CROUPOUS PNEUMONIA. A CONTRIBUTION ,7- 
TO THE h S’ /0 
* \ 
CLINICAL HTSTOR^ 
OF 
Croupous Pneumonia. 
A report of Eleven Cates of Croupous Pneumonia occurring in private practice 
between the dates of Feb. .and June, 1878. 
By D. WEBSTER PRENTISS, A. M., M. D., 
Professor Mat. Medicaand Therapeutics, National Medical College, of Washington, D. C. 
(Read before the Med. Society of Dist. of Columbia, March 25, 1879.) 
Croupous pneumonia is an endemic disease belonging to the 
class of infectious diseases. 
It is only of comparatively recent date that the nature of 
this disease has been correctly understood, nor indeed is it 
even now admitted by all writers that the above proposition is 
true. 
To Austin Flint in this country, and Meinyer Jiirgensen and 
others in Europe, is due especial credit for pointing out with 
clearness the natural history of croupous or “lobar” pneumonia, 
and showing it to be a self limited disease, of constitutional 
character, in which the local inflammation in the lung is but a 
symptom of the general disturbance—-just as is the a flection of 
Peyer’s patches in typhoid fever, or the skin eruptions in the 
exanthemata. The onset of croupous pneumonia is almost 
always sudden, preceded by a chill, in which it corresponds 
with other zymotic diseases. The lung lesion frequently does 
not appear until the 2d or 3d day—and then bears no constant 
relationship to the severity of the fever. The fever is regular 2 
in its course with morning decline and evening exacerbation. 
At the sudden crisis, about the 7th day, the pneumonic inflam- 
mation often continues unabated, as indicated by the physical 
signs and quickened respiration—but the fever utterly disap- 
pears—the pulse and temperature becoming normal, and the 
appetite returning. 
The disease is most prevalent in the presence of its exciting 
causes, chief of which is exposure to cold, wet weather; but 
we cannot believe, reasoning by analogy, that these conditions 
alone are suflicient to produce it. 
In the cases reported below, no connection whatever existed 
between them, nor with any other case as far as could be ascer- 
tained ; yetthere are instances occurring continually in the 
practice of physicians, that look suspiciously as though an 
element of contagion was present. Two or three years since I 
was called to a case of croupous pneumonia in a child—in a 
family of four children, all under the age of eight years. The 
parents were wealthy and the children hearty and robust— 
well cared for in a warm comfortable house, where they had 
the least possible exposure to cold. When the first child had 
been sick four or five days, the other three were all taken down 
at once with the same disease. All the cases ran the typical 
course to recovery. 
Again in the winter of 1876 and 1877,1 noted a case in a child 
10 years of age, coming on without any unusual exposure to 
cold, and running the regular course to crisis on the 7th 
day and prompt recovery. Just at the time of the crisis a 
younger brother, aged 6 years, was attacked with the same 
sequence of symptoms and result. 
These latter two cases made the greater impression, that my 
interest in them was closer than a merely professional one, and 
I was watching them night and day. Such cases create the 
suspicion that the disease is contagious, though only to a faint 
degree, and indicate that the period of incubation is a short 
one—from 4 to 7 days. If it is contagious, analogy would sug- 
gest the sputa from the diseased lungs as the principal source 
of contagion, just as are the enteric discharges of typhoid fever 
and cholera. 
It would be inappropriate in an article of this description to 3 
enter into a discussion of the diagnosis between croupous and 
catarrhal pneumonia, albeit the differences between the two pre- 
sent the strongest argument in favor of the zymotic character 
of the former. 
Catarrhal pneumonia presents a picture exactly the opposite 
of that given above, except only as to physical signs—the in- 
sidious approach, the irregular character of the fever, no defi- 
nite course, and especially the close sympathy between the lung 
disease and the general symptoms. 
Case I.—Croupous Pneumonia at Base of both Lungs in an Adult. 
Mrs. S., Irish, 48 years of age; stout, healthy woman, who 
has had no sickness for many years. 
February 28th, 1878.—Chill in evening, followed by fever and 
cough, after prolonged exposure to cold. 
March 2d.—First saw the patient at G, P. M., in bed, suffering 
no pain, but feeling sick and distressed. Carefully examined 
lungs, but could detect no sign of disease. Has occasional 
cough. 
DATE. 
o | 
S?1 
°5 
1 
5 
Tempera- 
tore. 
"cC 
u 
’& 
QD 
© 
Pulse res- 
piration 
ratio. 
TREATMENT AND REMARKS. 
March 2, A. M. 
3 
96 
March 3, A. M. 
4 
96 
102 
29 
3.44 
Still no crepitant rale. 
March 4, A. M. 
5 
96 
105 
28 
1 
3.44 
Abundaut crepitus at base of right 
lung; slight crepitus at base of 
left lung. Ordered quin. sul. grs. 
xx at one dose; carb. amnion, 
mixt.; milk and beef tea. 
March 5, A. M. 
6 
100 
104 
32 
1 
3.13 
Repeat quinine. Continue treat- 
ment. Oiled silk shirt. 
March 6, A. M. 
7 
108 
105 
28 
1 
3.96 
Repeat quinine. Continue treat- 
ment. 
March 7, A. M. 
8 
100 
103 5 
32 
1 
3.13 
Repeat quinine. 
March 8, A. M. 
9 
90 
100.3 
22 
1 
3.64 
Quin. grs. ij. ter die ordered in place 
of dose of grs. xx. 
March 9, A. M. 
10 
80 
98.5 
16 
1 
5 
Treatment continued. Profuse 
sweating. 
March 11, A. M. 
12 
80 
99 
15 
1 
5.33 
Lung disease nearly disappeared. 4 
This patient was only seen once daily, and the record is 
therefore oidy for the morning, and does not show the antipy- 
retic effect of the quinine; but according to the report of the 
nurses, each dose was followed by relief to the patient and 
reduction of fever, the latter rising again in the early morning 
hours. On the night preceding the 4th of March she was 
extremely ill; so much so that she insisted she was dying, 
and had the priest summoned to administer the last sacrament. 
There was no return of this extreme illness after the adminis- 
tration of the first dose of quinine, although the temperature 
arose equally high subsequently. The whole twenty grains of 
quinine were given between three and four o’clock, P. M., each 
day, and their effect in reducing fever lasted twelve or fourteen 
hours. 
The 5th, 6tli and 7th days of the disease were the worst. 
Defervescence began on the 8th day from the initiatory chill 
occupying 48 hours, but was not complete until the 10th day, 
ending in profuse sweating. There was no sudden crisis. 
Sweating still continued when attendance was closed, March 
11th. The local disease was principally in the lower lobe of the 
right lung, posteriorly; the lower lower lobe of the left lung 
was slightly affected. There was no stage of complete hepati- 
zation, the crepitant rale being abundant duiing the whole 
course of the attack. Cough, expectoration and pain were insig- 
nificant. The pain complained of was in the right side, in front. 
Recovery was prompt. Average pulse respiration ratio J_. 
3.87 
Case II.—Croupous Pneumonia of both Lungs in an adult. 
James M., Irish, 37 years of age, stone polisher; is a drinking 
man; drinking by sprees, but sober in the interval; good con- 
stitution. 
Was taken sick March 5th, 1878, with chill followed by pain 
in the left side in front, and sweating. Painful cough. Con- 
tinued to work until March 9th. March 10th, first seen. Severe 
pain in cardiac region, causing dyspnoea and suppressed cough. 
Profuse sweating. Auscultation shows pneumonia in lower 
segment of left lung, liespiratiou in right side normal. 5 
DATK. 
