REMARKS ON CROUP 
AND DI PHTH FRIG CROUP, AND THU 
VALUE OF INTUBATION. 
BY 
FRANCIS P. BALL, M.D., 
OF LOCK HAVKN, PA. 
FROM 
THE MEDICAL NEWS, 
November jo, 1894. [Reprinted from The Medical News, November io, 1894.] 
REMARKS ON PSEUDOMEMBRANOUS CROUP 
AND DIPHTHERIC CROUP, AND THE 
VALUE OF INTUBATION,1 
BY FRANCIS P. BALL, M.D , 
OF LOCK HAVEN, PA. 
The two principal points which I think we 
should consider and discuss to-day are the identity or 
non-identity of diphtheric croup and pseudo-mem- 
branous croup and the value of intubation in these 
cases. 
When we consider the wonderful advances made 
in bacteriology in the past few years, and the ability 
of the bacteriologist to designate the exact micro- 
organisms which are the cause of many diseases, and 
especially when we remember that the specific 
microorganism of diphtheria is a well-recognized 
bacterium, it would seem as though the first pro- 
position for discussion were useless; for the presence 
or absence of that bacterium should settle the ques- 
tion as to the identity of the two diseases. But such 
is not the case. A review of the literature of the 
subject will show quite a diversity of opinion on 
this point, with an array of substantial reasons, both 
for and against the opinion. 
In France, where diphtheria was known and 
1 Read before the Clinton County Medical Society, August 15, 
1894. 2 
studied long before it was recognized in England or 
in this country, writers on this subject, I believe, are 
almost a unit in their belief that all cases of laryngeal 
croup are diphtheric; and their writings and 
experiences have had an effect upon the Germans, 
who hold the same belief; and to some extent, 
though not so universally, upon the English, many 
of whom also believe in the identity of the two dis- 
eases. Mackenzie refers to the influence of the 
experience of the French in his argument support- 
ing the unity theory, and gives them the credit just 
referred to. 
In this country, however, pseudo-membranous 
laryngitis was recognized as a well-defined pathol- 
ogic condition, its clinical features carefully ob- 
served and accurately recorded by competent phy- 
sicians long before diphtheria invaded our land. As 
remarked by J. Lewis Smith, it is impossible to 
suppose that all these cases coming in the hands of 
able practitioners, as they did, should have been 
examples of unrecognized diphtheria primarily affect- 
ing the windpipe, and none of them showing the 
symptoms of faucial diphtheria. It is impossible to 
suppose that so many able observers should have 
been so completely deceived in their clinical study 
of the disease, and it is also impossible to suppose 
that so many cases as are recorded and were under 
observation should have been primary laryngeal 
diphtheria, for we know that it is not by any 
means the rule, nor does it occur in many cases, 
that the diphtheric pseudo-membrane forms pri- 
marily in the larynx. The result of the early expe- 
rience and study of membranous croup, when 3 
diphtheria was an unknown disease in this country, 
has, I suppose, had much to do with the faith many 
American physcians have in the dual theory. And 
this early experience is to me a strong argument 
in favor of that theory. It is no argument to the 
contrary to say, as is so often done, that, because 
croup has increased vastly in numbers of cases since 
diphtheria was introduced into this country, therefore 
diphtheria is the sole cause of croup. It only argues 
that diphtheria is another factor in the production 
of croup, and that the larynx is only another field 
for the development of the diphtheric membrane. 
But it would seem as though the careful bacterial 
study of these cases should elucidate the point which 
has been discussed by many writers, and settle it 
beyond dispute. As Osier remarks, work in this 
field is very much needed. 
The Klebs-Loeffler bacillus is the bacterium of 
diphtheria, and is found in all cases of diphtheric 
croup. When found, therefore, in any case of 
membranous croup, it of course proves the disease 
to be diphtheric. But it is not found in the fibrinous 
exudation of membranous croup. There are various 
cocci found, the staphylococcus and streptococcus, 
and among others the streptococcus pyogenes, but 
not the true bacterium of diphtheria. 
If this proposition can be established, if it can be 
shown that in a certain class of cases the Klebs- 
Loeffler bacillus does exist, and in a certain other 
class it does not exist, there should be little diffi- 
culty in settling the question of identity or non- 
identity of the two diseases. The anatomic appear- 
ances of the two diseases are so nearly identical that 4 
if there is any difference it is not distinguishable, 
and unless they can be differntiated bacterially, as 
suggested, the question of unity must still remain 
open. 
