m - r ■ : : . . A MONOGRAPH 
ON THE 
PATHOLOGY AND RATIONAL TREATMENT 
OF 
INFANTILE LARYNGO-TRACIIEITIS, 
/ ctemMQ 
CROUP. 
BY E. E. PEASLEE, A. M., M. D.,^ 
PROF. OF ANATOMY, ETC. 
[From the American Medical Monthly, August and September, 1854.] 
Although the readers of the Monthly have so recently perused the 
able article on Croup, by Dr. Horace Green,* the great practical importance 
of this subject affords a sufficient apology for again so soon calling their 
attention to it. Moreover, the writer of the present article desires, while 
Dr. G.’s views are fresh in recollection, to express his own convictions, both 
from experience and observation, of their correctness, so far as the mis- 
chievous consequences of the violent treatment usually resorted to are con- 
cerned ; while he at the same time proposes certain ideas he has for some 
time held of the pathology of this disease, and thus attempts to lay a foun- 
dation for its rational treatment. 
The sanguinary and heroic means generally resorted to in the treatment 
of croup, would seem to show that it is regarded as essentially different 
from all other infantile diseases; and hence, the caution and regard for the 
delicacy of the little patient, which should characterize all medication at 
this period of life, has apparently been regarded as here out of place. At 
least, the disease has been too generally treated with an energy—a despera- 
tion even—which no other opinion can justify. 
It is believed, however, that croup may be shoAvn not to be Avanting in 
analogies with other diseased conditions, both in the infant and the adult; 
and that some salutary, practical inferences will floAV from a knowledge of 
the relations here to be pointed out. 
* See the June No. of the Monthly, p. 409-421. 2 
PATHOLOGY OF CROUP AS THE 
Two varieties of croup are admitted by all writers—the spasmodic and 
the inflammatory. 
The spasmodic croup—otherwise called false or spurious croup—is 
merely a laryngismus ; in other words, it is merely a spasmodic condition 
(a spasm) of the muscles of the larynx. It is very unfortunate that tire 
word “ croup” has ever been applied to this affection, it having but a single 
symptom in common with genuine croup, viz., the peculiar stridulous sound 
accompanying inspiration. This should hereafter be termed laryngismus, 
merely, and not croup; and by that term it will be designated in this paper. 
The inflammatory variety of this disease (with which some degree of 
laryngismus is always associated), is called true croup, and sometimes 
membranous croup; and more recently has been termed “ pseudo-mem- 
branous laryngitis.”* The last name implies two distinct propositions: 
1st. That croup is a laryngitis, i. e. an inflammation of the mucous mem- 
brane of the larynx ; 2d. That this inflammation is accompanied by the form- 
ation of a false membrane. 
Here, then, are the two essential pathological elements of this disease, 
and without the co-existence of which, croup does not exist.f But, assum- 
ing these propositions, in order to have a definite point of departure, in dis- 
cussing a subject so differently understood by different writers,—several 
questions at once suggest themselves. 
Does laryngitis occur also in children, as in adults, without false mem- 
brane ? And, if so, shall it not also be termed croup ? On the other hand, 
does laryngitis with false membrane occur in adults ? And is it not here 
true croup also ? Is the actual pseudo-membranous laryngitis of infants 
and children a specific inflammation ? And, in this form of disease, does 
the danger to the patient result mainly from the presence of the false mem- 
brane, as seems to be so very generally admitted ? or is the inflammation 
alone often sufficient to produce fatal results ? 
These, and other inquiries suggested by these, will be answered as we 
proceed. They have all been variously answered by different writers; and 
hence we deem it necessary to examine them anew. 
1st. Does laryngitis, without false membrane, occur in the infant as in 
the adult ? 
We may very summarily dispose of this question, by reminding ourselves 
that several writers admit a catarrhal variety of croup, in which it is con- 
* Some make croup to be a tracheitis, instead of a laryngitis. It will be seen,, 
however, that both these portions of the air-passages are, almost uniformly, and 
even the bronchi also are, not infrequently, affected in succession, or at the same 
time, in this disease. 
f M. Bouchut says, “Sans ce produit [fausse membrane] il n’y a pas de croup.” 
5 Guerf ent and Bretonneau hold the same idea.—Dr. H. Green on Croup, p. 6-7. BASIS OF ITS RATIONAL TREATMENT. 
3 
fessed that no false membrane is formed. But a mere catarrh is an increased 
secretion from a mucous membrane, from congestion or irritation, or both, 
and is no evidence of inflammation at all. True membranous croup is often 
preceded by a mere catarrh of the larynx and trachea ; and a catarrh often 
stops short of true croup. But to term a mere catarrh of the upper part of 
the air-passages in a child croup, while we at the same time admit its in- 
flammatory character, is as objectionable as to term an increased secretion 
of the Schneiderian membrane (as from the irritation of snuff') an inflamma- 
tion of this part. And the absurdity of this idea is still further shown, if we 
decline to term a similar catarrh “ croup,” when it occurs in the adult; and 
moreover, hold, with some, that this same catarrh is, in the child, the result 
of a peculiar—a specific inflammation. 
If there be an actual inflammation, there will in all cases be something 
different upon the membrane from a mere catarrh. This will be explained 
further on ; and, meantime, we shall object to the term croup being applied 
to any morbid state in which inflammation is not an element. 
Now, regarding croup as always an inflammation, all well know' that in 
fatal cases of true croup, so called, the development of the membrane is not al- 
ways completed before death ensues. But all analogy favors the presumption 
that a laryngitis may run through its course and terminate favorably in the 
infant as well as in the adult, without necessitating the formation of a false 
membrane in any degree. Inflammations of even the serous membranes are 
not uniformly productive of false membranes, in either infants or adults ; 
indeed, they are so only in a minority of all the cases. Highly improbable 
is it, therefore, that inflammation of the mucous membrane of the infant’s 
larynx should always produce a false membrane. 
And does it alter the case, if we admit, with some, that croup is a specific 
inflammation ? Not at all, as we shall see when we come to explain the 
manner in which a false membrane is invariably produced. 
Or we are, perhaps, assured that croup is an inflammation mainly of the 
mucous follicles of the larynx and trachea, and therefore the false mem- 
brane is developed. We cannot conceive how, in any case of laryngitis, 
these follicles can possibly escape the inflammatory process, if we consider 
either their number or their position. But how they are more likely to be 
especially attacked in the infant than in the adult, or, if so, why they are in 
the former more likely to lead to the formation of a false membrane, none 
of the received principles or analogies of pathology can explain. 
Are we told that these follicles when inflamed secrete an albuminous 
fluid, and this becomes converted into the false membrane ? I reply, that 
the secretion (incorrectly so called) is not “ albuminous,” though generally 
so represented; and that a false membrane, moreover, is never developed 
from a secretion. 4 
PATHOLOGY OF CROUP AS THE 
But if the false membrane extends into the trachea, it is found to be 
thickest on the posterior wall, where the follicles are most abundant. Pre- 
cisely so ; and the true explanation of this fact will be given further on. 
Others, still, assert that the false membrane is produced from the fact, 
that the submucous areolar tissue is inflamed in membranous croup. This, 
however, is an entirely gratuitous assertion.* 
The presumption is, therefore, in favor of a laryngitis not leading to the 
formation of a false membrane, in the infant as well as in the adult. 
And what facts can be found to bear on this question ? Do we not meet 
with cases of supposed membranous croup, in which recovery takes place 
without the existence of a false membrane having been demonstrated at all 
during the progress of the case ? And in how many cases in which the 
membrane is said to have been coughed up, or vomited up in a “ dissolved 
state,” or in the form of “ flakes,” is it certain that the supposed false mem- 
srane was actually such ? It is very true that children, up to nearly or 
quite seven years of age, usually swallow whatever they force up through 
the larynx by the act of coughing. But it is also true, that various sub- 
tances ejected from the stomach of a healthy child, even, might sometimes 
be found precisely to resemble these “ shreds ” of false membrane, so called, 
which sometimes appear in the circumstances under consideration. 
We do not, therefore, by any means deny that shreds of false membrane 
are often ejected from the stomach during the continuance of true croup : 
but we d,o insist that very often they could not be demonstrated to be such, 
especially if they had remained for a short time in that viscus; and, 
moreover, that very frequently they would not have been pronounced such 
on examination even, were they not expected, in such a case, as a matter of 
course. We accept, therefore, such observations, except when the fragments 
are distinctly tubular, or of considerable dimensions, with a degree of philo- 
sophical doubt; just as we listen to accounts of worms appearing in the 
alvine evacuations, “ cut up ” and “ dissolved,” after giving a vennifuge on 
the suspicion that they are present in the alimentary canal—though no 
other previous or subsequent proof of their existence can be adduced. 
On the other hand, not infrequently does it occur that in autopsies of 
fatal cases of what was diagnosticated and treated as true croup, no false 
membrane at all is found. Had it here become detached, and been expec- 
torated before death ? There has been no proof of this whatever. 
Such facts, we think, render it extremely probable that in many cases, 
* The writer by no means denies that inflammation of the submucous areolar 
tissue of the larynx ever exists. On the contrary, “submucous laryngitis” is a well- 
known disease, and oedema glottidis is a frequent result of it. But croup is another 
vsease, according to all writers, and is here regarded as mere laryngo-tracheitis. BASIS OF ITS RATIONAL TREATMENT. 
