time of the operation the false membranes do not extend beyond the larynx, the child dies very quickly.

7th. When, previously to the operation, the false membranes have extended to the nares, or if they cover the blistered surfaces-when the child is pale and somewhat bloated, without having taken mercury or been bled-or when he has lost much blood, there is little to be expected from the operation.

8th. When, previously to the operation, the pulse is moderately frequent; and if, after it, the pulse remains calm, hopes may be entertained.

9th. The more deeply the false membranes have extended, the greater, cæteris paribus, the danger.

10th. It is a bad sign, if, immediately after the operation, the respiration becomes very frequent, without or with very little cough; even when all is going on favorably, the occurrence of great frequency of respiration is a bad sign.

11th. More boys than girls recover after the operation; children under two and over six years of age seldom recover.

12th. The more rapid and energetic the inflammation which attacks the wounds in the trachea, the more are the chances of success: a sudden sinking of the wound is a mortal sign.

13th. Should the wound become covered with false membranes; if after withdrawing the canula, it remains gaping for a long time, or if, after having become completely cicatrized, it reopens, the child is in danger.

14th. Agitation and sleeplessness are bad signs, so is also the occurrence of convulsions. The younger the patients, and the more blood they have lost before or during the operation, the more liable are convulsions to supervene.

15th. The sooner after the operation the larynx is disembarrassed, the sooner may the canula be removed, and the more rapid and certain the cure.

16th. If the expectoration becomes mucous and catarrhal by the third day after the operation, the child will recover. If there is no expectoration, or it is serous, or like half-dried portions of gum acacia, he will die.

17th. If the patient reacts vigorously under the injections into the trachea, of warm water or a solution of nitrate of silver, and the sponging out of the trachea, we should not despair, however unfavor able the other symptoms.'

18th. When, after the tenth day, the drinks pass almost entirely from the pharynx into the larynx and trachea, even if they are readily rejected, the child most generally dies.

19th. The increase of the fever after the fourth day, agitation, sinking of the wound, dryness of the trachea, frequency of the respiratory movements, and attempts to cough, announce the invasion of

In place of nitrate of silver, Barthez recommends the instillation into the trachea of a tepid concentrated solution of chlorate of soda. Three out of seven of the patients in which it was used recovered.

pneumonia, which, at first lobular, becomes sometimes pseudo-lobar, and is to be treated by the same means as are employed in the pneumonia of children: we should, however, exclude blisters, because they too often become covered with false membranes.

We have said nothing, as yet, on the subject of diet in croup. During the forming stage, the diet should be the same as in violent cases of bronchitis: during the height of the disease, little or nothing else should be allowed, than some mild, mucilaginous fluid in small portions at a time; while after the disease has been subdued, and throughout the period of convalescence, the child should be allowed the mildest and most unirritating articles of food, care being taken that even in regard to these, no excess be committed.

For a long time after recovery, there is very considerable danger of a relapse, upon the slightest exposure to cold or moisture, or to the most trifling transitions of temperature; from these, therefore, the child who has recently recovered from an attack of croup, should be carefully guarded, by appropriate clothing, and every other judicious precaution. The daily use of the warm bath, and daily exercise in the open air, during mild and dry weather, should never be neglected.

7.-Spasmodic Croup.

Millar's Asthma.-Spasmodic Laryngitis.-False Croup.

Catarrhal Croup.

There is a form of disease of frequent occurrence during childhood, which has very generally been confounded with croup, to which it bears a strong resemblance in some of its features, but differs from it, nevertheless, in its less serious character, and the absence of any tendency to the formation of a false membrane in the air passages. The disease to which we allude has been variously named by different writers. Millar, who was the first that directed attention to it, denominated it Asthma, which name was retained by Wickman and others; Bretonneau named it Stridulous Angina, Guersent, Laryngismus Stridulus, while Rilliet and Barthez prefer the denomination Spasmodic Laryngitis, as indicating what they believe to be the true character of

the disease.

