PSEUDO-MEMBRANOUS LARYNGITIS.
BY A. JACOBI, M.D.
PATHOLOGY.—Pseudo-membranous laryngitis is characterized by the presence, on and in the mucous membrane, of a pseudo-membrane of a whitish-gray 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 fossæ Morgagni and trachea. Lymph-vessels 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 fossæ 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 membrane. 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 blood-vessels 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 again—that 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 hyperæmia of the brain, liver, and kidneys, and bronchitis, broncho-pneumonia, or pulmonary oedema, 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.1 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 pseudo-membranous 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).
1 A. Jacobi, Treatise on Diphtheria, p. 111.
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.2 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.
2 Treatise, p. 27.
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 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, sterno-cleido-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; dyspnoea 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 irregular; 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 hyperæmia, inflammation, and oedema.
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 but little, as far as the laryngeal stenosis is concerned, for it is the latter which destroys by suffocation. Only when tracheotomy has been performed, and the immediate danger of suffocation has been removed, the further progress in a downward direction gives rise to a new series of symptoms. After the temporary relief procured by the operation dyspnoea will set in anew, not always, however, of that intense degree of the laryngeal stenosis; respiration will become dry and loud again, and a little more frequent than in the uncomplicated laryngeal cases. Death will finally also result, either from suffocation or from the symptoms I enumerated above.
Lastly, when membranous laryngitis is but the terminating development of extensive membranous bronchitis, the symptoms differ from those described above in this, that the laryngeal symptoms last but a short time. For days or weeks no symptoms but those of an ordinary bronchial and tracheal catarrh were observed: all at once the process reaches the larynx; in a few hours the very last stage of croupous stenosis is reached; even tracheotomy does not relieve the symptoms. Or the fibrinous bronchitis was extensive enough to give rise to a sufficient number of symptoms before the larynx was reached. Amongst them is, foremost, frequency of respiration, because of its insufficiency; diminution of respiratory murmur over the area supplied with the affected bronchi; sometimes localized absence of respiratory murmur, while the percussion sound is sonorous. Another complication is emphysema, either subpleural or pulmonary. It is not frequent, except in combination with fibrinous bronchitis. The increase of respiratory movements is quite sudden, percussion sound tympanitic, and auscultation negative. Pulmonary oedema is quite frequent; it is the result of the rarefaction of air in the bronchi, the consecutive dilatation of the blood-vessels, and the effusion of serum by intravascular pressure. Every severe case is accompanied with it; in every tracheotomy it is met with coming up into the incision. Oedema of the glottis is less common, but it is met with in the same manner and with the same symptoms which characterize the glottic oedema of catarrhal laryngitis.
PROGNOSIS.—It is not favorable even in the simple and uncomplicated cases. Infants and children under two years almost invariably die. The percentage of average mortality rates very high—from 80 to 90 and more. It is probable that some recent therapeutical advances have reduced it, will reduce it, considerably. Tracheotomy is known to do so certainly, as from 20 to 45 out of 100 operations prove successful. The previous condition of the patient is of very little account in regard to the course and termination of the disease; no constitution protects or saves. The more the disease is local the better the prognosis. When fever makes its appearance, it means a complication, such as extending diphtheria or bronchitis or bronchi-pneumonia, and impairs the chances of recovery. The expectoration of membranous shreds or whole membranes does not improve the prognosis much, as the new formation of membranes may be very rapid indeed. I have seen new membranes rising to a formidable extent in from two to seven hours. The prognosis is improved when the cough becomes looser, expectoration more purulent, pulmonary respiration become audible again after having been covered by the laryngeal noises, rhonchi become moist, and portions of lungs which before were inaccessible to air by clogging membranes are reopened. Increasing debility, frequent and irregular pulse, are ominous symptoms. Even more so is the failure on the part of emetics to take effect.
DIAGNOSIS.—It may be quite difficult to diagnosticate croupous from catarrhal laryngitis, particularly in those cases where the former is not complicated with any visible exudative process in the fauces. In membranous laryngitis stenosis begins gently (except in those cases which ascend from the bronchi) and increases gradually; there are, it is true, remissions in the morning (mostly), but they are but slight, and the subsequent evenings are worse than the previous ones. It increases from day to day until a slight cyanotic hue of the lips is followed with more general cyanosis. There is no fever or very little, except in the cases of generalized diphtheria. The character of the cough does not change; perhaps it becomes more dry and suppressed after a while. Hoarseness does not improve, but increases steadily into aphonia. Expectoration is but scanty; now and then a small portion of mucus from the lower portion of the respiratory tract, now and then shreds of membrane, are expelled.