I find recently published the following results of 
the work of different observers bearing on this point 
of the bacteriology of diphtheria, which in this con- 
nection lead to interesting conclusions: Baginsky, of 
Berlin, examined 154 cases of diphtheria, and 
found the Klebs-Loeffler bacilli in 118, and none in 
the other 36. Prudden, of New York, examined 24 
cases of diphtheria, complicating or following scarlet 
fever, and found no Klebs-Loefiler bacillus. Martin 
examined 200 cases, and found the characteristic 
bacillus in 121, leaving 79 without the diphtheric 
bacterium. Park, of New York, found it in 129 
cases, and absent in 79. Thus, in a total of 534 
cases of what was diagnosticated as diphtheria by 
different observers, the Klebs-Loeffler bacillus was 
present in 366 and absent in 168. With this array 
of cases, and their bacteriologic examination before 
us, let us refer to the rules formulated by Koch for 
the establishment of a complete chain of evidence as 
to the production of a disease by any special micro- 
organism. They are as follows, viz. : 
1st. The presence of the organism in all cases of 
the disease, and in such distribution as will explain 
the lesion. 
2d. The isolation of the organism in pure cul- 
ture. 
3d. The reproduction of the disease by inocula- 
tion with the isolated organism, and the presence 
of the latter in the tissues of the inoculated animal. 5 
It is only necessary to apply the first of these rules to 
the foregoing cases to force us to the conclusion that 
we either have two diseases diphtheric in character, 
but quite different in their bacteriology, or that the 
Klebs-Loeffler bacillus is only accidentally present, 
and has really nothing to do with the case. 
Few of us, I think, would have the temerity 
to assert that the latter part of the proposition is 
correct, and consequently we must conclude that 
there are two diseases diphtheric in nature and 
very similar in their manifestations, yet differing 
quite materially in their bacteriology; the one a con- 
tagious disease, the other not, and, as has been shown 
in a further report of the cases referred to, the one 
a much milder disease and more prone to recovery. 
The existence of two diseases having the same 
physical appearance but differing in their bacteri- 
ology, the one a true diphtheria, and the other a 
false diphtheria, has been recognized lately by the 
Chief of the Bureau of Bacteriology of Brooklyn, 
and the difficulties of diagnosis have been acknowl- 
edged to the extent of establishing a method of 
bacteriologic examination of all cases of suspected 
diphtheria at public expense. In a recent journal I 
find that this Bureau of the Department of Health 
of Brooklyn recognizes the fact that 
"Recent bacterial investigations have shown that a 
considerable proportion of the cases of pseudo-mem- 
branous and exudative inflammations of the throat and 
upper air-passages, commonly considered as diphtheria, 
and having the anatomic appearances found in diph- 
theria, are not true, but false diphtheria. On the other 
hand, it has been shown that a considerable proportion 
of the cases which are apparently false diphtheria prove 6 
on bacterial examination, to be true diphtheria. While 
in true diphtheria the mortality is very high and the 
danger of transmission to others is very great, in false 
diphtheria the mortality is low and the danger of infec- 
tion slight.” 
These statements and the recognition of a true 
and a false diphtheria, the one a disease in which the 
Klebs-Loeffler bacillus is found, and the other in 
which various microorganisms, but not the diph- 
theric bacterium, are found, may account for a state- 
ment often made to me by a member of this Society, 
that in Kansas, where he formerly practised, his 
cases of diphtheria were much milder and the re- 
coveries more frequent, so that death was seldom 
expected from a case of diphtheria in that locality. 
Such cases did not differ in their physical aspect 
from the diphtheria seen elsewhere, and which is so 
much more fatal, but no doubt would have differed 
very essentially if examined bacterially. 
