PRACTICAL REFLECTIONS 
ON THE 
NATURE AND TREATMENT 
OF 
CROUP. 
BY 
J. H. HOBART BURGE, M. IX, 
StTBGEON TO THE IX)NO ISLAND COLLEGE HOSPITAL, BROOKLYN, N. T 
[REPRINTED FROM THE NEW YORK MEDICAL JOURNAL, JULY, 1870.] 
NEW YORK: 
D. APPLETON & COMPANY, 
90, 92 & 94 GRAND STREET. 
1870. Maudsley on the Mind. 
The Physiology and Pathology of the Mind. By IIenry Mauds- 
ley, M. D., Physician to the West London Hospital. 8vo, 
pp. xv-442 (tinted paper). . . . Cloth, $4.00 
Dr. Maudsley’s aim in the preparation of this volume has been to treat of menta. 
phenomena from a physiological rather than, as has hitherto been the habit, from a 
metaphysical point of view, and in his history of the inductive method, as applied 
to the interrogation of the mind, he shows conclusively that self-consciousness—the 
favorite resort of the schoolmen—is inadequate, contradictory, and unreliable. N* 
book of the present day, devoted to the study of the mind, has attracted more atten 
tion or caused more comment than this. It is one of those works which mark the 
beginning of a new era in the study of mental science, and at the same time it is 
conceded on all sides to be, in its practical portions, a most reliable guide for the 
diagnosis, description, and treatment of insanity. 
“Dr. Mandsley has had the courage to undertake, and the skill to execute, what is, at 
least, in English, an original enterprise. This book is a manual of mental science in all its 
parts, embracing all that is known in the existing state of physiology. * * * Many and 
valuable books have been written by English physicians on insanity, idiocy, and all the 
forms of mental aberration. But derangement had always been treated as a distinct subject, 
and therefore empirically. That the phenomena of sound and unsound minds are not mat- 
ters of distinct investigation, but inseparable parts of one and the same inquiry, seems a 
.ruism as soon as stated. But strange to say, they had always been pursued separately, and 
oeen in the hands of two distinct classes of investigators. The logicians and metaphysicians 
jccasionally borrowed a stray fact from the abundant cases compiled by the medical author- 
ties ; but the physician on the other hand had no theoretical clew to his observations be- 
yond a smat tering of dogmatic psychology learned at college. To eifect a reconciliation be- 
tween the Psychology and the Pathoiogy of the mind, or rather to construct a basis for both 
in a common science, is the aim of Dr. Maudsley’s book.”—London Sat. Rev., May 25,1867. 
“ The first chapter is devoted to the consideration of the causes of insanity. It would bo 
well, we think, if this chapter were published in a separate form and scattered broadcast 
throughout the land. It is so full of sensible reflections and sound truths, that their wide 
dissemination could not but be of benefit to all thinking persons. In taking leave of Dr. 
Maudsley’s volume, we desire again to express our gratification with the result of his labors, 
and to express the nope that he nas not yet ceased his studies in the important field which 
he has selected. Our thanks are also due to the American publishers for the very handsome 
manner in which they have reprinted a work which is certain to do crodit to a house already 
noted for its valuable publications.”—guar. Journal qf Psychological Medicine and Medical 
Jurisprudence. j. 
“Then follow chapters on the diagnosis, prognosis, and treatment of insanity, each 
characterized by the same bold and brilliant thought, the same charming style of composi- 
tion, and the same sterling sense that we have found ail through., We lay down ttie book 
with admiration, and we commend it most earnestly to our readers’ as a work of extraordi- 
nary merit and originality—one of those productions that are evolved only occasionally in 
the lapse of years, and that serve to mark actual and very decided advances in knowledge 
and science.”—N. Y. Medical Journal, January, 1868. 
