IV. The Larynx and the Laryngoscope.

THE three treatises which form the subject of this notice illustrate in a very striking manner the rapid development of our knowledge of laryngeal diseases. It is not so many years since Dr. Horace Green's work excited much interest in this country and some incredulity, by the statements it contained as to the author's method of treating affections of the throat. At that time it was regarded as barely possible to brush out the larynx with a caustic solution, or to penetrate so far as the vocal cords with an instrument.

Now we have a record of 100 consecutive cases of growths in the larynx removed by a single operator. The rapid growth of our powers of diagnosis and skill in treatment is almost equally well illustrated by a comparison of the excellent article on diseases of the larynx in the new edition of Holmes's 'System of Surgery' with that in the first edition of the same work published in 1862. The results of eight intervening years, embraced as they are in the more recent article, have entirely changed the aspect of this branch of practical medicine. Like most other modern achievements, this one has resulted not so much from any pathological discovery as from an improvement in our methods of investigation. Conditions that we could before only guess at, we can now see clearly reflected in the laryngeal mirror. The narrow chink of the rima glottidis, which in our days of darkness we endowed with such exquisite sensibility, that we thought it barely possible to safely traverse it with an instrument, we now boldly approach with our forceps, our knife, or the galvanic cautery. Just as our diagnosis has become more certain, so our treatment has become more scientific and more successful. To no one after the illustrious inventor of the laryngoscope is this progress more due than to the author of the works now before us. Dr. Mackenzie has given many years of steady and devoted attention to this subject; and ever since the publication of the first edition of his book on The

11. The Use of the Laryngoscope. Third edition, with several additional illustrations and new matter. By MORELL MACKENZIE, M.D. Lond., M.R.C.P., &c. &c. London, 1870.

2. Essay on Growths in the Larynx: with Reports and an Analysis of one hundred consecutive Cases treated by other Practitioners since the Invention of the Laryngoscope. By MORELL MACKENZIE, M.D. Lond., M.R.C.P., Physician to the Hospital for Diseases of the Throat, and to the Royal Society of Musicians; and Senior-Assistant-Physician, and Lecturer on Diseases of the Throat, at the London Hospital. London, 1871.

3. A System of Medicine. Edited by J. RUSSELL REYNOLDS, M.D., F.R.S. Vol. iii. London and New York, 1871. Article, "Diseases of the Larynx." By MORELL MACKENZIE, M.D.

Use of the Laryngoscope' has been recognised as our first authority. A work that has reached a third edition needs little comment, and this one is so well known that we shall merely allude to the improvements which have been introduced. These consist mainly of descriptions of new laryngoscopic apparatus, the chief of which are the author's excellent clinical lamp and examining chair. The latter looks at first sight a somewhat formidable kind of pillory for the patient, but we can speak strongly from our own observation of its practical utility. Laryngeal sounds' for examining the attachments of new growths, or for investigating the depth and extent of ulcers, are figured for the first time. In the section on inhalation a description is given of the author's ' eclectic inhaler,' which is certainly the most perfect instrument of the kind yet invented. The treatment of many forms of chronic laryngeal disease will be greatly facilitated by the use of this apparatus; and if we mistake not the old method of inhalation, will, now that it can be applied more perfectly, again assert its supremacy in many cases over the more recent fashion of using atomized fluids. Such are some of the chief additions in this new issue. There are many minor improvements, and the book is even more handsomely got up than its predecessors.

The essay which gained for Dr. Mackenzie the Jacksonian Prize in 1863 was at the time promised to the profession, and has ever since been eagerly expected. We can easily understand, however, that the time for publishing it in its original form has long passed. The great additions made since then to our knowledge of laryngeal diseases have compelled our author to publish a series of monographs instead of his original essay. The second of these is devoted to "Growths in the Larynx,' and by its excellence fully reconciles us to an arrangement, which promises to give us a series of essays of great value.

All malignant growths have been intentionally excluded; the growths treated of are defined as "new formations of benign character, forming projections on the mucous membrane of the larynx, generally giving rise to aphonia or dysphonia, often to dyspnoea, and occasionally to dysphagia." The synonyms by which these growths are known are given afterwards, so that the scope of the work is clearly defined at the beginning. A historical sketch of the subject follows, from which we learn that Koderick in 1750 was the first to operate on a laryngeal polypus. More than a century later only nine instances had been recorded in which attempts had been made to remove the growths during life. One of these is so vaguely described, that it is of little value; in the remaining eight cases the growths were removed four times through the neck, and four times through the mouth. Such was the work of one hundred years in

pre-Laryngoscopic times. The dozen years that have followed the invention of the laryngoscope have seen some 289 cases treated, of which no less than 100 are recorded by the industrious author of this essay. We know no more convincing commentary on the vast influence exercised on our art by the invention and application of new methods of research.

