Modern Laryngology.
1
188 MODERN LARYNGOLOGY.—INSANITY AND THE CRIMINAL LAW. word on the subject has not been said, but the considered views, founded on careful experiment, of such a high authority may be regarded as at least a classical contribution to the vast mass of literature on the aetiology of influenza. , Modern Laryngology. WE publish in THE LANCET this week two addresses illustrating modern developments of laryngology. The first of these is the Semon Lecture, delivered at the Royal Society of Medicine by Dr. H. S. BIRKETT, professor of oto-laryngology at the McGill University, .on the occasion of his reception from the University of London of the Semon Medal. In this address Prof. BIRKETT deals exhaustively with the trans- atlantic developments of rhino-laryngology, save that he abstains from mentioning the personal part that he himself has played therein. This deficiency was made good in warm terms by Sir JAMES DUNDAS- GRANT and Sir STCLAIR THOMSON in moving the vote ,of thanks of the audience to the lecturer. The second address, which is by Sir STCLAIR THOMSON, is an .admirable illustration of how far operative treatment in the hands of the expert can now proceed in dealing with such a terrible disease as cancer of the larynx. The two addresses may well be read together. The one describes the rise of laryngology and the other provides a striking example of the point to which it has risen. Prof. BIRKETT shows that the story of scientific laryngology, though its earliest chapters may be dated in the eighteenth century, commenced for practical purposes with the introduction of the laryngoscope, and his elaborate and dated record of the way in which GARCIA’S invention was received by the medical profession should be a shock to British self -complacency. For the Semon Lecturer makes it clear that to the Americans in particular, and secondly to the Germans, belongs the credit of having seen what the invention of the laryngoscope might mean, and of having patiently, exhaustively, and cleverly brought laryngoscopic work into the front of surgical procedure. :Sir STCLAIR THOMSON’S address was delivered on Thursday last before the Tenth International Congress of Otology in Paris. He describes the operation of laryngo-fissure with special reference to its results in the intrinsic variety of cancer, and shows how the prospects of lasting cure in cases of cancer of the larynx are very different according to the location ,of the disease. When the gullet, for instance, is invaded surgical treatment is wellnigh out of the question ; and it has onlv been considered when the cervical portion of the gullet is affected. In the larynx there is a remarkable difference in the prospect of lasting ,cure, according to the exact site of origin. It was proposed by ISAMBERT and KRISHABER in the last quarter of last century to divide cancer of the voice- box into two main groups, the intrinsic and the <extrinsic ; the former originating in the cavity of the organ and the latter on its walls. The value of this classification has been generally accepted, chiefly ’because of the clinical difference between these two types. A cancer starting on a vocal cord is usually slow and benign in its early history ; it progresses in an indolent way and may remain limited to a cord for months, even for years, before it extends to other parts of the lafynx or invades the glands. On the other hand, a cancer of the walls of the larynx-i.e., of the epiglottis, aryepiglottic folds, the arytenoids, or the posterior cricoid region, tends to progress rapidly ,and is often considerable before it makes its presence felt. In this situation the glands are early invaded; indeed, it is not uncommon for a secondary gland in the neck to be the first symptom to attract attention to an extrinsic laryngeal growth. With this difference of life-history, there is a very different prognosis for surgical treatment. The intrinsic type-slow in growth and limited at first to the vocal cord and neighbourhood-can be extirpated with astonishingly good results. The extrinsic type is insidious and rapid in its evolution, and early in its invasion of the glands. It was well called " a dire disease " by BUTLIN, who, with FELIX SEMON, was a pioneer in the suc. cessful surgical treatment of the more favourable, intrinsic form. The whole subject of