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accompanied by a genuine febrile reaction; the pulse is frequent, but weak, faltering, with diminution of caloric, great prostration, rapid reduction of the vital powers, anæsthesia of the skin, paralysis of the pharynx, amaurosis, deafness; in short, exhibiting an exquisite adynamic character with alteration of blood such as we frequently meet with in diphtheria.* Its action evidently arrested in our case the exudative process, and favoured a speedy exfoliation of the false membranes and rapid cleansing of the throat. In a paper on diphtheriat we recorded our observations on twenty-three cases of this disease; since then we have had seven more to attend, thus making up a sum of thirty. In twenty out of these Bromine proved most successful when the diphtheritic exudation in throat or larynx was accompanied by great prostration. I lost one patient under the Bromine treatment when in convalescence; it was a youth of fifteen years, affected with the most malignant form of this disease; the nares discharging an ichorous fluid, and profuse hæmorrhage from them caused a high degree of anæmia: he sank under serous effusions in the pericardium and pleura. It is but fair to mention that the patient which forms the subject of this paper was, out of twenty, the most severe case, and we have no doubt that the champagne contributed a great deal to bring him through.

I consider the local application of Bromine as most important, as it contributes greatly to the rapid detachment of the false membranes, and prevents generally new exudations at the same place. Where sponging of the throat cannot be executed, either through the impossibility of opening the mouth from swelling of the glands or by resistance of the child, and the larynx begins to be involved in the exudative process, I use the Bromide of Potasium, 1st dec. trit., one or two grains of which I blow into the throat, by means of a glass

* Vide Noack and Trinks, Arzneimittellehre; Höring and Heimerdinger, Physiologische Prüfungen des Brom, gekrönte Preisschrift; and Huette, Rames, Pluhe, Ozanam, &c.

+ Neue Zeitschrift für homœopathische Klinik, 1862-1863.

tube, during an inspiratory movement, which causes generally cough, and often the expulsion of membranes.

The intermittent paroxysms of dyspnoea and suffocation in laryngitis exsudativa have given rise to various interpretations as to the relations existing between these violent transitory symptoms and the anatomical lesions. Bretonneau considered exudation in the larynx as the exclusive cause, not only of the permanent difficulty of breathing, but also of the periodical suffocatory paroxysms. In post-mortem examinations, fibrinous exudations are occasionally observed coating the larynx in all its parts, without the patient's having exhibited any symptoms of obstruction of the glottis; and, on the other hand, many children have died under all the phenomena of croup, and, to the great surprise of the observer, no trace of false membranes could be detected in the windpipe, but only a simple erythematous or catarrhal inflammation, without even considerable swelling of the mucous tissue. This latter circumstance has greatly favoured the views of Albers, Jurine, and Vieusseux, who long before Bretonneau professed that the paroxysms of dyspnoea, as well as death, were caused by a spasmodic contraction of the muscles of the larynx. This opinion is still held by the generality of pathologists of the present day is it therefore the more correct? No; it is in contradiction with physiologo-pathological facts, according to which we observe, wherever we meet with inflammation of any intensity either of the mucous or serous membranes, not only the submucous and subserous. connective tissue, but also the respective muscles are infiltrated by a serous liquid, pale and discoloured. It is, à priori, not to be admitted that the muscles in this condition are susceptible of spasmodic contraction. Rokitansky declares "that the infiltrated and discoloured muscles become paralysed." That this is indeed the case is proved by the loss of elasticity of the intercostal muscles in pleurisy, and the suspension of the peristaltic movement of the alimentary. canal in peritonitis and dysentery. These, as well as other analogous facts, render it impossible to admit that the muscles of the larynx covered by an intensely inflamed

mucous membrane, and therefore infiltrated, should be in a state of spasmodic contraction; the reverse (paralysis) is more in accordance with physiological pathology. That paralysis of the muscles of the larynx causes dyspnœa is, moreover, proved by the section of the pneumogastric nerves in young animals; the dyspnoea hereby produced exhibits the same stridulous, prolonged inspiration as that caused by croup, so that no doubt can exist as to their identity.* If, on the other hand, we take into consideration the anatomical disposition of an infantile larynx, we are at once convinced that, from the time that the glottis is no more enlarged in the moment of energetic inspiration by muscular action, its lips must close together and shut out the air from the trachea and lungs. The basis of the arytenoid cartilage in children has no extension, and the glottis forms but a narrow fissure, and not a triangular open space as in adults. In the larynx of a child, cut out with its trachea, it is easy to demonstrate the occlusion of the glottis by aspiring the air through the trachea.

