there is a copious secretion from the granulating surfaces, which possibly flows into the trachea and is followed by bronchitis and then pneumonia with a fatal result. Pneumonia is also set up by the entrance of saliva, or food, into the trachea through the abnormal opening that exists between it and the pharynx. To guard against this occurrence it is necessary to carefully fill up the cavity of the wound next the trachea, and this object he has sought to attain by the introduction of suitable packing. Strips of iodoform gauze, the usual medium, have proved insufficient, as it is difficult to fix the packing so well that it will not be moved out of place when the patient swallows, and so come to lie with one end of the gauze in the throat, setting up coughing and vomiting, or to pass by the side of the tracheotomy tube into the trachea, causing signs of suffocation. The påcking also gets loose in a few days, and on the fourth or fifth day one is forced to change it before the surfaces of the wound are covered by granulation tissue. It is obvious that the second packing will not lie so well in position as the first, and in consequence the danger of "aspiration" pneumonia is greater even than before. The artificial nourishment of the patient has therefore to be carefully attended to, and some surgeons at the end of the operation pass a flexible catheter through the nose or through the opening in the neck into the œsophagus, by means of which the patient is fed for a time. Surgeons have been on the look-out for a method that would separate the wound and pharynx from the trachea, and have tried to effect this by a plastic operation, sewing together, after partial extirpation, the remaining part of the posterior wall of the larynx, and the hyothyroid membrane.

A truly decisive result was attained through the experimental studies of Gluck and Zeller on the origin of septic pneumonia after the operation on the larynx. They came to the conclusion that resection of the trachea is an infallible means of preventing such a pneumonia, and on the basis of these experiments Gluck proposed freeing the trachea from its surroundings, and so making it mobile, then resecting it and stitching the distal cut end to a button-hole in the skin, thus

interposing an impermeable barrier between the wound and the lungs which renders the inspiration of foreign bodies impossible. By the adoption of this method the results of the operation were so improved that Gluck was able to reduce the mortality to 4.5 per cent. Gluck's modification is applicable to those cases in which the laryngeal carcinoma is so widely spread that total extirpation of the larynx is required.

If, however, one considers that, thanks to the spread of laryngology, we are more frequently in a position to recognise early carcinomata of the larynx, or at least such as are still confined to one side, where unilateral resection of the larynx is sufficient, then it is evident that Gluck's modification can proportionately seldom be employed. Even in cases of total extirpation of the larynx, both the patient and the surgeon are loath to give up a direct communication for purposes of phonation between the air passages and the mouth, and the idea of being obliged to use an artificial larynx is regarded with disfavour. The unpleasantness associated with the wearing of such an apparatus, even when practicable, is well known, and patients prefer to give up loud phonation rather than go about with one. Surgeons again always have in mind the phonetically faultless results in cases of extirpation of the larynx by the earlier methods, thanks to the use of a Schornstein cannula, by which the patient could phonate perfectly while holding the end closed with the finger. A classic example of this is the case of Franzos, operated on by Stoerk and Gersuny with so successful a result.

The method employed by Föderls must be pointed out, by which he attempted to shut off the large cavity of the wound from the trachea, and at the same time to retain a permanent communication between the trachea and the mouth. moved the whole thyroid cartilage, the arytenoids, and the upper part of the posterior lamina of the cricoid cartilage, in the case of a carcinoma that had spread over the entire larynx. He then drew the trachea upwards after freeing it from its surroundings, and sutured the anterior part of the cricoid to the body of the hyoid. This procedure was carried out in one case by him, and the result was excellent; but it is

scarcely possible in all cases on account of the displacement of the trachea that is necessary, and, as a matter of fact, in Germany, as in Vienna. a few similar attempts of other surgeons did not attain the desired results, because the stitches. between the trachea and the hyoid separated. The method has a further disadvantage, in that the patient is not able to swallow easily, especially fluids, as the opening of the air passages is not sufficiently covered during deglutition. With solid food this imperfect closure is of no special consequence, and after a few months patients learn to swallow almost faultlessly, even if they have difficulty at first, but the difficulty of swallowing liquids remains to some extent.

