General Washington died within twenty-four hours of the commencement of his illness; and we cannot deny that in this supposed case of croup, the remedies employed, however justifiable in the then state of medical information, probably shortened the general's life. If bleeding fails to subdue an inflammatory disease, it will be hurtful" by depressing the power by which the muscles act;" and on the vigorous action of the muscles which expand the chest, depends a continuance of that struggle by which the lungs are supplied with air sufficient for the arterialization of the blood.

We acquire a juster view of laryngitis by contrasting that disease with croup. They are both truly inflammatory diseases, but in that point alone do they resemble each other. Croup is a disease occurring before puberty, generally affecting, not merely the larynx, but the whole of the bronchial membrane, ending in an effusion of lymph on the free surface of the membrane, to be cured, probably, in ninetynine cases of a hundred, by emetics and bleeding timely employed; and it is a disease in which a surgical operation will only add to the danger, to which in the second stage the patient is exposed. Laryngitis, on the other hand, is a disease which rarely occurs before puberty; is confined to the upper extremity of the windpipe; ends in a serous effusion into the cellular tissue beneath the mucous membrane; will probably terminate unfavourably in a great majority of cases under any method of treatment, in which emetics aggravate the danger and bleeding is often a doubtful remedy, and in which, when the patient is in extremis, bronchotomy will afford the only reasonable hope of safety.

Bloodletting has been successfully practised in this disease, as the reader may be convinced by several recorded cases: for example, by a case to be found in a paper on laryngitis, published by Dr. Beck of New York, in the twelfth number of Dr. Beck's Journal. The case occurred in the person of Dr. Francis, one of the editors of the journal, who, having for three days had soreness of the fauces and thirst, was attacked with pain, difficulty of breathing and swallowing, and a sense of strangulation, for which symptoms 152 ounces of blood were abstracted. For three or four days after, the patient was still in a precarious condition, and required a repetition of the bloodletting. Other cases are published, in which the lancet was successfully employed in one of these, to be found in the sixth volume of the Medico-Chirurgical Transactions, viz. that of Sir J. Macnamara Hayes, as reported by Dr. Roberts of Bishop Stratford, we learn that the first bleeding "was attended with considerable relief," the second "with manifest advantage," by the third "his safety appeared to be ensured." In the case of a young woman who earned a pittance by gathering cockles on the strand at ebb-tide, and afterwards hawking them through the streets of

On the 17th Nov. 1823, V.S. ad xl. evening, 3xx. 18th Nov. 3xvi.; evening, 3xvi. 19th Nov. 3xvi.; evening, 3xvi. 20th Nov. 3xvi. 22d Nov. 3xii. Total želii.

Dublin, who, on the 13th of July 1813, presented herself at the county of Dublin Infir mary on the second day of laryngitis, pale, scarcely able to articulate or swallow, the effort producing a convulsion as when a crumb enters the windpipe, the voice sounding as if she were throttled, inspiration being slower than natural and sibilous, the following treatment proved successful. At noon, she was bled ad deliquium, which by the way had nearly proved fatal. The venesection was repeated twice in the course of the evening. On the following day respiration was rendered difficult hy the least exertion; hitherto unable to swallow. She was again bled, and a purgative enema and blister prescribed. Next day she began to expectorate yellow mucus, and could swallow fluids. On the 16th July convalescent.

It is observable that the lividity of complexion which, especially in the more advanced stages of laryngitis, arises from imperfect arterialization of the blood, did not exist in any of these cases.

