are quite common, so to speak, several thousands of cases being on record, and as many or more probably being unrecorded. Heredity does not seem to play any special part in their production. They are occasionally congenital, and may be developed at any age; but they are encountered the most frequently in subjects between the ages of thirty and sixty years, probably because of the greater exposure to laryngitis attending the activity incidental to the prime of life. Males are affected far more frequently than females, probably on account of greater exposure to sources of laryngitis. Benign growths are sometimes followed by malign growths in recurrence, and are sometimes converted into malignity by irritation, whether physiological, mechanical, or instrumental. Malign growths are attributed to cold, chronic laryngitis, and traumatism as the initial exciting causes. Butlin suggests a cryptogamic origin. They are far more common in males than in females, and occur chiefly between the ages of twenty-five and seventy, but they have been noted as occurring exceptionally much later, and even as early as the first year.

PATHOLOGY AND MORBID ANATOMY.-By far the greater number of laryngeal morbid growths belong histologically to the category of benign neoplasms, but the important location they occupy often renders them clinically malign. By far the greater number of benign growths are papillomas, perhaps fully two-thirds, although Elsberg has reported that but 163 instances were papillomas out of 310 seen in his own practice.' This has been an exceptional experience. Then we have fibromas, myxomas, adenomas, lymphomas, angeiomas, cystomas, ecchondromas, lipomas, and composite. neoplasms. Laryngeal morbid growths, too, occasionally undergo the fatty, colloid, or amyloid degenerations. Papillomas are frequently multiple, and most frequently sessile, but the other benign neoplasms are most frequently single and are more often pedunculated. All this class of morbid growths affect the anterior half of the larynx more than the posterior. They are most frequent on the vocal bands or very near to them, although they may occupy any portion of the larynx. They vary in size from the smallest protuberance to a bulk sufficient to block up the cavity of the larynx and even project above it. The dimensions of the greater number of papillomas vary from the size of a pea to that of a small mulberry. Other benign neoplasms rarely reach the bulk attained by papillomas.

Malign growths are far less common than benign ones. They comprise both sarcomas and carcinomas. Sarcomas occur in the varieties of spindlecelled, round-celled, giant-celled, mixed-celled, fibrosarcoma, lymphosarcoma, and myxosarcoma. Some attain only the size of small beans, and few exceed the size of a pigeon's egg. The majority of them are primary growths. Most of them originate in the interior of the larynx, whence they may extend by contiguous infiltration, even penetrating the laryngeal walls. The vocal band and the ventricular band are the most frequent seat. The epiglottis is a common seat. These growths appear either in irregular, smooth, spheroid masses, or nodulated, mamillated, and dendritic. They are much the more common in males, and occur chiefly in subjects between the ages of twenty-five and fifty. Their growth is slow for a year or more, and then becomes more rapid.

Carcinoma is much more common than sarcoma. It is most frequently primary, and primarily limited to the larynx, but occurs likewise in extension of carcinoma of the tongue, palate, pharynx, oesophagus, or thyroid gland. It rarely extends to the esophagus or penetrates the laryngeal walls. Squamous-celled carcinoma or epithelioma is the commonest variety, large spheroidal-celled or encephaloid being much less frequent, and small spheroidal-celled and cylindrical-celled occurring still more rarely. Intrinsic 1Archives of Laryngology, p. 1, New York, 1880.

laryngeal carcinoma is usually unilateral at first, and most frequently in the left side. Its most frequent seat is at the vocal band. It rarely occurs below this point, and when it does, as in the five cases analyzed by Butlin,' it seems to be at some point just beneath. Extrinsic laryngeal carcinoma usually begins in the epiglottis, and sometimes occupies that structure only. It may begin in a cicatrix in the skin. Carcinoma is the more common in males, chiefly in subjects between the ages of fifty and seventy. It has occurred within the first year, at three years, and as late as at eighty-three years. Carcinoma is liable to extend by infiltration of tissue and destroy all the contiguous and overlying tissues, so that it may extend into the pharynx or even externally; the large spheroidal-celled variety presenting the most frequently progressive ulceration into contiguous tissue, and the squamous-celled, intrinsic ulceration. Hemorrhage is frequent. Perichondritis, abscess, necrosis, and fistula take place in old cases.

