3. The cartilages of the larynx are subject to very important diseases, some of which seem to be peculiar to fibro-cartifage 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 1 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 1 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 of thedisease seems to be a change of structure in some of thecartilages, 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 round, 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 epiglottis, in every case that I have seen, more or less removed by ulceration. The whole con figuration of the organ is lost or spoiled, and scarcely bears a resemblance to the natural shape and appearance of a healthy larynx. We cannot even form a conjecture of the causes that occasion this formidable disease, or of the circumstances that dispose to its production. At some time beyond the middle period of life the cartilages of the larynx, except the epiglottis, and often of the trachea also, become converted into bone, and from the circumstance of carious bone being so constantly found in these ab scesses, it would appear that it is either during the process of ossification or immediately after wards that the disease commences. I have always imagined that it was at the former of these periods, and that the affection was pro duced by some imperfection or irregularity in, or deviation from, the ordinary and natural pro cess—in a word, that this earthy unorganized material was formed instead of healthy bone. I
had once an opportunity of seeing a case which I regarded as an example of the commencement of this disease, in the person of a man who, having suffered from laryngeal symptoms for some months, suddenly died in the 111 eath Hospital, ap parently from the effects of spasm. "On slitting up the larynx, the cricoid cartilage appeared to be highly vascular and organised. Its substance was internally as red as blood, and in three or four places there were specks of an earthy white substance that crackled under the knife, and was I evidently of the same nature with that usually found in caries of the laryngeal cartilages." I am aware that one case can prove but little, particularly in pathological science, but oppor tunities of seeing the incipient stages of such an affection as this must be very rare, and every case ought to be recorded that will in any man ner tend to throw light on a disease the etiology of which is so extremely obscure.
However occasioned, this earthy degeneration of the laryngeal cartilages is an extremely in sidious disease, its approach being so gradual as scarcely to alarm the patient, and its progress slow. There is usually sore throat and difficulty of swallowing, although this latter is not neces sarily a constant symptom; hoarseness, and at first but triflingly impeded respiration. These inconveniences in the commencement are not such as to produce much distress; for I have known one patient suffer for three months and another nearly nine, beforeeither applied for relief, and in both the disease had a final termination. Afterwards, however, the symptoms become more aggravated, the difficulty of breath ing is exceedingly distressing, and there are exa cerbations that bring the patient to the point of death by suffocation. I have already noticed one case in which dissolution took place at a very early period, and when the occurrence could only be explained by the suddenness and severity of the spasm. At length, as the dys pncea becomes extreme, the patient suddenly experiences some partial relief; his cough, which wasbefore teasi ng and troublesome, now becomes softer, and the expectoration free and copious. is latter has all the characters of purulent matter, and there are, mixed with it, particles of that white, gritty, earthy substance already described. Occasionally, pieces of the size of a pea of this unorganised substance are coughed up, and when they appear they leave very little doubt of the nature of the complaint. Towards the latter end of the disease the breathing be comes loud and sonorous, with a whistling noise, so as to be heard at a considerable dis tance. The cough is incessant ; the expectora tion copious, with a peculiarly fetid gangrenous smell ; the patient's breath has this odour also, which may also be regarded as an unfavourable symptom. There is at all times convulsive struggling for breath, with occasional exacerba tions. In most cases, but not in all, the chest becomes affected ; pain in some one part of it or other, with a sensation of tightness round the thorax as if the patient could not draw a full inspiration. His strength seems to give way rapidly under these symptoms; his body becomes emaciated ; he has night sweats accompanied with excessive restlessness; and at last he sinks exhausted in the struggle and dies.