"DOCTOR," said a wealthy Boston patient, "I want you to be thorough, and strike at the root of the disease." "I will," said the doctor, and brought his cane down with a smash on a decanter standing on the side-board. It was his last professional visit at that house.

SPECIAL NOTICES.

IRON AS A TONIC.-Iron, says Le Progres Medical, is one of the most important principles of the organism, and the only metal the presence of which is indispensable to the maintenance of life. It exists in all parts of the system, but nowhere does it acquire such importance as in the blood. The blood of a person in good condition contains about forty-five grains of iron. When this amount is diminished, a decline takes place--the appetite fails, the strength is enfeebled, and the blood loses its fine natural color and quality. In a great number of diseases, such as anemia,chlorosis, hemorrhages, debility, etc., it sometimes happens that the blood has lost half its iron, and to cure these diseases it is absolutely necessary to restore to the blood the iron which it lacks. The problem has been to find a preparation of iron in the proper form for penetrating the organism without unduly taking the digestive tract or interfering with the essential qualities of the gastric juice. A preparation containing iron in such a state is scientifically prepared by Wm. R. Warner & Co., under the name of Pil Chalbyeate. It is prepared in such a way that carbonate of potash and sulphate of iron are compounded so that they do not combine until they are taken into the stomach; there the reaction takes place, and the proto-carbonate of iron (ferrous carbonate) is formed without any excess of air, thus forming a salt which is quickly assimilated, and the therapy of the preparation is soon shown by its effects. It will be found, in taking these pills, that neither constipation nor other ill effects will result from their use. It has been proven in clinical practice that in cases of chloro-anemia the Pil Chalbyeate, as prepared by Wm. R. Warner & Co., will regenerate the red globules of the blood with a rapidity not before observed under the use of any other ferruginous preparation, it adding to their physiolog ical power, and making them richer in coloring matter. Moreover, being neither styptic nor caustic (as just enough carbonate of potash and sulphate of iron are used to neutralize each other, and form nothing but carbonate of iron and a small quantity of sulphate of potash), and having no coagulating or astringent action on the gastrointestinal mucous membrane, the Pil Chalybeate of Wm. R. Warner & Co. can cause no deleterious effects to the patient; at the same time the therapeutic effects are rapid and energetic, and do not give rise to the sensation of weight in the stomach or the gastric pain and indigestion occasioned by other preparations of iron. When a more tonic effect is desired, the same combination as Pil Chalybeate can be obtained with 1-6 of a grain extract nux vomica added, under the name of Pil Chalybeate Comp. (Warner & Co.), thereby

increasing the tonic effect, and giving renewed strength to the patient.

The above results can be proven by a trial of one bottle of the above pills, a sample of which will be mailed to physicians upon request-Med. ' Brief, Jan. 10th.

CONTEMPT OF COURT.-Of all the curious reading that we have enjoyed in some time, we think that afforded by a communication from Dr. F. E. Stewart to the current number of the Druggists' Circular certainly caps the climax. It affords a splendid illustration of the wisdom of the adage which advises the shoemaker to stick to his last. Whenever a physician strays from his own profession into the intricacies of the law, and especially the patent laws of this country, his feet are on dangerous and slippery ground, no difference where his head or heart may be. In the present paper Dr. Stewart attacks the recent decision of the United States District Court in the matter of the suit of Battle & Co. against the Grosses (Daniel W. and Edward Z.) for infringement of their copyright of Bromidia. He declares that the decision is not final or binding, and advises the Grosses and druggists generally not to pay any attention to it. Dr. Stewart thus puts himself in contempt of the United States courts, and advises others to place themselves in the same foolish and dangerous predicament. The queer part of the matter, however, is that every reason which he advances against the validity and justice of the decision is the strongest possible argument in its favor, and the reader must be obtuse indeed not to see that it is so. This view of it was evidently taken by the editor of the Circular, who says: "While giving Dr. Stewart's argument publicity on account of its novelty, we think it proper to remind pharmacists that they are bound by the decision so long as it is allowed to stand;" which advice is good sound sense, like pretty much every thing that emanates from the editor of the journal quoted.-St. Louis Medical and Surgical Journal, January, 1888.

