down constitutions, or when it is connected with a previous abuse of mercury or with ossification of the cartilages, little more than temporary relief is in general to be expected; and when it is a mere complication of phthisis pulmonalis it is, of course, altogether hopeless.

Treatment.-To be successful, the treatment of acute laryngitis must be prompt and active. As the disease is one of inflammation accompanied by a remarkable tendency to spasm about the glottis, our object should be, to subdue the inflammation by antiphlogistic measures; and allay or prevent the spasm by the simultaneous employment of anodynes, and by the local application of warmth and moisture. If there be any considerable febrile disturbance, the necessity of general blood-letting is sufficiently apparent; and even if not, should the local affection prove severe, and provided the patient be of good constitution, it ought never to be neglected in the first instance. The patient may be bled to such an extent as to induce a tendency to syncope; immediately after which, two or three grains of calomel, with a grain of opium and a quarter of a grain of tartar emetic, may be given, and repeated every three or four hours, till the constitution becomes affected by it. After general bleeding, six, eight, ten, or twenty leeches, according to the age of the patient and particular circumstances of the case, may be applied to the external throat, followed either by a large warm poultice, or assiduous sponging with very hot water. At a more advanced period, a blister may be applied, and afterwards kept open by means of savine cerate. Of course, the strictly antiphlogistic regimen must be observed; and in order to prevent irritation of the glottis, and thereby mitigate the spasm sometimes so painfully felt during inspiration, the patient's apartment ought to be

maintained at a moderately warm and steady temperature. By perseverance in these general and local remedies, occasionally aided by additional diaphoretics and the warm bath, the symptoms will often be found to give way, a well-marked amendment being often distinctly observable as soon as the system is brought fully under the influence of mercury. When the acute stage of the disorder is past, the patient may employ, night and morning, external friction with some anodyne or stimulating embrocation, and wear a piece of flannel round his throat for some time afterwards.

When the obstruction to the breathing is such as to threaten suffocation, it has been proposed to perform the operation of tracheotomy; but although such an operation in some instances becomes absolutely indispensable, and affords the only chance of saving the patient, it must be confessed that it has rarely been followed by success.

In chronic laryngitis, the treatment will no doubt require to be modified somewhat, according to the nature of the predisposing and exciting causes; nevertheless the same objects are to be kept in view as in the acute form of the complaint. General bleeding will seldom be required, our chief reliance being placed on the more or less frequent application of leeches, fomentations, poultices, blisters and liniments; with the internal administration of anodynes; and occasionally, small alterative doses of some mild mercurial. Four grains of extr. conii or extr. hyoscy., with a grain of pil. hyd. night and morning, or four grains of Plummer's pill with four or five of Dover's powder every night, will sometimes answer the purpose very well, giving however, at the same time some demulcent anodyne mixture or linctus to assist in allaying irritation about the glottis. It is of so much importance

to mitigate the cough, that in many instances the stronger preparations of opium may be employed with the greatest advantage, either alone or in combination with diaphoretics.

It is in the chronic forms of laryngitis, that attention to the patient's general health constitutes a most influential part of the treatment. The powers of the constitution are generally impaired, and we must endeavour to improve them by such tonic medicines, as cinchona or sarsaparilla with mineral acids, by the iodide of potassium, by small doses of Fowler's solution, the warm bath, and good nourishing diet, and country air.

When oedema of the glottis threatens, whether from recent and acute, or from chronic and slight inflammation, a mustard poultice has occasionally afforded, at least, partial relief.

CROUP.

The Cynanche Trachealis of Cullen.

This disease, with few exceptions, makes its attack between the periods of weaning and puberty, but perhaps most frequently of all from the age of three to ten years. It very commonly presents more or less of the character of a common catarrh at its commencement, being, like catarrh, also preceded or accompanied by the ordinary signs of febrile excitement. In the course, however, of one, two, or at most three days, the disorder develops itself, and displays its characteristic symptoms. The little patient is affected with a cough, which is attended with a very peculiar harsh, husky, or crowing sound, but with little or no expectoration; the respiration is greatly obstructed, the breathing being quick, and each

inspiration accompanied by a hissing and sometimes by a rough grating noise; the voice is harsh, as if the individual spoke through a brass tube, or it is husky and does not amount to more than a whisper: from the obstructed breathing, the face is flushed, or both face and lips present a livid paleness; there is now and then a slight degree of redness and swelling observable in the internal throat, and occasionally tenderness about the neck, with slight pain in swallowing. The most remarkable, constant, and characteristic symptoms are unquestionably, the husky, hoarse, or brassy voice; the shrill or ringing cough; and the obstruction to the breathing, which is liable to great and sudden aggravations, and is at all times most urgent during inspiration.

In bad cases, these symptoms go on increasing till the difficulty of breathing amounts to a most distressing sense of suffocation, which is perhaps for a time somewhat relieved by the expectoration either of a quantity of mucous or muco-purulent matter, or of a few shreds of a membranous-looking mass detached from the larynx, trachea, or bronchial tubes. In this way, the case may proceed for one, two, three, or more days, with various degrees of severity, until the patient sinks completely exhausted, either by the mere permanency of the dyspnoea, or by the violent paroxysms which are so apt to supervene during the whole continuance of the disorder. In other instances, the patient expires suddenly, being actually strangled, either from spasm affecting the muscles of the glottis, or in consequence of a detached portion of false membrane being forced into and blocking up that aperture; or the functions of the lungs are at length so interrupted, and the congestion of the brain is such, that asphyxia or convulsions close the scene.

The disease consists essentially in inflammation affecting the mucous membrane of the larynx, trachea, or bronchial tubes; these several parts being involved in variable proportions in different cases. It is a disease, nevertheless, which in its progress, leads to results very different from those of ordinary inflammation of a mucous membrane, results probably depending less upon the degree than upon the kind of inflammation. Instead of the usual modifications of mucous secretion, an albuminous matter is thrown out, which forms a more or less perfect adventitious membrane overspreading the inflamed surface. This false membrane proves a mechanical cause of obstruction to the respiration; it sometimes gradually encroaches on the aperture of the glottis till it suffocates the patient; or, its lower portion becoming detached by the violence of coughing, it is forced into the glottis, acts like a plug, and so destroys life.

On dissection, we find the albuminous matter deposited on the parts that had been inflamed, either in separate and irregular flakes, or in the form of a more or less uniform membrane, of various degrees of thickness and consistency, and of a whitish, yellowish, or greyish colour. This membrane sometimes appears to be made up of several layers; it is usually softer and more loosely adherent below than above; in the trachea and bronchi it usually takes on the tubular forms of these parts, and its free surface is very commonly found covered with a thickish mucous or muco-purulent fluid.

Diagnosis. Croup appears to be the inflammatory laryngeal affection of infancy and childhood, as ordinary laryngitis is that of adults; and although common laryngitis may unquestionably occur in the former, and thereby give rise to symptoms closely resembling those of croup,