Reprinted from the Transactions of the Medical and Chirurgical Faculty of Maryland, 1883. 
LARYNGEAL STENOSIS. 
Report of Cases, with Remarks on the History and Treatment, 
B Y 
H. CLINTON McSHEKRY, M. D., 
LECTURER IN THE SPRING COURSE, AND CHIEF OF CLINIC ON DISEASES OF THE THROAT AND 
CHEST IN THE UNIVERSITY OF MARYLAND. Reprinted from the Transactions of the Medical and Chirurgical Faculty 
of the State of Maryland, 1883. 
LARYNGEAL STENOSIS. 
Report of Cases, with Remarks on the History and Treat- 
ment. 
By H. Clinton McSherry, M. D. 
Lecturer in the Spring Course, and Chief of Clinic on Diseases of the Throat and Chest in the 
. University of Maryland * 
This being the first occasion upon which the Medical and Chirur- 
gical Faculty has recognized laryngology even as a part of one of its 
Sections, and as I have been appointed a representative of this branch, 
it seems proper for me to make a report, as is the custom of gen- 
tlemen belonging to a Section, of something of interest that has 
occurred during the preceding year in the department I represent. 
I will therefore select for the subject of my remarks laryngeal stenosis, 
which will be illustrated by giving the history of two cases that have 
been under my care during the year, with a passing reference to a 
third case treated by me some time ago, and the exhibition of a 
patient showing the result of treatment. I will also give an account 
of the history and general management of the condition, which may 
prove not uninteresting. 
The first patient was a female, who came to me on the 2d of April, 
1882, from Dr. Alex. Tunstall, of Norfolk, who wrote in regard to 
her previous history as follows : “ I have occasionally, over a period 
of four or five years back, prescribed for her, nearly all her ailments 
being attributable to the effects of syphilis directly acquired from a 
worthless husband. Chronic metritis, occasional recurrences of 
cystitis, pharyngitis, laryngitis, with frequent attacks of aphonia, &c. 
Last year she seemed much benefited by constitutional treatment, 
combined with tonics (ol. morrhuae), external use of iodine over the 
larynx, and spray of carbolic acid, &c., internally. These and a trip 
* The plates for this paper were kindly drawn for me by Drs. N. A. S. Keyser 
and Henry Rolando. 2 
to the mountains improved her so much that the treatment was 
omitted by her, and she had some five or six weeks back an alarming 
attack of acute laryngitis, with great dyspnoea, aphonia, and stridulous 
breathing, and pain in breathing, and tenderness in swallowing 
solids. She has again been placed under constitutional treatment of 
hydrarg. chlo. cor. with potass, iod., externally iodine tr. and steam 
inhalations, &c. She has much improved, but nearly all her 
symptoms are occasionally in lesser degree manifested, and I fear, 
without special local examination and treatment, bad results.” 
When this patient was brought to my office her breathing was ex- 
tremely labored and noisy, although she had come in a carriage, and 
the only exertion she had made was to walk into the house. On 
laryngoscopic examination I found the whole larynx pale, and the 
arytenoids particularly were very much enlarged and oedematous 
looking, not showing any of the contrast of color that is character- 
istic of phthisis. The ventricular bands also were seen so much 
thickened and broadened that on attempted phonation they met 
together, so that the vocal cords were not seen at all. The voice pro- 
duced was a muffled or choked whisper. On deep inspiration the 
ventricular bands and vocal cords separated slightly, but not suffi- 
ciently to give much breathing space. The left vocal cord was not 
visible, and only the edge of the right one was in view, as will be 
seen by referring to the diagram, showing the condition of her larynx. 
Fig. 1. 
Fig. 2. 
With the exception of this appearance of the throat the general 
condition of the patient seemed to be pretty good. She was quite 
sufficiently nourished and in fact rather fleshy. She remained under 
my treatment three months, until June the 7th, when I allowed her 
to return home, and sent the following letter to Dr. Tunstall. “ After 
introducing the laryngeal tubes several times I came to the conclu- 
sion that there were no adhesions producing the stenosis of the larynx 3 
in Mrs. case, but that the trouble was due to thickening of 
the ventricular bands, and enlargement of the arytenoids due to 
syphilitic perichondritis, these conditions being shown on the diagram 
I have sent you. Therefore I determined to give up the use of the 
tubes and rely upon local applications and constitutional treatment. 
