The first is as to the results. We have such men as Dr. Deaver reporting a large number of cases, as Dr. Eastman has called attention to, something like twenty cases he reported last year at Atlantic City without a death. Dr. Murphy at the present time has had twenty-four cases with only one death. Dr. Murphy insists that these cases were diffuse, and he says "general peritonitis." That brings up again the question of definition. But he calls them general peritonitis. They are due to many causes. Many of them were perforations of the stomach, gall-bladder, intestines and appendix, as well as to other causes which I did not have time to discuss in a paper of this length. The element of tympanites was treated of by only two of those who answered my questions, and in briefing these replies I omitted to mention that two of those who replied to my questions advocated the opening of the intestines and relieving the tympanites. I think that is a questionable proceeding, for the reason that where we have it to that extent it is usually due to paresis, and it usually returns if you do open the intestine. However, it is practiced by good men. The element of drainage is varied to suit the individual cases. I thank you gentlemen.

CANCER OF THE LARYNX, WITH REPORT OF CASES.

BY DR. L. F. PAGE, OF INDIANAPOLIS, IND.

History. As to the nature and specific cause of cancer little is yet known. At present a widespread effort is being put forth to investigate the cause and nature of this formidable affection, and from the vast amount of intelligent investigation which is going on in different countries we may soon hope for results. The illness and death of the Emperor Frederick of Germany gave a sudden and universal impetus toward the study and a better understanding of cancer of the larynx. Immediately following this notable case were published the researches of Prof. Frankel of Berlin, the collective investigations by Semon of London, and many other remarkable papers and report of operative work. We are perhaps more indebted to Krishaber, of Paris, than any other for his previous study in the anatomy and pathology of this region. His classification of malignant disease of the larynx under the two heads, intrinsic and extrinsic cancer, marked a distinct era in the progress of the study and operative work on this organ. The region of the larynx comprised under the intrinsic division are the ventricular bands, the vocal cords, and the subglottic areas, while under the extrinsic may be included the epiglottis, the arytenoids, and the aryepiglottic folds. This classification is based upon the glandular supply. Operation on the extrinsic form of carcinoma is rarely successful, owing to the rich glandular supply of this region and the metasteses which result, and recurrence, which is almost certain. In the intrinsic form the outlook is far more promising, owing to the sparse glandular supply.

Diagnosis. Butlin in an introductory paper on the early radical treatment of laryngeal cancer states the situation as we all find it in regard to diagnosis. He says that we must admit there are three classes of cases; the first, in which anyone and every

one can make the diagnosis; the second, in which the better instructed or more experienced make it, and others do not; and the third class, in which the conditions are so obscure that no one can make the diagnosis until the larynx is opened, and in some of which it is even then difficult to be sure of the nature of the disease.

The value of an early diagnosis in this affection can not be overestimated. There are no groupings of symptoms, nor any laryngoscopic appearances, nor any microscopic findings which always point unmistakably to malignancy, Symptoms are often very suggestive; the trained eye in recognizing first laryngoscopic appearances counts for much, and the microscope is an invaluable aid, yet we should not exclude any one of these. McKenzie would reject the microscope entirely as being "misleading and inconclusive" and condemns the removal of fragments of the growth for this purpose. He says that it subjects the patient to dangers of autoinfection at the point of incision and to metasteses elsewhere, and that it stimulates the local growth of the cancer.

McKenzie it would seem is almost alone in this view. The majority of operators regard the microscope as a valuable aid to diagnosis, but not to be relied upon exclusively. The laryngoscopic appearance of the tumor, including its contour, its location, its surroundings, its color, the mobility of the vocal cords, the age of the patient, the character and location of the pain, with other subjective symptoms, aid the experienced eye in making the diagnosis; yet none of these are infallible signs. We are to differentiate from inflammatory diseases, benign tumors, pachydermia laryngis, syphilis, tubercle, lupus, laryngeal paralysis, and perichondritis. Syphilis and tuberculosis are the most confusing and most frequent to be considered, as either may be associated in the same case. Even where syphilis is not suspected a course of the iodides should be administered before resorting to operation.

