Fig. 31 (^), represents the handle adapt-
ed to all of Tilrck*s operative instruments
yet to be described.
a. Shifter; within the tube of the
handle is a second one which is moved by
means of the shifter a, into which is
screwed the end of the wire ff. Fig. 31 [a).
The union is the same as in catheters. I n
order to secure both more, screwy, Fig. 31
(a) is placed like a key over e. The tube
and handle represent the segment of a
circle, to facilitate the handling of the in-
strument.
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io8 THE PRINCIPLES AND PRACTICE OF
Case i. — Illustrations. — CEdema of the left ventricular
bandy causing great difficulty of breathings hoarseness and
fain. Cured by scarification.
M. M., aet. 29., Irish servant at the Fifth Avenue
Hotel, applied to me one morning in June 1866, com-
plaining of great pain in the throat, hoarseness and
difficulty of breathing. For five nights and days he
had suffered frightfully, unable to lay down on account
of the dyspnoea.
Laryngoscopic Examination. — The upper margin of
the left ventricle and aryepiglottic fold formed a
swelling which extended over one-half across the glot-
tis. I could not see the left vocal cord. The color of
the swelling was of a deep, rather dark red, but with a
yellow spot in the centre. The mucous membrane
over the neighboring structures was also inflamed and
slightly swollen.
Treatment. — Lanced the part freely with Turck's
instrument, which was followed by a quantity of blood.
The next day, upon examination, the swelling had nearly
entirely disappeared and the patient had slept well and
had a good appetite. Made local applications to the
part a few times with a solution of nitrate of silver.
The cure was satisfactory. No return of the malady.
Case 2. — Abscess at the base of the epiglottis ; great dis-
tress of breathing and pain; incision into the abscess ;
cure.
Mr. A., aet. 32., an inveterate smoker and of irregu-
lar habits, consulted us in August 1866, on account, as
he stated, of a sensation of choking in the throat. He
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LARYNGOSCOPY AND RHINOSCOPY. 109
could neither breathe nor swallow food without great
pain and for two nights had no sleep, because he could
not lay down, and had constantly to expectorate viscid
matter. Us<d gargles and purgatives to no purpose.
The laryngoscope revealed the throat in a greatly
congested state, the epiglottis swollen and much in-
flamed, whilst near the tubercle I could perceive a swell-
ing of rather yellowish appearance, which corresponded
to the point that the patient indicated from without
with the fingers. At times the sensation felt was of a
throbbing nature.
Active interference being decided upon, I introduced
Mackenzie's laryngeal lancet by the aid of thei laryngo-
scope, and opened by one incision the abscess, from
which there was discharged about two teaspoonsful of
matter and blood. Though suffering much, the patient
felt much relieved at once, and in about half an hour
after the operation was very comfortable. A few days
sufficed for complete recovery.
Dr. Johnson also mentions one case in which punc-
turing the mucous membrane rapidly reduced an oede-
matous swelling over the arytenoid cartilages.
But one of the most splendid illustrations of the good
which may result from scarification was the case of a
boy with a cyst in the larnyx, which occurred in Guy's
Hospital, London, in June, 1863, under the care of Dr.
Wilks, operated upon and communicated by Mr. Dur-
ham to the Royal Medical and Chirurgical Society.*
♦ A description of the above case is, on account of its great value and interest, here
appended, as given by Dr. Johnson, page 6i, and reported in the Med. Times and
Gazette of Nov. ai, 1863, and in the Lancet, vol. ii. p. 593, 1863.
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no THE PRINCIPLES AND PRACTICE OF
"A boy, eleven years of age, was admitted into
Guy's Hospital, under the care of Dr. Wilks, on June
I o, 1 863. He had for three years suffered from gradually
increasing impairment of voice and difficuky of breath-
ing and swallowing. On admission, all the symptoms
were very severe. During the night of the 14th, he
was seized, as he had previously been on several oc-
casions, while asleep, with a very severe attack of
dyspnoea. Tracheotomy was on the point of being per-
formed, but was delayed by the desire of Dr. Wilks,
and on the following morning Mr. Durham was re-
quested to make a laryngoscopical examination. On
doing so, the epiglottis could not be distinguished in its
normal form, but instead there appeared a large, round,
tense tumor, projecting backward and downward,
and completely covering in and concealing the glottis ;
the tumor could be reached by the finger. Feeling
certain that it contained fluid, Mr. Durham, with the
concurrence of Dr. Wilks, incised it with along, curved,
sharp-pointed bistoury covered, except at its point, with
sticking-plaster. The incision was followed by a
sudden gush of thick, glairy mucous, mixed with a
little pus and blood. All the patient's symptoms were
at once relieved, and in the evening he was singing in
bed. In the course of a few days he was perfectly well.