The attack of spasmodic croup is usually preceded, for a day or two, by slight catarrhal symptoms-coryza, watering at the eyes, a sense of chilliness followed by flushes of heat; slight hoarseness, and cough. The paroxysms usually occur during the night, though they occasionally take place during the day. The child is, generally, suddenly awoke from sleep by a sense of impending suffocation. He starts up in a sitting posture, or throws himself upon his knees, with the body bent forward. He cries out that he is choking, tears away every covering from his throat, and pushes away those who surround, or offer to assist him. The face becomes congested, and of a red or violet hue, the eyes projecting and humid, and the expression of the countenance anxious in the extreme. The respiration has a peculiar prolonged hissing sound, which is occasionally so loud that it may be heard in a neighboring apartment. There is at the same time a frequent

hoarse cough. The voice is constrained, but seldom whispering or abolished. There is great quickness of pulse, and heat of the skin. After continuing for a short time, the paroxysm ceases suddenly, and the child falls asleep.

The disease may be confined to a single paroxysm, or a second may occur during the same night. Usually, the child continues during the ensuing day tolerably well, though in many cases affected with hoarseness and a frequent, short, barking cough, with or without expectoration, but during the night following is again attacked with a suffocative paroxysm. The disease may thus continue for several days, the paroxysms then ceasing to recur, and the cough and remaining symptoms speedily disappearing. In a case detailed by Jurine, a decided alteration of the voice continued for a long time after the cessation of the disease. In some cases, the paroxysms continue to recur, night after night, and to augment in intensity, until death takes place finally from asphyxia. In other instances, after one or more paroxysms, the patient becomes affected with the utmost inquietude, constant nausea, repeated vomiting, with great exhaustion, and a small frequent pulse, and soon sinks. Usually, however, the disease is one readily managed, having very seldom a fatal termination.

Spasmodic croup is one very liable to return. According to Rilliet and Barthez, its recurrence may take place at the end of six months, or of one or two years. In a case reported by Vidal, the first attack occurred when the child was two years old, the second when it was five, when, in the space of three months, it had three attacks. We have seen it more frequently recur at intervals of nine and twelve months than at shorter periods; we have known, however, three or four attacks to occur within the same year.

The prognosis in spasmodic croup is to be drawn chiefly from the progressive violence of the paroxysms, and the short intervals at which they recur. When the intervals between them extend to twenty-four or forty-eight hours, and the paroxysms gradually de crease in intensity-when the voice is but little affected-the cough moist-and the febrile reaction slight-a favorable termination may be anticipated. When, on the contrary, the paroxysms are protracted beyond the third day, and gradually increase in violence; particularly, when the paroxysms are succeeded by a state of great restlessness, with nausea and vomiting; when the pulse continues soft and feeble, when a suffocative cough remains, and when the patient's strength gradually diminishes, an unfavorable termination is to be apprehended. The true pathology of this affection has not yet been very accurately made out. Millar, and after him most of the German physicians, considered it to be a purely spasmodic disease, having some resemblance to hooping-cough; Desruelles and Bricheteau describe it as the first stage of a very mild form of croup. Guersent supposes it to consist in a transient inflammation of the mucous membrane of the larynx: Bretonneau believes the local affection to consist in a mere congestion of short continuance; a simple, transient intumescence of the rima glottidis. Rilliet and Barthez rank the disease as an actual inflammation of the larynx, their opinion being based on the circumstance of

the attack being generally dependent on a sudden exposure to cold; its being usually preceded by coryza, watering of the eyes, oppression, &c., and attended by some degree of febrile excitement. In connection with this mild laryngitis, they presume that there occurs a spasmodic affection of the glottis, upon which the sudden paroxysms of suffoca.. tion by which the disease is characterized depend. The correctness of this opinion is borne out by our own observations.

That the disease is connected with some degree of laryngeal inflammation is proved by the result of the few post-mortem examinations that have been made in consequence of the disease rarely terminating in death-not unfrequently traces, more or less decided, of inflammation of the mucous membrane of the larynx, are to be detected: even when no increased redness of this part exists, its secretion will generally be found augmented, and of an opaque, yellowish, or reddish color. When death takes place with great suddenness, it is probable that it is the result of the spasmodic closure of the glottis, and the consequent asphyxia.