Day of 
Disease. 
Pulse. 
Tempera- 
ture. 
s 
"eS 
u 
E. 
x 
l> 
as 
Pulse res- 
piration, 
ratio. 
SYMPTOMS, ETC. 
March 10, A. M. 
6 
116 
105 
48 
1 
Rusty sputa; carb. amnion, gr. v 
2.42 
every 4 hours. 
March 11, A. M. 
7 
116 
105.7 
36 
1 
Pain and dyspnoea very distressing. 
3.22 
Quinine grs. xx at one dose. 
March 11, P. M. 
100 
102 
28 
1 
General condition greatly iinprov- 
3.57 
ed ; cough and pain continue. 
March 12, A. M. 
8 
104 
104 
28 
1 
Quinine grs. xx repeated ; crepita- 
3.71 
tion in lower lobe, right lung. 
March 12, P. M. 
100 
102.7 
32 
1 
Chloral grs. xx; morphia gr. i, to 
3.12 
relieve pain and produce sleep. 
March 13, A. M. 
9 
112 
105 
44 
l 
Pain not relieved. Ordered bath 
2.54 
at 88° for 10 minutes in wash tub, 
in place of quinine. 
M’ch 13,3 P. M. 
108 
101.5 
30 
1 
Great relief. 
3.60 
M’ch 13, 9 P. M. 
92 
100.3 
28 
1 
Repeated chloral and morphia. 
3.28 
March 14, A. M 
10 
108 
105 
44 
1 
Fever rose again at 2, A. M.—14 hrs. 
2.45 
after bath. Repeat bath and in 
-i 
addition quinine grs. xx. 
M’ch 14, 5 P. M. 
96 
103 
44 
Middle and lower lobes of right 
2.18 
lung hepatized ; returning crepi- 
tation in left lung. 
M’ch 14,9 P. M. 
88 
100.5 
32 
1 
Whiskey every 2 hours. 
2.75 
March 15, A. M. 
11 
84 
102 
36 
1 
Repeat quinine grs. xx. 
2.33 
M’ch 15, 9 P. M. 
72 
100.2 
40 
l 
1.80 
March 1G, A. M. 
12 
68 
99.5 
36 
1 
Left lung improving ; condition of 
1.88 ; 
right lung unchanged. 
M’ch 16, 9 P. M. 
76 
100.3 
32 
1 
Profuse sweating. 
2.37 
March 17, A. M. 
13 
64 
99 
36 
1 
Profuse sweating. 
1.50 
March 18, A. M. 
14 
78 
99 
32 
1 
Profuse sweating. 
2.4.3 
March 19, A. M. 
15 
76 
100 
2c 
1 
Profuse sweating. 
2.78 
March 20, A. M. 
16 
68 
98 
2t 
1 
Ordered cit. quinine and iron gr. v. 
2.43 
and cod liver oil f.?ss 3 times a 
day. 6 
DATE. 
Day of 
Disease. 
Pulse. 
Tempera- 
ture. 
a 
* 
- 
a 
n 
© 
Pulse res- 
piration, 
ratio. 
SYMPTOMS, ETC. 
March 21, A. 
M. 
17 
68 
24 
1 
2.83 
March 22. A. M. 
18 
68 
99 
24 
1 
Appetite returning. 
2.83 
March 29, A. 
M. 
25 
76 
Severe headache. Ordered brom. 
potas. grs. xxx ter die. 
Returning rales in right lung; 
lung normal; convalescing, 
still very weak. 
left 
April 1st. 
28 
80 
but 
(Continued.) 
This case is a type of the severer form of croupous pneu- 
monia. Defervescence did not begin until the 10th day from 
the initiatory chill, and cannot be said to have been completed 
until the 16th day, a period of six days, so that the termination 
of the febrile symptoms was by lysis rather than crisis. It is to 
be noticed, as bearing on the question of diagnosis between 
croupous and catarrhal pneumonia, that on the twelfth day, when 
the pulse had returned to 68, and the temperature to 99.5°, the 
diseased process in two-thirds of the right lung continued una- 
bated. The record of the case shows most conclusively the 
antipyretic effect of quinine in gr. xx. doses, as well as of the 
tepid bath. 
On the morning of the 7th day the thermometer indicated a 
temperature of 105.7°; gr. xx. of quinine was administered, and 
in the evening the pulse had fallen to 100 from 116, and the tem- 
perature to 102°, a decline of 3.7° in seven hours. So on the 
following day there was a similar fall of 1.3°. 
On the morning of the 9th day the pulse was 112, and tem- 
perature 105°. Quinine having been given two consecutive 
days, it was deemed advisable to substitute the warm bath. In 
nine hours the pulse had fallen twenty beats, and the tempera- 
ture four and seven-tenths degrees. This could not be attrib- 
uted to the crisis—for on the morning of the 10th day, the 
fever again arose to 105°. On this day, the bath and quinine 
were both given, and devervescenee set in. Carbonate of am- 
monia was given all through the attack, aud beef tea and milk 
relied upon for uourishineut—both being taken freely. 7 
The pleuritic pain in this case was very distressing and was 
complained of in front, although the pneumonic inflammation 
was mostly posterior. Average pulse respiration ratio _L 
Case III.—Croupous Pneumonia in the Lower Lobe of Right 
Lung, in a Young Child. 
Alvin M., male, aged 3 years ; plump, healthy child. Taken 
sick March 28, 1878. First seen March 20th, when pneumonia 
was developed in the lower lobe of right lung. Dyspnoea 
marked. 
DATE. 
D a y o f 
Disease. 
Pulse. 
Temper- 
ature. 
Respir’n. 
| Pulse-res- 
1 piration 
ratio. 
SYMPTOMS AND REMARKS. 
1878. 
March 29, A. M. 
2 
128 
104 
80 
1 
D60 
W arm bath ordered every 4 hours. 
March 30, A. M. 
3 
128 
101.7 
40 
1 
March 30, P. M. 
3 
140 
104 
56 
3.20 
1 
2.50 
Quin. gr. v. at one dose. 
March 31, A. M. 
4 
148 
103 
40 
1 
do' do. do. 
April 1, A. M. 
5 
120 
100.3 
40 
3.70 
1 
3.00 
do. do. do. 
April 2. 
April 3. 
April 4. 
6 
7 
8 
101.5 
28 
Great improvement. Pulse, etc. 
not recorded. 
Convalescent. VisitB discontin- 
ued. 
The antipyretic effect of the quinine was very decided, but 
does not show in the chart, for the reason that but one visit was 
made daily after its administration was commenced. The ter- 
mination was by lysis—tin* period of defervescence extending 
over seventy-two hours, from the 5tli to the 8th day. 
Average pulse respiration ratio J_ 
Case IV.—Croupous Pneumonia in an Adult, Right Lung, 
Asthenic Form—Death on the 9 th Day. 
I). *1. B., aged 50 years, American, rather slender built, 
weight, about 140 tbs ; conductor on street cars, 8 
March 9th, 1878.—Had slight chill, followed by fever, cough 
and dyspcena. Continued to work until evening of March 10th, 
but u laid off” and went to bed March 11th. 
eS 
c 
A c 
DATE. 
O x 
s? © 
1 
© © 
S-S 
a 5 
*c8 
t-j 
‘5- 
ac 
© o 
$ ci.g 
® -C 
TREATMENT AND REMARKS. 
P 
Ph 
© 
H 
© 
K 
3 p. 2 
PH * 
March 12, A. M. 
4 
108 
104.8 
30 
1 
3.60 
Crepitant rale with marked dullness 
over middle lobe of right lung. 