5 
not distinguishable for any practical purpose from true croup, during life, a 
false membrane is not formed at all; and that, therefore, laryngitis without 
the formation of a false membrane occurs in the infant as well as in the 
adult. 
But this point will be still further elucidated, when we have next con- 
sidered the source from which false membranes are in all cases derived, and 
the manner in which they are developed. 
I. A false membrane is, in all cases, formed from the plasma of the blood, 
and which consists principally of its fibrine. It was remarked, several years 
ago, by Dr. Alison, that there is, in all inflammations, a tendency to the 
exudation of plasma from the vessels of the inflamed part. We maintain 
that in all inflammations an exudation actually does occur. It is, however, 
sufficient for our present purpose, that the plasma is exuded from the en- 
gorged vessels of the part and upon the surface, in all cases of inflammation 
of membranes, at least. Nobody doubts this assertion in regard to serous, 
membranes; and even the purulent discharge (often called a secretion) from 
an inflamed mucous membrane, is known to be derived from the plasma 
exuded by a degeneration of the exudation-corpuscles into pus cells. More- 
over, if an actual false membrane forms in croup upon the mucous surface, 
it is equally derived from the same source. 
1. The first step towards the formation of a false membrane in croup, 
therefore, is the exudation of plasma upon the surface of the mucous mem- 
brane, as explained, in consequence of the laryngitis. The amount of the 
exudation will depend upon several circumstances; of which, the state of the 
blood, the extent of the inflammation, and the vascularity of the part, are 
the most important. In membranous croup, the exudation is most abund- 
ant, and therefore the resulting membrane is thickest, on the surface where 
the mucous follicles are most abundant; and this, in the trachea, is the case 
with the posterior wall. The follicles are merely an inversion of the mucous 
membrane; so that here is a great amount of free surface, and a vast num- 
ber of small blood-vessels inclosed within a very small space. In other 
parts, the surface is much more smooth, the vascularity less, and thus the 
exudation, as well as the resulting membrane, is thinner. It has already 
been asserted, that it is not the secretion of these follicles that becomes 
organized, nor is the exudation “ albuminous.”* 
2. The second step in the development of a false membrane is the 
organization of the exuded plasma. But it is very well known that, in the 
majority of instances, this never takes place, even on serous membranes, and 
therefore no false membrane is formed. 
* The fact observed by Hasse, that fibrous bands or threads sometimes extend 
from the false membrane into the follicles, is thus shown to be precisely what we 
should expect. 6 
PATHOLOGY OF CROUP AS THE 
Iii fact, three entirely different results may ensue to the layer of plasma 
exuded upon the free surface of a membrane in consequence of inflammation ; 
provided it is allowed to remain in contact with it. 
1st. It may be entirely reabsorbed. 
2d. It may be converted into pus; exudation-corpuscles being formed 
in it, and these becoming, subsequently, degenerated into pus cells. 
3d. It may become fibrillated (coagulated), and thus form a false mem- 
brane ; which, subsequently, may become more highly organized; and, in 
case of serous membranes, even vascular, at last. 
Now, either of these results is possible, in case of inflammation of both 
serous and mucous membranes. In case of the latter, however, the part 
affected may be so situated as to be brought into contact with foreign sub- 
stances (as is the case with the mouth, pharynx, and other parts of the 
alimentary canal); and the exudation may thus become at once detached, 
and in that case, neither of the three results above-mentioned can ensue. 
Moreover, the opportunities for reabsorption on mucous membranes are very 
slight indeed, and often null. 
To illustrate these results in case of a serous membrane : In pleurisy 
the exudation being reabsorbed, perfect recovery takes place ; if it becomes 
organized, false membranes and adhesions are the result; or if it is con- 
verted into pus, empyema is the result. 
Now, the circumstances favorable to the organization of the plasma are : 
1st. Its perfect contact with the living tissues; 
2d. Perfect rest of the part, or maintaining the required contact, and for 
the necessary time also ; 
3d. Smoothness of surface, as also subservient to the first condition. 
On the other hand, the following circumstances are unfavorable to 
organization : 
1st. Motion of the part affected ; 
2d. Contact of foreign substances ; 
3d. Irregularity of surface. 
But there are certain other conditions of the exudation itself, also, which 
affect the result. The former is more liable to become organized, and the 
membrane is more perfectly formed, in proportion— 
1st. To the amount of fibrine contained in it; 
2d. To the slowness (amount of time allowed) of the fibrillation. 
Here we should, however, remark, that all the formative processes are in 
much less time completed in the young than in the adult animal; and it is 
in accordance with this ultimate fact, that Jurine and other experimenters 
could artificially produce false membranes in the air passages of young 
animals alone. In adult animals, the exudation would become detached 
before its organization was complete. BASIS OF ITS RATIONAL TREATMENT. 
7 
Now, if we compare the probabilities that an exudation upon a serous 
membrane will become organized, with those that the same result will occur 
upon a mucous membrane, we find the former allows— 
(1st.) Of a far more perfect contact; since it is smooth, and compara- 
tively or entirely at rest (e. g., remark the immobility of the ribs in respira- 
tion, in pleurisy). (2.) It excludes the exudation from the air and from 
foreign substances. (3.) Allows time for the perfection of the process of 
organization. (4.) The fact, also, that contact of the exuded plasma with 
the living tissues occurs on both its surfaces at the same time (being between 
the two layers of the serous membrane), must not be omitted here. Nor 
(5) must we fail to add, that in case of inflammations of serous membranes, 
the blood (and therefore, probably, the exudation also) contains a greater 
amount of fibrine than exists in it in inflammations of mucous membranes. 
Mucous membranes, on the other hand, are opposed to the serous, in all 
the respects just mentioned. 1. Having a conoidal instead of a delicate, 
scaly epithelium in most parts (e. g., over the whole respiratory passages, 
and the alimentary canal from the cardiac orifice of the stomach to the 
sigmoid flexure), they do not allow of so perfect a contact of the plasma 
with the living tissue of the membrane itself. 2. They afford contact only 
on one side of the plasma. 3. In most parts, the plasma is exposed to the 
air and the contact of foreign substances. 4. There is more motion of the 
part. 5. All these circumstances afford less time for the organization to 
occur; so that it may fail of being completed, if commenced. 6. And, 
finally, the plasma itself is less organizable than in the case of inflammation 
of serous membranes. 
We have no difficulty, then, in accounting for the fact that false mem- 
branes occur very much more frequently on serous than on mucous mem- 
branes. Nor is there any in accounting for the fact that, in certain cases, 
they are formed on the latter also, as well as the former. 
False membranes have been known to form in cases of inflammation of 
the rectum, the vagina, the uterus, the nasal passages, the pharynx, larynx, 
trachea, and bronchial tubes; and in all these parts certain peculiarities 
exist, more favorable to the organization of the plasma than the mucous 
membrane in other parts presents. The rectum and vagina have a scaly 
epithelium, and are comparatively at rest—the rectum, even, being void of 
faeces and of motion, except during the act of defecation. The uterus, also, 
allows of still greater rest of the exuded plasma, though it has a conoidal 
epithelium. The Avhole extent of the air passages is provided with a conoidal 
and a ciliated epithelium ; but it has no foreign body in contact with it, ex- 
cept the air ; and in this respect, and in point of motion of the surface, has 
the advantage of the alimentary canal above the rectum ; where false mem- 
branes do not become organized. In children, however, there is less motion 8 
PATHOLOGY OF CROUP AS THE 
still; and, they also requiring less time, we should expect organization to 
occur more frequently than in adults. 
Now, to return to the subject directly under consideration. 
In cases of actual laryngitis with false membrane, or membranous croup 
in children, the exuded plasma becomes to some extent organized—fibril- 
lated at least. But can we suppose that this result occurs in every case of 
laryngitis in the early years of life ? If the plasma is often absorbed, and 
also frequently converted into pus, in case of inflammation of a serous mem- 
brane (e. (j. in pleurisy), can we doubt that either or both these results often 
occur in cases of inflammation of any and of all mucous membranes? And 
to say that croup is a peculiar or specific inflammation, in order to account 
for the formation of the false membrane, would, for the sake of consistency, 
compel us also to invoke a special imflammation in those cases of pleurisy 
in which adhesions occur, while a common inflammation will answer if 
recovery occurs by absorption, or if empyema en sues. Our ideas, then, of 
the pathology of croup, so far as the answer to the first inquiry has estab- 
lished them, are these :— 
1st. An inflammation of the larynx, extending into the trachea occurs; 
offering in its essential nature nothing different from any other case of in- 
flammation of the same parts, either in the infant or the adult. It is gen- 
erally preceded, in both infants and adults, by congestion and irritation, and 
therefore by catarrh. 
2nd. An exudation of plasma occurs on the inflamed surface, as in the 
adult; this being most abundant, in the trachea, on the posterior wall, for 
reasons already given (p. 5). 
3rd. This exudation may be disposed of, in at least two ways, provided 
it is not at once removed, as it generally is, in adults but not in infants, by 
coughing; reabsorption probably very seldom occurring in this disease, 
though it is not impossible. 
a. It may become degenerated into pus (purulent matter,) and thus, of 
course, at once be detached, which is the most common result. 
b. It may become organized into a false membrane. This is more prob- 
able if the blood is rich in fibrine (e. g. in a plethoric child); if there is but 
little cough (an adult generally expelling it thus), and if time is allowed for 
its development (less being required in the child than in the adult) (p. 6). 