AN ALVINE MOTOR.-Various are the means resorted to for the relief of chronic constipation, but unfortunately most of them are, in a sense, futile, since the effect is but temporary. Dr. George W. Hoagland, of Columbus, Ohio, writes that he uses .6 ELIXIR PURGANS" (LILLY) with the very greatest satisfaction, and cordially recommends it to other practitioners. This preparation is used extensively in the Carney Hospital and the Lying-in Hospital, in this city, the Childdren's Hospital, New York, the New York Ophthalmic Hospital, and others, while it is held in high esteem by a large number of physicians. Dr. G. A. Jordan, of Worcester, Mass., says it is certainly the best alvine motor he has ever used, and that it gives satisfaction in every instance.Massachusetts Medical Journal.

HEALTH AND HOME.-A better journal for the purposes indicated in its title could not well be published than the Health and Home, of Chicago, It is but $1 a year, and it offers to all persons who renew their subscriptions, also to each new subscriber, their choice of one of three valuable premiums.

VOL. V. [NEW SERIES.]

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than any thing else.-RUSKIN.

Original Articles.

THE IDENTITY OF MEMBRANOUS CROUP AND DIPHTHERIA OF THE LARYNX.*

BY W. CHEATHAM, M. D.

Clinical Lecturer on Diseases of the Eye, Ear, and Throat, University of Louisville, Medical Department.

CROUP. Is there a difference between croup and diphtheria of the larynx? The dualists say that there is a difference pathologically and clinically.

Virchow, who was the first to announce the distinction between the membrane in croup and diphtheria-that the former was a coagulation upon the mucous membrane, and the latter was poured into the membrane; that the former could be easily stripped from the membrane, leaving a healthy surface below, and that the latter could not-soon discovered his mistake.

Here is what Cohen, a dualist, says of it (Cohen, pages 149 and 150):

"Attempts at discrimination in the nature of the exudation have failed, although characteristic differences, chemical, microscop ical, and physiological, are still contended for by some pathologists. The discriminating condition pointed out by Virchow some years ago, and so extensively supported, that the pseudo-membrane of diphtheria is adherent to the mucous membrane, or infiltrated into it, while that of croup simply lies upon the mucous membrane, is now acknowledged by him as lost in particular cases.

Read before the Louisville Clinical Society, January 10, 1588. For Discussion see page 78.

No. 3.

"The difference in the nature of the epithelium of the pharynx and vocal chords (squamous) and that of the nasal passages and larynx generally (ciliated) is deemed. sufficient to account for the adherence of the adventitious material in the one case, and its mere apposition in the other.

"We can not establish any essential difference on anatomical grounds, the pathological products of the two affections being identical as far as our means of examining them are to be relied upon.

"There is no absolutely characteristic manifestation in the location of the pathological product, nor in the condition of the mucous membrane beneath it; even destruction of tissue being sometimes encountered in croup as well as in diphtheria."

Dr. Charles West, another dualist, says:

"I have come to the conclusion, which I long hesitated to adopt, that what differences soever exist between croup and diphtheria, they must be sought elsewhere than in the pathological changes observable in the respiratory organs. The mere extent of false membrane in the air-passages certainly affords no ground for a distinction. between the two affections, though I think it is more common to find the false membrane reaching to the tertiary bronchi in diphtheria than in primary croup." (Quain, page 320.)

Sanne (page 58) says:

"When we pass to the examination of German works, we encounter from the first a confusion of words which contributes singularly to the complication of the question.

"By a deplorable abuse of language, applying to the anatomico-pathological pro

cesses terms which serve to designate diseases, the authors beyond the Rhine, after

the example of Virchow, called croupal inflammation a phlegmasia, which, without touching the structure of the mucous membrane, deposits upon its surface an exudate, a false membrane; and diphtheritic inflammation an interstitial phelegmasia, characterized by a sero-fibrinous exudation, which infiltrates the tissues and causes their mortification. Diverting the word croup from its true acceptation, which is that of an acute suffocative and pseudo-membranous disease of the larynx, they have created the singular terms, croupal pneumonia, croupal nephritis, etc., under the pretext that, in these pathological cases, the fibrinous exudation is formed on the surface of the pulmonary alveoli, urinary tubuli, etc.

"Be that as it may, the German work may be summed up under two opinions, which I shall now present in detail:

"According to the first, set forth by Virchow, and continued by Wagner, Buhl, and Rindfleisch, the false membrane is a production of the epithelium of the mucous membrane, with or without infiltration of the mucous corium.

