or an extremely able assistant are the only "laryngoscope holders" admissible.

As to the mirror itself I prefer glass, covered with pure silver and thereupon either metal, wood, or ivory. Its precise shape matters little, so that it is large enough, and can be introduced and held properly. Frequently, when I could not obtain a good artificial light, I have found advantage from using Wintrich's double mirrors, by which we can avail ourselves of the multiplication principle of light.

The rays of the sun, whenever they can be made use of, are incomparably best for illumination, directed into the oral cavity by means of either a plane or an ordinary toilet mirror. A calcium light, or even gas or kerosene oil light, properly managed, is perfectly sufficient, however, besides allowing of invariable constancy and convenience. To concentrate the light of my kerosene lamp I use a system of lenses with reflector, arranged for me by the late Mr. Fitz, telescope maker of New York City, and, in connection with an Argand gas-burner, I use Tobold's apparatus, adapted for the purpose by Mr. Bogert, gas engineer. This is quite portable; a little pot to heat water is attached to it; it is very easily adjustable, and altogether leaves nothing more to desire. The illuminating mirror I attach sometimes to the spectacles of Semeleder; more rarely to the forehead band of Weiss (the celebrated London instrument maker's, which is in fact the improved plan of Czermak's laryngoscope); generally I have it held by a separate stand or the foot or bar of the lamp, as Türck, Voltolini, Lewin, Tobold, and others, have recommended before me. The focal length of the reflector should be from six to ten inches.

The distance at which the patient should sit from the operator should be such that the posterior wall of the pharynx, when the mouth is well opened and properly illuminated, is at the point of the most distinct vision of the operator; the patient's body should be erect, or a little bent forward and the head as slightly backward. A protecting towel or oil-silk cover should be fastened around the patient's neck, and extended over both him and the operator. I have also a spittoon attached to my operating chair.

I need not here dwell upon the care required in introducing with the left hand the mirror (previously warmed to prevent its being tarnished by the breath), and holding it so as to show the tumor best; upon the directions to be given to the patient in each special case to facilitate the operation, or upon the still more difficult task

of carrying the caustic holder in the right hand safely beyond the epiglottis and accurately to the tumor. Lewin's description of his mode of proceeding still holds good: "With the point of the in

Fig. 1.'

db

strument I pass, without touching any portion of the pharynx or epiglottis, to the neighborhood of the cords. Without touching, I rest here a moment to give the instrument its proper position to

1 See Case X., page 707; also Fig. 25.

ward the polypus. The patient, who has already inspired profoundly to raise the epiglottis, inhales air once more, then holds his breath so that the various parts do not move much, while I instantly, without coming in contact with intermediate or adjacent parts, touch the polypus."

As the same description answers for the introduction of cutting instruments, the front and side view of the parts, given in the accompanying figures (Figs. 1 and 2), in which the mirror is seen

to be introduced into the fauces, and my polyp-forceps into the larynx, will be sufficient to give an idea also of the introduction of the porte caustic.

That the operation is not the easiest in the range of surgical practice is obvious; the good effects sometimes following simple cauterization in cases of morbid growth are illustrated in the report of cases, Section IV.

II. DISCISION.-All instruments designed for intra-laryngeal operations must, of course, have the proper size, bend, and construction, so that they can be passed directly down into the cavity, and that the cutting, or otherwise operating, portion can be easily brought into contact with the tumor to be operated upon; nor does the same size and bend exactly suit all individuals. To these two points I shall not again allude.

Discision, or the method of extirpating a morbid growth within the larynx by repeated incisions, has first been accomplished by Von Bruns, who has made it the subject of a monograph.' On three successive days a number of small incisions were made into the tissue of a polypus attached below the left vocal cord. On the first day the bleeding was comparatively profuse; the patient experienced no pain at all; for about three-quarters of an hour he threw up blood with coughing, amounting, perhaps, to two ounces, and for the rest of the day he hawked up a little more with phlegm. After the third day the polyp began to look like necrosed connective tissue, and was rapidly disintegrated and thrown off, so that in two days more it had all disappeared but a little suppurating stump. This gradually cicatrized and shrank still more, so that the hoarseness and acantophonia, under which the patient had previously labored, entirely disappeared. With all the preparatory exercises the treatment lasted two months. The discisions were performed with a kind of scissors-a very ingenious instrumentbut Lewin justly criticizes it as rendering the operation exceedingly difficult. Bruns himself has since operated by excision with a greatly simplified instrument, which may also be used for the method now under consideration, and of which the accompanying figure (Fig. 3) is a representation (of almost natural size) taken from his most recent work. The best knife for this purpose, however, is Leiter's, the instrument maker's of Vienna. This is recommended by Semeleder and others, and a description of it in English has just

'Op. cit., pp. 28-31.

2 Nachtrag zu meiner Schrift: Die erste Ausrottung eines Polypen in der Kehlkopfshöhle. Tübingen, 1863.