CROUP. AN 
INAUGURAL DISSERTATION 
ON CROUP, 
PRESENTED AT THE PUBLIC EXAMINATION BEFORE THE 
MEDICAL FACULTY OF HARVARD UNIVERSITY FOR 
THE DEGREE OF DOCTOR OF MEDICINE, 
FEBRUARY', 1838. 
By J. H. WRIGHT. 
NORTHAMPTON : 
J. H. BUTLER. 
M DCCO XXXVJII. The Dissertation which I have ventured to offer to the 
reader was written while I was a pupil of Dr. J. H. Flint of 
Northampton. For nearly four years I have been privileged 
to observe his private practice and to watch the progress of 
this disease in a great number of cases. Indeed my remarks 
on the Treatment of Croup convey the substance of his 
instructions on this subject, and I have been greatly aided by 
his familiar conversations in the preparation of this essay. I 
have therefore presumed on a freedom of remark, which I 
hope will be tolerated, when it is understood that I have not 
been a mere looker on, but have had many cases of this for- 
midable malady committed to my exclusive care. J. H. W. 
CENTiNEL AND GAZETTE PKESS, BOSTON. CROUP. 
Croup is commonly employed, as a generic 
term, to designate an affection of the Larynx or 
Trachea, or of both, marked by difficult and 
sonorous respiration, hoarse or broken and 
suppressed voice, and a peculiar dry cough or 
bark, ringing as though it passed through a 
brazen tube. The disease may, with the 
Larynx and Trachea, also pervade the Bronchi 
to their minutest branches, without changing 
the character of its symptoms. There is also 
a grave affection of the Bronchi alone, which 
is attended by the same pathological distinctions, 
and has been called Bronchial Croup, though 
not marked by the peculiar symptoms, which 
have been mentioned. 
We prefer to retain the popular term in our 
remarks on this subject without making any 4 
pretensions to exactness of nomenclature. For 
though Croup, as thus defined, comprises two 
varieties of disease,—one inflammatory and the 
other spasmodic,—and though the former may 
be subdivided according to the degree and 
particular seat of the inflammation, still each 
affection is expressed by the same prominent 
symptoms, and these symptoms are referable to 
the same cause. The immediate exciting cause 
of the difficult respiration, the barking cough 
and the other characteristic signs of Croup is 
spasm of the Larynx, whether the disease be 
inflammatory or spasmodic. Any irritation 
capable of provoking spasm, whether it be 
direct or sympathetic, will produce “ croupy 
sounds.” 
Severe inflammation of the mucous mem- 
brane, both from the tumefaction of the 
membrane at first, and the exudation of false 
membrane afterwards, is a direct and mechan- 
ical cause of irritation and spasm. This 
constitutes one variety of Croup, (Cynanche 
Trachealis. Pseudo-membranous Laryngitis.) 
In these cases those constitutional symptoms 
which accompany local inflammation are super- 
added to the peculiar cough and the alarming 
changes in the voice and respiration, which 5 
have been already referred to as the charac- 
teristic signs. 
An oppressed and irritated stomach, and, 
according to some writers, even irritation from 
teething will also induce croupy symptoms in 
subjects predisposed by great nervous suscep- 
tibility to spasmodic affections. Thus we have 
another variety of Croup, constituted by this 
spasmodic affection, which is purely spasmodic 
and unattended with either local inflammation 
or general excitement. 
There are, then, two affections, expressed 
by the same distressing and distinct local 
symptoms, though differing widely in the pa- 
thological conditions and the degree of danger 
attending them. We associate them together 
and designate them by the same popular term, 
because nearly every case of Croup exhibits 
the union of both to a greater or less extent. 
Though we divide Croup into two varieties, 
—the inflammatory and the spasmodic,— and 
attach to each its appropriate name, though we 
may speculatively diagnosticate each with great 
exactness, yet in the practical consideration of 
the disease we shall find the former including 
the latter. Inflammatory Croup does not de- 
velop itself until spasm supervenes. Though 6 
the narrowing of the rima glottidis, by mechan- 
ically obstructing the respiration, may occasion 
the symptoms which give us warning of the 
approach of the disease, yet we cannot account 
for the suddeness of the paroxysm only on the 
hypothesis that it is caused by spasm. The 
unsuspected inflammation generally progresses 
insidiously for a number of days, until spasms 
of the Larynx, provoked by direct irritation or 
by the sympathy with the stomach, suddenly 
induce alarming symptoms. In the same man- 
ner after inflammation has subsided, and there 
is ?n entire abatement of the general excitement, 
croupy paroxysms may occur with unmitigated 
severity, which must be referred solely to irrita- 
tion. Is not this the case in some instances of 
what is called Chronic Croup, Typhoid Croup, 
&c. ? The spasmodic may, under favorable cir- 
cumstances, be exalted into an inflammatory 
affection: and in the course of the same attack 
may not inflammatory be converted into spas- 
modic Croup ? It is one of Dr. Copland’s 
pathological conclusions “that the relapses, 
which so frequently occur after intervals of 
various duration, and which sometimes amount 
to seven or eight, or are even still more 
numerous, may each present different states or 7 
forms of the disease from others ; the first attack 
being generally the most inflammatory and 
severe, and the relapses of a slighter and more 
spasmodic kind.” 