On the other hand, bloodletting has been unsuccessfully practised in laryngitis, not only in the case of General Washington, but also in many others. In the second attack of laryngitis, that to which Sir John Hayes fell a victim, he was three times bled from the arm on the second day of his illness, and the result of his case and the other cases reported by Dr. Baillie, in which also bloodletting was practised, led Dr. Baillie to affirm that "venesection, even when employed strenuously and early, was of no real use." But the most remarkable instance of the inefficacy of bloodletting may be found in Dr. Armstrong's Practical Illustrations of Typhous Fever, p. 393. The loss of one hundred and sixty ounces of blood within six hours gave temporary respite to the difficulty of breathing, yet was so far from arresting the inflammation that death took place within twenty-four hours. As, then, there are cases in which bloodletting is salutary, and cases in which it is hurtful, let us try to ascertain when and to what extent that remedy ought to be practised; and let us be permitted to premise that cases will occur in which it may be difficult to come to a satisfactory conclusion with respect to bloodlettingin which the considerations for and against that remedy will be balanced, so as to make the most skilful and experienced physician pause. In such a dilemma, however, it will be well that the physician should not allow his doubts to transpire; as doubts which may be the result of an accurate weighing of indications against contra-indications, and which prove that he is a pathologist, will, perhaps, by the world and by his unreflecting brethren, be thought to proceed from inexperience and perplexity.

We conclude, first, that bloodletting will be more clearly indicated in youth than in age: it may be observed that the same means by which Sir John Hayes was relieved during his life, failed fifteen years after :--and, secondly, first attack which took place in the meridian of that we may bleed with most hopes of success when the symptoms of inflammatory fever are

most evident in Sir John Hayes, during the first attack, the face was swollen and flushed, the eyes were protruding and bloodshot; there was fulness about the neck, the muscles feeling very turgid, and the breast being suffused with a purplish colour; whereas in the second attack, we find that his skin was not hot, nor his pulse more frequent than in health.

"At the beginning of the attack, it may be advisable," says Dr. Baillie, "to take as much blood at once as to produce fainting. We beg to submit to the reader, that blood in laryngitis is sometimes so imperfect a stimulus to the heart, that if the action of that organ is interrupted, it is not improbable that it will never be resumed. In certain conditions of the circulation in this disease, I have found bloodletting a very dangerous measure. I think it was fatal to a patient who came to the County of Dublin Infirmary about twenty years ago, when I was one of the physicians to that hospital. By my orders he was let blood, not till he fainted, but till he became pale and fainty; very shortly after the operation, which sensibly reduced his strength, he was seized, upon slightly exerting himself, with a paroxysm of difficult breathing, not more violent than many from which he had emerged during the two or three previous days, and expired." In Dr. Beck's paper, already referred to, we learn that Dr. Hoffman of the United States Navy was called to a patient in laryngitis whose countenance was anxious, flushed, and covered with sweat; eyes staring, and dyspnoea insufferable; that a vein was opened in each arm, which bled freely, and that death took place in a few minutes after. Mr. Porter, in the eleventh volume of the Medico-Chirurgical Transactions, after drawing a very lively and accurate portrait of laryngitis in a man about thirty years of age, who came to the Meath Hospital with his face pale and swollen, his lips livid, his mouth closed, his nostrils widely extended, his eyes protruded and starting from their sockets, but at the same time with the conjunctiva very white and covered with a watery suffusion, and with an expression of indescribable anxiety; his pulse hurried, and his breathing very laborious, making two or three or even more attempts at inspiration for one expiration, and his convulsive struggles for breath truly painful to behold, breathing with a hissing or whistling sound, while the utmost endeavour at speech was only an indistinct whisper;-tells us that he ordered from thirty to forty ounces of blood to be taken from both arms, and adds that in about two hours afterwards, when he returned to the hospital to perform bronchotomy, there was scarcely a pulse to be felt at the wrist; the extremities were cold; the patient lay on his back almost insensible, and seemed sinking with amazing rapidity. Knowing the candour of the intelligent and skilful reporter of this case, we are not afraid to observe that this was a combination of symptoms in which bloodletting was not likely to improve the condition of the patient, for whose sufferings the proper remedy was the knife, which was afterwards successfully employed. Indeed, Mr. Porter, in his valuable

remarks on the case, has affirmed that it presents a strong illustration of the inefficacy, in laryngitis, of bleeding, blisters, and the various internal means usually resorted to for the purpose of subduing inflammation. We conclude, that although we may bleed in certain states of the disease so as to influence the pulse, it would be unsafe under any circumstances to bleed usque ad deliquium.

