be looked for, attacked and arrested, or it will inevitably progress downwards to a fatal result. The strong solution of nitrate of silver, that great "modifier of the mucous surfaces," as Ricord calls it, is to be applied directly to the larynx by a sponge filled with it, and passed into the glottis.

This topical medication has been fully carried out in France by M. Loiseau, who has invented an instrument for "catheterism of the larynx," which he urges as a substitute for tracheotomy. "His method is simple and infallible," says Trousseau, who recited to the Academy of Medicine, at Paris, several cases of croup and diphtheritis in which catheterism and cauterization had been successful, and concluded with the remark, that if this method did not "take the place of tracheotomy it should at all events be tried before practising that operation."

More recently M. Bouchut proposes the mere "tubage" of the larynx, and the "forced dilatation of the glottis" by the introduction of a silver tube or canula constructed for the purpose, through which air may enter and false membranes be expelled. This canula is retained by a special arrangement and allowed to remain in place from one to three days, until the symptoms of asphyxia cease to threaten. I can hardly imagine the possibility of the persistent presence of such a body in the glottis, however, without destructive irritation, although I might hope for immediate and temporary relief from its occasional insertion.

Dr. Reed, of Ohio, speaks of membranous croup in his region, as being most successfully treated by the employment of the ethereal solution of iodine, in the proportion of 3j to 3j, carried into the larynx by a sponge; the little patient being brought under the influence of mercury as soon as possible. (Trans. Am. Assoc., vol. v.)

We should examine the lips of the glottis. Occlusion of this opening by cedematous effusion may occur, and admits of immediate relief by incision. Dr. Buck, of New York, has invented a very convenient instrument for this purpose.

If collapse threaten-the pulse sinking, and other signs of muscular and general debility supervening-I would have recourse promptly to the stimulant diaphoretics. The vol. alkali is particularly well suited, and may either be prescribed with oil as before mentioned, or in syrup. Camphor is also useful, and so is opium. The two are united in the tinct. op. camp., which deserves our confidence, and should be freely administered. Sinapisms should be applied to the extremities, and the powers of life supported by wine whey and wine.

I must not close the consideration of the treatment of croup without entering briefly into the question of the propriety and relevancy of bronchotomy as it is called, laryngotomy or tracheotomy.

The truth appears to me to be as follows: Croup is at first confined to the upper part of the windpipe-the larynx and adjoining trachea. If the rapid effusion of tenacious mucus which attends the invasion of the disease cannot be got rid of by the sufferer, or if the swelling of the lining membrane of the part be so great, whether by cedema or inflammatory congestion and tumefaction, as to occlude the opening of the glottis, or if the false membrane, so much talked of, be formed in mass sufficient to prevent the passage of air; if, under either of these contingencies, a sudden stop be threatened to the process of

respiration, and the usual means of relief, promptly and freely applied, including the tube and sponge, be unsuccessful, then we are bound to resort to the operation. A patient should not be suffered to die of suffocation in an early stage of croup; an opening should be made in the windpipe for the admission of air. But we should satisfy ourselves, by a careful examination, that the impediment to breathing is confined to the larynx; the thorax should be resonant on percussion, and the respiratory murmur or loose mucous râle should be distinguishable. At the Hôpital des Enfans Malades, in Paris, out of 161 operated on, 36 were saved. Archambaut, Trousseau, and others, report instances of success.

But, in the more advanced stages of croup, the disease is no longer a local inflammation of the larynx and trachea. Post-mortem examinations prove it to have extended itself through the minutest ramifications of the bronchi and air-cells, which are gorged with mucus, or occluded with organized lymph, and even the pulmonary tissue has become solidified or "hepatized." This extension is inferred in the living subject, from the peculiar complexion, ghastly pale or livid, and from the loss of resonance on percussion, and respiratory murmur.

We have to contend with bronchitis and pneumonitis as well as laryngitis and trachitis.

Suppose the occlusion of the upper and large tubes capable of being instantly and totally removed, what will we have gained?

Bronchotomy is not, in any sense, a remedial means; it has no tendency to remove the inflammatory actions going on in the trachea, or to check their progress. By its success, we merely obtain time for the vigorous and persevering employment of the proper measures, and if these should be neglected or carried into imperfect execution, the extension of the disease into the lung will be as likely to occur, and to prove fatal, as if the operation had not been resolved on.

