[Extracted from the American Journal of the Medical Sciences for April, 1875. 
CASE OF INTEA-LARYNGEAL TUMOUR 
(Showing under the microscope mixed characters, principally, however, 
those of small-cell sarcoma)—in a Syphilitic Subject. Partial 
Evulsion, Perichondritis, Abscess pointing exteriorly, 
Fistula of Larynx, Necrosis of Thyroid, Cartilage; 
Tracheotomy; Death; Examination, 
Post-mortem; ftemajj/cs.1 
By BEVERLEY ROBINSON, M.D., 
SUROEON TO THE MANHATTAN ETE AND EAR HO'PITAL (DEPARTMENT OF THE THROAT}, 
Michael S., set. 32, born in Ireland, farmer, 14 years in the United 
States. When in the United States Army, in 1864, contracted hard 
chancre. Patient had anti-syphilitic . treatment for several weeks after 
primary lesion was recognized. Since that time rare constitutional symp- 
toms of mild type have manifested themselves. 
By careful examination of patient’s present condition we have been able 
to detect but two physical signs of the existence of constitutional syphilis, 
viz., 1. slight alopecia, 2. a number of enlarged indurated lymphatic gan- 
glia, in different regions of the body. There are no traces of present or 
ancient syphilitic affection of the integument of the face, trunk, or limbs. 
As much may be said of the mucous lining of the buccal cavity. Con- 
stantly recurring nocturnal pains of osteoscopic character are complained 
of, and appear to indicate functional trouble of specific nature, inasmuch 
as no tumefaction of bone or periosteum can be detected. 
Three years ago patient caught a severe cold, and during five months 
from above period, has had at times incomplete aphonia. Later, and till 
a few days before Christmas, 1873, voice remained permanently feeble, and 
there were few if any intervals when it notably improved. During the 
latter days of December, 1873, pain localized over region of larynx became 
a prominent symptom. This has increased somewhat in the past few 
weeks, and now (May 1st, 1874) is always present. It is made still worse 
by an attempt to swallow, or a paroxysm of cough. For two or three 
weeks deglutition has been imperfectly accomplished. Solid substances 
pass into the stomach with difficulty, and occasionally particles of food get 
into the larynx, cause cough, .and are expectorated for several minutes 
after a wearisome and insufficient meal is terminated. Liquids are swal- 
lowed only after repeated trials, and it is not infrequent to see them 
1 The history of this case, with the accompanying marked specimen of intra- 
laryngeal growth, was presented to the New York Pathological Society, at a stated 
meeting, held June 24th, 1874. rejected in great part through the month and nose. The oesophagus is 
apparently free from disease, and the difficulty of swallowing is due either 
to the pain which this act occasions, or to loss of healthy function of the 
epiglottis and pharyngeal muscles, and not to organic obstruction in the 
passage way of the alimentary bolus. Patient is pale and thin, and has 
been losing strength daily for about one month. There is, however, no 
family history which would lead one to suspect tubercular deposit in the 
lungs, and the signs given by percussion and auscultation of these organs 
remain wholly negative. The vesicular murmur is partially obscured, it is 
true, but this is owing to exaggerated sound transmitted from, and which 
takes origin in, the vocal organ. There is abundant expectoration of white, 
frothy mucus, and at times the sputa are viscous, non-aerated, and resem- 
ble thick boiled starch. These latter appear to come principally from 
the pharynx and larynx, as few rales can be heard in the bronchial tubes, 
and accumulated mucosities are brought into the mouth by an effort of 
hawking. After slight physical exertion of almost any kind (walking, 
talking, etc.), respiration becomes noisy, and in a measure difficult, and 
dryness of the throat is on these occasions a symptom which causes much 
annoyance. The voice and cough are now broken, husky, and imperfect, 
and have lost much of their normal strength and pitch. In a word, our 
patient is incompletely aphonic. 
Larynx.—The interior of this organ offers a diseased appearance in its 
entire area. This aspect, as shown with the laryngeal mirror, is, as nearly 
as possible, expressed by the term fungoid. First, and most prominently, 
there is a large, pinkish, mammillated growth situated on the right side 
of the larynx.1 This growth tills up about two-thirds of the superior open- 
ing of the larynx, and has a broad base attached to the greater portion of 
the right ventricular band. It extends as far forward as the anterior com- 
missure, but leaves a small orifice behind its margin and the posterior com- 
missure. The size of the growth is about that of a very small hazel nut, 
and conceals from view in great part the right vocal cord. The mucous 
membrane covering the arytenoid cartilages is red and swollen, and the 
submucous tissue infiltrated. Upon the superior surface of the right aryte- 
noid cartilage is a single ulceration. Below the left vocal cord is a second 
neoplasm as large as a lentil, irregular in outline, and apparently of similar 
structure to the one first described. 