The question of bleeding may with most safety be determined by the condition of the circulating fluid. We may, with comparative safety, bleed while the complexion is good, or, in other words, so long as the quantity of atmospheric air admitted into the lungs is sufficient to produce that chemical change by which venous blood, in passing from the right ventricle to the left auricle, is converted into arterial; but when the alteration in the appearance of the patient takes place remarked in the advanced stages of the disease, which indicates that the blood is no longer arterialized in its passage through the lungs; when the face and lips, especially the latter, become livid, the expression anxious, the eyes protruded and watery, and when these appearances are established permanently, we may conclude that the stricture of the glottis is of a nature not to be relieved by bloodletting, and if so, that the patient will be injured thereby.

In the early stages of laryngitis, would not the application of leeches to the palate and tonsils be deserving of a trial? This question the reader will be better able to answer after he shall have read a short but valuable paper by Surgeon General Crampton, in the third volume of the Dublin Hospital Reports, on the application of leeches to internal surfaces. Mr. Crampton informs us, that in no instance in which leeches have been applied to the tonsils within the first twelve hours of the attack of inflammation, has the disease proceeded to suppuration.

We would bleed the patient freely during the first twenty-four hours; we should be disposed to do more—so long as the complexion of the patient is good, we would have recourse to venesection, keeping a finger on the artery while the blood flows, and closing the orifice when the pulse is reduced; we would have leeches applied, or blood removed from the nucha by cupping; and should be disposed to bleed again, or even a third time, so as to abstract forty or fifty ounces of blood, and at the same time let the patient have a powder containing two or three grains of calomel, three or four of pulvis Jacobi veri, and one-half or one-third of a grain of opium, every third or fourth hour, till the gums become affected. This we prefer to an exhibition of tartar emetic, not wishing to expose the patient to the danger of vomiting, which is productive of a frightful struggle in laryngitis. Blistering the neck is of very questionable efficacy, and by the inflammation, stiffness, and soreness which it occasions, adds much to the sufferings of the patient, and, when bronchotomy becomes necessary, to the inconveniences which attend that operation. If the physician reposes much confidence in the antiphlogistic power of a

blister, let it be deferred till bleeding has been carried as far as is expedient, and then let it be applied to the upper part of the sternum. "From bleeding and opiates," says Dr. Baillie, "if no substantial advantage is produced in thirty hours, it might be advisable to perform the operation of bronchotomy at the upper part of the trachea, just under the thyroid gland." We apprehend, however, that a consideration of the mere duration of the disease will lead us astray; thirty hours may be too long to wait, or it may be too short. If the circumstances of the patient, especially the condition of the circulating fluid, be such as to contra-indicate bleeding, and to show that asphyxia is imminent, it may be improper to put off the operation for thirty minutes. If the complexion is good, if asphyxia is not threatened, the operation may be delayed for thirty days.

In Dr. Baillie's second case already referred to, it is stated," in the night time, the patient becoming much worse, Mr. Tegart, who scarcely ever left him night or day, went for Mr. Home and Mr. Wilson to perform the operation of bronchotomy. Mr. Wilson was out of town on professional business, but Mr. Home came about four in the morning. The patient, however, was beginning to sink, so that no advantage from an operation was now to be expected." It is, indeed, probable that bronchotomy would not have saved the patient; but as that operation in an adult can be performed without difficulty, and as there are mstances of its having been successful even when the brain was oppressed, which is the most alarming symptom in this disease, we humbly think that no patient who is not in the article of death ought to be deprived of the chance of escape which it affords. The patient operated upon by Mr. Goodeve, surgeon to the Clifton Dispensary, was quite insensible when the operation was performed; "no pulse could be found at the wrist, his face was suffused with blood and his lips livid, and it was hard to say whether he breathed or not," and yet he recovered.

There can be little doubt but that in most cases the aperture ought to be made between the thyroid and cricoid cartilages, but in this matter the surgeon must be the arbiter.* The opera

On this subject consult Mr. Lawrence's paper in the sixth vol. of the Medico-Chirurgical Transactions.

