hours, either alone or combined with extract of hyoscyamus, in the intervals of the paroxysms, and have invariably been much pleased with its effects. In mild cases, small repeated doses of the mel scillæ compositum of the United States Pharmacopoeia, may be advantageously substituted for the ipecacuanha.

Blisters upon the chest or between the shoulders are recommended by some-when employed, they should be allowed to remain on only long enough to redden the skin, when the parts occupied by them should be covered by a soft emollient poultice. We have seldom, however, seen much good result from the application of blisters in cases of spasmodic croup. Covering the breast, however, with a hemlock or assafoetida plaster, has appeared to us to have very generally a decidedly beneficial effect.

Purgatives are only required in those cases in which they are indicated by a costive or torpid state of the bowels. Hence a dose of calomel, followed by castor oil or magnesia, will be proper; a free state of the bowels should be subsequently maintained by an occasional dose of some mild laxative.

Assafoetida, either by the mouth or by enema, is unquestionably a remedy from which the best effects are to be anticipated in violent cases of the disease, subsequent to depletion and the use of the warm bath. It should be administered a few hours after the paroxysm has terminated.

Wichmann recommends the musk as a specific in this disease; Henke, Wendt, Goelis, and others, speak also in strong terms of its curative powers. Wendt gave it in the dose of a grain every hour. It is all important that the child affected with spasmodic croup should be kept in a state of perfect tranquillity, warmly clad, and in an apartment where the atmosphere is pure and of moderate and equable temperature. During the paroxysms he should be supported in an erect posture, and all covering or ligatures should be immediately removed from about the neck. His food should be light and of easy digestion his drinks should not be given perfectly cold-tepid lemonade or barley water slightly acidulated, will perhaps be the best.

8.-Spasm of the Glottis.

Laryngismus Stridulus.—Thymic Asthma.-Kopp's Asthma. This disease, which consists in a sudden spasmodic closure of the glottis, giving rise to a severe paroxysm of dyspnoea, and a peculiar crowing sound in inspiration, as if from strangulation, but without fever, and often without any material derangement of the general health, is of much more frequent occurrence than is generally supposed. It has often been mistaken for and treated as croup, and in its milder form it has received the vague term of "inward fits."

It generally comes on suddenly. The child, apparently in perfect health, is suddenly seized, either during or upon awaking from sleep, or in taking drink or food, or upon being teased or irritated, with a difficulty of respiration; inspiration being often entirely suspended for a few seconds. After violent, even convulsive struggles, he finally

succeeds in getting breath, with a shrill crowing sound, somewhat similar to the ringing inspiration of hooping-cough.

In severe attacks, during the efforts at inspiration, the whole of the respiratory muscles are thrown into violent action. The nostrils are dilated, the mouth is extended, the eyes are rolled upwards, and the whole countenance expresses the utmost anxiety and suffering. The head is thrown backwards, and the chest outwards; the diaphragm and abdominal muscles contract violently, and even the extremities become rigid. The feet and hands are cold. The face is commonly pale, or of a livid cadaverous hue; the external veins, turgid with highly carbonized blood, form black streaks upon the forehead and temples, which, according to Ley, may continue long after the cessation of the paroxysms. The backs of the hands and insteps are often swollen and hard. The thumbs are rigidly contracted, and locked across the palms of the hands, and the toes are bent down towards the soles of the feet; the wrists and ankles being rigidly and permanently bent by the action of the flexor muscles. In many cases these carpo-pedal contractions have a very singular appearance, and in the opinion of Rees, are characteristic of the disease. The fingers are extended upon themselves, but semiflexed upon the metacarpus, and this at times upon the carpus; in the same manner the toes are flexed upon the metatarsus.

The attacks of laryngismus are paroxysmal, and vary in duration and intensity. At first a single paroxysm may occur, and after a short time, often a few minutes, cease spontaneously; the breathing, at first somewhat hurried, soon becomes perfectly free and regular, and the child presents no apparent indications of disease. Days, and even weeks may pass without the occurrence of a second paroxysm. In other cases, the paroxysms recur with alarming frequency, and are protracted to fifteen or thirty minutes, or even longer. Their inten sity and duration increasing, generally, with their frequency. In the early periods of the disease, the paroxysms usually occur in the night, or after a tranquil sleep, from which the child awakes as it were in a fright, when the difficulty of inspiration immediately ensues. When the disease is more fully established, the paroxysms take place at all times of the day or night.