If it is true that there is a true and a false faucial 
diphtheria, are we not justified in the belief that 
there is also a non-identity of the two diseases under 
discussion; or, to be more moderate, are we not 
correct in at least considering the question still 
open? The truth is that the number of cases of 
laryngeal croup examined for the purpose of eluci- 
dating this point is yet too small for positive con- 
clusions, and it is a matter of surprise that there has 
not been a greater amount of investigation on this 
subject by bacteriologists. The question of the 
bacteriology of the disease seems to me in our 
present knowledge to settle down to the statement, 
the author of which I cannot now recall, viz: “If the 7 
Klebs-Loeffler bacillus be accepted as a sine qua non 
in the etiology of diphtheria, then croup (pseudo- 
membranous laryngitis) must necessarily be sepa- 
rated from it.” Clinically, there is a difference in 
the symptomatology of the two diseases more easy to 
describe than appreciate, but the dissimilarity does 
certainly exist. I must confess, however, that my 
own experience is that of all with whose views on the 
subject I am familiar, that it is no easy task to differ- 
entiate between pseudo-membranous croup and 
primary laryngeal diphtheria. This fact is illus- 
trated in Case VI reported herewith. In this case 
I was as careful as I could be in my efforts at mak- 
ing a diagnosis, and had the assistance of several 
other physicians, and yet the results, much to my 
sorrow and chagrin, showed that we were mistaken. 
To summarize and abbreviate as much as possible, 
the clinical differences consist in about the follow- 
ing points, viz: 
1. Membranous croup usually begins in the larynx, 
and the fauces are but slightly if at all effected. 
An examination of the fauces in a vast majority 
of these cases reveals nothing. There may be very 
little increased redness and almost no swelling. 
2. Croup is not infectious. 
I have attended, and so have many others, case 
after case of pseudo-membranous laryngitis in which 
there was every reason to expect other children to 
contract the disease if it were contagious, and yet 
no such result has followed. This point is well 
illustrated in the following cases, with the excep- 
tion of one in which an error of diagnosis is 
admitted. It is said by Dr. J. C. Wilson in Pep- 8 
per’s System of Medicine, that cases of tonsillar 
diphtheria also occasionally run their course with- 
out infecting others, though there may be exposure 
of susceptible persons. But it is admitted that 
diphtheria is an infectious disease, and the instances 
of escape of susceptible persons are exceptional; 
whereas, in the experience of the physicians of this 
city, at least, the rule in membranous croup is that 
the affection is non-infectious, and susceptible 
persons are exposed with impunity. 
3. Croup has none of the serious asthenic symp- 
toms of diphtheria. 
All the serious symptoms which arise in croup are 
due to the obstruction of respiration, and therein 
alone lies the danger. 
4. Croup is not followed by paralysis. 
In contradiction of this statement, Mackenzie says 
that the reason for this is that about all cases terminate 
fatally, but in those cases which recover paralysis 
does occasionally occur. His article was written 
before intubation was extensively done, and conse- 
quently there were but few recoveries. Since then 
many cases have been saved by this operation ; but 
I have learned of but few cases of paralysis within 
my own experience or that of others, and in those 
cases we are willing to admit that the disease was 
probably diphtheric, for it must be borne in mind 
that we do not assert that cases of pseudo-mem- 
branous laryngitis are never diphtheric and that 
we are painfully conscious of the difficulties of diag- 
nosis. 
5. Croup is a sthenic disease, while diphtheria is 
adynamic. 9 
6. Croup is a local disease. 
Whether diphtheria is first local and then general, 
or vice versa, is still a disputed point, but it is a fact 
that it is ultimately constitutional. No such state- 
ment substantiated by sufficient proof can be made 
in regard to croup. 
7. The lymphatic glands are not affected in croup, 
but are enlarged in diphtheria. 
This is explained by Mackenzie and others, by 
citing the well-known fact that there is no commu- 
nication between the mucous membrane of the 
larynx and the superficial cervical glands. 
8. There is no albuminuria in pseudo-membranous 
croup. 
I am sorry the urine was not examined in all of the 
cases here reported, but this paper was not contem- 
plated at the time the cases were under observation. 
The examination was made in only one case, and 
that was diphtheric, and showed a quantity of 
albumin. 
While, then, on these grounds of bacterial and 
clinical difference, we argue the non-identity of the 
two diseases, it must still be admitted that it is very 
difficult and, in many cases, impossible to diagnos- 
ticate between cases of primary laryngeal diphtheria 
and pseudo-membranous croup. One of the cases 
here reported shows this difficulty, for after being 
carefully examined by several physicians and pro- 
nounced pseudo-membranous croup, subsequent 
events proved it to be diphtheric. This difficulty 
of diagnosis is spoken of by most authors, and in 
fact, is used as an argument for the identity of the 
two diseases. 10 
This difficulty of diagnosis being true and an ad- 
mitted fact, I fully indorse the action of the New 
York Board of Health in designating all cases of 
croup as being the safest method under 
the circumstances for the avoidance of possible risk 
of contagion. In fact, I would urge upon all, in 
view of my own experience, the propriety of isolat- 
ing all cases of croup, and in future I shall certainly 
do so myself, though this is not an admission of the 
identity of the two diseases, but only a confession of 
the difficulty of diagnosis. 
