escaped into the poultice, and a more copious outflow has taken place daily on the removal of the tent; and it has happened once or twice that the discharge has diminished rapidly as the lung expanded; and that at the end of two or three weeks the opening has been permanently closed. But to this more fortunate course there are, it must be confessed, frequent exceptions; the pus has often speedily become fœtid, thin, and irritating; and hectic symptoms have supervened. In these circumstances I have washed the chest out with tepid water every day; and have employed a solution of iodine, which, when it has failed to check the discharge, has almost always had the effect of greatly lessening the fœtor. It still, however, remains a question whether, if air could be perfectly excluded from the pleura while provision is made for the escape of the matter, a much more certain and a speedier recovery might not be ensured. A case where my colleague, Dr. Buchanan, by means of a canula fixed in the wound, the end of which was opened once a day, and the pus removed by Bowdich's exhausting syringe, and which had a remarkably favourable issue, appears to me to invite further trials in the same direction. There are some difficulties in the details of any plan with this object, but they might, I think, be overcome. There are other cases which call for notice, where the wound made in tapping continues fistulous, or where the opening made by nature remains unclosed. In two cases of this kind I tried the system of drainage as recommended by Dr. Goodfellow. The result, however, was not quite satisfactory, for the presence of the tube seemed to produce increased irritation, and to render the discharge more profuse, while the posterior wound in both cases became unhealthy, and compelled the removal of the tube. Considering that the great elasticity of the chest-walls in early life, while it favours the occurrence of deformity has the counterbalancing advantage of facilitating the escape of matter, I have employed on two occasions a silver-gilt canula adapted to a broad shield, which has admitted of the ready outflow of the pus, and has allowed of the washing out of the pleura with tepid water, and the injection of iodine solution into it. I have begun with one part of tincture of iodine to seven of water; and have increased its strength to one in four; but have always allowed the injection to flow out immediately. In several cases this has had the effect of restraining the discharge of pus; I think I may say of arresting * Medico-Chirurgical Transactions, vol. xlii.. BB 370 DEFORMITY OF CHEST FROM CHRONIC PLEURISY. its secretion, and I have in no instance seen harm result from its employment. Lastly there remains the question of the best means of obviating that deformity of the chest which follows in cases of chronic pleurisy on the hypertrophy of the sound lung, and the shrinking of that side on which the effusion was situated. These changes in the chest call for a more attentive study than they have yet received, for time seems to play a considerable part in removing much of the deformity which seems to threaten soon after paracentesis has been performed. This, no doubt, is due to the gradual expansion of the compressed lung, which takes place to a greater extent than, judging from the case in its earlier stages, one would have thought possible. Still, whenever the contraction seems to be steadily on the increase, I should recommend the employment of Tavernier's belt, with a crutch under the arm of the contracted side; a contrivance which has seemed to me to arrest the progress of the deformity, and to give opportunity for nature to restore in great measure the symmetry of the two sides of the trunk. LECTURE XXIII. CROUP. Reasons for not studying it earlier in the course-discrepancy of opinion with reference to it-two distinct though allied diseases included under the name. LARYNGEAL CROUP; or CYNANCHE LARYNGEA.-Causes of the disease-its frequency in childhood, in the male subject, in northern climates, in rural districts. Post-mortem appearances-variations in the extent of false membrane in the airpassages changes associated with it-affection of the fauces and soft palate. Symptoms-occasional sudden onset-catarrhal stage, general course of a fatal caseoccasional delusive appearances of amendment.-Evidences of auscultationchanges in tracheal sound. Duration. Prognosis. Treatment-importance of abstraction of blood-directions for its performance, and for the administration of tartar-emetic-when and how mercurials are to be employed. Modifications in treatment produced by alterations in epidemic constitution. Importance of not exaggerating them, and of not confounding in their treatment croup and diphtheria. IN strict propriety the very important disease which we are about to investigate to-day ought to have engaged our attention immediately after we had completed our study of infantile bronchitis. Two reasons, however, independent of mere convenience, have led me to postpone till now the consideration of the subject of croup. One of these reasons is, that its gravity is often greatly increased by the association with it of inflammation of the lungs a complication the importance of which it was essential that you should thoroughly understand; the other is, that croup, though an inflammatory disease, is not without a very evident spasmodic element in every case: so that it may very appropriately form a sort of transition between the inflammatory and the spasmodic diseases of the respiratory organs. It can scarcely be necessary to tell any of you that croup is the English name for the disease designated by scientific writers cynanche trachealis, or cynanche laryngea. It consists in inflammation, generally of a highly acute character, of the larynx or trachea, or of both, which terminates in the majority of cases in the exudation of false membrane more or less abundantly upon the affected surface. The formidable nature