Other symptoms are described as of constant or occasional occurrence; thus, Kopp has noticed a thrusting out of the tongue between the lips, which is also present to a certain extent during the intervals of the paroxysms; Ilirsch, an involuntary discharge of the contents of the bladder and bowels. In severe cases, Caspar has observed a convulsive contraction of the muscles of the hands, and abductors of the thumbs, during the intermissions.

Immediately preceding, as well as subsequently to, a paroxysm, the sound of the patient's breathing is often that which would result from an increased secretion of mucus in the respiratory tubes.

The patient may expire during the first paroxysm of asphyxia; or the disease may be protracted to many days, weeks, or months, and death be preceded by epileptic convulsions, deep coma, hydrocephalic symptoms, or those of acute meningitis.

Laryngismus is to be distinguished from spasmodic croup by the absence of all catarrhal symptoms, febrile excitement, and cough, by the respiration being unaffected during the intervals of the paroxysms, and by the contractions observed in the extremities.

The crowing inspiration also, of laryngismus, is not marked by the peculiar hoarse, rough, and grating sound peculiar to the inspiratory effort in croup.

From hooping-cough, laryngismus may be distinguished by the absence of the convulsive cough, and the retching, vomiting, or free expectoration of glairy matter, by which the paroxysms of pertussis are so generally terminated. Hooping-cough is also more gradual in its approach, the characteristic paroxysmal cough being in general preceded many days by catarrhal and febrile symptoms.

Dr. James Reid, of London, who has written a very instructive treatise on Infantile Laryngismus, describes it as occurring under four different forms. In the first there is only a slight constriction of the rima glottidis, which occurs suddenly and transiently. This causes, for an instant, an exertion on the part of the infant to recover its breath, and produces a feeling of oppression and alarm, indicated by a short cry, and the anxiety depicted on the countenance. There is no convulsive action of any part of the body. The attacks come on at irregular intervals, and at uncertain times, although most generally whilst the infant is asleep, or at the moment of awaking.

So little importance is generally attached to this symptom by nurses, that when the physician is called upon at a later period to treat the more severe form of the disease, the "catching" alluded to is often not mentioned until questions are put, when it is found that it had been of frequent occurrence, but was always arrested immediately upon the child being lifted from the recumbent to an erect position.

In the second form Dr. Reed describes the area of the glottis as being still more diminished by the nearer approximation of its edges; the closure is not, however, complete, except perhaps for a moment.

In this form there is a much longer interruption of the respiratory function, and the symptoms of impending suffocation are more imminent. The countenance exhibits the characteristics of great anxiety and distress, becoming at first red, but soon changing to the purple hue of strangulation. The face, and, in some cases, the tongue also become turgid and swollen. In other instances there is an ashy paleness of the face. The arms are thrown out; the eyes are either wide open and staring, or, more rarely, turned up in their sockets; the nostrils are dilated; the head is thrown back; the limbs become rigid, and the abdominal muscles contracted. There is frequently, also, a convulsive and violent action of other muscles, especially of the flexors, causing a peculiar contraction of the wrists and ankles--carpo-pedal spasm. Occasionally, the body itself is bent suddenly backwards, as if by a violent effort. When to the bystanders it would appear as if nature could hold out no longer, the attempt at respiration will become partially successful, and attended by a shrill hooping noise, which has been termed crowing, although it more closely resembles the concluding rising note produced by the clucking of a hen. This

sound is not of so full and sonorous a character as that of hoopingcough; it is more acute, and without the rough hoarseness of croup. This is often an indication that the paroxysm has terminated, but sometimes a succession of incomplete or interrupted, shrill, sibilant catches supervene before a full and complete inhalation takes place, as if the margin of the glottis were for a time somewhat relaxed, but becoming immediately again constricted; the expirations bearing, in some degree, a resemblance to the short and feeble bleating of an animal.

When respiration is re-established, the infant most commonly bursts into a fit of crying, and then falls asleep; when the attack is unusually severe, a listlessness and torpor often continue for a short period, whilst in rarer instances the child continues, during some hours, in a state of anxious distress.