I have applied twice daily the iod. glycerine, for which I will send 
a formula, and have had her on potass, iod. combined with amnion, 
mur. The thickening of the ventricular bands has almost entirely 
disappeared and the arytenoids have been much reduced in size. She 
no longer has any of the labored breathing she had when I first saw 
her, and the dysphonia is due to an absence of the proper approxima- 
tion of the vocal cords on attempted phonation, on account of the 
comparative immobility of the arytenoids, owing to the thickening re- 
maining both about those cartilages and in the inter-arytenoid space.” 
This patient was not seen again until September 1882, when she 
told me that she had passed a very comfortable summer and had very 
little difficulty with her breathing, but that her voice was still husky. 
I did not state in my letter to Dr. Tunstall that before she left me in 
the spring she was able to sound her voice, as I thought that would 
speak for itself; nor did I mention that after the thickening of the tis- 
sues had reduced considerably, and the voice did not improve much, I 
made applications of galvanism to the larynx, as I thought the want of 
approximation of the cords might be partly due to paresis, as the re- 
sult of prolonged pressure of the infiltrated tissues as well as to the 
swelling remaining, and after this the voice became stronger, but was 
not clear. In October a gentleman in Norfolk who was interested in 
her case wrote me that she was very much benefited by my treatment, 
but she was still being treated for her voice. 
The second case to which your attention is asked is the patient 
whom I now present to you with a history of his condition. I 
was called in haste to see him about 7 o’clock P. M., March 
18th, 1882. His wife, who came for me, told me that he seemed 
to be dying, because he could not get his breath. She said, further, 
that for three or four months before his breathing had not been good, 
and on that account he complained particularly of the difficulty he 
had in climbing a hill he was obliged to pass on his way home 
in the evening. This had of late been getting more troublesome, un- 
til that afternoon when, after he had proceeded but a short distance, he 
seemed not able to breathe at all, and was carried home. I took my 
laryngoscope and other instruments with me when I was called, for, 4 
from what his wife told me, I suspected the trouble to he laryngeal 
stenosis, because he had been under my care from January to March 
18th, 1881, about a year before, for sore throat of a specific nature. 
At that time the velum palati was slightly adherent to the posterior 
wall of the pharynx, but there was a sufficient opening for free respi- 
ration through the nose; the uvula was gone. There were ulcerations 
on the posterior wall of the pharynx, in the larynx and epiglottis. 
Under treatment of local application of solutions of cupri sulph., ar- 
gent. nit. and hydrarg. acid, nit., with constitutional remedies, all these 
ulcerations healed, and although I advised him to continue treatment 
longer, or at least to call occasionally for me to make an examination 
of his throat, he neglected to do so, and I did not see him again until 
I was called on this occasion. 
When I got to the house I found Dr. E. R. Walker with him, who 
had made use of inhalations of chloroform and had applied a sina- 
pism and afterwards a belladonna plaster over the throat. The 
breathing was extremely stridulous and labored and had been so 
since five o’clock, it was then 7.20 P. M., the voice was stridulous 
and whispering, the pulse small and quick, and the face dark and 
anxious. On inspection of the pharynx I now found the uvula gone, 
the velum adherent to the posterior wall of the pharynx with the 
exception of a portion about £ an inch in length on the left side, and 
scars of cicatrization on the velum and posterior wall of the pharynx. 
Laryngoscopic examination revealed complete destruction of the 
epiglottis and inflammation of the ventricular bands, with so much 
swelling as to hide the vocal cords from view. On strained inspira- 
tion the glottis was not opened further than would allow the passage 
of a small goose-quill. I ordered at once for him steam inhalations of 
tr. benzoin com., to relieve the temporary inflammation present, but 
without much effect, and as the breathing was becoming more labored, 
the face livid and the pulse fluttering, and as there was not sufficient 
opening for successful tubage of the larynx, I suggested to Dr. Ferd. 
Chatard, Jr., who had come to the house to see a sick child, Dr. 
Walker having left, that the only way in which death by suffocation 
could be prevented was to perform tracheotomy ; he concurred in my 
opinion, and I called on Dr. J. E. Michael to perform the operation. 
