at least delay the employment of mercury till the excessive pain is relieved, which is alone sufficient to keep up that state of the system on which the sloughing of a sore depends. It has already been mentioned, that the difficulty of swallowing is very great, so that life has in some cases been sustained chiefly by nourishing enemata. Many persons have doubted the possibility of our effecting a cure, if the ulceration has once extended to the larynx itself. This opinion appears to me, however, to be erroneous, as, in one or two instances which I have examined, I have seen what had all the appearances of cicatrices from former ulcerations. This was particularly observable in the larynx of a woman who had all the usual symptoms of ulcerated larynx in a severe degree, and was discharged cured. She continued well for several months, and was then re-admitted into the Lock Hospital, with a return of the symptoms, accompanied with phthisis pulmo nalis; of which she died. An ulcer was seen in one side of the glottis, with a ragged depression in another part of the larynx, which was probably the remains of the previous attack. Judg ing from their resemblance in feeling to some fatal cases, where dissection had verified the observation previously made with the finger, I believe that I have felt ulceration of the epiglottis and sides of the chordæ vocales, in persons who have been afterwards cured. In one very remarkable case, after the symptoms of ulcerated larynx had subsided, the cicatrix seemed to have so far contracted as nearly to close the glottis, producing very great difficulty of breathing, with a noise evidently showing the small size of the tube through which the air had to pass. The greatest relief was obtained by the occurrence of fresh ulceration in the lower part of the pharynx, which appeared to have in some measure re-opened the cicatrix of the former ulceration. The most dangerous symptoms attending ulceration of the larynx, have been stated to arise from the difficulty of breathing; and this takes place, not from any actual impediment to the passage of the air through the larynx, but from a spasmodic action of the muscles of the glottis, produced by the ulcers in the vicinity. The consequence of this difficult respiration is the excessive debility of the patient, from the insufficient supply of arterial blood: and here, perhaps, the prostration of strength and death of the patients do not arise so much from want of nutrition, as from the circulation of dark venous blood through the body, by which the brain and nervous system become oppressed. For the emaciation of the patient is not always in proportion to the extreme degree of languor and debility under which he labours; and in one case the patient died in convulsions, as if from an affection of the brain. This view of the subject will easily account for the inefficacy of common antiphlogistic treatment in this stage of the disease;* for, if the symptoms are for a time relieved by them, the actual cause, namely, the ulcer in the larynx, remains unaffected and incurable by these means. The symptoms will therefore return again and again, till the cause is removed. There are, therefore, two objects which we ought to aim at in the management of ulcerated glottis: the first is, to relieve the excessive irritation produced by the ulcer, which threatens to destroy our patient, before much progress can be made in the healing of the ulcer itself; and, having thus in some measure ameliorated the most urgent symptoms, the cure of the ulceration itself must next engross our attention. . Several plans may be tried in order to gain the first object; such as inhaling the vapour of a strong infusion of conium or opium, or of nitric acid diluted with warm water. If the ulcer can be touched with the finger, the solution of lunar caustic may be applied, in the manner recommended by Mr. Charles Bell, which appears to perform the same part here that it does in severe cases of spasmodic stricture of the urethra. It does not act as an escharotic, but simply diminishes the nervous irritability on which the contraction of the muscles depends. On the whole, however, I believe that fumigations of cinnabar are by far the most powerful means we possess of effecting this purpose. Very great relief is often experienced from the first time this plan is resorted to. Half-a-drachm or a drachm of the red sulphuret of mercury may be used once or twice a-day, according to the facility with which it is borne, or the benefit that is derived from it. The mercurial fumigation is not employed with a view to its specific action upon the system, for its effects are equally obvious when the constitution is not at all affected by it, as when the gums are made sore by its employment: salivation, indeed, to any great degree, would be disadvantageous, and perhaps dangerous. The action of the cinnabar rather appears to be local, though it would perhaps be difficult to explain exactly the manner in which it acts. It must be obvious that the use of the two latter remedies are chiefly applicable to those ulcers which follow the chronic ulcer of the throat; and that the soothing plan is most appropriate in the more acute and inflammatory species, while the violent local action exists. As a few hours are often of consequence, we may call in the aid of leeches and blisters to the throat, or even of general bleeding, if circumstances require it; for, although these means *Medico-Chirurgical Transactions, vol. vi. p. 249. are not to be trusted as our principal remedies, they are sometimes very useful auxiliaries. Having checked the most urgent symptoms by some of the preceding plans, we gain time to effect such a change upon the system as to ensure the healing of the ulcer. For this purpose sarsaparilla may be given, which requires a few days before its virtues are exerted in any sensible degree, and should therefore be generally employed from the beginning, in the manner before mentioned: or, if we wish for a more immediate change in the constitution, we may employ bark in large quantities, the effects of which may be obtained in a few hours. I prefer, however, the less obvious, but more steady, action of sarsaparilla. The employment of ammonia in pretty large doses is of great service in some cases. At the same time, the diet must not be neglected; but it should, in general, be light and nourishing. After a few days, if the case goes on favourably, a very great change is perceived in the symptoms. The respiration becomes less laborious, and the patient is no longer disturbed in his sleep by convulsive starts; he can swallow without inconvenience; his pulse changes its character; and the colour of the lips and surface of the body