of dressing forceps; it was firm, whitish, and tough. Within a day or two of her return home her little brother was attacked by a sore throat, attended with slight fever. Two other children were shortly after similarly affected. In none of these did the exudation exceed in quantity or tenacity that I have described as existing in the first family. Now this example shows, I think conclusively, that the exudation does not afford a criterion by which to distinguish diphtheritic scarlet fever from true diphtheritis. It is, however, as unnecessary as it would be wearisome to accumulate any more arguments upon this point: I shall, therefore, pass on to the consideration of Bretonneau's Shibboleth―croup. The position which Bretonneau has taken up in this part of his argument is a very strong one, chiefly in consequence of the strict limitations he has imposed upon the class of facts which he thought might be produced against him. It might appear at first sight that had he made a mistake upon this point (the coexistence of scarlet fever and croup), it would have been a simple matter to convict him of it; or, on the other hand, if this could not readily be done, that the very paucity of evidence would show that he was substantially correct in his opinion, though somewhat inaccurate in expressing it. The view would not, however, be correct; since he has made this (as he asserts invariable difference) his crucial distinction between scarlet fever and diphtherite. Numberless authorities assert the coexistence of scarlatina and croup; but Bretonneau admits the validity of no evidence upon this point which is not supported by post mortem examination. Now, as the existence of croup, as a generally recognized disease, dates only from the year 1765, when Dr. Home* published his observations upon it, and between that date and the year 1826, when Bretonneau published his book, no notorious epidemic of malignant sore throat had prevailed; and since, moreover, the occurrence of diphtheritic scarlet fever is rare, and the termination of this by croup rarer still, it cannot be surprising that such conclusive evidence is but scanty. The prize offered by Napoleon I, in 1807, for the best dissertation on croup, was divided between Jurine,† of Geneva, and Albers, of Bremen. Albers' book I have been unable to procure, and shall, therefore, endeavour to ascertain the value of his assertions by a reference to the same authority § from which Bretonneau inferred that he had not established the existence of this combination. Albers defines croup to be " an inflammation of the mucous membrane of the larynx, trachea, and its divisions; an inflammation which has a *Inquiry into the Nature, Cause, and Cure of Croup. Edinburgh: 1765. 8vo. This essay was never published: an abstract of it may be found in Royer-Collard's Report. § The Official Report of the Commission appointed by the Emperor to report on the Essays sent in to compete for the prize. Precis Analytique du Croup, &c.: par J. Bricheteau. Précédé du Rapport sur les Mémoires envoyés au concours sur le Croup etabli par le Gouvernement en 1807. Par Royer-Collard. Deuxième edition. Paris: 1826. 8vo. peculiar progress and characteristics, and the most common effect of which is to provoke the secretion of a peculiar material, essentially composed of coagulable lymph and fibrine. This matter is always designated by the author plastic lymph.'" (Op. cit.; p. 78.) "The most formidable of all the complications of croup is that of scarlatina. The author has unfortunately had numerous opportunities of observing it, and he reports several examples. * The author confesses that he has lost thirty-six cases.' (Pp. 99, 100.) * * "When the croup is simple the lungs are always healthy after death, in the complications with variola they are often found inflamed, more rarely so in the complications with rubeola, and never in those with scarlatina." (P. 114.) If medical evidence were never less conclusive there would be an infinite saving of time and trouble; to my mind this is quite satisfactory proof that Albers had had post mortem evidence of the correctness of his statement. I shall, however, proceed to quote some evidence of a similar character from English authors. * * * Mr. Sym, of Kilmarnock, Ayrshire, says, "Early in the spring of 1824, ulcerated sore throat, accompanied in some instances by scarlatina, became prevalent in this neighbourhood. In general it did not prove fatal; but a number of cases became complicated with croup, and of such cases I only met with one which terminated favourably. The disease seemed to be contagious among children. In infants the symptoms of croup were most decided, the affection of the fauces being in many cases so trifling that it had not been attended to by their mothers, until I detected the ulcers, upon examination, after the accession of the croup had commenced. In one family, consisting of three children, who were