126 



REGIONS OF THE LEG. 



trachea was too small to allow of the intro- 

 duction of any instrument for the extraction 

 of the offending substance if such was there, 

 so J merely satisfied myself with keeping the 

 wound open, in the hope of its being coughed 

 up. Whenever from any accident the wound 

 in the throat became obstructed, the breathing 

 became dreadfully oppressed, but he obtained 

 instant relief when it was opened again and 

 cleaned. Such were the phenomena of the 

 case generally up to the 6th of October, when 

 it was found that the wound had gradually 

 closed and healed so as to leave the artificial 

 opening very small, and on that day, in con- 

 sequence of the increased difficulty of breath- 

 ing, I was obliged to open up the whole wound 

 anew. This second operation afforded im- 

 mediate relief. On the Gth of December the 

 wound being again nearly healed, in a despe- 

 rate fit of coughing he expelled a small stone 

 about half an inch long by about two lines 

 broad, through the rima glottidis. 



There were many other interesting facts con- 

 nected with this case, which I omit here, my 

 object being only to show that the difficult re- 

 spiration which rendered the operation neces- 

 sary was not caused by the mechanical occlu- 

 sion of the bronchi by the presence of the 

 stone, but had its seat in the larynx. The 

 child had always repose when not called upon 

 to employ the rima in respiration, although the 

 stone was present in one or other of the bron- 

 chi, and in this case it was remarkable that 

 it shifted its position, as proved by stethoscopic 

 evidence. 



It is sufficiently well known that the pres- 

 sure of an aneurism, and of course of any 

 other tumour, on the trachea or bronchi will 

 produce difficult respiration to such an extent 

 as to simulate laryngitis and to place the pa- 

 tient's life in imminent peril. This has been 

 supposed to proceed from the mechanical ob- 

 struction given to the passage of the air by the 

 compression of the tumour, and I shall not 

 deny that this cause may occasion inconveni- 

 ence, but still may be allowed to doubt that it 

 produces the stridulous breathing and other 

 laryngeal symptoms at least in the majority 

 of cases. In the month of July, 1837, I was 

 requested by another practitioner to see a case 

 of acute laryngitis and to operate if I deemed 

 it necessary. The case appeared to be seriously 

 urgent : the man seemed to be on the point of 

 suffocation ; and having made some inquiries 

 as to the history, and particularly as to the con- 

 dition of the chest as ascertained by auscul- 

 tation, I operated immediately. The relief was 

 as marked and as decided as I had ever seen 

 in any laryngeal affection ; and, after allowing 

 the patient two or three hours' repose, I had 

 him removed to the Meath Hospital, in order 

 to be under my own immediate care. He died 

 on the fourth day afterwards from the bursting 

 of an aneurism of the aorta within the chest, 

 and on examination the larynx was found in a 

 perfectly healthy and normal condition ; yet 

 was it evident, from the relief experienced on 

 the opening being made below it, that the ob- 

 struction to respiration that existed during life 



had been caused within this organ. Those 

 who, with Le Gallois and Magendie, explain 

 spasm of the glottis by a compression exer- 

 cised^ on the recurrent nerves, may possibly 

 consider that the aneurism in this case pro- 

 duced such pressure, and I am not in a con- 

 dition to deny it, because the sac was collapsed 

 and empty, and I could not say what pressure 

 it might have created directly or indirectly 

 when tense and full of blood. But the sac in 

 no situation lay in contact with the nerve, or 

 seemed to hold any relation to it that would 

 lead to such a conclusion. I may add, inci- 

 dentally, that I have seen aneurismal tumours 

 which must have implicated this nerve, in 

 which the spasmodic difficulty of breathing 

 did not exist, and therefore whilst I believe 

 that spasm of the glottis may be produced in 

 consequence of, or in connexion with, the ex- 

 istence of some tumour compressing the trachea 

 or bronchi, I cannot (in the present state of 

 our knowledge) yield to the opinion that refers 

 it so entirely to a compression of the recurrent 

 nerve. 



The ligaments of the larynx are, of course, 

 liable to disease. Thus, during life, we argue 

 on the possibility of an abnormal state of ten- 

 sion or relaxation, from observing certain alte- 

 rations of the tone of voice which are thus 

 supposed to be capable of being explained : 

 but the most frequent morbid appearance found 

 after death is ulceration, although there is no 

 evidence of its ever commencing in these struc- 

 tures. In all cases of phthisis laryngea, the 

 ligaments suffer severely and in some are actu- 

 ally destroyed ; for the expulsion of the ary- 

 tenoid cartilages by coughing is no infrequent 

 symptom of that disease, and it could not other- 

 wise occur. I have often imagined that this 

 ulceration of the ligaments was one cause of 

 the difficult respiration, particularly in cases 

 where there is a marked difference between in- 

 spiration and expiration, by allowing to the 

 arytenoid cartilages too great a degree of mo- 

 bility, and permitting them to be thrown down 

 on the rima. When the connexions between 

 the cricoid and arytenoid cartilages are cut 

 across posteriorly, it is easy to lay the latter 

 down in such a manner as nearly to obliterate 

 the rima ; and if a similar division be effected 

 by disease, why may not these little bodies, 

 become loose, be acted on by the current of 

 air and shut like a valve in every act of in- 

 spiration ? 



( W. H. Porter.) 



LEG (REGIONS OF THE). If the importance 

 of a part, and the interest connected with the 

 study of its structure and its diseases, be mea- 

 sured by the general amount of suffering 

 through it entailed upon mankind, by its ex- 

 treme liability to accident and injury, and by 

 its value in the general movements and well 

 being of the body, certainly the leg would 

 possess claims to our consideration greater than 

 any other portion of the system of the same 

 extent. From the integument to the bone, and 

 from the knee to the ankle, every part of it is 

 the frequent subject of disease, more or less 



