\ -r-rV CROUP. ^----W / ^ DIPHTHERITIS OR THE MEMBRANOUS DISEASE, COMMONLY CALLED MEMBRANOUS CROUP, AS IT APPEARS IX ROXBURY AND THE VICINITY OF BOSTON. By B. E. COTflNG, M.D. [Beprlnted from the Proceedlngt of the Boston Society for Medical Improvement.] BOSTON: DAVID CLAPP, PRINTER.........184 WASHINGTON STREET. MEDICAL ASD SCSCICAL JOURNAL OFFICE. 1S59. The substance of the following Paper was offered at the close of a discussion on " Diphtheria," so called, in the Norfolk (Mass.) District Medical Society, at its meet- ing in Roxbury, In July last. Subsequently, August 8th, the Paper was communicated to the Boston Society for Medical Improvement, and printed for its "Proceedings," in the Medical Journal. It is an attempt to rescue The Membranous Disease, an affection sui generis, the only one, in fact, entitled to the name of Diphtheritis, frofn the great and increasing confusion arising from the supposition that a new disease has appeared and is making progress amongst us, and augmented by the frequent practice of applying the term Diphtheritis, Diphthcrite, or Diphtheria, indiscriminately to membranous disease and Various other affections which differ from it and each other in causes, symptoms and history, and which, of themselves, never have a proper membrane—an application not justified by the derivation of the words, and already productive of much mischief. It is an attempt, also, to place the treatment of The Membranous Disease on a more ra- tional basis; and to prevent, if possible, milder disorders, or symptoms of other com- plaints, from being clothed with the terrors of that formidable affection. Roxbury, September, 1859. THE MEMBRANOUS DISEASE. " Another thing which prevents some practitioners from knowing the futility of their own prescriptions, and what Nature loft to herself can do> is that they never leave Nature to herself. The moment they are Called, they fall to work with their draughts, juleps, and apoxcms, and persevere with unrelenting assiduity till the disease terminates one way or the other 5 if the patient recovers, the medicine gets the credit; if he dies, the disease is thought to have been incurable."—Med. Sketches, by Jons Mooas, M.D. Lond., 1788. A membranous disease of the mucous tissues, peculiarly fatal when affecting the air-passages, has been known from time immemorial. Evidences of this knowledge may be found under " a vast variety of names " in the works of older authors, and we have the best authority for the assertion that " it may reasonably be doubted whether the ancients were not fully as well acquainted with dis- eases of the fauces and windpipe as the moderns are." This vagueness in names, " which have fluctuated perpetually in mean- ings ascribed to them," pervades also more recent descriptions, to such a degree that the number of new appellations has become even greater than that of the old. From the Prognostics of Hip- pocrates down to the late harangue of Trousseau, these names have represented symptoms, lesions, and localities, commingled in almost inextricable confusion. Singularly enough, the term most prevalent with the ancients, and that almost universally adopted within the last century, so far as they have any significance in themselves, indicate inconstant or unimportant symptoms merely, common to other complaints, or seldom occurring in true uncompli- cated membranous disease. The former has been obsolete for a 6 long time; the latter,* now the cause of much violent and misdi- rected treatment, should be restricted to a single form of disease, or else discarded from use altogether. Of all these appellations, ancient and modern, that given by Bretonneau, about thirty years ago, would have been the most worthy of universal adoption, had not he and his followers persist- ed in classing under it various kinds of " angina "t—thereby mak- ing it as vague as any of its predecessors. At first this term met with some little opposition and ridicule; subsequently it fell into apparent neglect, but now seems to be starting afresh into general favor. Such, however, is the professional tendency to extremes, that, from present indications, all the acute diseases of the throat and air-passages, however dissimilar, will before long have a place prepared for them under the expansive title of Diphthcrite, or its English corruption, Diphtheria. The original Greek word,! far superior in all respects to any of its recent derivatives, certainly indicates the peculiar characteris- tic of membranous disease; and perhaps it is not too late to hope that this or some other appropriate term may sometime hereafter be received and restricted to that disease alone. In the momen- tary indulgence of such a hope, the following remarks will be con- fined as far as possible to the membranous disease, commonly called in this vicinity " membranous croup "—a true diphtheritis. The con- clusions to be offered are founded on those cases only where the pe- culiar membrane was obtained and carefully examined, after spon- taneous ejection in cases of recovery, or by cadaveric autopsy. The membranous disease is an affection, the result of a distinct influence, giving rise to characteristic symptoms or outward mani- festations, through which, as is the case with other diseases, it be- comes known to us. These symptoms are both constitutional and local. The constitutional may be so severe and so rapidly develop- ed as to destroy life before the local have become a source of dan- ger ; or they may be so slight as to be overlooked. The local also may have the violence, though not the other characteristics of rapid inflammations, or their existence may even be a matter' of doubt until made evident by obstruction caused by the membrane fully formed. 