“ Prune juice ” expectoration— 
harassing cough ; dyspnoea mark- 
ed; anxious countenance. Ordered 
quin. grs. xx. at one dose. Carb. 
ammon. and milk punch freely. 
Repeat quinine grs. xx. Beef tea 
and stimulants ad. lib.; dusky flesh 
on cheeks, oiled silk shirt aiound 
chest. 
M’ch 13, 2 P. M. 
104 
103.5 
28 
1 
Upper and middle lobe right lung 
solid, and crepitant rale heard in 
5 
3.71 
lower lobe. Dyspnoea greatly in- 
creased. Expectoration of same 
character and more in quantity. 
March 14, 12 M. 
108 
104 
32 
1 
Condition about the same; expec- 
6 
3.37 
toration same; cough very 
troublesome, preventing sleep. 
Ordered tepid bath to be followed 
by quinine grs. xx.; morphia and 
chloral mixture to control irrita- 
ble cough. Beef tea and milk 
punch continued. 
Expectoration less in quantity and 
not so bloody; cough in a mea- 
March 15, 12 M. 
7 
96 
102.5 
sure relieved by anodyne mix- 
ture. Quantity of whiskey in- 
creased to oz. ss every two hours. 
March 16, A. M. 
100 
103 
34 
1 
Passed a bad night. Watchers 
8 
24)4 
went to sleep, so that he got 
neither medicine nor nourish- 
ment during the night. Got out 
of bed himself to get water. 
Right lung entirely hepatized ; 
dyspnoea very distressing ; cyan- 
osis marked; larynx rises and 
falls during respiration ; supra- 
clavicular spaces sink in. Or- 
dered camphor grs. iij. in emulsion 
every two hours, and to push 
whiskey and beef tea. Dyspnoea 
still greater and cyanosis more 
marked. Treatment continued. 
M’ch 16,10 P.M. 
8 
104 
103 
36 
1 
Dying. 
2.88 
March 17, A. M. 
9 
120 
103 
40 
1 
Died at 2 P. M. 
3.00 9 
In this case there were prodromal symptoms for two weeks 
before the onset of the disease. The patient’s habits of life 
had formerly been irregular, but for the past several years had 
been correct. 
The record of pulse, temperature and respiration would not 
indicate a severe attack of the disease, but the accompanying 
symptoms of distress, cyanosis and “ prune juice” expectora- 
tions pointed clearly to a severe case. The pulse, three hours 
before death, was but 120, and temperature 103°. 
It is a matter of great regret that just at the most critical 
period of the disease—the night between the 7th and 8th day— 
he should have been neglected by the sleepiness of those in 
charge of him. Had the stimulants and nourishment been kept 
up regularly during this time, and the patient been prevented 
from getting up out of bed, a different result might reasonably 
have been expected. 
The record of pulse and temperature shows a remarkably low 
average for a fatal case. 
Average pulse respiration ratio _i_ 
Case V.—Croupous Pneumonia, Lower Lobe of Right Lung, in 
an Infant. 
Ed. O’C., healthy infant, aged 22 months. Taken with chill 
followed by fever, March 29th, 1878. Supposed by family to 
have intermittent fever. Was not seen until 4th day, when 
pneumonia was found developed in lower lobe of right lung, 
crepitant rale being distinct, with dullness on percussion. 
DATE. 
Day of 
Disease. 
Pulse. 
cS 
is 
a P 
P 
V 
H 
a 
*35 
u 
'S. 
s 
Pulse res- 
piration 
ratio. 
REMARKS, 
April 1, A. M' 
4 
192 
10« 
48 
1 * 
4.00 
Warm bath anil quiu. grs. iv. at 
once. 
April 1, P. M. 
4 
160 
102,f> 
52 
1 
3.07 
April 2, A. M. 
5 
160 
103 
56 
1 
2.85 
Repeat bath and quinine. 
April 3, A. \1. 
6 
112 
98 
40 
1 
2.80 
Attendance discontinued. 10 
Average pulse-respiration ratio _L 
Termination by crisis on the 6th day. 
The violence of the symptoms on the 4tli day, as indicated 
by pulse of 192 and temperature of 106°, were such as to create 
serious doubts as to the result; but the prompt effect of the 
warm bath and quinine in alleviating the alarming condition 
was altogether satisfactory. 
The temperature fell 3.5° and the pulse 32 beats per minute 
in six hours, which was not due to the crisis of the disease, the 
temperature rising to 103° the following morning. 
Case VI.—Croupous Pneumonia, affecting whole of Right Lung, 
in a Young Child. 
Louisa H., German parentage, 3£ years old; robust, healthy 
child. Taken sick with chill, followed by fever on the 1st of 
April. Was sent for on the morning of April 2d, on account 
of violent convulsion which had been preceded by vomiting. 
DATE. 
o ® 
ao 
s?s 
Pulse. 
Tempera- 
ture. 
a 
"cS 
— 
’3. 
3C 
V 
X 
Pulse res- 
piration 
ratio. 
TREATMENT AND REMARKS. 
April 
2, A. 
M 
2 
160 
104 
— 
Convulsion and vomiting. Calomel 
grs. i. every 4 hours; also brom. 
potas. grs. v., eo. spt. aeth. gttxv. 
April 
2, P. 
M. 
148 
105.5 
— 
every 4 hours alternately with 
calomel. 
April 
3, A. 
M 
3 
148 
105.7 
Diarrhoea. Stop calomel. Warm 
bath and quin. grs. v. 
April 
3, P. 
M. 
132 
103.5 
1 
2.50 
1 
2.00 
Have been examining lungs at each 
visit, but found no sign of disease 
until now, when pneumonia is 
discovered in the base of right 
lung. Carb. ammon. grs. iv. every 
4 hours. 
April 
4, A. 
M. 
4 
140 
105 
56 
Dr. 8. C. Bnsey in consultation. 
Quin. grs. v. repeated. Syr. sen- 
egae added to carb. amiuon. inixt. 
April 
4, P. 
M. 
128 
103.5 
44 
Beef tea and milk punch for nour- 
ishment. 
April 
5, A. 
M. 
5 
144 
105.8 
76 
1 
1 80 
1 
2315 
Dr. Busey in consultation. Nearly 
whole of right lung hepatized 
Quin, repeated. 
April 
5, P. 
M. 
-• 
132 
103 
56 
Orders left to repeat quin, if fevei in- 
creased, and it was done at 2 A. M. 11 
(CONTJNUKI).) 
rt -H 
® s 
» a 
q 58 
2.2 . 
DATe. 
Pulse 
5*2 a 
3 t * 
i s ® 
H M 
Pulse 
pirat 
ratio 
TREATMENT AND REMARKS. 
April 6, A. M. 
6 
130 
105.304 
1 
l)r. Busey in consultation. 
2.12 
5 o’lock, P. M. 
132 
103.564 
1 
An attack of syncope, apparently 
from cough and dyspnoea. Wliis- 
2.00 
1 
key administered freely. 
9 o’clock P. M, 
128 
104 00 
Has revived. 
2.13 
April 7, A. M. 
7 
132 
103.556 
l 
Dr. Busey in consultation. 
2.35 
April 7, P. M. 
130 
105 00 
1 
2.20 
Repeat quinine. 
April 8, A. M. 
8 
110 
98 .. 
1 
Dr. Busey in consultation. 
April 8, P, M. 
92 
98 32 
2.87 
April 9, A. M. 
9 
120 
101.556 
1 
Headache. 
2 14 
April 10, A. M. 
10 
116 
98.5 .. 
1 
Returning rales in right lung. 