While then it is of importance to decide at 
the outset whether an attack of Croup is in- 
flammatory or spasmodic, it is equally important 
to determine'how much is due to spasm alone 
in the progress of the inflammatory disease, 
in order to apply the appropriate treatment. 
An acute inflammation of the Larynx or 
Trachea differing in no respect from other in- 
flammations of the mucous membrane, unless it 
be in severity, occurring before puberty, may 
give rise to Croup. The inflammation is in 
many cases progressive, commencing with the 
Larynx and creeping down the Trachea into the 
Bronchi. The inflammation in this disease 
resolves itself by increased mucous secretions 
and by an exudation from the inflamed vessels. 
This exudation by the evaporation and absorp- 
tion of its fluid particles speedily concretes into 
false membrane. When the inflammation pro- 
ceeds from the Larynx downward the character- 
istic exudation follows its course. In most 
cases the history of the disease closes in 
asphyxia, not from spasmodic or mechanical 8 
obstruction of the Trachea, but from effusion 
upon the Bronchial membrane, suspending the 
action of the air on the blood. 
The formation of false membrane in the air- 
passages is considered a pathological distinction 
of this disease. In the dissection of fatal cases 
we observe a great variety of lesions, from an 
abundant viscid secretion, which seems to be 
but a slight modification of the natrual mucus, 
to a tenacious and completely formed mem- 
brane.* We must not necessarily regard the 
inflammation as specific—sui generis—because 
it results in the singular product which forms 
the false membrane. This result is not univer- 
sal, and similar morbid lesions are the conse- 
quence of inflammation artificially induced in 
young animals, false membrane being com- 
pletely formed in young subjects, when a suffi- 
ciently severe inflammation could be provoked.f 
The consistence and quality of the exudation 
vary with the intensity of the inflammation, 
whether spontaneously or artificially generated. 
The presence of false membrane, though it 
greatly aggravates the malady, by exciting 
spasm and mechanically obstructing the respi- 
* Copland Diet. Pract. Med. Art. Croup, § 32—37. 
f Experiments of Duval and others, Copland, § 40. 9 
ration, is not essential to a fatal termination ; — 
blit effusion upon the bronchial membrane to 
any great extent renders the case hopeless. 
Death often occurs before any membrane has 
been formed from the obstruction of the smaller 
air passages by the viscid secretion merely. 
We may always hope for recovery after the 
formation of membrane if the air passages can 
be kept free. 
We have alluded to the doctrine of “ inflam- 
mation sui generis,” because we believe its 
practical tendencies have been exceedingly 
pernicious in encouraging the employment of 
supposed specifics, to the procrastination or 
entire exclusion of those decisive means which 
are adequate to the urgency of the inflam- 
mation. 
Brettonneau is the most distinguished and 
decided advocate of specific inflammation and 
specific local treatment. Mackensie, Weath- 
erhead and others in England adopt similar 
views and recommend local applications to the 
fauces on the same principle. A great con- 
trariety, in the general symptoms„ exists be- 
tween the disease as it occurs sporadically with 
us and the epidemic described by Brettonneau. 
Indeed, we must consider that disease as some- 10 
thing very different from what we call inflam- 
matory Croup, which may be identified with 
Angina Maligna, which spreads by contagion, 
in which fever is erratic and scarcely perceptible, 
and bleeding, general and local, blistering, 
vomiting and purging, pernicious, and local 
treatment with the internal use of calomel alone 
beneficial.* If this be Croup, and its seat, 
local symptoms and pathology would lead us 
to suppose it very similar, it would seem to 
constitute a congestive variety of the disease. 
This conjecture is sustained by the fact of its 
prevailing epidemically, and stimulation, by 
means of muriatic acid to the affected parts, 
proving to be the most successful treatment. 
At any rate, the disease is widely different in a 
practical view from the one we are about to 
remark upon. The disease described by Bret- 
tonneau is probably identical with those cases 
of Scarlatina Anginosa, which we now and then 
meet with, in which the ulceration or exudation 
extends from the fauces to the Larynx and 
Trachea: as in the cutaneous phlegmasire 
generally, a natural determination to the skin 
supersedes the necessity of vigorous antiphlo- 
* Medico CJiir. Review, Oct. 1826, p. 419. 11 
gistic measures, while a degree of general and 
local congestion would, in some cases, suggest 
a contrary course of constitutional treatment 
and the application of local stimulation. The 
disease seems to vary greatly in different coun- 
tries, and hence there is a great variety in the 
descriptions and treatment of different writers. 
As we do not intend to fill out an elaborate 
treatise on the subject of Croup, we shall go 
no farther into the history, symptoms and pa- 
thology of the disease than is necessary to 
illustrate the few practical considerations we 
are intending to suggest. 