The writer of this article many years ago recommended the introduction of a trocar and canula,without previous incision. This operation is justly condemned by Mr. Wood in his valuable paper published in the seventeenth vol. of the Medico-Chirurgical Transactions. Mr. Wood observes: "Dr. Cheyne has advocated an operation equally reprehensible with that of Dessault, (who recommended the introduction of an elastic tube through the nostril into the trachea,) that of introducing into the trachea a trocar and canula without previous incision. The reflection that the canula must irritate by being moved up and down with the larynx, which does not move in association with the skin, combined with the danger of wounding a large blood vessel irregular in its course, the œsophagus and contiguous important parts, and the depth it may be necessary to penetrate in consequence of the unusual depth of the

tion has often proved perfectly successful, and a canula has been worn for a long time without much inconvenience. Thus the patient operated upon by Mr. Goodeve wore a tube for more than six months; he was then able to lay it aside, and his voice was quite restored. In the fourth volume of the Dublin Hospital Reports, we learn from Mr. White that one of his patients was wearing a tube without being prevented from working at his trade, which was that of a cabinet-maker, two years after the operation; the sides of the opening, which was of an oval shape, and one inch in depth to the trachea, being perfectly healed, smooth, and covered with a thin cuticle. But the most remarkable proof of the relief which the canula is capable of affording, is that which is supplied by the case of Mr. Price of Portsmouth; we learn in the twenty-ninth number of the Medico-Chirurgical Review, in which journal there is much valuable information to be found on laryngitis, that Mr. Price had been breathing for about fifteen years through

a canula.

Laryngitis sometimes is more of a chronic than acute affection, in which case the affected organ probably undergoes a considerable change of structure; in the case in Mr. Lawrence's paper, which we have already alluded to, which continued for nearly four months, the mucous membrane had assumed a thick and puckered condition, and had partially thrown out coagulable lymph of a stringy and fimbriated texture, which obliterated the ventricles of the larynx. In one of our cases which had lasted four months, the membrane lining the glottis, and arytenoid cartilage, was like a thin layer of flexible cartilage. In chronic laryngitis, mutatis mutandis, the same principles of treatment are applicable as in the acute species. Bronchotomy may be necessary to prevent that fatal exhaustion arising from continued disturbance of the respiratory function, as it was in the case related by Dr. M. Hall in the tenth volume of the MedicoChirurgical Transactions; but medical means alone will often prove sufficient for the removal of the inflammation if it be unaccompanied with ulceration. The remedies chiefly to be relied on in chronic succeeding acute laryngitis, are, change of air-this remedy we again specify, even at the risk of being thought to harp a little too much upon one string;-the establishment of a discharge from both sides of the larynx by means of small caustic issues; and mild mercurials, with the infusum sarsaparillæ compositum of the Dublin pharmacopoeia. (J. Cheyne.)

LEGITIMACY. See SUCCESSION.

LEPRA.-Airga: from Aegis -ga, scaly ; th. Xénis, or Aéros, a scale. A scaly disease of the skin, occurring generally in circular patches. At a very early period of medical literature, the

trachea from the surface, ought to preclude this use of the trocar,' " &c. This quotation is introduced

as an amende for the inconsideration that led to the proposal of an operation which is so objectionable.

confusion, which afterwards became "worse confounded," began to reign concerning the terms lepra and leprosy. The Arabian physicians had described the tubercular elephantiasis, the elephantiasis of the lower extremity, and some varieties of scaly disease, under distinct appellations, which became frequently misapplied. When, at the revival of learning, their works were rendered into the European languages, the Latin translator multiplied the perplexity by interpreting the Arab word juzam by the term lepra, which the Greeks had applied to designate the scaly disease defined above. In the middle ages the term leprosy was indiscriminately applied to the different forms of elephantiasis, the scaly diseases, and, in fact, to any form of chronic skin-disease which was bad enough to entitle the subject of it to admission to the lazar-houses which were established over Europe at that time, where the indigent were glad to get the subsistence they provided at the expense of being called lepers. This confusion has been a subject of complaint with writers from age to age, yet it became perpetuated. Hensler's learned treatise, written with a view to elucidate the subject, left it nearly as complicated as ever; for he and Sprengel treated under the term leprosy the various forms of elephantiasis, the Greek leuce, and the proper scaly lepra. Many modern writers do not appear to desire the removal of this obscurity, as they persist in describing the former of those under the name of leprosy. We trust, however, that medical men will now see the expediency of adhering to Willan's correct nomenclature in this instance, which restores to the term lepra its proper and original signification, namely, the scaly disease, the subject of this article.

