as good as, or mostly better than, anything else. Diaphoretics and diuretics act quite well; the best of them all are warm beverages of any kind. They need not come from the apothecary's nor be very unpleasant to take-water not too cold, Apollinaris, Selters, or Vichy, hot milk, tepid lemonade in large quantities and very often. Sinapisms have a good effect. When not kept on longer than a few minutes-long enough to give the surface a pink huethey may be applied every hour or two.

Some urgent symptoms may require symptomatic treatment. When secretion is copious, but too tough, and expectoration insufficient because of both the character of the mucus and the incompetency of the respiratory muscles, ipecac in small doses or camphor is indicated. A child's dose of the latter would be gr. (gramme 0.015-0.03) every one or two hours. In these cases the hydrochlorate of ammonium may be combined with the carbonate (ammon. chlorid. 3ss. (2.0); ammon. carbonat. Dj (1.25); extr. glycyrrh pur. Dij (2.5); aq. pur. f3iij (grammes 100.0)-teaspoonful every hour). When the difficulty of expectoration is excessive an emetic may be resorted to. It is true that infants and children vomit with less straining and difficulty than adults, but, still, the practice of flinging emetics around is too common. The unpleasantness of getting up in the night because of a pseudo-croup in a distant patient's baby is not a correct indication for encouraging the indiscriminate use of emetics. When they are required, antimonials ought to be excluded from the list. Ipecac, sulphate of zinc, sulphate of copper, turpeth mineral are preferable.

In urgent cases the hydrochlorate of apomorphia may be used hypodermically (six or ten drops of a 1 per cent. solution in water). Cases of such urgency, and so excessive dyspnoea coupled with cyanosis, as to necessitate tracheotomy are but very rare. But once in thirty years and in many more than four hundred tracheotomies have I been compelled to operate for a case of catarrhal laryngitis. Still, a few such cases are on record. The bestknown amongst them is that of Scoutetten, who operated successfully on his own daughter six weeks old.

Narcotics prove quite beneficial, particularly in complications with pharyngeal catarrh. A dose of gr. j-jss of Dover's powder (gramme 0.05–0.1) at night will secure rest for several or many hours to a child of two or three years; an adult is welcome to a dose of 10 or 12 grains (0.6-0.75). When the irritation is great during the day, it is advisable to add a narcotic (acid. hydrocyan. dil., min. j; vin opii, min. viij-xij; codeine gr. -, or extr. hyoscyam. gr. ij-iij-daily) to whatever medicine was given. I am partial to the latter, giving it up to gr. viij-x (0.5-0.6) to adults daily in their mixture, retaining the single dose of opium or morphine to be taken for the night. At that time a single larger dose is rather better than several small ones. Narcotics cannot be dispensed with in all those cases in which-as, for instance, in tubercular laryngitis-deglutition is very painful because of the catarrhal and ulcerous pharyngitis. Bromide of potassium has a fair effect, but frequently fails, and the administration of morphia before each meal is sometimes an absolute necessity.

That complications, such as bronchitis, have their own indications is selfunderstood. The general rules controlling the treatment of laryngitis are. not interfered with by them. Edema of the glottis, however, when occurring during an attack of laryngitis, has its own indications, and very urgent ones indeed in all acute cases. In chronic cases a causal treatment is required according to the etiology of the affection as specified above. In acute cases it is not permitted because of want of time. The danger of immediate strangulation is often averted only by a deep scarification or the performance of tracheotomy.

Chronic cases require all the preventive measures enumerated above and

the internal use of iodide of potassium or sodium (9j-Diissgramme 1.253.0 daily, for adults), and tincture of pimpinella saxifraga three or four teaspoonfuls daily. When it is given it ought to have an opportunity to develop its local effect on the pharynx also by giving it but little diluted, and not washing it down afterward (tinct. pimpinella saxif., glycerin. āā, teaspoonful every two hours). In these cases, while the local salt-water treatment recommended above is indispensable, the nitrate-of-silver spray mentioned in that connection is here again referred to as very beneficial indeed. But the solution of 1 per cent. is the highest degree of concentration allowable. Conducted through the nose, it will reach the larynx better than through the mouth. When both accesses are rather difficult the application must be made directly to the larynx.

PSEUDO-MEMBRANOUS LARYNGITIS.

BY A. JACOBI, M. D.

