INFLAMMATION OF THE LARYNX.-The Association of the Members of the King's and Queen's College of Physicians of Ireland has published the following case of this disease, in which an opening into the windpipe was made with success, by Mr. Carmichael, an eminent surgeon of Dublin:

"Judith Mahony, æt. 30, of a robust habit and sanguine temperament, was admitted into the Whitworth Hospital on the evening of the 8th of May, affected with a dull pain in the region of the larynx, and a sensation of constriction about the epiglottis, which greatly impeded respiration.

Each inspiration was lengthened, stridulous and sonorous, performed with great effort, and attended with a convulsive elevation of the chin. Expirion was performed with ease. The voice was hoarse, and speaking was observed to aggravate the difficulty of breathing. She had little cough, but was frequently hawking up a tough, yellowish mucus. Swallowing was little impeded, but attended with some pain. Externally there was no observable tumour, nor did pressure upon the region of the larynx occasion pain. Upon examining the internal fauces, the mucous membrane appeared slightly inflamed. The right tonsil was enlarged, and the uvula, which appeared rigid, had its tip looking forwards, and placed at right angles with the velum. The tongue was slightly furred, and upon making pressure on its root with the shaft of a spoon, in order to obtain a more complete view of the mouth and fauces, the patient twice remarked, that she felt her breathing relieved, owing, no doubt, to an increase in the area of the glottis during the pressure. The pulse was about 108 in the minute, and rather contracted. The bowels had been freed by medicine.

"The account which the patient gave of herself was, that about six days previous to her admission, after leaving off a cap which she had been in the habit of wearing, she was seized with pains in both ears, which were soon followed by the symptoms of inflammation of the larynx.

"With a view to clear the bronchial tubes of the mucus and phlegm with which they seemed to be oppressed, Dr. Cuming ordered an emetic, consisting of 20 grains of ipecacuanha and 1 of tartar emetic, which was immediately administered, and 1 ounce of the following solution was directed to be taken every fourth hour:

Take of Camphorated Mixture 6 ounces,

Emetic Tartar 1 grain. Mix.

"The emetic operated well, and produced a considerable discharge of mucus; but she passed a sleepless night; the difficulty of breathing was by no means alleviated, and she was, for the most part, obliged to sit erect in bed, from an impending sense of suffocation."

"On the morning of the 9th, twelve leeches were applied to the external fauces; these, however, failing to produce any decided benefit, fourteen more were immediately laid on, and the quantity of blood drawn was considerable. No impression, however, seemed as yet to be made on the disease; the inspirations became more and more sonorous and convulsive; the countenance was expressive of the greatest distress; and the patient, in the agony of her suffering, was most earnestly imploring the attendants to do something that might afford her relief.

"A bolus, containing five grains of calomel and one-third of a grain of

opium was now administered, and directed to be repeated every third hour. A blister was also ordered for the throat, but its application was for some time deferred, in order that, if the symptoms should become more urgent, it might not interfere with the operation of tracheotomy, which was in contemplation.

"About half-past five o'clock in the afternoon, as the distress still continued unabated, and the danger of suffocation became every minute more imminent, Mr. Carmichael was called upon, who instantly proceeded to perform the operation. An opening was made into the windpipe, in that space which intervenes between the inferior edge of the thyroid gland, and the superior extremity of the breast-bone. During the performance of the operation, the quantity of blood lost was very inconsiderable*.

"As soon as the windpipe was perforated, the air rushed out with a peculiar hissing noise, and upon enlarging the opening from above, downwards, and cutting out a small portion of the cartilage, the change which took place in all the symptoms was as beneficial as it was immediate. The countenance, which before the operation was of a pallid hue, and expressive of the utmost anxiety, suddenly resumed its natural appearance; and inspiration, which had been previously attended with so much difficulty, was now performed with apparent ease through the artificial opening. That convulsive elongation of the windpipe, which