“ This work of Dr. Maudsley’s is unquestionably one of the ablest and most important, 
on the subjects of which it treats, that has ever appeared, and does infinite credit to his 
philosophical acumen and accurate observation. No one has more successfully exhibited the 
discordant results of metaphysical, physiological, and pathological studies of the mind, or 
demonstrated more satisfactorily the uselessness of an exclusive method, or the pressing 
need of combined action, and of a more philosophical mode of proceeding.”—Medical 
Record, Nov. 15, 1867. 
“In the recital of the causes of insanity, as found in peculiarities of civilization, or relig- 
ion, sex, condition, and particularly in the engrossing pursuit of wealth, this calm scientiflo 
work has the solemnity of a hundred sermons ; and after going down into this exploration 
of the mysteries of our being, we shall come up into active life again chastened, thoughtful, 
and feeling, perhaps, as we never felt before, how fearfully aud wonderfully we are made.”- 
Evening Gazette. 
“Dr. Mandsley’s treatise is a valuable work, and deserves the careftil Consideration oi aD 
who feel an interest, not only in general metaphysical facts, but in those manifestation* 
which mark the boundaries between health and disease in the human mind.”—Providenet 
Ut. J.) Journal. PRACTICAL REFLECTIONS 
ON TIIE 
NATURE AND TREATMENT 
or 
C E O U P. 
BY 
J. H. HOBART BURGE, M. D., 
SURGEON TO THE LONG ISLAND COLLEGE HOSPITAL, BROOKLYN, N. T. 
[REPRINTED FROM THE NEW YORK MEDICAL JOURNAL, jrZU 1870.] 
NEW YORK: 
D. APPLETON & COMPANY, 
90, 92 k 94 GRAND STREET. 
1870. PRACTICAL REFLECTION'S 
OF THE 
NATURE AND TREATMENT 
OF 
crou p: 
Croup was doubtless known to Hippocrates, but we find 
no clear description of it earlier than that of Blair in Scotland, 
1718. Home, of Edinburgh, also gives it a distinct place in 
the family of diseases in 1765. After which time it is found 
under a great variety of names in nearly all works on general 
practice; and many monographs of more or less merit have 
appeared from time to time. 
Of all the titles given to this disease I prefer laryngo- 
tracheitis, as expressive of the fact that it is an inflamma- 
tion of the larynx and trachea. In this I but conform to the 
1 Read before the King’s County Medical Society, November 10, 1869. 4 
PRACTICAL REFLECTIONS ON THE 
view of Cullen, Home, Dickson, Peaslee, Condie, and a host 
of others. 
This opens at once the question, What is essential to an 
attack of croup ? and, if I were to pause for a reply, the an- 
swers which would he given, by the different members of any 
medical society of this size, would sufficiently indicate the 
necessity of a thorough discussion of the subject, and a better 
understanding of each other’s views. 
Never shall I forget the confusion of sentiment and expres- 
sion which existed at a session of the New York State Medical 
Society seven years ago, when this subject was introduced, in 
connection, I think, with a paper by Dr. Bissell, of Utica, on 
diphtheria. I am sure a majority of those present felt a pain- 
ful sense of the ludicrous. Just such a scene occurred in this 
society several years ago, when a creditable paper was read by 
Dr. Crane. 
Some insist upon several varieties, and so call every attack 
croup, which has for its main feature dyspnoea or threatening 
suffocation, which dyspnoea depends on obstruction in or of 
the larynx. Others restrict the title croup to those cases in 
which a false membrane exists. At first sight this would only 
seem to create a war of words—a confusion in our means of 
communicating our views to each other. 
This, however, does not constitute the main difficulty ; for 
the question is one of pathology and not of terminology. 
One class of medical men hold that membranous croup is 
a distinct and fearfully-fatal disease, having no connection 
whatever with the other varieties so called; while another 
class contend that these varieties are only different grades and 
states of the same affection. Of two medical men equally 
well informed, one tells us that, while membranous croup is 
almost always fatal, the spasmodic and simply inflammatory 
will almost as surely recover even without treatment; the 
other tells us that they are in essence the same thing, and that 
the milder varieties, as he calls them, will, unless resolution 
take place, go on to diphtheritic deposits or to death without 
this symptom. 
