The more severe variety is well illustrated by cases of scald or burn of the larynx, although, as has been said, the affection is sometimes due to other causes.
Immediately after the scald the child complains of pain in the throat, and this part on inspection is seen to look white and shrivelled ; but there is at first no difficulty of breathing and the larynx seems to have escaped. The patient screams violently and will not attempt to swallow ; but after a time the immediate effects of the accident appear to pass off, and when put to bed the child falls quietly asleep. After a few hours, however, usually from three to six, his breathing is noticed to be noisy and whistling. Laryngitis has now begun. The respirations become laboured and rapid ; the face is pale and tinted with lividity about the eyelids and mouth ; the pulse is small and feeble ; the skin is cool ; the extremities are cold ; and the child is drowsy, although he can be roused with difficulty. If at this stage the finger be passed into the back of the fauces, the epiglottis will be felt hard and swollen to the shape of a gooseberry or small marble. There is recession of the soft parts of the chest in inspiration, and an examination detects sonorous and sibilant riles all over the lungs. There is no dulness on percussion.
After a few hours all the symptoms become aggravated. The breathing is more and more laboured and "croupy," the larynx rises and falls rapidly, and at each inspiration the soft parts of the chest—the intercostal spaces, supra-clavicular foss, and the epigastrium—sink deeply in. The child lies with his head retracted, his face swollen and livid, his eyes injected, his nares acting, and his mouth open, making convulsive gasps for breath. His extremities are cold, and his pulse is often too frequent and feeble to be counted. Although only half conscious the child is much agitated, tossing his arms about and showing signs of the greatest distress. Per cussion of the back usually detects some want of resonance, and much large bubbling is heard in the air-tubes. Sometimes there is local dulness from collapse of lung. In this state the child may sink and die slowly, or expire more suddenly in a convulsive fit.
The above is an aggravated case, but 'unfortunately far from an uncom mon one. Death may occur as early as twenty-four hours after the acci dent. The end is not, however, always reached so rapidly. The child may linger for two, three, or four days before he finally sinks ; or life may be prolonged to the end of the week. The duration depends in great
measure upon. the degree of interference with respiration and the patient's capacity for taking nourishment. If the cedema of the glottis be less com plete, the breathing after being laboured and stridulous for twenty-four or forty-eight hours, with signs of deficient aeration of the blood, may become easier, and then gradually return to a normal state. The voice is very hoarse and the cough " croupy." In these cases the dyspncea varies in degree from time to time, being subject to occasional increase when the child is distressed or made to swallow. After the cessation of the more urgent symptoms the voice may remain hoarse and the cough be occasion ally " croupy " for some days.
A little boy, aged four months, was brought to the East London Chil dren's Hospital at one P.M. On the previous night the bed on which he was lying had caught fire, and the child, who had been placed on a water proof cloth, was surrounded with flame and smoke. Happily he was quickly rescued, although not before the palliasse had been nearly destroyed. When taken out his body was blackened with the smoke. Soon afterwards his breathing became difficult, and at times the mother thought he would be suffocated: On admission the skin of the arms was seen to be tinted brown from the action of the heated air, but there was no external sign of burn. The infant's breathing was laboured, and his cry hoarse and weak. At each inspiration the soft parts of the chest receded deeply. The face was dusky, the pares acted strongly, and the external jugulars and superficial veins generally were unusually Visible. The fauces looked red and swollen. Temperature, 98° ; pulse, 160 ; respirations, 72. In the evening the tem perature rose to 103° ; pulse, 140 ; respirations, 80. The child slept fairly well in the night, and in the morning expectorated a piece of membrane one inch in length and a quarter of an inch broad. It had the ordinary naked-eye appearance of false membrane. The next day the breathing was easier and the lividity of the face less. Two days afterwards signs of pneumonia were discovered at the left back ; but this disease ran a favour able course, and in about ten days from the time of the accident the child was convalescent. He never had any difficulty in swallowing. He was treated with hot linseed-meal poultices and a saline mixture containing small doses of antimonial wine.