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 Diphtherite : 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 ment, and the part is even painful on pressure externally ; every attempt to swallow is so dreadfully distressing that patients will suffer to be half-famished rather than attempt to get down a spoonful of fluid. In attempting to examine the throat there is often great diffi culty, because the patient either cannot, or from the pain it occasions, will not open his mouth ; but if it can be seen, it is observed to be of a deep red colour, verging on purple, sometimes diffused over the surLace, sometimes in patches, and even from an early period abundantly covered by a thick glairy tenacious mucus that it is difficult to wipe from it. If the disease is severe, the membrane soon be-. comes sloughy: " the colour of the slough is grey or ashey : in some few instances it appears brown; its edges are abrupt and well defined, and it is surrounded by inflammation of an intensely deep red colour. The slough is in general slow in separating, and when thrown off it appears to resemble a membrane of viscid lymph not unlike the adventitious substance formed in croup, and the surface underneath looks of a bright red colour, is nearly level with the adjoining parts of the membrane, and seems more like the blush of erythema than the relic of mortification. I believe that wher ever croup has appeared to have been conta gious it will be found that malignant scarla tina has prevailed also; and that the occur rence of the laryngeal or tracheal disease was occasioned by the spreading of the inflamma tion from the fauces to the windpipe, or per haps by the actual presence of one of these sloughing ulcers in the immediate neighbour hood of the glottis." Such is the description of the effects of an gina rnaligna on the mucous membrane written in the year 1825, but without any suspicion on the part of the writer that it could ever be ranged by the side of the affection termed croup : for besides the essentially opposite characters of the fever in each, which by them selves would be all-sufficient, there are the following differences. The angina maligna, diphtherite, or by what other appellation it is to be known,—for with respect to it we enjoy a most happy abundance of nomenclature,—com mences always in the fauces, and when it at tacks the windpipe, which is by no means very frequent, it does so secondarily by spreading to it; whereas croup seldom or never com mences in the fauces unless when it appears as the sequela of some serious inju7, such as the swallowing of boiling water. Cynanche ma ligna even locally is not confined to the mucous membrane, as is evidenced by the intense pain in swallowing, the difficulty of opening the mouth, the enlargement, suppuration, and even gangrene of some of the adjacent glands; and it occasionally exhibits something like a me tastatic transfer of disease to some important organ, such as the brain or liver. And even when recovery takes place, the difference is still remarkable: it is slow, often imperfect, and followed by anasarca or some similar evi dence of a broken and rachectic habit. This
is not the place to enter more fully into the examination of these two diseases, which the reader will find admirably contrasted in Dr. W. Stokes' work on diseases of the chest, where the angina is spoken of under the name of secondary croup.
There remain two other affections of the larynx to be noticed accompanied by asthenic fever, in both of which the pathological con dition of the submiicous tissue is of great im portance, viz. erysipelas and diffuse inflamma tion. I believe the larynx is very seldom the primary or original seat of an erysipelatous attack, at least such has not come under my observation ; but I have not infrequently seen it seized either by the spreading of the disease from the head and face, or by some species of metastasis. The constitutional symptoms during life are of a low and typhoid character; the local, those of painful and difficult deglutition and respiration, and the termination (as far as I know) always fatal. Nor are the appear ances after death always satisfactory, for, as in other cases of erysipelas, the tumefaction often subsides and the colour fades very soon after death. In most instances, however, we find the mucous membrane of a pale yellow colour and apparently greatly thickened : the sub mucous tissue filled sometimes with serum, sometimes with a gelatinous lymph, and some times with a sloughy and putrid matter ; th natural folds of the organ obliterated, and th rima more or less blocked up and closed by th thickening and tumefaction of the adjacent part But one of the most curious affections t which the larynx is liable is that of diffuse in fiammation. I say " curious," because it is 11 necessary that the mucous membrane shoul be inflamed or thickened or otherwise engage or that there should be any remarkable swel ling of the parts, and yet the breathing is harsh sibilous, or croupy, as if from the presence o some mechanical obstruction. In these which are always fatal, the cellular tissue is th seat of the disease, and is found tilled wit offensive purulent matter and flakes of unor ganized lymph, sometimes around the larynx trachea, and esophagus, sometimes at the iron of the throat, and not infrequently extendin to a considerable distance down into the ant rior mediastinum.
Chronic inflammation of the mucous meni brave of the larynx resembles in its effects similar form of disease in other structures, ex ceps that as the aperture of the glottis is small and its functions essential to life, the same de gree of alteration or of disorganization cilium have place here that may occur in other situa tions without the patient generally experiencin a degree of distress that will at least direct hi attention to the subject. Still is this affectio sufficiently insidious, and its progress in man instances so slow, that often irremediable mi chief is produced before assistance is sough for: and thus it happens that we are obliged t speak of chronic inflammation' not with re 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 he extremely common, and I know of nothing more diffi cult than to subject the 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.