^* When examined four months afterward, he was
in every respect well. There was no appearance of the
cyst, but the cicatrix of the incision was just visible on
the lower part of the laryngeal aspect of the epiglottis."
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LARYNGOSCOPY AND RHINOSCOPY. iii
Section II.
THE REMOVAL OF MORBID GROWTHS FROM THE LARYNX.
The greatest triumph in the treatment of disease by
the aid of the laryngoscope has finally been achieved in
the removal of tumors, polypi and warty growths from
the interior of the larynx through the mouth.
Previous to the summer of 1861, when Prof, von
Briins of Tubingen, Germany, removed a polypus by
decision, from the larynx of his own brother,* the extir-
pation of growths from the laryngeal cavity was of very
rare occurence.^
* Die erste Ausrottung eines Polypen in dem Kehlkopf. Lihle, etc, by Doctor Victor
v. Briins, Tiibingen, 1861.
t The following are the only well-authenticated cases of extirpation of growths from
the larynx before the introduction of the laryngoscope, as collected by Dr. Mackenzie.
(<>) . Koderick, who operated successfully with a curved flexible tube, referred to by
Semeleder, page 59.
{h). Pratt removed a tumor by subhyoid laryngotomy from the left half of the
under surface of the epiglottis, which though it projected into the fauces, could not be
got at from above. The tumor was firm, grayish-white, and fibrous. Semeleder, page
60.
(c). Sir Astley Cooper removed twice, with his finger, a large cancerous tumor
about the size of a hen*s egg, from the under surface of the epiglottis.
(d). Ehrmann removed a growth fi-om the left vocal cord by first dividing the cricoid
cartilage and several of the upper rings of the trachea ; after 48 hours the larynx was
divided in the median line up to the base of the hyoid bone. The parts being drawn
apart the tumor was removed with the knife. Recovered in three weeks from the
operation; the aphonia remained, but died of typhus fever five months latter. (Histoire.
des Polypes du Larynx. Strasbourg. 1850).
(e). Dr. Horace Green, of New York, removed a pedunculated tumor (about the
size of a cherry), which was (thought to be) attached to the left vocal cord. (Polypi
of the Larynx, page 56. New York. 1852).
(/.) Professor Middeldropf, of Breslau, removed a tumor from the upper opening of
the larynx by means of the galvano-caustic wire. Ruste, who saw the case six years
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112 T'HE PRINCIPLES AND PRACTICE OP
Since the introduction of the laryngoscope, however,
these operations are by no means uncommon.
Professor Briins, of Tubingen, who, as already
stated, was the first to operate successfully on a polypus,
aided by the light laryngoscopy had shed upon these
classes of hitherto incurable diseases, removed 17 poly-
pi or growths, alone, on as many different patients.*
Lewin, Turck, Semeleder,f Tobold, Fauvel, on the
continent. Dr. Walker of Peterborough, Drs. Gibb
and Mackenzie, of London, Messrs. Bracey and Bol-
ton of Birmingham, and undoubtedly others, have each,
more or less often, extirpated growths from the larynx,
with complete success. Dr. Elsberg,J of New York,
has also reported several cases. Three cases in our own
practice we refrain, for the present, from reporting, as
they are still under observation. They shall be made
public at some future time.
after the operation, saw no symptom at that time of any return of the growth (Galvano-
caustic W.).
If we except the first case, which is very vague, it appears that the growth could be
seen in all cases which were operated upon with instruments, and in two instances
(that of Sir Astley Cooper and Prof. Middeldropf) they could be felt with the finger.
In the case of Ehrmann and Pratt the operations were indirect, and preceded by
tracheotomy. " In Dr. Green's case," Dr. Mackenzie remarks, " the tumor could be
seen, and though it was thought to be attached to the vocal cord, it more probably
grew firom the ventricular band or aryepiglottidean fold. If the polypus had been
attached to the vocal cord, it could not have been seen projecting through the
opening of the larynx, unless it had been unusually large,or its pedicle had been much
longer than is usually the case.**
* Dr. von Briins, Laryngoscopische Chirurgie. Tubingen. 1865.
f Semeleder states the number of neoplasms removed since the introduction of the
laryngoscope to be about 100.
X Laryngoscopal Surgery, by Dr. Louis Elsberg. (Pamphlet. 1866.)
