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 dyspncea, 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 tinder 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'imatomist, 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 chords' 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, 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 i3 engaged) produce symptoms of diffi cult deglutition, exactly resembling those of stricture of the esophagus : 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 aflbrd this important organ the requi s.te 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 Aluseum 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 spews 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 tire 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 chords' vocales at the left side: its surface was about the size of a shilling, and of a dirty green colour ; its edges quite slolighy, and its centre excavated to a considerable depth : the mucous membrane around highly vascular and covered with a pellicle of lymph.