cutting dilator, which I will describe a little further on, but not having one, and as I thought it improbable that it could be obtained in this country, I determined to watch the case a little longer, and if necessary to have one made or send to England for it. Fortunately, however, it has not been necessary; for after keeping up the use of astringent applications for about a month, the thickening of the cords, which had been great, was reduced, and their mobility became excellent.

In fact the glottis was then dilated to such an extent that I determined to remove the tracheal tube altogether, which I did on March the 19th, about six weeks ago, almost exactly one year from the time of first introduction.

The wound in the throat has entirely closed and he has had no difficulty in breathing through the glottis since. The voice remains a little husky, but as it is improving daily, and the appearance of the vocal cords is becoming more natural, I expect by the continued use of astringent applications that it will be perfectly restored.

These two cases, as well as one I reported to the Clinical Society in 1877, in which there was a stricture of the glottis due to contraction of the tissues from cicatrization of ulcerations in the larynx, which was relieved entirely, without tracheotomy, by the use of Schrötter's tubes, may be considered illustrative of the condition, and it is hardly necessary for me to add much to the history of such cases to what I have already given in an article published in the Md. Med. Journal, January, 1878, from which, with some slight alterations and additions, I will make a quotation. This is almost the unvarying history of laryngo-stenosis,, for its occurrence in any other manner than as the result of chronic laryngitis of syphilis is very exceptional. It does not occur as a sequence of the ulcerations of chronic tuberculous or carcinomatous laryngitis, as observers have decided that those ulcerations, if extensive, do not cicatrize. The rima glottidis is sometimes narrowed, it is true, in chronic idiopathic laryngitis from cicatrization, or, as in tuberculous laryngitis also, by a thickening from fibrinous infiltration of the submucous tissue of the ventricular bands and vocal cords, or of the subglottic mucous membrane, but rarely to such an extent as to cause a marked constriction; but there is a condition which, though nearly always a concomitant of syphilis, may, I believe, occur in connection with other forms of laryngitis. I refer to those cases where the inflammatory exudation becomes organized into fibrinous bands, which stretch from one part of the larynx to another, very often from one

vocal cord to the other, and by gradual contraction draw the two together and hold them fixed. Of this variety of stenosis there are a number of cases reported by Morell Mackenzie, Schrötter, Elsberg and others, and I have myself seen two cases, in one of which nearly the anterior half of the glottis was closed in this manner, while in the other there was a single membranous band extending across the glottis from the middle of one cord to the other. Again a laryngeal stenosis is occasionally met with as the result of the inhalation of flame or from scalds of the larynx, or in some rare instances mentioned, from typhus or typhoid fever, variola or measles, by which perichondritis or chondritis is occasioned or an inflammation is produced which has gone on to ulceration and cicatrization.

As regards the diagnosis, the discovery of an obstruction in the larynx is readily enough detected by the appearance of the patient, the changed voice, the distressed stridulous breathing, the rales that are often heard at some distance, but are always very marked on auscultation over the larynx, and the abnormal percussion dulness that can be detected, not only of the chest, but also, by, acute examiners, of the larynx itself; exactly the character of the obstruction can, however, only be appreciated by laryngoscopic examination. In reference to the treatment, although, as I have said, nearly all cases of stricture of the glottis are due to syphilitic disease, yet constitutional treatment will never effect a cure of a well-marked case. To prevent death from gradual suffocation, local treatment must be primarily and immediately undertaken, always with the object of overcoming the constriction in such manner as to allow the lungs to receive again the normal amount of oxygenated air which has for a time been cut off from them. It has long been the custom in this emergency to obviate the trouble by the creation of a second one, tracheotomy, which is but little better than the first, and by which, although air is certainly allowed to pass to the lungs, the original trouble is in nowise benefited nor its progress stopped.

In some cases of imminent death this treatment is not only justifiable, but is most judicious. Before being undertaken, however, a most careful laryngoscopic examination should be made; for sometimes, when the permanent constriction is not very great, the breathing may be temporarily obstructed, either by a slight oedema glottidis or a collection of mucus in the larynx, in which case the trouble can be treated through the natural passage, either by scarification of the oedematous membrane with the laryngeal lancet or by tubage of the

glottis, without any necessity for an external opening being made in the throat.

