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prevent access of air by a valve of adhesive plaster. In a few days, the canula was removed and reintroduced an inch and a half from the point of the previous puncture, and again, as before, allowed to remain. After this, hepatic friction, which had previously been audible, disappeared, and the movements of the liver with respiration ceased, showing that adhesion had taken place. A free incision was then made between the two points at which the trocar had been introduced.
The advantage of the abdominal bandage, as a means of preventing motion of the liver and of holding it fixed, is sufficiently manifest and needs no special comment. Under such treatment, a patient should be kept absolutely quiet in bed. The proper treatment of the large abscess in the posterior part of the right lobe is a question of considerable doubt. In many cases, aspiration is the only resource. Should the abscess, however, be near the surface—and this can be ascertained by the depth to which the needle attached to an aspirator must be introduced before
is reached—I believe that, in case the abscess has been aspirated and the sac has refilled, it would be wiser to make a free incision, even should it be necessary to exsect a portion of a rib in order to accomplish the drainage of the sac. A careful consideration of each case would be necessary, as, without proper precautions, the pleural sac would be opened.
The medical treatment must be directed to symptoms. Rest, a cool climate, and maintenance of the nutrition and strength of the patient, are the main points to be secured. The important point, however, is to provide an early and safe exit for the pus.
Since writing the above, I have met with two additional cases of liver-abscess. One of these was the case of a laborer, who was in the habit of lifting heavy weights, which he carried on his left shoulder, supporting them by the right hand carried over his head. The abscess was situated in the upper and right portion of the right lobe. The liver did not descend below the free border of the ribs, and it was adherent. The symptoms were, pain in the right shoulder and in the right side, loss of flesh and strength, with some febrile movement, and
nocturnal perspiration. The case was referred to me by Dr. Fruitnight, of New York. Twenty-two ounces of a chocolatecolored liquid were removed by aspiration by Dr. Fruitnight, on November 29, 1884, through a puncture in the ninth intercostal space in the inferior axillary region. I had recommended this space because it was the point most tender on pressure, and, on exploratory puncture, pus was found two or three inches below the surface. The result of the case is still uncertain.
DR. THOMAS F. ROCHESTER, of Erie County. I think the fact that no comments have been offered upon Dr. Janeway's paper should be accepted as complimentary rather than otherwise ; and I rise only to express my thanks to the author, who has so thoroughly exhausted the subject of his paper that he has left no room for discussion.
MEMBRANOUS CROUP; DIPHTHERITIC CROUP;
By J. Lewis SMITH, M. D., of New York County.
Read November 20, 1884.
The term pseudo-membranous laryngitis, laryngo-tracheitis, or true croup, is applied to a common and fatal disease, the essential anatomical character of which is inflammation of the larynx, or of the larynx and trachea, with the formation of a pseudo-membrane upon its surface. It occurs most frequently between the ages of two and twelve years, but infancy, after the age of six months, and early adult life are not exempt from it. For the sake of brevity, I shall use the term croup to indicate this form of inflammation, although I recognize another form of croup, the spasmodic or catarrhal, in which no pseudo-membrane occurs.
Ætiology.-Wherever diphtheria prevails as an endemic or epidemic, it is well known that a large majority of the cases of membranous croup are local manifestations of this disease; and this inflammation is, therefore, in such localities, commonly designated diphtheritic croup. Physicians have endeavored to discriminate between croup due to diphtheria and that dependent upon other causes; but, whatever be the cause, the anatomical characters, the clinical history, and the appropriate treatment are so nearly identical, that attempts to differentiate the disease when produced by other agencies than diphtheria from that due to diphtheria, have proved futile and unsatisfactory in localities where diphtheria occurs, except in a few instances, as, for example, when croup has been manifestly caused by swallowing or inhaling some irritating agent.
Inflammation of the laryngeal and tracheal surfaces, whatever be its cause, when it reaches a certain grade of severity, may be attended by the exudation of fibrin and the formation of a pseudo-membrane; but such a result more frequently occurs in the inflammation caused by diphtheria than in that produced by other agencies. In diphtheria, a moderate laryngo-tracheitis is attended by the pseudo-membranous formation.
The percentage of cases of diphtheria in which the larynx becomes implicated and croup occurs varies in different epidemics and in different seasons and localities. In epidemics of a mild type, the cases appear to be fewer in which the larynx is involved than in epidemics of a severe form. In New York the percentage is large. From December 1, 1875, to July, 1878, I preserved records of all the cases of diphtheria which came under my notice. The number was 104, and in twenty-five of these, or about one in four, croup occurred, producing the usual obstructive symptoms and constituting the chief source of danger. During the two and a half years embraced in these statistics, the disease was usually severe. In the last five years, amelioration has occurred in the type of diphtheria in this city, and the proportion of croup-cases has not been so large.
So commonly is membranous croup, when it occurs in a locality where diphtheria is endemic or epidemic, a local manifestation of diphtheria, that physicians come to regard every case of this disease of the larynx as produced by the diphtheritic poison. In New York, physicians recognize scarcely any other form of membranous croup. It is well, therefore, to briefly recall the evidences that croup, in a certain proportion of cases, results from causes other than diphtheria. The occurrence of croup in localities where diphtheria is unknown of course indicates the operation of some other agency than the diphtheritic poison. Thus, in 1842, before diphtheria was established in this country, Dr. John Ware, of Boston, published his wellknown paper on croup; and in seventy-four of the seventy-five cases embraced in his statistics, the membranous exudation was
present upon the faucial surface. The statistics relating to the introduction of diphtheria into New York city, and the recorded death-statistics of this city, have been annually published. The first death from diphtheria in this century, within the city limits, certified to by a physician, was that of a German woman, at 638 Hudson Street, on February 15, 1852. Two other fatal cases occurred in 1857, and since then the reported deaths from croup and diphtheria have been as follows:
Since 1875, weekly bulletins were issued instead of the annual reports.
Thus, in the first years after the introduction of diphtheria, the deaths attributed to croup so greatly outnumbered those of diphtheria (as in 1858, when five died of diphtheria and four hundred and seventy-eight of croup), that it is evident that most of the cases of croup in those years were attributable to other causes than diphtheria. Since, as I have stated, any inflammation of the surface of the larynx and trachea, if sufficiently intense, may produce a pseudo-membrane, croup may occur as a primary disease and as a complication of various maladies. According to my observations in New York city, the chief causes of croup, arranged in the order of frequency, would be about as follows: diphtheria, “taking cold,” measles, pertussis, scarlatina, typhoid fever, and irritating inhalations. I have elsewhere related cases of scarlet fever of a severe type, in which a thin film of pseudo-membrane was found upon the surface of the larynx and trachea and there was no other lesion to indicate that diphtheria had supervened. The croup was, to appearances, caused by the scarlatinous and not by the diphtheritic