the prolongation of the attack, it throws the children into a state of weakness which makes them ill for several days.

Such are the appropriate means to be employed in the treatment of stridulous laryngitis. They are quite numerous enough, and sufficiently varied. Great precaution must be exercised in their choice, so as not to make use of the most energetic amongst them against an attack which would cease quite naturally of itself. The last means are especially appropriate in the case of important complications, bronchitis or pneumonia. An emetic is then very advantageously employed. As to blisters and bleeding, they must be reserved for the most severe cases, and should only be prescribed when special indications are present.

APHORISMS.

157. A sudden nocturnal attack of suffocation, accompanied by a dry, hoarse, hissing, and sonorous cough, announces false croup.

158. False croup, very violent at its commencement, diminishes in a few hours, whereas true croup advances without intermission, daily increasing in intensity.

159. Two or three fits of suffocation, less and less severe, with an interval of twenty-four hours, characterize false croup.

160. False croup is very readily cured by the administration of an emetic.

CHAPTER III.

FOREIGN BODIES IN THE LARYNX.

It is rather rare to meet with foreign bodies in the larynx of children at the breast, in consequence of the small dimension of this organ; but still there are examples of this, and the one which I here report seems to me worthy of interest.

The kernel of a cherry fell into the larynx of a child two years old, and remained fixed there; suffocation necessitated the employment of laryngotomy, which was not followed by the expulsion of any foreign body. Just as the wound cicatrized the suffocation reappeared, and during the manoeuvres which were made to reopen the wound, by means of a sound and other instruments, the child died asphyxiated.

Here is, in addition, a case reported in the Gazette Medicale:

Case. A child two years old, which would speak while eating cherries, the stones of which it swallowed, was suddenly seized by violent attacks of cough and a fit of suffocation. The asphyxia was imminent, and the account of the above circumstances also simplifying the diagnosis, M. Corbet immediately performed laryngotracheotomy. As soon as the respiratory tube was opened, the anxiety disappeared

and the respiration became free. The foreign body, however, was not met with. The wound cicatrized, and fifteen days passed during which the health was perfect and the respiration quite regular.

The opening into the trachea was then quite closed, and the external wound nearly healed, when the child was seized with symptoms still more alarming than the first. M. Corbet, without hesitation, incised the newly-formed tissue, introduced a female catheter into the trachea, and explored it in every direction, using the finger as well as a twig of whalebone armed with a small piece of sponge. The foreign body could not be discovered; the suffocation increased and carried off the child in one of the fits.

On making the post mortem examination, the respiratory tube was divided to the point of the bifurcation of the bronchi without anything being discovered. The fact that death supervened notwithstanding the very large opening of the cricoidean region, led to the supposition that the foreign body would be more likely to be met with below the wound. On cutting open the larynx, the cherry stone, which had descended into the trachea, was at length found, undoubtedly displaced by the movements which were made in order to place the head of the subject on a block. In fact, the right ventricle of the larynx was hollowed into a cavity formed by ulceration, and so placed that on introducing the stone into it its surface could be scarcely perceived, provided its large diameter was placed parallel to that of the ventricle.

It may be easily understood why the surgeon could not recognize the presence of this stone in the glottis, although during the second operation he introduced his two index fingers, one from above downwards by the back of the throat, the other from below upwards by the wound of the larynx, until they touched each other. But another instructive fact, more directly allied to the treatment, may be derived from this case: it is that in similar cases of fruitless search for foreign bodies after tracheotomy, roughly shaking the patient, in suddenly changing the position of the head, should never be neglected. It was this manœuvre which alone succeeded in the case of the engineer uia Brunel, in dislodging the piece of money which had up to that time resisted all means of extraction. The details of the autopsy just related prove that it was to movements of this kind that the displacement of the cherry stone in the body of the patient operated on by M. Corbet was also due.