It springs from the left side of the cricoid ring. The vocal cord and 
ventricular band on the left side, have a pinkish coloration, and in their 
entire extent a mammillated appearance, with numerous points where evi- 
dent ulcerations are situated. 
What was the vocal cord and ventricular band on this side, viz., the 
left, is now covered with, or included in, morbid tissue. The posterior 
commissure is very much thickened. 
Such was the condition presented by the interior of the larynx during 
the ordinary movements of inspiration and expiration. During an effect 
of phonation the first and larger growth obstructs the lumen of the larynx 
completely and presents the approximation of the vocal cords, or, more 
properly speaking, the layer of morbid tissue in which these fibrous bands 
are comprised. Both arytenoid cartilages rotate partially, and so far as 
1 The exact point of origin of the neoplasm could not at first be determined, but 
in later examinations it was seen to arise from the right ventricular band. The 
necropsy confirmed the accuracy of this diagnosis. 3 
they are doubtless able to do, having in view the mechanical obstruction 
due to the presence of a tumour on the right ventricular band, and having 
also the thickened condition of the index-arytenoid commissure. The crico- 
arytenoid articulations are not, therefore, if we consider the evidence fur- 
nished by the laryngeal mirror, in a diseased condition. 
Treatment.—Inhalation tinct. benzoini comp. (3j-oj) several times in 
twenty-four hours. As nourishment a thick mixture of essence of beef, 
yolk of eggs, and oatmeal porridge. 
May 5. Patient admitted into the Manhattan Eye and Ear Hospital. 
On this and following days, several partially successful attempts were 
made by my friend and colleague, Dr. Andrew H. Smith, and by myself, 
to tear away the larger of the two growths in the larynx. Bits of the 
growth were brought away by one of us on these occasions by means of 
Mackenzie’s antero-posterior cutting forceps. The successive operations 
were well supported, caused but moderate pain and little or no hemorrhage 
subsequent to the evulsion. Anti-syphilitic treatment was employed, viz., 
frictions over region of larynx with unguent, hydrarg. and administra- 
tion of potass, iodidi externally. Applications of cupric sulph. (gr. xv- 
Sj) and insufflations of iodoform were made more than once, and appa- 
rently with some good effect, to the interior of the larynx. 
12th. Has evidently improved; deglutition is more easily performed and 
without being followed, as a few days since, by regurgitation through the 
mouth or nasal passage. The breathing, which previously became noisy 
after the slightest exertion, is now more tranquil under similar conditions. 
The voice is somewhat stronger; localized pain has not diminished, and 
on examination of the region of the larynx, considerable redness and 
tumefaction are seen, which we ascribe to irritation caused by the mercurial 
frictions. These latter were stopped, and poultices ordered to be applied 
and frequently renewed ; the size of larger growth has considerably di- 
minished, and at present more than one-third its original volume ; the 
pulse continues weak and accelerated; the thermometer in the axilla was 
found to mark 100°.2 Fah. (May 5th), and has varied but little since. 
23c?. Patient having failed to show himself at hospital, he was visited 
to-day at his house by Dr. A. H. Smith and self, and found ill in bed ; he 
is very weak and much emaciated; has suffered from diarrhoea, which 
happily is now arrested ; for seven days he has been able to take very 
little nourishment, owing to extreme soreness over laryngeal region ; 
during afternoon lie was again transported to Manhattan Hospital in a 
carriage; on his arrival there attempts were made to examine the larynx; 
on account of great intolerance of mirror the inspection of the vocal organ 
was imperfect; yet it was evident that the upper orifice of the larynx was 
still considerably obstructed by what remains of the growths already de- 
scribed, by neighbouring thickening of mucous membrane and by submu- 
cous infiltration; discharge of muco-purulent character lines the interior 
surface of the larynx. 
Externally, an abscess of considerable volume was immediately recog- 
nized. It was situated over region of thyroid cartilage, and pointed some- 
what towards median line. When opened by a vertical incision one-half 
inch in length, two or three teaspoonfuls of fetid sanious pus came out, or 
were pressed from the interior of the pyogenic cavity. Mingled with the 
pus were several air globules. The existence of these latter was explained 
by the decomposition of pus, which doubtless had its origin in the peri- 
chondrium covering the thyroid cartilage. 4 
With the probe considerable burrowing on the left side of the neck 
(two inches) was made apparent. On the right side there was less separation 
of the skin from the soft parts beneath; no necrosed points of cartilage 
were discovered after a tolerably thorough examination; a strip of lint 
was introduced by the external opening of the wound, and instructions 
were given that the cavity should be washed during the evening with 
carbolic lotion. The incision of abscess relieved patient of much pain. 