successively attacked by the disease, two died and one recovered, the only cure of the complicated affection that occurred in my practice. Having examined the windpipe of one of these children after death, I found it filled with a thick, firm lymphatic tube, which extended into the bronchial ramifications. In the case which terminated favourably the ulcers were getting better when the croup commenced; and to this circumstance I attribute the efficacy of the remedies in operating a cure. From what I observed I concluded that the ulcerated sore throat, which appeared to be closely allied to scarlatina, constituted the contagious part of the disease; and that the croup was occasioned by an extension of the inflammation at the margin of the ulcers into the rima glottidis, and from thence along the mucous membrane of the trachea. This idea seems to derive confirmation from your cases; † and if further supported by the observation of other practitioners it may * London Medical and Physical Journal; vol. lv, from January to June, 1826. †These observations were communicated to Dr. G. Gregory. account for the contagious character of certain species of croup." (Loc. Cit.; pp. 14, 15.) In the same journal we find the following remarks upon this subject by Mr. W. Pretty: "I have witnessed many severe and fatal cases of croup, after, or rather in conjunction with, simple scarlet fever and malignant sore throat and here I have no hesitation in subscribing to the belief of its (croup) being contagious, but not as the primary disease. It usually comes on after several days continuance of one or other of the diseases just mentioned, and seemed to owe its production to the extension of inflammation from the fauces to the larynx and trachea in young children; and they were, to the best of my recollection, exclusively the objects of its violence: it proved generally fatal. * * * "While practising in Kent, about nine years ago, I had an opportunity of seeing a great number of persons ill with an epidemic visitation of scarlet fever and malignant sore throat; the young and middle aged in the lower classes of society were very generally affected by it. The croupy symptoms were confined to young children. obtained opportunities of examination after death; and in all who died with croup as a symptom (and I recollect none who died without it), I found extensive inflammation of the fauces, larynx, and trachea. * * * I "The adventitious membrane commonly found in fatal cases of cynanche trachealis, was present in many instances; in others only a copious exudation of thick mucus; in some a positive sloughing of the tonsils, velum palati, and epiglottis. I well remember one dissection of a child about five years old, where I found the last described state of parts, with the addition of ulceration in the interior of the larynx, and a perfect lining of the tracheal tube a considerable way down towards the lungs, formed of coagulable lymph; I might here observe that the scarlet efflorescence on the skin was wanting in some cases in adults, and that those who had it not, or but faintly, generally had the worst throats. The same contagion produced in some the scarlet fever, in others the malignant sore throat." (Loc. Cit.; pp. 9, 10.) I shall quote yet another case from the same journal, attended and related by Dr. George Gregory. "On visiting the child (atat four and a half), I found him extremely ill with ulcerated sore throat, which had been present six days, and by the mother's account (which was, however, very indistinct), had been preceded in its early stage by a scarlet eruption. * * Returning on the following day, I found that about midnight he had been seized with well marked symptoms of croup. * * * The child died within twenty-four hours from the invasion of the croupy symptoms. * "Permission being given to open the body, the trachea was found lined by a pretty thick tube of coagulating lymph, extending down nearly as far as the division of the bronchi. The larynx contained a considerable quantity of a dense glairy effusion. The trachea was removed, and submitted the same evening to the inspection of a number of gentlemen, who considered it as exhibiting a fine specimen of this remarkable morbid appearance." (Op. Cit.; vol. liv, p. 285.) Two other children, occupying the same room, within a few days became similarly affected and died. If it be objected to these observations that they do not specifically state the conjunction, in any individual case, of unmistakable scarlatina with post mortem proof of croup, it is very evident that the reporters believed that such a conjunction did occur; and it cannot be doubted that the epidemic was one of scarlatina, and that in cases which the observers believed, apparently upon substantial grounds, to be examples of the prevalent disease, croup was proved by necroscopic examination to have been the cause of death. In the face of such facts it