Facts of this kind are not rare in children of more advanced age. Here is one which is not less curious than the preceding, and in which broncho-tracheotomy was equally useless in determining the expulsion of the foreign body. It occurred to M. le Docteur Rendu, a medical man at Compiègne.*

Case. Foreign body in the larynx. A child, five years of age, having by mistake swallowed a bean, was immediately seized by a fit of suffocation, which was repeated on the following days. M. Rendu practised broncho-tracheotomy, but the foreign body was not expelled, notwithstanding the extent of the wound. This had cicatrized, when a violent fit of coughing came on three months after the accident, and was * Bulletin de l'Académie de médecine. Paris, 1850; t. xvi, p. 105.

ནོ

૩૬

followed by the quick expulsion by the mouth of purulent matter, in the midst of which was found the bean which had sprouted. From this moment the symptoms ceased, to return no more.

[One of the most remarkable instances of a foreign body getting into the windpipe without passing through the rima glottis is mentioned by De la Martinière (Mem. de l'Acad. de Chir., vol. v), in which in a child a large copper pin without a head, about an inch and quarter long, had pierced through the windpipe from left to right. It was detected through the skin, cut down on, and removed. The child recovered in a few days.

The following case came under my own notice while house surgeon at the Queen's Hospital, Birmingham: A little girl about four years old was sucking a glass bead, and on taking a sudden inspiration it disappeared; the bead was described as hollow, made of thin glass, about an inch in length, and a quarter of an inch in diameter at the middle, whence it gradually tapered towards the ends. There was not much difficulty of breathing, and the foreign body could be heard moving up and down the trachea after a longer expiration than usual. After a little time, several partial attacks of dyspnoea having supervened, tracheotomy was performed by Mr. Knowles, and the bead was ejected with considerable force from the wound. The patient made a rapid recovery.

The time which a foreign body, after the first severe symptoms have passed by, may remain lodged in the air passages varies very considerably. An instance of a prolonged period is that mentioned by Sue (Mem. de l'Acad. de Chirurg.; vol. v, p. 533). A female, when nine years old, had the rump bone of a pigeon slip into her windpipe; she became subject to attacks of hæmoptysis and other symptoms of pulmonary disease, but without wasting, until her twenty-fourth year, when she began to decline rapidly. Two years after she threw up the bone in a violent fit of cough; but she died eighteen months after with profuse purulent expectoration. In a case which occurred at St. Thomas's Hospital, a girl, six years old, who was suddenly thrown back whilst eating cherries, was immediately seized with a violent fit of choking, and every symptom of impending suffocation. This condition lasted for an hour, and then she fell asleep. On the next day she had some spasmodic pain in the chest, and on the following morning the breathing was very difficult, and other symptoms of inflammation present, which were relieved by bloodletting, a calomel and jalap purge, and calomel and opium. On the afternoon of the fourth day she had a violent convulsive seizure, with cough, small quick pulse, a livid surface, suffused eye, and every sign of suffocation. The spasm subsided after two hours' continuance; and a few days after, she was so tranquil as to lead to the belief that no stone could have passed into the trachea. In the middle of the following day the fit returned, on the seventh day also, on the thirteenth, and, from that time, daily, till the nineteenth day when she had frequent paroxysms of croupy cough, attended with great restlessness and the peculiar grasping of the throat. Under these circumstances, tracheotomy was performed, but the stone was not thrown out; the breathing, however, became tranquil, and the cough also ceased. It returned, however, on the twenty-sixth day, but less severely. About six weeks after, the wound, which had been tented, healed; and soon after, the child coughed incessantly, had night sweats, with loss of strength and appetite. In this condition she remained till the ninety-sixth day after the accident, when she threw out the stone, together with a table spoonful of pus, during a violent paroxysm of cough; having expectorated pus, in small quantities, for many days previous. From this time the cough never returned, and the general health was soon reëstablished.—(Med. Chir. Trans. ; vol. xxiii, 1840.)

In proof of what a large-sized body may be admitted into the larynx, Dr. Burow

(Casper's Wochenschrift, No. 39) relates the case of a boy, aged twelve, who, while engaged in blowing through the larynx of a recently killed goose, was seized with a cough, and swallowed it. Eighteen hours afterwards he presented symptoms of asphyxia; and, on passing the finger down to the rima glottidis, it was ascertained that the larynx of the goose had passed through it. The entire larynx of the animal was with some difficulty removed; and the child was quite well on the ninth day. The larynx of the goose had twelve rings of the trachea connected with it.-P.H.B.]