Catheterization or tubage of the larynx was advocated by Desault as far back as 1793, and afterwards by Bouchut, Trousseau, Weinlechner and Horace Green, for some cases of urgent dyspnoea; but in all these instances it was only intended to give temporary relief, and to Schrötter is due the credit of introducing the use of tubes for the systematic dilatation and permanent cure of laryngeal strictures. During the winter of 1874-75 that I spent in Vienna, Schrötter was experimenting very enthusiastically with hard rubber tubes intended to be passed into the larynx, for the gradual dilatation of those cases of laryngo-stenosis in which the constriction had not become so great as to necessitate laryngotomy.

These tubes are of gradually increasing diameters, and are about ten inches long, have perforations at the end, and are hollow throughout their calibre. They have a long curve of about one-third their length, for introduction into the larynx, and at the oral end of the instrument a curved cylinder about two inches long is inserted, to prevent its slipping, and to protect the face of the operator from mucus, &c. The introduction of the tubes is effected in this way: Having slightly warmed and well oiled one, it is passed behind the epiglottis and placed over the orifice of the glottis; then by keeping up constant and steady pressure it will, if it be of a proper size, presently glide through the opening into the trachea, and the breathing through it will be instantly apparent by the tubular sound, and may be felt by placing the hand over the end of the tube.

The benefit afforded the cases that I saw treated in this manner in the Vienna Hospital was so marked that I determined under similar circumstances to adopt the same measures, hoping for as happy results as I saw there; and as the condition of the patient treated by me in 1877 was so satisfactorily relieved by this means, I made use of it also in the two cases seen during the past year, although one of them had had laryngo-tracheotomy performed. The first of these patients, the female, did not require any continued use of the tubes, but the last required and had them passed almost daily for about six months.

The length of time the patient will allow the tube to remain in the larynx varies. At first it can only be retained a few seconds, but after each introduction it is better tolerated, and sometimes may be worn for one or two hours, or longer. Of the cases treated by

INSTRUMENTS USED FOR THE TREATMENT OF LARYNGEAL STENOSIS, AFTER THE METHOD ADOPTED BY DR. SCHROTTER.

FIG. 1. Tin bougie for the treatment of laryngo-stenosis, with the thread drawn through the tube.

FIG. 2. A tin bougie of greater diameter; the thread from this is drawn through the tube, by means of the wire that is seen alongside of it, and wound tightly around the handle.

FIG. 3. Small forceps to fasten the bougie, by the slender neck on the end of it, in the canula. FIG. 4. The improved method of holding the bougie in position after its introduction into the larynx.

FIG. 6. Curved cylinder to be inserted into the oral end of the tube to hold it in position.

me, the first retained the tube about fifteen minutes, and the second equally as long without much discomfort; but the third, the one that I show to-day, never allowed it to remain longer than three or four minutes, so I introduced it several times at each sitting, which proved sufficient to break the adhesions and dilate the glottis to quite a sufficient extent for easy respiration.

It would probably be well for me to mention here, what I stated in my former paper, that the sensation or irritability of the larynx is usually very much diminished in chronic laryngitis.

The method that Schrötter makes use of for those cases in which tracheotomy had been performed either through necessity or otherwise, and where the tracheal canula had become a "vade mecum," that they were doomed to bear silently to the grave, was like the tubage foreshadowed and suggested by the experiments that preceded it. The most remarkable cases in ante-laryngoscopic times are those of Mr. Liston. One was a laryngeal stenosis treated and cured by him in 1827, by passing bougies of increasing sizes into the larynx through a tracheal fistula that had been made in attempt at suicide. The other, a tracheal constriction, is still more noticeable. Here he passed bougies of different sizes through an opening in the trachea up through the larynx and out the mouth; when one was passed he grasped it there, and then pushed the other end down into the trachea, and finally allowed one the size of an oesophageal bougie to remain fifteen days in the trachea, and this case was also cured.

After the invention of the laryngoscope we have records of this trouble being treated by Czermak, Busch, Semelder, Trendelenburg, Gerhardt, and later by a number of others.

In most of these cases dilators were passed through a tracheal opening and upwards into the larynx; in none of them, however, was the method employed considered satisfactory, but I believe that an instrument, invented by Stoerk in 1878, for dilatation from below, altered so as to have three dilating blades instead of two, which would open antero-posteriorly as well as laterally, will be found most useful, and is one which, as modified by myself, I shall in future employ where tracheotomy has been performed. The dilators can have blades of different lengths to suit the necessities of the case, and after being introduced into the stricture the dilatation can be gradually increased day after day by turning the nut on the screw outside of the plate of the canula. My instrument shows the extent of dilatation by markings in millimeters on the screw, and it also has a flange or rim on the