PATHOLOGY.-Pseudo-membranous laryngitis is characterized by the pres ence, on and in the mucous membrane, of a pseudo-membrane of a whitishgray color, various consistency, and different degrees of attachment. It has been called croupous when it was lying on the mucous membrane without changing much or at all the subjacent epithelium and could be removed without any difficulty. It has been called diphtheritic when it was imbedded into the mucous membrane and was difficult to remove. This difference exists, but it does not justify a difference of names except for the purpose of clinical discrimination; for the histological elements of the two varieties are the same, and the difference in their removability is explained by the anatomical conditions of the territory in which they make their appearance. The membrane consists of a net of fibrin studded with and covering conglomerates of round cells, mixed with mucus-corpuscles, epithelial cells more or less changed, and a few blood-cells. The fibrinous deposit is either quite superficial or lies just over the basal membrane or on layers of round cells originating from the basal membrane. It is continued into the open ducts of the muciparous follicles, filling them entirely in the worst cases, or meeting the normal secretion of mucus in the interior of the duct. The principal seat of the pseudo-membrane is that mucous membrane which is covered with pavement epithelium; thus it is that the tonsils are the first, usually, to exhibit symptoms of diphtheria. But cylindrical epithelium is by no means excluded. However, while pavement epithelium is generally destroyed by the diphtheritic process, the cylindrical epithelium is frequently found unchanged, or but little changed, on top of the mucous membrane under the pseudo-membrane.

The nature and consistency of the pseudo-membrane in the larynx is best studied by the light of the study of its anatomy. There is a great deal of elastic tissue in both epiglottis and larynx; the mucous membrane of the latter is thin, and sometimes folded on the vocal cords. The epithelium of the epiglottis is pavement; only at its insertion it is cylindrical. In the larynx it is also pavement on the true vocal cords and in the ary-epiglottic folds, and fimbriated toward the fossa Morgagni and trachea. Lymphvessels are but scanty on the epiglottis, still more so in the larynx. Of acinous muciparous glands there are none on the epiglottis, none on the true vocal cords; they are more frequent in and round the fossa Morgagni, with cylindrical epithelium in the glandular ducts. The trachea and bronchi contain a good many elastic fibres, less connective tissue, fimbriated epithelium, some lymph-vessels, but no lymph-glands, and acinous muciparous glands in large numbers. Wherever the pavement epithelium membrane is abundant the membrane is firmly adherent and imbedded into the mucous me:nbrane. Where it is cylindrical and plenty of acinous glands secrete their mucus, they are loosely spread over the mucous membrane, from which

they can be easily removed; while the histological condition of both the imbedded and the loose membrane is exactly the same.

Before the membranous deposit takes place the surface is in a condition of catarrh. Round the membrane the mucous membrane is red and slightly swollen. Not always, however, is that so. Particularly, the epiglottis may be covered on its inferior surface with a solid membrane or be studded with tufts of membrane, without much or any hyperæmia. The same can be said of the larynx, which is supplied with but a scanty distribution of bloodvessels and a sufficient network of elastic fibres to counteract the dilatation of blood-vessels peculiar to the catarrhal and inflammatory processes.

In uncomplicated cases of membranous laryngitis the membrane is confined to the larynx. Dozens of years ago-viz. before 1858, when diphtheria began to settle amongst us, never, it appears, to give up its conquest againthat took place in most cases. But since that period we meet with few such simple cases. As a rule, the membrane makes its appearance in the pharynx first, from there to descend into the larynx, and not infrequently into the trachea and bronchi. In other-fortunately, but few-cases the membrane is formed in the bronchi and trachea first, and invades the larynx from below. Other organs suffer but consecutively and from the results of impeded circulation only. Thus, in post-mortem examination hyperemia of the brain, liver, and kidneys, and bronchitis, broncho-pneumonia, or pulmonary edema, are met with. Only those cases of membranous laryngitis which are complicated with general diphtheria yield the additional changes of the latter.

ETIOLOGY.-Intense irritants will produce an irritation on mucous membranes. In the larynx the product is, according to the severity of the irritation, either a catarrhal or a phlegmonous or a croupous laryngitis. The irritating substances may be mechanical, chemical, or thermical. Heubner produced diphtheria of the bladder by cutting off, temporarily, the supply of circulation. Traumatic injury of the throat and larynx will soon show a croupous deposit. Caustic potassium, sulphuric acid, caustic ammonium, corrosive sublimate, arsenic, chlorine, or oxygen, applied to the trachea or larynx, produce croupous deposits.' Inhalations of heat, smoke, and chlorine have the same effect. These, however, are not the usual causes of croup. Cold and moist air is a more common cause, mainly during a prevailing epidemic of diphtheria. In former times, which are unknown to the younger generation of physicians, when no such epidemics existed, the only form of diphtheria occurring now and then was the local laryngeal diphtheria called pseudomembranous croup. It was then a rare disease, while at the present time it is of but too frequent occurrence. In my Treatise I have explained at some length the relations of the two (p. 128).