SYMPTOMATOLOGY.-Small growths in localities where they neither provoke cough nor interfere with voice or respiration may run their course for a long time without giving rise to any symptoms at all. Growths of larger size, pedunculated growths, and growths located upon important structures give rise to interference with voice, respiration, or deglutition as may be-to cough, and even to pain. Dysphonia is due to mechanical interference with vibrations of the edges of the vocal bands; aphonia, to mechanical interference with their approximation; diphthonia, to mechanical interference at an acoustic node. These manifestations may be permanent or intermittent. Dysphonia is one of the earliest symptoms of carcinoma, and is usually continuous for a number of months before any other indication. Aphonia in carcinoma is often due to nerve-lesion. Dyspnoea is due to some considerable mechanical occlusion of the respiratory tract, whether by the growth itself or in consequence of oedema or of intercurrent tumefaction. It is inspiratory rather than expiratory, and subject to aggravation at night. As with the dysphonia, it varies with the size, location, and mobility of the growth and the position of the head and neck. It may be intermittent or permanent; be slight or severe; or it may terminate in apnoea by spasm, by mechanical occlusion of the calibre of the larynx, or by impaction of the growth at the chink of the glottis. Marked encroachment on the breathingspace is not accompanied with as marked dyspnoea as in acute processes, the parts seeming to acquire tolerance during the slow growth of neoplasms.

Dysphagia is due to a growth at the top of the larynx or on some portion of its pharyngeal surface. It is quite frequent in carcinoma, preceding dysphonia in the extrinsic varieties. It may be associated with regurgitation of food, drink, or saliva into the larynx, provocative of paroxysms of suffocation. Cough is due to growths which project from the vocal bands or press upon them, or to hemorrhage or accumulation of secretory or suppurative products. Hemorrhage, cough, and expectoration of bloody and fetid masses are indicative of carcinoma. Pain is usually due to intercurrent conditions. Aches in the part and sensations of the presence of a foreign substance are more frequent. Intense pain is exceptional in benign neoplasmata; it is often an early symptom in carcinoma, in which it is apt to radiate toward the ears and along the neck. Epileptic seizures and vertigo are sometimes occasioned by reflex influence. Exceptionally, large growths may produce change in the external configuration of the larynx. The general health is not much involved in benign growths, unless they interfere seriously with important physiological functions. Impaired health is far less manifest in sarcoma than in carcinoma. Emaciation, pyresis, and marasmus eventually occur as constitutional manifestations of malign growths.

1 On Malignant Disease of the Larynx, p. 36, London, 1883.

2

* Cohen, Transactions American Laryngological Association, p. 113, 1883.

