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ulcers of the lower extremity. I repeat it with the utmost confidence based on a very large and long experience. One and the chief reason that I have so long forborne to communicate to the profession a method which I consider so valuable was that I wished to accumulate such a number and variety of cases in which it had been successfully employed as would leave no room for doubt, and, being quite without the vast facilities afforded by hospital practice, such accumulation was a gradual process. The form of ulcer which yields most readily; with a rapidity which is sometimes really wonderful, is that most common of all, the varicose ulcer. The reasons for this are obvious. That sort of ulcer is caused and maintained by malnutrition of the skin from the engorged, impeded circulation, which is at once relieved by the bandage. In those cases caused by a languor and imperfection of circulation in the legs, from deficiency in quality or quantity of blood, or feebleness of the heart's action, the bandage accomplishes a cure by the warmth and moisture it secures, favoring the circulation in the cutaneous capillaries and inducing a removal of blood to the surface. In these cases, familiar to all surgeons for their obstinate resistance to treatment and the imperfection and unreliability of their cicatrization, the ulcers called by Hippocrates, and the classic surgeons "Chironian"-round or

1. During most of this time, although I have spoken very freely to phy. sicians of my use of these bandages and furnished them with opportu nity to test their usefulness, and, in this way, the method has become widely known, I have never hitherto published any of the results of my experience. I have never, in a pretty extensive reading of periodical medical literature, met with any account of the use of the strong elastic bandage in the way I recommend. In the London Practitioner for May, 1876, there is a very brief paper entitled "Use of blisters in chronic ulcers," by S. D. Turney, of Circleville, Ohio. It has nothing to do with blisters, but is a very interesting record of the very rapid cure of five or six bad ulcerated legs by applying Esmarch's bandage every day as tightly as could be borne by the patient, for a very short time. So far as I know, the paper has attracted no notice or comment, but it notes an important fact, and I refer the reader to it, as, to a certain extent, corroborative of what I have written.

2. Chironian Ulcer, So called because so difficult of cure that Chiron (who taught Apollo fiddling and physic) alone, or one his equal, might cure it.

roundish, with perpendicular sides, as if punched out of the whole thickness of the much-thickened skin, with hard, white, scathing, often almost cartilaginous edges, yield to the bandage and to that alone, and with far more perfect and stable results than by other methods of treatment, but they are cured much more slowly than any other variety of non-specific ulcer. Before anything like reliable cicatrization of these ulcers can occur, the hard edges must be entirely got rid of. The constant pressure of the strong elastic bandage is an efficient agent in promoting the absorption of this impediment to cure; but it is a slow process. In such cases I recommend that the patient should wear the bandage night as well as day, while in the very large class of ulcers caused and maintained by a varicose condition of the veins, I direct the bandage to be worn only during the day, as before stated.

In, perhaps, the worst curable case I ever saw of this inveterate sort of ulcer, in an old, feeble, ill-nurtured patient who had been, off and on, under treatment for nearly nine years, whose ulcer had been nominally "cured" again and again, and in each instance, almost immediately on resuming labor, the cicatrix had broken down, I used the bandage alone as a test case. Of course I could have much expedited the cure by removing the gristly border of the ulcer by caustic, or the knife, but I depended on the bandage only, and in four months, during which the patient continued to labor without any intermission, his ulcer was solidly and well healed, and has now, for nearly five years, remained so. I may say here that not only with this method is the patient allowed to continue his ordinary avocations, however laborious, but is much better able to work while wearing the bandage than he would be without it. This is particularly to be noticed in all varicose conditions of the leg. I have had many cases in which it was only by wearing such a bandage that a patient could do his daily work. I shall refer to this point again in a future paper, in which I hope to demonstrate the extreme value of these bandages as a palliative in cases of varicose veins of the leg, uncomplicated with ulcer. I am aware how hastily and roughly this paper has been thrown together, but I believe it.

indicates pretty clearly my method of treating ulcers by the strong elastic bandages, and my perfect confidence in that method, and that is its entire end and object. If it attracts the notice of the profession, and leads to a practical approving of a method so easily tested, I shall have accomplished what I wished and intended. In another paper, prepared at the request of the publication committee of the American Medical Association, I have described six cases illustrative of results of treatment of a variety of ulcers, and other diseases and injuries. I suppose that paper may be published in due time, and to it I refer the reader. I would also say that I shall be very happy to answer any inquiry as to points connected with the subject on which my readers may wish to be informed.

