affirmative. One of the most decisive epidemics on record is that related by Terrand (De l'Angine Memb. Thèse; Paris, 1827): in a neighbourhood of very small extent, no less than sixty cases of croup, all of which were fatal, occurred in six

months. A remarkable epidemic, extending over the greater part of central Europe,

occurred in the years 1805-6-7. Guersant and others strongly maintain the contagious nature of croup, but its epidemic tendency serves to explain why instances of apparent contagion have been observed.-P.H.B.]

ANATOMICAL PATHOLOGY.

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The presence of a false membrane on the surface of the mucous membrane of the larynx is the fundamental anatomical character. Without this new formation, croup does not exist. is dita The false membranes appear under the form of thin elastic layers Came of a whitish grey colour, and rather tough. They adhere with more or less tenacity to the mucous membrane; they are exclusively composed of fibrine; their form and extent are variable. They occupy, in some patients, the tonsils and the superior part of the larynx, without penetrating into its interior. In others, this organ is attacked at the same time. Sometimes they only exist in the larynx, and in a small number of children they extend themselves to the trachea and in the bronchi, even to the smallest divisions.

They form, in the mouth, patches of a greater or less extent; they often enclose the epiglottis-like the finger in a glove. In the larynx, in the trachea, and in the bronchi, they form tubes which it is possible to raise entire. I have collected several of these false membranes their dimension exactly corresponds to that of the cavities which enclosed them. Those which occupy the bronchi, represent, in a perfect manner, all the divisions of these tubes. Some are met with which are divided, to an infinite extent, like the bronchial tubes, and which form an exceedingly delicate tail, of very remarkable appearance. Their superior surface is smooth, and covered with plastic mucosities. Their inferior surface, which corresponds to the mucous membrane, is uneven, and sprinkled with very numerous red points, which have been very well described by M. Blache in his memoir on croup.

These false membranes are quite insoluble in cold water, and even in warm water. Sulphuric, nitric, and hydrochloric acids, harden, contract, and detach these productions. Liquid ammonia, and alkaline

2:

solutions, dissolve them, and convert them into a transparent and luck. diffluent mucus. It is important to remember these characters, which will find their application in the treatment of the disease.

The mucous membrane is thickened, sometimes slightly softened; its epithelium has disappeared; its surface is uneven, eroded, and covered with reddish dots, which correspond with the red spots situated on the inferior surface of the false membranes.

[Most of the higher British authorities support the doctrine that the general form

of croup met with is the rare exceptional form of M. Bouchut and his compatriots. The existence of the diptheritic form is not only admitted by us but is known to be very prevalent under particular circumstances; but it is a primary, idiopathic affection of the parts beneath the glottis, and not of the fauces, that most practitioners here consider the more general malady. Dr. Willshire (British and Foreign Med. Chir. Rev.; July, 1853) alludes to the fact of the above variance of opinion having its origin in the prevalence of certain geognostic, endemic, and epidemic influences, in either climate, which are sufficient to stamp the malady we both call croup with particular characters.-P.H.B.]

SYMPTOMS.

Croup presents in its progress three stages, which it is nearly always possible to distinguish.

1st Stage. This stage is very difficult to recognize among children at the breast. Thus, the shivering and the uneasiness which are observed in children, pass by unperceived amongst infants.

In default of these symptoms, there are others more important, the study of which should not be neglected. The young children who are attacked by this disease are restless, have slight fever, and pain in the throat; their voice is hoarse, and they cough continually.

The cough and the hoarseness are two very important signs. As soon as they are observed, the back of the mouth should be examined; the pharynx presents a more or less intense redness, and on the tonsils false membranes are observed already formed. Sometimes there is remarked at this epoch, an abundant nasal flux, and false membranes in the nostrils. When a wound exists on the body, a blister for example, its surface is often covered by a production of the same nature. It is sometimes difficult to establish this stage, for the parents do not always perceive the commencement of the symptoms, and they hesitate when they are interrogated on this point. It usually lasts from four to five days, but this estimation is not at all a certain one. There are cases in which it has not lasted twenty-four hours.

[Prof. Gölis (De rite cognoscendâ et sanandâ angina membranacea) relates the case of a little boy four years old, previously in good health, who having passed from an overheated room into the open air, during extremely cold weather, was seized while walking with all the symptoms of most violent croup, which proved fatal in fourteen hours; and West refers to a case of a child seven years old who went to bed apparently well at eight o'clock, two hours afterwards began to breathe with the peculiar noise characteristic of croup, and presented all the symptoms of the disease before midnight.-P.H.B.]

2nd Stage. The symptoms of the second stage are—increase of the fever and general disturbance of the economy; dry cough, coming on by slight fits at first, afterwards by excessively painful attacks, followed by efforts of vomiting, and even by the rejection of matters in which false membranes are observed; hoarse and hissing ringing cough,

loss and hoarseness of the voice, difficulty of respiration, and more or less profound anxiety.

The cough presents characters which deserve to be studied in a

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special manner. It is hoarse, dull, and followed by a peculiar ringing,utalee as if metallic. Its tone is very extraordinary, and resembles somewhat the noise that young cocks make when they attempt to crow. Much Aug more frequently the cough is hoarse like the voice, and, often like it, it is smothered or extinguished.

When the cough is accompanied by expectoration, which does not take place amongst young children, or when it is followed by vomitings, the rejected matters should be examined. False membranes r may be met with, the form of which may be useful to consult when

it is necessary to establish the seat of croup. Thus, when tubular

false membranes are found, the situation of their formation is judged trian of by their calibre. The membranous tubes of the trachea, and lite

those of the second, third, and fourth orders of bronchial divisions, are very readily recognized.