In catarrhal laryngitis stenosis begins abruptly and suddenly, and is often at its height a few minutes after the commencement of the attack. Remission sets in soon, is more marked, sometimes complete, and a new attack, just as sudden as the first, may occur in the next night. Real cyanosis is but rarely developed; when it is, it changes soon into a more normal condition. Catarrhal laryngitis in the child is a febrile disease. In it the cough changes after a little time, some moisture mixes with the expectoration and changes both cough and articulation; also, the voice is not equally husky; now and then a clear note comes in. Close inspection of the throat exhibits sometimes a thick, viscid mucus floating up and down with the excursions of the larynx in catarrh. It never has any membranous expectoration.
Local oedematous swelling of the ary-epiglottic folds, with or without membranous deposits in some other parts of the larynx, yields all the symptoms of membranous croup with its dangers and death-rate. The effect of this oedema is partial paralysis of the vocal cords. Thus, inspiration is impeded, as in membranous obstruction; expiration, however, is free and the voice intact to a certain extent. This local oedema may be detected by palpation.
General oedema of the larynx (glottis) is fortunately rare. The attack is very sudden; there is no cold, no hoarseness, no choking cough, no membrane; there is only dyspnoea, gasping, asphyxia, sopor, and death, unless relief is given almost instantaneously.
The presence of a foreign body has been mistaken sometimes for membranous laryngitis. The history is a different one; there was no prodromal catarrh; the children were taken suddenly while playing or eating.
The laryngoscope would be a great aid in diagnosis if it could be used during the distress of a membranous laryngitis. Still, it has been employed by Ziemssen, Rauchfuss, and others. But the opportunities are rare.
TREATMENT.—The objects of treatment differ with the various stages of the disease. The inflammatory symptoms of the commencement, the completed exudation, the maceration and disintegration, and also the expectoration of the pseudo-membranes, and, finally, the asphyctic stage, have each their own indications. If there is anything which must not be recommended, it is depletion. Fortunately, there are but few practitioners left who still apply leeches or employ more general depletion, but these few are still doing too much harm by their practice and teaching. The application of ice, however, in bags over and near the larynx, and of iced cloths frequently changed, combined with the swallowing of small pieces of ice from time to time, is apt to be beneficial in well-nourished, hearty children. Such as have been anæmic, with thin muscles and pale mucous membranes, do not bear it so well.
The most powerful and reliable preventive and solvent, thus far, is hydrargyrum. It is true that many voices have been raised against it, but from Bard, Bretonneau, and Billard to Rauchfuss, Ch. West, Lynn, Pepper, and others, the remedy has had its admirers. Large single doses of calomel have been given by some, amounting to 15–30 grains (gramme 1.0–2.0), but that treatment has not found many friends. In small and frequent doses it has been of good service to me both in fibrinous laryngitis and bronchitis, particularly in the latter; gr. ¼–½ may be given every half hour or every hour. Tartar emetic is liable to develop so many unfavorable effects that even doses—in combination with calomel—of 1/100 of a grain require great caution. The most reliable mercurial preparation, in my experience, and the least hurtful, is the corrosive chloride. In the stomach it combines with the chloride of sodium, is absorbed without being changed, and transmuted into an albuminate during its circulation in the blood. Babies of tender age bear one-half of a grain and more, daily, many days in succession. Salivation and stomatitis are exceedingly rare after its use. Gastro-intestinal disturbances are not at all frequent; diarrhoea, if observed at all, is very moderate, and can be avoided or removed by the administration of mucilaginous and farinaceous food or a mild dose of an opiate. But the administration of the bichloride requires care in regard to its solution. A fiftieth of a grain may be safely given to a baby a year old every hour, but it must be dissolved in one-half of a tablespoonful or a whole tablespoonful of water. The solution of a grain in a pint of water is about correct. In those very rare cases in which no preparation of mercury is borne internally the inunction of sufficient and frequent doses of the oleate of mercury may take the place of the internal administration or alternate or be combined with it. The blue ointment is not so effective as the oleate. The subcutaneous injection of the corrosive chloride may be added to the modes of administration if no time must be lost in introducing as much as possible of the drug into the system. Now and then, however, the subcutaneous tissue of the child does not tolerate it well in that form, though the solution may be not larger than 2 per cent.3 The cyanide of mercury, in doses of a hundredth of a grain every hour, has been warmly praised by A. Erichsen and C. G. Rothe.