'Croup: a vulgar Scol^^first introduced Into medical Itare by P. H0mTT^~ t On appelle encore commitment An,,:„,, cmrtdmcM (., ,„» lki,,. . , 'Y T,'P' . 7 It is a self-limited disease; having its beginning, middle, and ending, as marked and uniform in progress, and as uncontrolled by any means now known, as variola, measles, or any other disease that can be cited. It is as distinct from all other diseases of the mucous tissues, with most of which it has been confounded, as measles is from scarlet fever, which two were so long considered identical. The formation of the membrane, a constant condition (as constant as the eruption in variola*), does not always correspond in amount to the severity of the other symptoms, general or local—in this also resembling the diseases alluded to. The membrane may be only a thin film, or it may have the thickness and toughness of mois- tened parchment. It may cover only a very limited space, or it may occupy the whole mucous surface of the organs attacked. It usually forms gradually, at first a very thin layer (which may be likened in appearance, and adhesiveness to the surface beneath, to the first coat or "priming" of white paint on a pine board); then this layer becomes thicker and tougher day by day, until it reaches its limit. Its progress, so far as it has any, is from above downward, and any deviation from this rule is rather apparent than real. From the outset, however, it generally covers all the surface that it ever will during the attack, increasing only in density. Its thin- ness may prevent its being early noticed on parts within sight, though clearly visible at a later period of the disease. During its formative stage it remains firmly adherent to the mucous tissue beneath it; so firmly that it is impossible to remove it, even by the most careful dissection. As soon as this stage is completed, usually in four or five days from the onset of the disease, the mem- brane begins t*o loosen from its foundation, and soon becomes en- tirely separated. This is a process as natural as the separation of a scab from a sore; and if a portion be artificially removed by violence or otherwise, another forms in its place, as a new scab succeeds to one prematurely detached. When loosened spontane- ously, it creates sufficient irritation and cough to cause its expul- sion. It is sometimes cast off without observation, while at others its ejection is attended with convulsive efforts of the greatest se- verity. Harsh attempts, by emetics, probangs, and the like, to dislodge the membrane before its natural separation, are often • M.mbranous disease without tho membrane would be as great an anomaly as "variola tine variolis." • r? accompanied with fearful risks; and, could the proposed object be effected, it would involve a re-formation—more to bo dreaded in the exhausted state of the patient than its first appearing.* The membrane itself is of a peculiar structure—a tissue of elastic fibres longitudinally arranged; the fibres smooth and in no degree transversely striated. Great elasticity is one of its cha- racteristics. It is inorganic in its nature, or so much so that it never tends to organic union with the subjacent tissues. This membrane differs essentially from the lymph or plastic secretions which encrust the tongue, tonsils, and fauces, in many acute disor- ders and aphthous diseases of the parts; and which may be con- densed and removed in filmy shreds, or even generated, by the application of caustics or strong acids. These shreds sometimes greatly resemble the membrane, but ordinarily they can be as rea- dily distinguished from each other by experienced observers as the fabrics of linen and cotton can be by those who deal in them. Like theso fabrics, however, they may occasionally require minute and even microscopic examination to determine their true cha- racter. Membranous disease is a disease of childhood. But Nature knows no abrupt limitations. It occurs frequently in infancy, and is not unknown in advanced age. In infancy, however, the mem- brane seldom descends into the larynx, and therefore rarely be- comes a source of danger. In adults, on the other hand, forma- tions of a membranous character in the pneumonic portions of the bronchi are more common than generally supposed, but, being thrown off without difficulty, escape notice and are therefore sup- posed not to have existed. Their appearance, generally, is less leathery when from these parts, and, on that account, less liable to attract attention. When, on the other hand, such formations in- vest the trachea and larynx of an adult, they often become re- markably thick, firm, and adherent, and render a fatal result ex- ceedingly probable. Membranous disease is not very infrequent. In Roxbury, a city of now nearly or quite 20,000 inhabitants, during the past eight years, according to the public register, there have been 71 deaths from « croup." This may be considered about the true number of face, win an appearance somewhat similar