While the method of Gluck in total extirpation reduces the danger of "aspiration" pneumonia to a minimum, we are still obliged to make as absolute a separation of the trachea as possible from the wound cavity by the use of packing, as in the majority of cases cancer of the larynx is unilateral. To improve upon the disadvantages of the method of dealing with the wound already discussed, Koschier uses another method, the results of which have given him entire satisfaction. After finishing the laryngeal extirpation, he lines the cavity of the wound with a broad double strip of iodoform gauze, under the guidance of the fingers, and takes special care that the space within the remaining part of the cricoid, or the space at the commencement of the trachea if the cricoid had to be removed, be sufficiently filled up. The upper part of the wound opposite the pharynx is treated in like manner, and into the sac thus formed a narrow strip of iodoform gauze is introduced in such a way that first the lower and then the upper part of the wound is filled accurately. The packing must be done very carefully, and as long a strip as possible carried into the sac. If during the operation a horizontal incision was necessary at the level of the upper border of the thyroid cartilage, then the edges of the wound will remain open and have to be united exactly by sutures. The air is then allowed to come out of the Trendelenburg cannula, which is then removed and replaced by an ordinary perforated Stoerk's tracheotomy tube. A light bandage

is put on to keep the packing in position and to permit it to become firm, and the patient is not allowed to swallow, but is fed, if necessary, per rectum. On the third day the packing has become quite firm, and all the cases operated on by him and so treated were then able to swallow without difficulty. As displacement of the packing is not possible, thanks to the gauze on the one side and the bandage on the other, he was always able to leave the packing undisturbed for nine or ten days after the operation. On the seventh or eighth day the packing being soaked with secretion, permits fluids swallowed by the patient to come through, and it becomes necessary to use an œsophageal tube for feeding purposes. On the ninth or tenth day the packing is removed, first the strip and then the gauze, and in all such cases one could then be sure that the cavity of the wound was perfectly granulated over. As a result of this the danger of septic pneumonia is much lessened. After removal of the first packing the wound is then re-packed in the same way, only of course the second packing does not close the cavity as accurately as the first, and it is therefore necessary to continue to nourish the patient artificially. The packing is changed every four or five days until the wound is healed. The wound diminishes gradually, and in spite of the fact that it has not been sutured, it looks as well as if it had been. In many cases it is necessary to close the fistula in the neck. This method has not failed in any of his cases, and not one has died of septic pneumonia. The only case of death that he has to recount was in his private practice, and as the history shows, it resulted on the sixth day after the operation in consequence of hæmorrhage from a thyroid vein.

On the basis of these results, this method can be recommended by Koschier in cases of total extirpation, as it has the inestimable benefit that, after healing has resulted, the patient is able to breathe and phonate through a Schornstein tracheotomy tube.

In conclusion, he discusses the indications for the various operations for the removal of cancer of the larynx. He opposes the method employed by some surgeons in Germany of endolaryngeal removal of cancer, on the ground that the

chance of a radical removal is minimal, for even if the case is seen early it is not possible to decide by the image in the laryngeal mirror how far the tumour has extended into the deeper tissues. An exception can be made only in those cases in which on other grounds a severe surgical operation is contra-indicated, if, for example, the age of the patient and his general condition render an anæsthetic, and prolonged after treatment inadmissable, and where the size of the carcinoma already occasions difficulty in breathing, which one could relieve by a simple and easily performed endolaryngeal operation.

Cancer grows much slower in old people than in the young; an example of this is seen in the case of a patient, aged seventy-three, with marked atheroma of the blood vessels and chronic bronchitis on which he operated. Under such circumstances the removal of the almost bean-sized tumour by endo-laryngeal means was justified.

Considering the unreliability of laryngoscopic examination in clearing up the probable extent of the carcinoma, one should open the larynx and make a closer inspection, and then decide if thyrotomy is sufficient, or if extirpation of the cartilage appears to be necessary. The thyroid cartilage does not become carcinomatous in the middle line at first, but about one cm. to the side of the middle line, corresponding to the favourite primary site of carcinoma of the vocal chord, at the junction of the anterior and middle third. When the cricoid is found to be involved at this point the necessity for hemisection of the larynx is determined, and according to the extent of the tumour either the ala of the thyroid cartilage with the arytenoid of the affected side, or also the affected part of the cricoid is removed. Since the carcinoma originates most frequently on the anterior part of the vocal chord, the anterior commissure and anterior part of the vocal chord on the other side is frequently also diseased. It is therefore very necessary always to remove a portion of the thyroid cartilage on the other side with the soft parts attached, so that one has more certainty of reaching healthy tissue.