VOL. III.-9

DIAGNOSIS.-Laryngoscopic inspection usually reveals the growth and furnishes the best means of diagnosis. Intra-ventricular and subglottic growths may elude detection. Palpation is sometimes available, especially with children. Palpation with probes under laryngoscopic inspection is sometimes requisite to determine the mobility of a growth, its form and seat of attachment, and even its size. It seems, too, to discriminate a neoplasm from an eversion of a ventricle. While the histological character of a growth cannot be definitively decided by laryngoscopic inspection, the varieties present a series of characteristics sufficiently pronounced for approximative discrimination. Papillomata are often multiple, usually sessile, and usually racemose or dendritic. Some are white, but the majority are red, and the tinge varies from one extreme of the tint to the other. Some are as small as the smallest seeds; most of them have a bulk varying from that of a pea to that of a berry; some of them are so extensive as to appear to fill the larynx or even project above its borders. They are far the most frequent in the anterior portion of the larynx, and are often located upon a vocal band. Fibromata are most frequently single, smooth and pedunculated, and red. Some are white or gray. Some are vascular. When fully developed they vary in size from small peas to large nuts. They are more frequent upon a vocal band. Their development is slower than that of papillomata. Myxomata are usually single, smooth, pyriform, and pedunculated. They are usually red or reddish. Their ultimate size varies from that of grains of rice to that of Lima beans. They are most frequent at the commissure of the vocal bands. Angeiomata are usually single, reddish or bluish, vary in size from that of small peas to that of berries, and are most frequent on the vocal bands. Cystomata are usually globular, sessile, translucent, and white or red. They are most frequent in a ventricle or on the epiglottis. Their size varies from that of hempseed to that of peas. Ecchondromata are usually developed in the posterior portion of the larynx. Other benign growths are very rare, and do not seem to present special features for recognition by laryngoscopic inspection. Sarcomata are usually present as sessile, hard, well-circumscribed growths, smooth or lobulated. Some are dendritic on the surface, but not to the extent noticed in papillomata, and their location at the posterior portion of the larynx would suggest their true character, for papillomata rarely occupy this position except in tuberculosis. Superficial ulceration occurs in some cases, but is not extensive. There is no peculiarity in the color of the mucous membrane, which may be paler or redder than is normal. The lymphatic glands are not involved. Carcinomata present first as diffuse tumefactions in circumscribed localities, gradually undergoing transformation into well-formed growths, then nodulation, and then ulceration. Meanwhile, especially in extrinsic varieties, the submaxillary and the cervical lymphatic glands become successively involved and tumefied. Squamous-celled carcinoma becomes pale, wrinkled, and nodulated, and sometimes dendritic. Large spheroidal-celled carcinoma becomes nodulated, dark, and irregularly vascular, and finally ulcerated, perhaps at a number of points. In the ulcerative stage of carcinoma of the epiglottis and of the interior of the larynx discrimination is requisite from syphilis and from tuberculosis. In all cases of doubt as to malignancy, laryngoscopic inspection should be supplemented by microscopic examination. of fragments detached for the purpose. The early detection of sarcoma may lead to surgical measures competent to save life-a remark applicable, perhaps, in a far more limited degree to intrinsic carcinoma.

PROGNOSIS. The prognosis is usually good in benign growths submitted to proper surgical treatment. Left to themselves or treated medicinally, the prognosis is bad both as to function and to life. Such growths are occasionally expectorated after detachment during cough or emesis. Some occasion

1 Butlin, op. cit., p. 14.

ally undergo spontaneous absorption. Some remain without change for years. Most of them enlarge and compromise life as well as function. Recurrence occasionally follows thorough removal, and this recurrence is occasionally malign in character. Repullulation frequently follows incomplete removal. The prognosis is favorable in sarcomata, provided thorough eradication can be accomplished by surgical procedure. Incomplete removal is followed by repullulation or recurrence. Unsubmitted to operation, sarcoma will destroy life either mechanically by apnoea or physiologically by asthenia.

The prognosis is unfavorable in carcinoma. Recurrence takes place as the rule despite the best devised resources of surgery. Intrinsic carcinoma offers some hope of success to the surgeon; extrinsic carcinoma, little if any. Life is shortest in the large spheroidal-celled, and longest in the small spheroidalcelled variety, other conditions being equal. Death may take place by apnoea or asthenia, as in sarcoma, or by hemorrhage, collapse, or pyæmia. Submitted to tracheotomy at the proper moment in cases in which death is threatened by occlusive dyspnoea, life is prolonged and suffering mitigated. The fresh lease of life is longest in the squamous-celled variety.

TREATMENT. The essential treatment is surgical, and to surgical works the reader must be referred for details. Suffice it to say that when a benign growth is small and does not embarrass respiration, it need not be attacked at all, unless its interference with the voice deprives the patient of his means of livelihood. The majority of benign growths are accessible to instruments passed through the mouth. Some require external incision into the larynx, whether partial or complete. The intra-laryngeal procedures in vogue include cauterization, both chemical and by incandescence, incision, abscission, crushing, brushing, scraping, and evulsion. According to the character and location of the growth, direct access from the exterior is practised by infra-hyoid pharyngotomy, by partial or complete thyroid laryngotomy, mesochondric laryngotomy, cricoid laryngotomy, complete laryngotomy, laryngo-tracheotomy, or tracheotomy, as may be indicated.