"The external incision was about an inch and a half in length, and the hæmorrhage was so inconsiderable that there was not more than half an ounce of blood lost during the operation; for owing to the steadiness of the patient, and a clear light, the large veins on the fore part of the trachea were distinctly seen and avoided. The incision into the trachea was first made by dividing the membranous substance between two of the rings; then the inferior of the two was divided by a perpendicular incision, and this opening was enlarged by laying hold of one edge of the divided ring with a forceps, drawing it forwards, and cutti g off a slice with the knife. A similar piece being removed from the other edge of the divided ring, a square opening was left sufficiently large not only for the easy passage of air, but of mucus--a circumstance of the greatest moment with respect to the success of the operation; for if the opening should not be large enough to admit of the expulsion of mucus, a recurrence of a state of suffocation must ensue from its accumulation in the trachea and larynx, as there is little chance of its being expelled by the glottis, now that the patient breathes through the wound in the trachea. The removal of a piece of one or two of the rings, as recommended by Mr. Lawrence, is therefore, in my opinion, far preferable to the introduction of a canula, for the latter is not only a source of great distress, but is by no means equal to the other for admitting the easy exit of mucus. If we are contented with merely dividing the membranous substance which conuects the rings, recourse must be had to the canula, as the opening will soon become clogged with mucus in spite of all he efforts of the patient to expel it; and, for obvious reasons, we should prefer a canula of as large a diameter as can be introduced."

before attended each inspiration, was now completely removed; and the pulse, which had previously been about 108 in the minute, fell to 90. The patient, though now incapable of speaking, sufficiently evinced by signs how much she was relieved.

"On being replaced in bed, and propped up in the erect position with pillows, she soon fell asleep, and continued dozing during the remainder of the evening. On awaking, it was found that she swallowed with ease, and having signified a desire to smoke tobacco, she was gratified with a pipe. The edges of the external wound were kept separate by tin retractors covered by adhesive plasters, which were connected to each other by two strings tied behind the neck. A canula had been introduced into the aperture in the trachea, but the excessive irritation which it occasioned rendered its immediate removal necessary. At bed-time she had a draught, containing twenty drops of laudanum ; and the calomel boluses, of which she had only taken one, were ordered to be discontinued.

"During the night she slept well, and breathed with tolerable ease. At four o'clock of the morning of the 10th, she rejected a considerable quantity of mucus, mixed with coagula of blood, from the mouth. At breakfast-time she took two cups of tea, and a little bread with appetite; and she continued pretty well till about 12 o'clock at noon, when, consequence of the accumulated mucus, which obstructed the aperture in the trachea, the breathing became again laboured, and attended with somewhat of the same convulsive-like inspiration and peculiar hooping sound, which existed before the operation. The voice had, to a certain extent, returned, and she was able at times to articulate distinctly.

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"A probe wrapped round with lint was introduced into the aperture, by which the mucus was from time to time removed, and the external wound was kept clean by sponging. The difficulty of breathing, however, continually recurred, and the efforts to expectorate by the mouth were frequent and ineffectual. A considerable quantity of mucus escaped through the opening in the trachea, and it was observed, that when the opening was completely obstructed by the sponge, the patient was occasionally able to get up some mucus, and reject it by

the mouth.

"The difficulty of breathing continuing to increase, a bistoury was introduced in the evening, by which the opening was enlarged upwards. The good effects of this enlargement became soon evident, for the patient lay down on her side for the first time since the performance of the operation, and slept soundly for two hours. Respiration, during this time, was performed with apparent ease, through the aperture in the windpipe. Throughout the day she took a little beef tea and bread. The pulse was about 96, and she had three evacuations from the bowels. without medicine. She passed a tolerable night; breathing pretty freely, except when the aperture in the trachea became obstructed with mucus, which the nurse had particular directions to remove. She suffered considerable uneasiness, however, from a slight dysenteric affection which occurred in the night, and for which a draught, containing half an ounce of castor oil and twenty drops of laudanum, was administered on the morning of the 11th. The affection of the bowels was probably owing

to the calomel which had been taken in a single bolus, as there was a strong mercurial fœtor from the breath; and she complained of slight uneasiness of the mouth.

"About 11 o'clock at night she complained of weakness, and there was evident sinking of the pulse. A small quantity of wine, therefore, diluted with an equal proportion of water, was directed to be taken occasionally; and having fallen asleep soon after, it was observed, that she had drawn the blanket over her face, which evidently proved, that the obstruction to the passage of air, must have, in a great degree, subsided. She slept well throughout the night, but towards morning, in consequence of one of the tin retractors, by which the edges of the external wound were kept separate, having fallen out, the breathing became again a little impeded, and she expressed a desire that it might be replaced: this was accordingly done.