CHRONIC LARYNGITIS-Laryngeal Phthisis.-This form of disease has of late attracted much attention, and though it is not absolutely a new malady, as some suppose, is certainly more frequently met with in the last few years than formerly. It is known without difficulty. The sound of the voice is peculiar, or the aphonia is entire, the patient being able to speak only in a hoarse husky whisper, and with a painful and fatiguing effort. The larynx is the seat of uneasy sensations, and suffers when handled or pressed. There is a sibilant weak cough, usually dry and teasing; in some cases, there is expectoration of a thin tenacious mucus, sometimes of a little pus. Dysphagia is occa sionally the most annoying symptom, from inflammation of the epiglottis. There is dyspnoea and much panting after muscular exertion. As the case progresses, the ordinary symptoms of phthisis supervene -emaciation, hectic, colliquative sweats, and diarrhoea.

Its causes are not clearly defined. It attacks far most frequently the scrofulous constitution. Clergymen are subject to it, especially such as read discourses in public. Its intimate connection with, or dependence upon tuberculosis is established.

Autopsy. The local changes seen after death are, 1. Edema of the glottis. 2. Inflammation of the mucous membrane of the larynx,

with redness and swelling. 3. Ulceration of this surface, and of the epiglottis. 4. Ossification, caries, and necrosis of the cartilages. It is rarely fatal, however, without the presence of tubercular deposit extensively in the lung, and the supervention of pulmonary inflammation with its usual results; as described hereafter under the head of Phthisis.

Treatment. In the first instance bloodletting, both general and local, may be demanded, with the application of poultices and sinapisms to the throat. Emetics are often serviceable in relieving paroxysms of dyspnoea. Mercurials are strongly recommended by Trousseau and Belloc in France, who urge them to the production of ptyalism, and by M. Hall in England. I have not derived much benefit from them. Narcotics are always useful. The Dover's powder, if well borne, is to be preferred; the salts of morphine are among the best palliatives. They may be applied to blistered surfaces with benefit. Inhalations of vapor, simple and mingled with ether, camphor, chlorine, &c., have been recommended.

The nitrate of silver has been long in use as a gargle or local application to the fauces and pharynx, for the relief of the troublesome dysphagia, which it controlled better than any other remedy; but to Dr. Green belongs the merit of introducing it freely and efficiently within the larynx. He uses for this purpose a bit of sponge strongly attached to a stick of bent whalebone, the insertion of which, dipped in a solution of nit. argent. Jij to 3j in aq. dist. 3j, is productive of far less irritation and annoyance than would readily be imagined, and is in many cases followed by highly beneficial results. Its employment should always be fairly tried. Dr. Allison uses, in the same way, olive oil, glycerine, and mucilage, either simply or as vehicles for morphine, atropine, and conia, the application of which, he affirms, will very much relieve the patient.

LARYNGISMUS STRIDULUS-Spasmodic Croup.-This is comparatively a rare disease, confounded under the same name, but very dif ferent in nature from croup properly so called. The dyspnoea, the only symptom common to the two affections, is in this transient, spontaneously subsiding, and recurrent, and accompanied with convulsive or spasmodic action of other muscles than those concerned in respiration. It attacks children almost exclusively-and for the most part while teething. The patient's thumb is turned in upon the palin with the fingers closed over it; the toes and instep bent backward, the breathing for a time suspended, suffocation seeming imminent; the eyes are open and turned upward; the nostrils dilated; the limbs and trunk rigid. After a short struggle, the attempt at inspiration becomes partially successful, and a series of sharp, sibilant catches precede the inhalation of a full breath, which is attended with a shrill sound, very different from that of true croup, but equally characteristic, described as "crowing" or clucking. The paroxysm lasts from a few seconds to two or three minutes; it is sometimes accompanied with general convulsions, and has occasionally proved promptly fatal.

I have had under my care an adult above 50 years of age subject to well-marked attacks of this character.

Its cause is found, we are told, in exposure to alternations of weather during dentition, and in gastric and intestinal disorder. It is supposed to depend upon reflex irritation of the 5th or 8th pair of nerves, the recurrent or some branch of the pneumogastric.

Autopsy reveals nothing to account for the symptoms.

The treatment consists in a careful attention to all obvious or suspected sources of disturbance. The gums should be scarified if swol len; the bowels kept gently moved by proper cathartics; and anodyne diaphoretics administered in moderate doses. The application of the nitrate of silver to the fauces, pharynx, and parts adjacent, is recommended on the ground that it tends to subdue any morbid irritability of the mucous surface, and the suggestion is reasonable and promising. Change of air is urged by Robertson as the true remedy and prophylactic.

BRONCHITIS.-Inflammation of the mucous membrane lining the trachea and bronchi occurs as acute and chronic.