As it is of the utmost importance to the treatment to know if false membranes are the cause of dyspnoea, or mere paralysis of the muscles of the larynx induced by collateral infiltration, it is necessary to observe if inspiration and expiration are equally difficult, or the latter the latter easy and following immediately on the former. In the first case, the pseudo-membranes, in rendering the glottis more rigid, impede both inspiration and expiration; therefore it is that the latter in croup is generally preceded by a pause, and is always nearly as stridulous as inspiration. In paralysis of the muscles, expiration is easy and soft, as the current of air from the lungs opens the lips of the glottis without the intervention of muscular action; in inspiration, the pressure of air in the trachea is inferior to that accumulated above the larynx: it ensues that the column of air in the throat pressing on the lips of the glottis effectually closes them. The muscles crico-arytenoidei postici, whose function it is to

* Rosenthal, Die Athembewegungen und ihre Beziehungen zum Nervus Vagus, Berlin, 1862. Cl. Bernard, Physiologie du système nerveux, tome ii.

open the glottis, become generally paralysed first, when the mucous membrane of the pharynx which covers them is inflamed. This is the reason why the French consider only as laryngitis membranacea that where false membranes exist also in the throat, and affirm that real croup begins always in the pharynx. The periodical paroxysms of dyspnoea, which are not explained by the paralysis of the muscles, can rationally be attributed to the accumulation of carbonic acid in the air-cells of the lungs, where it irritates the peripheral terminations of the pneumogastric nerve, causing thus, by reflex action, increased necessity for breathing, the satisfaction of which finds an obstacle in the relaxed glottis; therefore the paroxysms of dyspnoea grow more frequent with the progress of the disease, till, with the increase of asphyxy, organic and animal life become more and more paralysed.

The obstruction which the air meets with in its passage through the larynx causes the thorax to dilate, and consequently the air in it becomes rarified; the result of this is a symptom characteristic of croup which strikes even laymen forcibly, i. e. by every inspiration the epigastrium and the lower part of the sternum are strongly retracted. By the diminution of the pressure of air in the thoracic cavity, the diaphragm is drawn forcibly into it, and thus determines a great tension on the xyphoid cartilage: that this is really the case is easily demonstrated by percussion and auscultation of the heart and liver during inspiration, as both describe then a high ascendant nerve.

Since Wade drew attention to the frequency of albuminuria in diphtheria maligna, it has been observed as a common occurrence not only in the malignant, but also in milder forms of this disease. In twelve cases out of thirty I ascertained the presence of albumen in the urine, and, according to some pathologists, it is considered as a constant symptom, as invarible as the exudation by which the disease is characterised, and seems therefore to be in intimate connection with the latter, one of its symptoms, and the consequence of the particular state of the blood, which shows a great tendency to albumino-fibrinous exudations;

a dyscrasy engendered directly by a morbific cause, or the result of cosmical unfavorable influences. Bouchut sees great analogy between diphtheritic albuminuria and that which accompanies purulent infection. According to him, the kidneys are in both diseases congested, their volume increased, the tissue more or less altered; in diphtheria, as well as in purulent infection, a morbid product is absorbed. When croup sets in, the phenomenon becomes complex, as in that case the imperfect oxydation cannot but increase the congestion of the kidneys, prevent the combustion of the azotized principles, and augment the discharge of albumen into the urine; as soon as respiration becomes freer, the albumen diminishes in the urinary secretions. Bouchut and others have observed almost an immediate diminution of albumen after tracheotomy.

Microscopical examination has shown us the albuminous sediment to consist generally in epithelial casts and cells, amorphous granules, seldom hyaline cylinders; the latter, however, are frequent in secondary diphtheria in scarlatina.

Körner has already drawn attention to the phenomena which accompany or precede albuminuria in acute diseases, and which consist especially in dilatation of the left ventricle and auricles of the heart, and diminished elasticity of the arteries. Our case corroborates his observations.

OBSERVATION II.—I was called to see a little girl of three years old, in the evening of March 5th, 1863, who presented all the symptoms of croup in the second stage: skin hot and dry; forehead covered with cold perspiration; pulse 140, resistant; respiration sawing, 45 per minute; between inspiration and expiration a pause; face pale, and expressing great anxiety; lips bluish, head thrown back, fan-like motion of the nostrils. All the respiratory muscles expanding the chest are in the most energetic state of contraction; she is very restlesss, changing her position at every moment; voice extinct; cough hoarse, bellowing, stifling, which causes each time a paroxysm of suffocation, as happened during my visit. The face became swollen, dark red; the eyes seemed to protrude from their sockets, with expression of unutterable

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