ABNORMAL ANATOMY OF THE LARYNX. 



again are supported and restrained by resisting 

 cartilages externally, so that if the submucous 

 tissue which is here so loose as to allow the 

 membrane to be thrown into natural folds, 

 should become the seat of infiltration, the 

 swelling so produced cannot take a direction 

 outwards, but must tend to compress and 

 close the aperture of the glottis. This is the 

 oedema of the glottis, a formidable and too 

 often a fatal affection, but nevertheless present- 

 ing very considerable pathological varieties. 

 Thus it is sometimes attended by fever, and 

 forms only part of a more extended inflamma- 

 tion, involving tonsils and fauces, pharynx and 

 larynx : again, it is purely local, confined to 

 the larynx alone, and so entirely free from any 

 accompanying fever, that the patient only com- 

 plains of the difficulty of breathing and the 

 cough. It is often idiopathic, but may be 

 produced by injury, and is a common result of 

 swallowing caustic poisons and boding water ; 

 nor is it in this latter respect confined to the 

 adult, for I have thus seen the superior aper- 

 ture of tiie glottis, in a very young child, 

 pursed up and closed as if by the drawing of 

 a running string. It may be situated only in a 

 part of the larynx, the rest remaining free ; thus 

 it is no uncommon occurrence to see only one 

 side of the glottis puffed and swollen, and the 

 slit-like aperture thus converted into a curve; 

 but the most interesting because the most prac- 

 tical illustrations of partial oedema will be 

 found in cases published by Sir Henry Marsh, 

 in which the disease appeared to be confined 

 to the epiglottis alone.'* Lastly, I believe it is 

 possible to have this oedema produced without 

 any external evidence of inflammation. In 

 the Museum of the School of Park-street there 

 is a preparation shewing it as apparently occa- 

 sioned by the vicinity of a large carcinomatous 

 tumour. 



Considering the pathology of this affection, 

 the degrees of inconvenience and of danger 

 likely to result from it will be easily under- 

 stood. The symptoms will be, a loss or imper- 

 fection of voice, which is generally very well 

 marked, the utmost effort at articulation amount- 

 ing to no more than an indistinct whisper ; and 

 difficulty of respiration, including cough and 

 other signs of local irritation. The danger will 

 probably be in proportion to the rapidity with 

 which the effusion is formed, for life may be 

 maintained with a wonderfully diminished 

 supply of air to the lungs, provided the dimi- 

 nution takes place gradually and slowly: but 

 it may not arise solely from this cause, for here, 

 as in every other form of laryngeal disease, spas- 

 modic exacerbations are painfully frequent, and 

 place the patient's life in momentary danger. 

 Dissection, therefore, developes three different 

 causes of death. One, the most infrequent 

 where the patient has perished by spasm : the 

 glottis, although swollen, is still pervious - 

 perhaps apparently sufficiently so for the ordi- 



* See Dub. Journ. of Med. Science, March 

 1838, v. 13, no. 37. This excellent paper of Sir 

 H. Marsh's contains many illustrations of the 

 same tact. 



nary purposes of respiration ; but in order to 

 observe the relaxation after spasm, several hours 

 must be allowed to elapse between death and 

 the post-mortem examination, for the bodies of 

 those who die of laryngeal disease become ex- 

 tremely rigid, and remain in this state a consi- 

 derable time. A second, in which the effusion 

 having been poured out with great rapidity, the 

 rima is found mechanically blocked up, and 

 immediate suffocation occasioned : in this case 

 neither the lungs nor brain are engaged, at least 

 not necessarily. The third is, where the dis- 

 ease has lasted three or four days or more, the 

 oedema has been developed but slowly, and 

 the diminution of the supply of air been less 

 sudden : in these cases, besides the symptoms 

 of strangulation, others, indicative of a con- 

 gested condition of the lung and brain, are 

 observed during the latter periods of existence, 

 and corresponding morbid appearances are dis- 

 coverable after death. 



Very severe inflammatory affections of the 

 mucous membrane of the larynx are unfortu- 

 nately too frequent to admit of doubt or to 

 create difficulty ; but a good deal of confusion 

 has arisen from an attempt to identify them, or 

 some of them, with croup, because an exuda- 

 tion takes place from the surface in some re- 

 spects resembling the adventitious membrane 

 formed in the latter disease. One of these has 

 been described with graphic accuracy by M. 

 Bretonneau of Tours, by him supposed to be 

 the same with croup, and named Diphlherite : 

 but although the differences between these af- 

 fections have been observed and pointed out, 

 the name is still frequently applied (I fear) 

 without very precise ideas attached to it. The 

 exact disease described by Bretonneau I do not 

 profess to have ever seen, neither have I heard 

 of it, unless in one instance in a family in this 

 country which lost four of its young and inte- 

 resting members by a visitation at least bearing 

 some resemblance to it. In hospital I have 

 heard the name applied to some throats which 

 I never should have thought of identifying 

 with that described by the French writer, and 

 I feel satisfied that the attempt to mix up 

 different and it may be opposite diseases 

 under one generic name has done anything but 

 simplify the study of pathology. If, however, 

 by asthenic croup or diphtherite is meant the 

 peculiar local disease which accompanies the 

 eruption of scarlatina anginosa, or which is 

 frequently met with without any cutaneous 

 eruption, especially in adults which is ac- 

 companied throughout by low and typhoid 

 fever, and is often propagable by contagion- 

 then is the affection well known and its de- 

 scription easy: but it bears no similitude what- 

 ever to inflammatory croup. For besides that 

 the constitutional affections are totally oppo- 

 site, a circumstance of the greatest importance 

 as influencing the progress of the respective 

 cases, the local symptoms and appearances have 

 marked and distinct characters. Thus the as- 

 thenic angina is always ushered in by shivering 

 and other precursors of fever ; the soreness of 

 the throat is intense from the very commence- 