returns to a healthy state. How far the operation of bronchotomy may be successful in cases of ulcerated larynx, is a question of some importance. [ have only seen it performed in one case of this kind, which was a disease of the larynx following the acute sloughing ulcer of the throat. The patient was seized with a sudden fit of difficult respiration, having all the appearance of spasmodic action of the muscles of the glottis. He was evidently so nearly dead, (and in fact he died in less than five minutes after the seizure,) that I considered myself justified in opening the larynx immediately, as the only possible means of saving his life. He scarcely lived long enough, however, to breathe through the artificial opening; nor was his recovery to be expected, from the large quantity of frothy mucus with which the lungs were gorged. In Mr. LAWRENCE's paper on the Affections of the Larynx requiring the operation of Bronchotomy,* a number of successful cases are recorded; but almost all of them were performed for the extraction of foreign bodies, or for acute diseases of the larynx; and I do not recollect any successful case, in which ulceration of the larynx was known or suspected to exist, although there are several cases in which the patient's death was evidently retarded. I cannot but think that the operation is only likely to be attended with success in the more acute discases of the larynx, * Medico-Chirurgical Transactions, vol. vi. p. 240, 241, et seq. and 250. and is not at all advisable in cases of ulceration. It is allowed on all bands, that the effects of diseases of the larynx "are in themselves fatal after a certain time, even if the original obstruction be obviated:" hence the operation is ineffectual, unless performed early."* There are very few cases of ulceration in which the operation is likely to be proposed till the disease has existed so long that these fatal effects have probably. supervened; and I am inclined to think that all those who. would get well after the operation, might be cured without it. Of the two last cases mentioned by Mr. Lawrence, the firstappears to me to have been evidently one of inflammation; the last was one of ulcerated larynx, mentioned also by Mr. Bell, who performed the operation: the former succeeded, the latter failed. Mr. Lawrence remarks, "The different results of Donovan'scase, (the ulcerated larynx,) particularly after the favourable appearances exhibited in some parts of its progress, leads us to reflect on the causes of such a difference. Although the operation was longer delayed in the latter instance, and the artificial opening less free, yet the death of the patient must, I think, be ascribed to an original difference in the nature of her affections: a difference which, for the reasons so well pointed out by Dr. Latham, cannot be recognized by the symptoms. We have already seen that different affections are discovered, after death, in patients whose symptoms, derived from the interruption of the respiratory and vocal symptoms, which is common to them all, exhibited no diagnostic differences; that in some there was a mere thickening and change of structure in the membrane, while in others the cartilages were diseased. We may be allowed to conjecture that Jones's disease was of the former kind; while we know, from dissection, that Donovan's was of the latter." It appears, from these remarks, that Mr. Lawrence would not advise the operation of bronchotomy where the cartilages of the larynx are diseased. It has been my endeavour, in this paper, to point out the diagnostic characters by which this may be known: with what success I have done this, it is not for me to determine. It would be useless to enlarge upon the more advanced stages of this disease, as, probably, such affections are, in the present state of our knowledge, wholly incurable. St. George's Hospital; December 1822. * Medico-Chirurgical Transactions, p. 248. ART. II. Remarks on Pneumonia; being an Abstract from a Report of Cases treated at Fort-Pitt Hospital. By JAMES FORBES, M.D. Deputy Inspector of Military Hospitals. DISEASES of the order Phlegmasia, affecting the respiratory organs, may be arranged under three heads:-1. Primary acute inflammation; 2. Acute inflammation supervening upon chro nic; 3. Chronic inflammatory action succeeding to acute. Dr. Cullen has, in his Nosology, attempted to establish a diagnosis between inflammation of the parenchyma and investing membrane of the lungs, and Dr. Good has followed his example; yet, with that good sense which characterized him when really practical points were in question, he says, "Nei ther do our diagnostics serve to ascertain exactly the seat of the disease; nor does the difference in the seat of the disease exhibit any considerable variation in the state of the symptoms, nor lead to any difference in the method of cure:" and again, "It seems to me very doubtful if any acute inflammation of the lungs, (i. e. the case of an inflammation beginning in the paranchymatous or cellular texture of the lungs, and having its seat chiefly there,) or any disease which has been called Peripneumony, be of that kind." Inflammation of the substance of the lungs, as a primary affection, may therefore be presumed to be very rare, excepting in cases where these organs are in a state of excitement from other causes, or of disorganization. If it does occur, it is commonly communicated, more or less, to the investing membrane. This membrane may be considered as, in general, the seat of active inflammation. I am surprised to find Dr. Good stating, under the head of Pleuritis Vera, that the inflammation, in this case, commences on that side of the membrane which lines the ribs; while it is distinctly, and I be lieve truly, stated by Dr. Cullen that this is a rare occurrence, and that the disease much more frequently begins in, and chiefly affects, the pleura investing the lungs. The inflammation of that portion of the pleura which covers the upper surface of the diaphragm, has been distinguished by a particular name; and Dr. Good states, that" painful constriction around the præcordia, and small quick pulse, and laborious breathing," sufficiently decide that the inflammation is seated chiefly in the diaphragm; abandoning the older diagnostics of phrenitic delirium, risus sardonicus, and other convulsive motions, with which this variety of thoracic inflammation was supposed to be attended. Dr. Darwin says he could distinguish paraphrenitis, or pleuritis diaphragmatica (as it is more correctly denominated by Good), from pleuritis, by observing whether the patient carried on respiration most by the elevation of the ribs, or the depression of the diaphragm. In pleuritis, he says, the ribs |