April 11, A. M. 
11 
92 
28 
364 
Average pulse-respiration ratio -i. 
Tlie bowels were loose from the start, sufficiently so to re- 
quire use of starch water and laudanum enemas and bismuth 
powders to cheek the frequency of' the loose watery discharges. 
The pneumonic iutiammation did not develop so as to be recog- 
nized until the evening of the .'hi day, although the lungs were 
carefully examined each visit in consequence of the doubt as 
to the diagnosis. The local disease was confined to the right 
lung, but so crippled the entire lung that death was imminent 
from suffocation from the 5th to the 7th day of the attack. 
The crisis occurred suddenly on the Sth day, with relief of 
all the symptoms except the frequent respiration, which was 
governed by the local disease iu the lung. The effect of the 
quinine was very regular in reducing the temperature from t.5° 
to 2.8° after each administration, this effect lasting about 
twelve hours. In this case tin* administration of the quinine 
was followed each time by quiet sleep of three or four hours— 
with a fall iu pulse and temperature indicated. 12 
Case VII.—Croupous Pneumonia at Base of Left Lung, in a 
Young Child. 
Louis H., aged 5 years, strong, hearty child. Taken sick on 
the night of April 9th with chill. First seen evening of April 
10th, when the crepitant rale was abundant at the base of the 
left lung. 
DATE. 
| Day of 
| Disease. 
Pulse. 
(h 
® ® 
aj= 
S* 
d 
1h 
*P- 
ac 
4. 
Ph 
Pulse-res- 
piration 
ratio. 
TREATMENT AND REMARKS. 
April 10, P. M. 
2 
140 
103.5 
44 
1 
3.18 
Flaxseed poultice to chest. Fever 
mixture of sweer. spirits of uitre 
and spirits uiiudererus. 
April 11, A. M. 
3 
132 
103 
44 
1 
aToo 
April 12, A. M. 
4 
132 
100.3 
40 
l 
3.30 
April 13, A. Al. 
5 
100 
98.5 
32 
1 
3.12 
Resolution of the luug disease 
commenced. 
This case is interesting as illustrating the mild or abortive 
form of croupous pneumonia. The diagnosis was clear, but the 
diseased action in the lung was hardly set up, before it began 
to decline; and, on the 5tli day, when the crisis occurred, he 
was to all appearance well. 
1 had an exactly similar case in the child of Mr. J. H. IS., 
aged 4 years, the notes of which 1 have unfortunately lost. 
The initiatory fever in this latter case however rose to 105.5°, 
but the local disease aborted just as above, and the patient 
was well suddenly. 1 believe that many of the eases of so- 
called u ephemeral ferer ” referred to by the older writers, belong 
to this form of croupous pneumonia. 
Tetmination by crisis on 4th day. 
Average pulse respiration ratio J_ 
Case VIII.—Croupous Pneumonia in Adult in Lower Lobe of 
Left Lung. 
D. P. M., aged 58 years, cabinet maker by trade, slender 
build and rather delicate in appearance. Was taken with chill April 15th, 1878. Had been troubled with a cough for two 
weeks previously. 
DATK. 
Day of 
Disease. 
Pulse. 
Tempera- 
ture. 
~ce 
(H 
’a 
35 
ab c 
£.2 . 
® .2 REMARKS AND TREATMENT. 
.2 S -g 
- a, 
April 
18, A. 
M. 
4 
104 
104 
20 
1 Puwum. of lower lobe of left lung. 
5 20 Quinine grs. xv. 
April 
19, A. 
M. 
5 
88 
102.5 
18 
1 Cough troublesome with pain, left 
side. No rusty sputa. 
April 
20, A. 
M. 
6 
104 
10:1 
18 
1 Repeat quinine. Garb, ammon., grs. 
?k77 v- «ver.V 4 hours. 
April 
21, A. 
M. 
7 
84 
100.5 
Quinine ordered grs. iij 11 times a 
l day. 
Profuse sweating. 
4.25 
April 
22, A. 
M. 
8 
68 
98.7 
16 
April 
25, A. 
M. 
11 
52 
98 
12 
1 
Average pulse respiration ratio, _L 
This patient was very weak and recovered strength slowly. 
The previous history, as indicated by the symptoms of bron- 
chial catarrh preceding the onset of pneumonic inflammation, 
would seem to point to catarrhal pneumonia, but rapid course 
of fever, terminating in eri«i», between the 7tli and 8th day, 
clearly establish the diagnosis of croupous pneumonia. As in 
Case IV, there were present prodromal symptoms for two weeks 
before the iniatitory chill. Defervescence carried the pulse and 
respiration below the normal. 
Case IX.—Cron,pom Pneumonia in an Adult in Lower Lobe 
of Left Lung. 
John D., 45 years of age. Never sick, but not robust. Was 
taken with a chill April 18th, 1878. First saw him April 20th, 
when he was sufering with acute pain in left side, in front, 
painful cough with rusty sputa. Auscultation discovers pneu- 
monia in the lower lobe of the left lung. 14 
DATE. 
Day of 
Disease. 
Pulse. 
Temper- 
ature. 
| Respir’n. 
Pulse-res- 
piration, 
ratio. 
TREATMENT AND REMARKS. 
April 20, A. M. 
3 
120 
103.2 
18 
1 
6.66 
Fever mixt. of sweet spirits nitre 
and liq. am. acet. Cliroral and 
morphia to relieve pain. 
April 21, A. M. 
4 
120 
104.5 
28 
1 
A33 
Quin. gr. xv. at one dose. 
April 22, A. M. 
5 
11G 
103.2 
28 
1 
4.14 
Quin, gr. xv. repeated. Left lobe 
of left lung hepatized. 
April 23, A. M. 
6 
120 
102 
30 
l 
4.00 
Quin. gr. xv. repeated. Carb. am- 
mon. gr. v. every 4 hours. 
April 24, A. M. 
7 
92 
99 
24 
1 
3.83 
1 
5.66 
Diarrhoea. Profuse sweating. Carb. 
ammon. stopped. Quinine gr. iij. 
3 times a day. Beef-tea and milk 
punch. 
April 25, A. M. 
8 
68 
95.5 
12 
Returning crepitation in lung. 
April 28, A. M. 
11 
■' )* 
Patient down-stairs sitting, but 
very weak. Crepitation rale still 
distinct in lower portion of left 
lung. 
Average pulse, respiration, ratio _i_ 
Termination by crisis on the 7th day. On the 8th day the 
temperature fell to 95.5°, with respirations only twelve per min- 
ute. There is a very great similarity between this ease and tin* 
preceding one, the recovery from the lung disease being pro- 
tracted. Defervescence below the normal, both as to tempera- 
ture and respiration. 
Case X.—Croupous Pneumonia in Upper Lobe of Right Lung 
in a Young Child. 
Samuel S., aged 3 years, robust, healthy child. Had attack 
of spasmodic croup May 24th. Was taken with chill, followed 
by fever, quick breathing and Hushed face May 26th, 1878. 15 
DATK. 
O x • 
. CB © 
£ " J£ 
73 X V* 
aia £ 
Tempera- 
ture. 
a 
*08 
— 
*5. 
X 
- 
M 
Pulse res- 
piration 
ratio. 
REMARKS. 
May 27, A. M. 
2 148 
103.8 
44 
1 
3.36 
Warm bath ordered. 
May 27, P. M. 
.. 132 
101.5 
44 
1 
3.00 
Pneumonia of upper lobe right 
lung. 
May 28, A. M. 
3 148 
102 
52 
1 
2^84 
May 29, A. M. 
