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siderable percentage of cases treated by X rays, andthis in itself is sufficient ground for continuing theirapplication.

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THE OPERATIVE TREATMENT OF CANCEROF THE LARYNX.

UPINION nas not yeu aenmLeiy crystamsea on tne

subject of the most satisfactory methods of removalof cancer of the larynx in its various stages and inthe various degrees of involvement of the organ.For most forms of extrinsic growth, and for intrinsicgrowths which have become extensive, it is generallyagreed that total laryngectomy offers the only hopeof cure ; but a considerable difference of opinion stillexists as to whether cases of early cancer confined toa vocal cord, or even to a part of it, should be sub-mitted to laryngectomy, or whether in such cases thefar less mutilating operation of thyrotomy, or laryngo-fissure, is sufficient to provide a really good prospectof eradicating the disease. The operation of thyro-tomy, which was largely developed by the work ofSEMON and BUTLIN, has been far more in favour inthis country than abroad. Sir STCLAIR THOMSONhas reported a series of 38 cases with one death fromoperation and but nine recurrences, and in AmericaCHEVALIER JACKSON, in a series of 42 cases, hadno immediate mortality and only five recurrences.Such results are surely as good as those for canceroperations in any part of the body, and, when oneconsiders that the voice is usually very fair and thatno other disability results, it might be expected thatthe question would have been definitely settled infavour of this operation.

In an interesting article in the last number of theJournal of Laryngology 1 Dr. J. E. MACKENTY, of NewYork, prefers a strong plea for the operation oflaryngectomy for cases of early laryngeal cancer.

Since 1917 he has rejected all cases of extrinsiccancer for the good reason that, during several yearsof surgical effort, he had not succeeded in ultimatelysaving one. But it is the question of the early caseswhich we are here considering. Three of his cases

Iwere in a stage so incipient that the mobility of the Iinvolved cord was normal in two and but slightlyimpaired in the third ; the neoplasm in all three

occupied from one-quarter to one-third of the extentof the cords, leaving apparently normal tissue bothin front and behind the growth. Nevertheless, theywere submitted to laryngectomy. Dr. MACKENTY isquite convinced that the opinion of the majoritywould have condemned the radical procedure inthese cases, " so wedded are laryngologists to con-servatism in the treatment of laryngeal cancer " ;and he is certain that careful microscopic study ofthe three larynges gave conclusive evidence that nopartial operation would have saved the victims fromrecurrence. In two the areas of malignancy extendedinto the angle of the anterior commissure, and in thethird it extended in both directions, stopping justshort of the arytenoids and the anterior commissure. Incontradistinction to this, Sir STCLAIR THOMSON statesin his book on " Diseases of the Nose and Throat "

that good results are even obtainable if the diseasehas spread across the anterior commissure, so thatall one cord and a portion of the other have to beexcised ; and he gives an illustration of such a casetreated by thryotomy and free from recurrence

eight years after operation. So that it is doubtfulwhether Dr. MACKENTY’s proof is really conclusive.The operative results of his laryngectomies are verygood, with a surgical mortality of less than 2 3 percent., and he lays stress on the fact that many of hispatients are leading useful and strenuous lives inbusiness and professional careers.

In the same issue Mr. J. S. FRASER and Mr. DONALDWATSON, of Edinburgh, report on 14 cases of intrinsiccancer of the larynx. They conclude that thyrotomyis only indicated if the cord is still fairly movable

1 Journal of Laryngology and Otology, February, 1924.

and if the growth does not transgress the anteriorcommissure or reach the vocal process, and theypoint out the tendency to infiltrate between thethyroid and cricoid cartilages. In the larynx, aselsewhere, the chief hope at present lies in earlydiagnosis and early operation, and we would endorsethe latter authors’ conclusion that " They would liketo see a notice in large type sent to all general practi-tioners as follows : Every case of hoarseness whichlasts more than a few days should have the larynxexamined. If you can’t do it yourself, send thepatient to someone who can."

THE AVAILABILITY OF PHYSIOLOGICALKNOWLEDGE.

THE present plethora of scientific progress has itsdifficulties as well as its gains. It is by no means easy,and is becoming progressively harder and harder, fora man to gather in from all the varied lines of advancethe items which are germane to his particular interests.And it is often from these side lights that he getsmost illumination. Men like SYDNEY RINGER couldknow all about physiology as well as clinical medicine.Indeed, such a possibility was open to any industriousand retentive intelligence up to about 25 years ago.But no one could do it nowadays; it would be anappreciable part-time job for anyone to survey thecontents of the journals of the sciences, which, thoughimmediately connected with medicine, have not yetattained their majority. We print in another columna letter from Dr. T. LuMSDEN putting forwardcogently the difficulty of securing that the progressof anatomical and physiological knowledge shall bereflected in any clinical work to which it may beapplicable. The difficulty is a real one; many ofour readers are possibly unaware of Dr. LUMSDEN’Sown investigations on the location of the variousrespiratory centres in the medulla and pons whichhave appeared during the last 12 months or so inthe Journal of Physiology. And in the end thedifficulty is a very old one, for it is the difficulty ofknowing all about everything.

Nevertheless, a good deal might be done to diminishthe difficulty. Anatomists, physiologists, biochemists,geneticists, and so on, can of their own initiative dolittle ; they do not know what particular topics areof interest to the clinician, and if they have beenduly attentive to their own studies they will find thatin the 10 or 20 years which have gone by since theirown experience of the wards-if, indeed, they havehad such experience at all-clinical problems havegreatly changed. It must rest with the clinician toextract for himself what is of moment to himself ;he alone knows the problem which interests him andcan appreciate which pieces of information are of valuein that particular connexion. How to know whatinformation is available is the real difficulty.Dr. LuMSDEN suggests that the clinical journalsmight publish more in the way of reports onscientific progress, and that the Royal Society ofMedicine might have sections for the ancillary medicalsciences. Both projects would probably be useful,though some might doubt whether the people concernedwill put up with any more meetings than are held atpresent, and it is possible that a section of physiology,for example, would be frequented only by physio-logists. On the whole we should attach more import-ance to improvements in the available currentliterature. The new American journal 11:[ edicineprovides admirable reviews by experts which deal,despite the title, almost entirely with what isordinarily called physiology or pathology. The Physio-logical Review again covers in much the same waytopics which, mostly physiological, range into suchmedical subjects as the setiology of rickets. It shouldcertainly be possible for the clinical journals to reportto their readers the titles of the monographs whichappear in these two most useful publications ; theoriginals are available at the libraries if they happen