Beef-tea, milk, egg, brandy, were prescribed in such quantities as patient 
might wish to partake of them. 
24th. Breathing is frequent and noisy, but without great difficulty or 
oppression; passed a restless night; with probe necrosis of thyroid car- 
tilage in neighbourhood of anterior insertion of vocal cords is discovered, 
and after some search a point where there is a small orifice communicating 
with the interior of the larynx; introduction of probe by this orifice occa- 
sions a paroxysm of painful cough. When patient closes his mouth and 
nose he can blow air from lungs through the fistulous opening; skin is 
still hot; pulse 108; less fever, however, than yesterday; moderate dis- 
charge of fetid pus from wound ; diminished soreness on pressure ; skin 
has adhered in part on both sides of wound to soft tissues beneath ; cough 
very troublesome ; expectoration at times of muco-purulent sputa, tolerably 
tenacious, and again of a white, frothy liquid ; less viscous and adherent. 
There is but little blood mingled with sputa; milk taken was vomited as 
a heavy, solid coagulum. Ordered liq. morph, sulph. 5j at bedtime, to be 
repeated if necessary. Mist, expect, (ipecac, acacia, etc.) 3j occasionally 
when the cough is troublesome; liquor calcis mixed with milk 
jelly, port-wine, egg, milk, beef-tea, etc. 
26th. Temperature 101°.2 Fah. ; pulse 112; expectoration easier; 
passed a good night; taken a tolerable amount of food ; fistula patulous, 
as yesterday. When patient coughs, air passes freely by orifice. Ordered 
suppositoria c quince sulph. gr. iij three times a da}'. 
27 th. Pulse 108; weaker; coughs continually; abundant viscid expec- 
toration ; has taken very little nourishment; great thirst; one motion of 
bowels ; cold, clammy, and very excessive perspiration. 
31s£. During the evening the patient was suddenly attacked with in- 
tense dyspnoea. ,Dr. A. H. Smith, who was immediately sent for (as I 
was absent from the city), found patient breathing with less difficulty than 
he had done a short time previously. Deeming it prudent, however, to 
prevent a possible recurrence of dyspnoea, and the hour (11 o’clock P. M.) 
being unfavourable for a major operation, he enlarged the wound some- 
what, and excised a small portion of the left thyroid ala, where it was 
necrosed. Patient breathed more easily after the operation, and passed 
the night with relative comfort. 
June 1. About mid-day patient took ether. So long was he in being 
sensibly influenced by it, that a moderate proportion of chloroform was 
used so as to produce complete anaesthesia. The operation of tracheotomy 
was then successfully performed by me, aided by Dr. Smith. No large 
vessel was divided. There was, however, moderate hemorrhage after the 
introduction of the canula. 
2d. Doing about as well as could be expected yesterday afternoon ; the 
expectoration alone, by its abundance, giving legitimate cause for imme- 
diate anxiety. He passed a restless, feverish night, and enjoyed little or 
no sleep. No nutriment was taken, so great was the pain occasioned by 
the effort of deglutition. This morning at 5 o’clock A.M. the canula 5 
became stopped up with viscid phlegm, and patient was nearly choked to 
death before efficient aid could be given by the nurse in attendance. The 
canula caused much pain, and liquids, when swallowed, pass into the 
larynx and trachea in part, and are thrown back after cough or violent 
expiration through the wound and tracheal tube. Pulse is irregular and 
very feeble; respiration very frequent. Since early morning has taken 
but a small quantity of beef-tea and milk. 
3d. Yesterday in the afternoon a consultation was held with Dr. A. 
II. Smith, and it was determined that the operation of thyrotomy should 
be performed, and that after complete separation of the alee of the thyroid, 
the interior of the larynx should be rid, so far as possible, of the morbid 
growths contained therein ; that explorations should be made to find out 
the exact situation and limits of the processes of necrosis, and that what- 
ever portions of dead cartilage were to be got at, without increasing the 
already very serious condition of the patient, should be removed, and that 
afterwards, supposing no incidental circumstances were to arise and 
counter-indicate such treatment, the canula should be withdrawn, and the 
implicated parts brought together by means of stitches. Such was the 
plan of procedure adopted after much reflection, and it was, in reality, 
the only one left us if we were not prepared to stand by quietly, and see 
death follow surely and promptly. 
