the submucous cellular tissue, or that among the laryngeal muscles, or even the cellular tissue exterior to the larynx, may become inflamed, and, terminating in suppuration, proves another though a more remote cause of chronic inflammation of the larynx itself.

The affection, however, to which the name of chronic laryngitis is most properly applied, is represented as approaching in the following manner. After exposure, while warm, to cold, humid air; or after great or unusual exertion of the voice, as in long-continued speaking, crying, or singing, the voice becomes hoarse and husky,-so far as the larynx is concerned, is entirely lost, and may continue so for some days, probably in consequence of an inflamed and slightly thickened state of the laryngea, mucous membrane. Under the use of remedies or spontaneously this generally goes off; but from carelessness or mismanagement on the part of the patient, is reproduced in consequence of fresh exposure to one or more of the original causes. The voice becomes again hoarse, with a dry husky cough, and a sensation of tearing pain about the thyroid cartilage, which is aggravated by attempts to speak above a whisper, or to swallow. In some instances these sensations may be attended with shivering, headache, quick pulse, and great uneasiness in the windpipe during the night. All these symptoms depend, according to Mr. Porter, on a permanent chronic action of the laryngeal membrane, which becomes thickened and more or less red. In this state of matters he has been in the habit of using mercury, he states, with the happiest effects; though he admits, that, where the disease has been of long standing, while the

"the

other symptoms disappear, power of articulating clearly," he should have said, "the faculty of laryngeal voice" is never again recovered. This suggests the remark, that cases of this kind of disease are found to be more benefited, first by a full bleeding from the arm followed by the repeated application of leeches in the neighbourhood of the pomum Adami, with the internal use of antimonial medicines; and secondly, by the frequent use of blisters over the throat, and the insertion of a seton under the skin.

Notwithstanding the use of all these means, however, this disease may go on, and by its obstinacy become highly formidable, and bring the patient into the most imminent danger. From some cause observed or unobserved, the breathing becomes suddenly very difficult and laborious; and, during the ineffectual efforts to inspire, the trachea and larynx are drawn as high as possible on the neck, and the digastric muscles are seen in strong and violent action. The symptoms, in short, are quite similar to those of laryngitis oedematosa, acute laryngeal inflammation.

In this form and stage of the disease, Mr. Porter thinks bronchotomy particularly called for, and if seasonably employed, very rarely employed in vain. "The disease is caused by a mere thickening of the mucous membrane, without any morbid alteration of structure; but the circumstance of the larnyx being in constant use tends to maintain the action that is going forward, and, finally, if not relieved, to produce such thickening of the part as will be incompatible with the maintenance of its functions. It is thus that, creating an artificial passage for the air, operates in pro

moting recovery; and there is reason to believe that after the operation, the power of nature would be sufficient to work out a cure, even without the intervention of medicine, merely because the organ can enjoy repose. p.

124.

Laryngeal Consumption, Phthisis Laryngea. To this head must be referred all the other forms of laryngeal disease enumerated in the last section, viz. ulceration of the membrane, abscess in the submucous or intermuscular cellular tissue, abscess complicated with disorganization of one or more of the laryngeal cartilages, and abscess with mortification of the laryngeal cartilages.

In abscess in the submucous or intermuscular cellular tissue, which is in some cases of the nature termed diffuse inflammation by Dr. Duncan Junior, the practice observed by Mr. Porter is that of making a deep incision down to the trachea; and though the matter may not at first be thus reached, it never fails to appear in the wound in the course of a day or two, on the same principle as that which regulated the practice of Dr. Graves, as mentioned in the Edin. Med. and Surg. Journal No. 91, p. 318. The observations on the usual site of this sort of abscess, and on the mode of ascertaining its presence, are extremely interesting, and deserve the attentive perusal of the surgical reader.

Abscess, with earthy disorganization of the Laryngeal Cartilages. -This severe and generally incurable disease, Mr. Porter regards as the result of a morbid change which the cartilages undergo, according to his observation, about the age of thirty two,

and between this and thirtysix. This process is preceded and accompanied with marks of high organization in the structure of these substances, the section of which, when divided, is then red and vascular. It commences most commonly in the posterior broad part of the cricoid cartilage, near the centre of which a small hard gritty patch, whiter than the neighboring red part, is deposited. This is progressively enlarged till it occupies the greater part or the whole of the cartilage, when, from its inorganic nature, and the high sensibility of the surrounding and neighboring parts, it operates as an extraneous irritant, and gives rise to inflammation, which soon terminates in abscess. When the matter is discharged, which it does by several openings, gritty or earthy exfoliations take place; and the copious but fetid expectoration, and bad breath, soon announce the hopeless nature of the malady. The original source of irritation continues to operate; the patient is worn down with cough, difficult breathing, and incessant irritation of the air passages; and he expires with most of the symptoms of hectic fever.

In this state of misery, the business of the medical attendant is chiefly palliative; and the surgeon, though he is assured of the nature of the disease, need scarcely make an attempt to save his patient. Mr. Porter, though he states that he has prolonged a life of misery for a month by performing the operation of bronchotomy, and is aware that others have been still more successful, admits that a small addition to existence procured on such terms is no advantage, and dissuades the surgeon from performing the ope

ration, unless under very peculiar circumstances, and at the urgent solicitation of the patient or his friends.