"The second approaches the French idea of exudation, excepting some details. The false membranes are formed essentially of emigrated leucocytes (Cohnheim) and a fibrinous substance transuded through the diseased walls of the vessels of the mucous membrane. (Steudener, Boldyrew, Senator, etc.)"

Senator made a decided step toward the ideas of Bretonneau, and described four anatomical forms of diphtheria:

1. Catarrhal form (Sanne, page 62): "One frequently meets, during an epidemic, cases of simple catarrhs of the air-passages, which may degenerate into true diphtheria, of which they are evidently the first stage or a slight attack.

2. The croupal form, of which the type is found in the pseudo-membranous inflammation of the larynx and trachea.

3. "The pseudo-croupal, which is characterized by gray or milky membranes scattered in patches or bands upon the mucous. membranes of the soft palate and the ton

sils, and more rarely upon the buccal mucous membrane.

4. "The diphtheritic form, properly so called, is that in which the process is gangrenous and not pellicular."

Niemeyer, while preserving the distinction between the croupal and the diphtheritic processes, and recognizing simple croup, differs formally from physicians who confound. this simple croup with croupal laryngitis dependent upon diphtheritic infection. He says: "I can not share in this view. The division of diseases according to the anatomico-pathological modifications which they entail in their train is but a last shift.

"Whenever it is possible to demonstrate, as occurs in primary croup and diphtheritic croup, that two disturbances of nutrition anatomically alike have an essentially dif ferent origin, we are no longer allowed to confound one with the other.

"Diphtheria is seen, finally, in its true light by Wariman and Hagner, who consider it as one process susceptible of taking on distinct anatomical forms according to the organ on which it is localized. The works of the French school experience during these latter years' the German influence. The principal are those of Lorain and Lepine, Cornil and Ranvier, Mathias, Duval, and Reboullet. Let us note, however, a memoir of Homolle, in which the author demonstrates that the exudate is formed of a coagulable liquid in which are imprisoned the young cells deposited in large quantities on the surface of the mucous membrane."

Conclusions. What must we conclude from the preceding views? The whole question reduces itself to two points: Is the false membrane a fibrinous exudate? Or is it, on the contrary, a product of epithelial transformation?

The second opinion admitted in whole by Wagner and Buhl, and in part by Rindfleisch, is combated by Boldyrew, Steudener and Senator, who return to the theory of Bretonneau by perfecting it and bringing it up to a level with modern science.

There is a point on which all the world is now agreed, that is, the exudative nature of

the false membranes, subglottic portions of the larynx, and the remainder of the respiratory passages. On this subject modern observers hold common ground with the ancients.

When we come to the pharyngeal false membrane divergences arise, but more apparent than real.

According to Senator the necrotic process is the almost constant rule; on the other hand, when he describes the laryngeal false membrane he is careful to tell us that this anatomical form is never found pure in the pharynx. Upon this latter point he is entirely correct, the more so as this proposition rectifies that in which the first was too absolute. Certainly the gangrenous (necrotic) process is observed in the pharynx, and much more frequently than the school of Bretonneau thought; but we fall into error by supposing that all the diphtheritic false membranes of the pharynx are eschars. It is evident that the authors who formulated this latter opinion made their examinations in only one of the forms of diphtheria, the grave form which resembles gangrene or is accompanied with it. But the product of diphtheria presents itself under the most varied forms. While there are some false membranes which are thick, firm, adherent, gray or brown, others, on the contrary, are thin, transparent, white, slightly adherent, and become detached in a very short time. It can not be a question in these latter cases of eschars and of the gangrenous process. (The question is so strong in the negative that there is no ground for disagreement.)

This difference did not escape Rindfleisch, who, though a partisan of the epithelial transformation, described the croupal inflammation of the pharynx. Niemeyer did the same thing, but he considered croup of the pharynx as foreign to the diphtheritic infection.

Disregarding the interpretation as insignificant, let us only establish the anatomical fact, a superficial fibrinous exudation may be produced on the surface of the pharynx. Therefore, while affirming that the false membranes of the pharynx and of the larynx

are of the same nature and proceed from the same cause, I am prepared to recognize that these morbid products offer certain differences of aspect. To present these diverse characteristics in their true light, to exhibit their real nature, this is the important point in the question.

