second and the third day, once or twice the fourth day; it may then be left off altogether.

"At the same time the trachea is to be touched with a small piece of sponge fixed to the end of a very flexible piece of whalebone, and moistened with a concentrated solution, fifteen grains of nitrate of silver to 3ij of distilled water.

"This last means is sufficient if there is room for supposing that the larynx has alone been invaded. The cauterization by the sponge should be made as often, and for the same length of time, as the instillations through the canula.

"The instillations of water and the spongings still hold an important position in the treatment.

"If the cough is loose, if the expectoration is easy, it is not necessary to drop in the water. In the contrary case, eight or ten drops of tepid water should be dropped in, once or twice an hour; it becomes mixed with the mucosities, softens them, and will facilitate their ejection.

"Water should always be dropped in after the application of the nitrate of silver, so as to separate the mucosities which may have become coagulated, and to facilitate the expectoration. The instillations of water should be made several times in an hour; when the respiration becomes frequent and serratic, that is to say, imitating the noise of a saw in cutting stone, it is proper to make them after each application of the sponge.

"The sponging should be employed as often as the canula or the trachea appear embarrassed. The sponging will be rendered more efficacious by the previous instillation of water. If a flapping noise is heard in the trachea, or a peculiar hissing leads us to suppose that there are some false membranes loose, the sponging should be repeated several times until these false membranes are detached and expelled. The sponging will never be more efficacious than when it is performed at the moment the canula is withdrawn, and when the lips of the wound of the trachea are kept widely apart by means of a dilator. The sponging is the more necessary in proportion as the symptoms which follow the operation are more unfavourable. It never causes bad symptoms; it is always followed by a greater calmness of respiration, even when the children are in their last moments, and when the sponge withdraws neither mucosities nor false membranes."

Although the success of tracheotomy is not very brilliant, the results are, however, such that they ought to encourage the medical attendant of a child half asphyxiated by croup. M. Bretonneau, out of twenty operations, has saved six children; out of one hundred and sixty, I have saved forty-five. M. Leclerc (of Tours), who has adopted the same treatment, reckons one successful in two operations he has performed. M. Velpeau has cured two children. in ten. M. Pétel (de Cateau-Cambrésis), who has followed the same steps, has performed three successful operations out of six he has attempted. Thus, in one hundred and ninety-eight operations of tracheotomy, fifty-seven successful cases may be reckoned, that that is to say, a little more than one fourth.

[Mr. Smith (Med. Times and Gazette, March, 1853) relates four cases of croup in which tracheotomy was performed. All the patients were in extremity, and in all the result was fatal. M. Guersant (Bull. de Therapeut., xlii) refers to a case in which tracheotomy was performed twice in the same child. M. Guersant has now operated

150 times. The earlier cases were less successful than the later, thirteen of the last forty private cases, and thirteen of the last thirty-one hospital cases recovered, or at the rate of 36.62 per cent. In three cases there was faulty deglutition after the operation, and food escaped through the tracheal opening. In such cases the child must be fed through the oesophageal tube passed in through the nares.-P.H.B.]

APHORISMS.

150. Croup exists from the time that false fibrous membranes are developed on the mucous membrane of the larynx.

151. A smothered, hoarse, dull cough, followed by a metallic hissing, and accompanied by fever and anhelation, reveal the presence of croup. 152. In croup, extinguished cough and voice, together with noisy, rough, serratic respiration, announce the approach of asphyxia and death. 153. Croup advanced to the stage of the fits of suffocation is fatal. 154. There are some cases of croup which may get well and others which are cured.

155. Croup should be treated by repeated emetics alternating with doses of calomel.

156. Croup arrived at the period of the fits of suffocation, where death appears imminent, should at once be treated by tracheotomy.

CHAPTER II.

ON FALSE CROUP OR STRIDULOUS LARYNGITIS.

The name of false croup, or stridulous laryngitis, is given to a nervous affection of the larynx, which has the greatest analogy with croup, but from which it is easy to distinguish it. This disease is rarely observed quite alone; on the contrary, it is developed in the course of bronchitis , and of the inflammatory affections of the organs of respiration.

It is characterized by a fit of suffocation, which comes on suddenly, and may determine asphyxia of the children.

This division of membranous laryngitis and stridulous laryngitis has been for a long time opposed, and numerous errors have been committed in referring to the presence of false membranes in the larynx, attacks of suffocation, purely nervous, in children who were not labouring under croup. They refused to admit the fundamental distinction between these two diseases, so essentially different in their nature, although similar in some of their symptoms. Observation has at last come to demonstrate their existence. The honour of this discovery is due to M. Bretonneau, and especially to M. Guersant, for up to this period pseudo-membranous and false croup were confounded in the minds of medical men. Many imagined they had cured true croup when they

had only vanquished the nervous fits of suffocation which were insensibly getting better.

CAUSES.

Stridulous laryngitis is common enough. It only affects very young children, and especially infants at the breast. It may be several that's times observed in the same children. Some have always at the Colds. commencement of their colds, one or two attacks of stridulous laryngitis. As M. Guersant has remarked, it is probable that certain Hardilu cases, cited by authors as examples of the return of croup, belonged

to simple false croup, and that Jurine and Albers have been mistaken in this respect, and have confounded different diseases.

SYMPTOMS.