to ulceration, may be noticed^ 1^ ^ 9 deaths from membranous disease, for although some may be so recorded which occurred from other causes, yet it is quite as pro- bable that as many died of this malady but were classed under other names, since the complaints commonly called "croup" in this vicinity are seldom or never fatal, unless of a membranous charac- ter. The number thus recorded gives about 1 death for every 40 from all causes; and, on an average, 1 in eacli year for every 2,200 inhabitants. The yearly average is 9—the least number being 4, and the largest 13. Of these 71 deaths, 1 only occurred in the month of July and 1 in August. In November there were 12 deaths; in February, 11; in April, 10. Although the proportion of deaths from this disease in this city has in sonic years equalled, or even exceeded, that of Paris in the years when it was there called epidemic, it has never been con- sidered epidemic here; nor has it been notably connected with any other epidemic. We have seen no evidence that it is contagious. Although seve- ral cases have sometimes occurred at the same time in the same household, the attending circumstances have been such as to pre- clude the probability of its having been communicated from one to another. Membranous disease occasionally supervenes upon other dis- eases— scarlet fever, measles, and the various diseases of the throat. In this respect, it resembles some other affections (ery- sipelas, for example) which appear spontaneously and alone as a general rule, but sometimes accompany, or become complicated with, other complaints. According to foreign accounts, it is a fre- quent attendant on severe or malignant anginas, as they term them, and perhaps common inflammatory diseases of the throat. Such is not the case in this vicinity. Whenever membranous disease occurs as a complication with any other acute or inflammatory affection, a fatal result is almost certain. It requires an acute and practised observation to detect mem- branous disease in the first hours of its commencement. So slight are its symptoms that parents frequently omit to send for their physician until the third or fourth day, and then often with hesita- tion, lest he should think the attendance unnecessary. At this later stage of the disease the patient usually has an anxious ex- pression of countenance and manner, and appears oppressed. He 10 labors in breathing—the prolonged inspirations and expirations being of nearly equal length and difficulty. But the peculiar close- ness or muffled sound of respiration is the principal diagnostic sign. It is very difficult to describe this sound. It can only bo learned by attentive and frequent observations. Yet it is more re- liable and therefore more valuable than all other diagnostic signs. Once in a while it can be detected before any other indication of the disease is manifest, say in the first two or three hours. Pa- rents have, in rare instances, detected it thus early, after having lost one or two children by the same disease, while the fatal sound was still ringing in their ears. The muscular movements of the face, neck, and chest, concerned in respiration, assume a peculiar laboring appearance or expression, which becomes more marked as the disease advances. But the difficulty of breathing is not always in proportion to the amount or thickness of the membrane, for this difficulty is much influenced by the more or less disa- bled condition of the muscles and other appendages of the glottis. When in other respects the disease makes equal progress, the difficulty of respiration becomes alarming in proportion as the membrane is very thick and abundant. The cough, if any, and the voice, when not stifled, partake of the characteristic sound of the respiration. But the patient speaks as seldom as possible, and then only in a whisper; and is not often troubled with cough until some portion of the membrane has begun to separate. When this separation has somewhat advanced, the paroxysms of coughing be- come more and more frequent, and resemble in a marked degree the ordinary efforts to dislodge a foreign substance, rather than a common cough. The pulse is not sensibly altered at first, but becomes more dis- turbed and frequent as the disease advances, and at last is very small, feeble and rapid. Where the disease is more constitutional than local, the pulse is more decidedly affected from the outset. The appearance of membrane in the throat, or on the tonsils, is only an indication that membranous disease exists in and involves these parts, but is no sure sign that it includes other places in the attack. Nor is the absence of membrane within sight sufficient evidence that the disease is not present, for it may have seized upon the parts below only. The tonsils and throat are often, in other diseases, covered with plastic or fibrinous products, which on a hasty glance may be mistaken for membrane, but which in reality 11 consist of other and variously developed materials, and must be regarded as essentially different from the croupous. These plastic, non-croupous exudations readily condense into shreddy sheets on the application of caustics or acids, and, brought up upon a probang, have been the source of many a wrong diagnosis. The tongue is often, but not uniformly, furred in membranous disease. There is generally no appearance of inflammation