For the purpose of illustrating some of the points 
enumerated, namely, the non-contagiousness of 
croup, clinical history, pathology, difficulties of 
diagnosis, and also the results of treatment, I call 
attention to the following cases : 
Case I.—Daughter of Geo. G., aged six years. 
The brother had died a week or ten days previously 
of diphtheric croup. She had no deposit on the 
fauces, and I do not recall any glandular enlarge- 
ment ; nevertheless, considering that her brother 
had died of diphtheric croup a few days before, I 
felt justified in pronouncing her case also diphtheric 
croup. There was no fetor of the breath, such as 
usually occurs in diphtheria, nor was the constitu- 
tional disturbance in any way different from what 
we would expect in a case of pseudo-membranous 
laryngitis. The usual remedies failed, and I at- 
tempted intubation with the assistance of Dr. Wat- 
son. The operation was a complete failure. At 
that time I thought it was on account of loose mem- 
brane filling the tube, thus interfering with respira- 
tion, but now I believe it was want of skill in intro- 
ducing the tube, and have my doubts whether it was 11 
in the windpipe at all. It was my first case of 
intubation, and I have learned a good many things 
about the operation since. 
Case II.—A son of John C., aged seven years, 
was taken with symptoms of croup, and the disease 
rapidly developed, so that there was no difficulty in 
diagnosticating his disease as membranous croup. 
There was no offensive odor of the breath nor 
glandular enlargement, and the constitutional dis- 
turbance was mild, the temperature not running 
much above ioi° or 102°. His brother played 
around him, kissing him and inhaling his breath, 
and in fact no effort was made to keep them sepa- 
rated, nor were any disinfectant measures used. His 
brother and some other children who were allowed 
the freedom of the sick-room without restraint did 
not take the disease, nor did any of them have the 
least sore-throat. I was somewhat anxious to know 
whether they did or not, and so kept myself in- 
formed in regard to all who came in contact with 
the patient. With the assistance of Dr. Armstrong 
I attempted intubation in this case. Whether the 
tube was in the larynx or not I am not prepared to 
say, for at that time my knowledge of the landmarks 
was not very accurate. But this I do know, that 
with a mighty effort he coughed up the tube and 
with it a membrane several inches long and a per- 
fect cast of the windpipe. He died, however, of 
exhaustion the next day. In this case, as in case 
No. 1, the operation was too long delayed even if 
skilfully performed, to be of any service, deep 
cyanosis having occurred and mucous rales being 
distinctly heard over the lungs in both cases 
Case III.—A Russian Jewish boy (son of A. S.), 
aged five years, deaf and dumb, was taken with 
croup-symptoms, and Dr. Watson being called, 
diagnosticated the case as one of membranous croup. 
I saw the child the next day with the doctor and 12 
confirmed his diagnosis. We intubated him, and he 
recovered. No precautions were taken to keep the 
other children away, and the surroundings were the 
most unhygienic that can be imagined. Though 
other children had free access to him no other cases 
occurred in the family or neighborhood. A peculiar 
accident happened in this case. The little fellow 
being deaf and dumb could not be made to under- 
stand that he was not to disturb the string, and in 
some way he managed to chew the string off and 
finally to get the tube into the esophagus and swallow 
it, passing it by the rectum some days after. That it 
was really in the windpipe is proved by several cir- 
cumstances. The breathing was much improved 
after its introduction, and he had the peculiar metal- 
lic ring in his voice. He vomited before he was 
put to bed, so that if the tube had been in the eso- 
phagus, instead of in the windpipe, he would cer- 
tainly have thrown it up. While the tube was in 
position with the string fixed to his ear he was given 
liquid food, which he swallowed easily, and this he 
could not have done had the tube been in the gul- 
let. I mention this accident, as it was a peculiar 
one and because it had afforded some amusement to 
my friends. I was especially chagrined at it, as it 
was my first case of intubation in which the patient 
recovered. 