27 Dudley street, Boston, October 1st, 1877.

Postscript.-Since my return from Chicago, and as a result of my remarks at the meeting there, I have received very numerous applications for bandages, and for the address of a dealer from whom they could be obtained. To meet the requirements of the profession I have made arrangements with Messrs. T. Metcalf & Co., 39 Tremont St., and Messrs. Leach & Greene, 1 Hamilton Place, Boston, who will, in future, have always on hand an ample supply of bandages for the leg, made under my direction and inspected by myself. These gentlemen will also keep on hand bandages of the exceptional length and breadth I have alluded to, and also the bandaging of which any required number of feet may be obtained for the very varying requirements for the different joints.

I find, on reviewing what I have written, that I have omitted to state that, after cure of varicose ulcer, many of my patients, whose occupations require much standing or walking, continue to wear the bandage, both for the relief of their varicose veins and as a preventive of a return of the ulcer. Other patients I recommend to resume the use of the bandage if there is any symptom of return of the ulcer, or if they are obliged to be much on foot.

A CONTRIBUTION TO LARYNGOLOGY. TWO CASES OF DISEASED ARYTENOID CARTILAGE TREATED BY LOCAL DEPLETION.

BY E. CUTTER, M. D., Cambridge, Mass.

CASE I.-A middle aged lady, residing in Newton, Mass., complained of hoarseness, partial loss of voice, dysphagia, cough and throat distress. There was no difficulty in breathing. She was placed under the writer's charge, for examination and treatment, by Prof. Field; and, on inspection with the mirror, the larynx was found to be normal, except that there was a large, red, pear-shaped enlargement of the tip of the left arytenoid cartilage. The right cartilage was of normal size. The left was of the size of a cranberry, or more definitely, fromto of an inch in diameter. To the touch it felt hard, but not stony, and was movable from side to side. The question of malignancy was raised, but not sustained by the rational signs. It was, therefore, concluded that the enlargement was not carcinomatous, but hypertrophic; and the subsequent history has sustained the conclusion, as ten years have now elapsed since the patient's recovery.

Satisfied as to the character of the growth, the next question was that of treatment. The writer had then never seen, heard nor read of such a case. The entire subject of laryngology was then in its infancy; and, as a consequence, having no guide, either from experience or history, the treatment was conducted on general principles.

Hypertrophy of the periarytenoid tissues, accompanied by congestion of the blood vessels, involves an enlarged and dilated condition of the capillaries, by blood accumulation, resulting in an altered condition of nutrition, the vessels being, as it were, paralyzed by mechanical distension. By dividing

the vessels they would be enabled to unload themselves of their contents and to contract to their normal caliber. Thus they should regain their tonicity and subsequently proceed to a better discharge of their functions. Whether this reasoning were right or wrong, it became really a part of the history of the case, as explaining the course that was pursued. A knife was specially constructed, by Messrs. Codman & Shurtleff, of stout, flattened steel wire. The end was sharpened, like a lancet, on both edges. Two inches from the distal extremity, it formed an angle of 120°. When in position, the flattening was lateral, so that the greatest strength of resistance was in the direction of the thrust. The operation of local depletion was practiced two or three times a week for two months, as follows: the patient was seated as in ordinary laryngoscopy, and the throat was illuminated by natural or artificial light. The parts being exposed to view by the laryngoscope, the special scarificator was then introduced, guided by the eye. Incisions were made freely over and into the substance of the swelling, until the hemorrhage amounted to a mouthful or more. The evacuation of the blood was followed by considerable relief to the local symptoms and subsidence of the enlargement, resulting in the complete relief of the patient.

Since this paper was written, Prof. Field has informed the writer, that the disease had not recurred, and the cure was permanent.

REMARKS. The general tendency of medical opinion is against depletion; but it is surely an error to desist from its use in chronic engorgements and infarctions. In the present instance, it not only did no harm, but was followed by the happiest results. It should be stated that no pus or serum was discharged, but only blood, and no abscess resulted. The writer has been in the habit of scarifying every local chronic congestion in the throat, and has never yet seen any reason to regret such a course, for incisions of this sort heal very readily, and result in relief from pain. They do good, apparently, by emptying engorged vessels, by relieving the semi-paralyzed condition of their walls, and by allowing them to resume their functions. In the condition of natural tonicity, a capillary will admit, at