Abscess, with mortification of the Laryngeal Cartilages. Of this Mr. Porter has met with two instances, one of which was acute, and run its course with great rapidity; the other chronic, and proceeded so slowly as to disguise its real nature, till the operation of bronchotomy was performed. The cartilages in this complaint are red, but without distinct vessels in their substance, less dense than in the healthy state, and become spongy by maceration. When the action is completed, they appear black and dissolved like wetted or rotten leather, p. 117. This disease gives rise to secondary suppuration of the laryngeal cellular tissue; openings take place at one or more points, in some instances into the œsophagus; and when the air is admitted, the car tilage is seen lying at the bottom of the sore, of a brown color, shrunk and shriveled like horn which has been exposed to the fire. The dead cartilage, in such circumstances, emits a most fetid smell, which, though different from that of carious bone, is equally offensive, and is almost pathognomonic of the nature of the dis

ease.

Mr. Porter has not met with any description of this disease by authors; and the two cases which have fallen under his personal observation do not enable him to speak of it with much certainty. As cartilage is not authentically known to admit of reproduction, he infers that the larynx must be permanently destroyed; and that existence can be maintained in no other mode than by establishing

an artificial opening during the remainder of life. The wasting and fatal influence of the constitutional symptoms, and of the local irritation, however, hold out no great encouragement to this measure. This conclusion, indeed, is in general applicable to most of those forms of laryngeal disease, which have been shown to give rise to phthisical symptoms.

On the subject of foreign bodies in the larynx and trachea, Mr. Porter has entered into a very full and comprehensive inquiry, and illustrated his views by very apposite cases, either from personal observation or from respectable published authorities. It is needless here to enter into any lengthened account of this part of the work of Mr. Porter. It is sufficient to say, that he takes great pains to point out all the circumstances which may modify the effects of this accident, whether from the shape of the foreign body, or the situation in which it is fixed; and to distinguish the cases in which the operation is to be beneficial from those in which it is likely to be unavailing.

The last subject of consideration in the volume is that of wounds of the larynx and trachea, and more especially the operation of bronchotomy itself, which the author contrasts with wounds inflicted with the intention of suicide. Bronchotomy, he thinks, has been hitherto rather an unsuccessful operation, because it has been performed unseasonably late,whether for saving life during an attack of laryngitis, or for the extraction of a foreign body from the trachea. In other instances its want of success has been simply negative, that is, when it has been performed in cases of orga

nic change of structure quite incurable, and when consequently it could not be expected to be more beneficial than any other remedial measure. These objections are certainly not essential to the operation, and are of that kind which more varied experience, greater deliberation, and more patient attention, might unquestionably obviate entirely.

Another difficulty, however, perhaps more important than these, has been very properly adverted to by Mr. Porter in his examination of the effects of any incision into the windpipe. This consists in the effusion of blood from the wound, sometimes in such abundance as to flow into the windpipe, and if not the occasion of instant death, is at least the cause of very threatening cough and suffocation. In a large proportion of cases this accident becomes infinitely the most serious inconvenience of the incisions of bronchotomy; and if it be not so frequent as to merit the opprobium of an essential objection, it takes place at least under circumstances where very great caution and consummate dexterity are not always successful in preventing its occurrence. It is doubtless true that the performance of the operation in the cricothyroid membrane, as proposed by Mr. Lawrence, diminishes, but does not remove the chance of this inconvenience. Nor is it always very practicable to tie the vessels, at least after the opening into the windpipe has been completed. It is therefore of some moment to state, that the perpendicular incision is much less liable to this inconvenience than the transverse one; since the vessels are not only much less likely to be divid

ed, but may, by cautious dissection, be pushed aside, while the operator proceeds, by successive steps, to complete his opening into the larynx. It is not hemor rhage merely which he has to fear in such circumstances, but the effusion of blood into the windpipe, so as to cause a greater evil than that which it is his purpose to remove, and render instantaneous and certain the fatal event, which, though near, was neither immediate nor inevitable. On this point the remarks of Mr. Porter at pp. 238, 239, and 249, will be perused with advantage.

The foregoing hasty sketch of the principal subjects discussed in the present volume, though not intended as a complete account of the work of Mr. Porter, will perhaps communicate some idea of the nature of its contents, and of the manner in which the author has treated them. It is possible that in the account now given the language of panegyric has been less liberally used than the merits of the work may seem to justify. In answer to this it may be very safely said, that its intrinsic value is really so great, that to be justly appreciated it requires only to be attentively perused, and the best encomiums will be derived from the spontaneous suffrage of the members of the profession. The general conclusions are illustrated by the detail of several appropriate and instructive cases; and what is deficient in the former is amply supplied by the latter. On the whole, little doubt can be entertained that the treatise of Mr. Porter will speedily secure for itself the rank of a standard work, and for its author the character of an able writer on surgical pathology.--Ed. Med. Jour.