4 152 
104.5 
72 
1 
‘ZTo 
Wet towel around chest renewed 
every two hours ; carb. ammonia 
mixture. 
May 29, 9 P. M. 
.. |132 
102 
56 
l 
235 
May 30, A. M. 
5 120 
101.7 
40 
1 
3.00 
May 31, A. M. 
6 120 
101.7 
40 
1 
33)0 
June 1. 
7 104 
99 
40 
1 
2.60 
Resolution of lung disease prompt 
and complete. 
Average pulse respiration ratio -L 
Tennination by crisis on the 7th day. 
Attention is called to the application of the wet towel in in- 
fants as a substitute for bathing. This child struggled and fought 
so against the bath that it was deemed unwise to persevere in its 
use, the excitement attending its administration antagonizing 
its good effects. A large towel was folded lengthwise, dipped 
in water at temperature of 80° and wrapped around, the chest 
being covered with dry flannel. This was changed every two 
hours, with tin* most satisfactory effect. The child does not 
rebel against this treatment, it is quickly done, and in my ex- 
perience, is a most valuable aid in reducing temperature in 
infants. 
When we bear in mind that in early life the limbs bear a 
much smaller proportion to the body than in adults, and that in 
children the intensity of fever is greatest in the body and head, 
the value of this mode of application becomes apparent, and 
when conjoined with cold applications to the head, fulfills the 
whole indication of the antipyretic use of M ater. I am speaking 16 
only of young children, and in them this has been a favorite 
method of controlling fever for several years. Of course, where 
the fever is the more intense, the wet towel must be changed 
the more frequently. 
Case XI.—Croupous Pneumonia, occurring during the incubation 
of Measles and followed immediately by that disease.—Pneu- 
monia in middle lobe of right Lung. 
W., aged 3 years, girl, healthy child. Has been exposed to 
contagion of measles for a week, another child being down sick 
with it in the same house. Has had fever every other day for 
several days, and a teasing cough. 
Was taken June 1st, in the morning, with a chill, and about 
noon had a violent convulsion. 
a 
? a 
U . 
'a 
g.S 
DATE. 
w ao 
& 
£ 
» .2 
tkkatmkst and kkmakks. 
a go 
Qq 
ao 
'B 
Ph 
3 = 
V 
H 
So" 
« 
£ 2 +3 
a -S g 
P-l 
Jane 1, 1876... 
1 
Convulsion following chill. — 
Brom. potas. grs. vi., elix. val. 
amrnon. £3b every 3 hours for 3 
doses. Rested well all night. 
June 2, 12 M. 
2 
224 
Capillary congestion almost as dark 
as scailatina. Cincho. quin. grs. 
iij. every 6 hours; spts. aeth. nit. 
June 2, 4 P. M. 
200 
104 
- - - - 
and liq. ammon. acet. for febri- 
fuge; occasional doses o: bromide 
with tr. opium gtt. iij. 
June 3, 9 A. M. 
3 
180 
105 
.... 
June 3, 12 M. 
103.3 
June 4, 2 A. M. 
4 
180 
104.3 
.... 
Quinine grs. iij. 
June 4, 8 A M. 
144 
101.4 
Irritating cough of most distressing 
character and almost continual; 
child greatly exhausted; percus- 
June 4, 10 A. M. 
.. 
160 
100 
.... 
sion dull over middle lobe of right 
lung, which also gives crepital 
rale on auscultation. Ordered tr. 
opii deod gtt. iv. every 4 hours 
until spasmodic cough is relieved. 
June 4, 5 P. M. 
154 
105 
Cincho quin. grs. iij.; carb. ammon. 
andsyr. senegaein emulsion; soap 
liniment freely to chest. 
June 5, 5 A. M. 
5 
140 
99-5 
T * 
Cough still distressing, no appetite. 
June 5, 12 M. 
-- 
136 
98.3 
30 
Occasional doses of opium as re- 
quired; beef tea and milk punch 
4.53 
ad libitum. 
June 5, 5 P. M. 
99.6 
36 
Dr. C. E. Danner in consultation. 
J une 6, 8 A. M. 
6 
134 
98.4 
40 
1 
3.35 
Dr. H. in consultation. '1 reatment 
continued. 
June 6, 8 P. M. 
150 
103 
44 
l 
Eruption of measles beginning to ap- 
3 40 
pear. Resolution taking place in 
lung. 17 
DATE. 
Day of 
Disease. 
Pulse. 
E 
8.8 
a 5 
H 
| u^jidsdjj 
Pulse res- 
piration 
ratio. 
TREATMENT AND REMARKS. 
June 7, 6 A. M. 
7 
120 
100 
30 
1 
4.00 
Dr. H. in consultation. 
June 7, 10 P. M. 
•• 
160 
103.2 
60 
1 
2-66 
Warm bath. 
June 8, 1 A. M. 
8 
160 
103.2 
70 
1 
2.28 
Quinine grs. iij. 
June 8, 8 A. M. 
144 
102 
66 
1 
2.18 
June 8, 6 P. M* 
164 
104 
72 
1 
2 -25 
Collapse in middle lobe of right 
lung. 
June 8, 8 P. M. 
•• 
170 
105.2 
70 
1 
2.42 
Quinine grs. v; carb. ammon. mixt. 
and stimulants freely. 
June 9, 2 A. M. 
9 
144 
102.460 
1 
:M0 
June 9, 6 A. M. 
128 
99.6 
54 
1 
2.37 
Oiled silk shirt. 
June 9, 8 P. M. 
144 
101 
36 
_L 
4.00 
Sulph. quin. grs. v. 
June 10....... 
10 
120 
98.236 
1 
3.33 
Eruption fading; appetite return- 
ing. Phosphat. emulsion of cod- 
liver oil. 
(COKTUCUED.) 
Pulse-respiration ratio j-L 
Crisis occurred on the 5th day of the pneumonia. On the 6th 
day from the initiatory chill the eruption of measles begun to 
appear, with an increase of temperature to 103°. On the 8th 
day collapse of that portion of the lung affected by the pneu- 
monia occurred, with sudden aggravation of all the symptoms. 
The most noticeable effect of the rubeola poison in the system 
was the intense irritative cough—the regular measles cough— 
so greatly aggravated that the father, who is a physician and 
watched the case most carefully, thought several times that she 
must die from exhaustion. This cough was relieved by full 
doses of opium and gradually disappeared as the eruption 
faded. The collapse of the lung was the only other symptom 
which could be ascribed to the complication of the two diseases, 
each disease with these two exceptions—of the intense irrita- 
tive cough and the collapse—running a normal course as though 
the patient had but the one at a time. 1 must confess that 1 
watched the development of the measles with great anxiety, 18 
fearing and expecting the occurrence of an acute catarrhal 
pneumonia which would have proved quickly fatal in the weak- 
ened condition of the little patient. 
The collapse of the lung rapidly disappeared under the free 
administration of tonics and stimulants. 
The subsequent progress of this case was entirely favorable, 
and at this date (July, 1878), no trace of the severe illness re- 
mains, except a slight roughness of voice. 
The following tables present in a condensed form an analysis 
of the more prominent symptoms occurring in the foregoing 
cases: 
CASE. 
6 
5C 
< 
Average 
Pulse. * 
Average 
Temp * 
| Average 
1 Pulse 
Resp’n 
| Ratio. 
ONSET OF DISEASE. 
POKTION OF LUNGS 
AFFECTED. 
1 
48 
F 
99 
103.3 
1 
T87~ 
1 
Sudden ; ushered 
in by chill. 
Lower lobe right lung 
principally; left lobe 
of lelt lung slightly. 
