Essay on growths in the larynx : with reports, and an analysis of one hundred consecutive cases treated by the author, and a tabular statement of all published cases treated by other practitioners since the invention of the laryngoscope

Front matter

ESSAYS ON THROAT DISE.

No. II.

GROWTHS IN THE LARYNX.

Preface

IN the year 1863, the Jacksonian Prize was awarded to me for my " Essay on Diseases of the Larynx." It was my intention to publish that work at the time, but my increasing engagements prevented me from at once carrying out this project, and Laryngology made such rapid advances that the views of one year became almost an anachronism in the next. Under these circumstances, I determined to publish, from time to time, a series of monographs on Diseases of the Throat, based on my original Prize Essay, but brought up to the most recent date.

For the subject of my first Essay I selected Nervo- Muscular Affections of the Larynx, on account of their very frequent occurrence and great importance ; and the great interest which attaches to Laryngeal Growths has induced me to choose this subject for my second Essay.

Since Ehrmann published his classical Histoire des Polypes du Larynx, in the year 1850, the Laryngoscope has effected an entire change in our views, and it is thought that sufficient time has now elapsed to enable us to consider these diseases from the new standpoint.

VI

PRE FA CE.

The present Essay is based on an experience of nearly 150 cases of laryngeal growth. It includes detailed Reports of 112 cases, of which 26 have been previously published in the Medical journals or the Transactions of Medical Societies, and 86 are now brought forward for the first time.

Of my 112 cases, 100 underwent treatment, and 12 were merely observed with the laryngoscope.

The 100 cases are consecutive, no treated case having been intentionally omitted : 77 of the cases were cured, in 18 improvement took place, in 3 the result was negative, and 2 died. Of the fatal cases, one was an infant, and the other an adult. In both tracheotomy had been performed.

The circumstances of nearly every case, which I have successfully treated, are known to one or more medical practitioners, and in by far the greater number of cases, the growths have been removed in the presence of professional confrhes.

I have excluded all cases of carcinoma, although in some instances great temporary benefit has resulted from the more or less complete removal of such neoplasms ; and I have also excluded all cases of "false excrescence." ^

I have likewise omitted a few other cases, — some because the notes were too imperfect to be of any value, some because they were only seen in consultation with other practitioners, and one because (no treatment having been advised by me) the case was subsequently reported by another physician.

PREFA CE.

vii

There still remain a considerable number of true growths which have come under my care since June, 1870; but as for statistical purposes it was convenient to limit the number of cases treated to 100 — a number probably sufficient to eliminate accidental circumstances — I have omitted all those subsequently seen.

In addition to my own cases, I have appended a record of all the published cases which have been treated since the invention of the Laryngoscope : all sources available in this country down to the end of the year 1870 have been carefully searched. In this arduous work, which relates to cases not only in England and America, but to a much greater number in Germany, France, Russia, Italy, Austria, and Hungary, I have received great assistance from Dr. JAGIELSKI and Dr. BauMLER.

My thanks are due to my colleagues at the London Hospital, Dr. ANDREW Clark and Dr. Fenwick, for their kind assi-stance in the microscopic examination of many of my specimens, and to my brother, Mr. Stephen MACKENZIE, who has made careful microscopic drawings of the neoplasms removed by me during the last two years.

I am also greatly indebted to my assistant, Mr. LENNOX Browne, for much valuable help in bringing out this work. All the laryngoscopic drawings made for me since the year • 1867 have been taken from life by him with great fidelity and artistic skill, and he has made finished drawings of those which I myself had sketched at an earlier date. In addition to this, he has greatly aided me by taking notes of the greater number of my cases during the last four years. My former pupil and friend, Mr. PUGIN THORNTON, has also viii

PREFACE.

given mc valuable assistance by keeping records of many of my cases.

Lastly, I have to thank the numerous medical friends who have'brought so many of the patients under my notice, and those who, by their presence at my public demonstrations, have encouraged me to persevere in the treatment of these laborious and difficult cases.

13, Wkymguth Street, Portland Place, W., Junc\ 187 1.