4th. Croup is, therefore, merely a laryngo-tracheitis in infants and 
children, and offers nothing essentially different from the same inflammation 
in adults.* The exudation in case of adults is, however, usually at once 
ejected by coughing, or in the form of purulent matter ; while the liability 
* The idea of Copland and others, that the false membrane in infants is due to a 
greater amount of albumen in the blood, is entirely without support. BASIS OF ITS RATIONAL TREATMENT. 
9 
to its organization in infants is greater; though, after all, a comparatively 
rare result, considering the whole number of cases—for the reasons before 
mentioned.* 
5th. Practically therefore, as well as pathologically, we cannot say with 
Bouchut, “ Without a false membrane, croup does not exist." This mem- 
brane never exists till the inflammation—the essential element of the dis- 
ease, as we believe—has preceded, and has produced the exudation of 
plasma, as before shown. No sooner does the catarrhal irritation merge 
into inflammation, than the plastic lymph is thrown out ;f and this inflam- 
mation and its accompanying exudation are the elements always present in 
croup.J 
We, therefore, need not, for any practical purpose, admit an “inflamma- 
tory and a membranous ’’ croup, as some writers have done, any more 
than we should make the same distinction in regard to pleuritis or periton- 
itis. All croup is inflammatory, at any rate; and a few cases are also 
accompanied by the formation of a false membrane. But the latter should 
not affect the treatment of the disease as an inflammation, but merely from 
its mechanical effects, and cannot be predicated in any case till it is actually 
seen; and this is not possible in most cases in which it is developed at the 
very onset of the disease. 
Finally, we would drop the term croup entirely, and use the term laryn- 
go-tracheitis instead. In a work on the diseases of children, we would call 
particular attention to the fact that a false membrane is formed in about 
one-sixth of all the cases of this disease ; while in adults, this is of very rare 
occurrence. But we would not make an accident the distinguishing feature 
of this disease, more than we do in the case of others, nor allow it to enter 
into either our name or our definition of it. 
As in all other inflammations, so in this ; the distinction of “ sthenic ” 
and “ asthenic ” is important, both in a pathological and a therapeutical 
point of view. So far also as laryngismus enters into any particular case— 
and it does into all cases of true laryngitis to some extent—the case is, of 
course spasmodic ; but this term must not be applied to the exclusion of 
the idea of inflammation. Genuine spasmodic croup, we have already seen, 
is a mere laryngismus. There is more or less spasm in all cases of bron- 
chitis, and still more in whooping-cough; in the latter case in the larynx 
also; so that infantile laryngitis does not present any peculiarity in this 
* In Dr. Ware’s “Contributions to the History and Diagnosis of Croup,” false 
membrane was found in only 22 eases out of 131, or about one-sixth of the whole, 
f Hasse’s Diseases of Organs of Circulation and Respiration, p. 277. 
% Dr. H. Green also holds this idea, though in different terms. See his work on 
Croup, p. 13. 10 
PATHOLOGY OF CROUP AS THE 
respect. Catarrhal infantile laryngitis we regard as a contradiction of 
terms (p. 3). 
2. Does laryngitis (and tracheitis) with false membrane occur in the 
adult, as in early life ? 
We do not hesitate to answer this question in the affirmative, having 
seen such membranes ourselves, and having demonstrated their fibrillated 
structure under the microscope. Such cases are comparatively rare, for the 
reasons already assigned (p. 8 ; b.); and therefore occur more frequently 
in females who are not accustomed, or (as in some instances) not able, to 
expectorate at all. I received and still retain such a membrane, expelled in 
a tubular form by an adult female patient of Dr. G. W. Garland, now of 
Lawrence, Mass. 
Even “ membranous croup,” then, if we retain the term, occurs, though 
rarely, in adults, it being at all ages essentially the same disease so far 
as its pathology is concerned. 
3. Is croup a specific inflammation ? 
Our negative reply to this question has already been anticipated 
(p. 8; 4th). 
4. In infantile laryngo-tracheitis with false membrane, does the danger 
to the patient result almost entirely from the presence of the membrane, as 
seems to be so generally admitted ? or is the inflammation alone often suf- 
ficient to produce death ? 
Surely no reason can be assigned why a disease so fatal to adults as 
laryngitis and tracheitis should not be equally so in early life. And yet, 
since the decease of the “ Father of our country ” to the present time, adults 
have died without the formation of a false membrane, in almost all instances, 
so far as can be ascertained. 
The fact cannot be overlooked, that an inflammation of the larynx is a 
serious and a dangerous matter, at anytime of life, as a mere inflammation, 
aside from the final disposal of the exuded plasma. The treatment is there- 
fore to be directed primarily to the disease as a mere inflammation. Of 
course, the formation of the membrane brings a new danger to the patient, 
since it partially, and (if it extends to the bronchial divisions in the lungs) 
in some parts completely, closes the air passages, and thus produces a grad- 
ual asphyxia. Occurring, as it does, also, after the patient is reduced by 
the previous inflammation, its dangerous effects are increased. 
But we must, however, bear in mind the fact that the membrane is not 
organized till the inflammation has subsided in the part. The inflamed 
vessels relieve themselves by the exudation, and thus the inflammatory pro- 
cess is arrested.* The treatment, therefore, to subdue inflammation, so 
* “The secretion of the lymph weakens the inflammation most commonly, and in BASIS OF ITS RATIONAL TREATMENT. 
11 
proper at first, is not proper after the false membrane is formed in the larynx 
and trachea. We have here a consequence of inflammation to treat, in a 
part which the inflammation itself has left. But this point will be more 
definitely considered farther on. The thicker the membrane, the greater the 
danger and amount of asphyxia; but the small trachea of an infant being- 
closed in a greater ratio by it than the larger tube of the adult, the danger 
is comparatively slight in the latter from its formation. It is seldom more 
than line thick at the thickest part, in the child; and usually to 1 
■only. But before proceeding to apply the preceding views to the treatment 
of infantile laryngo-tracheitis, the following points also may profitably be 
briefly alluded to. 
1st. The progress of laryngo-tracheitis is invariably from above down- 
wards. The observations of the best pathologists have established this point. 
Generally, or at least very frequently, a catarrh commences in the nasal 
passages, and extends backwards into the pharynx ; then, descending into the 
larynx, continues such for a time, or at once merges into an inflammation. 
Often the pharynx becomes inflamed, and a false membrane appears upon it 
before the inflammation descends into the larynx and trachea. In some 
cases the larynx may be the part first affected; but if so, such cases are 
to be regarded as exceptional, and the inflammation never extends upwards, 
but always downwards from that organ. The existence, therefore, of a 
catarrh for two or three days, and especially of a false membrane on the 
pharynx, before the peculiar ringing cough of infantile laryngitis occurs, 
are most important elements of diagnosis in this disease, though their 
absence is not demonstrative of its non-existence. It will be recollected, 
therefore, that we said the exudation of plasma relieves the inflammation 
of the part, though at the same time it may be extending downwards to 
other parts lower in the air passages. 
2nd. In infantile laryngitis it has been stated that it progresses down- 
wards into the trachea. In some cases (and not unfrequently) it extends 
into the bronchi, and even into their subdivisions in the lungs. The exuda- 
tion is sometimes so copious in the smaller tubes in the lungs, that they 
become filled with a solid cylinder of plasma, instead of being lined with a 
false membrane. The same often occurs in cases of bronchitis in adults. 
We can have no warrant that this result will not occur in any case where a 
the end puts a stop to it entirely.”—F. Ryland on Diseases and Injuries of the 
Larynx and Trachea, p. 134. 
Exudation always at once puts a stop to the inflammatory process in the precise 
part where it occurs. But it does not necessarily preclude its return in the parti 
and therefore, in croup, two or three membranes, it is believed, have sometimes formed 
in succession on the same surface. We, however, wait for farther proof of this 
assumption; though the possibility is admitted. 12 
PATHOLOGY OF CROUP AS THE 
false membrane bas been formed ; nor that convalescence Avill commence at 
once, though large portions of it have been expelled from the trachea. Nor 
can we expect the convalescence to progress rapidly as soon as the laryn- 
gismus and ringing cough have ceased, since a bronchitis may still 
remain for a few days, or may even prove fatal at last. 
Some seem to think that if the false membrane is removed from the 
larynx and trachea, all danger is over. Nothing, however, is gained by 
merely passing the air through the air passages ; it must enter the air 
cells, before the blood is aerated thereby. Whether, therefore, the trachea 
is diminished to one-half of its capacity by a false membrane ; or one-half 
of the smallest bronchial tubes are completely closed by solid cylinders of 
plasma, will not make the least difference so far as the production of 
asphyxia is concerned. 
3rd. The false membrane is often formed in a very short time after the 
exudation is -femnd-out (see the conditions, p. 6); but it is an important 
fact that a false membrane formed on a mucous surface never becomes vas- 
cular, and therefore permanent, as it may on a serous membrane; but it 
soon becomes detached, and spontaneously falls off. This is well known to 
be the case in vaginitis and the endo-metritis which sometimes accompanies 
dysmenorrhoea ; and the disease now under consideration is not at all dif- 
ferent from these in this respect. Only a fibrillation existing in the false 
membrane, and therefore no vascular connection between it and the sub- 
jacent surface, it soon loses its slight vitality, and is cast off accordingly. 