of the symptoms by which it is attended, and the rapidity with which it tends to a fatal issue, have led 372 TWO DISEASES INCLUDED many of the ablest physicians to devote much time and attention. to the study of croup. It might, therefore, be anticipated that our knowledge of a disease which betrays itself by very manifest and highly characteristic symptoms, and which gives rise, when fatal, to changes easily appreciable after death, should, by this time, be very definite and settled. With reference to many of the more important points in the history of the malady, writers are now, indeed, pretty well agreed; but croup, like many other diseases that depen to a great extent on atmospheric and telluric causes, is modified in many of its symptoms by peculiarities of air, water, and situation. The affection assumes one character among the poor of a crowded city, and another among the children of the labourer in some rural district.* I have preserved a record of 23 cases of croup that came under my notice at the Royal Infirmary for Children between May 1839 and April 1849. Of these 23 cases, 11 were idiopathic, 12 secondary; five of the former and two of the latter recovered. In two of the idiopathic cases that recovered, a scanty formation of false membrane was observed upon the velum and tonsils, but no such appearance existed in the other idiopathic cases. Three of the six fatal idiopathic cases were examined after death: in two the false membrane was confined to the larynx; and there was but little injection of the trachea or bronchi: in the third case there was great redness both of the trachea and bronchi, and a large quantity of purulent secretion in both, and ulceration of the mucous membrane of the larynx, but no false membrane. Of the twelve secondary cases, one supervened in the course of pneumonia; in the other eleven, croup appeared as the sequela or concomitant of measles, and ten of the twelve terminated fatally. In the cases which recovered, and in three of those which terminated fatally, there was no false membrane on the velum or fauces, but in the other seven false membrane was present in those situations as well as in the larynx, and twice this false membrane extended into the oesophagus. Six of the fatal cases were examined after death in one there was no false membrane anywhere, but intense redness of the larynx, trachea, and bronchi, with an uneven granular appearance of the larynx, and ulceration about the epiglottis. In the other five cases the larynx contained more or less false membrane, and its surface was ulcerated; and in four of the cases the palate and tonsils were inflamed and coated with false membrane. In all these five cases, pneumonia existed in both lungs, and four times it was found to have reached in some parts the stage of purulent infiltration. These results, which differ in so many respects from the conclusions of many most excellent observers in this country, approach much more nearly to those obtained in the Hôpital des Enfans Malades at Paris. The district in which my observations were made is low, with defective sewerage, open drains running close to many of the houses; and most of the patients were the children of poor parents, who occupied only one room, and who consequently were placed in most unfavourable hygienic conditions. I may further add, that with the change of my field for observation since the opening of the Children's Hospital in 1852 a more sthenic form of the disease came under my notice; and in some of the fatal cases which occurred in that institution under my care, a complete false membrane not only lined the trachea, but extended even into the tertiary bronchi. This state of things continued for some five years, and then once more the disease assumed an asthenic character as it increased in frequency; and became associated with diphtheria, in which latter disease it has almost completely merged. The following abstract from the tables of the Children's Hospital is not without interest UNDER COMMON NAME OF CROUP. 373 If, therefore, you find that my account of the disease varies in any respect from the description given by some other writers, or from the results of your own observation hereafter, do not too hastily assume either that your teacher has been mistaken, or that your own observation has been incorrect. The difference may be nothing more than a fresh exemplification of the old story of the shield, silver on the one side and golden on the other, about which the knights in the fable quarrelled. There are, indeed, two diseases which have often been included under the common name of croup, though the points of difference between them are at least as numerous and as important as are those in which they resemble each other. Of these two diseases, the one is almost always idiopathic, the other is often secondary; the one attacks persons in perfect health, is sthenic in its character, acute in its course, and usually proves amenable to antiphlogistic treatment; the other attacks by preference those who are out of health or who are surrounded by unfavourable hygienic conditions, and is remarkable for the asthenic character of the symptoms which attend it. The one selects its victims almost exclusively from among children, is incapable of being diffused by contagion, is governed in its prevalence by the influence of season, temperature, and climate, but rarely becomes, in the usual acceptation of the term, an epidemic; while the other attacks adults as well as children, is propagated by contagion, and though it occasionally occurs in a sporadic form, is susceptible of wide-spread epidemic prevalence. The one is developed out of catarrh, and the amount of disease of the respiratory organs is the exact measure of the danger which attends it; while the other affects as illustrative of these changes in the epidemic constitution of the time since it was opened. I need not say that it is not to be taken as illustrative of any other fact. |