face of the epiglottis by means of a soft brush, in all the early cases, both of pharyngeal and laryngeal complication; and had frequently witnessed its good effect, not only upon the part to which it was immediately applied, but upon the laryngeal structures also, attributing it, in the latter case, to an action excited in the upper respiratory passages from continuity of the mucous membrane. But I had never ventured to apply anything directly to the larynx itself,-not from any doubt as to its possibility, but from misgivings as to its effects, and apprehension of its danger. For some months past, however, I have done so extensively in cases of chronic laryngitis, whether idiopathic or tubercular, and very frequently with marked success.

At the commencement of the laryngeal symptoms, a solution of the crystals of nitrate of silver, varying in strength from ten grains to half a drachm to the ounce of distilled water, passed, by means of the instrument recommended by Dr. Green, into the opening of the larynx, is often productive of great relief; I have known the voice regained, the irritable cough removed, and the tenderness and difficulty of swallowing dissipated entirely by it; indeed, I think we might almost speak of its curative effects, (so far, at least, as the larynx is concerned,) in some very early cases. As a palliative, at a more advanced period, it often acts beneficially by relieving some of the most troublesome symptoms, more particularly the loss of voice and difficulty of de

glutition, and of this no better proof can be adduced than the frequency with which many patients are found asking for its repetition.

I would not advise it to be practised, however, when there is reason to believe that the mucous membrane is extensively ulcerated, nor when the pulmonary disease is in a very advanced stage, and the strength of the patient much exhausted; in such cases, it could do no permanent good, and it seems scarcely justifiable to expose the sufferer to the annoyance of the operation. I have known it act prejudicially under such circumstances, by increasing the cough, and adding to the general debility. The early stage of the laryngeal disease, and when the lungs are not much affected, nor the strength much reduced, present the most promising opportunities for its employment.

The operation itself is not attended with risk, when properly performed; and is easily accomplished after a little experience. The tongue should be pressed downwards, and drawn a little forwards with a spatula having a curve corresponding with its upper surface; by this means the epiglottis is curved forwards, and generally brought into view, when the sponge (previously saturated with the solution) may be readily passed into the larynx. At the first, or even the second operation, it is sufficient, and perhaps safer, to apply the solution, by means of a piece of sponge or a soft brush, to the parts around the epiglottis, reserving for the

second or third application the actual passage of the instrument into the larynx itself; the irritability of the opening is thus gradually lessened, and the structures below more easily reached. Without some little experience, and even occasionally after it, the sponge may enter the pharynx or the œsophagus, instead of the larynx; but it is easy to tell, from the effect upon the patient, which has really happened.

In order to avoid the unpleasantness or the alarm which the introduction of the sponge into the larynx may occasion, I frequently drop the solution of caustic through the glottis by means of a pair of properly constructed forceps, to the end of which is attached a small piece of sponge. By depressing the tongue in the same way as before, and, with the other hand, squeezing the sponge previously charged with the fluid, over the opening of the larynx, the application may be effected as completely, and, I believe, as efficaciously, as by the other method.* My colleague, Dr. Thompson, has invented a small syringe, which answers the same purpose.

Inhalations seem to have very little influence upon this disease. I have tried them in various forms, both with a curative and palliative view, but hitherto with but trifling success. The vapour of

See the Medical Times and the Lancet for June 1852. The forceps are made by Mr. Coxeter, Grafton-street East.

hot water sometimes soothes the irritable cough, and the addition of conium, hyoscyamus, hops, or hydrocyanic acid, occasionally affords still further relief; but I have generally found, after a short time, a decided unwillingness on the part of patients to persevere with their employment-a very conclusive testimony of their trifling utility.

Medicine exerts nothing more than an indirect influence upon tubercular laryngitis, every internal remedy having hitherto failed in exerting a specific local action over the progress of the disease. The tinct. benz. co., or the balsam of tolu or of copaiba, added to a mucilaginous cough mixture, soothes the irritated parts, and lessens the cough. But in other respects, no departure is necessary from the ordinary medicinal treatment which would be pursued in simple phthisis uncomplicated with laryngeal disease.

241

CHAP. V.

A MORE PARTICULAR DESCRIPTION OF THE CHIEF AGENTS EMPLOYED IN THE TREATMENT OF CONSUMPTION.

Change of air and climate. In the remarks already made upon this subject, I have ventured upon the following statements:

1st. That change of air and scene is one of the most important elements both in the prevention and treatment of consumption; and in an early stage of the disease, when the strength will permit, may, as a general rule, be sought in the spot most agreeable to the taste of the patient.

2nd. That after tubercular softening has commenced, and, for still stronger reasons, after cavities have formed, the patient should not leave his native shore.

3rd. That it is unnecessary, at any stage of consumption, to seek a foreign residence, as England offers advantages equal to, and in many respects greater than, any other country.

But since some of these opinions are at variance with popular doctrine, it is necessary that I should explain the grounds upon which they have been formed.

In the first place, climate exerts no talismanic

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