28 THE TONER LECTURES. 



that hoarseness, aphonia, dyspnoea, or dysphagia sets in, the 

 larynx should be examined with the utmost vigilance both 

 from without and by the laryngoscope. If oedema or ulcera- 

 tion be found, but the danger be not as j-et severe, leeches, 

 iodine, ice in rubber bags, or possibly a blister may be used 

 externally, and astringents, nitrate of silver, etc., internally, 

 together with proper general treatment. In 1819, Lisfranc 

 proposed scarification and operated succesfully in six non-febrile 

 cases, and in 1847, Buck revived the practice and devised an 

 appropriate knife. The laryngoscope has made such treatment 

 far more certain, and it should first be tried in suitable cases. 



But, should these means fail? Then an early rather than a 

 late tracheotomy, for otherwise we add to the previous enfee- 

 bling disease a prolonged battle for breath, with its ensuing 

 pulmonary congestion and general exhaustion. Especially is 

 this to be commended in the peculiarly fatal necrosis of tlie 

 cartilages. Of G7 positive cases, 41 of which occurred in men 

 and only 10 in women, all died but 2, one with and one with- 

 out an operation; 22 were operated on, 45 were not. But as 

 before mentioned, 2 died from displacement of the canula, at 

 least one of which had practically recovered ; 8 cases of recovery 

 after tracheotomy are not included, since, though the presump- 

 tion in favor of necrosis is very strong, yet the evidence is not 

 positive. Were only these 8 included, and it is certainly fair 

 to do so, it would stand 30 operations and 10 recoveries, a 

 mortality of 61 per cent., and 45 not operated and 1 recovery, 

 a mortality of nearly 98 per cent. 



Once, then, that perichondritis is established, death is almost 

 unavoidable if no operation be done. If bronchotomj' be re- 

 sorted to, the chances are greatly improved. Indeed, it is pro- 

 bable that if the dangers which surround such cases be recog- 

 nized in the future and a prompt attempt at relief be made, far 

 more favorable results will be obtained. I would, therefore, 

 join with Sestier in urging an immediale operation the moment 