Unfortunately the impressibility or weakness of the patient was such 
that we found ourselves obliged to forego carrying out the above indica- 
tions. 
On two successive occasions, all proper precautions being exercised, an 
attempt was made to bring the patient under the influence of chloroform. 
Inasmuch, however, as alarming symptoms manifested themselves after 
but a few inspirations, the inhalation was considered too hazardous to be 
continued. The idea of any further operative measures was then defi- 
nitely abandoned, and it was believed that, if persisted in, they would 
cause an immediately fatal result to the patient. 
The pulse and respiration increased in frequency during the afternoon 
and evening, the patient taking little or no nourishment of any kind. 
His strength failed him more and more, and, sinking gradually, he died 
at o’clock P. M. (June 2d), the proximate cause of death being the 
clogging up of the smaller bronchial tubes by an excessive amount of 
muco-purulent secretion. 
Necropsy (June 3d), fifteen hours after death, was confined to the 
larynx, as circumstances did not admit of further examination. Upon 
dissection of soft tissues, so as to separate the larynx from the adjacent 
parts, and take it out completely from the cadaver, no burrowing to any 
extent in cellular tissue under the skin was remarked, and apparently the 
cavity of the abscess, opened into some days previously, had become 
almost if not entirely obliterated. After separating the intrinsic muscles 
of the larynx in front from the alas of the thyroid cartilage, a considera- 
ble part of the right ala, in the neighbourhood of its lower margin, was 
found to be without perichondrium ; bare and rough to the extremity of 
the probe. In fact, there was evidently a condition of necrosed cartilage 
at this level. On the right side the soft tissues presented a greenish 
aspect, due to putrefactive changes. In this direction, also, there was 
distinct proof of fistulous burrowing previous to death. The left ala was 
less diseased in front than the right, and no portion of this region was 
bare, or showed detached perichondrium. The fistulous orifice commuui- eating with the interior of the larynx, which had spontaneously shown 
itself before death (after incision of the abscess mentioned in the history 
of the case), and which had been enlarged by Dr. Smith, situated 
just on a level with the anterior attachment of the vocal cords and ven- 
tricular bands. The larynx having been laid open from behind on the 
median line, a good view was obtained of its interior. The following is 
an accurate description of its appearance: The free border of the epi- 
glottis was but little affected. It was free from ulceration, and only very 
slightly thickened. Considering the’ageof the patient (thirty-two years), 
the yellow coloration of the fibro-cartilage was more apparent than usual. 
The base of the epiglottis—and, in fact, the general aspect of the larynx 
when looked into from above—to be expressed by a term which nearly 
approaches accuracy, is fungoid. So true is this word to the idea in the 
mind, that the question immediately suggests itself, have we not here a 
malignant growth of carcinomatous structure ? To particularize—the 
inferior two-thirds of the epiglottis, the ary-arytenoid folds, the posterior 
commissure, and the mucous covering of the arytenoid cartilages, are all 
much thickened, and offer a very light pinkish coloration. At the base 
of the epiglottis, to the right, is a round, somewhat rnammillated growth 
about the size of a large pea, adherent to the mucous membrane by a 
broad base, of almost equal diameter to the prominent portion of the 
growth. The rest of the posterior surface of the epiglottis which we are 
considering, viz., the inferior two-thirds, presented mammillary elevations 
due to smaller pathological formations of same nature with the preceding, 
alternated with depressions occasioned by ulcerations of lenticular configu- 
rations. One of these presented a yellow fundus, which was none other 
evidently than the fibro-cartilage of the epiglottis. The ary-arytenoid 
folds and mucous membrane lining the arytenoid cartilages presented 
several points of ulceration. 
One of these ulcerations, isolated and very distinct in outline, is situ- 
ated on the superior aspect of the mucous membrane covering the right 
arytenoid cartilage. Lower down, what remains of the growth spoken of 
in the history of the case, is distinctly seen to take its origin in the right 
ventricular band, and to cover over and conceal from view almost entirely 
the right vocal cord.1 The left ventricular band and left vocal cord are 
very indistinct in their outline and barely distinguishable, on account of 
infiltration of their mucous lining, with deposit of similar structure to 
what forms the neoplasms described. The lumen of the larynx is dimin- 
ished, but not sufficiently to account by itself for the intense dyspnoea 
which came on suddenly, during the evening when Dr. Smith enlarged the 
fistula of the larynx.2 
At the posterior wall of the larynx, and on either side, is a fistulous 
passage which extends for some distance amongst the soft tissues which 
laterally are in relation with the cricoid cartilage. This cartilage is much 
diseased in the superior half of its posterior wall. 