History of the disease.-Lepra generally begins on the extremities, below the larger joints, where the skin covers but thinly the tibia and ulna respectively. It commences by small, roundish, smooth points, slightly prominent above the surface of the skin, which soon become red and shining from being overlaid by minute transparent scales. These become soon detached and replaced by others. The eminences by degrees enlarge; the scales become thicker, and are chiefly formed on the circumference of each spot. They observe the circular form in spreading, and attain the size of a shilling or a half-crown piece; and as they increase, the circular border becomes raised and encloses a red area, which is free from the squamous development. A red areola is also perceived external to the raised circumference where the scales collect. These orbicular patches, in spreading, touch and intersect one another; and though in this stage the circular form is lost, we may still trace the segments sufficiently well to shew their original conformation. They unite usually first at the elbows and knees, the parts, as we have said, where the disease first shews itself. In the progress

* P. G. Hensler. Vom Abendländischen aussatz im Mittelalter, nebst einem Beitrag zur Kentniss und Geschichte des Aussatzes. Hamburg, 1792.

of the affection, while the existing patches are enlarging in this manner, new ones arise; the abdomen, the back, and the chest become affected; and in some cases it spreads to the head, face, and hands.

The scales fall off and are renewed very frequently. Sometimes they are so easily detached and form so rapidly, that the patient's clothes and bed are filled with scales, which cause some irritation: in other instances they adhere more firmly, and accumulate in such quantity as to impede the motions of the joints,-a still greater source of troublesome annoyance.

By their multiplication the scales become aggregated apparently in an irregular manner; yet each one is propagated from a centre, and is attached by a pulp to the dermoid tissue: this fact is proved by tearing one off, when a slight red speck is seen to project from the middle of the inferior surface, corresponding to a depression in the spot whence it has been displaced. When the disease has lasted long, or is in process of cure, the scales, as they fall, present the reticular eminences proper to the cuticle, and leave the surface red, smooth, and marked by corresponding reticulations.

The description here given will apply to the great majority of cases of lepra, but it presents varieties derived from its extent, duration, and treatment. The accidental circumstances of situation and colour also impart to it certain peculiarities.

It sometimes covers the whole body, commencing for the most part from the extremities; it begins usually on the two arms and legs at once, and propagates itself, as described, to the trunk; it rarely spreads to any extent on the face: the forehead, the temples, and the external angles of the orbits are, however, often the seat of some scaliness spreading from the hairy scalp. When the scalp becomes affected, the scales are very minute, and generally cover an exudation derived from the inflamed bulbs of the hair; a moisture is also remarked to accompany the scaliness when the disease invades parts where there is a necessary friction, or places furnished with many sebaceous follicles,-as the nates and inside of the thighs, the axilla, the verge of the arms, &c. These form exceptions, however; for it is one of the essential characters of the disease that the desquamation is quite dry.

In cases of a very chronic nature, where the disease is of such extent as to spread over the hands and invade the root of the nails, these become much altered in structure, curved, and of a dirty yellow colour. It has been observed in some rare instances that the dermoid tissue which secretes the nail has become inflamed and furnished a sanious discharge (Rayer). In the cases which are complicated by any of those accidental secretions, the lymphatic glands sometimes inflame and swell, as Richter remarks; but we cannot admit into the description of lepra the rhagades and ulcerations which are mentioned in his excellent work.*