Dr. Sands, of New York, opened the larnyx for the removal of a tumor, in a case
in St. Luke's Hospital. It projected from the left ventricle of the larnyx. Recovery
complete, except that the voice remained a little rough. (Translator's note to Se-
meleder, p. 136.)
Dr. J. W. S. Gouley, of New York, has reported, very lately, in the September
number of the New York Medical Journal, a case of polypus of the larnyx, and where
Laryngo-tracheotomy was twice performed, the first time being followed by recurrence
of the disease. (New York Medical Journal, for September, 1867, vol. v. No. vi.) ,
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LARYNGOSCOPY AND RHINOSCOPY. 113
The special course to be adopted in removing a neo-
plasm from the larnyx is determined by its position,
size and nature of insertion.
Sometimes one single particular operative proceeding
suffices, oftener it requires two or more different methods.
A growth may then be removed
I J/, By the operation of Cutting : Decisiony Excision and
Puncture.
indy By Crushing.
^rdy By Cauterization.
4/A, By Gahano-caustic.
1st. Decisiony Excision and Puncture. — These operative
proceedings deserve first consideration according to To-
bold,* wherever there does not exist, from some cause
or other, an absolute impossibility to enter the cavity of
the larynx with sharp instruments. Besides the char-
acter of the growth itself, the size of the pharynx and
larynx are important factors entering into consideration.
Polypi, attached either by a thin or strong stem to
the lateral walls of the larynx above the vocal cords, in
a horizontal position, as well as those inserted into
either free border of the glottis and hanging into the
cavity of the larynx are to be operated upon either by
decisiony-^ that is by making repeated incisions into the
growth, after which, in the course of two to four days
generally, it is thrown off as a disintegral mass, leaving
a little suppurating stump which is usually cicatrized in
a few days more, or by excisiony which implies the
total removal of the polypus at its base, the complete-
* Die Chronischcn Kehlkopfikrankheiten. Dr. A. Tobold. Berlin. 1866.
f First practiced by von Bruns with the knife. 18 61.
10
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114
THE PRINCIPLES AND PRACTICE OF
ness of which operation will depend upon its attach-
ment, and lastly, by puncturey which modus operandi
is employed for the destruction of cyst polypi^ when after
puncture the colloid mass or fluid contained within
the cyst oozes out and the growth disappears.
Numerous, almost too numerous to be mentioned,
are the instruments employed for the above purposes.
Those of Dr. Tobold claim here a prominent place on
account of their usefulness.
Fig. 32. Fig. 23'
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LARYNGOSCOPY AND RHINOSCOPY.
Fig. 34. Fig. 35-
"5
Figures 32, 33 j 34 and 3^ represent the instru-
ments used by Dr. Tobold for decision, excision, and
puncture.
Voltolini has suggested an instrument similiar to the
tonsil-guillotine of Fahnenstock.
Prof. Turck* has of late introduced several ingenious
and useful instruments, which are here for the first time
brought to the notice of the profession, except in the
original edition of his superb work lately published.
* Opu» cit., p. 573.
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ii6
THE PRINCIPLES AND PRACTICE OF
Fig. 36. Fig. 37.
^H^ /ilk P^g- 3^y ^^d Fig- 37j represent
(^kl H^BI ^^^^ Tiirck calls his large fenestrated
^^H; \][\^ knives, similar to a tonsil- ins tru-
'^â– r In?/ ment, handled in like manner.
â– J Fig. 36 represents the instrument
II open before the operation. Fig. 37,
II I the same closed after excision. It
II I is very flat, both sheath and knife
I if very thin, must be held firmly in
its position during the operation and can be used to
extirpate hard or soft substances with either broad or
narrow attachments.
Fig. 40.
Fig. 38. Fig. 39.
The operation can only be suc-
cessful, if these instruments are
used, when we succeed to secure the
growth into the same just as a lasso
is thrown around an object.
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LARYNGOSCOPY AND RHINOSCOPY. 1 1 7
Figures 38, 39 and 40 represent smaller fenestrated
knives, different in construction, of which Fig. 38 is
specially applicable to the removal of growths from the
inner borders and under surface of the true vocal cords.
Fig. 39, for bodies near the anterior angle of the glot-
tis, and if the stem of the instrument is modified by-
being properly bent, the same knives can also be used
for other operations in the throat above the larynx.
Fig. 40 is applicable for the removal of neoplasms
from the inner plane of the aryepiglottic folds, on the
upper surface of the false and possibly also true vocal
cords.