The time elapsing before the spontaneous detachment of a false mem- 
brane varies in different cases; but seldom exceeds five or six days after its 
formation. But this result will surely occur, if the patient’s strength contin- 
ues, and thus life is sufficiently prolonged to afford the necessary time. 
4. It has been seen that laryngo-traclieitis occurs in the adult as well 
as in the infant; but is not the “ Diphtherite ” of M|. Bretonneau a differ- 
ent disease ? * 
We see no necessity for any such admission. In diphtherite, the false 
membrane, almost always covers the pharynx and tonsils, and often extends 
into the posterior nares, covering both surfaces of the velum; and then 
descends into the larynx and trachea. The same often occurs also in con- 
nection with scarlatina and rubeola. 
But all this also, often occurs in the young child, and therefore the terms 
“ Diphtherite,” or “ Croup of Adults,” we consider objectionable, as calcu- 
lated to foster the idea of a radical difference as to the nature of inflamma- 
tion of the larynx and trachea in the young child and the adult, while they 
are pathologically the same. To say that this is an “ exudative inflamma- 
tion ” of the parts affected, is tautology ; since all inflammations of mem- 
branes are accompanied by an exudation at least, as already shown. BASIS OF ITS RATIONAL TREATMENT. 
13 
Diagnosis of Infantile Laryngo- Tracheitis. 
While it is in the highest degree important that a correct diagnosis be 
formed early in the course of this disease, it must also be acknowledged that 
this is often a matter of the greatest difficulty. We are, however, decidedly 
of the opinion that if the usual “ perturbating” treatment of the disease is 
to be carried into execution, the little patient’s prospects of ultimate recov- 
ery will, in most cases, be at least as good if we commit the mistake of 
deciding that the disease does not exist when it actually does, and thus give 
the patient the chance of recovery without any medication at all, as if we 
err in the opposite direction, and therefore apply the treatment though 
there is no serious disease at first. 
In a suspected case, therefore, we wrould assume that this disease does 
not exist, till some positive reasons appear for the opposite conclusion. 
The question is usually between laryngo-tracheitis on the one hand, and 
mere laryngismus or catarrh on the other. The general differential diag- 
nosis of these three pathological conditions, may be expressed as follows : 
Laryngismus. 
Attack sudden. 
Usually attacks delicate 
and irritable children. 
Is an affection of the spi- 
nal (diastaltic) nervous sys- 
tem. 
Neglected, the attack 
may pass into general con- 
vulsions. 
Is no fever. 
Attack sudden ; cessa- 
tion ditto. 
Eyes unaffected ; no 
sneezing, or discharges. 
Cough absent during in- 
tervals of attacks; seldom 
croupal during them. 
Respiration free in the 
intervals; often stridulous 
during attacks; no uneasi- 
ness in air passages during 
intervals. 
Voice unchanged in the 
intervals. 
No false membrane on 
the fauces. 
Caused by irritation of 
dentition, disordered bow- 
els, dee. 
Catarrh. 
Ditto gradual. 
Attacks children of all 
conditions. 
Is an irritation and con- 
gestion of the mucous mem- 
brane 
Neglected, may be tran- 
sient; or, inflammation may 
ensue. 
No fever usually at first. 
Progress and decline gra- 
dual. 
Suffusion of the eyes; 
sneezing and discharges 
more or less copious and 
acrid. 
Cough persistent, short, 
frequent, and harassing; 
not croupal. 
Respiration hurried; tick- 
ling or relaxation in the 
throat; redness and tender- 
ness in the fauces. 
Voice hoarse; uneasiness 
and tightness of the chest. 
Do. do. 
Caused by exposure to 
cold, or inhalation of irri- 
tating matter. Is often epi- 
demic. 
Laryngo-tracheitis. 
Ditto gradual, and often 
preceded by catarrh. 
Most frequently attacks 
robust children. 
Is an inflammation of the 
membrane affected. 
Neglected, recovery mav, 
after several days, occur; 
less probably in the mem 
branous form. 
Constant febrile symp- 
toms. 
Ditto ditto. 
These symptoms gener- 
ally precede for two or 
three days the development 
of laryngo-tracheitis. 
Cough persistent, and 
peculiar—“ croupal.” 
Respiration has peculiar 
sound; inspiration being 
“ stridulous.” Fauces in- 
jected at least. 
Voice husky or lost, con- 
tinuing so constantly. 
False membrane some- 
times on the fauces. 
Caused by exposure to 
cold and damp; less fre- 
quently epidemic. Children 
of some families peculiarly 
liable to it 14 
PATHOLOGY OF CROUP AS T1IE 
If we find, in addition to the preceding signs, that portions of false 
membrane have also been ejected, the case is demonstrated to be “ laryngo- 
tracheitis with false membrane,” this sign being pathognomonic of this 
form of the disease. 
If, then, a child, hitherto in perfect health, wakes in the night with a 
croupy cough and stridulous breathing, the presumption is that it is mere 
laryngismus; and this idea is confirmed if the patient be a delicate, irritable 
child, and has not completed the process of dentition, or is probably suffer- 
ing from irritation in some portion of the alimentary canal. A simple 
emetic of ipecac, or wine of antimony, is the most powerful remedy which 
would be justifiable in such circumstances; and such a remedy will usually 
at once remove the symptoms. 
If the child has had a catarrh for two or three days, however, the dan- 
ger of laryngo-tracheitis is increased. But if there is no fever, we are not 
yet justified in considering the case any thing more serious than catarrh. 
The prevalent medical diathesis of the time will, however, aid much in 
deciding this point. If there is an epidemic catarrh at the time, the pre- 
vious presumption will be confirmed, and mild treatment only will be justi- 
fiable. On the other hand, if laryngo-tracheitis is common at the time, the 
patient must be watched with the greatest care, after the simple remedies 
required by the present condition have been administered. We are, how- 
ever, also to remember that a dryness of the mucous membrane, in exposure 
to cold, may produce a sudden hoarseness like that of catarrh. 
The probability of incipient laryngo-tracheitis is increased, however, in 
the circumstances just mentioned, if the patient, or if an older child in the 
same family, has before had an attack of this disease; while a previous at- 
tack of laryngismus, or mere catarrh, with similar symptoms, leads to the 
opposite presumption. The existence of a false membrane on the pharynx? 
confirms the idea of true laryngo-tracheitis. Hence, the fauces and the 
pharynx should, in every case, be carefully examined. 
The stridulous inspiration of laryngo-tracheitis may be very well imi- 
tated in mere laryngismus; and in the former disease may often be detected 
by the aid of the stethoscope, before it can be in any other way. 
These are the most prominent points to be observed in enabling us to 
distinguish laryngo-tracheitis from mere laryngismus and catarrh. It is not 
deemed necessary here to enumerate the points which distinguish it from 
erysipelatous and submucous laryngitis, or oedema glottidis, which may result 
rom them. 
The question in regard to the sthenic and the asthenic varieties of 
laryngo-tracheitis, must be decided by the character of the symptoms, and 
the condition of the child at the time of the attack. The presumption may 
be that the disease will assume the first form in a robust, plethoric child, BASIS OF ITS RATIONAL TREATMENT. 
15 
and the second fdtm in opposite circumstances. Regard must also, however, 
always be had to the medical diathesis of the time; the strongest children 
not unfrequently having the asthenic form of the disease, from certain con- 
temporaneous epidemic influences. 
The treatment of Infantile laryngo-Tracheitis, or Croup, as rationally 
based on the preceding views of its pathology. 
The indications in the treatment of infantile laryngo-tracheitis, or 
croup, are at once suggested by the following recapitulation of the promi- 
nent points of the preceding part of this paper. 
1st. Croup is always a laryngo-tracheitis, or inflammation, not of a spe- 
cific kind, of the mucous membrane of the larynx, extending thence into 
the trachea, also, at least. 
2nd. Like other inflammations, it may be either sthenic or asthenic. 
3rd. Its progress is always downwards in the air-passages, whether it 
commences in the larynx, or (as is more frequently the case) higher up. 
4th. It is always attended by an exudation of plasma upon the surface 
of the inflamed membrane. 
5tli. The inflammation subsides in the part on the occurrence of exu- 
dation. 
6th. If the plasma remains on the surface (it being usually detached 
and removed in case of the adult, by coughing), it may 
a. Become re-absorbed, which is a rare result; or, 
b. Be converted into purulent matter, and then excreted ; or, 
c. Become organized into a false membrane. This last result is far 
more common in early life than in adults, though then occurring only 
in about one-sixth of all the cases. Consequently it can never be pre- 
dicted, at the commencement of the disease, whether a false membrane will, 
or will not, be formed. 
7th. If a false membrane is formed, it will become spontaneously de- 
tached, if the patient’s life is sufficiently prolonged. Its removal, however, 
in whatever way effected, does not insure recovery. 
8th. Laryngismus is associated, to some extent, with true laryngo- 
tracheitis, as a matter of course. 
9th. Catarrh generally precedes infantile laryngo-tracheitis. But the 
catarrhal discharge, so-called, during the more advanced periods of this dis- 
ease, is the purulent fluid formed by the degeneration of the exuded 
plasma. 
10th. Diphtherite, or the “croup of adults,” differs not pathologically 16 
PATHOLOGY OF CKOUP AS THE 
from infantile laryngo-tracheitis. Generally, howrever, it is an asthenic form 
of laryngo-tracheitis, since it usually attacks persons already debilitated by 
other diseases. 