Upon section this portion presents a dark-brown coloration of the can- 
cellated portion of what has evidently become transformed into osseous 
1 Before evulsion was commenced, this growth extended below the right vocal 
cord. 
2 This dyspnoea is doubtless sufficiently explained by suddeu spasm of the 
adductor muscles, or else by sudden obstruction of the calibre of the larynx, with 
viscid and purulent secretion, coming from the bronchial tubes. structure. From this portion of diseased cartilage the fistulous orifices 
and trajeets mentioned, take origin. The lower half of the cricoid cartilage 
appears healthy.1 Below the inferior border of the cricoid cartilage the 
tracheal wound is visible in the median line. The mucous membrane at 
one point to the right and behind—on a level with the inner extremity of 
the canula—is ulcerated, and offers evident marks of inflammatory pro- 
cesses in the immediate neighbourhood. Elsewhere the mucous membrane 
of trachea shows numerous congested spots. One or two of the tracheal 
rings, especially on the left side, for about one or two lines, are broken and 
bent backward into the tracheal passage and the wound of the trachea, 
though on the median line and made with a single incision of the bistoury, 
is irregular on its margin—as if notched, and a portion of the tracheal 
rings had been removed, by two or more incisions, made in different direc- 
tions.2 
Note.3—Appended to this microscopic examination, are the characters 
discovered with the microscope, and which have been given me by Charles 
S. Bull, M.D., Pathologist to the Manhattan Eye and Ear Hospital* 
“The growth is mostly of a fibro-cellular structure with the cells largely pre- 
dominating—in fact there seems just enough of fibrous connective tissue present 
to hold it together except towards what looks like the base of the tumour, 
where it is somewhat more abundant. Only in isolated spots on section did I 
meet with any epithelial cells covering the surface. The mass of the growth is 
composed of small, round, nucleated cells, with granular contents, about size 
of a pus corpuscle. There were some few fusiform, or caudate cells scattered 
through the tumour, and near the base they were quite numerous, being 
arranged together as we see them in a true fibro-cellular growth. There were 
some larger ovoid cells, few in number, about twice or three times the size of 
the round cells, with nucleus and nucleolus. The numerous bloodvessels 
proved the growth to have been somewhat vascular. I could not find any 
remains of glandular tissue, and though the tumour resembles very closely a 
lympho-sarcoma, yet there were spots, or vacuoles, which we meet with in the 
papillomata, which were filled with a homogeneous mucous matter, giving the 
appearance of a myxo-sarcoma. The centre of each piece of the tumour was 
much softer than the outside.” 
“To sum up the examination, I should call the growth a small-cell sarcoma, 
towards the base being of the fibro-cellular variety, while the rest of the growth 
is of a myxo-sarcomatous character.” 
Subsequently a communication was received from Dr. Bull, as follows:— 
1 The point of origin of disease of cartilage, as perichondrium is not evident. 
Did chondritis, as perichondritis develop itself first in thyroid, or cricoid cartilage ? 
Impossible to affirm positively from ocular examination. 
2 We would draw attention to the fact, that the smaller growth situated under 
the left vocal cord, of which we speak in the history of our case, is not mentioned 
in the microscopic description, as made after death, and with the morbid specimen 
before our eyes. This smaller growth is no longer visible. What has become of 
it, we cannot assert positively. Was it torn away in great part, in our last opera- 
tion within the larynx, by means of the laryngeal forceps, and what remained 
behind, afterwards expectorated with secretions from the bronchial tubes ? Such 
is the probable explanation, and we remember to have seen a like phenomenon 
occur in an analogous case. 
3 The other organs could not be examined, owing to opposition met with on the 
part of relatives of the deceased. 8 
“ The perichondrium was very much thickened, and seemed to be much 
denser in structure than is usual. The cartilage itself was very hard, and to 
the touch and naked eye gave the impression of being ossified. A microscopic 
examination showed a very marked hypertrophy of the connective tissue of the 
perichondrium, and a very general infiltration by the same round and fusiform 
cells that existed in the neoplasm. The vascular development was marked, 
and in some spots there occurred masses of pigment of irregular shape and 
size, lying free in the connective tissue, while occasionally some was found 
inclosed in the cells.” 