Section I

HISTORY.— Koderik, Lieutaud, Albers, Brauers, Regnoli, Ryland, Ehrmann, Rokitansky, Horace Green, Gurdon Buck, Middeldorpf, Prat, Astley Cooper. Invention of Laryngoscope. Increased Number of Cases observed . . .

SECTION IL

CAUSES. — Influence of Chronic Hyperemia of the Mucous Membrane, Influence of Dyscrasi^, Influence of Acute Diseases, Influence of the Inspiration of Irritating Vapours and Particles of Matter, Influence of Age, Influence of Sex, Influence of Occupation ..v

Section III

SYMPTOMS. — Functional Signs. — Modification of the Voice, Cough, Dyspnoea, Pain, Dysphagia. Physical Signs. — Laryngoscopic Signs of — Papillomata, Benign Epithehal Growths, Fibromata, Myxomata, Lipomata, Fasciculated Sarcomata, Cystic Growths, Adenomata, Angeiomata. Laryngeal Sounds and Crotchets. Digital Exploration. Forced External Elevation of the Larynx. Auscultation and Percussion of the Larynx. Microscopical Examination, Constitutional Condition. Course and Termination. Complications

X

On CnnvtJis in i/ic Larynx.

SECTION IV. Page

DIAGNOSIS.— Eversion of the Ventricle, Syphilis, Condylomata, False Excrescences, Gummata, Elephantiasis, Lupus, Laryngeal Phthisis, Malignant Growths, Outgrowths 34

Section V

PA T H OLOGY.— General Remarks — Papillomata — Relation of Papilloma to Warty Cancer— Benign Epithelial Growths —Fibromata— Fibro-Cellular Growths, or Mucous Polypi — Myxomata — Lipomata — Fasciculated Sarcomata — Cystic Tumours— Adenomata— Angeiomata— Other Kinds of Growth - Degeneration of Growths. Comparative Pathology

SECTION VI. PROGNOSIS.— In Relation to Life— Adults— Children— In

Relation to Voice 57

Section VII

TREATMENT.— Palliative— Radical— BY INTERNAL OR LARYNGOSCOPIC TREATMENT. MECHANICAL TREATMENT — Preparatory Measures — Anaesthetics Method of Procedure— Evulsion— Common Laryngeal Forceps— Tube-forceps-CRUSHiNG— Cutting— Cutting

Forceps, Knives, Scissors or Shears, Ecraseurs, Wire Loops and Rings— No Danger in Ecraseurs or Wire Loops- Guillotines. CHEMICAL TREATMENT-Caustics, Escharotics, Galvanic Cautery. EXTRA-LARYNGEAL METHODS OF TREATMENT— Contra-Indications for —Division of the Thyroid Cartilage, or Thyro- TOMY— Indications for Operation— History— Method of Procedure— Thyrotomy Table— Comparative Merits of

On Grozuths in the Larynx. xi

Page.

Thyrotomy — In Relation to Life, In Relation to Voice, In Relation to Recurrence. Removal of Growths by Division of the Thyro-hyoid Membrane — Indications for Operation — History — Method of Procedure^ — Comparative Merits of Operation. Removal of Growths BY Laryngotomy OR TRACHEOTOMY— Indications for Operation, History, Method of Procedure. Comparative Merits of Operation. The Combined Method of Removing Growths (Tracheotomy or Laryngotomy being first performed, and the growth being subsequently removed by Laryngoscopy) ^°

APPENDIX A.

Reports of One Hundred Consecutive Cases treated by the

Author i°7

APPENDIX B.

Short Reports of a few Cases in which Radical Treatment was not adopted

APPENDIX C.

Table of One Hundred Consecutive Cases treated by the Author

APPENDIX D.

Table of all Published Cases treated by other Practitioners

since the Invention of the Laryngoscope 227

Lithographic Plates II. III. IV. and V., with descriptions 249

Index

ESSAY ON GROWTHS IN THE LARYNX,

BENIGN GROWTHS IN THE LARYNX.

Definition : —

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.

Synonyms :—

Latin. — Polypus Laryngis ; Tumor Laryngis.