The indications in the treatment of infantile laryngo-tracheitis, which 
flow from this view of its pathology, are as follows : 
I. To arrest the inflammatory process, and control the laryngismus. 
II. To prevent the organization of the exudation into a false membrane. 
III. To remove the false membrane, if formed. 
IV. To support the patient’s strength, so far as may be, through the 
disease. 
I. Means for averting the inflammatory process. 
We here include :— 
a. Blood-letting. 
b. Tartrate of antimony, nitrate of potassa, mercurials (?).* 
c. Emetics (?). 
d. Expectorants (?). 
e. Counter-irritants (?). 
/. External application of cold. 
g. Applications internally to seat of inflammation. 
a. Abstraction of blood. In a clear case of sthenic laryngo-tracheitis, 
two or three leeches, according to the patient’s age, may be applied to the 
throat or the top of the sternum, and the bleeding be promoted by a cata- 
plasm ; but it must be remembered that 3 oz. of blood lost by a child six 
months old, is more, proportionately, than 1£ lb. lost by an adult, and that 
children generally manifest but a sliglft tolerance of blood-letting. More- 
over, it must be remembered that this remedy is applicable only for the sake 
of arresting or removing the inflammation, and is therefore entirely out of place 
after the exudation is poured out, and the progress of the inflammation is thus 
arrested. The only fact in favor of its adoption after this has occurred, is, 
that as the inflammation progresses dowmvards, it may still be advancing 
below the point covered with the exudation. This will be indicated by the 
* The remedies marked (?) are of doubtful value for fulfilling this indication. BASIS OF ITS RATIONAL TREATMENT. 
17 
state of the pulse, and of the respiration, and by other concurrent signs 
But the presumption always is, that blood is not to be taken in the absence 
of decided reasons to the contrary. 
Venesection, we believe, to be very seldom proper in a patient less than 
7 years old ; and blood should not be taken, in any way, in asthenic cases. 
b. Tartrate of Antimony. It is a fact never to be overlooked in the 
treatment of inflammation, that the tartrate of antimony may be so admin- 
istered as to become a most valuable substitute for blood-letting. I allude to 
its powerful effects as a sedative, when administered in small and frequently 
repeated doses, e. g., one-thirtietli to one-twentietli of a grain dissolved in 
water, administered every hour or two, to an infant of twTelve months, until 
the pulse becomes softer and slower, and the surface cooler, when the fre- 
quency of the doses is, of course, diminished, so as merely to continue this 
effect. In this way the reducing effects of loss of blood are produced tempo- 
rarily, and till the inflammation is arrested ; with the advantage over blood- 
letting, that on withdrawing the remedy, at any time when desired, the cir- 
culation rises again, and all permanent debility is prevented. 
The effects of this remedy are, however, to be watched with the utmost 
care. Some infants easily yield to its sedative effects, and in some, violent 
irritation of the alimentary canal is produced by it. An infant, six months 
old, has been destroyed by one-thirtieth of a grain of this remedy; and 
another barely escaped with life, after taking, in three doses, sixty drops of 
the hive syrup. If given to the amount to produce vomiting, its sedative 
effect, as is well understood, is not experienced. It is better tolerated in 
combination with very small doses of an opiate. 
Nitrate of Potash.—This remedy should hardly be relied on as a seda- 
tive in infantile laryngo-tracheitis, unless in asthenic cases, and also when 
from a peculiar irritability of the alimentary canal, or some other cause, the 
tartar emetic is not wrell borne. In such cases it may be given freely in 
solution, with some probable effects in averting the inflammatory process. 
The entire inappropriateness, however, of this remedy, and still more of 
blood-letting and antimony, after the exudation has occurred, and the pulse 
has fallen, will be apparent to all. (p. 11.) 
Mercurials, especially Calomel.—This will be considered under the 
next indication, as we believe it has very little, if any, power to arrest 
inflammation of the air-passages, A single dose of two to five grains may 
be given as a cathartic at the outset, if for any particular reason it is indi- 
cated, as a stimulant to the liver; and from both its safety and certainty 
of operation in children, it is generally judicious to administer it as above 
if any cathartic is required. 18 
PATHOLOGY OF CROLT AS THE 
c. Emetics.—Much stress has been put upon the action of emetics in. 
infantile laryngo-tracheitis; and all, as we believe, upon a false theory of 
their action. This particular point, however, will be considered under the 
second indication. 
Inasmuch as laryngismus is often produced by irritating matteain the 
stomach, and when present in this disease, is doubtless increased by these 
causes, a mild emetic is never injurious, and is often very beneficial at its 
commencement. Indeed, in some cases of catarrh, very difficult at first to 
distinguish from this disease, an emetic will at once completely relieve the 
patient, and remove all anxiety as to the nature of the case. 
Moreover, when given in the first stage of actual laryngo-tracheitis, an 
emetic may produce such a shock to the system as to put an end at once to 
the disease, by its mere “ perturbating ” effects. After the disease is fairly 
established, however, emetics, frequently repeated, are entirely out of place, 
as will be shown further on. While an emetic operation promises such an 
effect, or if the contents of the stomach are such as require to be removed, 
an emetic of ipecac, and tartrate of antimony, or, in asthenic cases, ipecac, 
and sulphate of zinc, may be used; it being understood that the emetic 
operation is not to be repeated unless positive indications subsequently 
arise. 
When called to a doubtful case (like those of the second preceding 
paragraph*), vre have generally given 3 8S- to 3 j- of the syrup, Scillre 
Comp. (Hive Syrup), every fifteen minutes till free emesis is produced. 
d. Expectorants are useful rather to fulfill the second and third indica- 
tions, than for the arrest of inflammation. The tartrate of antimony, if given 
as already recommended, at the same time proves an efficient expectorant. 
We shall specify certain expectorants, in the proper connexion, merely 
adding here, that they must not be given in the early stage, to the exclu- 
sion of the remedies which arrest the inflammatory process. 
e. Counter-irritants are, moreover, not of any decided benefit, we 
believe, in the first stage of the disease; and they also interfere with the 
external local applications for the removal of inflammation, next to be men- 
tioned. 
After the heat of surface and the excitement of the circulation have 
somewhat subsided, and the application of cold is no longer beneficial, 
blisters and stimulating liniments may prove very beneficial in promoting 
the absorption of the exuded plasma; and they will, therefore, be again, 
alluded to in another connection. 
* See also p. 14, second paragraph. BASIS OF ITS RATIONAL TREATMENT. 
19 
f. Cold applied externally.—We consider this of the greatest value 
and importance. If cold applications are efficacious in all cases of external 
inflammation, they are scarcely less so here, where the inflamed surface is so 
nearly superficial. Cold must, however, be continuously applied, to pro- 
duce the desired effect. Applied at intervals, indeed, it rather promotes 
than retards the inflammatory process; since, during the intervals, the tem- 
perature rises above the normal standard, in consequence of the reaction of 
the chill on the surface. 
Cold water may be constantly dropped from a sponge upon a compress 
laid over the throat of the child; and the latter should be of only one or 
two thicknesses of linen, that evaporation may go on as rapidly as pos- 
sible. 
The application of hot water, early in the disease, as sometimes recom- 
mended, therefore appears to us objectionable; and that of rapid vesicants 
(aqua ammonire, &c.) still more unwarrantable. 
(j. Internal applicatiomto the scat of the inflammation.—First to 
be mentioned under this head is the solution of lunar caustic, applied 
by means of a syringe, or as recommended by Dr. 
Horace Green. We have used both instruments, and decidedly prefer 
the latter, as applicable in all cases of disease in which the solution is re- 
quired , while the former is not so, in our judgment, though it answers 
well in many instances. 
The solution most frequently used is that of 40 grains of the crystals of 
nit. silver, to 1 oz. of distilled water. This solution has a more sedative 
and less irritating effect upon the mucous surface than a weaker one, as of 
10 or 20 grains to the ounce of water. 
In our judgment, there is no local application for arresting the inflamma- 
tory process in this disease, to be at all compared with the solution just 
mentioned. It should be, at first, applied to the fauces and pharynx only; 
and then, in 15 to 30 minutes, the probang may be passed into the larynx, 
and through the rima glottidis if required. The operation should be re- 
peated in some cases, three or four times daily, in others only once.f Other 
solutions, or fluids, thus applied, may also be found useful—such as glycer- 
ine, olive oil, &c.; but none will probably be found to possess the efficacy 
of the nitrate of silver. Applied to the pharynx and fauces, indeed, as soon 
* The sponge must not exceed one-third to one-half inch in diameter, to pass 
through the rima glottidis of a child two years old, one-third inch being rather large 
at one year. 
f Dr. H. Green has established the interesting fact, that much less irritation is 
produced by this operation in children with croup, than in adults with chronic 
laryngeal disease. 20 
PATHOLOGY OF CROUP AS THE 
as the false membrane has appeared in these parts, it has frequently arrested 
the inflammatory process at once, and thus prevented its extension into the 
larynx and trachea. We should, therefore, feel it an unpardonable omission, 
at the present day, should we fail early to cauterize the pharynx (and the 
larynx and trachea, if already invaded by the disease), and to repeat the 
operation as circumstances might require in every case of laryngo-traclie- 
itis. The objections sometimes raised, that this is a difficult operation, and 
also, if accomplished, a dangerous one—were always too puerile, and are 
now too generally known to be entirely unfounded, to require a refutation 
here. 