Spasmodic croup is essentially a disease of childhood; according to Guersent it occurs most frequently between two and seven years, and according to Rilliet and Barthez between three and eight. We have met with it in children of nine or ten months, but less frequently than in those between two and eight years of age.

There is, in many instances, a peculiar predisposition to the attacks of spasmodic croup in the children of the same family; we have known not a few families all the children of which when they attained the age of between two and three years were successively affected with it. This predisposition is said, in many instances, to be hereditary. The disease occurs more frequently in boys than in girls.

Though generally sporadic, it occasionally prevails as an epidemic. Jurine describes an epidemic of spasmodic croup which occurred in Geneva in 1808.

Its occasional cause is, almost exclusively, exposure to cold, or a sudden alternation in the temperature of the atmosphere. After an attack has happened, the occurrence of any sudden or violent mental emotion is liable to excite a paroxysm.

The disease with which spasmodic croup may most readily be confounded, is tracheitis or genuine croup. The following comparative diagnostic peculiarities, borrowed partly from Valleix, and partly from Rilliet and Barthez, will enable the two diseases very readily to be distinguished.

In Genuine Croup, the disease commences with fever of variable intensity, with most generally, pseudo-membranous angina, and slight hoarseness. There is a gradual increase of the hoarseness, to which, sooner or later, there is added a hoarse ringing cough. The cough becomes hollow and feeble, and the voice faint or extinct. There is occasionally an expectoration of false membrane. There is no remission of the fever.

The dyspnoea constantly increases in intensity-the croupal sound

continues during the intervals of the paroxysms-the voice and cough become finally extinct.

In Spasmodic Croup the symptoms of invasion are slight-there is generally a slight catarrh, and a cough somewhat hoarse. The throat is unaffected. Sometimes there are no prodroma.

The paroxysms attack suddenly-usually at night. Between them the patient appears tolerably well. The fever disappears or declines. The voice may be hoarse, but never becomes extinct.

There is an expectoration of mucus.

The paroxysms gradually decrease in violence.

The remedies to be employed in a case of spasmodic croup will depend pretty much upon the violence of the attack, and on the age and condition of the patient. When the indications of laryngeal inflammation are strongly marked, and when the spasmodic paroxysms are very violent and prolonged, the application of leeches to the throat, in numbers proportioned to the age and strength of the child, will be demanded. When the patient is over five years of age, and of a robust habit, a bleeding from the arm will often be attended with the best effects. In no case, however, should the amount of blood drawn from the arm or by leeches be considerable, nor the operation repeated at short intervals, or too late in the disease.

The warm bath is always an important remedy; it may be employed in the commencement of the attack, or subsequent to bleeding.

Lehmann advises, at the very onset of the paroxysm, the application of a sponge of the size of the fist, dipped in very hot water, and then carefully squeezed in the hand, to the fore part of the neck; it being left a moment in contact with the skin and its application renewed at short intervals. This produces a redness of the neck, and a general perspiration, which latter is to be promoted by the exhibition of an infusion of elder and chamomile. By this means, it is said, the paroxysm may be cut short, and all the leading symptoms of the disease quickly removed.

When the paroxysm is very violent and long-continued, and there is danger of the occurrence of asphyxia unless immediate relief is obtained, the operation of tracheotomy should be performed without delay.

An emetic given on the first accession of the disease will often, when followed by the warm bath and sinapisms to the extremities, have the effect of abating the violence of the paroxysm and shortening its continuance. Also, when considerable hoarseness of the voice and a short barking cough continue during the intermissions, the exhibition of an emetic will be found advantageous-generally removing very promptly the remaining symptoms, and preventing the recurrence of a par

oxysm.

We have usually preferred, in the cases occurring in young children, the ipecacuanha to the emetic tartar-excepting where the former, as is often the case, fails to produce a prompt and full operation; under these circumstances, as well as in older children, we have never hesi tated to prescribe the tartarized antimony. We are in the habit of giving the ipecacuanha in small nauseating doses, every two or three