English. — Polypus of the Larynx; Fibrous Tumour; Fibrous Growth ; Connective-tissue Growth ; Wart ; Warty Growth ; Excrescence ; Vegetation ; Cystic Tumour ; etc.

Section I. History

Isolated cases of laryngeal polypus are to be found from an early date, and the case in which Koderik successfully operated on a^ growth through the mouth, about the year 1 750,' is one of the first described.

Seventeen years later, Lieutaud^ published two cases of undoubted laryngeal polypus.

In the beginning of the present century the Imperial Government of France offered a prize for the best work on Croup, and several eminent practitioners in different parts of Europe turned their attention to diseases of the larynx.

' George Herbinaux, Paraime des diffirens Instruments, avec les Mlthodes de ien sa-vir pour pratiquer la Ligature des Polpyes dans la Matrice, enforvKdeLeitre a M. Roux, avec Figures. A la Haye, chez Gosse et Percl. I77i-

-This case is quoted by Lewin in his able and comprehensive article in the Deutsche Klinik, March 29, 1862.

inexpectata. ....

In reporting these cases, Ehrmann, in his classical Histoire des Polypes du Larynx (Strasbourg, 1850), remarks at page 5 as follows :-" Les deux observa-

History.

We hence find a number of cases observed at this time, and subsequently published. Albers, of Bonn, one of the successful competitors, published an important work' in the year 1833 ; and in the same year, Brauers, of Louvain, attempted to extirpate a laryngeal polypus by division of the thyroid cartilage. In 1836 Regnoli*^ recorded a case in which he removed a growth from the larynx through the mouth, after performing tracheotomy ; and the following year Ryland^ devoted several pages of his classical work to tumours of the larynx. It was not, however, until the year 1850 that a complete monograph appeared. Then it was that Ehrmann published his celebrated treatise,"* which included thirty-one cases of laryngeal growth. In the year 1851^ Rokitansky brought forward ten additional cases ; and in 1852 Dr. Horace Green,'' of New York, published thirtynine cases, two of which had occurred in his own practice. In the' following year, Dr. Gurdon Buck collected forty-nine cases, including his own interesting example; and in 1854 Middeldorpf^ brought together sixty-four cases. Finally, in the year 1859, Prat published a case in which he had removed a growth through the thyro-hyoid membrane.^

Amongst all these cases, there are only nine in which an attempt was made to remove the growth during life, and ohe of these, viz. that by Koderik, already referred to, is so vague, that it must necessarily be excluded. Of the remaining eight cases, in four instances (those of Brauers, Ehrmann,

' Dissert, de Tuniorib. in Cavo Laryngis. Bonn.

^ A Treatise on the Diseases and Injuries of the Larynx and Trachea. ^ Op. cit.

* Zeitschrift der k. k. Gesellschaft der Aerzte zu Wien, Marz, 1851. ® Polypi of the Larynx and (Edema of the Glottis. New Yoric, 1852. Transactions of the American Medical Association, 1853. ' Die Galvanokaicstik. Breslau, 1854.

" Gazette dcs //fipitaiix, 1859, No. 103, p. 809.

Gurdon Buck, and Prat), direct incision was made through the neck ; whilst only in the cases of Regnoli, Professor Middeldorpf, and the two cases of Dr. Horace Green, was the growth more or less completely removed per vias naturalcs. In Regnoli's case the patient was a peasant, aged 70, who suffered from great dyspnoea and dysphagia. On opening the mouth widely, a tumour, about the size of a hen's egg, could be seen at the back of the throat, and, on introducing the finger, its peduncle could be traced down to the arytenoid cartilages. After performing tracheotomy, Dr. Regnoli removed the growth through the mouth. Unfortunately, the growth returned, and had to be removed a second time. The patient soon after sank from weakness.'