Case IV.—A daughter of Charles G., aged four 
years, was taken sick with vomiting and fever, and 
the parents thought also sore-throat. I was called 
to see her in the evening and found the child asleep 
on the mother’s lap. When I attempted to examine 
her throat she struggled and resisted so that I could 
not see what her condition was. I intended to see 
her the next day, but the father came to see me and 
said she was up and running around and that I 
would not need to call. On the fourth day of her 
illness, however, he came to see me again and said 13 
that she had lost her voice, and, immediately sus- 
pecting the case to be one of true croup, I at once 
went to see her. I found her running around the 
room, apparently well, except that she had lost her 
voice. An examination showed that she was suffer- 
ing with diphtheric croup, the fauces and tonsils 
being covered with the membrane. She was immedi- 
ately put to bed and a very serious prognosis given. 
She was isolated from the rest of the family and given 
mercuric chlorid and tincture of ferric chlorid, 
and a spray of bichlorid was also used. On the 
fifth day respiration was so much interfered with 
that with the assistance of Dr. Watson I intubated 
with the most gratifying results, the little one get- 
ting so much relief that she herself said “ I’m bet- 
ter.” The tube remained in place and gave every 
satisfaction until the seventh day (two days) when 
it became filled with membrane and mucus, and 
after a while was expectorated along with shreds of 
membrane. The respiration again becoming labored 
the tube was re-introduced, with complete relief of 
the dyspnea, but the child died on the following 
morning, not from interference with respiration, but 
from the toxemia of the diphtheric poison. 
Case V was a son of S. E., aged five years, seen 
by Dr. Watson, and a diagnosis of pseudo-mem- 
branous laryngitis was without difficulty made. I 
saw the case in consultation on the next day, and 
did not hesitate to confirm the diagnosis, and that 
evening performed intubation. The tube remained 
in place for four days, during which time there were 
no untoward symptoms, the little fellow feeling well, 
and exposing a frequent desire for something to eat 
and making a complete recovery. There was no 
effort at isolation, and though other children had 
frequent communication with him no other cases 
developed. 
Case VI.—A son of G. W. B., aged four years, 14 
had been sick two days previously to my visit, with 
croupy symptoms and fever, but had not complaind 
of sore-throat, nor was there any enlargement of the 
cervical glands. There was no especially offensive 
odor to the breath, but on inspection of the fauces 
there was distinctly visible a small white patch ot 
pseudo-membrane on the posterior and inferior 
aspect of each tonsil. The systemic disturbance 
was slight, the temperature being 103° in the axilla, 
and digestion and appetite not more impaired than 
would be expected with such a febrile reaction. I 
am now convinced that I made a mistake in diagnosis 
when I pronounced the case one of membranous 
croup. No precautions were taken to prevent the 
other children from having access to the boy, and the 
consequence was that several cases of diphtheria of 
a mild type, and one of diphtheric croup, to be re- 
ferred to again, followed this case in the same 
family. My only justification is that the case was 
seen by a number of other physicians, and the diag- 
nosis was confirmed by all. It certainly was not 
secondary to faucial diphtheria, and was so mild in 
all the symptoms, except those of obstruction, that 
it was difficult to realize that it was actually a case 
of diphtheric croup affecting primarily the larynx. 
The interference with respiration was so marked and 
continuous that in the presence of a number of phy- 
sicians I intubated him. He was given tincture of 
ferric chlorid and mercuric chlorid, and allowed to 
inhale the vapor of slaking lime. The tube re- 
mained in place for four days, the temperature 
gradually fell, and as there were no contradicting 
symptoms the tube was removed at the end of this 
time, and with the exception of the fact that about 
this time he developed measles, through which he 
had to pass in the usual way, he made an uninter- 
rupted recovery. 
Case VII.—A son of W. H., aged seven jears, 15 
was seen by Dr. Watson on April 29th. An inspec- 
tion of the fauces revealed diphtheric membrane 
covering the tonsils and palate, and this with the 
interference of respiration, loss of voice, rapid feeble 
pulse, and temperature of 103°, made it very easy to 
diagnosticate the case as one of diphtheric croup. 
The boy had been sick less than twenty-four hours 
when the physician was called, and at that time he 
was croupy, so that the probabilities are that the 
membrane was formed previously in the larynx, or 
at least at the same time that it formed in the fauces. 
The child was completely isolated from the other 
children of the family, and no other cases followed. 
He was given the usual course of treatment, but it 
proved of no avail, and two days after he became 
ill the obstruction to respiration made it necessary 
to intubate, which we did successfully and with 
complete relief to his breathing. The tube used, 
however, was too small, and he coughed it out about 
six or eight hours afterward. A larger one was 
introduced and remained. A few days afterward 
he developed measles with catarrhal pneumonia, from 
which he died four days after intubation. The 
breathing was not in the least obstructed, and he 
died just as he would have done from pneumonia un- 
accompanied by croup. 