11 
37 
M 
105 
103.4 
2330 
1 
2.80 
Not sudden ; chill, 
a f t e r w h i c h 
worked 4 days 
before takiug ti 
bed. 
Lower lobe of left lung 
and middle and low- 
er lobe of right lung. 
III 
3 
M 
133 
102 0 
Sudden ; if chill 
did i ot know. 
Lower lobe right lung. 
IV 
30 
M 
100 
103.4 
1 
3.25 
1 
3.18 
Prodromal symp- 
toms for 2 weeks; 
slight chill at 
onset. 
Whole of right lung. 
V 
22$ 
M 
17u 
103.8 t 
Sudd, li ; chill. 
Lower lobe right lung. 
VI 
3* 
F 
123 
104.3 
1 
2.43 
1 
3.12 
Sudden; chill ush- 
ered in by con- 
vulsions. 
Whole of right lung. 
VII 
5 
M 
135 
102.3 
Sudden ; chill. 
Lower lobe left lung. 
VIII 
58 
M 
95 
102.5 
1 
4.88 
Chill ; prodouiata 
for 2 weeks. 
Lower lobe left lung. 
IX 
45 
M 
119 
103.2 i 
1 
iT7 
Sudden; chill. 
Lower lobe left lung. 
X 
3 
M 
130 
102.4 
1 
2.78 
1 
2.83 
Sudden ; chill, pre- 
ceded by spas- 
modic croup. 
Upper lobe right lung. 
XI 
3 
F 
178 
103.3 
Chill; convulsiouB, 
preceded by a 
remittent fever; 
sudden. 
Middle lobe of right 
lung. 
* Average pulse and temperature are estimated to time of beginning defervescence. 
§ Months. 
f On the 4th day of case V the temperature arose to 106°, the highest observed in any 
Of the cases. 
{ In case IX, on the 8th day, the temperature fell to 95.5°. 19 
CASK. 
FAIN. 
COUGH. 
SPUTA. 
TKKMINATION. 
I 
Right Hide in 
front. Not 
severe. 
Neither f r e - 
quent nor 
distressing. 
Not significant 
By crisis on Hth day, 
defervescence 1 a s t - 
ing 48 hours. Profuse 
sweating. Recovery 
prompt. 
11 
Very severe in 
cardiac re- 
Kiou. 
Very frequent 
aud suppres- 
sed on ac- 
count of 
pain. 
Rusty, abun- 
dant. 
By lysis; defervescence 
began on Utth day, 
and was not complei e 
until lfith day, a pe- 
riod of 6 days. Pro- 
fuse sweating. 
111 
Unable to lo- 
cate it on ac- 
count of age. 
Insignificant. 
Not seen. 
By lysis from 5th to 8th 
day, occupying 72 
hours. 
IV 
Severe, but 
marked b y 
dyepmea. 
Very haras- 
sing, of irri- 
table char- 
acter. 
“ Prune juice” 
in character. 
Very abun- 
dant. 
Death on 9th day from 
asphyxia. 
V 
Not noticed. 
Insignificant. 
Not seen. 
By crisis on 6th day. 
Defervescence less 
than 24 hours. 
VI 
Not noticed. 
Troublesome. 
Not seen. 
By crisis on 7th day. 
Defervescence less 
than 24 hours. 
Vll 
None. 
Insignificant. 
Not Heen, 
By crisis on 4th day. 
Defervescence less 
than 24 hours. 
VIII 
Pain in left 
Hide anter- 
iorly. 
Trouble some 
from giving 
pain. 
Not rusty. 
By crisis on 7th day. 
Defervescence less 
than 24 hours. Pro- 
fuse sweating. 
IX 
Pain severe iu 
left Bide an- 
teriorly. 
Painful cough 
liusty. 
By crisis on 7th day, 
Defervescense less 
than 24 hours. Pro- 
fuse sweating. 
X 
Not noticed 
Insignificant. 
Not seen. 
By crisis on 7th day. 
Defervescence less 
than 24 hours. 
XI 
Not noticed. 
Cough parox- 
ysmal, ii imi- 
tative. most 
haras sing 
and exhaust- 
ing. Consti- 
tuted a dan- 
gerous ele- 
ment iu the 
disease. 
Not seen. 
By crisis on 5th day. 
Defervescence less 
than 24 hours. 
Au examination of these tables of summary of symptoms 
shows: 
1st. As to age, that six of these eases were between tin* ages 
of one and tive years. Five eases were adults between ages of 
thirty-seven and fifty-eight years. There was no case between 
the age of tive and thirty-seven years. 20 
2d. As to sex, eight were males and three females, or a per- 
centage of males of 72.7 to 27.2 of females. 
3d. Pulse.—The average pulse during the febrile stage for 
the adults was 105, while the same for the children was 145 
beats per minute. 
Nothing peculiar was noticed as to pulse, except that in the 
asthenic cases it was slower than in the sthenic cases, whereas 
it might naturally have been expected to be more rapid from 
the enfeebled state of the patient. The pulse kept pace very 
regularly with the temperature curve. 
4th. Temperature.—The average temperature for the eleven 
cases to the commencement of defervescence was 103.1°, the 
highest recorded being 100° in an infant of twenty-two months, 
and the lowest 95.5° in Case IX, where the crisis oscillated the 
temperature to three degrees below the normal without appar- 
ent detriment to the patient. The typical morning depression 
and evening rise in temperature were interfered with by th6 anti- 
pyretic treatment and hence do not show in the record. 
5th. Pulse-Respiration Ratio.—In the normal state of health 
the relation between the pulse and respiration is that of 1 to 4£, 
the pulse being taken at 72 per minute and respiration at 16, 
for an adult. About the same proportion exists in children, 
both being increased in the same ratio according to age. 
The same thing is true in regard to febrile diseases which 
quicken the heart beats and breathing. The relative proportion 
is maintained as long as there is found at the same time no 
morbid condition of the thoracic, viscera, but as soon as heart or 
lungs become implicated by diseased processes, the normal 
pulse-respiration ratio of one to four and a half is destroyed, and 
in the case of lung disease, other things being equal, the degree 
of variation becomes an accurate measure of extent to which the 
lung tissue is implicated. 
It is, therefore, a most valuable factor in the early diagnosis 
of the form of lung inti ami nation at present under considera- 
tion, especially because, being an infectious fever, ah initio, the 
local lesion does not become apparent in many cases for two or 
three days (as in Case Vi of this report) and the symptoms may 
all be referable with equal propriety to any of several of the 
zymotic fevers. 21 
While, however, other symptoms fail to furnish any differen- 
tial elm* as to the previse nature of the fever, which we are 
alumt to be called upon to battle with, if the ratio between the 
pulse and respiration is augmented to any marked degree, we 
may be sure that in a very short time there will be found tin* 
crepitant rale, and dullness on percussion over some portion of 
the chest. 
We have above an average* pulse respiration ratio in the 
whole number of eases of J_, but it would be more exact as ex- 
3.33 7 
expressing tin* true ratio existing between tin* pulse and resin- 
ration, in typical cases running a regular course, if we exclude 
eases VIII and IX, which are exceptional in presenting a pulse- 
respiration ratio less than normal, being rerjactively -i.and J_ 
Leaving out of account these two cases, we have from those 
remaining an average J_, which probably expresses very nearly 
the true ratio existing between these prominent symptoms in 
croupous pneumonia. 
(ith. The onset of the disease.—An examination of the above 
table will show that the attack was ushered in suddenly by a 
chill in eight of tin* cases, and in two (VI and XT) in children, 
the succeeding fever was accompanied by convulsions. 