Fig. 41. Fig. 42.
Figs. 41 and 42 represent knives without frame on
one side, applicable for new formations too large to be
inclosed within the frame. The knife must be adapted
to each case.
Figs. 43 and 44 are what Tiirck calls his sheath-
knives, made like his instrument for crushing polypi,
with the exception that the lower arm or blade is pro-
vided with a sheath for the reception of the upper sharp
cutting one.
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ii8 THE PRINCIPLES AND PRACTICE OF
Fig. 43. Fig. 44.
In Fig. 43 the blades extend obliquely from a
second short arm, capable of being either placed toward
the handle of the instrument, or vice versa. If direct-
ed toward the handle, it is adapted for formations
arising from the posterior surface of the epiglottis, if
forward, for the anterior surface of the same or for the
anterior plane of the posterior wall of the larynx.
It remains yet here to mention the scissors-shaped
instruments for the above-mentioned operations,
though perhaps not so frequently used as formerly.
When the larynx is large and all other conditions
favorable, these complicated instruments are to be rec-
ommended and may be used to advantage ; but these
desirable features being wanting and the throat and larynx
only of ordinary size, they are objectionable on account
of the space they occupy within the larynx, interfering
considerably with the complete view of the parts and
place of operation, whence it it is not unfrequently im-
possible to see in the mirror the part of the instrument
which actually accomplishes the process of cutting or to
keep the same in view during the progress of the operation.
2nd. Crushing is another mode of destroying intra-
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LARYNGOSCOPY AND RHINOSCOPY.
119
laryngeal morbid growths, whereby their nutrition is
impaired and mortification is produced.
This process of procedure can only be applied to such
neoplasms as are free, that is, unattached except by a
thin feeble stem and which, either singly, or in a mass,
are suspended within the larynx.
When, on the contrary, the mass to be extirpated is
extensive and of soft texture, conditions which are
not unfrequently met with, or cannot be reached by
any other means, a modification of the process of
crushing, namely that of evulsiotiy has been proposed
and in some cases successfully executed, though depre-
cated by Tobold and other observers.
The operation is executed with pincers and forceps
(polypus-crushers), of which those proposed by von
Br^ns, Tobold, Moura-Bourouillion, Semeleder, Leiter
and Winterich are excellent. Pincers of various
construction have been used for the operation, yet
they|are inferior to other instruments in regard to
strength and action. They are useful for extirpating soft
neoplasms when in a horizontal position, as compared
with their point of attachment.
Fig, 45. Fig. 46. Fig. 47.
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THE PRINCIPLES AND PRACTICE OF
Fig. 48. Fig. 49. Fig. 50. Fig. 51 .
'^
6TT0-REYMDERS
Fig. 45, gives Turck's pincette, adapted to soft
growths.
Figs. 46, 47, 48, 49, 50, 51, represent the various
polypus-crushers or polypus-forcepsof Professor Tiirck.
Fig. 46, Large doubly indentated polypus-crusher.
" 47, Large sharp polypus-crusher.
" 48, Small sharp polypus-crusher.
" 49, Sharp polypus-crusher, with blades placed
square.
" 50, Single indentated polypus-crusher.
" 51, Large double indentated polypus crusher.
Each of these instruments is to be chosen with refer-
ence to the peculiarities of the case. As a general rule
the indentated forceps or crushers are well adapted for
soft masses, and the sharp double-bladed instruments
for hard, resisting growths.
An attentive examination of the foregoing cuts will
readily show wherein the difference and advantage of
each respective instrument exists.
For a more detailed description, the reader is re-
ferred to Tiirck's Clinic on the Diseases of the Larynx,
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LARYNGOSCOPY AND RHINOSCOPY. 121
etc., where each instrument is separately described.*
Suffice it to say, that all of the many difficult operations
within the larynx performed by this most ingenious and
successful laryngoscopist are accomplished by the aid of
these instruments.
Ligation^ which comprises the removal of laryngeal
growths by the galvano-caustic ligature and by the
ecraseuVy is simply a modification of the operation of
crushing^ and is properly considered here.
Galvano-cautery forms the subject of a subsequent
chapter ; the ecraseur demands now our attention.
The object of the ecraseur is, to catch with a loop of
fine wire the laryngeal tumour like a noose, to draw
it home (tight), when the pedicle is cut across and
the tumour detached. Dr. Gibb, of London, first sug-
gested the use of the ecraseur and his first instrument
was constructed after Wilde's snare, used for the extir-
pation of aural tumours. The wire loop projects from
the extremity of a curved tube, which is divided into
halves, by a partition running through it. The free
ends of the wire project from the openings of the tube
behind, and are wound around a cross-beam which slides
on the bar or tube, against which the fore and middle
fingers rest.