3 The Medical Record, May 24, 1884.
The large mortality in croup and the inefficiency of remedial treatment have been the reasons why the recommendations of remedies have been very numerous. Alkalies were held in great favor during different periods of our literature, mainly the carbonate and bicarbonate of potassium (and sodium), in daily doses, to a child, of ½ drachm or 1 drachm or more; also the chlorate of potassium or sodium. As an adjuvant it may be useful; as an antidiphtheritic or antimembranous remedy it must not be regarded. What it can do is to heal or prevent a catarrhal stomatitis and pharyngitis. The best and most reliable is probably the iodide, in larger doses than are usually given. One or two drachms daily (grammes 4.0–8.0) are well tolerated when sufficiently diluted. Benzoate of sodium was recently recommended for its supposed antifermentative and antibacteric effect; its practical utility is but very limited; not even its antifebrile effect is anything but reliable. Lime-water has not fulfilled in my hands the promises made by others—neither its internal use nor spray nor inhalation. The most certain mode of introducing lime particles into the larynx is, after all, the inhalation of slaked lime, which allows a quantity sufficient to be somewhat effective to enter the respiratory organs. Its comparative inefficiency has been acknowledged by those who add 1 per cent. of the liquor of caustic potassium or sodium to the lime-water.
Quinia, in doses of 15 or 30 grains (grammes 1.0–2.0) daily, has been recommended by Monti for the same indications, mainly in the commencement of febrile cases. It has been claimed that cold applications, to be changed every hour or two according to the Priessnitz or hydropathic plan, had a great power in macerating and disintegrating mucous membrane. Many of the successful cases of these, as of all other specialists, are undoubtedly the result of the convenient substitution of a grave diagnosis for a milder one. The effect of such applications in laryngeal catarrh, like that of warm applications, is undoubted. Vesicatories applied to the neck over the larynx are never useful—frequently injurious by the sore surface becoming the seat of a pseudo-membrane.
Inhalations of warm vapor are decidedly beneficial, but atomized water is not of equal value. Thus, Richardson's atomizer is not so useful as Siegle's inhaler or other apparatuses working on the same plan.
Lactic acid, in solutions of 1:10 or 25 (Monti's solution of 1:200 is certainly too weak), has been applied by means of a sponge, inhaled, or thrown in from an atomizer for the same purpose. Good results have been reported, failures also; and still, recoveries are rushed into print much more readily than failures. The same may be said of the local applications of glycerin, boric acid, carbolic acid in solutions of 1 or 2 per cent., salicylic acid, iodoform, and hypermanganate of potassium; also of bromine (bromine and potas. bromid. aa) 1:water 500, or a stronger solution.
Tannin, dry or with glycerin, is rather more injurious than it can be useful. It is apt to coagulate the mucus contained in the pharynx and the upper part of the larynx, and to render the dyspnoea graver than before. Such an aggravation of symptoms must be carefully avoided, though it be but temporary. The same must be said of alum, which has been used solid, in finely-powdered condition, down to a 3 per cent. solution in water.
Spirits of turpentine are inhaled either from an inhaling apparatus or by saturating the air of the room. Water is kept boiling constantly on a stove, oven, or alcohol lamp (not on gas, which consumes a larger quantity of oxygen), and a tablespoonful of the spirits of turpentine is poured hourly or in shorter intervals upon the boiling surface.
Hydrochlorate of ammonia can be used in the same manner as described in the article on Catarrhal Laryngitis.
Hydrochlorate of pilocarpine was introduced into the treatment of diphtheria and pseudo-membranous croup some years ago, and recommended as no less than a specific. It increases, physiologically, the secretion of the skin, the mucous membranes, the lachrymal and muciparous glands, the kidneys. It also depresses the heart's action. In all cases in which the latter effect is to be feared the drug is contraindicated; thus in septic diphtheria, in pseudo-membranous croup with great asthenia, in general debility and anæmia. By increasing the secretion of the mucous membranes it is expected to macerate the pseudo-membrane and raise it from its bed. This can be accomplished wherever the membrane is deposited upon the mucous membrane—that is, whenever the number of muciparous follicles is large and the epithelium is cylindrical. This is not so on the vocal cords, and thus the floating effect of pilocarpine cannot be obtained exactly where it is most needed—that is, on the vocal cords, where the pseudo-membrane is more intimately imbedded into the tissue than, for instance, on the posterior wall of the fauces or the trachea and bronchi. Still, pilocarpine may be tried, in combination with other modes of treatment, as long as the heart's action is competent and the general condition satisfactory. It is dissolved in water; its dose, for a child a year old, 1/30 grain (2 milligrammes = 0.002) every hour. A subcutaneous injection every four or six hours of 1/60 grain (three drops of a 2 per cent. solution) will prove very effective for good and evil. I believe it has rendered me good service in some well-marked but mild cases of pseudo-membranous laryngitis, which it either aided in healing or prevented from getting worse.
Emetics have their distinct indication. It is irrational to expect any relief from them when the larynx is narrowed by firmly-adhering pseudo-membranes. Their indication depends on the possibility of removing something which acts as a foreign body. This something can be either mucus or loose or partially loose membrane. The peculiar flapping sound produced by the latter admits of or requires the administration of an emetic. Above I have stated which of them ought to be selected. Turpeth mineral in a dose of from 3 to 5 grains, repeated in six or eight minutes, acts quite well. Hypodermic injections of apomorphine may be required in urgent cases.