Stridulous laryngitis usually commences in the night, in children who had fallen asleep in a perfect state of health, or who had only a simple catarrhal affection of the bronchi. It also manifests itself, ste but very rarely, in the middle of the day. Lastly, it is observed as a complication in the course of pneumonia. The children suddenly experience a deep, very distressing sensation; they awake very agitated, with considerable difficulty of respiration; their cough is loud, dry, sonorous, hoarse, and hissing, returning by prolonged fits which each time threatens them with suffocation; their face is swollen, red, bluish; they are in the most distressing agony, and fall back tired, pale, and covered with perspiration. each attack, these phenomena reappear; then the symptoms vanish, and the children relapse into their usual quiet condition. The pulse preserves a considerable frequency, the voice is roughish, but distinct; the cough is scarcely altered, and respiration is quietly performed.

At

If the back of the throat is examined, neither redness nor the accidental productions similar to those of croup are observed, and there is no engorgement of the submaxillary glands. Auscultation does not usually reveal any alteration in the lung. A sibilant or mucous râle is heard which belongs to bronchitis. In some some is bes very rare cases, abnormal sounds of respiration are heard which are in connection with pneumonia.

The attacks of the suffocation of false croup last about one or two hours. The symptoms, at first apparently very severe, gradually des diminish in intensity and completely disappear. Their progress is quite different in true croup. They increase, on the contrary, uninterruptedly until death.

When the fit is over, the child calmly reposes until the production a of fresh attacks which sometimes reappear, but very seldom, in the

1

I that all same night. The fresh attack does not usually return until the following night, it is always less violent than the first and lasts a shorter attack Tack time than it. Thus three or four attacks of suffocation are observed during three or four consecutive days. They are daily less severe and less prolonged.

Stridulous laryngitis thus terminates sometimes after the second or third attack, without leaving traces of its visit, unless it develops bronchitis or febrile phenomena.

Stridulous laryngitis usually marks the commencement of a slight catarrhal affection of the bronchi. Then, at the end of the attack,

Sen the children retain a little fever, they continue to cough, but their

cough does not present any important character, their respiration is 1119 scarcely at all obstructed, and the rales of which we have above ul. spoken are heard in the chest. This condition is never very serious, the children are cured at the end of several days.

DIAGNOSIS.

As may be observed, the progress of this disease is essentially different from the progress of true croup. In stridulous laryngitis a sudden invasion of frightful symptoms of suffocation is observed, which cease, appear afresh with less intensity, and finally disappear in a definitive manner. The intermission is well characterized. Moreover, the first attacks are the strongest, and they diminish in proportion as the disease is prolonged. In their interval, the health does not appear to have suffered any serious derangement.

Pseudo-membranous croup is, on the contrary, characterized by a morbid state which daily becomes more serious; and when the attacks of suffocation manifest themselves, the first are scarcely felt, but they become more and more violent, to the extent of occasioning death by asphyxia. In their interval the children are a prey to a dreadful obstruction of respiration, the colour of their face clearly indicates the existence of an obstacle which impedes the performance of the respiratory functions.

Lastly, the examination of the back of the mouth does not furnish any result in stridulous laryngitis: it points out, on the other hand, the nature of the disease in true croup, as there are frequently observed upon the mucous membrane, false membranes which constitute its unexceptionable character.

We must then recognize, with MM. Bretonneau, Guersant, and the greater part of physicians, the existence of a disease which slightly resembles croup in some symptoms, and which yet is not croup, since the progress and nature of the disease are entirely different. This disease is stridulous laryngitis.

It is important it should be recognized that it may not be treated

by the means which are employed against membranous laryngitis or true croup. This has indeed very often happened, but undoubtedly it will never occur again.

Stridulous laryngitis, with its fit of noisy suffocation, with its sonorous, rough, and hissing respiration, is distinguished from phrenoglottism, that is to say from phreno-glottic convulsions; in short, in the latter disease the respiration, nearly motionless, is performed without noise, and it is at the end of the attack that a single sonorous sound announces the entrance of air into the larynx and the termination of the phrenic convulsion.

PROGNOSIS.

Stridulous laryngitis is apparently a very serious disease; it seems to put the life of the children in jeopardy; one would say they were going to perish in the midst of the attack; but if the testimony of M. Guersant on this point is to be credited, this result has never yet been observed. It is more usual to see the disease cease of itself and rapidly disappear under the influence of an appropriate treatment, or to prolong itself, on the contrary, when the therapeutical means have been improperly selected.

TREATMENT.

Simple stridulous laryngitis should be treated by means of sedatives and ordinary antispamodics administered in draught or by enema. Gum juleps with ether containing a small quantity of tincture of musk or of the extract of valerian are very useful. They rapidly calm the agitation of the children and favour their repose. To the nic same end, enemata of valerian or assafoetida are administered in the proportions of four to eight grains of these substances to four or six ounces of water. To these means must be conjoined the use of clane cutaneous excitants, such as irritant pediluvia or sinapisms. employment of blisters is quite useless in this disorder.

Then

When stridulous laryngitis manifests itself, as is usual in a child attacked with bronchitis, the extent of this disease must be investigated and the febrile condition attended to. The preceding means should be made use of, but consecutively to the administration of an emetic, ipecacuanha in preference, in the dose of from four to six grains in gum syrup for young children. This plan of treatment always produces a great amelioration.

False croup rarely necessitates the employment of local or general bleeding. The loss of blood is useless except in cases of inflammatory complications of the bronchi or of the lung. It is even injurious, for the blood is the regulator of the nervous system, sanguis moderator nervorum, and if this loss of blood does not produce as a consequence