Laryngotomy was decided on, as we thought that would make the 
opening below the seat of the disease, and if necessary it could be 
made laryngo-tracheotomy. Everything being ready at half-past 
eight, and having chloroform at hand in case of need, the operation 5 
was done without an anaesthetic. After the superficial incision, Dr. 
Michael, to avoid cutting the anterior jugular vein, as it was large, 
made with a bistoury a vertical incision into the crico-thyroid space; 
but this opening not allowing sufficiently free breathing, he attempted 
to cut through the cricoid cartilage, but found that the knife would 
make but little impression on it, as it was ossified. We determined 
then that it would be better to do tracheotomy also; therefore having 
pushed the isthmus of the thyroid gland down, he made an incision 
in the space between the second and third cartilages, and cut up 
through the second and first rings, and sawed with the knife through 
the ossified cricoid cartilage, making the operation laryngo-tracheotomy. 
The double canula was then introduced, the inner one being removed 
to give as much air as possible, and the breathing through it became 
at once excellent; but the patient seeming to be very weak, whisky 
and water was given with a spoon, which he swallowed with but 
little difficulty, but in about fifteen minutes, as his pulse had become 
very small, I gave him four syringefuls of whisky hypodermically. 
After this he rallied, and at half-past ten o’clock, having made'him 
comfortable, we left, giving orders for whisky to be administered 
from time to time during the night and the room to be kept well 
heated, a steam kettle constantly boiling on the stove, and the canula 
covered with gauze. 
The next morning at 10 o’clock he was breathing quietly, but the 
pulse was small and quick. Whisky was ordered to be given during 
the day, and nourishment in the form of broths. In the evening at 5 
o’clock the breathing was tolerably regular and the pulse weak; con- 
tinued supporting treatment. 
2d day after operation at 10 A. M. condition about the same as 
evening before, except that there was some bronchitis with mucous 
expectoration. At 3 P. M. was sent for; some fever had set in, and I 
ordered spt. ammon. aromat., liq. ammon. acetat. and aq. camph. 
At 6 P. M. fever had abated and he seemed easier. 
3d day 10 A. M. I was told that he had passed a miserable night, he 
had not slept at all, as his breathing had been, and was still, very 
much oppressed. The family thought him near his end. 
On examination I found that the cause of the difficuly in breathing 
was that the canula was plugged with hardened mucus. I removed 
and cleansed it thoroughly and replaced it, at the same time directing 
how the inner canula should be taken out and cleansed. The breath- 
ing now immediately improved and the expression of his face became 
much more tranquil. He complained of a sense of fulness of his 6 
bowels, and as there had been no passage for three days he was given 
ol. ricini § ss. His temperature was 99?, pulse 102 and small. Later 
in the evening he was very weak, but I attributed that to the exertion 
caused by movements from the bowels, of which he had had two dur- 
ing the day. There was, however, a little more fever. Respiration 22, 
pulse 102, temperature 102?. 
4th day, at 10 A. M., he stated that he had slept well during the 
night, and was feeling stronger; respiration 22, pulse 94, temperature 
102?. I found that the inner canula had not been introduced far 
enough by his wife, who had removed and cleansed it twice during 
the night, and the outer one was a little clogged, so I removed both 
of them, washed and replaced them. At six o’clock again saw him. 
He had passed a comfortable day, and expressed himself as feeling 
better. There was rather free expectoration. Respiration 26, pulse 
100, temperature 103 L 
5th day, doing well. In the morning, respiration 23, pulse 94, 
temperature 1011; in the afternoon, respiration 28, pulse 94, 
temperature 103f. 
6th day, 2? P. M., respiration 28, pulse 92, temperature 102. 
7th day, respiration 28, pulse 92, temperature 102. As the 
tracheitis and bronchitis had become very troublesome, I ordered 
potass, iod. 3 ii, ammon. mur. 3 i, tr. cinchonse co. and water aa § ii, 
dose 3 ii t. d. 
8th day. He said he had had a good night. At 2£ P. M., res- 
piration 28, pulse 92, temperature 98. 
9th day. Sitting up all day. At 6 P. M., respiration 24, pulse 
74, temperature 98. 