Inflammatory Croup is generally the sequel 
of a common catarrh, which may or may not 
have been attended with slight febrile excite- 
ment. We have been accustomed to watch 
the precursory signs of Croup with great care 
and to treat them with great promptness. A 
rough cough, uneasiness about the throat, 
loaded tongue, and an inflammatory blush of 
the fauces in a plethoric child, are symptoms 
which always awaken solicitude. We would 
prevent exposure to the cold as far as possible, 
and besides the usual precautions as to dress 
and diet, we provide for the prompt evacuation 
of the first passages by an emetic or an emeto- 12 
cathartic. From five to twenty grains of 
ipecacuanha, combined with from one to ten of 
calomel, may be exhibited at bed time, and fol- 
lowed by an oily and terebinthinate laxative 
in the morning. This treatment is to be re- 
peated every night until the local symptoms 
yield or the restoration of the mucous secretion 
renders the cough loose. In all affections of 
the air passages in young children the stomach 
often becomes suddenly oppressed with the 
tough mucous which is coughed up and swal- 
lowed, and perhaps by its own increased 
secretions. Great general excitement is the 
consequence, calling often for the daily evacua- 
tion of the stomach. 
It is during this season of increased excite- 
ment that the local inflammation is increased 
and those spasms of the Larynx supervene 
which constitute the paroxysm of Croup. By 
seasonable evacuations of the stomach we can 
thus forestall one of the most active exciting 
causes of croupy symptoms. 
Should the catarrhal symptoms continue ob- 
stinate after the evacuation of the first passages, 
it may be proper to create a stronger derivation 
to the bowels by small doses of ipecac and 
and calomel during the day, vomiting being 13 
procured by an increased dose of ipecac at 
night. We have pursued this treatment in a 
great number of instances with the satisfaction 
of seeing an incipient inflammation, which, if 
neglected, might have arrived at a severity con- 
stituting Croup, stayed in a mild form and 
kindly yielding in a few days. We find it diffi- 
cult to instance a case in which these means 
have been defeated and the croupy paroxysm 
supervened. We do not suppose that the 
catarrhal signs, we have alluded to, are in 
every instance the unfailing prognostics of 
Croup. Nature, if unaided, would in many 
cases have controlled the disease before it 
eventuated in Croup. Yet if we meet promptly 
the dubious symptoms of every case, we shall 
have the happiness not only to procure the 
abatement of the milder malady, but of fore- 
stalling severe disease in not a few instances. 
The milder catarrhal symptoms exist from 
one to four days. The increasing roughness of 
the cough is generally the only indication of 
approaching disease. Some observers say that 
a very close inspection of the membrane of the 
mouth will sometimes disclose a slight degree 
of inflammation. The paroxysm occurs sud- 14 
denly, sometimes induced by exposure to the 
cold, and sometimes by sympathy with an op- 
pressed stomach. Thus the child is generally 
attacked at night after a hearty supper. 
It is often difficult to decide during the first 
paroxysm whether inflammation is present or 
not, or rather whether inflammation exists to 
such a degree as to call for the immediate 
employment of the more decisive antiphlogistic 
measures. The constitutional symptoms are 
in some cases so marked as to enable us to 
decide this question at once, especially when 
we place in connexion with them the existence 
of previous catarrh. But there are cases of a 
mixed character in which the evidence of in- 
flammation is obscure,— cases in which we are 
doubtful, how much is to be ascribed to spasm 
provoked by inflammation, and how much to 
spasms excited solely by some sympathetic 
irritation. A slight degree of local inflamma- 
tion may be present, just sufficient to pre- 
dispose the larynx to spasmodic action, without 
calling for any definite and decisive antiphlo- 
gistic measures. The evacuation of the 
stomach and the general and local employment 
of anti-spasmodics allay almost immediately 
every alarming symptom. It is in attacks of 15 
this kind that the successful use of emetics, 
snuff, tobacco, opium, and numberless domestic 
specifics, have given these means an undeserved 
prominence in the treatment of inflammatory 
Croup, to the exclusion of bloodletting and 
other antiphlogistic measures. Evacuants and 
anti-spasmodics may be relied upon when there 
is but a slight inflammation of the air passages, 
because it would not eventuate in the forma- 
tion of membrane if left to run its course 
uncontrolled. 
When called, therefore, to treat a case of 
Croup during the first paroxysm, in which 
there is any doubt as to its precise character, 
we would first direct our attention to the re- 
moval of any direct or sympathetic cause of 
irritation, which may have induced spasm. 
To effect this object the indications are, 
1st. The evacuation of the first passages. 
2d. The local application of anti-spasmodics. 
3d. An equal diffusion of warmth. 
We would then envelope the patient in warm 
flannel, apply dry heat to the extremities, and, 
if necessary, resort to frictions, sinapisms to 
the feet, &c. See.* 
* Dry heat and dry frictions aided by rubefacients are preferable to the 
warm bath, as a means of procuring an equable warmth of surface and deter- 16 
The exhibition of ipecac and calomel com- 
bined, followed in a few hours by an oily laxative 
is a safe and certain means of procuring the 
requisite evacuations. An embrocation to the 
throat and chest of camphorated oil and opium, 
with or without the addition of an irritant, as 
the oil of turpentine, exerts an excellent and 
speedy control over the spasmodic action of the 
Larynx. 
We await the operation of the emetic. If 
the paroxysm is thereby relieved and the general 
excitement does not demand immediate vene- 
section it is generally safe to postpone further 
measures for a few hours. The patient may 
then be tranquilized by sleep and copious evac- 
uations of the bowels will be obtained. Thus 
if the paroxysm occurs at midnight, the patient 
may be left until morning, when we shall be 
able to judge of the case with more deliberation 
and precision. 