of the throat in uncom- plicated cases. If there be tenderness about the neck, it is usually slight. Pain is not often complained of; nor is swelling an ordi- nary symptom. The cervical and other glands are seldom affect- ed. The appetite often continues, and deglutition is comparatively easy. Sometimes the patient appears exceedingly tranquil and conscious, though laboring to exhaustion for breath; at other times he is restless, frequently changing his place and position. The whole surface of the body is often drenched in perspiration. Co- ma sometimes supervenes. Suffocation, often so imminent toward the last, sometimes takes place very suddenly. More frequently, the patient dies exhausted, worn out by the exceeding difficulty and unremitting labor in breathing. The disease has not the brevity nor rapid progress generally attributed to it—its earlier stages being overlooked or disregarded. On the approach of nightfall, the symptoms become aggravated, or rather attract more attention through the surrounding stillness. The careful observer will have noticed, however, that the disease has not in reality abated during the day. In the last named, as in almost every other respect, membra- nous disease differs essentially from that noisy breathing, or rather cough, so frequently attending catarrhal affections of the fauces and glottis, and which by its hoarse, or roup-like sounds, gave ori- gin to the popular name of croup. This kind of "croup," as it is called (improperly, if the same term must be applied to membra- nous disease also), is only a harmless symptom of another disor- der. Its noisy demonstrations and strangulating sensations are often exceedingly alarming to the inexperienced, but it derives most of its terror from being confounded with membranous dis- ease, with which it has little or no affinity. The danger, more or less, to the sufferer is only that which the " cold" or catarrh would give rise to without this attending disturbance. Children are said to be subject to it, which expression ought to satisfy one of its innocuous character. It occurs mostly in the night, suddenly 12 arousing the patient from sleep, and will soon pass off if left to its own course. It is generally, but without apparent reason, at- tributed to spasm of the glottis. The conjecture of palsy is more plausible. It is rather due to the catarrhal or other irritation, en- croaching upon and stiffening the parts. The paroxysm is often- times brought on by the irritation being aggravated at the moment by dryness from breathing through the partially open mouth—the nostrils having become obstructed by catarrhal secretions. If this " croupy " symptom need any special treatment at all, which is more than questionable, thin mucilaginous or aromatic liquids will prove sufficient. The usual practice of parents and physicians to attack it with great energy and " tumultuous rapidity " by emetics and other harsh agents, is entirely uncalled for, and may prolong into days what would of itself continue only a few hours—to say nothing of the unnecessary struggles and suffering of the patient. The only excuse for such violence is the fear that the complaint may " run into " the membranous disease—a thing which never happens. The sooner the two receive names as unlike as they are in nature, the better it will be for science and humanity. At any rate, the violent treatment should no longer be tolerated, for to no disorder are the words of Sydenham more applicable, that (i it often happens that the character of the complaint varies with the nature of the remedies, and that symptoms may be referred less to the disease than to the doctor." Without a due recognition of its true nature and laws, membra- nous disease has hitherto been treated, for the most part, most distressfully—by bleeding, leeches, cupping, blisters, sinapisms, mercurial and drastic purgatives, by emetics, often of the harshest kind, and lastly by severe cauterizations. That recovery takes place in spite of such treatment only proves how much mortal flesh may endure, and how much less dangerous the case may be than apprehended. Fortunately, most of these agents are becom- ing practically unknown to the new generations of practitioners, though there is still far too much to be unlearned. One by one the agents alluded to have been gradually discarded by influential individuals as having nothing but their power of disturbing the constitution, and of weakening the already weakened body, to re- commend them. Emetics, once considered the « divine remedy," and last to be laid aside, are now only resorted to by those who practise upon the traditions of the elders. Emetics cannot arrest 13 the disease; cannot dislodge the membrane until it has separated and is ready to be cast off by a natural process, nor even then without dangerous risks. They often throw the sufferer into a condition of lamentable debility. Their use should be avoided.