In three cases, tin* commencement was gradual, in two of 
which (IV and VIII) then* were decided prodromal symptoms 
for two weeks. 
A chill was present in all the eases, except the third, and in 
that it was not observed, although from the age (3 years) of the 
child, it might easily have been overlooked. 
7th. The hnuj or part of lun</ affected.—The whole of the 
right lung was involved in two cases, one of which proved 
fatal. 
Upper lobe of right lung attacked 3 times. 
Middle lobe of right lung attacked 4 “ 
Lower lobe of right lung attacked (> u 
Total 13 u 
Upper lobe of left lung attacked 0 times. 
Lower lobe of left lung attacked 5 “ 
Total 5 “ 22 
In several instances more than one lobe was inflamed in indi* 
vidual cases, so that the whole number of lobes attacked in the 
eleven cases was eighteen. Marked preference is shown for 
the lower lobes, they being singled out in eleven out of the 
eighteen times. 
Both lungs were affected in two cases. The right lung was 
involved eight times, and the left lung tive times, giving a pro- 
portion between the two of eight to tive, which corresponds 
very nearly with the statistics of the latest authorities. 
8th. Pain.—In none of the cases occurring in children, was 
pain in the chest observed, and if present in any degree was 
certainly not severe, and could not be located. 
In all the severe cases in adults, pain was a prominent symp- 
tom, and a cause of much suffering. 
In every case where present, it was felt in front to one side or 
the other of the median line, according to the lung affected, while 
the pneumonic inflammation invariably approached nearer the 
surface—posteriorly. 
9th. Cough.—Nothing peculiar to the disease under consid- 
eration appeared in the cough. It was present in all the cases, 
but in those unattended by severe pain from the pleuritic com- 
plication, it was insignificant. Where pain was marked, the 
cough became the most distressing, by aggravating a torment, 
which was quiescent as long as the patient remained undis- 
turbed. In the fatal case, the cough was peculiarly harrassiug, 
being almost constant, of a hacking character, and only absent 
from the influence of narcotics. 
In the 11th case, the character of the cough was evidently 
influenced by the measles complication, and was of so serious 
a nature, that dangerous exhaustion resulted. 
10th. Sputa.—Children under the age of five years very rarely 
expectorate, and in the six infantile cases no sputum was seen, 
although in some it was evidently abundant from the loose 
cough, and was swallowed. Of the five adults it was colored 
by blood in three cases, and not so in two. 
In case IV, it was abundant, like “prune juice,” ami in the 
result verified the unfavorable prognosis of older writers from 
the presence of this symptom. 
11th. Termination.—Termination was by crisis in eight cases; 23 
by lysis in two, and death one. The crisis occurred in the first 
set as follows: 
In 1 case on the fourth day. 
In 1 case on the fifth day. 
In 1 case on the sixth day. 
In 4 cases on the seventh day. 
In 1 case on the eighth day. 
In the second set of two cases, terminating by lysis, the 
defervescence began in one on the oth day and was complete 
on the 8th ; and in the other case did not commence until the 
10th day and was not complete until the lOtli. 
The exact time occupied by defervescence, where less than 
twenty-four hours, could not be determined, on account of suffi- 
ciently frequent daily visits not being made; nor, for the same 
reason, could tin* hour of the day when defervescence began 
be definitely fixed, but according to the reports of the nurses 
the improvement began shortly after the morning visit (11, 
A. M.), and continued through the night, taking the place of 
the usual evening exacerbation. 
In seven cases, the time occupied in the reduction of temper- 
ature to the normal degree was lest than twenty-four hours; in 
one case it was forty-eight hours; in one, seventy-two hours, 
and in one six days. 
Profuse sweating accompanied the defervescence in four 
cases, which were also the most severe. 
It will appear from the above record that the crisis may occur 
anywhere from the 4th to the 10th day, the 7th day being the 
one on which it most frequently takes place; also that the time 
of defervescence in a particular case is influenced by its severity, 
being earlier in mild eases and retarded in the graver forms. 
.Jurgensen (Ziemsen’s Cyclop., vol. v., p. 54) gives a table of 
721 eases, terminating all the way from the 2d day (eight 
rases) to the 18th day (two eases), of which 1 <»."» came to an end 
on the 7th day. 
The eases above reported are susceptible of division into 
two groups, viz: sthenic and asthenic. In the former group 
are eight eases, including all the infants, which present no pecu- 
liarities, but are typical cases of croupous pneumonia. 
In the latter group, the asthenic, are three eases (IV, VIII, IX) 24 
which differ from the former in several important respects 
worthy of especial notice. Two cases (IV and VIII) were pre- 
ceded for two weeks by prodromata of bronchial catarrh and 
malaise, which statistics show to be not common in this form of 
pneumonia. 
In all three the pulse, temperature and respiration were very 
low, considering the gravity of the cases. In Case IV the 
pulse ranged from 9(5 to 120, the latter rate being but a few 
hours previous to death, when the the temperature was but 
103° and respiration 40. 
In Cases VIII and IX, the average pulse respiration ratio is 
2L and — respectively, being in both less than that of health. 
In Case VIII, defervescence carried the pulse down to 52 
and respiration down to 12 per minute, and in Case IX the 
temperature fell to 95.5° and respiration to 12—all below 
normal. 
A report of this character does not allow space for a full 
discussion of the question of diagnosis which might be opened 
by the consideration of these latter three cases, but it is clearly 
suggested, from a clinical point of view, that eases do con- 
tinually occur where the diagnosis between croupous and 
catarrhal pneumonia will hinge upon the termination by crisis 
or lysis—about the usual time for such termination in the 
natural history of the former disease. 
In Cases VIII and IX the termination was by crisis on the 
7th day. In case IV death on the 9th day, but the history and 
symptoms so closely parallel the other cases that the diagnosis 
is not in doubt, and could life have been prolonged a day or 
two longer, there was every reasonable hope that the crisis 
would have taken place. 
As to the preceding bronchial catarrh, whether that was a 
true prodroma or merely an ante hoc, is an open question—for 
there is no reason why croupous pneumonia should not be 
developed during the existence of a bronchitis, the same as 
though the latter did not exist, or just as in case XI it made its 
attack during the forming stage of measles. 
Treatment.—It is of the utmost importance in connection with 
the treatment of croupous pneumonia, to take into considera- 
tion its natural history. It is an intensely febrile disease, self- 25 
limited—running its course more rapidly perhaps than any 
other zymotic disease, and terminating with abrupt suddenness 
about the seventh day. 
This order of sequence in the symptoms we may confidently 
predict under any plan of treatment not absolutely injurious, 
for the prognosis is in healthy subjects most favorable, being 
even more so in children than in adults. 
It is a disease in which the physician can well afford to bide 
his time, and bear out the old rule, which I had firmly impres- 
sed upon me, when a student, by my venerable preceptor, the 
late Dr. Joshua Riley,—“To be sure if you can do no good, at 
least to do no harm.” 
There is no malady in the catagory of medicine, which yields 
to the medical attendant so much honor from the patient and 
his friends as the one under consideration, because in the very 
height of severe illness, the fever often reaching its maximum 
just before tin* crisis, the sick man is suddenly well, and of 
course the doctor and his last remedy get the credit for the 
cure. 
Nor is it unfrequently the case that the physician himself is 
deceived, taking the post hoc for the propter hoc, and thinking 
that lie has found a specific remedy. Happily this multiplica- 
tion of specific remedies has received a check by the attention 
now given to the study of the natural history of disease, and 
tendency is to reduce rather than add to the already cumber- 
some materia medica by interposing a more correct knowedge 
of what would be the symptoms, course and termination in 
typical cases unintiuenced by drugs. 