BOOK V.

ON DISEASES OF THE THYMUS.

The thymus is a very large gland, which begins to appear at the second month of intra-uterine life, and which gradually increases up to the time of birth. It increases even yet after this period, according to Haugsted, up to the end of the second year. It weighs from seventyfive to 300, 450 grains. It extends from the base of the heart to above the clavicles, and sometimes to the larynx. After the second year, this gland becomes atrophied and disappears.

The thymus is sometimes wanting in cases of acephalia. Sometimes it is very large, especially in strong and well developed children, but this disposition does not cause any special symptoms. Thus, in sixty thymus glands of children of from two to four years, which M. Hérard has examined, fifty had the normal weight of from fifteen to sixty grains, and ten weighed from 105 to 555 grains. The ten children to whom these thymus glands belonged, died; six of croup, one of acute laryngitis, one of asthma, one of small-pox, and one of meningitis. The special phenomena in connection with the glottis, which are referred S to hypertrophy of the thymus, and which have been described under the name of thymic asthma, or the asthma of Kopp, are not absolutely allied to this hypertrophy. It is much more true to state that in the cases of asthma, considered as thymic, the thymus gland often preserves its normal dimensions, as the autopsies have demonstrated. This thymic asthma is only a spasm of the glottis and of the diaphragm, which has been previously described in the section on diseases of the encephalon, under the name of phreno-glottism.

1ST. INFLAMMATION AND SUPPURATION OF THE THYMUS. Collections of pus have sometimes been found in this organ; they have been remarked by several authors, but chiefly by M. Paul Dubois,

4

the

who attributes their formation to a specific inflammation occasioned by hereditary syphilis. In fact, this author has never met with this alteration except amongst infants exhibiting other phenomena of syphilis, or born of parents themselves affected with this disease, and that has sufficed him to establish the syphilitic nature of the alteration. This opinion will hold good as long as the possibility of a congenital suppuration of the thymus, independent of the venereal cause, is not demonstrated.

Care must be taken not to confound this abscess with the lactescent infiltration of fatty matter which is met with in the thymus in its physiological state.

[A single case is recorded by Portal, of a collection of serum in the thymus of a boy two years old. Alexander Wood refers to enlargement and induration of the thymus in children at the breast: and Hood directs attention to the doubtful fact that such enlargement and induration, when sufficient to exert marked pressure upon the veins conveying the blood from the head, may, under such circumstances, sometimes give rise to a hydrocephalic condition, and, at the same time, not rarely be accompanied by asthmatic trouble.

Dr. Mauch (Die Asthmatischen Krankheiten der Kinder) alludes to the frequency of scrofulous deposits in the thymus, especially during the first years of life, and details numerous cases. In connexion with pyogenesis in the thymus of children under two years of age, Dr. Mauch rejects the case of Sauvages, Naumann, Vogel, Billard, and Veron, as illustrative of the results of acute inflammation of the organ, and affirms that he knows of no satisfactorily recorded case of inflammatio suppurativa of the gland, or thymelcosis. Haugsted quotes a case of inflammatory softening, from Portal, and another from Mason, where the thymic abscess is stated to have opened into the trachea; whilst Hasse observes that "inflammation of this gland is, in point of fact, very problematical." Dr. Mauch, alluding to the cases in which was found in the serous cavities, as also in the thymus, observes that these purulent collections cannot be regarded in the light of abscesses, the consequence of suppurative inflammation, "seeing that they are neither enclosed nor secreted by a special (secerning) membrane."-p. 79.

2ND. DEGENERATION OF THE THYMUS.

The thymus may be transformed into scirrhous tissue, into tubercular or calcareous matter. The schirrous transformation is unknown in the child, and the calcareous transformation is also very exceptional. Binninger has, however, seen it once in a little girl three years old, who died of a disease of the ung, with cough and considerable dyspnoea. The tubercular transformation is, on the contrary, rather frequent, and is observed in scrofulous children who die with the tubercular bronchitis, and of tubercles in most of the viscera.