* For some years past the application of caustics has been the gene- ral fashion, and their indiscriminate use the rage even, with the more zealous and incautious believers in their efficacy. Whatever these agents may do for other diseases, in membranous disease they can be little else than an injury. Being generally thrust into the pha- rynx only, they do not reach the seat of danger. The commotion necessarily attendant on their application, to say nothing of the local burn, greatly increases the risk of the patient. When they are applied by a competent hand, on an instrument small enough to enter the orifice,t and are actually forced within the verge of the glottis, the struggles and convulsions of the patient are vio- lent and uncontrollable, so that dangerous accidents not infre- quently happen, and even a fatal result may immediately follow the operation. Their use is deprecated by those whose great ex- perience, and observation of their effects in this disease, entitle their opinion to high confidence. Our own observation, the pri- vate testimony of many practitioners, and the publications of numbers of others, including advocates of the treatment, furnish so little evidence of good results^ from the use of caustics in mem- * An old friend, and senior by quite a number of years, on reading the foregoing pages append- ed the following : " True description ; my memory, my disturbed conscience so tell me. May I be forgiven for the calomel, the antimony, the ipecac, and the squills, I have given. I promise to afflict the innocents no more with them.'' t In children the length of the glottis (by frequent measurements) is from five sixteenths to three eighths of an inch ; and its width, at the widest part, not over one eighth. Age, under 12 years, makes but little difference in the size of the glottis. In disease the dimensions of the on6ce may be diminished by membrane, by inflammation, or by oedema. &c. The trachea is usually, at the pe- riod spoken of, less than half an inch in diameter. Yet, notwithstanding the position, size, diseased state of the parts, and other difficulties, reporters of cases speak of passing through the glottis and larynx into the trachea probangs charged with the strongest solutions of nitrate of silver, as though it were a thing of the greatest ease. Wo are even told of a sponge probaug, of sufficient size to enlarge mechanically the calibre of the air-tube, having been, with revivifying results, passed re- peatedly down the whole length of the trachea of a child then in a state of asphyxia, with purple face and lips, cold extremities, and clammy surfacc-and the profession coolly asked to believe ,t. Post-mortem indications (as sometimes reported) of caustic having; passed into the trachea are probably due, when really existing, to an overflow into the cleft of the glotns. open and s,,flened by disease, from a saturated sponge compressed on entering the pharynx. t The passing of the probang into the pharynx, by removing the accumulated mucus, occasion ally .eerns to afford relief for the time beta* bul these appearances are very decen ,v. The,,. ease generally soon becomes more desperate in eoosequencoof the interference. Il I. ne l,a,c the aKady loosened membrane be ejected soon afterward, the probang gets the credit of ,t, mos. 14 branous disease, while, on the other hand, the danger of evil and of even fatal consequences is so manifest, and the suffering so cer- tain and unavoidable, that it would seem in the light of science rashness and folly, and in the eye of humanity unmitigated cruelty, to persist in their employment. " I fear not to assert," says Trousseau, " because it is my entire conviction, that there would be vastly more success by tracheoto- my if, as sometimes happens, children could reach the croupal suf- focation entirely untouched by these kinds of treatment, which have no other result than to debilitate them." This is undoubt- edly true. It is also true, and needs but the trial for any one to be convinced of it, that children would be vastly better able to endure the severities of membranous disease, and to pass through its most fearful stages to ultimate recovery, if they could be left undisturbed by such dangerous kinds of treatment as we have just spoken of. What, then, is the best treatment ? Certainly that which, from the outset, will best sustain the strength, soothe the suffering, and, if possible, diminish, or at least not increase, the labor or the number of respirations, nor add to the struggles of the patient. Mild and nutritious diet, including, if possible, such articles as the patient willingly accepts, is to be preferred to abstinence, cer- tainly to a stimulating course. The inhalation of watery vapor, by an inhaler or other practicable expedient, is often, not always, very agreeable; and if it is not very effective, is at least without objec- tion.* A warm fomentation, or better still a warm emollient poul- tice, covering the whole anterior half of the neck, is probably of ser- vice. But above all, anodynes, sufficient to subdue restlessness and ensure quietude, are the most important agents. The particu- lar form is of little consequence. Dover's powder, or an equiva- lent syrup containing the strength of a grain of opium and a grain of ipecac to the ounce, is a very convenient form. The ipecac, however, is not important. Mucilaginous drinks are also general- ly acceptable. Such treatment, as old as the history of medicine, and incidentally mentioned with approbation by almost all writers, ancient and modern-such treatment, with that all-important care dul,?,! P°PUliari2 °f th;SkPraC,ice in *'» Vicinil*>te" °' fifteen years ago, was doubtless as much due to the good effect of abstumug from violent measures, as to any positive efficacy in the method 15 usually included in the phrase " good nursing," will increase the chances for a happy termination. So much for general or medical treatment.