The only other method of direct local application we shall mention, is 
by inhalation. The inhalation of aqueous vapor is especially to be com- 
mended, on account of its soothing effects upon the inflamed surface; and 
it is also a valuable remedy for diminishing the laryngismus accompanying 
true laryngo-tracheitis. Its efficacy in this respect may be also increased 
by the addition of camphor, or stramonium, and other narcotics. 
Remedies to diminish the Laryngismus. 
We have just mentioned aqueous vapor, with camphor or stramonium. 
Tartrate of antimony also diminishes it, while producing its general se- 
dative action; and any appropriate emetic, even, may be given with a 
view to diminish it, if it appears to be mainly due to irritating matters in 
the stomach. Opiates, and especially laudanum, have also been recom- 
mended. We would advise them only to the extent to overcome any ex- 
isting nervous irritation, cautiously avoiding any decided narcotic effect 
upon the respiration, in a disease in which diminished aeration of the blood 
is the principal cause of a fatal result. For a similar reason inhalations 
should be continued only for two or three minutes at a time, and frequently 
repeated, and the apartment kept thoroughly ventilated. We also recom- 
mend the hydrocyanic acid as both a valuable sedative and anti-spasmodic. 
II. Remedies to prevent the organization of the exudation into a false 
membrane. 
The means included under this head are: 
1st. Those intended to remove the exudation at once,* viz. expectorants, 
emetics, and the sponge-prohang. 
2d. Remedies which diminish the organizability of the plasma: calo- 
mel and alkalies. 
3d. Remedies promoting absorption of the exudation : counter-irritants. 
a. Expectorants.—In adults the exuded plasma is usually removed at 
* See p. 8, third. BASIS OF ITS RATIONAL TREATMENT. 
21 
once, or after degenerating into pus, by the act of coughing and expectora- 
tion. In infants this result far more rarely occurs, since they do not expec- 
torate by voluntary efforts. Any remedy, however, which will render more 
fluid and abundant the secretion upon the air passages, will so far aid in 
detaching the exuded plasma; and which will then be expelled by the 
simple act of coughing. Expectorants, therefore, are beneficial to this end, 
and may be administered to fulfill this indication. We will mention only 
the syrup and other forms of ipecac, seneca, and the squill. Alkalies 
become expectorant also, as will be seen under the next indication. 
b. Emetics exert no marked effect in removing the plasma from the air 
passages, and hence are not to be commended. But this topic also will be 
considered at length, under the next indication. 
c. The Sponge-probang. But the most certain method of directly 
removing the plasma, is the application to the surface, of this instrument. 
If merely moistened with water, it will very well accomplish this object. 
But since the solution of nitrate of silver (grs. xl. to 3 j. water) before men- 
tioned, acts on the exudation both to destroy its organizability and to 
detach it, while it at the same time arrests the inflammatory process, as has 
been shown, we always employ it. Indeed, we should not hesitate to make 
an opening into the trachea through which to apply the solution, in some 
cases, if it were otherwise impossible. But we shall recur to this again 
(p. 2*). 2) 
2. AVe next consider the remedies administered to diminish the organi- 
zability of the exuded plasma. 
a. The preparations of mercury, properly administered, possess the 
property just mentioned ; but since the proto-chloride of mercury (calomel) 
is the one which manifests this property in the highest degree, and has 
been much vaunted by some in the treatment of infantile laryngo-traclieitis, 
we shall speak of it somewhat at length, believing that some remarks upon 
its precise effects in inflammation will aid in assigning to it its true value 
in the disease under consideration. 
It has long been admitted that calomel is most useful in inflammations 
of serous membranes. E. g. in pleurisy, it is believed to promote the re- 
absorption of the exuded plasma, and thus to prevent the formation of 
adhesions and false membranes. It has, therefore, also been termed an 
“ absorbefacient,” or excitor of the absorbents. 
AVe admit that calomel is most useful in inflammations of serous mem- 
branes, or rather in all inflammations where false membranes may be 
formed; also that it favors the absorption of the exuded plasma, and thus 
may prevent their formation ; but, at the same time, it does not in any way 
increase the action of the absorbent vessels of the part affected; nor does 
it arrest the inflammatory process itself. 22 
PATHOLOGY OF CKOEP AS THE 
The whole effect of calomel in the diseases just mentioned, may be thus 
expressed : it merely diminishes the oryanizahility of the exuded plasma ; 
so that it is not so rapidly organized, and therefore a longer time is afforded 
for its re-absorption before organization takes place. This effect may now 
be regarded as established by experiment. 
We are not cognizant of a single fact tending to show that calomel has 
any direct effect to arrest the inflammatory process itself; and therefore we 
have not given it any prominence in our list of remedies for that object 
(p- *0/6 
But in cases of inflammation of the alimentary canal (enteritis, colitis, 
&c.), calomel may exert a very decided indirect effect to arrest the inflam- 
matory process itself. All the blood in the minute vessels of the mucous 
membrane of the alimentary canal, being collected by the vena portae, and 
transmitted through the liver, any remedy which excites the action of the 
liver (i. e. acts as a cholayoyue), promotes the circulation through the vena 
portae, and they relieve congestion of the membrane itself. Thus calomel 
indirectly acts in enteritis and colitis to arrest the inflammatory process 
itself; while at the same time the flow of the bile, thus produced over the 
inflamed surface, also produces a positive soothing effect. 
But it is only when calomel acts as a cholayoyue, and therefore to some 
extent as a cathartic, that it arrests the inflammatory process even in the 
diseases just mentioned. To produce this effect it must be given also in 
doses (to an adult) of 5 to 15 grains. In laryngo-tracheitis, on the other 
hand, it has no such effect, in any dose, to arrest the inflammation ; and so 
far, therefore, and in such doses, it is not indicated in this disease, except 
perhaps, in a single dose at the outset, as before explained (p. VHj./Q 
On the other hand, calomel administered in doses, frequently repeated, 
of £ grain to 2 grains (to adults), produces no cholagogue effect, but an 
entirely different one, from its gradual absorption, probably, into the blood, 
viz. a diminished power of organization in the blood plasma, as before 
stated. Whether this effect is produced by diminishing the fibrine, and 
therefore weaJceniny (and thinning) the plasma, is not yet conclusively 
decided ; though we regard this as the true explanation. Hence the value 
of calomel in small doses in all inflammations in which false membranes 
and adhesions are liable to occur, as pleurisy, endo-carditis, and the disease 
now under consideration. 
While, therefore, we unqualifiedly condemn the custom of some, of 
giving large doses of this remedy (10 to even 20 grains) every three or 
four hours, in infantile laryngo-tracheitis, we may also perceive that small 
doses regularly repeated may prove of the utmost benefit. But we are to 
arrest the inflammation first, by the means before recommended, or at least 
employ them for a time, before we resort to this remedy. BASIS OF ITS RATIONAL TREATMENT. 
23 
After the first twenty-four or forty-eight hours, therefore, according to 
/circumstances, it is desirable in a sthenic case, to commence with doses of 
calomel of J to f grain (for a child 9 to 12 months old), every four hours, 
or oftener; diminishing the quantity if any marked cholagogue effect is 
produced. This last effect is less liable to occur if to \ grain of the pulvis 
ipecacuanha comp. (Dover’s powder) is added to each dose. 
Yet calomel must be administered in this disease, even in the small 
doses just recommended, with great caution, and constant reference to the 
delicacy of the little patient. True, there is very little danger of ptyalism 
occurring before the age of five to seven years; and it has been pronounced 
impossible before the first dentition commences. But it is now pretty 
generally known that mercurial preparations (and especially calomel) are 
not well borne by scrofulous—and we will also add anaemic—subjects, 
whatever their ages or diseases. It produces great general debility ; and if 
any accident exists requiring the aid of the reparative process, as an ulcer 
or a wound, it may indefinitely prevent this process from occurring, or even 
lead to phagadsena, or perhaps sloughing, in the part instead. The plasma 
always possessing a low grade of vitality (organizability) in such persons, 
becomes so far debilitated by the mercurial that reparation is impossible; 
and it is only on discontinuing it, and substituting tonics and proper diet, 
that the desired result ensues. 
The fact just mentioned is here introduced for the sake of application 
in this connection, as well as for illustration. In scrofulous children the 
danger of organization of the plasma into a false membrane in true laryngo- 
tracheitis, is far less than in robust children, on account of its low vitality 
there ; nor do they tolerate the calomel if given as just explained. To such 
children, therefore, it is better to give the pil. hydrargyri (if any mercu- 
rial), and to withhold calomel entirely. In every case of asthenic laryngo- 
tracheitis, the propriety of administering calomel must be thoroughly 
canvassed before it is decided to administer it. As a general principle, 
certainly, it should be administered only in the sthenic form of the disease. 
Though we have so far prolonged our remarks upon calomel, we must 
also record our testimony in favor of one more preparation of mercury in 
this disease : the subsulphate, or Turpeth mineral.* It is a valuable sub- 
stitute for calomel in less sthenic cases, in doses of J to f of a grain; and 
is to some extent an expectorant also. 
b. Alkalies. It has been established by experiment that alkalies also, 
like calomel, diminish the organizability of the blood plasma. They are, 
however, much less efficient in this way; and for that very reason are 
appropriate in the asthenic form of the disease. 