treatment of cancer of the larynx formed the subject of discussion at the Inter. national Congress of Otology and no doubt communi. cations on the treatment of the extrinsic form will shortly be published, even if the only available method of treatment remains the serious operation of complete extirpation with entire loss of laryngeal voice. A wholly different picture is given by Sir STCLAIR THOMSON in regard to the treatment of the intrinsic variety, to which he limits consideration. He records every case he has operated on in the last 21 years. Of 51 cases no less than 30 are to-day alive and well at various periods up to 13 years after opera. tion, possess a good if rough voice, and can carry on their previous vocations. Eleven are dead from other causes than cancer, and only eight have died from a local recurrence. When we remember that the opera- tion of laryngo-fissure, by which these results have been obtained, was only established in recent times, we can congratulate Sir STCLAIR THOMSON on carry- ing on the pioneer work done in this country by BuTLiN and SEMON. It is a bold claim to make that an early epithelioma, if limited to a vocal cord, can be removed by laryngo-fissure without operative death-rate, with preservation of a useful voice and with every prospect of permanent freedom from recurrence, but it seems to be justified. This happy result may be looked for in at least one manifestation of cancer, if early diagnosis is made, and it is fortunate that hoarseness, slight but continuous, is a constant symptom and one that cannot be overlooked. It follows that no one, at any age, should remain hoarse continuously for any extended period-say three weeks or a month-without obtaining a careful opinion on the appearance and movement of the vocal cords. At any age such an examination may give help in the diagnosis of some remote condition; it may secure an early diagnosis of tubercle; or it may expose a malignant growth, while that growth is still in the stage of being permanently curable. Insanity and the Criminal Law. As was stated in THE LANCET of July 15th, the Lord Chancellor has appointed a Committee " to con- sider and to report upon what changes, if any, are desirable in the existing law, practice, and procedure relating to criminal trials in which the plea of insanity as a defence is raised, and whether any, and if so what, changes should be made in the existing law and practice in respect of cases falling within the provisions of Section 2, Subsection 4 of the Criminal Lunatics Act, 1884." This is the outcome of the case of RONALD TRUE, and of the attacks made upon the Home Secretary in consequence of TRUE’s reprieve as insane, but, though that case supplied the immediate impulse, many lawyers and doctors have felt that some inquiry into the position was needed, and had been needed for a long time. The names of the Committee have been given. They are all men of experience, and some
Transcript of Modern Laryngology.
188 MODERN LARYNGOLOGY.—INSANITY AND THE CRIMINAL LAW.
word on the subject has not been said, but theconsidered views, founded on careful experiment, ofsuch a high authority may be regarded as at leasta classical contribution to the vast mass of literatureon the aetiology of influenza. ,
Modern Laryngology.WE publish in THE LANCET this week two addresses
illustrating modern developments of laryngology.The first of these is the Semon Lecture, delivered atthe Royal Society of Medicine by Dr. H. S. BIRKETT,professor of oto-laryngology at the McGill University,.on the occasion of his reception from the Universityof London of the Semon Medal. In this addressProf. BIRKETT deals exhaustively with the trans-atlantic developments of rhino-laryngology, save thathe abstains from mentioning the personal part thathe himself has played therein. This deficiency wasmade good in warm terms by Sir JAMES DUNDAS-GRANT and Sir STCLAIR THOMSON in moving the vote,of thanks of the audience to the lecturer. The secondaddress, which is by Sir STCLAIR THOMSON, is an
.admirable illustration of how far operative treatmentin the hands of the expert can now proceed in dealingwith such a terrible disease as cancer of the larynx.The two addresses may well be read together. Theone describes the rise of laryngology and the otherprovides a striking example of the point to which ithas risen.
