in the presence of laryngeal diphtheria the muscles of the vocal bands are rather in a paretic state, which, among other circumstances, is readily explained from the serous infiltration of the muscular tissue.

The duration of laryngeal diphtheria is not rarely from one to three days; occasionally the disease is protracted for a week. Only exceptionally does the disease last longer, although isolated instances have been recorded in which croupous membranes were expelled for more than nine weeks.

Death is generally the result of asphyxia, which may be caused by extreme laryngeal stenosis or by the supervention of lobular pneumonia, or both together.

Among the complications of laryngeal diphtheria bronchitis and bronchopneumonia are most frequently encountered. The latter is by some physicians designated croupous pneumonia in consideration of the primary disease. Occasionally the violent respiratory movements cause rupture of pulmonary alveoli, in consequence of which interstitial emphysema of the lungs, and, secondarily, subcutaneous emphysema (earliest in the jugular fossa), or occasionally also pneumothorax result. Acute emphysema of the lower and median borders of the lungs will be recognized from the fact that the upper border of liver-dulness is unusually low, and the area of cardiac dulness is diminished in extent. Atelectatic areas in the lungs must attain an extent and thickness of at least four or five centimeters in order to give rise to dulness on percussion and to bronchial breathing. In contradistinction from pneumonic foci, they are characterized by the fact that they disappear within a short time as soon as the airless portions of the lungs are again distended with air. Pericarditis and endocarditis are rare occurrences. The liver often is increased in size in consequence of venous hypostatic hyperemia. Delirium and coma occur when the blood contains an excess of carbon dioxid. Death is occasionally preceded for a short time by clonic muscular contractions.

Among the sequelae of laryngeal diphtheria long-continued hoarseness, chronic bronchitis, and pneumonia may be mentioned. In some patients also distention of the lungs-that is, alveolar emphysema of the lungs-persists. At times laryngeal diphtheria is followed by scrofulosis, pulmonary tuberculosis, or, after some time, by miliary tuberculosis.

Diagnosis. In the differential diagnosis of laryngeal diphtheria other varieties of acute laryngeal stenosis, such as occur in children, especially in consequence of marked catarrhal states, as pseudocroup, must first be taken into consideration; further, the entrance of foreign bodies into the larynx and the presence of retropharyngeal abscess. Acute edema of the glottis occurs but seldom in children. In cases of retropharyngeal abscess a fluctu

ating prominence will be visible and palpable upon the posterior pharyngeal wall, while in the presence of foreign bodies the history is generally important in the diagnosis. In the differentiation between pseudocroup and croup inquiry should be directed to determining whether diphtheric alterations are present in the pharynx, which would be in favor of croup. In addition, instructions should be given to collect all of the expectorated and vomited matters in order that they may be examined for croupous membrane. The fact that pseudocroup is generally unattended with danger to life, and that the symptoms of acute laryngeal stenosis do not, as in the case of croup, increase progressively, but frequently disappear during the day, to return on the subsequent night, as well as that pseudocroup not rarely is frequently repeated in children in the course of years, whereas croup generally occurs but once in children, can but seldom be depended upon in the differential diagnosis.

The most rapid and the most certain means of clearing up the diagnosis consists under all circumstances in laryngoscopic examination, the practice of which in children, it is true, is in and of itself difficult, but which is particularly attended with great difficulty in children in a state of threatening suffocation. In the laryngoscopic image the interior of the larynx will be seen to be covered with the characteristic fibrinous deposits. The vocal bands exhibit, besides, deficient respiratory and phonatory mobility.

Attention should be directed at this place to the fact that not all fibrinous inflammations of the laryngeal mucous membranes are caused by diphtheria-bacilli. The circumstance that diphtheric lesions are present in the pharynx would be in favor of laryngeal diphtheria. Should these be situated upon the posterior surface of the pharyngeal structures, they may readily escape

detection.