* As for tracheotomy, alternately advocated and decried in times past, and to which at- tention has of late been again directed, and which, Trousseau its present great advocate says, does not cure but only hinders from dying, it is difficult to speak as one would, without danger of mis- apprehension. The operator should certainly bear in mind that the disease is constitutional as well as local, and not merely an obstruction to respiration, that death often takes place even when the glottis and larynx are freely open, that the apparent revival on the first opening of the trachea is by no means a sure forerun- ner of resuscitation, that there are great and obvious reasons against any surgical operation during an acute disease, that the operation itself has its own peculiar dangers which are far from being trivial, that it is not safe in individual cases to reason on the reports of extraordinary restoration after hope, if not life itself, was extinguished ;t and further, he should remember that instances are not very uncommon of spontaneous recovery in desperate cases, after all treatment had been abandoned, and an operation, offered as the only chance, had been refused by the parents; and, still further, that if " they order this matter better in France," a large portion of their reported success must be attributed to dif- ferent forms of disease being included under one name, and to hospital attendance, appliances and after-treatment, rarely attaina- ble in private practice. It is time for the operation, if ever, when " the countenance becomes blue or extremely pale, when the inferior part of the sternum is enormously depressed during inspiration, when the • Perhaps allusion should have been made to the treatment by alkalies, those «' pretended specifics," as they are called by a distinguished disciple of Bretonneau. They were reputed to neutralize—a mere conjecture—the plastic condition—a pure assumption—of the blood in membranous disease. No analysis has as yet shown an abnormal plasticity of the blood in this disease. Besides, the membrane is not a mere mechanical or chemical exudation, condensed on comin- to the surface of the mucous tissues. If, however, any practitioner wishes to amuse him- self, o"r the attendants, by the administration of such agents, he can probably do it, in moderate doses, with less danger to the patient than by mercury or antimony, both of which have had a similar fictitious reputation. t \s for instance Berard's incredible case, where the heart did not beat until fifteen minutes, nor respiration return until fifty-seven minutes after the trachea was opened—4m. Jour. Med Seitneet, 2d Series, vol. iii. 16 vesicular murmur is totally absent in the lungs, when the pulse becomes frequent and small, when a sort of quietude succeeds to efforts of the most violent character, when, in fine, an indescriba- ble expression of countenance gives unmistakable signs of ap- proaching dissolution."* Tracheotomy having been decided upon and performed, the after treatment devised and recommended by Trousseaut and his con- freres in Paris, and improved upon by Dr. George II. Gay| and other members of the Boston Society for Medical Improvement, should be followed, and adapted to the exigencies of each particu- lar case. The introduction of calomel, caustics, and other agents through the wound, though suggested and advised by some high authorities, needs further trial and proof to warrant acceptation. In estimating the probability of recovery in any single case, there are many things to be considered. In infants, the disease, occupy- ing perhaps only the posterior nares or the pharynx, may be of little moment. In children, the constitutional symptoms may be a greater source of danger than the membrane. The location of the membrane may endanger life by suffocation, although the ex- tent of surface attacked may be very small. The amount of sur- face involved may be such as to destroy life even after the whole of the membrane has been spontaneously thrown off. Again, the membrane may be of such amount and in such position as to cause so great an obstruction to free respiration (though short of suffo- cation) that the excessive exertions in breathing, continuing through several days and nights without remission or the possi- bility of the least rest, may exhaust all the vital power. This is not an infrequent termination. The patient dies like an over- tasked animal, and there is reason for believing that a change takes place in the arteries, not unlike that when an animal is dri- ven to death. As it is very difficult if not impossible to ascertain very accurately the actual condition and extent of the parts in- • Trousseau, Rapport, Nov. 2, 1858, p. 25,1. 18, die. t A canula of a diameter superior to that of the glottis ; a double-tubed canula : a neck-cloth of good thick matenals, obliging the patient to inhale the air from around the jaws and not a mere piece of muslm ; a warm temperature, and a proper moisture of the air; cauterization of the lips of the wound ; lastly, supporting the patient by food, &c.