Acute bronchitis resembles closely, in the first instance, an attack of catarrhal fever, from which it is then only distinguished by a more special prominence of the tokens of local and thoracic irritation and inflammation. Its access is usually with a chill, accompanied by a sense of soreness and stricture in the trachea, and a tickling, dry, and frequent cough; fever soon follows, with harsh, hot skin, flushed face, thirst, pain in the back and limbs. There is a loud mucous râle, and diffused feeling of rawness over the chest, the resonance of which is usually little, if at all, impaired.

These symptoms continue for four or five days; the cough and febrile excitement being somewhat increased at evening and in the night. Expectoration becoming freer, they subside gradually and disappear in a week or ten days.

But in some cases, as of old and infirm persons, a sort of collapse of the lung or a portion of it takes place from occlusion of the air-tubes probably by the great amount of thick tenacious effusion. Here we shall notice an extending dulness; the dyspnoea is urgent, with a distressing tension across the chest, and much pain in coughing. The patient cannot lie down; oppressed with the accumulating mucus, he cannot expectorate. If these symptoms be not promptly relieved, he may sink exhausted by his struggles; or the expectoration becomes somewhat freer and fuller, and the disease subsides, or passes into a chronic condition.

Post-mortem examination shows the submucous tissue of capillary vessels highly injected, the tubes and air-cells being filled with a secretion of varied appearance, sometimes a tenacious ropy mucus, again a thick, purulent fluid, mingled occasionally with a serous, ichorous, or sanious effusion. The substance of the lungs partakes of the results of the inflammation if protracted, and becomes more or less solidified, or, as the phrase is, hepatized.

Cause.-Exposures to cold, moisture, and alternations of temperature, are familiarly known to produce bronchitis. It has been excited by inhalation of some of the irritating gases. It is more frequently met

with among persons engaged in certain occupations, millers, cottonginners, needle-grinders, &c.

The prognosis is readily inferred from the degree of dyspnoea, and the apparent ability of the patient to struggle with the impediment to his breathing, and to bring out from the air-passages the offending mucus. Free expectoration is, therefore, favorable, and a hard, dry ringing cough the reverse. Very old and infirm persons, and young children suffer the most serious risks.

Treatment.-Venesection is in some cases an indispensable remedy, and must be promptly carried to as great an extent as can be borne without injury. Emetics are serviceable, both as expectorants and diaphoretics, and are peremptorily demanded in the cases of infants, and the very aged. They may be repeated from time to time. Ipecac., squills, and seneka are preferable; if these are not sufficiently active, tart. antim. may be added. Cathartics are useful. I select the saline, and combine them with diaphoretics, as the infusion of serpentaria or seneka. Much has been said against the employment of cathartics in thoracic diseases; but these objections are speculative; experience shows them to be, in the early stages, not only safe, but admirably beneficial. In the advanced periods of such cases, they are not required, but the bowels should be kept regular and soluble throughout. Nauseating doses of antimony are much extolled. I am not fond of the practice, but prefer to use the veratrum viride to reduce the undue force and rapidity of the circulation.

When the febrile excitement is in some measure subdued, opium is an invaluable medicine. Dover's powder is a good combination to insure its effect as diaphoretic and anodyne.

Of topical applications, after cupping I prefer the warm poultices, with which I envelop the throat, and cover the chest. Leeches imply too much exposure.

To relieve the cough, demulcents are required; mucilaginous solutions, with opium, form the basis of the most valuable of these. Spermaceti, so often prescribed formerly, is now too much neglected. Rubbed into powder, with equal parts of loaf-sugar, and one-fourth of the nitrate of potass, taken into the mouth, and allowed to dissolve slowly, it is well adapted to relieve a teasing, frequent cough.

The apartment should be kept comfortably warm, and no current of air allowed to pass over the body of the patient.

In the asthenic bronchitis of the old and infirm, the peripneumonia notha of writers of the last age, stimulants and stimulating diaphoretics are demanded early, and must be given freely. On account of the enormous secretion of mucus into the air-cells and tubes a quick undepressing emetic may be now and then required. Prof. Mereis' expectorant formula is well adapted here as in the cases of young children. R.-Hydrochlorate of ammonia grains viij to xij, water oz. ij, with a little tinct. opii and liquorice. Of this, a child may take a teaspoonful, and an adult a tablespoonful pro re nata. The carbonate of ammonia and camphor, with or without a few drops of chloroform, will also tend to relieve the cough and render expectoration easier. Opium must be prescribed with caution if at all. The strength