Case VIII.—A son of A. F., aged twelve years, 
showed croup-symptoms, and Dr. Corson, of Charl- 
ton, was called. The boy had a moderate elevation 
of temperature, no swelling of the cervical glands, 
no offensive odor of the breath, and no deposit of 
membrane on the fauces. Dr. C., who is a strong 
advocate of the diphtheric origin of all these cases, 
confessed that this was different in its clinical features 
from the cases of diphtheric croup which he had 
seen before. When called in consultation with him 
I fully agreed in the diagnosis of pseudo-membran- 
ous croup. Obstruction to respiration had become 16 
so serious that it had been feared he would not be 
kept alive until I should arrive, and so we proceeded 
with intubation. The child made a complete re- 
covery, and in four days the tube was removed. He 
was not isolated, and, so far as I know, no other 
cases can be attributed to him as the source of in- 
fection, though there was ample opportunity if the 
disease had been contagious. A peculiarity of 
this case was the age of the patient. He was the 
oldest child I ever saw with pseudo-membranous 
croup. Cases at this age are certainly very rare. 
Case IX.—A son of R. C. H., aged six years, 
was taken with symptoms of catarrhal croup some 
two weeks after an attack of measles. He had been 
sick several days when his father came to me for 
some croup-medicine, never thinking of membranous 
croup, but incidentally and rather accidentally re- 
marked that the little fellow had lost his voice. My 
suspicions were at once aroused, and on visiting 
him my fears were confirmed, though I had some 
difficulty at first in deciding between catarrhal and 
pseudo-membranous croup. There was no deposit 
in the fauces. The temperature was ioi° under the 
tongue. The boy was given tincture of ferric chlorid 
and mercuric chlorid, with inhalations of lime-water 
and carbolic acid. He was not isolated, and his sister 
played with him, and once I found her lying beside 
him. Other children also were admitted to the 
room. No other cases followed. Obstruction to 
respiration became so alarming that intubation be- 
came necessary on the third day after I was called, 
which I performed with the assistance of Dr. Watson 
and my student, Mr. Salmon. Rapid recovery en- 
sued. 
Case X.—This was the youngest child I think I 
ever saw with membranous croup, being only sixteen 
months old, small for its age, and of a strumous di- 
athesis. The parents not appreciating the gravity of 17 
the disease had neglected it till the last minute. 
With the assistance of Drs. Watson and Lichten- 
thaler I intubated, but not without a good deal of 
difficulty. When I saw the child a few hours after- 
ward its temperature was 105° in the groin, and while 
respiration was not obstructed, it breathed 74 times 
a minute. It died seven hours after intubation, but, 
much to the parents’ satisfaction, was relieved of the 
dyspnea. 
Case XI was a son of G. W. B., aged two years. 
This is the case referred to in reporting Case V, and 
occurred in the same family just two months later. 
In the meantime, however, there had been several 
cases of diphtheria of a mild type in the family, and 
I had urged the isolation of the affected children 
without avail, though as the original source of the 
disease was an old partly filled well into which the 
wash-water and refuse were thrown, and which com- 
municated with the house by a pipe, and which I 
had tried in vain to have removed, they would prob- 
ably have taken the disease even if they had been 
isolated. This child when first seen had faucial 
diphtheria, but no symptoms of croup. After a few 
days’ illness, however, he began to be croupy, and 
his voice was markedly changed. On “flood Mon- 
day” he became so croupy and his respiration so 
labored that intubation was necessary. The house 
being surrounded by water, Dr. Watson and I got 
into a boat, went out, and performed the operation. 
On the fourth day after intubation rales were heard 
all over the lungs, and little air seemed to enter the 
vesicles. I thought that possibly the tube was filled 
with mucus and membrane, and removed it, but 
without relief, and the child died the same even- 
ing. Evidently the deposit had extended to the 
bronchial tubes, and I have no doubt even into the 
smaller ones. 18 
On analysis of the foregoing cases, we find that 
five were diphtheric and six were not, and that in all 
except one of the former isolation was enforced so 
that no other cases developed from them ; but in the 
latter, in those cases diagnosticated as membranous 
croup, no effort was made to keep other children 
away, and yet in no case except the one referred to 
as a mistake in diagnosis did any other children 
contract the disease or any sore-throat, though in 
every instance there was exposure of susceptible 
persons. On this fact, as well as the clinical history, 
is based the supposition that the diagnosis in these 
cases was correct. The one case in which a mistake 
was made I now believe could have been diagnosti- 
cated properly if due importance had been attached 
to the small speck of membrane on each tonsil. 