Dr. Horace Green, as already remarked, reported two cases : in one, he removed a pedunculated tumour about the size of a cherry, which was (thought to be) attached to the left vocal cord (but which may have grown from the ventricular band). When the mouth was widely opened, and the patient coughed, a round white fibrous-looking tumour could be seen projecting upwards between the ary-epiglottic folds. Green was able to seize the growth with the ordinary tonsil forceps, and then divided it with a long slender knife. Dr. Green's second case was that of a gentleman, aged 42, who was suffering from aphonia, dyspncea, and dysphagia. By passing a sponge probang saturated with a strong solution of nitrate of silver into the larynx. Dr. Green succeeded in separating a number of small polypoid excrescences, varying in size from a millet-seed to a duck-shot. The number of particles dislodged at different operations exceeded thirty. The breathing improved, but the aphonia remained.

In Professor Middeldorpf's- case he succeeded in removing a tumour from the upper opening of the larynx, by means

' I have been unable to find Regnoli's work in this country, but I am informed by my friend Dr. Massei, of Naples, who, at my request, kindly forwarded me details of the case, that it is also reported in Professor Andrea Ranzi's edition of Regnoli's Lectures on Surgical PatJiology, vol. iv. Florence, 1850, as well as in Ossei~v. chir. &c., 1836.

' Of: cil., ]). 212, and Riihlc : Die Kchlkopfkranklteiten. Berlin, 1861, p. 229.

History.

of the galvano-caustic wire. "The sarcomatous growth showed a high degree of cell-development," and as a portion remained behind, a very doubtful prognosis was given : solutions of nitrate of silver were afterwards used. Ruhle, who saw the case six years after the operation, states " that there was no symptom at that time of any return of the growth." In addition to these recorded cases, there remains another, which was not published at the time. The patient was treated by Sir Astley Cooper,' who removed with his finger a large cancerous tumour, about the size of a hen's egg, from the under surface of the epiglottis. It grew again, and was again removed, and the patient finally died from haemorrhage. This case is very similar in its clinical history to that of Regnoli, except that tracheotomy does not appear to have been necessary.

In perusing the various cases collected by different authors in ante-laryngoscopic times, it will be seen, that, in many instances, the growth was of distinctly carcinomatous character, and that others are altogether of a different kind, to those contained in this treatise.

The invention of the laryngoscope has naturally given a great impetus to the study of throat diseases, and since the genius and perseverance of Czermak placed the laryngeal mirror in the hands of the medical profession, a very great number of cases have been reported. To him, who brought the laryngoscope to perfection, was also reserved the honour of first discovering a growth with the laryngeal .mirror. On the 2nd of January, 1859, Dr. Hirschler I'equested Dr. Czermak to see a patient, who for some years had been treated for " nervous hoarseness." On laryngoscopic examination, it was at once seen that the dysphonia was due to a small warty growth on the right vocal cord.^

Since that time, upwards of 200 cases have been- published, in which laryngeal growths have been treated with

The specimen is preserved in the Museum of Guy's Hospital (No. 1685). This case was first published by me, in the year 1.865, '"^ ^'^'^ ^"^^1 edition of my work on The Use of the Laryngoscope, p. 1 1 1 et seq.

Wien. wed. Wochenschrift, 8 Januar, 1859.

On GrozvtJis in the Larynx.

the aid of the mirror. When we compare the cases observed with the laryngoscope with the specimens found in pathological museums, we are struck with the enormous antagonism, as to. the comparative frequency of laryngeal growths. In the museums of the Royal College of Surgeons and the various London Hospitals, there exist altogether only thirty-four specimens of true laryngeal growth, whilst in my own practice I have seen with the laryngoscope, in the course of ten years, more than four times as many cases. Dr. Krishaber ^ remarks that laryngeal growths " are to be met with in two or three per cent, of cases of disease of the larynx, exclusively local and chronic." In referring to this passage, Mr. Durham- observes that his own experience would lead him to " the conclusion that they are much less frequent even than this." I am unable to say how frequent laryngeal growths are, in comparison with other chronic local affections of the larynx, but I find, on an approximative analysis, that in relation to all other throat affections, including those of the pharynx, these cases have occurred in my private practice in the proportion of \\ per cent., whilst they have been present in only one-half per cent, of the cases under my care at the Hospital for Diseases of the Throat, and of my throat-cases at the London Hospital. The larger percentage occurring in private practice is not due to a greater liability of the upper and middle classes to this affection, but to the accidental circumstance, that the most common symptom — loss of voice — is of more consequence to the educated and wealthy than to those engaged in manual labour.