The thorough eradication of sarcomata usually requires a direct access by section of the thyroid cartilage or even of the entire larynx. This procedure failing or appearing insufficient, partial or even complete laryngectomy may be necessary. Temporizing is of no avail.

The treatment of carcinoma is palliative, unless it be decided advisable to attempt eradication, which may offer some chance of success in intrinsic carcinoma still confined to the larynx. Laryngectomy may be unilateral in some instances, and must be bilateral in others. Unilateral laryngectomy is the more hopeful. Eradication proffers no hope in cases of extrinsic carcinoma in which the growth has passed the boundaries of the larynx. After recovery from the laryngectomy an artificial appliance may be adjusted to the parts for the purpose of supplying a mechanical method of producing sound in the larynx for speaking purposes. Should no radical procedures be instituted, treatment is relegated to general principles, with prophylactic performance of tracheotomy in the presence of dangerous occlusion of the larynx. The voice should be used but little. All sources of laryngitis should be avoided. Ergot or hamamelis may be given to restrain hemorrhage, and morphine to relieve pain and secure sleep. Sprays can be used to keep the parts free from morbid products. Erythroxyline may be applied to produce local anesthesia as required. Semi-detached portions of growth may be removed from time to time. Nourishment may be given by the bowel when necessary, and so on as in other diseases of the larynx in which the funetions of respiration and deglutition are seriously impaired. Medicinally, arsenic may be given in the early stages, as that drug is conceded to possess some slight retarding influence on the growth of carcinoma.

Lupus of the Larynx.

Lupus is rare in the larynx. It usually occupies the structures above the vocal bands. It is most frequent in females, and usually associated with cutaneous lupus.

ETIOLOGY.-Scrofulosis and syphilis seem to be the predisposing causes. Climate may have some influence. The reason of the special proclivity of the female is undetermined. Of 9 reported cases, records of which are before the writer, 8 were in females.

PATHOLOGY AND MORBID ANATOMY.-Laryngeal lupus is usually an extension of the disease from the upper lip or the nose, extending along the nasal passages, pharynx, and palate. Destructive ulceration takes place, with irregular cicatrization and the formation of hard nodules of hyperplastic tissue of irregular conformation, varying from the size of hempseeds to that of small peas, similar to the cutaneous buccal and pharyngeal nodules.

SYMPTOMS.-These include dysphonia, dyspnoea, dysphagia, and cough. Pain is exceptional.

DIAGNOSIS.-Laryngoscopic inspection reveals the characteristic nodulation, the nature of which is inferred from the coexistence of external lupus. The disease may be confounded with lepra, syphilis, tuberculosis, or carcinoma. Discrimination from syphilis is the most difficult, and is predicated chiefly on its slow progress and on the absence of constitutional manifestations.

PROGNOSIS. This is unfavorable. The reported cures seem to have occurred only under the influence of antisyphilitic treatment.

TREATMENT. The prolonged use of cod-liver oil and of potassium iodide seems to be more beneficial than any other systemic treatment. Destruction of the nodules and ulcerated tissues is indicated when the diseased structures are sufficiently circumscribed and accessible. This may be done with the sharp spoon or with the electric cautery. Silver nitrate and iodine have been lauded as topical remedies.

Lepra of the Larynx.

Lepra is rare in the larynx.

ETIOLOGY.-Its cause seems to be climatic. In Europe it is most frequent in Norway and Sweden, and in America in Cuba and the West Indies.

PATHOLOGY AND MORBID ANATOMY.-It is always associated with cutaneous lepra, and usually with lepra of the nasal passages and the pharynx. According to Schroetter's observations, laryngeal lepra occurs as small connective-tissue nodules on the epiglottis or in the interior of the larynx, or as uniform thickenings, general or circumscribed. These may lead to stricture. Extensive ulceration may ensue.

SYMPTOMS.-Dysphonia, aphonia, dyspnoea, cough, and local anesthesia are the main symptoms. Pain is infrequent.

DIAGNOSIS. This depends upon the external manifestations of lepra and the laryngoscopic detection of the characteristic thickenings and nodulations. PROGNOSIS. This is unfavorable.

TREATMENT. This must be conducted on general principles. Elsberg commended iodoform topically and gurgun oil internally.