* The attention of the profession was first called to its use in this disease, we 
-believe, by Dr. Hubbard, of Hallowell, Me. 24 
PATHOLOGY OF CROUP A8 THE 
Hence they become a very valuable substitute for mercurials, to prevent 
the organization of the exuded plasma, and should always be preferred 
when a milder remedy is believed to be sufficient. We have had more 
experience of the effects of the bicarbonate of soda in this disease; giving 
it in the dose of 3 to 5 grains every 4 hours, to a child one year old. Al- 
kalies are well knowm to render less tenacious the viscid sputa of pneumo- 
nitis and acute bronchitis, and hence become valuable aids to expectoration 
in these diseases. Their power of rendering more fluid the fibrine mixed 
with the mucus in such sputa, accounts for this effect, and renders them 
also valuable as expectorants (see p. % as well as in preventing organiza- 
tion of the exuded plasma, in infantile laryngo-tracheitis. 
As alkaline stimulants, the bicarbonate and the hydrochlorate of am- 
monia, are also valuable in the advanced stage of the disease, for sustaining 
the patient’s strength, and promoting expectoration. 
3. Counter-irritants may, lastly, be mentioned, as promoting absorp- 
tion of the exudation, and thus preventing its organization. But, in regard 
to these, we merely refer back to page 18. 
III. Means for removing the false membrane when formed. 
These are direct, the probang; or indirect, as expectorants, counter- 
irritation, emetics, and tracheotomy. 
a. The only direct method of removing the false membrane which 
need be mentioned, is the application of the solution of the nitrate of 
silver as already explained. We need not insist on the value of this 
application for the direct removal of the false membrane, at the present day, 
since cases have been recorded, in most of the principal medical journals, 
within the last two years, in which portions of the false membrane have been 
at once thus removed, and the patient evidently saved.* The sponge is to be 
carriedinto the trachea, and the operation repeated once in 2 to 24 hours 
according to the urgency of the case. With our appreciation of the value 
of this operation, we could not conscientiously omit it in the fulfillment of the 
indication now under consideration. 
Expectorants and counter-irritants may still be continued, as under the 
preceding indication. 
b. The use of emetics for removing the false membrane. Since emetics 
frequently repeated, have almost uniformly been recommended for the pur- 
pose just mentioned, and much injury, in our opinion, results from this 
* For cases, see Dr. Chapman’s articles in the March and July Nos. of the New 
York Journal of Medicine, and Dr. Green’s paper in the July No. of the Monthly. BASIS OF ITS RATIONAL TREATMENT. 
25 
practice, we shall attempt to show that it is founded on a false hypothesis, 
and is objectionable in all respects. 
The foundation of the idea that the act of vomiting will expel a false 
membrane from the larynx or trachea, is the assumption that the acts of 
vomiting and of expiration from the lungs (including also coughing and 
expectoration) are, in their mechanism, almost identical. An account of 
the mechanism of botli these actions will, however, demonstrate their en- 
tire dissimilarity, so far as their effects are concerned, and that an emetic 
cannot possibly exert any direct effect in the expulsion of a false membrane 
from the air passages. 
Everybody knows that the object of the act of vomiting is the ejection 
upwards through the oesophagus into the buccal cavity, of the contents of 
the stomach ; while that of coughing or expectoration (or forced expira- 
tion) is to expel into the same cavity, through the rima glottidis, the con- 
tents of the air passage below. If, therefore, mere emesis will produce the 
latter effect, we should expect that coughing, or expectoration, would evac- 
uate the stomach, and that, therefore, we might administer an emetic or an 
expectorant, indifferently, to expel the false membrane. Admitting this, 
however, the remedy is not needed till the membrane is formed; and this 
occurs in only about one-sixth of all the cases. The indiscriminate use of 
emetics is, therefore, unjustifiable at all events and on any supposition. 
But we proceed to show that an emetic operation cannot possibly expel a 
false membrane from the air passages, on physiological grounds, except so 
far as it may do so by causing a violent concussion of all the contents of 
the thorax, or by some irregular and violent motions of the trachea—all of 
which indirect effects being also easily secured, as will appear, by far milder 
means. 
The following account of the mechanism of the two actions in question,, 
vomiting and forced expectoration, will explain the preceding remarks: 
1. In vomiting, a full inspiration first occurs, which, .diotwbi-ng the i 
thorax, puts all the smaller expiratory muscles on the stretch, while the ab- 
dominal muscles are in a passive state, and the diaphragm is depressed and 
strongly contracted. Next, the rima glottidis is closed, and all the inspired 
air being thus retained in the air passages, all the muscles just mentioned 
are fixed in the positions indicated. Thirdly, a sudden contraction of the 
abdominal muscles occurs; and the stomach, being thus compressed be- 
tween them and the previously depressed and fixed diaphragm, its contents 
are forced up through the oesophagus and pharynx, and the act of emesis is 
completed. Does the stomach also contract in aid of the abdominal 
muscles ? It is very nearly, and generally entirely, passive in emesis. At 
least, vomiting has been made to occur, experimentally, in the lower ani- 26 
PATHOLOGY OF CROUP AS THE 
mals, when a bladder, containing liquid and solid matter, was substituted in 
place of the stomach, after the latter had been removed. 
Here, it will be seen, ejection of any substance from the air passages is 
impossible, since the glottis is completely closed, and the diaphragm con- 
tinues depressed, and the thoracic muscles fixed—and of course the lungs 
cannot be compressed—till the first act of emesis is completed. Then follows 
another deep inspiration, and a second act of vomiting succeeds, as before 
explained. 
2. In coughing or expectoration, a full inspiration also first occurs, as in 
the case of vomiting, and the expiratory muscles of the thorax, and the 
diaphragm become fixed, as in that case already explained. Secondly, the 
rima glottidis is suddenly opened, and the abdominal muscles instantly 
contract upon the stomach as before. But the diaphragm immediately re- 
laxing, the stomach carries that muscle upwards against the base of the 
lungs; which being thus suddenly compressed, the contained air is vio- 
lently forced up through the trachea and larynx, and thus any solid or 
fluid substances are expelled through the glottis into the buccal cavity, and 
the act of expectoration, or coughing, is completed. 
Thus the first or preparatory movement to the acts both of vomiting 
and coughing, the full inspiration, is precisely the same; while the acts 
themselves have nothing in common, except the contraction of the abdom- 
inal muscles. 
We have seen that the act of vomiting cannot possibly expel matters 
from the air passages, because the glottis is closed. A less perfect closure 
of the cardiac orifice of the stomach occurs, however, during the act of 
coughing ; and, therefore, it sometimes happens that a violent paroxysm of 
coughing produces a partial evacuation of the stomach (or an act of emesis), 
at the same time. This is, indeed, very common in whooping-cough, and 
not very infrequent in phthisis; though frequently in the latter disease, the 
act of vomiting instantly succeeds that of coughing, being produced by the 
contact of the expectorated matter with the velum or pharynx, which are 
in a state of high irritation. Some irregular contractions of the diaphragm 
may also probably occur in this case, and the stomach thus become some- 
what compressed in the act of coughing; while, normally, it is scarcely so 
at all. Vomiting not seldom accompanies the cough produced by the in- 
troduction of the caustic solutions upon the sponge-probang into the larynx 
and trachea, since thus a temporary spasmodic closure of the glottis is pro- 
duced. We of course, distinguish between these cases and those where the 
caustic is applied only to the fauces or some part of the pharynx ; the vom- 
iting being directly due, in these instances, to the irritation of these parts. 
But we will not pursue the subject farthef. It is sufficient to have BASIS OF ITS RATIONAL TREATMENT. 
27 
shown that the act of vomiting does not, and cannot, directly, expel any 
substance from the air passage, through the glottis into the buccal cavity. 
But if a quantity of solid contents be forced from the stomach through 
the oesophagus, must not the mass, from the anatomical relations of the 
canals, act on the trachea and its contents, while on its way through the 
other tube ? Doubtless, it may produce motion of this tube to some extent 
—the latter being somewhat proportional to the amount and solidity of the 
matters ejected, and the force employed to eject them. But if any thing is 
to be gained in this violent and indirect manner, the same results may be 
secured by exciting attempts at vomiting (or retching) by titillation of the 
uvula, or the application of the sponge probang (with or without the caustic 
solution) low in the pharynx. In this way we might, at least, allow the 
patient to escape from the mischievous irritating and debilitating effects 
of the emetic upon the stomach itself; and which are all the more certain 
to ensue from the well-known difficulty in producing an emetic operation 
when infantile larnygo-tracheitis is somewhat advanced, and the consequent 
certainty, almost, that large doses, or violent remedies,* or both, will be 
administered. 
Our reasons will, however, now be apparent for our decided condemna- 
tion of emetics frequently repeated in this disease, with a view to remove 
the false membrane. We consider an emetic proper only at the commence- 
ment of the attack, as already explained, and at such other times 
during the progress of the disease as they may be required, simply to 
evacuate the stomach,f and believe the practice we are condemning has 
destroyed many a patient who might have recovered in the absence of such 
prostrating and perturbating treatment. 