requires, to say the least, some temerity to assert that croup is never a complication of scarlatina. This is not the place to enter into a consideration of the contagiousness of croup, which, however, as may be seen by some of the passages above quoted, corroborates the views I have advanced. I have, moreover, given Bretonneau the utmost possible latitude: for he himself asserts that there is no difficulty (and here I agree with him) in diagnosing between true croupy breathing, and stridor caused by the obstruction of the fauces from tumidity of the mucous membrane, and its being coated with lymph. Furthermore, if Bretonneau admit none but anatomical proof of the existence of croup, and yet contend that croup is an essential ingredient in malignant sore throat, then he cannot adduce any evidence whatsoever that the authors of the seventeenth century described (as he assumes they did) the same disease as himself; and this would almost justify the author of a review on his work in saying,* " Angina maligna, we think, we shall be able to show was never seen at all. Croup-but croup singularly modified-constituted the fatal, long prevailing, and hardly yet extinct epidemic." The conclusion which I draw from the foregoing considerations is, that the distinctions between diphtheritis and scarlatina, as laid down by Bretonneau, do not justify his assertion that there is no pathological affinity between the two diseases; and, consequently, I do not consider myself debarred from inquiring into the relation between epidemics of malignant sore throat undoubtedly congeneric with scarlatina, and others such as that at Tours, or the present one in which this connexion is less manifest, and perhaps questionable. The nature of the white patches seen on looking into the mouth * London Medical Repository; N. S.; July-December, 1826; p. 489. From internal evidence this review would appear to have been written by Dr. John Conolly. is a subject of considerable importance, not only as bearing on the identity of various epidemics, but because false notions on this point still exist. The production of false membrane, fibrinous exudation (or by whatever name we choose to call it) by an inflamed mucous surface, can be no more disputed than can the analogous production of pus by inflamed serous membranes. The tests by which we determine that it is from this process, and not from sloughing or destruction of parts, that the appearances in question result, are applicable most fully to cases which we have the opportunity of inspecting, but in a sufficient measure also to those recorded with precision by old writers, who were however less happy in their pathological explanations than in their descriptions of nature. It is, moreover, a fact-ascertained by Bard, corroborated by subsequent observers, and to which I can myself bear witness-that the appearances in question do depend on such an exudation upon the surface of the mucous membrane, and not on its destruction or death. The existence of ulceration is not of much importance, and I shall dismiss it by observing, that if there were sloughing this must have been succeeded by an ulcer; and if there were no sloughing there might yet have been some superficial ulceration, though I have never seen any myself. The real point at issue is, whether or no the older writers were right in calling those appearances—which they have described―sloughs. The first argument in favour of the identity of the throat disease in the various epidemics, is the applicability of the descriptions of the older writers to what we now meet with: thus Chomel,* speaking of his fourth patient, says, "On the next day, in the afternoon, in examining the bottom of the mouth, they perceived an aptha or white spot on one of the almonds (or tonsils), and this was constantly observed, that in all those that had the distemper these spots appeared in twenty-four hours from the seizure, and spread instantaneously. * * * The eschars filled, and as it were choked up at the bottom of the throat, and were near of the colour of hogs' lard" (Op. Cit; pp. 18, 19): in another (the seventh) case occurring in the same school the next day, "The almonds (or tonsils) were lightly covered with little white spots" (p. 28); on the sixth day this child vomited, and Chomel "distinctly observed several pieces of membranous eschars in what came up." (P. 29.) Fothergil! says, "Instead of this redness" (of the fauces), "a broad spot or patch of an irregular figure and of a pale white colour is sometimes to be seen, surrounded with a florid red; which whiteness commonly appears like that of the gums immediately after having been pressed with the finger, *An Historical Dissertation on a particular species of Gangrenous Sore Throat, which reigned the last year among young children in Paris. Translated from the French of Dr. Chomel, which was printed at Paris in the year 1742. By N. Torriano, M.D. London: 1753, 1 |