The great discrepancy between ante-laryngoscopic observations and present experience is to be accounted for by the following circumstances : — First, In former times, autopsies were, and even at present, are, frequently made without the larynx being opened at all. Secondly, Even if the larynx be opened, a small vegetation may be easily overlooked. As has

' Diet. EncyclopSd. des Sciences inMicales, Paris, 1868, art. "Laryngoscope." Holmes's System of Surgery, 2nd edition, vol. iv., art. "Diseases of the Larynx," p. 574.

History.

been remarked by Lewin, it is extremely probable, that, in former times, many cases of sudden death, attributed to apoplexy, or heart disease, were due to spasm of the glottis caused by growths. This author well observes, that "We have now the opportunity of . diagnosing many growths, which are so small, and are so situated, that though they give rise to symptoms, they do not cause death. If death subsequently take place from other causes, the larynx is either not opened at all, or is examined so superficially, that small growths are very likely not to be recognized. This is all the more likely to happen in consequence of the great diminution in volume which takes place in laryngeal growths after death."

Dr. Lewin also well remarks, that obstruction of the larynx may give rise to pulmonary apoplexy or oedema, and that these secondary affections have probably often been regarded as the true cause of death. To the objection, that growths in the larynx Would have given rise to some laryngeal symptoms during life, and that an inspection of the windpipe would therefore have been made after death, he urges, that, in the greater number of cases recorded before the invention of the laryngoscope, either no diagnosis was made, or the symptoms were attributed to phthisis, asthma, croup, ulceration of the larynx, spasm of the glottis, &c.^

' Deutsche Klinik, 1862. Lewin's arguments have been slightly epitomized. In each of the diseases referred to as having been wrongly diagnosed, and where growths were susbequently found, he quotes numerous cases from Andral, Senn, - Pelletan, Dupuytren, &c.

Section II. Causes

Influence of Chronic Hypercemia of the Mncous Membrane. — Chronic congestion of the mucous membrane of the larynx is, far above all other causes, the most important ^etiological feature, in the production of simple morbid growths in the larynx. In some cases, the disease appears to originate in an acute or subacute form of inflammation, but it is generally only as the starting-point of chronic hyperaemia, that the more acute attack indirectly leads to the production of a new formation.

Prolonged irritation of the mucous membrane of the larynx was long ago referred to by Ehrmann and Horace Green as the determining cause of polypus of the larynx, and of course that "irritation" acts by giving rise to hyperaemia.

The most common cause of hyperaemia is probably catarrh, and catarrh must therefore be looked upon as the great predisponent of growths. The various other influences, hereafter considered, probably only act through establishing a condition of hyperaemia.

Infljience of DyscrasicB. — Originating as the morbid affection does in local irritation, it is not surprising to find that diathesis appears to have little influence in its production. Neither syphilis nor phthisis, nor any other constitutional condition, appears to favour the growth of these neoplasms. In the later stages of laryngeal phthisis, imperfect papillary growths do occasionally appear on the posterior wall of the larynx, and on the mucous membrane covering the vocal

Causes. — Dyscrasice.