10th day. Sitting up. Respiration 22, pulse 70, temperature 98. 
From this time on he continued to do well, and wore constantly, 
without any great discomfort, the tracheal tube. About six weeks 
after the operation the larynx presented the appearance seen in the 
diagram of Case 2. I determined then to commence to dilate the 
Fig. 1. 
Fig. 2. 7 
stricture of the glottis by means of Schrotter’s hard rubber tubes, 
which I will speak of later ; but finding that the smallest that I have, 
which is about seven and a half millimeters in diameter at the end 
intended to pass into the glottis, could not be introduced, I made 
applications of cupri sulph. gr. xv- § i for two weeks, and having re- 
duced the thickening around the orifice in this manner, I was able to 
pass the tube, which was done daily for a month, increasing the size 
gradually, until he had a tolerably good breathing space in the 
larynx. He was then directed to wear the inner tracheal tube only 
at night, and during the day to keep the outer canula corked up as 
much as possible. This was advised, as I thought he could breathe 
through the fenestra in the canula, and by means of laryngeal 
breathing assist in dilating the orifice in the glottis. 
At first this corking up of the breathing space, to which he had 
become accustomed, was very troublesome; whenever he was walking 
about or making any exertion whatever he had to remove the cork, 
but he kept it in as long as fjossible without great inconvenience, and 
later, as the dilatation was continued, he was able to keep the 
tracheal canula constantly closed during the day. 
After the laryngeal tubes had been introduced daily for two 
months, the breathing space having become very much increased, I 
went away for my summer vacation, but before leaving I lent my 
instruments to Dr. F. W. Pearson and asked him to continue the 
same treatment. This he did for about three weeks, when I returned 
and resumed charge of the case, pursuing the same measures for the 
relief of the condition as before, until January of this year, when, 
thinking that his breathing would probably be better if he had more 
space for respiration than the fenestra in the tracheotomy tube he 
was wearing allowed, I had a new instrument made of hard rubber, 
with the fenestra enlarged so as to extend to the lower end of the 
tube; that is, about one-half of the diameter of the tube was cut 
away. This was to be cleaned by passing a bent wire, with a small 
piece of absorbent cotton firmly attached, along the tube. It had, as 
you see, a hard rubber plug to prevent respiration through it. He 
wore this for about a week or ten days, when he requested me to re- 
move it and replace the old one, which he said he found more com- 
fortable. I consented to do so, and with some difficulty replaced 
the silver tube. He now breathed quite comfortably again, but as 
there was some slight adhesion of the anterior portion of the vocal 
cords, I would have liked at this time to have used Dr. Whistler’s 8 
cutting dilator, which I will describe a little further on, hut not 
having one, and as I thought it improbable that it could be obtained 
in this country, I determined to watch the case a little longer, and if 
necessary to have one made or send to England for it. Fortunately, 
however, it has not been necessary; for after keeping up the use of 
astringent applications for about a month, the thickening of the cords, 
which had been great, was reduced, and their mobility became excel- 
lent. 
In fact the glottis was then dilated to such an extent that I deter- 
mined to remove the tracheal tube altogether, which I did on March 
the 19th, about six weeks ago, almost exactly one year from the time 
of first introduction. 
The wound in the throat has entirely closed and he has had no diffi- 
culty in breathing through the glottis since. The voice remains a little 
husky, but as it is improving daily, and the appearance of the vocal 
cords is becoming more natural, I expect by the continued use of as- 
tringent applications that it will be perfectly restored. 