When the precursory history of the disease 
and the general excitement at its access leave 
urination to the skin. The application of warm water produces sudden 
warmth, but unless proper precaution is taken, the evaporation of it induces 
an equally sudden and proportionate degree of coldness; this principle is not 
understood by many who employ it as a domestic remedy. Besides the 
simple process of applying warm flannels, &c., is attended with much less 
confusion and loss of time than the preparation of the warm bath, when there 
are no special conveniences for the purpose. 17 
no doubt that severe inflammation exists, blood- 
letting should not be postponed a moment. 
We would have it employed before the adminis- 
tration of emetics and cathartics. We should 
thus not only make an immediate impression on 
the circulating system, but provide secondarily 
for the more seasonable and kind operation of 
medicine. 
In the country, where medical advice cannot 
always be seasonably procured, the physician 
does not see the patient until the remission after 
the first paroxysm. Vomiting has perhaps been 
procured by some domestic expedient, or it has 
taken place spontaneously. There is now a 
complete subsidence of the more alarming 
symptoms. Medical aid is at no time more 
important than at this; at no time is one more 
perplexed in deciding on the appropriate plan 
of treatment. 
Is there inflammation of the air passages ? 
If there be, is it so severe as to call for decisive 
means ? How shall we decide these most 
important points ? The great improvement in 
the respiration, the restoration of the voice, the 
infrequent cough, the absence of all uneasiness 
about the throat and the buoyant spirits of the 18 
patient will often conspire to allay apprehen- 
sion. Yet with all these promising symptoms 
it has often proved a fatal error to set aside 
bloodletting for milder antiphlogistic means. 
Promptness in deciding is here required : a 
temporizing policy may jeopardize the life of 
the patient. If the inflammation eludes de- 
tection it will insidiously progress until a 
renewal of the paroxysm discloses the disease 
arrived at a severity baffling all the resources 
of medicine. 
In forming our diagnosis at this important 
period we must rely upon the constitutional 
indications of inflammation and upon the state 
of the mucous secretion of the air passages. 
One of the surest signs of inflammation is 
the absence of the mucous secretion. If the 
voice and cough indicate dryness of mem- 
brane, (and we may ascertain this by provoking 
coughing or crying,) or if the application of 
the ear to the throat and chest discloses the 
same, we may be confident that severe inflam- 
mation is at work. Notwithstanding the 
general tranquillity, we may be sure that our 
apprehensions will be realised, and the par- 
oxysm renewed ; and if we would prevent a 
fatal issue, bloodletting should not be post- 19 
poned a moment. We may have made mere 
dryness of membrane a subject of unnecessary 
alarm and subjected the patient to unneces- 
sary depletion, but it is a satisfaction to reflect 
that we have made his security certain. The 
absence of the mucous secretion, though a 
slight and often obscure symptom, is sometimes 
the only one on which he can rely in the tran- 
quil interval after the first paroxysm. The 
pulse, the general excitement, the appearance 
and sensations of the throat, sometimes afford 
evidence of inflammation, — but they very often 
give us no warning. 
The real difficulty of venesection in some 
cases, and a repugnance to the operation on 
the part of the patient, parent and physician, 
in all cases, together with the complete free- 
dom from all alarming symptoms, have too 
often prevented an early recourse to blood- 
letting. This error is irretrievable. Emetics 
and cathartics may arrest the disease, as they 
often have done in instances which, if neglected, 
would have eventuated fatally. Yet in the 
ordinary practice of the country a reliance is 
placed on these means in the early stage of 
inflammation, which permits the unchecked 
progress of the disease and renders nugatory 20 
the most appropriate subsequent measures. 
The assiduous exhibition of emetics and 
nauseants may be generally adequate to arrest 
inflammation of the pulmonary tissues, — but 
in this disease their operation is so uncertain, 
and the time for making a salutary impression 
is so short, that bloodletting becomes an in- 
comparably safer expedient. While we have 
seldom, if ever, witnessed ill effects from co- 
pious depletion, it has been a matter of un- 
speakable regret, that we have delayed the 
abstraction of blood, trusting too confidently 
to the efficiency of other means, until there 
was unequivocal evidence of the formation of 
adventitious membrane in the trachea or of 
effusion on the bronchi. 
If we decide that the disease is purely 
spasmodic, we then adopt those means which 
are calculated to remove general and local 
irritability and any accidental cause of spasm, 
and thus prevent its recurrence. These same 
indications, let it be borne in mind, are present 
even if we decide that the disease is inflamma- 
tory, and similar means are to be adopted so far 
as they are consistent with the antiphlogistic 
plan. 
Bloodletting, in whatever manner procured, 21 
unless carried to faintness, fails to make an 
impression sufficiently permanent. When we 
use the lancet we prefer to open the external 
jugulars, as the operation is more safe and 
certain. 
Leeches cannot always be obtained season- 
ably, nor in sufficient quantities, especially in 
the country : and if they could be procured 
the timidity and struggles of the patient would 
often preclude their use. Cupping is not 
available for the same reason. 