The introduction of catheters into the larynx, according to the methods of Horace Green, is a dangerous proceeding and ought not to be indulged in. It gave the idea to Loiseau and Bouchut to force a tube into and through the larynx, full of pseudo-membrane, for permanent use until the pseudo-membrane would have disappeared. This tubage was rendered ridiculous at once by the assertion of Bouchut (1858) that children suffering from croup who were supplied with this laryngeal tube were not only relieved at once, but expressed their gratitude in audible oratory. Still, there are some cases on record of more recent date in which tubage is reported to have been attended with success. It is not very probable, however, that a larynx which admits of no air, because of its being clogged with firm pseudo-membrane, should be willing to admit and endure the presence of a tube.
Massage of the larynx has been recommended by Bela Weiss. It consists in systematical gentle pressing and kneading of the larynx by the physician while sitting behind the patient. He asserts its satisfactory influence not only in catarrhal but also in diphtheritic (croupous) laryngitis.
The inhalation of oxygen has proved rather advantageous in my hands in a few instances. The most memorable case of the kind I have mentioned elsewhere. It was that of a child on whom tracheotomy had been performed. The pseudo-membranous process, however, invaded the bronchi, with the result of producing dyspnoea, cyanosis, and convulsions. Whenever a current of oxygen was introduced into the lungs through the canula both cyanosis and convulsions would cease, and returned when its supply was stopped.
But if no medication will have proved successful, the symptoms of stenosis, dyspnoea, cyanosis, and the supra- and intraclavicular and epigastric recension increase steadily to an alarming extent. When the pulse becomes frequent and intermitting, even without the presence of asphyxia and anæsthesia, air ought to be introduced into the lungs by tracheotomy. No positive rules can be laid down as to the length of time one ought to wait before performing it. No subdivision of the disease into several stages is of any benefit in selecting the exact period in which the trachea must or may be opened. No alleged contraindication to the performance of tracheotomy, whether the tender age of the patient or a complication with either an inflammatory or an infectious disease, must be considered valid. The one strict indication for the performance of tracheotomy is when the diagnosis of pseudo-membranous laryngitis is undoubted, the increasing dyspnoea, cyanosis, and approaching asphyxia, with the certainty that a well-directed and sufficient medicinal treatment has been, and in all probability will be, useless. Even under these circumstances there is no mathematical certainty. The matured experience of a well-informed and thoughtful physician will commit but few errors. If there be the slightest doubt, the operation ought to be preferred to suffocation.
The operative procedure and the surgical treatment after the performance of tracheotomy will form the subject of a [special article] in this work. In this place a few remarks upon the medicinal and dietetic treatment in that period of the disease must suffice.4
4 Cf. The Med. Rec., May 24, 1884.
The nutrition of the patient has generally suffered much. Before the operation but little food was taken, still less was digested, and the operation itself and the anæsthetic have added to the previous weakness or exhaustion. Moderate feeding and stimulation are therefore to be commenced soon. Vomiting after chloroform I have seldom seen to last long or to be embarrassing under these circumstances. Feeding and stimulation are the more necessary the more the hungry lymph-vessels are liable to absorb injurious material when not supplied with healthy food.
Is internal treatment required? The general treatment must be continued. If it consisted in the administration of hydrargyrum, either internally or externally, it must be continued. If its effect was not sufficient to clear the larynx and to render the operation unnecessary, it will or may be sufficient to complete its effect in the next day or two, to prevent the process from descending or the membranes becoming too many or too thick. No changes ought to be made in the treatment unless there be changes in the symptoms. Not infrequently the first symptoms of broncho-pneumonia come on within a few hours after the operation, recognizable by frequent pulse, respiration frequent beyond proportion, and physical symptoms. The stomach is not very reliable. Quinine answers best hypodermically. From 6 to 10 grains may be injected at once. The preparation which has served me best in the last few years is a solution of the carbamid in five parts of water. If an additional remedy is required, from 20 to 30 grains of sodium salicylate may be given in the course of three or four hours, in hourly doses, to reduce the temperature. Tincture of digitalis will prove advisable at the same time when the heart appears to require it. Strychniæ sulphas will act as a powerful nervine; 1/25 grain may be given to a child two years of age every two hours, until four or five doses shall have been taken. The rest of the treatment of the complications depends on their nature and character. It is not the name of the disease which has to be treated, here as in every case, but the individual patient.
In regard to stimulants I have but little to say. I use alcohol in the most pleasant shape, preferring brandy or whiskey. I use a great deal of camphor, 10 to 40 grains daily, or in cases of urgency Siberian musk, from 2 to 5 grains, every half hour or hour, until from 15 to 20 grains have been taken in cases of collapse or great prostration.