Tracheotomy, as subservient to the removal of the false membrane.— 
Tracheotomy is regarded by those only who remember that death almost 
always soon follows it, when performed in infantile laryngo-tracheitis, as a 
most formidable operation. The surgeon, however, of experience, does not 
apprehend any great risk to his patient from this operation, if performed 
under ordinarily favorable circumstances; and he very seldom finds a fatal 
result essentially hastened by it. The truth is, that the operation is usually 
performed as a last resort, when the patient is so nearly moribund that no 
human agency can prolong life more than a few hours or minutes even—or 
when the most trifling operation might hasten the fatal issue. If we are 
ever to form a just appreciation of the value of this operation in the disease 
under consideration, we must perform it seasonably, while the patient still 
* Sulphate of zinc and of copper are very generally recommended, 
f A tea spoon full of alum, dissolved in four ounces of water, is a very certain 
emetic for a child two years old, provided the stomach needs to be evacuated in the 
advanced stage of this disease. 28 
PATHOLOGY OF CROUP AS THE 
lias strength to survive the operation, and also to respond to the new cir- 
cumstances in which it places him. If the operation for hernia were always 
delayed till gangrene has ensued, it would be generally decried, and with 
just as good a reason, we submit, as tracheotomy now is. 
We do not mean to say that tracheotomy should be performed, and 
seasonably, in every case of this disease, as the other operation should be in 
every case of irreducible strangulated hernia. But we mean to insist that 
tracheotomy shall be performed seasonably, if at all, and that thus alone can 
we ascertain its true value. We mean also to express our conviction that, 
thus performed, tracheotomy will be found a most valuable part of the 
treatment of infantile laryngo-tracheitis in many cases in which a false 
membrane has formed.* 
We have implied that tracheotomy is not in itself a formidable opera- 
tion ; and yet, if a more safe and simple procedure than the one usually re- 
sorted to can be substituted, it were very desirable. Dr. Marshall Hall has 
h. very simple method. But for the purposes now about to be considered we 
should prefer the operation recommended by Dr. Batchelder of New York.f 
He, indeed, proposes to substitute laryngotomy for tracheotomy, but extends 
his incision downwards through the cricoid cartilage, and also the first ring 
of the trachea, if required; thus rendering the operation, when required, a 
laryngo-tracheotomy. This operation he has himself seasonably performed 
some fifteen or twenty times, and has always found it to answer “perfectly 
well ” the purpose for which the opening was made. 
We conceive that the operation in question must have in view one or 
more of the following objects: 
1. To prevent immediately fatal consequences from asphyxia, induced 
by laryngismus. 
2. To afford an opening into the trachea, for the admission of air, larger 
than the rima glottidis, which is now partially filled by the false mem- 
brane. 
3. To afford an opening through which applications may be made 
directly to the larnyx, trachea, and even to the bronchial tubes. 
4. That the false membrane maybe removed through the opening made. 
The second and fourth objects only, imply that a false membrane is 
formed. 
1. If we are present during a paroxysm of laryngismus, which wre judge 
must prove fatal, of course the operation is to be performed without delay. 
2. A recurrence to the pathology of this disease (p. 11, 1 and 2) 
will show how little probability there is, after the first two or three days, 
* Trousseau, who has probably operated more times, and with greater success, 
than any other person, operates earlier than is common with others, 
t New York Journal of Medicine, January, 1854. BASIS OF ITS RATIONAL TREATMENT. 
29 
that the false membrane does not already extend into the trachea, at least, 
if not into the bronchi. If we operate with this end alone in view, therefore, 
we shall very probably be disappointed. 
3. But we may make an opening for the sake of making applications 
through it to the larnyx, trachea, and bronchial tubes; and here an entirely 
new field opens to us. And we hope not to startle those overmuch who 
shudder at the idea both of the of the probang now so fre- 
quently mentioned, if we say that in our opinion cases may occur in which 
it is justifiable to make an opening into the trachea for the mere purpose 
of applying the caustic solution and other remedies directly to the seat of 
the disease, and to the extent required.* 
If, for instance, the case be a sthenic one, while from spasm or swelling 
of the larnyx, or some other cause, it is found impossible to pass the caustic 
solution through the rima glottidis, though it is very certain that a false 
membrane will be or has formed, and all of several children of the same 
family, attacked by the disease, have died of it* in this combination of cir- 
cumstances, certainly we should feel justified in performing the operation 
for the object now under consideration. 
4. Finally, we may operate in order to remove the false membrane 
through the opening, though the caustic may have been applied through 
the natural passages. For we may certainly act to greater advantage after 
the operation, if we have failed to remove the membrane before it. And 
now, as in the last case, we shall feel the necessity of applying the 
caustic solution, in order to bring away the membrane, and not wait for it 
to be discharged through the opening spontaneously. 
These we conceive to be the legitimate objects of tracheotomy, when 
performed in infantile laryngo-traclieitis; and if restricted to the cases in 
which it is actually required, and seasonably performed, we believe it will 
prove a powerful means of diminishing the mortality from this disease. 
We must add, however, that the number of cases otherwise actually 
requiring it is greatly diminished by the internal application, through the 
natural passages, which has been so often recommended; and that but 
few cases in which this can be effectually made, will require the use of the 
scalpel. 
IV. Means for sustaining the patient's strength. 
If it be recollected that the false membrane formed in infantile laryngo- 
traclieitis is uniformly detached spontaneously, if the patient’s life is suf- 
ficiently prolonged (p. 12, 3d), it will seem to be a matter of great 
importance to sustain the patient’s strength, so far as possible, not only by 
the avoidance of all unnecessary medication, but also by direct means, so 
* See page 21. 30 
PATHOLOGY OF CROUP AS THE 
far as circumstances will allow. This inference has by no means been 
sufficiently recognized; as both the heroic treatment and the withdrawal 
of nourishing aliment, so generally adopted, abundantly prove. 
We hardly need do more under this head, however, than to call atten- 
tion to this subject, to make its importance apparent, and to induce the 
adoption of the means best calculated to secure the object in each particular 
case. In asthenic cases, it is a matter of the utmost importance to continue 
the use of broths, milk-porridge, wine whey, weak milk-punch, and the like, 
throughout the disease; to which tonics and stimulants are also to be added 
as the strength declines. In the treatment of sthenic cases, also, it must not 
be forgotten that infants are very soon prostrated by inanition, as well as 
by blood-letting and powerful emetics; and while we avoid the latter, we 
must also see to it that nutriment enough is taken. 
We now give a tabular view of the treatment we have recommended 
for the two forms of this disease. Diphtherite, being regarded as an 
asthenic laryngo-tracheitis (p. XS, 10th), requires no special attention here. 
Sthenic Laryngo-tracheitis. 
An emetic; followed by 
a full dose of calomel, if 
required. 
Leeches to throat, or over 
the sternum; followed by 
cold applied continuously. 
Tartrate of antimony; 
sedative doses, cautiously 
administered. 
Internal application of 
solution of nitrate of silver. 
Inhalation of aqueous and 
narcotic vapors. 
Opiates, with caution. 
Hydrocyanic acid, do. do. 
Sponge-probang and 
caustic solution. 
Expectorants. 
Calomel, in small doses. 
Alkalies. 
Counter-irritation. 
Tracheotomy ? 
Continue caustic solution, 
do expectorants, 
do counter-irrita- 
tion. 
do alkalies. 
No emetics, or calomel. 
Tracheotomy, seasonably, 
if at all. 
Milk-porridge, arrow- 
root, broth, (fee. 
Tonics, if required. 
Asthenic Laryngo-tracheitis. 
Do. do.; or pil. hydrar- 
gyri, instead of calomel. 
Leeches doubtful. 
Cold continuously ap- 
plied. 
Nitrate of potassa. 
Do. do. 
Do. do. 
Do. do. 
Do. do. 
Stimulating expectorants. 
Turpeth mineral. 
Do. 
Do. 
Do. do. 
Do. 
Do. 
Stimulant alkalies. 
Do. do. 
Do. do. 
Do. do.; also wine whey, 
milk punch, <fec. 
Tonics and stimulants. 
I. To arrest the inflam- 
matory process, and control 
the laryngismus. 
II. To prevent organiza- 
tion of the exuded plasma. 
III. For removing the 
false membrane when 
formed. 
IV. To sustain the 
strength. BA6IS OF ITS RATIONAL TREATMENT. 
31 
Tlius we have given expression to our views of tlie pathology of infantile 
laryngo-tracheitis, or croup, and of the treatment rationally based upon 
those views. If, in attempting to simplify the pathology of a subject so 
very differently understood by different writers, we have committed the 
error in the opposite direction, of including under the same term patholo- 
gical conditions which are really, for any practical purpose, different, we 
heartily regret it. But we can hardly doubt that the attempt will be re- 
garded as having been made in the right direction; and we will be happy 
to acknowledge our error, when it is shown that our views are inconsistent 
Avith the present state of pathological science. 
In respect to treatment, we have not sought to add new modes—believ- 
ing the list of remedies already too ample—but rather to appreciate the 
precise value of the remedies sanctioned by long experience, and above allr 
to inculcate that caution in the use of them all, which the tender age and 
the delicacy of the patient demand, and Avhicli has too generally been 
almost entirely forgotten, we think, in the treatment of this disease. 
In conclusion, we may add, that the adoption, in practice, for several 
years, of the principles proposed in the preceding pages, has confirmed their 
correctness in our estimation; and we might have given cases of our OAvn 
in illustration, Avere it not that Ave should thus haAre extended this paper 
beyond the limits we had proposed, and at the same time, perhaps, have- 
someAvhat interfered with its logical construction. 
Dartmouth College, Aug. 1, 1854.