With regard to the disease which is tin* subject of this paper, 
this has of late years been very (dearly set forth, and the duty 
of the medical attendant in tin* premises is very much simplified. 
It is to guide the case, guard against excessive fever, support 
the strength and watch for complications, in other words anti- 
pyretic and supporting. The danger to be apprehended is prin- 
cipally two fold, indirectly from cardiac debility due to intense 
fever and lung obstruction, and directly from tin* extent of the. 
lung disease. 
The high temperature is to be combatted by baths and qui- 
nine. A reference to the temperature record of the above cases 26 
shows characteristically the effect of this treatment upon the 
fever heat, but it does not and cannot express the great relief 
accompanying it to the patient, of distressing symptoms. I 
have never used cold baths in this disease, but have prepared 
water at a temperature of 90° and reduced it ten degrees during 
the fifteen minutes occupied in administering it. 
Not that I believe any risk would be run by making the bath 
cold, but experience goes to show that quite as great reduction 
of temperature is obtained from the above graduated bath, with 
certainly greater comfort to the patient, and less violence to the 
prejudices of friends. 
If we consider for a moment the modus operandi by which 
the bath is ail effective measure in reducing temperature, I 
think we will be disposed to admit that the warm bath should 
have the preference. 
The siin is the organ by which the balance of temperature is 
preserved between the internal structures and external surface, 
and through the agency of the blood. A very great extent of 
surface in the capillary vessels of the skin, is exposed to the 
cooling influence of the external air with every pulsation of 
the heart, and the extent to which the surplus heat of body 
combustion is got rid of, is exactly in proportion to the amount 
of blood so exposed to the air in the skin, and the condition of 
the skin at the time. 
The application of cold contracts the capillaries of tin* skin, 
and drives the blood away from the surface towards the inter- 
nal organs. 
This is the effect of a cold bath, and although the reduction 
of temperature in the blood still remaining in tlie skin is 
greater than from a tepid bath, still the aggregate effect will 
be less. 
The warm bath relaxes the skin and invites blood to the sur- 
face, while the difference in temperature between water at 90° 
and fever heat (104° or upwards) is quite sufficient to give a 
decided clinical result. 
In addition, the absence of shock and greater feeling of com- 
fort to the patient is an advantage of the warm bath not to be 
overlooked. 
In some of these cases, where the convenience of a bath tub 27 
was not to be had, a common washing tub was used, the patient 
sitting in it, covered over tin* shoulders with a blanket, and 
this was found to be an efficient substitute. 
Whenever the patient became prostrated from the fever, or 
oppressed by tin* dyspnoea, the baths were discontinued and 
quinine relied on as an antipyretic. In children, if the baths 
were the occasion of struggling and screaming, they were not 
insisted on, the wet towel* and quinine being resorted to. 
The dose of quinine given to adults was from grs. xv to grs. 
xx, and was found to be sufficient. 
The reduction in temperature varied in different cases from 
1.3° to 4.7°, and lasted about fourteen hours from the time of 
administration. A dose given at mid-day would show decided 
effect in three hours, reach its maximum at b o’clock, P. M., 
and the temperature would begin to rise about 11 o’clock, A. M. 
In the severer cases tin* temperature would be again the 
following morning as high as before its administration. In the 
milder cases the fever did not appear to rise as high any more 
after tin* tirst dose of quinine. 
In some of the cases, especially marked in Case VI, it pro- 
duced a decided hypnotic effect, every full dose being fol- 
lowed by quiet sleep. 
Dr. S. C. Bussey, who was in consultation in this case, said 
he had frequently noticed the same effect. He had had his 
attention first called to it by Dr. ,Jas. C. Hall, of this city, a 
most acute observer, who had been in the habit for years of giv- 
ing quinine at bedtime, with the double purpose of promoting 
sleep and at the same time avoiding the annoyance of noises 
in head occasioned by this agent. 
Stimulants were administered as required. Carbonate of 
ammonia as a special cardiac stimulant where the respiration 
was embarrassed. 
Milk and beef tea were relied on for nourishment. 
Season of the Year. All the cases here reported occurred 
between the months of February and June inclusive, and eight 
out of tin* eleven were attended in March and April, four for 
each month. 
Se*> Case X. 28 
One case was noted in February, one in May, and one in 
June, the latter having its onset on the first day of the month. 
From the occurrence of the last ease to the present date 
(September 10th) I have seen but one ease, a child three years 
of age, who was taken sick August 28th. 
By courtesy of the Health Officer of the District of Columbia, 
Dr. Smith Townshend, I am enabled to append a report of 1915 
deaths from pneumonia during a period of six years and 
eight months, from January 1st, 1872, to July 31st, 1878. 
DISTRICT OF COLUMBIA, BOARD OF HEALTH. 
OFFICE OF HEALTH OFFICER. 
Washington, August 10th, 1878. 
Dr. I). IF. Prentiss, 1224 Ninth Street N. IF. 
Sir—In reply to your letter of the 2d inst., I transmit here- 
with table showing number of deaths from pneumonia in flu* 
District of Columbia from January 1, 1872, to August 1, 1878. 
Prior to August, 1874, there was no law requiring physicians 
to furnish certificates of deaths to the Health Department, and 
no permits for burials were required, hence the “table” is not 
reliable prior to that date, although it contains every case 
reported to the Health department to that date. Begretting 
my inability to furnish more complete information, 
I remain, very respectfully, 
Smith Townsiiend, M.D., 
Health Officer. 
Statement of Deaths from Pneumonia in the District of Columbia, January 1st, 
1872, to July 3lsf, 1878. 
YEARS 
January. 
February. 
March. 
April. 
May. 
June. 
July. 
August. 
September. 
October. 
November. 
December. 
TOTAL. 
1872 
12 
21 
20 
22 
17 
11 
1 
9 
3 
10 
9 
16 
151 
1873 
27 
14 
13 
13 
6 
6 
2 
4 
5 
7 
13 
110 
1874 
22 
14 
26 
19 
19 
2 
6 
*18 
9 
20 
18 
40 
213 
1875 
81 
69 
87 
47 
19 
17 
4 
14 
14 
24 
28 
42 
44(1 
1876 
51 
52 
78 
66 
41 
8 
7 
11 
14 
16 
22 
31 
397 
1877 
58 
61 
54 
33 
25 
18 
6 
7 
5 
13 
21 
26 
327 
48 
40 
45 
34 
49 
35 
20 
.271 
1 1 
Totals. 
299 
271 
323 
234 
176 
91 
50 
61 
49 
88 
105 
168 
1915 
'Absolutely correct Horn August 1874. to iiud including July, 1878. Prior to August 
’74, the records were very incomplete. Physicians not being required to make returns 
We have no records prior to 1872. This statement would appear at first sight to indicate an 
extraordinary mortality for this disease in the District of Co- 
lumbia; and such would be the fact, were they all cases of 
croupous pneumonia. It includes, however, all the forms of 
pneumonia—catarrhal pneumonia especially of old persons and 
young children, of invalids and consumptives, and not unlikely 
many cases of capillary bronchitis and pulmonary collapse. The 
statistical value therefore, in a mortuary sense, is lost, but the 
relative value as to frequency of occurrence at certain seasons 
of the year remains but little impaired. 
Thus during the four months from January to April, inclu- 
sive, there are deaths to 788 for the remaining eight 
months, and for the six months from December to May, inclu- 
sive, there are 1471 cases against but 444 for the other six 
months, showing it to be a disease of winter and spring months.