In cases of idiopathic or primary laryngeal diphtheria the diagnosis can be made with certainty only when diphtheria-bacilli are demonstrated in the expectorated shreds of membrane. The same anatomic alterations are, in rare instances, induced by other bacteria, as for instance, streptococci; and even toxic influences (the accidental entrance into the larynx of ammonia or acids, the inhalation of the vapors of chlorin, burns of the skin) may bring about similar anatomie alterations.

Prognosis. The prognosis of laryngeal diphtheria is most serious, as the majority of children die in consequence of asphyxia. The younger the child the greater is the danger, for especially in childhood, and particularly in early childhood, the laryngeal cavity is relatively quite small, so that even slight obstructions to the air-current may be followed by serious consequences. In addition, the results of tracheotomy, if rendered necessary, are the less certain the younger the child operated upon.

Treatment. The treatment of laryngeal diphtheria resembles wholly that of pharyngeal diphtheria in all cases in which laryngeal diphtheria occurs as a complication of pharyngeal diphtheria. Subcutaneous injections of Behring's antitoxic serum have, however, also been recommended in the treatment of primary laryngeal diphtheria. In addition, in order to facilitate the expulsion of the croupous membrane, the air of the room should be kept moist by vaporizing hourly, by means of the inhalation-apparatus of Siegle, sodium-chlorid solution (0.5 per cent.) or lime-water, at a considerable elevation. Lime-water, lactic acid, and other solvents of fibrinous membranes have also been employed by inhalation, although success is scarcely to be expected on account of the dilution of the solutions and because the inhaled fluid scarcely penetrates to the deeper portions of the larynx.

Patients with laryngeal diphtheria should always be provided with experienced and intelligent nurses, who know at once what should be done in a case of croup, when suffocation is threatened. An emetic should be kept in readiness, for occasionally membranes are expelled from the larynx in the course of the act of vomiting, after which the danger from suffocation lessens; for instance:

R Solution of copper sulphate, 1.0:100 (15 grains : 3 fluidounces). Dose: 10 c.c. (2) fluidrams) to be taken every ten minutes until vomiting occurs.

R Solution of apomorphin hydrochlorate,

Dose: 3 minims by subcutaneous injection.

0.2:10 (3 grains: 2} fluidrams).

The most certain means of averting the danger of suffocation either consists in the introduction through the mouth of metallic tubes into the pharynx, down to and between the vocal bands— intubation of the larynx; or the trachea is opened below the true vocal bands by means of an incision, into which a silver tubetracheal cannula-is introduced-tracheotomy. As the relatives generally object to bloody operations upon the patient, intubation is at the present day practised earliest and more frequently than tracheotomy, although it sometimes happens that it does not afford the desired relief, and tracheotomy subsequently becomes necessary. In this connection it should be borne in mind that neither operation will any longer be capable of affording relief when the bronchi or the lungs are already involved in the inflammatory process, and the respiratory area is excessively contracted and diminished. It is, therefore, important not to undertake the performance of the operation too late. It may also be of advantage to employ injections of antitoxic serum after the operation.

The prophylaxis of laryngeal diphtheria is the same as that of pharyngeal diphtheria (p. 464).

NASAL DIPHTHERIA.

Etiology.-Nasal diphtheria is generally a secondary disease, complicating antecedent pharyngeal diphtheria. Primary nasal diphtheria occurs but seldom. From the nature of the causative factors it can be understood why the disorder is most common in children.

The anatomic alterations are generally those of a necrotic, less commonly those of a fibrinous, inflammation.

The symptoms are the same as those described on p. 459. The diagnosis is not difficult, but should always be confirmed by bacteriologic methods.

The prognosis is grave, as death may result from septicemia. The treatment consists in the employment of Behring's antitoxic serum, in systematic irrigation of the nose with solution of mercuric chlorid (0.1 per cent.) or with lime-water, or in tamponade of the nares by means of absorbent cotton through the anterior nasal orifices.

