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been published.1 Fig. 4 represents it two-thirds the actual size. The object of discision is of course to interfere with the nutrition of the growth sufficiently to entail its death and separation from the organism. The presumption that scarifications or small incisions into its tissue will produce such an effect has, however, no general applicability. I entirely agree with Lewin that it will not occur very frequently that a mucous or fibrous polypus can thus be made completely to disappear as in the fortunate case of Prof. Bruns: "Analogy deduced from polypi in other situations argues against such an hypothesis."

III. CRUSHING.-Another mode of destroying the nutrition of intra-laryngeal morbid growths, and thus to produce their mortification, has been attempted by Moura-Bourouillou. He introduced small metallic bars, properly bent, and rubbed or crushed the tumors between these. The consequence was that pieces of the polypi were thrown off, and the patients experienced some relief. The modified Bruns' forceps, already spoken of and represented in Fig. 5, nearly actual size; Leiter's forceps, represented two-thirds actual size in Fig. 6:2 and my own polypus forceps, represented in Figs. 7 and 8 (page 687), could, there is no doubt, be used to greater advantage for this pinching or crushing, more especially as they possess the additional advantage that portions of the tumor may occasionally thereby be torn off and extracted, this constituting

IV. EVULSION.-Tobold and others object to the method of thus pulling off polypi, altogether, but there are extensive growths of soft texture occasionally met with, not easily or not at all removable by caustic, which, from both their position and nature, are well suited for extirpation by this plan, the more if, as has happened to me, excision produces too much hemorrhage, or the tumor cannot be reached by any other means. That no one should think of extirpating by violent evulsion a neoplasm firmly intergrown with a vocal cord, or the like, is almost too obvious to need assertion. Indeed, the greatest possible care should always be observed in these operations. It has happened to me once to have seized hold accidentally of the free edge of a vocal cord just at the moment of the mirror's becoming bespattered with sputum, and the patient jerk

American Medical Times, June 4, 1864.

2 Again taken from the translation by Dr. Caswell of Dr. Semeleder's Cases of Extirpation, American Medical Times, June 4, 1864.

VOL. XVI.-45

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ing his head at the same moment, I must, if I had not fortunately disengaged the instrument instantly, have done immense injury, for I had a perfectly firm (bull-dog) hold. As it was, the pinching was considerable. Fig. 7 represents my polypus forceps (smaller than actual size) opening laterally; and Fig. 8, the instrument opening and shutting forward and backward. It is highly necessary to be provided with both kinds.

In Figs. 1 and 2 I have had a front view and a lateral section made with the laryngeal mirror and my lateral polypus forceps in situ; the latter is one with cutting edge, and has just excised a polypus from the left vocal cord.

V. LIGATION.-Under this head I comprise the removal of laryngeal tumors both by the galvano-caustic ligature, and by the ecraseur. For such as project high enough above the superior aperture to be seen and accessible directly from the mouth, this method has been anticipated in ante-laryngoscopal times by the cases of Middeldorpf and Koderik. But how sterile these examples would have remained, and how limited the applicability of what they teach us is, in the light of our present knowledge, is obvious. The heated galvanic wire cannot be used as safely or as frequently as the simple wire of the ecraseur, on account of the injury it might inflict upon the vocal organs. I prefer to employ the laryngeal ecraseur whenever I possibly can, in the removal of tumors. I cannot but regard it as a most happy invention by Gibb, and am even proud of having at once caught up the idea, and having one constructed before I actually saw Gibb's instrument or a description of it. The one figured in the cut (nearly natural size) Fig. 9 represents one made by Windler, of Berlin. The fear of a tumor after being cut off by the wire of the ecraseur falling into the trachea and lower down and doing great damage, well founded as it appears, has never been realized by the occurrence of any injurious accident of the kind as far as I am aware.

VI. EXCISION.-I now come to speak of removal by cutting instruments strictly so-called. The method which Green employed in his first case, viz., "excision with a double hook and bistoury" long before the introduction of the laryngoscope, the tumor being brought into view by the patient throwing it up violently by coughing as I have related on page 670-Bruns endeavored to imitate in his first case of laryngoscopal extirpation, by carrying

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