To the thoughtful student, moreover, these facts are pregnant with the encouraging lesson, that when accuracy in diagnosis is once attained, art is not slow to discover new methods of alleviating suffering and saving life. Section the third is devoted to the symptoms, which are divided into functional and physical, after Dr. Causit's classification. This has been adopted in preference to the division into subjective and objective employed in the essay in Reynold's 'System of Medicine.' This chapter abounds in useful suggestions respecting the value of the first class of signs; and under the head of laryngoscopic signs there is given, after an enumeration of the more common position of the growths, a description of the appearance of each kind of polypus, according to its pathological nature. The pathology follows, and is very carefully written, and beautifully illustrated by drawings of the microscopical characters of the growths, and by exquisitely soft and finished chromo-lithographs of the laryngeal appearances. The artists deserve the highest praise for their work, which appears to have been executed under the inspiration of an enthusiasm equal to that of the author. We now pass on to the treatment. Here we are glad to find in limine the admission that operative procedures are not required in all cases. There is an honesty about this which some specialists would do well to copy. Small growths on the epiglottis or ventricular bands, especially fibromata, when the inconvenience is not great, may well be left alone. Sometimes the neoplasm is too ill-defined to warrant removal, and sometimes the age of the patient or the unimportant nature of the symptoms justifies non-interference. Treatment is, however, most commonly required. Little is said of palliative procedures; the radical treatment naturally occupies nearly all our author's attention. This may be (1) internal or laryngoscopic; (2) external or by direct incision into the airpassages; or (3) by the combined methods, i. e. tracheotomy being first performed for the patient's safety, and the growth subsequently removed through the mouth. The first of these three methods is the triumph of Laryngoscopy:

"By the removal of a growth in this way no chance of danger is incurred, little or no pain is felt, and scarcely a drop of blood is lost. By an operation of this simple character the long-lost function of a most delicate organ may be almost instantly restored, and a morbid

condition, threatening the immediate extinction of life, may be at once and for ever removed."

The continental modes of producing anesthesia of the larynx before operation are regarded as unnecessary or useless. The plan recommended is the same as that now generally adopted before using the laryngoscope in a sensitive patient, viz., allowing a little ice to dissolve in the mouth. Sometimes a few whiffs of chloroform are useful. Three methods of removal by mechanical means are described-evulsion, crushing, and cutting. Of these the first is the most generally applicable. It is performed by means of the common laryngeal forceps or the tube forceps; whichever is used should be bent at a sharpish angle, rather than gradually curved, as in this form it does not produce irritation by pressing against the epiglottis. Cutting, which is specially suitable for some cases, is performed either by the cutting forceps, scissors, ecraseurs, or the knife. Dr. Tobold, who is no mean authority, prefers the knife. For each case there is one method most suitable, and on points of this kind the experience of the operator must be the guide. The application of caustics is, we are glad to find, not recommended, and the galvanic cautery fares likewise. Such are the various forms of the internal operation. The other operations are discussed at length, and some very important materials are collected to show their comparative merits and applicability. On this part of the subject, which is mainly surgical, we have no space to enter. In the four appendices are given full reports of 100 cases treated by the author; short notes of other cases, in which radical treatment was not adopted; next a tabular statement of the 100 cases; and, lastly, a table of all the published cases treated by other practitioners since the invention of the laryngoscope.

It is in these appendices that the author's industry and love of his work is best seen. These parts of the book render it the most valuable contribution to the pathology of the larynx which has yet appeared in any language. It is a credit to the English school of laryngoscopy.

The hospital in Golden Square, at which many of these cases were seen, has been roundly abused many times since its establishment. The publicatiou of this book, containing a record of some of the work done within the walls of that hospital, is a perfect apologia pro vitá suá. If all special institutions would only show such honest and careful work, specialism would need fewer apologists.

The third volume of Reynolds's 'System of Medicine' has part of its space devoted to chapters on diseases of the larynx, by Dr. Mackenzie. One of these is, of course, devoted to

growths in the larynx, but is by no means such an artistic production as the monograph we have just considered. It bears traces of having been written at an earlier date, and before the author's views had ripened into the full excellence displayed in his larger treatise. The other chapters on throat affections are well done, and some of them strike us as being exceptionally good, but all are too much condensed. The space allowed was evidently too limited to enable the author to do justice, either to his subject or to himself. We regret this because Dr. Mackenzie is eminently qualified to write well on diseases of the larynx. With greater space at his command, he would have made his contribution, good as it is, much better. The ill luck, to call it by no stronger term, of the System of Medicine' is remarkable. Every new volume brings some fresh disappointment. The authors best qualified to write find little space or none, and some who write with small authority occupy great space. If in this third volume fifty more pages, which might well have been cut off some of the other articles, had been allotted to the larynx, Dr. Reynolds would have issued a volume more fitted to meet our present needs.

V. Dr. M. Duncan on Fertility and Fecundity.1

Dr. Duncan's work may be described as a statistical inquiry into certain obstetrical subjects. Figures form the basis of his work, and, therefore, in the very nature of things, a wide field for controversy is opened. But it must be said that his opponents will find considerable difficulty in refuting the arguments advanced in this able work, though they may find grounds for divergence of opinion.

The work is divided into ten parts, the first of which alone is devoted to the subject from which it takes its title. This, however, is the most elaborate portion of the volume, and one with which it is most difficult to deal, either critically or analytically. It is based, as Dr. Duncan avows, almost exclusively on a considerable mass of figures. That figures may be used very differently, according to the bias of the manipulator, and that very conflicting conclusions may be drawn from the same statistical data is notorious. This volume forms no exception to that rule, though, in justice to Dr. Duncan, it must be said that he has very fairly and with great ability handled

1 Fecundity, Fertility and Sterility, and Allied Topics. By J. MATTHEWS DUNCAN, A.M., M.D. Second edition, revised and enlarged. Edinburgh, A. and C. Black, 1871. Pp. 498.