Remarks.—There are several points of undoubted interest connected 
with the above case. And this interest is at once practical and theo- 
retical ; practical, inasmuch as the question of diagnosis and treatment 
should be considered; theoretical, because such a case is rare in some 
respects, not to say unique, and leads one naturally enough to propound 
certain questions, the answers to which must be more or less based upon 
hypotheses, and not, as we could earnestly wish, upon the fair interpreta- 
tion.of many similar or analogous facts. First, with regard to diagnosis; 
when we had thoroughly examined our patient, and had duly considered 
his previous history and the signs presented in his person, we came to the 
conclusion that the intra-laryngeal growths were of a syphilitic nature, 
and required specific treatment. Acting upon this idea, mercury and 
iodide of potassium were immediately put in requisition, and administered 
after what seems the most rapidly efficacious manner ; but apparently with 
no result, so far as arresting any threatening symptoms or producing re- 
sorption of tissue was concerned. And here, to be candid, and in making 
our acknowledgment give a lesson which may prevent others from being 
guilty of like neglect, we should say that a microscopic examination of the 
portions of growth brought away with the forceps was not made- till 
death supervened. In some cases such oversight or negligence might 
prove detrimental to the patient’s future cure. In the one we are consid- 
ering, we do not believe that the treatment should have been modified had 
we been aware in advance of the revelations which the microscope made 
known to us after death. The syphilitic infection was affirmed by the 
patient, and further corroborated by some few signs found upon his body 
at the time he put himself under our care. In a like position we would 
ever feel disposed to make use of specific remedies in properly managed 
doses, until one of two circumstances might arise : first, a manifest intole- 
rance should show itself to the medication employed; second, a wholly 
negative action were to be made evident. In either of the above alterna- 
tives we would abandon, naturally enough, the method first adopted, and 
seek after a wiser and more efficacious manner of treatment. Had no 
signs at all of constitutional syphilis been visible in the case reported, or 
which we could fairly attach to its existence, still we believe that looking 
merely at practical results, anti-syphilitic treatment was the one at first 
indicated. On more than one occasion already we have known of or seen 
patients who, with a past history of an indurated sore, have never from 9 
that time forward offered symptoms which a well-informed practitioner 
would feel justified to term syphilitic. At a given period, however, mor- 
bid signs became apparent in some organ or tissue of the frame, against 
which divers therapeutic agents were tried in vain. Specific remedies 
were then employed, and rapidly beneficial results have followed their use. 
The influence, it is true, of a constitution tainted with syphilis in becoming 
the source, as it were, of laryngeal growths in general, has not as yet been 
accurately determined. Some whose names we could cite, whose authority 
stands highest on this subject, would have us believe that polypi of the 
larynx are no more frequent in syphilic subjects than in others. On the 
other side, we find those who affirm that syphilis has a direct and evident 
influence in producing laryngeal growths. With these latter, sarcomatous 
and other malignant growths are apparently no more excluded from mani- 
festing this influence than are papillomata with a like situation. 
For us who believe in the utility of specific treatment in some cases, 
where legitimate doubt may be attached to its existence, if symptoms alone 
be considered, the wisdom of its adoption is not assailed by any revelations 
made with the microscope. In considering the diagnosis, the question 
was asked whether or not our case was one of laryngeal phthisis. It was 
at once eliminated. The family history of our patient was more than 
usually good ; no member of it had ever suffered from any serious affec- 
tion of the chest, and the aspect of the larynx, as shown with the small 
laryngeal mirror, was such as to do away entirely with even a suspicion of 
that condition. True it is that the great emaciation of the patient during 
the last few weeks of his life, his abundant expectoration, and occasional 
complaints of pain in the left side of the chest, were symptoms which 
might have occasioned anxiety with regard to the condition of the lungs. 
But there were so many signs, both physical and rational, absolutely 
wanting in order to permit one to pronounce the word tubercular with 
any degree of probability, that the mere idea was never for any length of 
time entertained. 
A few cases analogous in many respects to our own have occurred in 
the practice of Mackenzie, Turck, Cohen, etc., and it may very plausibly 
be sustained that a professed specialist in throat diseases is bound to be 
familiar with these examples, and prepared to encounter and recognize 
similar ones. And further, it may be added in a general way, that if 
medicine shall ever be ranked amongst the exact sciences, such trust can 
be hopefully cherished by her votaries only when exact observation of 
every fact, clinical or experimental, becomes for them an imperative law. 
When, however, there is a dearth of special facts, and detailed histories of 
those placed on record are wanting, allowances can properly be made for 
not detecting features of a portrait at no time fully drawn. Such, in a 
certain measure, is the story thus far of sarcomata of the larynx. The 
symptoms peculiar to them are not fully known, and according to Paget 10 
“ it would be wrong to draw many conclusions from so small an experience 
as yet exists of these tumours.” Mackenzie states in his work on laryn- 
geal growths (London, 1871), “ fasciculated sarcomata constitute a variety 
of growth, which is comparatively unfrequent in the larynx, only three 
cases having come under my notice, and there being but six amongst the 
cases treated by other practitioners.” So far as we are aware, no other 
case of similar structure to those just mentioned has been recorded since. 