cords' and the inner surface of the arytenoid cartilages, but this is the exception. Indeed, both the diathetic conditions referred to, appear to exercise a decidedly antagonistic influence to the development of new formations. Seeing that growths most commonly originate in hyperaemia, and that both syphilis and phthisis frequently give rise to that condition, it might have been expected that these constitutional states would have often been present in cases of laryngeal growth. The fact, however, is, that the congestion of laryngeal phthisis is soon followed by submucous changes, which interfere with growth at the free surface ; and though, in the early forms of syphilis, the occasional presence of condylomata shows a tendency to the formation in excess of an imperfectly organized tissue, these manifestations are forms of eruption, which tend to spontaneous subsidence. When a very protracted syphilitic congestion occurs, growths may arise, but this is a rare exception ; and Dr. Harlan has well pointed out, that few laryngeal growths can be attributed to syphilis.'-^ Of course laryngeal growths may occur in syphilitic persons as they do in the healthy, but syphilis does not appear to be a factor in their production. In the records of the specimens in the various Pathological Museums in London, syphilis is stated to have previously existed in several instances, and in a specimen in the London Hospital, the patient was the subject of hereditary syphilis. On the subject of dyscrasia, Virchow,^ who includes not only true fibrous growths, but connective-tissue tumours and papillomata, in his comprehensive division of Fibromata, remarks as follows : — "The various forms of fibroma are all essentially hyperplastic, completely homologous, indeed, or, as is otherwise said, hypertrophic ; even in those cases, however, where numerous growths occur in the same situation, as for instance, on the skin, they cannot be attributed to a special

' In the case of a patient who recently (January, 187 1) died from laryngeal phthisis, in the Hospital for Diseases of the Throat, a warty growth of considerable size was found on the left vocal cord. The neoplasm consisted entirely of very large epithelial cells.

^ American Journal 0/ Medical Science, vol. lii. p. 122.

^ Die krnnkhnflen Geschwiihtc, vol. i. p. 356.

C lO

Oil GroivtJis in tJie Larynx.

fibromatous dyscrasia .... It often happens that on the serous surfaces, a considerable elevation is found, consisting of larger and smaller fibrous nodules. These are ujiiversally regarded as the expression of an inflammatory irritation, which affected the whole surface, though it did

not give rise to the same result in all parts

These cases prove that, within a given area of dermal or connective tissue, a condition of vulnerability may exist, which under slight influences may give rise to isolated eruptions. The nodular tuberous fibromata are in this respect closely parallel with the warty growths, which are very often multiple, and which grow not only on the hands, in great numbers, but are also found covering a large surface of the rest of the body. Without further evidence, it cannot be concluded that there is such a thing as a warty dyscrasia, or a warty constitution of the body in general, for the skin is the only part affected. If we examine these cases, however, more closely, we find that with regard to the hands, the essential cause is external irritation, and that those persons, who are not subjected to any irritation, suffer little or not at all, from warts. There is no doubt, that the class of working people, who are not required to do much with their hands suffer very little from warts, whilst cooks, coachmen, and artisans are often very much troubled with them. This is evidently the result of their occupations, and other parts of the body, under certain circumstances, show a similar predisposition The greatest difference is seen, however,

to exist : one individual, under certain circumstances, being affected with warts, whilst another, under the same conditions, is perfectly free ; in the same individual^also, warts are more readily formed at particular times than at others. This proves that a variable predisposition exists in the tissues, which are the seat of these growths. This must depend on the condition of the part, inasmuch as different results are produced by the same external irritation. If the irritation which takes place be very transient, it may pass off without any result. Under these circumstances, I believe, that, after all, we must fall back on local predisposition, which

Caicses. —-Acute Diseases.

also thoroughly explains the multiplicity of these tumours. If the views of humoral pathology be logically followed out, we are driven to the conclusion that warts are contagious (a popular view, which is still largely entertained), and that the contagion lies in the blood.

" It is an old superstition that, if, when a wart is cut, blood flow on the skin, a fresh wart arises : this follows ■naturally from the old humoral pathology, and, to be logical, must be based on the supposition that the tflood in the wart is the essential carrier of contagion.

"The occurrence of those numerous cases of congenital fibroma, which increase from very slight irritation, and develop into large tumours, favours the idea of local predisposition. The much more rare hereditary forms, which develop after birth, and the multiplication of which is always limited to a single system, favour the same idea. The same may also be said of those numerous cases, in" which slight wounds are the attributed causes of the development of fibromata, or where the essential tumour-formation takes place in a tissue, predisposed through previous morbid processes, as is so clearly seen in elephantiasis. I have repeatedly remarked, that I do not exclude the idea of k dyscrasia, — nay, that I even do not deny the specific nature of such a dyscrasia. Syphilis is here the best example, and both the acuminated and the broad condylomata have been

attributed to this disease ^^^ould, however,

a dyscrasic condition be the cause of the irritation, a fibroma is essentially a formation of local character, and in common language, benign. If indeed it grows, and spreads itself, it has little inclination to ulcerate. On the other hand, many of the tumours now brought under consideration, especially warts and condylomata, and even the slighter forms of elephantiasis, frequently disappear spontaneously, being subject, as they are, to slow atrophy and resorption." .