These two cases, as well as one I reported to the Clinical Society in 
1877, in which there was a stricture of the glottis due to contraction 
of the tissues from cicatrization of ulcerations in the larynx, which was 
relieved entirely, without tracheotomy, by the use of Schrotter’s tubes, 
may be considered illustrative of the condition, and it is hardly neces- 
sary for me to add much to the history of such cases to what I have al- 
ready given in an article published in the Md. Med. Journal, January, 
1878, from which, with some slight alterations and additions, I will make 
a quotation. This is almost the unvarying history of laryngo-stenosis, 
for its occurrence in any other manner than as the result of chronic 
laryngitis of syphilis is very exceptional. It does not occur as a 
sequence of the ulcerations of chronic tuberculous or carcinomatous 
laryngitis, as observers have decided that those ulcerations, if extensive, 
do not cicatrize. The rima glottidis is sometimes narrowed, it is true, 
in chronic idiopathic laryngitis from cicatrization, or, as in tubercu- 
lous laryngitis also, by a thickening from fibrinous infiltration of the 
submucous tissue of the ventricular bands and vocal cords, or of the 
subglottic mucous membrane, but rarely to such an extent as to cause 
a marked constriction; but there is a condition which, though nearly 
always a concomitant of syphilis, may, I believe, occur in connection 
with other forms of laryngitis. I refer to those cases where the in- 
flammatory exudation becomes organized into fibrinous bands, which 
stretch from one part of the larynx to another, very often from one 9 
vocal cord to the other, and by gradual contraction draw the two to- 
gether and hold them fixed. Of this variety of stenosis there are a 
number of cases reported by Morell Mackenzie, Schrotter, Elsberg 
and others, and I have myself seen two cases, in one of which nearly 
the anterior half of the glottis was closed in this manner, while in 
the other there was a single membranous band extending across the 
glottis from the middle of one cord to the other. Again a laryngeal 
stenosis is occasionally met with as the result of the inhalation of 
flame or from scalds of the larynx, or in some rare instances mentioned, 
from typhus or typhoid fever, variola or measles, by which perichon- 
dritis or chondritis is occasioned or an inflammation is produced which 
has gone on to ulceration and cicatrization. 
As regards the diagnosis, the discovery of an obstruction in the 
larynx is readily enough detected by the appearance of the patient, 
the changed voice, the distressed stridulous breathing, the rales that 
are often heard at some distance, but are always very marked on 
auscultation over the larynx, and the abnormal percussion dulness 
that can be detected, not only of the chest, but also, by acute 
examiners, of the larynx itself; exactly the character of the obstruc- 
tion can, however, only be appreciated by laryngoscopic examination. 
In reference to the treatment, although, as I have said, nearly all 
cases of stricture of the glottis are due to syphilitic disease, yet con- 
stitutional treatment will never effect a cure of a well-marked case. 
To prevent death from gradual suffocation, local treatment must be 
primarily and immediately undertaken, always with the object of 
overcoming the constriction in such manner as to allow the lungs to 
receive again the normal amount of oxygenated air which has for a 
time been cut off from them. It has long been the custom in this 
emergency to obviate the trouble by the creation of a second one, 
tracheotomy, which is but little better than the first, and by which, 
although air is certainly allowed to pass to the lungs, the original 
trouble is in nowise benefited nor its progress stopped. 
In some cases of imminent death this treatment is not only justifi- 
able, but is most judicious. Before being undertaken, however, a most 
careful laryngoscopic examination should be made; for sometimes, 
when the permanent constriction is not very great, the breathing may 
be temporarily obstructed, either by a slight oedema glottidis or a 
collection of mucus in the larynx, in which case the trouble can be 
treated through the natural passage, either by scarification of the 
cedematous membrane with the laryngeal lancet or by tubage of the 10 
glottis, without any necessity for an external opening being made in 
the throat. 
Catheterization or tubage of the larynx was advocated by Desault 
as far back as 1793, and afterwards by Bouchut, Trousseau, Wein- 
lechner and Horace Green, for some cases of urgent dyspnoea; but in 
all these instances it was only intended to give temporary relief, and 
to Schrotter is due the credit of introducing the use of tubes for the 
systematic dilatation and permanent cure of laryngeal strictures. 
During the winter of 1874-75 that I spent in Vienna, Schrotter was 
experimenting very enthusiastically with hard rubber tubes intended 
to he passed into the larynx, for the gradual dilatation of those cases 
of laryngo-stenosis in which the constriction had not become so 
great as to necessitate laryngotomy. 
These tubes are of gradually increasing diameters, and are about 
ten inches long, have perforations at the end, and are hollow through- 
out their calibre. They have a long curve of about one-third their 
length, for introduction into the larynx, and at the oral end of the 
instrument a curved cylinder about two inches long is inserted, to 
prevent its slipping, and to protect the face of the operator from 
mucus, &c. The introduction of the tubes is effected in this way: 
Having slightly warmed and well oiled one, it is passed behind the 
epiglottis and placed over the orifice of the glottis; then by keeping 
up constant and steady pressure it will, if it be of a proper size, 
presently glide through the opening into the trachea, and the breath- 
ing through it will be instantly apparent by the tubular sound, and 
may be felt by placing the hand over the end of the tube. 