If we may put faith in our researches, we should be allowed to assert that 
our own case is rarer still, for we have not been able to find a single case 
of small-cell sarcoma of the larynx (and this is mainly the microscopic 
feature of the growth so accurately described by Dr. Bull) reported in any 
one of the late medical publications. With one exception, too, all the 
cases of spindle-cell sarcoma mentioned in Dr. Mackenzie’s exhaustive 
treatise occurred in patients older than ours. 
Beside, the symptoms manifested by our patient up to a very late date 
were hardly such as to justify a belief in the presence of any kind of malig- 
nant growth. And here the microscope would appear to be at fault, for 
it “cannot be relied on for differential diagnosis.” “Several cases have 
come under my notice,” writes Pr. Mackenzie, “ where the histological 
features were decidedly those of cancer, whilst the clinical history was of 
a totally opposite character, and vice versa.” The above remarks and 
citations absolve us fully, in our estimation, for not making the diagnosis 
of small-cell sarcoma in our case previous to death. In the instance 
related, the course of disease cannot be considered very remarkable. Where 
chondritis, or perichondritis, has followed trouble of a purely inflammatory 
character, or what is more frequently true, ulcerations caused by laryngeal 
phthisis, or by syphilis, we read that the abscesses formed, in the majority 
of cases, point inwards. Sometimes, however, as in the case reported, 
pus is found in the neighbourhood of the external perichondrium of the 
thyroid cartilage, and finally makes an exit for itself by a fistulous opening 
through the integument. It frequently happens also, as in our case, that 
the surgeon in charge, by a timely incision, allows the abscess to empty 
itself many hours before it otherwise could. 
This is the prudent course to adopt, for in this way and through proper 
after-treatment the disease of the cartilages may be prevented from ex- 
tending, or a permanent fistule opening exteriorly (the consequence of 
blamable procrastination) be entirely avoided. 
The abscess pointing outwards appears to us a more desirable state of 
things than the condition where it becomes prominent internally, and is 
readily visible with the aid of the laryngeal mirror. Then great dyspnoea 
and occasionally suffocation are produced before the abscess bursts or is 
opened. Subsequently, as we are aware, there is imminent risk of life 
resulting from sudden obstruction of the larynx or trachea by a piece of 
necrosed cartilage, unless the whole of the diseased portions be removed, 11 
and this very often is an almost impossible task. In a case related by 
Rokitansky, which has become famous, the anterior perichondrium of the 
thyroid cartilage had become affected, an abscess formed in the subcu- 
taneous tissue which gave rise to a fistule, and emphysema of the neck 
ultimately followed. 
We happily enough had not occasion to observe this unfortunate conse- 
quence of a similar condition with that noted in our case. Whilst in this 
latter the mobility of the epiglottis was much impaired, as proved by the 
particles of food which entered the larynx, we did not perceive “the deep 
red, shiny colour,” nor “ a much enlarged, elastic swelling of the epi- 
glottis” as described by Tobold, “ when the thyroid cartilage is attacked.” 
Our history is then an exception to a rule admitting of but few. The 
post-mortem examination has proved to us that had we been able to carry 
through our purpose, when thyrotomy was determined upon, we would 
not have been able to take away the whole of the diseased parts without 
extirpating the larynx. 
In view of the late unique case of Professor Billroth, where the larynx 
of a patient suffering from malignant disease of this organ was success- 
fully extirpated, we may ask, would this operation have been justifiable in 
our own case ? We do not believe it would. When thyrotomy was con- 
templated our patient was very weak, so much debilitated in fact that the 
propriety of laryngotomy could not be immediately resolved upon. The 
chances then of his surviving a more radical operation, and of necessity 
one in which considerable loss of blood must have been the consequence, 
were infinitely small. Even had his general strength been greater, we do 
not at present feel that it would have been indicated. For if we have re- 
gard to the very little, if any, permanent improvement in his breathing 
which followed tracheotomy, and consider the nature of the laryngeal 
growths, there is good reason for believing that secondary deposits had 
already been made in the lung tissue, which would have made ultimate 
cure an impossible result. And now if we examine carefully the experi- 
ments of Czerny (1870) on dogs, and the later more startling experiment 
of Prof. Billroth on man, we do not feel fully persuaded that extirpation 
of the entire larynx is as yet an operation which should be performed on 
the human subject in any case. 