After bleeding, a weak solution of tar- 
tarized antimony or small doses of ipecac and 
calomel, or both, may be given at intervals 
of from one to six hours, according to the ur- 
gency of the symptoms. When the general 
excitement does not forbid it, opium may be 
carefully given in combination, for the purpose 
of removing irritability. It has been objected 
to the internal administration of opium, in any 
stage of this disease, that it disposes to con- 
stipation. It would seem to be an a priori 
conclusion, for we have invariably found that 
when combined with the mineral alterants, by 
removing irritability and restoring regular 
action, it promoted rather than retarded the 
operation of medicine. 22 
The stomach should be evacuated as often 
as it becomes oppressed with accumulations 
which have passed into it from the air passages. 
An emetic often gives great relief, because the 
spasms of the Larynx may be renewed, from 
sympathy with the stomach. 
In very young children the stomach may be 
evacuated twice or thrice daily with benefit. 
As it is important to keep a steady determina- 
tion to the bowels, ipecac and calomel may be 
combined together in alterant doses, or as an 
emeto cathartic, alternated with the antimonial 
solution, and followed by castor oil and turpen- 
tine, or some other laxative. 
I have heard of practitioners who contend 
that there is no advantage in procuring evacua- 
tion in this disease. When we consider the 
manner in which evacuations are often pro- 
cured, we are almost disposed to concur in the 
opinion, at least so far as this, that great injury 
results from forcing the stomach and bowels 
with powerful drugs when mild means have 
failed to answer the purpose. There is always 
in this disease a degree of asphyxia, from the 
imperfect action of the air on the blood, which 
renders all the organs peculiarly insusceptible. 
When, therefore, large doses of tartarized 23 
antimony, turpeth mineral, &c. &c. are per- 
sisted in, the reactive power of the stomach 
is completely overborne, before vomiting is 
excited, if it can be at all, and the patient 
perishes in the early hours of the invasion — 
not of Croup—but a victim of medicine.* 
Evacuants are most successfully administered 
during the remission, when the natural sus- 
ceptibility is restored by the circulation of 
more perfectly arterialized blood. While the 
organs are oppressed by the general asphyxia, 
it is as idle to attempt to arouse them by large 
doses of irritating drugs, as to restore sensa- 
tion to a palsied limb by blisters, while the 
nerves are compressed by a ligature. It often 
happens that the torpor of the bowels is the 
secondary effect of congestion of brain f in- 
duced by the efforts of the patient and by local 
spasms. It is, therefore, good policy to em- 
ploy those means which will remove cerebral 
congestion. We have in this and other dis- 
eases, greatly relieved the vessels of the head 
* A chilil in the neighborhood was attacked with severe Croup about mid- 
night. A medical practitioner was called upon, who commenced operations 
with great vigor, by giving,according to his own elegant phraseology, “ tartar 
emetic enough to puke fifteen men.” His patient died in convulsions before 
morning,— but not of Croup. In another case eight grains of Turpeth 
Mineral were given at a dose, in the last stage of the disease, 
t Prof. Eberle. 24 
by drawing blood from the nostrils. A suffi- 
cient flow of blood may be obtained by plung- 
ing the lancet into the septum of the nostrils, 
and the hoemorrhage may be commanded at 
any moment by pressure. 
Notwithstanding the employment of these 
measures the paroxysm may be repeated. In 
order to subdue inflammation and mitigate the 
symptoms, repeated bleedings are often neces- 
sary. We should not spare the lancet until 
we are sure that the inflammation is con- 
trolled.— But we must not lose sight of the 
fact, that in every stage of the disease much 
is due to spasm. After the inflammation begins 
to abate severe paroxysms may occur in con- 
sequence of the irritability and spasmodic habit, 
(if I may use the expression) of the larynx. 
We should, therefore, be cautious not to carry 
depletion too far, when the paroxysms are to be 
attributed to the extreme susceptibility of the 
larynx to spasm rather than the obstinacy of the 
inflammation, since bloodletting would only en- 
hance the difficulty we are seeking to remove, 
by engendering greater general irritability. 
It is exceedingly difficult to decide, with the 
closest observation and discernment, when 
antiphlogistic measures are to be dispensed 25 
With and when we may rely on the internal use 
of opiates. It is impossible to give any rule by 
which we may unerringly distinguish inflam- 
mation from irritation. The history of the 
case, the effect of treatment, the state of the 
organs, particularly of the stomach, the 
idiosyncracies of the patient, and the consti- 
tutional symptoms at the time must all be 
carefully considered. 
We have alluded to the use of anodyne 
embrocations to the throat. These may be 
continued through the whole course of the dis- 
ease. The tobacco leaf or the plaster of snuff 
may be used on the same principle and have 
sometimes a very powerful effect. An excellent 
extemporaneous preparation is made by throw- 
ing together equal parts of camphor spirit, 
olive oil and laudanum. This may be applied 
warm with considerable friction, and a mod- 
erate degree of external warmth may be pre- 
served by a fold of cotton batting thrown 
loosely around the neck. We shall thus obtain 
the anodyne effect of the opium and keep up a 
safe derivation to the skin. 
But little benefit is derived from the applica- 
tion of direct irritants to the throat during the 26 
stage of excitement. When the general ex- 
citement is somewhat abated, it may be well 
to add some irritant to the embrocation or 
substitute a mercurial ointment in its place. 
Blisters may be also beneficially applied to the 
limbs and back, “ but never to the throat.”* 
Our own experience, and all our notions 
a priori, would lead us to protest strongly 
against the practice of vesicating the throat, 
which is still adhered to by many, though con- 
demned by some of the best writers on the 
subject. 
