ABNORMAL ANATOMY OF THE LARYNX. 



119 



ference to its commencement or the early pe- 

 riods of its progress, but to its effects or pro- 

 ducts, which, exhibiting various forms of de- 

 rangement and disorganization, shew to the 

 morbid anatomist the length of time the work 

 of destruction must have been in operation, 

 and the extraordinary changes of shape and 

 form and structure that may occasionally be 

 endured consistently with the maintenance of a 

 miserable existence. 



The simplest form of altered structure in the 

 mucous membrane that I am aware of is that 

 effected by a slow but progressive deposit (pro- 

 bably of lymph) within its substance, which 

 renders it firmer, thicker, and more solid ; and 

 although this must occasion inconvenience and 

 difficulty of respiration to a certain extent, and 

 is troublesome from the dry cough and occa- 

 sional spasmodic exacerbations that accompany 

 it, yet perhaps, whilst restricted to this stage, 

 it is seldom perilous to life. But these altera- 

 tions of structure, particularly if neglected, are 

 seldom quiescent, and however slow in their 

 progress have a tendency to move forward 

 either to a morbid or perhaps malignant change 

 of the tissues, or to the partial removal of these 

 by the process of ulceration. Thus, ulcers of 

 the larynx, however heretofore overlooked by 

 pathologists, are now found to be extremely 

 common, and I know of nothing more diffi- 

 cult than to subject ths numerous varieties of 

 them to any form of classification. They cannot 

 be arranged according to structure, for they are 

 very seldom so superficial or so insulated as to 

 engage the mucous membrane alone ; neither 

 can they be classed according to the symptoms 

 they occasion, for the suffering of the patient 

 or even his ultimate danger does not seem 

 entirely to depend on their extent or character. 

 The most practically useful division of these 

 ulcers would be as to their exciting cause if it 

 could always be discovered ; yet even here 

 there is so much uncertainty of symptom 

 during life and such diversity of appearance 

 after death as to render the subject obscure and 

 unsatisfactory. 



In some instances the larynx becomes the 

 seat of idiopathic ulceration, that is, the dis- 

 ease seems to have been occasioned by cold or 

 other causes of local irritation at least such is 

 the only explanation to be offered. " Thus the 

 laryngeal surface of the epiglottis and the in- 

 ternal parts of the organ itself may be studded 

 over with numerous minute aphthous ulcera- 

 tions ; sometimes the edges are marked by a 

 yellow line of superficial excoriation, bordered 

 by a deep blush of inflammation; and in these 

 cases I have always observed, during life, that 

 great pain and difficulty of deglutition accom- 

 panied the symptoms of dyspnoea, and often 

 formed the most prominent feature of the case. 

 Occasionally the ulceration is deep and foul, 

 and spreads with an almost phagedenic de- 

 structiveness : these sporadic sores, usually 

 commencing above, either in the soft palate or 

 the back of the pharynx and spreading down- 

 wards, too often involve the destruction of the 

 patient. Occurring as they constantly do in 

 bad and cachectic habits, they are little under 



the control of medicine, and operation, how- 

 ever it may prolong existence, scarcely holds 

 out a hope of ultimate recovery." 



In other cases the ulceration seems to be 

 sympathetic, and either precedes or follows 

 certain affections of the lung. Thus in cases 

 of tubercular consumption, aphonia is often a 

 very distressing symptom, sometimes accom- 

 panied by difficult respiration, and occasionally 

 by painful deglutition. In these instances not 

 only is the larynx studded over with specks of 

 ulceration, but the trachea and bronchial tubes 

 leading to the cavity in the lung present a 

 similar appearance, as if the matter possessed 

 some corrosive quality and its passage over the 

 mucous membrane became the cause of its 

 ulceration. These appearances have been too 

 frequently observed not to have attracted the 

 notice of the morbid anatomist, but still it is 

 extremely difficult to connect them with dis- 

 ease of the lung in the relation of cause and 

 effect, for sometimes the loss or imperfection 

 of voice precedes or at least is amongst the 

 earliest symptoms of consumption, and in other 

 instances it only becomes manifest in the very 

 latest stages. It is easy to conceive that the 

 presence of an ulcer in the larynx, by pro- 

 ducing difficult breathing and occasioning a 

 diminution of the supply of air, may deter- 

 mine the development of an abscess in a scro- 

 fulous lung already well disposed to such dis- 

 ease; but when the ulceration has occurred at 

 a late period, and the difficulty of swallowing, 

 the aphonia, and stridulous breathing appear 

 among the closing symptoms of consumption, 

 it will be difficult to account for the appear- 

 ances observed, unless by supposing them to 

 be sympathetically produced. 



But of all the causes from which ulcerations 

 of the larynx are known to proceed, some 

 specific or constitutional taint seems to be the 

 most influential, such as syphilis, scrofula, mer- 

 cury, or a combination of two or more of these. 

 As far as my own observation extends, I cannot 

 say I have ever seen the larynx engaged in a 

 case of venereal where no mercury had been 

 used, but on the other hand there is scarcely any 

 organ more likely to be attacked where the me- 

 dicine has been imperfectly or improperly used, 

 or in which the attack is more perilous and 

 unmanageable. Sometimes the larynx becomes 

 ulcerated in consequence of phagedena or other 

 destructive form of the disease spreading down- 

 wards from the throat or fauces, but more fre- 

 quently is it engaged alone. The ulcers here 

 are seldom solitary, but present several spots of 

 ulceration, and in some cases are so extensive 

 that the whole configuration of the organ is 

 spoiled and lost, the epiglottis being partially 

 or entirely removed, and the chordae vocales and 

 ventricles carried away. The surface of this 

 extensive ulceration is irregular, warty, and 

 gives the appearance of uneven granulation, 

 and there are chaps and fissures that pass 

 deeply into the substance of the subjacent car- 

 tilage, portions of which are removed. When 

 the ulcers are more superficial they very often 

 exhibit the herpetic appearance and the ten- 

 dency to spread observed in mercurial sores, 