The paroxysms vary much in frequency, duration, and severity. There is no regularity in the intervals between them; as the complaint advances, however, these generally become shorter, and, in some instances, do not continue beyond an hour or even half an hour at a time. The slightest noise or emotion is sufficient to excite them. The breathlessness, or struggling for air, is, in some cases, apparently relieved by a violent expulsion of wind from the stomach or per anum, succeeded by a fit of screaming: occasionally, during the paroxysms, involuntary evacuations occur.

Repeated attacks may take place without any crowing noise, especially when the disease becomes less severe in its character. An acute plaintive cry frequently commences or terminates the paroxysm; the child after the paroxysm entirely ceases remains quiet and subdued for some minutes, and then resumes its natural cheerfulness and aspect, enjoying, apparently, perfect health in the intervals.

The duration of the paroxysm varies from a few seconds to three or four minutes. When the duration of the paroxysm is prolonged, it is more properly a succession of paroxysms than a single one; some air gaining admittance into the lungs, during slight and almost imperceptible intervals. Remissions and exacerbations often take place for weeks, and sometimes for months, before a complete cure can be effected. In other cases, on the contrary, the complaint has been known suddenly to disappear.

In the third form of laryngismus, according to Dr. Reid, there is a combination of the foregoing symptoms, with general or cerebral convulsions; the latter resulting, in all probability, from the blood sup plied to the brain becoming imperfectly decarbonized, during the partial asphyxia caused by the spasm of the glottis.

In the fourth form of the disease, there is complete asphyxia; a sudden and convulsive closure of the glottis, causing almost immediate strangulation. No crowing sound is audible, inspiration being totally suspended, while the face of the child, instead of being flushed and turgid, exhibits often a cadaverous aspect, similar to that of persons asphyxiated by carbonic acid gas, or other noxious vapors. An infant, Dr. Reid remarks, may have passed through repeated severe attacks of the disease, combined with cerebral convulsions; it may

perhaps, be improving in general health; the paroxysms beginning to be separated by longer intervals, and, yet, with all these indications of apparent amendment, it is sometimes carried off without any previous warning. It may be laughing at the time, or quietly observing the occurrences taking place around it; not the slightest indication of danger being perceived.

The appearances upon dissection are very various. The thymus and cervical glands are often enlarged or in a state of disease. The heart is often found empty and flaccid. The lungs are generally gorged with dark-colored blood. The vessels of the brain are also often unduly distended, and serous effusion between the membranes, in the ventricles, or at the base of the brain, is of frequent occurrence. Tubercles of the brain are often met with, and occasionally, hypertrophy or induration of its substance. The foramen ovale is often found open, and not unfrequently there exists more or less disease of the gastro-intestinal, and in some cases, of the respiratory mucous membrane. No one of these morbid appearances is, however, constantly present. Perhaps, judging from the cases on record, most of which have, however, been adduced in support of particular pathological views, we ought to enumerate enlargement of the thymus body, and effusion within the cranium, as among the most common lesions met with. We suspect, however, that upon a more minute inquiry it will be found that enlargement of the thymus body is a much less frequent accompaniment of the disease than has been asserted. Dr. Reid states that on several occasions he has sought for indications of disease, but has been unable to detect any, even in the spinal cord. As a general rule, it may be stated, he remarks, that no unusual appearances are found to exist in the glottis itself, or in the adjacent parts; no trace of oedema, inflammatory action, or persistent constriction. He has never met with any enlargement of the neighboring glands sufficient to account for a fatal termination.

Spasm of the glottis is almost exclusively confined to the period of infancy and childhood. It may attack, according to Kerr, at any period from within a few days after birth to three years, but most commonly it occurs between the fourth and tenth month: Mr. Robertson (London Med. Gaz., 1849) has found the accession of the disease to be most frequent from about the fifth to the twelfth month. Twenty-one cases are related by him; in only three of which the disease occurred in infants beyond twelve; in none beyond fifteen months. The majority of those who treat of the disease, state, that it is most liable to occur during the period of dentition. An affection, Dr. Reid remarks, closely resembling spasm of the glottis, if not positively the same complaint, may be caused at any period of life by local or mechanical agency; but that form of spasm of the glottis which is the result of constitutional irritation, must, he thinks, be considered as a peculiar disease of infantile life. Most writers enumerate the lymphatic temperament as one of the predisposing causes of the disease; it is in consequence of this that we find it to attack almost all the children of some families, while those of others are entirely exempted from it. The predisposition from organization may also account for