Prof. BIRKETT shows that the story of scientificlaryngology, though its earliest chapters may bedated in the eighteenth century, commenced for
practical purposes with the introduction of the
laryngoscope, and his elaborate and dated record ofthe way in which GARCIA’S invention was received bythe medical profession should be a shock to Britishself -complacency. For the Semon Lecturer makes itclear that to the Americans in particular, and secondlyto the Germans, belongs the credit of having seen whatthe invention of the laryngoscope might mean, and ofhaving patiently, exhaustively, and cleverly broughtlaryngoscopic work into the front of surgical procedure.:Sir STCLAIR THOMSON’S address was delivered on
Thursday last before the Tenth International Congressof Otology in Paris. He describes the operation oflaryngo-fissure with special reference to its resultsin the intrinsic variety of cancer, and shows howthe prospects of lasting cure in cases of cancer of thelarynx are very different according to the location,of the disease. When the gullet, for instance, is invadedsurgical treatment is wellnigh out of the question ;and it has onlv been considered when the cervicalportion of the gullet is affected. In the larynx thereis a remarkable difference in the prospect of lasting,cure, according to the exact site of origin. It wasproposed by ISAMBERT and KRISHABER in the lastquarter of last century to divide cancer of the voice-box into two main groups, the intrinsic and the<extrinsic ; the former originating in the cavity of theorgan and the latter on its walls. The value of thisclassification has been generally accepted, chiefly’because of the clinical difference between these twotypes. A cancer starting on a vocal cord is usuallyslow and benign in its early history ; it progresses inan indolent way and may remain limited to a cordfor months, even for years, before it extends to otherparts of the lafynx or invades the glands. On theother hand, a cancer of the walls of the larynx-i.e.,of the epiglottis, aryepiglottic folds, the arytenoids, orthe posterior cricoid region, tends to progress rapidly,and is often considerable before it makes its presence
felt. In this situation the glands are early invaded;indeed, it is not uncommon for a secondary gland inthe neck to be the first symptom to attract attentionto an extrinsic laryngeal growth. With this differenceof life-history, there is a very different prognosis forsurgical treatment. The intrinsic type-slow in
growth and limited at first to the vocal cord andneighbourhood-can be extirpated with astonishinglygood results. The extrinsic type is insidious and
rapid in its evolution, and early in its invasion of theglands. It was well called " a dire disease " by BUTLIN,who, with FELIX SEMON, was a pioneer in the suc.cessful surgical treatment of the more favourable,intrinsic form.The whole subject of treatment of cancer of the
larynx formed the subject of discussion at the Inter.national Congress of Otology and no doubt communi.cations on the treatment of the extrinsic form willshortly be published, even if the only availablemethod of treatment remains the serious operationof complete extirpation with entire loss of laryngealvoice. A wholly different picture is given by SirSTCLAIR THOMSON in regard to the treatment of theintrinsic variety, to which he limits consideration.He records every case he has operated on in the last21 years. Of 51 cases no less than 30 are to-day aliveand well at various periods up to 13 years after opera.tion, possess a good if rough voice, and can carry ontheir previous vocations. Eleven are dead from othercauses than cancer, and only eight have died from alocal recurrence. When we remember that the opera-tion of laryngo-fissure, by which these results havebeen obtained, was only established in recent times,we can congratulate Sir STCLAIR THOMSON on carry-ing on the pioneer work done in this country byBuTLiN and SEMON. It is a bold claim to make thatan early epithelioma, if limited to a vocal cord, canbe removed by laryngo-fissure without operativedeath-rate, with preservation of a useful voice andwith every prospect of permanent freedom fromrecurrence, but it seems to be justified. This happyresult may be looked for in at least one manifestationof cancer, if early diagnosis is made, and it is fortunatethat hoarseness, slight but continuous, is a constantsymptom and one that cannot be overlooked. Itfollows that no one, at any age, should remainhoarse continuously for any extended period-saythree weeks or a month-without obtaining a carefulopinion on the appearance and movement of thevocal cords. At any age such an examination maygive help in the diagnosis of some remote condition;it may secure an early diagnosis of tubercle; or it
may expose a malignant growth, while that growthis still in the stage of being permanently curable.
Insanity and the Criminal Law.As was stated in THE LANCET of July 15th, the
Lord Chancellor has appointed a Committee " to con-sider and to report upon what changes, if any, aredesirable in the existing law, practice, and procedurerelating to criminal trials in which the plea of insanityas a defence is raised, and whether any, and if so what,changes should be made in the existing law andpractice in respect of cases falling within the provisionsof Section 2, Subsection 4 of the Criminal LunaticsAct, 1884." This is the outcome of the case ofRONALD TRUE, and of the attacks made upon the HomeSecretary in consequence of TRUE’s reprieve as insane,but, though that case supplied the immediate impulse,many lawyers and doctors have felt that some inquiryinto the position was needed, and had been neededfor a long time. The names of the Committee havebeen given. They are all men of experience, and some
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