"At 9 o'clock on the morning of the 12th, she was sitting up in bed, and breathing very freely through both apertures. Her countenance was perfectly composed, and not at all expressive of anxiety. She thought she could breathe with more ease through the natural passage, and entertained strong hopes of recovery. Her voice continued still croaking, but she could articulate distinctly; pulse about 90, and of tolerable strength; dysenteric affection gone. She was allowed chicken broth, and a small quantity of wine, which she took with some degree of appetite. Her deglutition was scarcely, if at all, impeded.

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Throughout this day and the following night she breathed with still more freedom, and could bend the head so far forward as to obstruct, in a considerable degree, the aperture in the trachea. The use of the retractors to keep the edges of the wound separate was now no longer necessary, as apparently but a scanty supply of air through the artificial opening was sufficient for respiration.

"On the 13th the edges of the external wound had considerably contracted, and part of it appeared filled up by the deposition of coagulable lymph. There was still sufficient space for the free ingress and egress of air; but respiration seemed now to be principally performed through the larynx. The patient could lie in any position with the greatest ease, and when sleeping she could bear the bed-clothes to be drawn up about her throat without inconvenience. The excretion of mucus through the artificial aperture, as well as through the mouth, had in a great degree subsided. From this period her amendment was progressive and decided, for on the 19th it was noted, that the passage of air, as well as mucus, through the artificial opening had entirely ceased; and the external wound, which was rapidly contracting, was perfectly healed on the 23d. She was, however, retained in the hospital until the 31st, in order that she might recruit her strength, on which day she was discharged well."

Had this patient been copiously bied, a blister applied over the throat, the inflamed tonsil and surrounding membrane scarified, and the customary purgative and sudorific saline medicines administered on the first attack of the disease, or when Dr. Cuming first saw her, would not the necessity of so formidable au operation have been prevented? Such a decisive mode of treatment should, in our opinion, have preceded the exhibition of an emetic, the object of which, Dr. Cuming admits, was to remove the effects of the disease!! The postponement of the applica

tion of a blister, that it should not interfere with the operation of tracheotomy, in case it should be deemed advisable, was indeed, to say the best of it, a considerate practice. Now might not the application of a blister have rendered the operation unnecessary? This is one of the acute diseases in which a decisive practice is necessary to save the life of the patient, or to prevent the necessity of an operation, to which many patients would prefer death. It is the indecisive, or what a physician of Vienna has termed it, play-practice of the physicians of France, that gives rise to so many operations in that country. The result of this case points out forcibly the necessity of physicians being well acquainted with surgery, for such practitioners uniformly proportion their remedies to the danger of diseases. In Dublin physicians are not allowed to interfere with surgery, and if a surgeon should practise pharmacy, he is deemed unworthy of being a member of the college!!! Hence in Dublin, a patient with an organic disease, to derive the advantage the healing art is capable of affording, must employ a physician, a surgeon, and an apothecary!!! This the medical tribe of that city consider a wise and a very politic regulation, thereby admitting that their brains or mental capacities are not equal to the study of every department of medicine.

Mr. Carmichael concludes his paper with the following observations: "This case affords a strong illustration of the advantages of having recourse to the operation (tracheotomy) in the early stages of croup and inflammation of the larynx (laryngitis) before the wind-pipe or larynx becomes coated with coagulable lymph, or effusion has taken place in the lungs, principles already sufficiently insisted upon in the writings of Dr. Farre and Messrs. Chevalier and Lawrence."

With respect to the size of the opening and the removal of a piece of one, two, or three of the rings, as recommended by Mr. Lawrence, much must depend on the object of the operation. If organic disease about the glottis, which is likely to advance, and will not admit of cure, renders the operation necessary, a portion of two or three of the segments of the rings and integuments should be removed, because the opening is to be permanent, but in cases of inflammation of the larynx and croup, the integuments should be preserved, and as little of the segments of the cartilaginous hoops should be removed, as will answer the purpose. In croup the division of the internal membrane of the windpipe, no doubt, contributes greatly towards the resolution of the inflammation.

It should be remembered that the opening is intended to relieve the glottis, or act as an auxiliary to it, and to be closed when the disease has terminated.

LIVER COUGH.-Dr. William Brooke, treasurer and reader to the Association of Physicians of Dublin, has met with a case of cough, which has satisfied his mind that there is such a disease as liver cough. The patient (a youth of about fifteen years of age) having, after a long walk, experienced a return of " his old cough," Dr. Brooke "was sent for;"" on the most minute and patient examination, he was unable to detect the smallest deviation from health, or the smallest derangement in any of the organs or their functions, save the cough alone." After a deep inspiration, " he uttered a short cough or ejaculation,