tion is secreted. In fact, it is still an unsettled question in the pathology of croup, whether the albuminous product is owing to some peculiarity in the nature of the inflammation, or in the structure in which it is developed.

Treatment. In discussing the treatment of croup, we propose to confine our observations to the particular remedy which is the leading feature of the author's monograph. The other remedies indicated are those usually adopted in similar cases. Dr. Green introduces his method of local treatment in the early stages of croup in the following terms:

"In the treatment of croup with topical remedial measures, I have always employed a solution of the nitrate of silver, as, in my opinion, there is no known therapeutic agent which, for safety, efficiency, and certainty of action, can be compared with the crystals of the nitrate of silver, in the local treatment of laryngeal, tracheal, and bronchial affections. In preparing the solution, the pure crystals should be employed, and not the fused or solid nitrate, as the latter is much more likely than are the crystals to contain the nitrate of potash, or copper or lead in combination. A solution of the crystals, of the strength of from two to four scruples of the salt to an ounce of distilled water, when applied freely to the mucous membrane, does not act, as has been supposed, by burning, or by a destruction of the textural matter. It forms immediately a union with the albumen and other secretions of the mucous lining; whilst it operates at the same time to produce a most favorable change in the vital action of the parts." (pp. 28-9).

In the first two cases in which the author applied this remedy, the disease was so far advanced, and the symptoms so intense, that it was only as a forlorn hope that he applied the solution of the nitrate of silver in the region of the glottis. Although both cases ultimately terminated fatally, still the beneficial effects of the application, however temporary, were so evident, that Dr. Green resolved to embrace the first opportunity of employing this remedy in the early stage of the disease; and the result of that coup d'essai is fully detailed in the two following cases, which we give in the author's own words :

"1. Several years ago, a son of Mr. and Mrs. W., of Franklin street, a fine healthful child of four years old, was attacked with membranous croup, and, notwithstanding the most energetic measures were adopted, died of the disease after a few days' illness. Some time after this, another son, only a little younger than the first, was at the time of his death similarly attacked, and died of the disease in about the same period of time. In November, 1847, the only remaining child of these parents, an interesting daughter of eighteen months old, was violently seized with the same disease, of which her brothers had previously died. Several hours after the occurrence of the croupal symptoms in this case, very late in the evening of Nov. 20th, 1847, I was called to see the child, and found her exhibiting all the symptoms of a severe attack of membranous croup. The heated skin, the frequent, oppressed, and stridulous respiration, the dry and ringing cough, tussis clangosa,' and the appearance of the tonsils and pharynx, which were highly inflamed, and coated with an albuminous exudation, left no room to doubt the nature and the stage of the disorder.

"For two or three days before the disease had merged into true croup, the child had been labouring under catarrhal symptoms, which were attended with hoarseness and a dry, hard cough.

"Immediately on my arriving at the house, and finding the patient in the above condition, I determined to try the effect, in this early stage of the disease, of remedies applied directly to the inflamed mucous surfaces. But in order, at the same

time, to secure the aid of general remedies, I ordered the administration of a few grains of ipecacuanha, and, after waiting several minutes, followed the medicine with the application of the sponge dipped in a solution of nitrate of silver, of the strength of forty grains to the ounce of water. With this the fauces, pharynx, and the laryngeal face of the epiglottis were well cauterized, and at the same time the sponge, wet with the solution, was carried into the larynx.

"As in the preceding cases, this operation was followed by a cough, and an effort at vomiting; by which a large amount of glairy, adhesive mucous was discharged, commingling with which shreds of the false membrane were distinctly visible. Within fifteen minutes the child breathed with more freedom, and there was an equally favorable change in the dry and ringing cough. Expecting to repeat the application, I remained a short time with the patient; but there was such an improvement in all the croupal symptoms, that no further application of the caustic was made that night. Five grains of calomel were directed to be given to the child; an emetic of ipecacuanha and tartarized antimony was ordered to be administered in the course of the night, if at any time there should be an increase of the peculiar symptoms of the disease.

"At an early hour the next morning I visited my patient, and found she had passed a night of comparative comfort. The respiration was not so laborious aa when I left on the previous evening, the cough was less croupal, and the heat of the surface was greatly diminished. The calomel had moved the bowels, and as the patient continued to improve during the night, the emetic was not given.

The same favorable indications continued during the day; but about nine o'clock that evening a message was received from the alarmed parents, requesting my immediate attendance, for their child, as the messenger reported, was suffering from a return of the croup. I found a recurrence of the same symptoms that had been present the preceding evening; but they were much less in degree, and a single application of the nitrate of silver to the larynx, which I made at once, relieved in a short time the embarrassed respiration, and lessened the croupal cough. "The patient again passed a comfortable night, and the next day, when I called, she appeared quite cheerful, and apparently almost free from disease. From this time no further medication was needed; the child has since passed through a severe winter without the recurrence of any symptoms of laryngeal disease.