-TrouSsead op cit p 58 t See published Records and Papers of the Boston Society for Medical Improvement' 1858 9 in Boston Medical and Surgical Journal, Vol. LIX., pp. 413, 417, 609. ,nProvement» '858-9, in 17 volved in the disease, a favorable prognosis must be assumed with greatest caution. In conclusion, from personal experience, we should say that the chance for a favorable termination of a case of membranous disease occurring in childhood, is about one in three. If anything better than this is to be hoped for in the future, may it not be from a much less perturbating treatment than that which is now generally adopted, with perhaps an occasional resort, in an extreme case, to tracheotomy, with its improved after management ? Such is a brief statement of some of the results of my own ob- servations in a very large number of cases, during a period of nearly twenty-five years. In the course of these observations I have repeatedly seen the membrane covering only the posterior nares and pharynx in infants, and once in a pair of nursing twins, both at the same time. I have seen in older children the mem- brane beginning below the larynx, and extending into the most distant divisions of the bronchi. In one of such cases, the patient, aged six years, while sitting up in bed and talking confidently of going to school, suddenly fell back and expired; the top of the membrane, which was loosened throughout, having fallen in, and completely closed up the orifice. I have seen a child, at the age of five and a half years, die on the sixth day of the disease, with the membrane in the trachea and branches, and only the slightest film in the larynx—worn out by the labor of breathing, without the failure of a due supply of air, and without the usual signs of suffo- cation—being simply exhausted to death. Ten days afterward I saw the younger sister die on the third day of the disease, with only a thin film of membrane extending less than an inch below the larynx, without being an obstaele to the free admission of air. In this case, as in some others I have seen, the membrane resem- bled a thin coat of white paint, and could not be removed by dis- section. In these last mentioned cases, the constitutional disturb- ance was intensely severe. I have seen several, who had thrown off all the membrane, to the amount of a wineglassful or more, sink away and die without any adequate cause that a post-mortem could reveal. So stealthy is the approach of this disease, and so unlike pre- conceived notions its progress, that in nine tenths of all the cases that I have seen, or known of, the nature of the disease was not 3 IS guspeetcd by the parents or friends until announced by the medi- cal attendant. I have seen a child, of six to seven years, playing in the melting snows of spring, within twelve hours of his death, the parents entirely unsuspecting dangerous disease (though the child had been unwell for several days), and indignantly repelling the physician who intimated that a fatal result was impending. While writing this sentence, I am attending a little boy, of six years, now convalescent, having ejected spontaneously a large amount of membrane eight days ago, in whose case the parents, very intelligent people, have not to this time suspected " croup," which they hold in great dread. In another case, where their fears had been aroused and their ears were still vibrating with the sounds pointed out to them in an older child then lying dead in the house, the parents thought they heard the fatal breathing and summoned me at once. It was ea*rly morning; I listened for more than half an hour at a time, and still could not be certain. Treatment, however, was commenced. Before forty-eight hours, the disease was sufficiently manifest, and went on its usual course. The crisis was past with ejection of the membrane seven days af- ter our first observation. The patient had not strength enough to rally, but sank exhausted on the fourteenth day. I have seen four cases, with three recoveries, in the same family, at the same time. This family had lost a child of the same dis- ease some years previously, in the country, yet did not recognize its recurrence as " croup," until it was told them. I have performed tracheotomy, unsuccessfully, when the mem- brane was found not to extend below the larynx, and again where it involved all parts, even to the bronchi. I have seen recoveries under almost every variety of treatment. I have seen more than one recover in rooms filled with the steamy atmosphere of cook- ing stoves; while all so situated seemed to suffer less than others in drier apartments. I have seen several recover, where no re- medial measures, real or pretended, were adopted; and still oth- ers, where only infinitesimals, equivalent to nothing, had been pre- scribed—even after abandonment, as hopeless, by the regular physician. In all these cases, and in all others on which the foregoing re- marks have been based, the peculiar membrane was obtained and examined. Those cases in which the membrane was thrown off or 19 found, and therefore known to exist, should alone be received and allowed to influence any discussion on this disease. After these opportunities of observation, and such an experience in the management of this disease, I cannot but express my con- viction that if the mild, rational treatment, and principles of ma- nagement above recommended, were generally adopted, the pro- fession would be a good deal surprised at the favorable result of the experiment. f