Age has some influence in its development. The disease is not frequent in the first year of life; between the second and seventh years almost all the cases are met with. There are families with what appears to be a general tendency to croupous laryngitis. It may return. Even tracheotomy has been performed twice on the same individual. It is contagious. In the same family, from a case of croup, either another case of laryngeal croup may originate or another form of diphtheria will develop in other members of the household. It is not so contagious, it is true, as generalized diphtheria must be, for the infecting surface is but small in uncomplicated membranous croup, and the membrane not so apt to macerate and be communicated. Boys appear to be affected more frequently than girls. But the previous constitution makes no difference.

SYMPTOMS.-Membranous laryngitis begins sometimes with but slight symptoms of catarrh, sometimes without them. Nasal, pharyngeal, and laryngeal catarrh may precede it a few hours or a week, with or without fever and with 1 A. Jacobi, Treatise on Diphtheria, p. 111. 2 Treatise, p. 27.

a certain sensation of pain or uneasiness in the throat and a moderate amount of cough and hoarseness. This condition has been called the prodromal stage of membranous laryngitis, though it is just as natural to presume that the changes in the mucous membrane merely facilitated the deposit of false membrane. The latter is more apt to develop on a morbid than on a healthy mucous membrane. The membranous laryngitis proper dates from the time at which, with or without an elevation of temperature, a paroxysmal cough makes its appearance-first in long, afterward in shorter intervals-which is increased by a reclining posture, mental emotions, or deglutition. At an early period this cough, which is very labored and gives rise to dilatation of the veins about the neck and head, is complicated with hoarseness, which gradually increases into more or less complete aphonia. Respiration becomes audible, sibilant, with the character of increasing stenosis. Inspiration becomes long and drawn; expiration is loud; head thrown back; the scaleni, sternocleido-mastoid, and serrati muscles are over-exerted; above and below the clavicles and about the ensiform process deep recessions take place in the direction of the lungs, which are expanded with air, but incompletely; dyspnoa becomes the prominent symptom, and occasional attacks of suffocation render the situation very dangerous and exciting indeed. These sudden attacks of suffocation are due-besides the permanent narrowing of the larynx by the membranes, which gradually increase in thickness-to occasional deposits of mucus upon the abnormal surface of the larynx and vocal cords, by partly-loosened false membrane, which now and then become audible, yielding a flapping sound, by oedema in the neighborhood, and by secondary spasmodic contractions. They are mostly met with in the evening and night; there is often a slight remission in the morning, which rouses new hopes, which soon, however, prove unfounded. Meanwhile, the pulse becomes more frequent in proportion with the increase of dyspnoea, and finally irregu lar; the temperature rises but little, and usually only when the throat or other organs, which are in more intimate connection with the lymph circulation than the larynx, are participating in the exudative process; and the laryngeal sounds become so loud as to render the auscultation of the lungs impossible. The glands of the neck are not swollen when the process is confined to the larynx. Now and then small or larger, rarely cylindrical, pieces of false membranes are expectorated, with or without any amelioration of the condition. In this condition the patient may remain a few hours or a few days.

Then the dyspnoea will rise into orthopnoea; the anxious expression and bearing of the little patient-for the vast majority of the sufferers are children becomes appalling to behold; cyanosis increases; the head is thrown back; the larynx makes violent excursions upward and downward; the abdominal muscles work in rivalry with those of the thorax and neck; the surface is bathed in perspiration; still, consciousness is retained by the unhappy little creature tossing about and fighting for breath, and in complete consciousness he is strangled to death. Now and then the carbonic-acid poisoning renders the pitiful sight a little less appalling to the powerless looker-on by giving rise to convulsions or anæsthesia and sopor, which finally terminate the most fearful sight, the like of which the most hardened man, the most experienced medical attendant, prays never to behold again.

Besides the brain symptoms just mentioned, but few other organs give rise to abnormal function. In the kidneys the stagnant circulation results in albuminuria in the bronchi and lungs, in hyperemia, inflammation, and

œdema.

The symptoms described above are the same both in those cases which are strictly localized and those which descend from the pharynx. In the latter there is fever only when the pharyngeal diphtheria was attended with it. The process descending into the trachea and bronchi changes the symptoms