On the application of a blister to the throat 
the inflammation has been renewed in an ag- 
gravated form and the tendency to spasm 
greatly increased. 
Cheyne advises vesicating the throat and yet 
holds the following equivocal language with 
regard to his own experience : “ I have seldom 
omitted a blister to the neck, and I believe it to 
be a valuable addition to the plan of cure, 
though I cannot affirm this upon my own expe- 
rience.” In a number of cases appended to 
Cheyne’s essay, the application of the blister 
was followed by a severe exacerbation. He 
* Copland. 27 
wrote a practical treatise from his own expe- 
rience. We have noticed in the dissection of 
fatal cases, in which a blister has been applied, 
an effusion of lymph into the cellular mem- 
brane over the inflamed parts of the trachea. 
If this intense inflammation was not increased, 
it certainly was not diminished by the con- 
tiguous vesication.* 
Cases are sometimes referred to, as examples 
of the inefficiency and injurious effects of ex- 
cessive depletions, which are, after all, but 
illustrations of the powerful action of blisters 
in kindling up inflammation anew and thus 
defeating the most prompt and appropriate 
antiphlogistic measures. While we consider 
counter irritation “ as a valuable addition to 
the plan of cure,” we would exempt the throat 
and chest from all applications except of a 
soothing kind during the stage of excitement 
and from very extensive or long continued irrita- 
tion subsequently. 
When we consider that a susceptible child 
may be thrown into convulsions by the applica- 
tion of blisters, we may believe that irritation 
of the throat is the very best means of provoking 
* Dr. Flint. 28 
spasm of the air passages already in a state of 
irritability. 
We subjoin the following case as a more full 
illustration of the plan of treatment: 
October 6th, 1836. I was called to visit a 
robust and ruddy child two years and a half 
old, with the symptoms of the advanced stage 
of Croup. I learned that the child had for 
some weeks been the subject of a common cold. 
Nine days ago the cough became hard and 
ringing — the respiration sibilous. To these 
were added constitutional symptoms — flushed 
cheeks — harsh and dry skin — the heat was 
and had been variable, but always above the 
temperature of health. The disease from its 
access had been modified by the judicious man- 
agement of the parents. Mild emetics and 
purges had been given, and various domestic 
remedies employed both externally and inter- 
nally. There was not much alarm until two 
days ago,—the seventh since croupy symptoms 
were manifested. On the evening of the eighth 
day all the symptoms had become so urgent 
that a neighboring practitioner was called in, 
who, apprehending the formation of membrane, 
pronounced it too late to bleed. He gave a 
powerful emetic, which procured free vomiting 29 
of a thick, glairy fluid. The parents thought 
that fine shreds, and patches were also dis- 
lodged. 
When I saw the child, on the morning of the 
ninth day, a partial remission had taken place 
— I did not make any minutes of the symptoms 
at the time. The characteristic respiration, 
cough and voice of croup were present. The 
paroxysm returned by afternoon. The patient 
was then in great distress from the difficulty in 
respiration and the constant suffocating cough. 
The face was deeply suffused — plum colored. 
The eyes watery. Patches and shreds of 
whitish membrane were expectorated or re- 
jected by vomiting. The pulse was hard and 
frequent,— the heat of skin not much above 
natural. 
I opened the jugular vein and bled to ap-< 
proaching syncope. As the ingesta had been 
thoroughly evacuated I directed once in four 
hours the following powder : 
Sub. Mur. Hyd. grs. ii. 
P. Ipecac. grs. ii. 
Half ounce of castor oil in the intervals until 
evacuations of the bowels were procured. If 
the stomach perseveringly rejected the oil, or if 
a movement of the bowels was long delayed, a 30 
mild but full injection was to be administered. 
An embrocation to the throat of equal parts of 
table oil, camphor spirit and laudanum. To 
be applied warm and warmth preserved by a 
cravat of cotton batting. Blister to the spine 
from the fifth cervical to the last dorsal ver- 
tebra. Stimulating applications to the feet. 
An equable diffusion of warmth by warm and 
dry flannels, &c. 
Before I left the patient, the more urgent 
symptoms had been relieved. 
10th. Vomiting of glairy matters followed 
the exhibition of each powder. No well 
marked paroxysm had occurred since the 
bleeding yesterday. The heat had somewhat 
increased; the pulse was more full and free. 
Bowels had not been opened. 
The same means to be continued. Injection 
to be repeated if necessary to procure evacua- 
tions before noon. 
11th. The child is better, though there have 
been several paroxysms. The tongue has 
somewhat improved. Cough and breathing 
less difficult. The countenance has lost much 
of its purple hue. The face is flushed. The 
heat higher than it was at first. Pulse about 
the same as yesterday. The stomach and 31 
bowels have been several times evacuated since 
yesterday morning. Shreds of membrane have 
been expectorated. Directed 1 -12th of a grain 
of tart, antimony in solution to be given once 
in six hours alternating with the powders of 
ipecac and calomel. Castor oil to be con- 
tinued once in six hours, a few drops of oil of 
turpentine to be added to the dose of oil. 
12th. Improvement in all the symptoms since 
yesterday. In connexion with the opiated 
embrocation a mild mercurial ointment was 
directed to be applied to the throat thrice daily. 