The respiration is then more frequent than in the normal state; mucous and sibilant rales are heard in the chest; these are the only phenomena of auscultation observed at this stage. The disorder of the respiratory functions is especially external. It is revealed by dyspnoea, e dull colour of the face, anxiety of the countenance, and by the gestures and attitude of the child.

The skin of the face is pale, and at the lower parts it is of a very slight bluish tint; the eyes are injected, the lips of a reddish brown colour, which indicates the venous congestion of the head. The dyspnoea comes on by fits, often after an effort of coughing; -101 great anxiety is depicted on the face; the child makes gestures expressive of a wish to be placed sitting up, a posture which when its strength permits it hastily assumes; suffocation threatens it for A a moment; then these symptoms disappear, and quietude is quickly restored.

This stage is in general short, and lasts from twenty-four hours to two or three days. Then, what is termed the third stage of croup, comes on, a period of struggle against the asphyxia which threatens, and which will probably triumph.

3rd Stage. In the third stage, the cough and the voice are quite extinguished; the respiration is accompanied by very loud hissing, which may be heard some distance off; it is very laboured,

for all the inspiratory muscles are in play; thus, the muscles of the s nose, neck, abdomen, and diaphragm, contract with energy; the child appears exhausted; the face is bluish, the eyes brilliant, the pupils contracted, the orbits excavated, the lips cyanozed, and the head remains thrown back. This state of depression, however, is

disturbed by violent fits of suffocation. In the midst of repose, after an attack of cough, the respiration becomes embarrassed, the face assumes a blue tint, the look disturbed and suppliant, and the child raises itself with an effort, carrying its hands to its neck, previous to falling into the arms of those who surround it.

If the termination of the disease is to be favourable, the symptoms gradually lose their intensity. A progressive decrease is observed in the preceding symptoms; the respiration becomes more easy, hissing no longer accompanies the inspiratory movements. The fits of suffocation disappear. The cough becomes less frequent, more moist, and loses by little and little the hoarse character which it presented. However, this modification, as well as the alteration of the voice, still persists a long time after the cure of the disease. As soon as the respiratory functions are reëstablished, the circulation becomes regular, the pulse assumes its ordinary characters, and the skin of the face and the rest of the body its natural white colour.

PROGRESS.

The progress of croup may be estimated by the type above indicated. The disease commences at the back of the throat, before it extends itself to the larynx and bronchi; it is a true pseudo-membranous angina which becomes transformed into croup. When care is taken to examine the children at the commencement of the disease, we shall find this to be always the case. Nevertheless, some accurately observed but very rare facts demonstrate that croup may originate in the larynx and in the bronchi. In these instances, the first stage, such as we have described it, is entirely wanting, and disturbances of the respiratory functions first signalize the existence of the disease.

Croup, then, usually presents three stages, when the disease begins in the back of the throat and extends itself to the respiratory tube. It only presents two when it primarily commences in the larynx and bronchi.

It would be a mistake to believe that false membranes must be absolutely established in the whole continuity of the respiratory tube. Happily it is not thus. These accidental productions, primarily deveAloped in the mouth, are always formed on the epiglottis and on the edges of the opening of the larynx, but they may fortunately not extend lower down. The disease is then much less serious. Its symptoms are otherwise the same as in those cases where the extent of the false membranes is much more considerable, even when they penetrate into the bronchial tubes.

The progress of croup is nearly always regular; the symptoms usually succeed each other in the order which has been indicated; still there are sometimes well marked remissions. They are observed

towards the end of the second stage. It may happen at the moment when the efforts of coughing and vomiting eject a large portion of the plastic concretions which obstructed the larynx. Then quietude is restored, but it is not of long duration. The false membranes form again, more delicate, it is true, than the first, and the symptoms of dyspnoea are developed afresh. Thus in some children two or three remissions of this kind are observed, produced by the detachment of false membranes, which are soon replaced by others.

Some authors have undoubtedly been mistaken concerning these remissions, for some of them, Jurine amongst the number, have described intermitting croup. I am of opinion that croup with false membranes cannot be considered as an intermitting disease. From the period that these concretions have become developed a certain number of symptoms appear, which are under their influence and last as long as they do. The only kind of croup that can be considered intermitting is that without false membranes-false croup or stridulous laryngitis. This is truly intermitting; it returns in well characterized fits, as will be described further on; so that when there is a complete intermission in the symptoms there cannot be true pseudo-membranous croup.

COMPLICATIONS.

Croup is nearly always complicated with pseudo-membranous angina; it commences with it, as we may be assured by examining the back of the throat at the commencement of the disease. This complication rapidly disappears, the false membranes of the mouth become, detached, and if the children are examined when the disease has been established for several days the buccal mucous membrane may appear quite healthy. Then it may be conceived that the croup has commenced in the larynx. This probably would not have been the case if the mouth had been examined from the first day of the appearance of the symptoms.

Pseudo-membranous coryza sometimes coincides with croup, and forms a most important complication amongst children at the breast. It must be treated by the most energetic means. The children can neither suck nor drink, for while they suck either from the breast Man is or from the bottle, they respire by the nose, and in this case this part is obstructed by false membranes. On the children attempting to puni suck they become suffocated, and are obliged to abandon the breast in order to breathe freely.

Inflammation of the oesophagus and pseudo-membranous gastritis are sometimes observed, but these complications are very rare.

The most frequent and the most dangerous complication of the disease which we are now considering is lobular pneumonia. This observation of MM. Blache, Guersant, and Trousseau, has been confirmed by all those

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