"The above case occurred in a family whose children were predisposed to the disease; and in its access and development, the affection presented all the symptoms of true, or membranous croup. With the exception of the small doses of ipecacuanha and calomel, which were given on the evening of the attack, no other means were used but the local employment of a strong solution of the crystals of nitrate of silver to the seat of the disease.

"During the months of February and March of the present year (1848), the occurrence of croup among children, in this city, has been more than ordinarily frequent. This is to be attributed, undoubtedly, to the epidemic influence of the atmosphere, which, for some cause, has been in a condition to favour the development of influenza, and other diseases of the respiratory organs, in adults, and of croup in children.

"The following cases appeared during this period, and also took place in a family where croup had before occurred, and in one or two instances had proved fatal.

“2. At a late hour in the evening of the 23d of February, the Rev. Dr. Bof this city, called at my office and desired me to accompany him, to see his little daughter, a child three years of age, who that evening had been violently seized with an attack of croup.

"She had been hoarse, and had had a rough, dry cough for several days previous to the full development of the affection. When I saw her a few hours after the occurrence of the disease, the symptoms of croup, which were present, were marked and severe, indeed, as I entered the hall of the house, the ringing cough and stridulous respiration of the child-sounds which no physician ever desires to hear 7-IV. 15

a second time, were distinctly audible through the closed doors of the chamber above.

"With the aid of Dr. J. Hancock Douglas, who was in my office when the father of the sick child called, and who accompanied me to his house, I succeeded in obtaining a good view of the throat of the little patient. The parts were highly inflamed, and the tonsils were covered with an albuminous exudation. The barking cough, and the embarrassed and tracheal respiration, plainly indicated the stage of the disease, and that the inflammation had extended to the larynx, and about the vocal chords.

"As no time was to be lost, I immediately administered ten grains of ipecacuanha, and after waiting fifteen minutes, prepared to cauterize the diseased parts.

"Assisted by Dr. D— I applied a solution of the nitrate of silver (forty grains to the ounce) to the fauces and pharynx, and also introduced the sponge saturated with the solution, into the cavity of the larynx. The introduction of the instrument was followed by a free discharge of muco-fibrinous matter, in which, and also on the sponge, were shreds of the membranous deposit.

"The little patient, very soon after the operation, appeared greatly relieved. "We remained nearly an hour after the application, in order to repeat it if the symptoms should indicate its necessity; but the child continuing to improve, we left for the night, after giving directions to have an emetic of ipecacuanha administered should there be any increase of the embarrassed respiration. Soon after we left the child fell asleep, and although the breathing was laboured, and the cough, which occurred often during the night, was croupal, yet she slept for several hours, and when I called the next morning, I found a great improvement in all the above symptoms The emetic had not been given. As there still appeared to be some inflammation about the throat, and the cough retained the peculiar sound of the disease, I had fears that there might be a return of all the unfavourable symptoms before night, and therefore concluded not to wait, but to repeat the application of the nitrate of silver to the diseased organ. This was done, and I feel confident the operation was attended with much advantage, for instead of having a recurrence of the croupal symptoms on the second night, as had occurred in a former instance (Case iii), and which is so likely to follow a remission of the disease in most cases, there was a constant improvement of all the croupal symptoms during that day, and the following night was passed with equally favorable indications.

"In short, after this date no further medication was needed, for the child rapidly recovered." (pp. 36-43.)

We wish that our available space admitted of giving the ninth case—a case of membranous croup complicated with spasmodic and bronchial symptoms, which we can recommend to the attention of our readers as containing several points of great interest and practical utility.

The instrument generally used by the author for making direct medicinal applications to the fauces, and into the cavity of the larynx, in the topical treatment of croup, is one composed of whalebone, about ten inches in length, slightly curved at one end, to which curved extremity is securely attached a small round piece of fine sponge. Care should be taken that the sponge be not only fixed to the rod of whalebone, but that it be not of a size too large to pass the aperture of the glottis. Anatomists are aware that there is but a very slight difference in size between the larynx of a child of two years and of twelve years of age; and that at this period of life, the calibre of the tube is from three eighths to half an inch diameter; consequently, if the sponge be formed so as not to exceed one third or half an inch in diameter, it can be made with slight pressure to pass the

aperture of the glottis, and to enter the laryngeal cavity. The instrument being prepared by suitably saturating the sponge with the solution to be applied, the head of the child being firmly held by an assistant, and the base of the tongue depressed with a spoon, the operator carries the wet sponge quickly over the top of the epiglottis, and on to the laryngeal fall of this cartilage; then, pressing it suddenly downwards and forwards passes it through the opening of the glottis into the laryngeal cavity. If any patches of false membrane are to be observed upon the pillars or tonsils, the sponge should be passed freely over those parts, and also upon the posterior wall of the pharynx.