The amendment subsequently was gradual 
and progressive. The paroxysms were less 
frequent and less severe, generally terminating 
by the expectoration of a patch of membrane. 
The bowels were more obedient and the secre- 
tions natural. After the general excitement 
had somewhat declined, the continuance of the 
cough and a degree of general irritability 
seemed to call for the use of opium internally. 
I have found in other cases, that a degree of 
irritability often supervened on the acute dis- 
ease, even when we were so fortunate as to 
prevent the formation of membrane. Some 
would perhaps attribute this to disproportionate 
general bleedings. Yet this would not con- 32 
stitute a valid argument against bold 
for they are incomparably the safest. In this 
stage and form of the disease we must place 
our entire reliance on anti-spasmodics.* 
Though this state of irritability is attended 
with very much the same local symptoms as 
inflammation, the constitutional symptoms will 
in this stage serve to distinguish it, and point 
out the appropriate plan of treatment. The 
pulse and the heat of the skin indicate debility 
rather than excitement. The tongue is some- 
times of a deep scarlet color. It would be a 
fatal mistake to resort to depletion under these 
circumstances : without doubt the croupy cough 
and difficult respiration are often enhanced by 
the untimely repetition of venesection. We 
might adduce cases from our own observation 
and that of others in support of this opinion. 
Perhaps in no disease do the symptoms which 
denote inflammation and irritation so com- 
pletely simulate each other as in this. The 
reason is obvious. The local symptoms in 
* The opium may be advantageously combined, in the form of a tincture, 
with the antimonial solution. The antimony, by making an impression, 
seems to prepare the way for the opium and to give a permanency to its 
effects. Thus through the aid of the antimony, smaller and less frequent 
doses of opium may be made to answer the purpose. 33 
either case depend on the same cause — the 
spasmodic affection of the larynx. 
It occasionally happens that depletion is 
promptly and copiously employed early in the 
disease and even twice repeated. Yet the 
physician is perplexed at the obstinacy of the 
symptoms which are rather aggravated than 
abated. There are no appearances of the 
formation of membrane, but the cough continues 
shrill and ringing, and the respiration irregular. 
The exacerbations are frequent and irregular. 
In such a case we would discriminate care- 
fully between irritability and inflammation. 
Most authors have divided the disease into 
different periods or stages, regarding sometimes 
the pathology and sometimes the diversity of 
the symptoms. We may instance Cheyne, 
who considers the disease under two stages, 
the inflammatory and the purulent: the one 
antecedent and the latter subsequent to the 
formation of membrane. Copland notices, 
first, the precursory signs,—then the developed 
or confirmed state, and lastly, the state of col- 
lapse. Although these arbitrary arrangements 
may have contributed to perspicuity of descrip- 34 
tion, they have been a fruitful source of prac- 
tical error. We are left to infer, that after the 
formation of membrane, the disease changes its 
type, and that a corresponding change of treat- 
ment is indicated, to the exclusion of the anti- 
phlogistic means of the preceding stage. 
We are told that when the disease, through 
neglect or inefficient management, has arrived 
at the last or post-membranous stage, then the 
only indications are, by all appropriate means, 
to provoke the discharge of the membrane, 
subdue suffocating spasms and sustain the vital 
energies. We believe that these indications 
are present, but it seems to us that there is one 
more important indication which is overlooked, 
viz.:—to arrest a progressive inflammation. 
After assiduously employing blisters, emetics, 
expectorants, narcotics and diffusibles, on the 
hypothesis that the period of inflammation had 
past, we find it difficult to refer to a single 
instance of recovery from this stage of the 
disease.* Indeed it is with deep mortification 
that we have witnessed the means of cure, fore- 
stalling the disease in hastening the case to a 
fatal termination. Entire relief of the more 
* Dr. Flint. 35 
urgent symptoms has often followed the expul- 
sion of a patch of membrane, and we have been 
ready to foster some trembling expectations of 
rescuing the patient. And when after a few 
hours our hopes have been all dashed by the 
patient’s sinking into asphyxia, by a renewal of 
the membrane, or by an extension of it, or by 
effusion into the bronchi, we have been led to 
suspect that the stimulant and expectorant plan 
failed of reaching all the indications of cure. 
Are we not, in fact, to regard Croup in 
many cases as a disease of progressive inflam- 
mation — a disease of inflammation to the last ? 
Though the inflammation may have run its 
course to exudation in the parts first attacked, 
it may be at its zenith in parts subsequently 
affected. While, therefore, the presence of 
membrane in one part of the trachea calls for 
the assiduous employment of all appropriate 
means to aid its expulsion, the existence of in- 
flammation, in the lower portions of the air 
passages, demands the employment of anti- 
phlogistic means also. In these cases (and 
they are many) in which the inflammation com- 
mences with the superior part of the trachea 
and descends gradually to the bronchial tubes, 
the disease does not prove fatal until there is an 36 
exudation on the bronchial membrane, which 
precludes the action of the air on the blood. * 
Though we may be fortunate enough to pro- 
cure the expulsion of a patch of membrane, 
much to the relief of the patient, still there is 
but slight ground for hope unless we can pre- 
vent a renewal of it and the fatal obstruction 
of the air passages. Is not then a persever- 
ance in antiphlogistic means indicated in this 
stage of the disease, as well as the discreet 
employment of expectorants and stimulants ? 