Fig. 52.
(
QJTOzfiEyMOCRS
Y O
Gibb's Laryngeal Ecraseur.
* Opus cit., p. 570, ct seq.
II
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122 THE PRINCIPLES AND PRACTICE OP
Fig. 52 represents Gibb's improved laryngeal ecras-
eur. Windier, of Berlin, has also constructed a most
admirable instrument, similar to the above.
This operation is preferable for the removal of soft
tumours, with a thin, stem-like attachment ; it can,
if desired, be replaced by the use of the above-men-
tioned instruments.
3d. Cauterization having already been considered
(Part ii.. Chap. 2, page 67, under Section i.. Solutions,
Section ii.. Powders, Section iii., Solid Caustic,
Section iv., Escharotics), the student is referred to
these respective sections for information on this subject.
We may add here, that cauterization, especially
with solids, is serviceable in removing small neo-
plasms. After operative extraction of growths, es-
pecially those of the character of papillomas, the ex-
tent of the attachment at the base may be cauterized,
in order to prevent a re-formation of the same abnor-
mal excrescenses.
4th. Galvano or Electric-Cautery. Correct as the rea-
soning is, that galvano-cautery or galvanic heat^ as it
is often called, can be applied to the destruction of
growths within the larynx, in the same manner as has
been done for a long time, with advantage, in cavities
of the body accessible from without, yet no such suc-
cessful attempt had been made before Dr. von Bruns
applied this agent in two cases of polypi of the larynx
in 1864;* although recommended by Czermak, and
later practised by Voltolini.
* The CMC reported by Middeldorpf (Galvano-Caustic, contribution to Operative
Medicine, Breslau, page 2X2, et teq.), cannot be considered an operation of this kind
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LARYNGOSCOPY AND RHINOSCOPY. 123
According to Dr. von Bruns* the difficulty which
we encounter in the application of the galvano-cautery
in practical laryngoscopy arises first of all from the want
of proper instruments adapted to the operation.
Two objects have to be attained : first, the instru-
ment must be so constructed as to occupy as little
space as possible, and secondly, the wires or conductors
must not only be of a certain definite size up to the
platinum-chain, but these must remain perfectly isolated
from one another, else upon the chain being closed,
instead of the platinum-wire alone being heated to
glowing, the entire chain becomes simultaneously
heated. A further drawback will be found in the man-
agement of these instruments, arising from the connec-
tion of the extremity of the conducting wires with the
battery. These wires, in order to be good conductors,
must be of considerable size and solidity, which inter-
feres very much with the necessary (sometimes almost
imperceptible) movements of the free extremity of the
galvano-cautery. Hence this resistance of the wires
must be overcome by greater exertion of force, which
interferes considerably with the motions of the sensi-
tive fingers through which that very force has to be
exerted. No operation of this nature ought, therefore,
within the cavity of the larynx. He removed a tumour that could be seen and felt in
the pharynx, which arose above the superior thyro-arytenoid ligament, from which it
grew upward into the upper part of the laryngeal cavity. The galvano-caustic chain
was applied with the finger, and the part above, as deep as the aryepiglottic ligament,
was entirely removed, so that fifteen minutes after the operation the stem of the
tumour, of the size of the little finger, could be felt on the upper aperture of the
larynx. Hence an operation not within the cavity but directly above.
* Opus, cit., 244, et seq.
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124 THE PRINCIPLES AND PRACTICE OF
to be undertaken without an assistant, who holds the
two wires and endeavors to guide them according to
the motions and requirements of the operator.
A final and not unimportant consideration is, that
the galvano-cautery, in order to accomplish its purpose,
has to remain longer within the larynx, in contact with
the object to be destroyed, than is the case when knives
or ecraseurs are used. The chain must remain applied
at least three, four, or five seconds, until the purpose is
accomplished. When, however, the part with which the
chain comes in contact is only in the least sensitive, an
inclination to cough, often severe cough, follows imme-
diately the application, or at least after two or three
seconds, when we are obliged instantly to discontinue
the application and remove the instruments.
If, on the contrary, when the cautery is well borne
and in full force, where it has been applied, contraction
of the walls of the larynx takes place, it happens not
unfrequently that the opposite wall is touched by the
cautery, in the same manner as happens during the ap-