The

M. Bretonneau, who was one of the first to recommend and employ the nitrate of silver as a topical remedy in the treatment of membranous croup, made no attempt to pass the instrument below the epiglottis. M. Guersent applied the solution in such a manner as to cause some drops of it to penetrate into the larynx. We have ourselves very recently heard some excellent clinical observations upon this subject at the Hôpital Neckar by M. Trosseau, recommending this remedy in croup. French practitioners, however, employ a much stronger solution than that recommended by Dr. Green. For example, M. Bonchet, in a recent work on Diseases of Children,'* advises the applicatiou of a solution in the proportion of one of the salt to three of water; and M. Guiet in his thesis entitled Considérations Pratiques sur le Tritement du Croup,' proposes a still more concentrated solution; namely, equal parts of the nitrate of silver and distilled water. The author has found a solution composed of from two scruples to a drachm of the salt, dissolved in one ounce of distilled water to answer all practical purposes. Dr. Green has also found beneficial results attend the application of the nitrate of siver in cases of diphthérite, or the croup of adults. M. Louis, who gives a graphic description of this disease, under the name of "Croup chezl'adulte," records only one case in which a cure was obtained by medical

treatment.

Having now concluded our analyses of the contributions to the pathology of children by Drs. Reid and Green, it only remains to remark upon their respective merits. The diseases which both writers have chosen for their theme are perhaps two of the most formidable, because the most likely to terminate suddenly in death, within the whole range of children's pathology; but how differently are they treated? Dr. Green, seeing the inutility of the ordinary or routine system of treating croup, boldly enters into a new field of inquiry, and with success. Dr. Reid is content to recapitulate the practice of others, so far as it is supported by his own experience. We have an invincible repugnance to a rechauffé of any kind unredeemed even with an air of novelty, but above all, to one of medical truisms; and it is our deliberate opinion that if an author has nothing new to offer before he rushes into print, he will do well to bear in mind that wholesome maxim of the Koran, which ordains, "If speech be silver, silence is gold!"

* Manuel Pratique des Maladies des Nouveaux-Nés et des Fnfans à la Mamelle.

ART. IX.

Pathological and Practical Observations on Strictures, and some other Diseases of the Urinary Organs By FRANCIS RYND, M. A., M. R. I. A., Surgeon to the Meath Hospital, and County of Dublin Infirmary, &c. &c. &c.-London, 1849. pp. 196.

THERE is a large class of works in medicine and the collateral sciences, which contain but little absolutely of new matter, and which are still, notwithstanding the deficiency, acceptable contributions to the literature of our profession. Some are meritorious, on account of their laying unwonted stress upon facts that have long been known, but insufficiently attended to in practice. Others, again, are valuable because of the style in which they are written, the fidelity with which they are compiled, the felicity with which they are illustrated; and besides these, there yet remain a large and valuable section which in some measure combine a portion of all these excellencies. We allude to works which present a clear résumé of the pathology and treatment of certain classes of diseases, that have engaged the particular attention of their authors, and in whose composition acquaintance with the experience and labour of others has been associated with personal observations and a thoughtful habit of mind; of such a character is the work before us.

Mr. Rynd presents us in the present volume with a very clear and intelligent treatise, in which thought is blended with experience, and research with practice; and from the perusal of which, although we do not agree in all the opinions that are advanced, we have derived both profit and gratification. As a specimen of views from which we dissent, it may be stated that Mr. Ryud denies the influence of gonorrhoea in producing stricture, and sneers at what he calls a "post hoc propter hoc fallacy." In this we think he is mistaken. It is not a violent gonorrhoea, which runs an acute course in a reasonable period, or stimulating injections employed in its cure, that we believe predispose to stricture; but it is the residue as it were of the disease, the long-continued and scarcely-noticed gleet, which lays the foundation of the complaint. So long as the mucous membrane of the urethra secretes an unnatural amount of fluid, it is in a state of excitement; it is redder and more vascular than ordinary; it exceeds by so much its healthy function; and as this continues sometimes for months, it is manifest that changes must take place in it. Accordingly it becomes thickened, loses its vital elasticity, and in parts begins to contract. It is no argument to say, as Mr. Rynd does, that the majority of persons affected with gonorrhea escape stricture; the question is, does stricture follow gonorrhoea sufficiently often to bear out the relation of cause and effect?

Mr. Rynd considers stricture to be occasionally hereditary, and cites the case mentioned by Hunter of a boy, four years old, with stricture and fistula in perineo, as corroborative of this view; but to us the proof is incomplete.

In applying anatomical and physiological considerations to the inquiry into the causes of stricture, our author makes the following observations, which we transcribe, as not only very plausible in themselves, but as offering a good example of his style.