It is not to different processes that these pellicular varieties owe their existence. The morbid action is the same, only its effects vary with the intensity of this same action and with the structure of the mucous membrane on which it is developed. That is a principle of general pathology applicable to diphtheria as well as to other diseases. The question thus brought back to its true terms, let us see the influence that these two factors exercise upon their products. The inflamed mucous membrane presents among others the wellknown alterations of the vascular walls, lesions which, according to the usually received opinions of Cohnheim, permit the emigration of leucocytes and the exudation of fibrin. That settled, we easily see how the product may vary under the influence of the intensity of the cause. When the inflammation is slight, an exudation is formed on the surface of the mucous membrane which is itself infiltrated with young cells. But the lesion is superficial, slightly intense, and recovers without cicatrix. At a higher degree the exudation is more profound, the vitality of the mucous membrane suffers, and a slight loss of substance follows the elimination. Finally, in the grave cases which correspond to what the Germans call the diphtheritic form, the inflammatory impetus is energetic, the exudation of fibrin and of young cells is profound and dense, and it chokes the circulation in the invaded parts. These latter mortify, assume an ashy gray or brown color, and from that time on follow the course of eschars.

The structure of the mucous membrane leaves, no more than the first, any special character upon the product of its inflammation. In the pharynx, and in the hyperglottic portion of the larynx, the epithelium is thick and composed of pavement cells; it adheres intimately to the mucous

corium. This anatomical condition favors the profound infiltration of the tissues. It explains why the pharyngeal false membrane, while remaining superficial and slightly adherent in the cases in which the process is moderate, becomes as thick and tenacious under opposite circumstances, and how, without having the gangrenous appearance, it may leave after its separation a loss of substance in the mucous membrane.

In the hypoglottic portion of the larynx, on the contrary, as well as in the remainder of the air passages, the epithelium is composed of cylindrical cells much thinner; but what changes principally the anatomical conditions is the existence of the basement membrane of Bowman, an amorphous layer which separates the epithelium from the corium, and forms a difficult barrier to cross. By studying this disposition we explain the generally superficial character and feeble adherence of the false membranes which are produced at these points.

When the inflammation has reached a degree sufficiently violent to produce necrosis. (gangrene) the morbid product is eliminated. as eschars are. The facility with which the false membrane separates varies according to the region.

In the pharynx the thickness of the epithelium and its connection with the corium enable the two parts to be invaded at once; there is therefore deeper penetration, and also a greater adherence of the plastic product to the subjacent tissues.

In the hypoglottic portion of the larynx and in all the respiratory tract the false membrane is more superficial; it is never intimately united to the corium from which the amorphous lamella or membrane of Bowman separates it. Hence it is much more easily detached. The detachment occurs in a period of time varying between two and fifteen days. It commences from the second to the tenth day, and ends from the ninth to the fifteenth. But successive exudations may be produced. It is thus that I have found false membranes in an autopsy made on the thirty-first day from the outset. I have

seen a patient attacked with croup expel false membranes up to the thirty-second day.

In reference to the pathology of diphtheria, Loffler has recently been experimenting with reference to the specific pathogenic micro-organisms, which, he claims, stand in the relation of cause and effect to this disease.

This bacillus is regarded as identical with that described by Klebs as the one peculiar to diphtheria. It is about the length of the tubercle bacillus, but double its breadth. Its modus operandi is supposed to be the development of a poison which causes the surrounding tissues to decay, and produces paralysis of the blood-vessels, thereby causing congestions and exudations, and also produces paralysis of nerve centers with death.

Alas! however, Loffler confesses that in certain well-marked cases of diphtheria the bacillus was absent. (New York Medical Record, 1885.) Sanne, (pages 63, 64, 66, 67, 68, 69, 76, 372, 374,) says:

I think, after this, all must acknowledge that pathologically there is no difference between croup and diphtheria. I will give the clinical features of true croup, as laid down in Flint's Practice:

He says "the exudation is primarily in the larynx. If in pharynx it does not extend to esophagus or nares; does not occur in other places. A considerable enlargement of cervical glands does not occur; albumen absent; disease sporadic; affects children almost entirely; no paralysis; not contagious. Diphtheria a general disease, other (croup) local."

Cohen says the symptoms of the two diseases are as follows, and he can, he thinks, recognize a difference.