24 AFFECTIONS OF THE LARYNX. 



place gradually with occasional expectoration of quantities of tough 

 sputum, containing a more or less profuse admixture of flakes of coagu- 

 lum the cough becoming easier, the voice louder, the symptoms of 

 narcotism disappearing, as the embarrassment of respiration subsides. 



In other instances, however, which are far less numerous than is 

 generally supposed, large masses of pseudo-membrane, and often tubular 

 casts of the bronchi, are thrown out after violent coughing, retching, 

 and vomiting, so that the breathing, till now extremely oppressed, sud- 

 denly becomes much more free. The child is safe from immediate 

 danger, if a reproduction of the exudation do not once more occlude 

 the glottis, or a new exacerbation of the inflammation again produce 

 oedema of the laryngeal muscles. >,"" 



After subsidence of the croupous process in the larynx, when its dura- 

 tion has been somewhat protracted, many children perish from hyperaemia 

 and oedema of the lungs, and bronchial catarrh. The comparatively 

 ill success of tracheotomy, after protracted croup, is entirely due to these 

 complications, the frequence of which we can easily show to be a neces- 

 sary result of the previous disease. When the thorax is expanded, and 

 the alveoli are made to dilate without allowing the atmosphere to pene- 

 trate into them, the air already contained in the bronchi and air vesicles 

 must be expanded and rarefied. The bronchial mucous membrane and 

 inner wall of the air-vesicles during croup are thus placed in a condition 

 similar to that of a portion of external skin under a cupping-glass. 

 Hyperaemia and increased secretion are the necessary result of the sus- 

 pension or diminution of the pressure to which the capillaries are habitu- 

 ally subjected. The circumstance recently urged by Bohn and Gerhardt 

 in their two valuable works upon croup, that bronchial catarrh invariably 

 and promptly associates itself with croupous laryngitis with constricted 

 glottis, seems to me to argue in favor of the genetic connection of the 

 two processes. With regard to the croupous pneumonia and bronchitis, 

 however, which complicate laryngeal croup in many cases, it is quite 

 otherwise. As I have stated in the opening words of this text-book, it 

 is catarrhal inflammation only which arises in consequence of vascular 

 engorgement of a mucous membrane.* I shall repeatedly recur to the 

 impropriety of regarding other forms of inflammation as an exaggeration 

 or a consequence of simple hyperaemia. " That the danger from croupous 

 laryngitis is considerably heightened by the addition to it of bronchial 

 catarrh " is perfectly admissible ; that, however, in real croup, " death 

 always proceeds from bronchitis or broncno-pneumonia " (JBohn) is cer- 

 tainly an exaggeration. The symptoms of the secondary croup which 



*I have no objections to make against the opinions of authors who do not consider 

 catarrh as an inflammation, but rather as derangement of secretion, characterized b) 

 swelling and succulence. 



