac complished by chromic acid or galvano cautery. As soon, however, as a neo plasm reaches beyond the dimensions of a split pea, removal with forceps, Fauvel's or Mackenzie's, should be resorted to, after anmsthetizing the larynx with a 20 per-cent. solution of cocaine. Trache otomy sometimes becomes suddenly nec essary when the growths are large. Gen eral anaesthesia under such circumstance can rarely be used, lest the saturation of the pulmonary residual air with the anes thetic cause death. Benign tumors do not recur at the same spot, if they recur at all.
Malignant Tumors.—The proportion of malignant as compared to benign growths, as shown by Semon's statistics is about 1 to 7, but the fact that the former are more likely to be reported than the latter would tend to suggest that this proportion is fallacious. One ma lignant case in 20 cases would, judging from the specialist's average experience, probably be nearer the truth.
CARCINOMA,—Cancer of the larynx is somewhat more frequently observed in men than women, and, as is the case with this variety of growth in other parts of the organism, the majority of cases, about GG per cent., are observed in subjects be tween the fortieth and sixtieth years. Cases are, though rarely, met with in children. Epithelioma is the variety usu ally observed, though all forms of cancer, even scirrhus, have been encountered in this situation.
Besides the symptoms observed in other forms of laryngeal tumor, ness, dyspncea, cough, etc., glandular largement in the neck, and dysphagia usually appear, sometimes early in the history of the case. Pain, another feature not complained of in benign tumors, is quite a prominent symptom and in some cases becomes intense. It is usually of a lancinating character and in some cases radiates toward the ear. The breath is foetid, the general health is undermined through general toxxmia and deficient nutrition, and death usually occurs from exhaustion. In some cases, however, ulceration through the coats of a large artery may cause sudden death from hwmorrhage; fatal pneumonia may be brought on by the aspiration of detritus, or asphyxia may be induced through the entrance into the laryngeal aperture of • masses of food.
The laryngoscopical image afforded at first varies greatly in different cases and according to the location. It may at first resemble a benign tumor, and be taken for it; one cord may simply be enlarged, rounded at the edge, and slightly con gested; a small ulcer, resembling an abrasion, may suggest syphilis, especially when the edges of the ulcer are sharp cut and yellowish; a grayish projection or ulcer may suggest tuberculosis, etc. Elimination by examining the sputa for tubercle bacilli, or the administration of iodide of potassium is often necessary in such cases to determine the true nature of the growth, and sometimes a small piece must be nipped off with forceps for microscopical examination. The devel
opment of the tumor is also irregular. Fungous masses, burrows, masses of necrosed tissue, and thick secretion, etc., make up a picture that is never forgotten when once seen.
The chances of recovery are absolutely nil when an early operation, including thorough removal of the growth, cannot be carried out. When such a procedure can be resorted to satisfactorily the nosis becomes comparatively favorable. —The safest rule as to the extirpation of laryngeal carcinoma sumes itself into instrumental methods whenever the case is seen near its cipiency. If there appears, after careful examination, to be no peripheral ment, and the growth is so situated that it can be, as it were, punched out with considerable surrounding tissue with special cutting forceps, this should be sorted to. An ulceration or thickening near or the edge of a cord or a lar band may thus be enucleated. Such cases are unfortunately comparatively _rare, and the laryngologist is usually sulted when the cancerous process has already advanced beyond this tively simple procedure. Excision then affords the only procedure capable of affording some chance of recovery. It is now advocated by most experienced laryngologists when the limits of the thyroid cartilage are not passed; that is to say, when only the tissues within the larynx proper are involved and when there is no glandular enlargement. Local applications of acids, cautery, arsenic, etc., but stimulate the development, and are therefore more hurtful than bene ficial.
_Review of all cases so far reported as treated by the x-rays and failure to find a single instance in which a cure was claimed. Although the good results which have been obtained from the action of these rays in malignant growths else where would lead one to hope for great benefit to the laryngeal cases, vet the evidence thus far available is too meagre to warrant taking very great chances. In early cases the only safe way, there fore, at the present time, is to recom mend the radical operation of extirpa tion, for that offers a good percentage of permanent cures. D. B. Delavan (Med ical Record, Oct. IS, 1902).
Case of laryngeal cancer treated by ap plications of the x-rays. The patient came under treatment in June, seemed cured by August, and was found in ex cellent condition in October. The aphonia which followed immediately after the treatment has been partially overcome by compensation by the remaining cord. This condition has gradually improved by constant practice. Scheppegrell (New York Med. Jour., Dec. 6, 19021.
To assuage the sufferings of the pa tient, much can be done. The tion of orthoform or the local application of a cocaine solution before meals to the ulcerating tissues enables the patient to swallow his food. When he can no longer do this, a stomach-tube or a large rubber catheter may be introduced alongside the growth, into the pyriform sinus, and the patient fed through it with nourishing liquids: milk and cream, soft-boiled eggs, broths, etc.
Tracheotomy, early in the case, when laryngectomy cannot be performed, by giving rest to the larynx seems to stay the progress of the growth. It should be performed low down and under strict antiseptic precautions.