If bloodletting has not been carried to the ut- 
most is it not important to employ it even now, 
as far as the circumstances of the case will war- 
rant, as the means of subduing inflammation ? 
The history of most of the cases, which have 
fallen under my observation, before death, and 
ihe appearances disclosed on examination after 
death, go to prove the progressive extension of 
the disease from the upper to the lower portions 
of the respiratory tube. 
A completely formed and firm-bodied mem- 
* Cheyne says that death occurs in this manner in nine cases out of ten. 
We do not on dissection often find the trachea impervious to the air from the 
obstruction of foreign matters, but it is possible that a state of contraction of 
the glottis might result from the high degree of irritation, and continue just 
long enough to suffocate the patient, and yet be relaxed after death. 37 
brane lines the superior portion of the trachea, 
which as we descend gradually loses its tenacity 
and consistence, until it becomes a mere deli- 
cate film, and in the bronchi an accumulation 
of glairy fluid only. On the hypothesis, that 
inflammation assails all parts of the respiratory 
tube simultaneously, we are unable to account 
for the variety in the morbid lesions of the differ- 
ent parts, indicating different stages of disease, 
and of course successive periods of its access. 
When we place in connexion the fact that the 
functions of the lungs are not fatally inter- 
rupted, until long after there are unequivocal 
evidences of the formation of membrane, and 
that death often takes place trom some sudden 
and altogether unexpected exacerbation, the 
proof of the progressive extension of the dis- 
ease seems complete. 
A slight inflammatory blush of the throat is 
noted by some as a common symptom before 
accession of croupy symptoms. Prof. Eberle 
says that both Brettonneau and Mackensie 
assert “ that the inflammation often commences 
in the fauces and on the tonsils, and descends 
thence into the trachea.” “ I have myself,” 
he adds, “ seen several cases of Croup, which 
commenced by a kind of erysipelatous or super- 38 
ficial inflammation about the tonsils and soft 
palate.” Bronchitis is a sequel of Croup. 
This law of progressive inflammation seems to 
hold good with regard to other affections of the 
mucous membrane of the air passages. No 
one can have failed to have observed the pro- 
gressive development of a common cold. A 
nasal catarrh is the most common precursor of 
the cough. Dr. Latham, speaking of the phy- 
sical signs of Peripneumonia Notha, says that 
if Auscultation informs him aright, “the in- 
flammation does not arise at once and over the 
whole surface which it is destined to pervade, 
but travels over it progressively ; so that va- 
rious portions of the same continuous surface 
are in different stages of inflammation at the 
same time. How possible this is, every one 
knows who has watched erysipelas travelling 
over the whole body.” 
If then we are still to deal with inflammation 
even in the last stages of the disease, what 
means are we to resort to ? Dr. S. Jackson 
reports a case in Am. Jour. Med. Science, 
p. 361, vol. iv., in which the application of 
leeches to lower part of the throat and chest 
was attended with success. M. Jadelot, senior 
physician to the Hospital for Children in Paris, 39 
** directs leeches to be applied when the pres- 
ence of false membrane is suspected ; but the 
moment they fall off he hastens to produce 
vomiting.” When the condition of the patient 
will permit, general bloodletting may be re- 
sorted to. The apprehension of exhausting 
the vital energies should not have too much 
weight in deterring us from bloodletting at a 
late period. The sinking of the vital powers 
is occasioned chiefly by the circulation of im- 
perfectly arterialized blood; to lessen the 
volume of the general circulation is taking one 
important step to improve the circulation 
through the lungs. The disposition to asphyxia 
is thus removed and the vital energies pre- 
served. During this state of oppression, the 
enfeebled pulse will be found to rise, the hue of 
the skin to be improved, the vital power to 
rally. 
This disease seems to vary greatly in differ- 
ent countries. The peculiar character of the 
epidemic described by Brettonneau of Tuors, 
has been noticed. By others the disease is 
regarded as essentially spasmodic. Prof. 
Eberle quotes Prof. Nasse as considering 
“ disturbed or impaired function of the Pneu- 
mogastric nerves as the proximate cause of the 40 
disease. The symptoms bearing a very strong 
resemblance to those which result from dividing 
the eight pair of nerves.” The generality of 
the German and French practitioners are said 
to entertain similar opinions. Perhaps the 
views we have presented will reconcile in a 
measure these discrepances of opinion by re- 
garding the inflammatory affection as manifest- 
ing itself by provoking spasmodic action. In 
the vicinity of Connecticut River, where I have 
been privileged to observe many cases of Croup, 
I have found the disease in a majority of in- 
stances of an inflammatory type, and one of 
severe inflammation. And if there be any 
treatment, which is entitled to be considered as 
specific, it is the prompt, fearless and persever- 
ing use of the lancet. Under such treatment I 
have found this formidable malady as manage- 
able as any other. While from considerable 
investigation with regard to the treatment of 
the disease in that part of the country, I am 
prepared to to assert that when the emetic and 
expectorant plan is exclusively adopted, there 
is no disease which is proportionally more fatal. 
Indeed, but a few years ago, it had come to be 
a proverb among the vulgar, “that children 
must always die of the rattles.”