The diphtheria-bacillus is capable of thriving in other situations than upon the mucous membrane of the pharynx, the larynx, and the nose, although such disease belongs to other departments of medicine. Occasionally diphtheria develops upon external wounds or upon the ocular conjunctiva. Necrotic alterations in the mucous membrane of the esophagus, the stomach, the intestines, the biliary passages, and the urinary passages are likewise designated diphtheric by such clinicians as do not restrict the name diphtheria to those diseases that are induced by diphtheria-bacilli. Under such circumstances other bacteria are generally operative.

II. TUBERCULOSIS.

CHRONIC PULMONARY TUBERCULOSIS.

Etiology. Chronic pulmonary tuberculosis is generally known as pulmonary consumption or pulmonary phthisis, and is an exceedingly widespread disease, as about one-seventh of all deaths are due to it. Like all tuberculous diseases, chronic pulmonary tuberculosis also is dependent upon the tubercle-bacillus discovered by Koch in 1882. Nevertheless, it should be borne in mind that, in most cases, other bacteria, and among these pyogenic cocci, especially Streptococcus pyogenes, also are found, together with the

1 With a view to precision, the use of the terms "consumption" and "phthisis" in place of "tuberculosis" is to be discouraged, inasmuch as tuberculosis is not invariably attended with destruction and wasting, while, on the other hand, these may attend non-tuberculous processes. In addition, the terms objected to imply a more unfavorable prognosis than the more strictly correct term, and have a correspondingly more depressing effect upon the patient.-A. A. E.

tubercle-bacilli, so that in the majority of cases of pulmonary tuberculosis a mixed infection is present, in which the tuberclebacilli, it is true, play the fundamental role under all circum

stances.

Infection with tubercle-bacilli will occur the more readily if favored by contributory factors. Among these, in the first place, the conformation of the body-constitution-is to be included. Experience has shown that generally not thick-set and robust persons are attacked, but rather tall, delicate, pale persons, with a long, narrow, and imperfectly distensible chest, a bodily constitution to which the designation phthisical habitus also has been applied. This is transmitted by heredity in some families, so that the physical conformation is hereditary.

Infection with tubercle-bacilli is favored further by a deficiency of pure, fresh air. Persons who spend the entire day in closed factories and workrooms, and inhale dust, are not rarely attacked by pulmonary tuberculosis, while the disease is rare in mountaineers and in sailors. A distinct difference is appreciable between those who live in the country and those who live in the city, to the detriment of the latter; and among urban dwellers those are attacked with especial frequency that live in overpopulated, damp, manufacturing cities. It can be understood that the danger of infection is increased by all such conditions as diminish the resisting powers of the body, including deficient nutrition, long-continued disease, anxiety, grief, and emotional disturbances of all kinds. It is also comprehensible that other antecedent disease of the lungs will render these organs more susceptible to infection with tubercle-bacilli. Injury to the chest, without obvious external wound, also favors infection.

Two varieties of chronic pulmonary tuberculosis are to be distinguished-primary and secondary. In cases of primary pulmonary tuberculosis the lungs become independently the seat of disease, while in cases of secondary tuberculosis infection of the lungs is consequent upon tuberculosis of some other viscus.

Primary pulmonary tuberculosis probably is generally of aërogenic origin-that is, tubercle-bacilli are inhaled with the air. The air in the vicinity of persons suffering from pulmonary tuberculosis contains tubercle-bacilli, because in the act of coughing, of sneezing, and even of speaking, a portion of the sputum containing tubercle-bacilli is disseminated in the air in the form of minute drops. In addition, the sputum of tuberculous patients, if expectorated without special precautions, dries, and becomes converted into powder, inhalation of which likewise gives rise to infection. Constant association with patients suffering from pulmonary tuberculosis is accordingly not free from danger, and sisters in religious orders are, therefore, frequently attacked by that disease, as, in the first place, they are in nursing brought