Influence of Acute Diseases. — Some of the exanthemata, especially variola, scarlatina, measles, and erysipelas, are supposed by Lewin to have a special influence, in the pro-

On Grozvths in the Larynx.

ductioii of laryngeal polypi ; but it is probable that they only act indirectly by giving rise to chronic inflammation of the lining membrane of the larynx.

It seems likely also that both croup and whooping-cough act in the same manner. As regards croup, however, it must be observed, that though attacks of that disease are likely to excite growths in the larynx, yet the growths themselves give rise, in children, to symptoms closely simulating croup. Hence a previous history of croup must always be looked on with suspicion. In all cases of laryngeal congestion, but especially in croup and whooping-cough, it is probable that not merely the hypersemia, but the frequent and violent coughing which characterizes these conditions, has an important causative influence.

Inflnence of the Inspiratioji of Irritating Vapours, and Particles of Matter. — The influence of an atmosphere impregnated with atomic matter, in the production of disease, has been recognized since the time of Pliny, and the Roman bakers,' whilst engaged in their occupation, were in the habit of covering their face with a kind of cloth. At a later period, Bubbe,^ Ramazzini,^ and others, drew attention to this cause of disease, and in our own time, Holland,* Heussinger,^ Virchow,'' Lewin,'' Headlam Greenhow,*' and other physicians have further elucidated the subject. Quite recently, the asso-

^ Dissei-t. inaugiu-., ^c. Halse, 1721. Hufeland''s Jotirn., vol. xcviii. p. 4. ' 'Abhandhijigen von den Krankheiten der Kiinstler und Handwerker, translated by Ackermann, 1780, vol. i. pp. 123, 147 ; vol. ii. p. 27.

* Diseases of the Lungs from Mechanical Causes, and Inquiries into Conditions of Artisans exposed to the Inhalation of Dust, by Dr. G. Calvert Holland. London, 1843.

' Beitriige zur Inhalations-therapie in. Krankheiten der Respirations-organe. Berlin, 1863. The whole subject has been worked out with great industry and ability, as well as with much statistical evidence, by this author. For several of my references I am indebted to his interesting work.

* Chronic Bronchitis. London, 1870.

Causes: — Irritating Vaponj's and Dust. 1 3 ciatlon of " Dust and Disease " has been popularized by Professor Tyndall.^ The observations of these various physicians and physicists have principally had reference to the production of disease in the lungs and bronchial tubes ; but if particles of matter can, as has been so clearly shown, give rise to disease in the lungs, a fortiori they be likely to produce it in the larynx. In the causation of growths, the influence is probably indirect ; hypersemia of the mucous membrane being the immediate result of the inhalation of irritants. Out of 55 adult males in my 1 00 cases, 8 were engaged in occupations which, of necessity, exposed them to these irritating influences. The employments in the cases referred to were those of carpenter, twine-spinner, wool-packer (2), mason, engine-driver (2), and farrier. In the 105 cases in Appendix D, in which the occupation of adult males is stated, 8 cases occurred in which the patients were subjected to the influence of dusty particles, the occupations being those of lapidary, cabinet-maker, carpenter, mason, tinsmith, chimney-sweep, ragman, fireman, and weaver. It will be seen, therefore, that in 11 '2 5 per cent, of all cases, the patients have been more or. less exposed to the mechanical influence now under consideration. It is very probable, also, hati the occupations been stated in all the foreign cases, that the influence of molecular irritants would have been still more marked. It must not be forgotten also, that people of every occupation, and of both sexes, are constantly breathing an air impregnated with atomic matter.