come aggravated, and the general aspect of the case is rendered less promising, in consequence of the suffering and distress which are thus superadded.

The origin of this complication is not always the same; sometimes it is due to the extension of what I have already spoken of as tubercular pharyngitis, in which case there may or may not be a subsequent deposit of tubercle; but, at others, it is the direct consequence of tuberculous matter forming in the larynx. Perhaps, in every case of its occurrence, the lungs are found to be likewise tubercular, and this has led to a belief that the tracheal or laryngeal inflammation is owing to the contact of the tuberculous expectoration which has escaped from the lungs: but, were this really the case, laryngeal phthisis would be far more frequent, and we should scarcely see it commence, as it often does, when the pulmonary symptoms are but very slightly developed. There cannot be a doubt, that the morbid secretion of tuberculous lungs must greatly irritate any inflamed surface over which it passes; and that, to this very circumstance, much of the difficulty in treating many cases of phthisical laryngitis may be due; but we have no proof of its being able, in itself, to originate inflammatory action upon a healthy mucous membrane.

M. Louis, never having met with tubercle within either the larynx or trachea, regards the lesions

which they present in connexion with phthisis as invariably the result of ordinary inflammation; but having myself seen it, I cannot concur in this opinion. It would probably remain but a short time upon such a structure as the larynx, which may account for its having escaped the notice of so accurate an observer as M. Louis.

The symptoms begin at an uncertain period of the original disease, sometimes during its first stage, but quite as often later,—and consist merely of a tickling cough, hoarseness of voice, tenderness or pain about the larynx, and occasional uneasiness in swallowing; but, from this time the local disease is subject to every possible variety; it may go on for weeks or months with scarcely any alteration, or it may increase in all its symptoms, and add so much to the patient's distress, as to end fatally within a very limited period. When the laryngeal affection advances rapidly, the lungs, in many cases, enjoy a respite, the morbid action appearing to be transferred from one part to the other; but very often it is otherwise, additional tubercle with destruction of tissue going on simultaneously in both organs.

Laryngitis is certainly one of the most formidable complications of phthisis; it generally baffles every effort to remove it, and, when arrived at an advanced stage, may be productive of sufferings which are but slightly relievable. Nothing can be greater than the distress which it sometimes occa

sions; the voice is often lost, and the act of swallowing rendered so painful that death ensues from actual starvation.

The pathological changes in the diseased structures determine, in a great measure, the amount of distress experienced by the sufferer. The mucous membrane may be thickened, softened, or ulcerated; but it is impossible to tell its precise condition during the patient's lifetime. Ulceration is nearly sure to exist where the symptoms have been severe and long-continued, and it may involve not only the mucous membrane, but extend also to the cartilages of the larynx or trachea.

Chronic laryngitis, arising from other causes than phthisis, is comparatively rare. Simple inflammation of a subacute or chronic form, ending in loss of voice, irritable cough, and uneasiness about the throat, now and then follows exposure to cold, and is also met with in persons who habituate themselves to an undue exercise of the voice. Malignant disease sometimes appears in the upper part of the respiratory passages; and syphilis is well known to be productive of structural changes in the same region. It is, however, generally easy to distinguish these diseases from laryngeal phthisis, not only on account of the very different aspect which their history and symptoms present, but also from the circumstance that the tubercular affection is invariably accompanied by a similar condition of the pulmonary organs.

175

CHAP. IV.

PHYSICAL SIGNS.

THE general symptoms of early phthisis are of themselves insufficient to declare, with any degree of certainty, the nature of the disease; and even at a later period, however unequivocal they may be, they are incapable of accurately pointing out the precise stage at which the disease has arrived. Under no circumstances, therefore, can a physical examination of the chest be deemed unnecessary; and a diagnosis should never be attempted without its assistance.

First Stage.-A small amount of tubercle may exist in the lung, without immediately effecting any sensible alteration, either in the symmetry or respiratory movement of the thoracic walls. After a time, however,—which is determined by the increase or otherwise of the tubercular deposit, and its effect upon the neighbouring pulmonary tissue, -the form of the chest becomes changed, and its action impaired. There is often at first a slight bulging of the infra-clavicular region of the affected side, in consequence of the tubercle being sufficient in quantity to distend the pulmonary cells,

or of its having become surrounded by a temporary hypertrophy or emphysema of a portion of the lung. This, however, soon disappears, the thoracic parietes over the morbid deposit invariably falling more or less inwards as the disease advances, owing either to atrophy of some of the air-cells, or to contraction of the pulmonary tissue from secondary inflammation.

But the regions about the clavicles are not the only parts to exhibit the effect of pulmonary tuberculosis. The whole contour of the chest soon becomes altered; the shoulders are gradually drawn forward, and the back is rounded, causing the patient to lose permanently in height.

The change of respiratory movement bears a direct proportion to that of the thoracic walls, and commences simultaneously with it. Until there is some depression, however, the alteration is so small, and, as it appears to me, so irregular and uncertain, as scarcely to claim any great attention. But no sooner have the parietes of the chest over the diseased parts fallen the least inwards, than the action of the thoracic walls is sensibly altered: there is less expansion of one side than of the other, especially during forced breathing, the swelling movement so characteristic of health being no longer observed. This becomes more and more marked as the case advances, until at length the anteroposterior diameter of the upper part of the chest is almost incapable of enlargement, and every effort at deep inspiration is attended with a