Malignant disease of the larynx usually presents itself in two forms sarcoma and carcinoma; the latter being infinitely more common. Sarcoma may arise from any part of the larynx, but is usually of the intrinsic variety. The tumor takes different forms

and is sessile rather than pendiculated and grows slowly. Metasteses are uncommon. Death usually takes place in this form in from one to four years, and is usually due to suffocation and exhaustion.

Intrinsic carcinoma usually appears as a warty growth. Ulceration takes place early with rapid infiltration of the subjacent tissues. The lymphatic glands become involved late with little tendency to secondary involvment of other organs. The extrinsic form of carcinoma is a much more formidable disease. It rapidly spreads to the tongue, tonsil, pharynx, palate, and the neighboring lymphatic glands. The duration of life is usually short.

Cancer of the larynx is far more common among men than women, and is essentially a disease of mature age. The great majority of cases occur between 50 and 60.

Treatment.-Drugs have proved of little value in the cure of laryngeal cancer. The antitoxin treatment has thus far been a failure. Ligation of the carotids by Dawbarn's method has not been curative but has in a number of cases retarded the progress of the growth. While the X-ray has not fulfilled our expectations, it has proved of decided value in alleviating some of the worst symptoms, and the disease in many cases has been materially checked. No reports on the successful application of radium to the larynx have been found.

It seems that no specific for cancer of the larynx has yet been discovered, and, as Delevan says, in the present state of our knowledge the only hope for a cure lies in early radical operation. The endolaryngeal removal of malignant growths is today universally condemned. This method only hastens the end. Of the extralaryngeal operations early thyrotomy has the preference among the English surgeons, while among the Germans partial or total extirpation seems to be generally preferred. The American surgeons are divided.

The mortality before 1881 for 41 total laryngectomies was 60 per cent.; that for 10 partial laryngectomies was 40 per cent.— average 50 per cent. In recent years Glick, who has the most successful record, has a mortality of only 8 per cent.

The operation selected should depend on the extent of involvment. Butlin and Semon have conclusively demonstrated that thyrotomy with removal of the diseased soft parts is the operation to be preferred in the early stages of the disease. In the more advanced cases hemilaryngectomy or total extirpation affords the only hope. When the natural air passage can be preserved, even with slight stricture, it is greatly to be preferred to the miserable condition which follows total extirpation.

Case I. William Long, age 72, a plasterer, was first examined September 5, 1903. Had always had excellent health until he lost his voice from a cold during the previous spring. Had used tobacco constantly and alcohol occasionally. Nothing in the old man's appearance indicated dissipation. The hoarseness had been persistent and ocasionally a little blood came from his throat. The only pain that had annoyed him was in the left ear. There was no history of syphilis or tuberculosis. Laryngoscopic examination showed a growth rather larger than a bean in the anterior commissure of the vocal cords apparently springing from the under surface of the left cord. There was considerable infiltration about the left cord. The surface of the tumor was irregular and nodular, very hard and light in color, and the cord perfectly immobile. A saturated solution of the iodides was prescribed and he was kept on large doses until it was found that they did not retard the growth of the tumor in the least.

By the first of the following February-five months-the growth had increased to such an extent and breathing was so labored that death from suffocation was evidently near at hand. The case afforded almost every clinical evidence of cancer. A radical operation was performed at the City Hospital on February 5th, in which the left half of the larynx was removed complete. The patient was placed in the Trendelenberg-Rose position and chloroform administered. The first incision extended from the hyoid bone to the sternum and the tissues were dissected and pressed aside exposing the laryngeal and tracheal cartilages. A low tracheotomy was done and the ordinary large canula was introduced and secured with tapes. The chloroform was then adminis