Though it was not larger than a grain of wheat, I 
believe such a deposit is almost diagnostic of diph- 
theria, for as far as I can now recall I think I never 
saw a deposit on the tonsils in pseudo-membranous 
croup. 
Clinically, it may be noticed that in these six 
cases of membranous croup there was no deposit of 
membrane in the fauces, a fact which seems a strong 
argument in favor of the diagnosis, and especially 
so when we recall that in 156 cases of laryngeal 
diphtheria referred to bv Dr. Northup, in only one 
was the membrane in the larynx alone, showing the 
great tendency to spread to adjoining parts in diph- 
theria as contrasted with the local tendency of mem- 
branous croup. 
Of the five cases that recovered not one had 
paralysis of any kind. 19 
Of those cases that recovered only one was an 
example of diphtheric croup, and of those that died 
all but one was diphtheric, the remaining one dying 
from a late operation in an enfeebled child of 
extreme youthfulness. 
In closing, I wish to make a few remarks on the 
value of intubation in these cases. 
O’Dwyer estimates that one child in ten gets well 
of membranous croup, whether diphtheric or pseudo- 
membranous, under medical treatment, but from my 
own experience and that of others with whom I have 
been intimately enough associated to know of their 
experience, I am convinced that when obstruction 
does really exist, when there is a pseudo-membrane 
actually formed, this percentage of recoveries is too 
high. And moreover I am convinced that when 
recovery does occur it is more by the accidental 
removal of the obstruction or by the vis medicatrix 
natures than by the potency of any drug or plan of 
medical treatment we can select. But even admit- 
ting that one in ten recovers, the mortality is still 
wofully high, and anything that will reduce it is 
certainly to be sought after most diligently. Intuba- 
tion has reduced the mortality to 26.77 per cent., 
or roughly estimated, about one in four recovers 
after this operation, which is quite a fall in the 
death-rate, as is readily perceived ; but I believe as 
the operation becomes better known, and is conse- 
quently not held in reserve to be used as a last 
resort, but, on the other hand, is performed early, 
the mortality will be still greatly lessened. 
If we refer to the cases here reported and exclude 
the first two cases, which should not be included be- 20 
cause they were not (for the want proper skill) 
intubated at all, and should not, therefore, be in- 
cluded in the intubations, we see that five of the 
nine cases intubated recovered, 55.5 per cent., or 
more than double the proportion of successful opera- 
tions as published in the books. Of course, the 
number is too small to make the results of much 
statistical value, as the next series of cases may 
reduce this favorable showing considerably, but I 
attribute the results to the fact that in all cases an 
operation was urged as soon as the obstruction be- 
came very decided and before the cyanosis became 
too pronounced. I believe that one of the cases 
(Case X) would at least have stood a better chance 
for recovery had I seen it earlier, notwithstanding 
its extreme youthfulness, being only sixteen months 
old, and of a strumous diathesis. I saw it only nine 
hours before death, and it died seven hours after 
intubation. 
Even in the cases in which intubation failed to 
cure, only in one case did it fail to give relief, relief 
most gratifying to parents and attendants, and no 
doubt, still more gratifying to the little sufferer. In 
the case in which it thus failed to relieve I am satisfied 
tracheotomy would also have failed, as it was quite 
evident the membrane had extended to the bronchial 
tubes, and, it seemed, also into the smaller branches. 
One of the great advantages of intubation is the 
willingness of parents to permit it, and if physicians 
would be less afraid to propose it I am sure there 
would be more early operations, and consequently 
more recoveries. The Medical News. 
Established in 1843. 
A WEEKL YMEDICAL NEWSPAPER. 
Subscription, $4.00 per Annum. 
The America7i Joiirnal 
OF THE 
Medical Sciences. 
Established in 1&20. 
A MONTHL YMEDICAL MAGAZINE. 
Subscription, $4.00per Annum. 
COMMUTA TION RA TE, $7 50 PER ANNUM. 
LEA BROTHERS & CO. 
PHILADELPHIA.