The benefit afforded the cases that I saw treated in this manner in 
the Vienna Hospital was so marked that I determined under similar 
circumstances to adopt the same measures, hoping for as happy 
results as I saw’ there; and as the condition of the patient treated by 
me in 1877 vras so satisfactorily relieved by this means, I made use 
of it also in the two cases seen during the past year, although one of 
them had had laryngo-tracheotomy performed. The first of thes§ 
patients, the female, did not require any continued use of the tubes, 
but the last required and had them passed almost daily for about 
six months. 
The length of time the patient will allow the tube to remain in 
the larynx varies. At first it can only be retained a few seconds, 
but after each introduction it is better tolerated, and sometimes 
may be worn for one or two hours, or longer. Of the cases treated by Instruments used for the Treatment of Laryngeal Stenosis, after the 
Method adopted by Dr. Schrotter. 
Fig. 1. Tin bougie for the treatment of laryngo-stenosis, with the thread drawn through the 
tube. 
Fig. 2. A tin bougie of greater diameter; the thread from this is drawn througli the tube, by 
means of the wire that is seen alongside of it, and wound tightly around the handle. 
Fig. 3. Small forceps to fasten the bougie, by the slender neck on the end of it, in the canula. 
Fig. 4. The improved method of holding the bougie in position after its introduction into 
the larynx. 
Fig. 5. Hard rubber tube. 
Fig. 0. Curved cylinder to be inserted into the oral end of the tube to hold it in position. 12 
me, the first retained the tube about fifteen minutes, and the second 
equally as long without much discomfort; but the third, the one 
that I show to-day, never allowed it to remain longer than three or 
four minutes, so I introduced it several times at each sitting, which 
proved sufficient to break the adhesions and dilate the glottis to quite 
a sufficient extent for easy respiration. 
It would probably be well for me to mention here, what I stated 
in my former paper, that the sensation or irritability of the larynx is 
usually very much diminished in chronic laryngitis. 
The method that Schrotter makes use of for those cases in which 
tracheotomy had been performed either through necessity or otherwise, 
and where the tracheal canula had become a “ vade mecum,” that they 
were doomed to bear silently to the grave, was like the tubage fore- 
shadowed and suggested by the experiments that preceded it. The 
most remarkable cases in ante-laryngoscopic times are those of Mr. 
Liston. One was a laryngeal stenosis treated and cured by him in 
1827, by passing bougies of increasing sizes into the larynx through a 
tracheal fistula that had been made in attempt at suicide. The other, 
a tracheal constriction, is still more noticeable. Here he passed 
bougies of different sizes through an opening in the trachea up through 
the larynx and out the mouth; when one was passed be grasped it 
there, and then pushed the other end down into the trachea, and finally 
allowed one the size of an oesophageal bougie to remain fifteen days in 
the trachea, and this case was also cured. 
After the invention of the laryngoscope we have records of this 
trouble being treated by Czermak, Busch, Semelder, Trendelenburg, 
Gerhardt, and later by a number of others. 
In most of these cases dilators were passed through a tracheal open- 
ing and upwards into the larynx; in none of them, however, was the 
method employed considered satisfactory, but I believe that an instru- 
ment, invented by Stoerk in 1878, for dilatation from below, altered so 
as to have three dilating blades instead of two, which would open 
antero-posteriorly as well as laterally, will be found most useful, and 
is one which, as modified by myself, I shall in future employ where 
tracheotomy has been performed. The dilators can have blades of 
different lengths to suit the necessities of the case, and after being in- 
troduced into the stricture the dilatation can be gradually increased 
day after day by turning the nut on the screw outside of the plate of 
the canula. My instrument shows the extent of dilatation by markings 
in millimeters on the screw, and it also has a flange or rim on the 13 
FIG. I 
FIG. 2 
FIG. 3 
FIG. 4 
FIG. 5 14 
inner canula, so that when the dilator is in position the canula can be 
corked and the breathing be carried on entirely through the larynx, 
which assists very materially the dilatation. 
