120 



ABNORMAL ANATOMY OF THE LARYNX. 



healing in one situation whilst fresh ones break 

 out in the neighbourhood, and cicatrizing with 

 a depressed surface and evident loss of sub- 

 stance. With respect to symptoms, the loss or 

 imperfection of voice will very much depend 

 on the situation of the ulcers; but the diffi- 

 culty of breathing and general distress are by 

 no means criteria by which the extent of de- 

 struction of parts can be estimated, for some- 

 times there is uncommon suffering where the 

 ulceration is extremely limited. Very fre- 

 quently these ulcers (particularly if the epi- 

 glottis is engaged) produce symptoms of diffi- 

 cult deglutition, exactly resembling those of 

 stricture of the oesophagus : but this is only 

 during the time the sores are actually open, 

 for, when healed, swallowing is performed 

 with astonishing facility, even although the 

 greater part of the epiglottis may have been 

 carried away. 



But the most interesting fact in connexion 

 with these ulcers is, that by rest and proper 

 treatment they are susceptible of cure, and for- 

 tunate it is that by means of operation we are 

 enabled to afford this important organ the requi- 

 site degree of repose. Mr. Carmichael has 

 published two most interesting cases illustrative 

 of this fact ; in which the patients recovered, and 

 in which we have consequently a right to infer 

 that the ulcerations healed. In the summer of 

 1838 I operated on a woman in the Meath 

 Hospital, who had symptoms of such extensive 

 destruction of parts as must have proved fatal, 

 but who nevertheless recovered with a complete 

 capability of breathing through the rima, but 

 with nearly a total loss of voice. The healing 

 of this kind of ulceration may be inferred from 

 that case also, but it is proved by the following 

 observation : " In the Museum of the School 

 of Park-street, Dublin, is a preparation taken 

 from a poor woman who had been an inmate 

 of the Meath Hospital ten or eleven different 

 times for venereal ulceration of the larynx, and 

 finally died there quite suddenly, as if from the 

 effects of spasm. It shews where a large por- 

 tion of the epiglottis had been removed, the 

 ulcer having healed by a puckered cicatrix. 

 From below the left ventricle a longitudinal 

 scar extended a full inch and a half down into 

 the trachea, the contraction of which had di- 

 minished the calibre of that part of the tube 

 very sensibly The right ventricle was totally 

 obliterated, and on different spots about the 

 superior part of the trachea there were several 

 small pale depressed cicatrices, evidently the 

 results of former sores that had been open at 

 different periods at which she had been in the 

 hospital. The only ulcer that existed at the 

 time of her death was a very small one, with 

 ragged irregular edges, situated midway be- 

 tween the natural position of the right ventricle 

 and the root of the epiglottis." 



The softer tissues of the larynx are also occa- 

 sionally liable to gangrene, circumscribed' con- 

 fined to the organ itself and not exhibiting any 

 tendency to spread. Of this I have as yet seen 

 but one example, and that one under circum- 

 stances that rendered it doubtful whether the 

 disease should not be considered as sympathetic 



with a similar affection of the lung. It was 

 the case of a man who died in hospital of gan- 

 grene of the lung supervening on acute pneu- 

 monia. Seven days before his death he was 

 attacked with symptoms of laryngeal disease, 

 hoarseness, with difficult and laborious breath- 

 ing, which gradually increased until the voice 

 was nearly lost and respiration quite stridulous. 

 After death, besides the gangrene of the lung, 

 a gangrenous ulcer was found, involving the 

 chordae vocales at the left side : its surface was 

 about the size of a shilling, and of a dirty 

 green colour ; its edges quite sloughy, and its 

 centre excavated to a considerable depth : the 

 mucous membrane around highly vascular and 

 covered with a pellicle of lymph. 



3. The cartilages of the larynx are subject to 

 very important diseases, some of which seem 

 to be peculiar to fibro-cartilage in this particular 

 situation, and all of which are attended with in- 

 convenience and danger by reason of their 

 interfering with the function of the organ. I 

 shall commence with that which I believe to 

 be the most frequent, the most important, and 

 the most fatal ; indeed, when allowed to run its 

 own course it is always destructive, and when 

 the patient's life is preserved by art, it is with 

 the alternative of breathing for ever afterwards 

 through an artificial aperture. In consequence 

 of the similarity of symptoms between this and 

 phthisis pulmonalis, it has obtained the name of 

 phthisis laryngea. 



The exact manner in which this disease com- 

 mences and the causes that lead to its produc- 

 tion have not yet been so accurately ascertained 

 as to admit of no farther doubt or question ; for 

 instance, Mr. Ryland seems to think that " in 

 most instances it is secondary to some inflam- 

 matory affection of the laryngeal mucous mem- 

 brane or its subjacent tisssue," whereas I have 

 ventured to believe that the original morbid 

 action was set up in the cartilage itself and was 

 proper and peculiar to it ; at the same time it 

 must be confessed that I have seen it apparently 

 produced by the presence of an abscess in the 

 immediate vicinity, and I believe there can be 

 no doubt of its being an occasional sequela of 

 typhus fever. Theessence ofthedisease seems to 

 be a change of structure in some of the cartilages, 

 followed by the death and disorganization of 

 the newly formed material, and an attempt at 

 its removal by abscess and ulceration. Thus 

 on a post-mortem examination of one of these 

 cases an abscess is always found in the situation 

 of some of the cartilages very generally of the 

 broad posterior part of the cricoid : and this 

 abscess has burst by one or more openings, one 

 of them being very frequently just behind and 

 above the rima. On cutting into the cavity of 

 the abscess, besides the matter, which is green- 

 ish, putrid, and abominably fetid, particles of 

 a grey or white earthy material are found, and 

 there are always portions of bone, thin, ragged 

 at the edges, white and perfectly dead. When 

 the disease has so far progressed, there is always 

 other and more extensive mischief; the exterior 

 parts in the neighbourood are swelled and thick- 

 ened, the mucous membrane ulcerated ; the 

 arytenoid cartilages often detached ; and the 



