This is a far more serious disease than the last, and has proved rapidly fatal in a large portion of cases.

The main cause of this complaint is exposure to cold, or to cold and wet; and young persons from tropical climates are very apt to be attacked soon after their arrival in Europe. The disease is liable also to be caused by mechanical violence or by chemical injury done to the Larynx. It has been caused on many occasions, in children,by their attempting to swallow boiling water out of a tea-kettle. The mineral acids, taken as poisons, have excited the disease, as also has the incautious application of Ammonia to the nostrils, in cases of hysteria, and of suspended animation; and Sir Thomas Watson mentions that he once knew a man nearly killed by the inhalation of the fumes produced from Cinnabar thrown upon hot iron, for the purpose of fumigation; and another case produced by the bungling attempt of a young surgeon to introduce the stomachpump, in a case of poisoning. But inflammation and swelling of the lining of the Larynx not unfrequently take place, and prove suddenly fatal in the course of other diseases. In inflammation of the tonsils, the inflammation will sometimes spread to the Larynx, and the same thing will sometimes occur in Small-pox, Measles, and Scarlet Fever.

At the commencement of the disease the patient complains of sore throat, and, if you look into his throat, you will perceive a certain amount of redness; but there is more restlessness and anxiety than can be accounted for by the visible inflammation. Occasionally among the earliest of the symptoms that betoken danger, and ought to excite alarm, is a difficulty in swallowing, for which no sufficient cause is visible in the throat; (whereas in Quinsy the reason of the difficulty in swallowing is sufficiently plain, the swelling of the tonsils); and to this is presently added a difficulty in breathing, for which no adequate cause can be discovered in the chest. The mode and character of the breathing are peculiar; it is attended with a throttling noise, as though the air were drawn in through a dry narrow reed. If you ask the patient where he feels the pain and distress, he points to that swelling on the throat, known as "Adam's Apple." If he coughs, he coughs with a peculiar harsh or else with a dry husky sound. He either speaks quite hoarsely, or all power of audible voice is lost, and he speaks by means of his lips and tongue only, in a whisper. There is tenderness of the cartilages of the Larynx, and they are painful if pressed externally. The face is flushed; the skin hot and dry; the pulse hard. As the disease advances, the patient's general distress increases: his countenance becomes pale or livid, anxious and ghastly; his eyes protrude; he is miserably unquiet; impatient for relief; declares or makes signs that he wants air, and begs that the window may be open; and if he does not obtain relief quickly, he dies choked.

The cause of this terrible disease is simple: the passage leading to the lungs is so obstructed and closed up that the patient grows drowsy and delirious, and dies by a slow process of choking. When fatal, the disease has generally run a rapid course, and carried off the patient before the fifth day. Death has occurred in less than twelve hours.

Treatment

In a case of this nature, time is important. If bleeding is to be done at all, it must be done early. In some cases bleeding appears to have saved the patient; in others it was of no service. Sir John M. Hayes suffered two attacks of this disease. In the first he was freely bled. Dr. Roberts informs us that the first bleeding was attended with considerable relief; the second also with manifest advantage; and by the third, his safety appeared to be insured. Fifteen years afterwards he died of the same disorder, although he was again bled and leeched. Again, Dr. Francis, of New York, recovered from this disease, after copious bleeding, and still survives.

Sir Thomas Watson says: "When I say that you must bleed early, if at all, I do not mean that you are to reckon so many days or hours from the commencement of the disorder; but you must ascertain what progress it has made; for it travels sometimes at a railroad pace. You must look to your patient's actual condition. When there is high inflammatory fever present, and the skin is hot, the pulse firm and full, the cheeks are red, and the lips florid, you may take blood locally from your patient with decision and advantage. But, if his powers are beginning to sink; if his skin be cold or even cool, his face pale or leaden, his lips blue, his pulse small and feeble, his mind wavering, you will do no good by bloodletting; nay, you will increase the danger which already exists, and hasten the fatal catastrophe."

If blood is taken locally, it will be best to take it by cupping from the back of the neck, or by leeches applied behind the ears; and a blister may be applied to the upper part of the chest, and not on the throat.

The feet and legs may be placed in hot water, and the outside of the throat may also be fomented; the following mixture may be taken, and continued till there is a certainty that its longer administration will be of no benefit: that is, till the inflammation has subsided, or there is a certainty that the patient's life cannot be saved without an operation:

Antimonial Wine..................................One Ounce.

Tincture of Henbane.............................Half an Ounce.

Water sufficient to make half a pint.

A tablespoonful to be taken every two hours.

When the disease is so far advanced that dependence can no longer be placed on medicine to save the patient's life, when the obstruction is so great that the patient must either be operated on or die, there need be no hesitation. Dr. Watson says: "It may, I repeat, be right and our absolute duty, to propose and to perform the operation even in cases that are utterly hopeless, with the different view of prolonging life for a while under circumstances of instant danger, and of rendering the act of dying at last more easy." "When you have good evidence that a mechanical obstruction to the passage of the air exists in the Larynx, and that the tubes beyond the Larynx are open and free, there are two things that I would urge upon you. First, I would most earnestly advise you not to wait too long before you propose or perform tracheotomy; and secondly, never to omit performing it merely because it may appear to be then too late." "If, in the acute and limited disease, an artificial opening be made while the patient's strength is yet entire, and before his whole system is poisoned with venous blood, or his lungs are overwhelmed with sanguine congestion and serous effusion, it will almost surely save his life. But, if the sinking of the vital power have got beyond a certain point, tracheotomy will not save him. It is a bad and foolish practice to wait, and try other methods, and postpone the operation as a last resource. In my own case, I should choose to be operated on early; the moment that I found early bleeding was not telling upon the local distress, and that any shade of duskiness became perceptible on the skin." "On the other hand, if you do not see your patient till his powers are nearly exhausted, do not abstain from the operation, even though you may feel convinced that it will be unsuccessful, for if it do not save life, it will deprive death of its agony. A patient will sometimes lie for hours, painfully labouring for breath in deep and strong catches, at considerable intervals from each other, being in fact, in the condition of a man with a cord round his neck, not pulled quite tight enough to suffocate him at once. Besides it is not always easy to say whether the period of possible recovery is gone by."

The operation has been performed, with success, in cases in which the patient appeared to be, if not dead, at least at the last gasp.

When a sufficient hole has been made in the windpipe, the voice of course becomes extinct, or nearly so; and the patient can neither speak nor cough. Now this is of some importance to notice, for he often wants to cough, in order to clear the air passages of mucus, or of blood, by which they may be embarrassed; and he may be helped to do so, or taught to help himself. First, he should draw in a full breath, and then stop the orifice for a moment with his finger, while he forces out the air. And, as the parts within the Larynx recover, the patient, by a similar manoeuvre, may enable himself to speak aloud.

The operation has been performed upon very young children. Sir William Fergusson operated with complete success upon an infant about two years old. Trousseau was equally fortunate with one infant of thirteen months, and with another two years old all but six days.

An opening having been made in the windpipe in order to prevent immediate death, it must be kept open, in order that the patient may breathe through the opening till the inflammation has subsided, and the thickening of the membrane has disappeared; and then the artificial opening may be suffered to heal, and the patient can again draw his breath through the natural channel.