Schrotter, however, treats these cases by passing, instruments from 
above into the larynx. His method consists in passing metal or hard 
rubber bougies a little over an inch and a half in length and of dif- 
erent sizes into the constricted glottis by means of a hollow staff, 
through which a string attached to the bougie passes and is tied 
at the handle so as to hold the two parts firmly together. After the 
dilator has been passed into the glottis, and the button on the end 
of it can be seen in the tracheal tube, it is fastened and held in posi- 
tion by a pair of small forceps which are passed through the canula, 
or, as modified by Schrotter, by transfixing the dilator by a curved rod a 
little over an inch in length that projects from the inner canula, 
which is only about i of an inch long. The string is then unfastened 
from the handle and the latter is drawn away, leaving the string 
hanging from the mouth or fastened around the ear. The dilator is 
then allowed to remain in position for 12, 24 or 48 hours, when it can 
be removed to be cleansed or replaced by a larger one. 
Schrotter says that the upward and downward movement of the 
bougie dilator, which was the greatest objection to the first mode of 
holding it in position, is obviated by the transfixion that he afterward 
adopted; but it appears to me that the dilator would occupy a large 
portion of the lumen of the tracheal canula and interfere with respi- 
ration being properly carried on, whereas I have seen persons breath- 
ing perfectly comfortably with it fixed by means of the forceps, and 
no doubt some of you saw in Baltimore last winter the patient upon 
whom Schrotter had operated, and who had from long practice be- 
come an expert in passing and fastening these bougies in his throat, 
wearing one with apparently but the slightest inconvenience. 
The two methods of Schrotter, the hard rubber tubes and the one 
I have just described, have given almost uniformly good results and 
are to be recommended, although the dilators of Morell Mackenzie 
and Navratil have been employed with success in some cases, and in 
one instance reported by Dr. Morris J. Asch, of New York, flexible 
metal sounds were successfully used to break the adhesion and dilate 
the constrictions. 
Whenever the adhesions are extensive, however, or if the stenosis 
is due to membranous webs or bands in the larynx, they should be cut 
either with the laryngeal lancet or, better still, with the ingenious 15 
Morell Mackenzie’s Dilator. 
Navratil’s Dilator. 
instrument devised by Dr. MacNeill Whistler, of London, which Dr. 
Morell Mackenzie told me he had used with satisfaction. This 
instrument of Dr. Whistler’s consists of an almond-shaped dilator 
with a concealed blade which is reversible, and will make a section 
when it is pushed out by the lever on the handle, either anteriorly or 
posteriorly, as required. 16 
Whistler’s Cutting Dilator. 
After Dr. Whistler passes his cutting dilator through the constricted 
glottis he introduces either his own instrument with the lancet 
concealed, or bougies, to prevent readhesion, though this would be 
more certainly ensured, I think, by a thorough cauterization of the 
cut surfaces before making use of the bougies. 
In conclusion I will state that the results obtained by me in the 
three cases will explain sufficiently my having called the attention of 
the society to them; for Lennox Browne, in speaking of this condition, 
says in his work on Diseases of the Throat, published in 1878: 
“ Laryngeal oedema must he met by the prompt performance of trache- 
otomy, and the same step may he necessary, at least as preliminary 
to later measures, if stenosis becomes extreme. With respect to 
the further treatment of this last condition, it cannot be said that 
any great success has, so far, followed attempts to remove the cica- 
tricial web, or to dilate the narrowed orifice by bougies or analogous 
measures carried on through the natural passage. It is better, there- 
fore, to warn the patient on whom tracheotomy has been necessary on 
account of such condition, that he will in all probability be obliged 
to wear the canula for the rest of his life”; and so eminent an 
authority as Cohen says in 1880: “ I have never been able to induce 
a patient to place himself under my care with such an uncertain 
prospect before him, and therefore lack personal experience in the 
procedure.” 
In all my cases the difficulty in breathing was relieved by the 
treatment, and I have shown to-day a patient who was for months 
absolutely dependent on a tracheal opening for respiration, who wore 
the tracheotomy tube for one year, and who is now breathing with 
perfect comfort entirely through the natural passage.