All the dogs operated upon by Czerny died within a short period of 
time subsequent to its performance, and by the last accounts from Vienna, 
recurrence of malignant growths in the bronchial tubes of Prof. Billroth’s 
patient was rumoured abroad, and believed in by many of those best in- 
formed about matters in the Allgemeiners Krankenhaus.1 
We do not desire to place an absolute damper upon the spirit which 
dictates such hazardous surgical methods, but we would have it properly 
1 Since writing the above, Prof. Billroth’s patient has died of lung disease of 
carcinomatous nature. 12 
tempered with thoughtful reasoning, in regard to intercurrent and future 
suffering and dangers, to the poor fellow subjected to very bold personal 
initiative. 
In surgery, as in most other things, it would be well in practice not to 
allow the golden rule to become obsolete. 
Finally, we wish to consider some point in connection with the morbid 
anatomy of our case. The growths had their origin doubtless in the sub- 
mucous layer, and afterwards implicated on one side the mucous membrane, 
on the other the perichondrium of the cartilages. 
They are of undoubted malignant structure, which is shown partly by 
the number of small cells that enter into their composition, partly by their 
soft consistence and vascular nature. 
More malignant are sarcomata of this kind, according to Virchow, than 
those of firmer consistence where fusiform cells greatly predominate. One 
of the characteristic clinical features of all varieties of sarcoma is to extend 
locally in the tissue, as matrix where they have first taken root, and to 
recur, more or less in situ, after removal. 
These facts will account for the appearance of the larynx internally, 
where nearly the entire mucous lining and submucous connective tissue 
were incorporated in the sarcomatous growth, and for the differences 
which exist in the description made of it before and after death. 
But the malignancy of sarcomata is not alone made apparent by their 
great tendency to extend locally ; they are also rapidly reproduced in the 
internal viscera. Transmission takes place through the bloodvessels, and 
the small cells make their way more readily into the bloodvessels than the 
larger fusiform cells. In no one of the internal organs do they repro- 
duce themselves more frequently than in the lungs. Our belief, therefore, 
that the lung tissue of our patient was already invaded at the time of his 
death, with secondary growths, would appear to be highly probable. The 
lymphatic vessels and ganglia are rarely infected. This differentiates sar- 
comata with cancers, properly speaking, where dissemination takes place 
by the lymphatics—at least in the earlier stages of the disease. 
Let us note that, in the history of our case, mention is not made of the 
lymphatic vessels or ganglia of the neck. 
Our attention, in fact, was not directed towards them for the simple 
reason that they were seemingly in a normal condition. 
The condition of the perichondrium and cartilage of the larynx should 
attract particular attention, because—1st, the apparent ossification of 
cartilage to both eye and touch is noteworthy when we consider the rela- 
tive youth of the patient (thirty-two years)—for though ossification of 
cartilage is not infrequent, as we are well aware, yet it usually becomes 
evident at a more advanced age. In this instance our belief was (till his- 
tological examination made us sceptical), that this change had been 
rapidly produced by, and was wholly due to, the inflammatory processes, which will in older patients bring about such transformation after a brief 
lapse of time. 
But after the revelations of the microscope that a portion at least of 
the cartilage, and more particularly the posterior portion of the cricoid 
ring which had a brown coloration, was infiltrated with sarcomatous cells 
and interspersed with masses of pigment “lying free in the connective 
tissue, while occasionally some were found inclosed in the cells,” we were 
and are in doubt. 
We do not know how far the growth itself may have been the cause of 
this change. 
2d. Pathologists have thus far been of the opinion that sarcoma does 
not invade cartilaginous tissue. Our case distinctly proves the error of 
such absolute assertion. 
Further: This question presents itself: Did the laryngeal growth have 
its origin in the mucous or submucous layer (as is very common, and as 
we have taken for granted in these remarks already before receiving Dr. 
Bull’s later communication), or did it really begin in the cartilaginous tis- 
sue, of which many of the normal cells were found to be atrophied or to 
have disappeared altogether?1 
The reply to this, it is perhaps impossible to give at present in a very 
decided manner. Still the great thickening of the perichondrium, and 
hypertrophy of its connective tissue, the density and resistance of the car- 
tilage itself, taken in connection with “the marked vascular development 
and general infiltration of the same round and fusiform cells that existed 
in the neoplasm,” render the latter hypothesis, to our mind, more than 
probable. 
15 West 26th Street, New York. 
1 Oral communication from Dr. Bull.