All agree as to the propriety of dividing croup cases into NATURE AND TREATMENT OF CROUP. 
5 
1ene and false, but one class restricts tlie title pseudo-croup to 
laryngismus stridulus1—a purely spasmodic affection—while 
another includes in this category all the inflammatory cases in 
which false membrane does not appear. 
One or the other of these distinct views is held positively 
and defended earnestly by comparatively few of the profes- 
sion ; while the great majority either suspend judgment on the 
controverted points, or hold loosely and in a vacillating man- 
ner whatever views they may be said to have on the subject. 
Practically, the great mass of the profession, in common 
with the laity, call every case croup in which an obstruction 
in or of the larynx (not caused by whooping-cough, oedema 
of the glottis, asthma, or a foreign body) gives rise to dysp- 
noea and threatened suffocation, and, when we are called to 
such a case, be the same catarrhal, spasmodic, inflammatory, 
diphtheritic, or false-membranous, laryngeal, tracheal, or 
bronchial, sthenic or asthenic, mild or severe, examine, sift, 
and compare the symptoms as we may, inform ourselves as 
thoroughly as possible as to the history of the attack, the sus- 
ceptibilities of the patient, and all other points of interest— 
still we are anxious as to the results. 
Why is this, if the distinctions are practically as clear as 
they are theoretically ? . 
For the sake of perspicuity I will stafte my conclusions first, 
in several propositions, and then say a few words upon each: 
Proposition I.—False croup is a simple spasmodic affec- 
tion, very well named laryngismus stridulus. It is rarely if 
ever fatal, and would hardly excite apprehension if it were 
always possible to distinguish it, and to feel sure that there 
1 In the use of this term, I do not forget that it was applied by Dr. 
Mason Good to that mysterious and sometimes chronic affection which 
the Germans call Thymus Asthma, and which Gooch denominated “child- 
crowing.” The difference between this and the false croup to which I 
allude is, that this seems dependent upon some organic lesion affecting 
directly or indirectly the recurrent laryngeal nerve; while the pseudo- 
croup, which I would carefully distinguish from this, as well as from 
laryngo-tracheitis, is a transient spasmodic affection, depending without 
doubt upon the reflex action of some remote irritation, as dentition, indi- 
gestible food, and the like. . 6 
PRACTICAL REFLECTIONS ON THE 
were no inflammatory complications. It is always sudden, 
generally occurs in the night, is frightful to witness, and dis- 
tressing to experience. 
Remar'ks.—Those who pride themselves on great accuracy 
of diagnosis, would hardly allow that it were possible to con- 
found this mild disease with true croup. Yet it is so con- 
founded constantly, and so heroically treated, especially by the 
non-professional, who manage a large proportion of these cases, 
that a multitude of lives have doubtless been unnecessarily 
sacrificed, and the cases charged to the account of “ mem- 
branous croup.” It is true that the points of difference be- 
tween this mild affection and the grave malady under discus- 
sion are sufficiently numerous and diagnostic when they can 
be made out, which, in the mild affection, is generally after 
needless medication has been resorted to. To show how easy 
it is to be in doubt, in real practice, in the middle of the 
night, when all is excitement and anxiety, and where it is next 
to impossible to get a light to shine into the fauces even, and 
where also it is quite impossible to learn whether the child 
was perfectly well on going to bed or not, I will quote two 
short paragraphs from that interesting and accurate work of 
Condie, on diseases of children. After having described the 
usual course of true croup in its different degrees of severity, 
he says: 
In other cases, however, the disease commences much more abruptly, 
and proceeds with great rapidity and violence. The patient, who retired 
to bed apparently in perfect health, is suddenly awoke from his sleep with 
a violent fit of loud, ringing cough, etc., etc. 
Ten pages further on he says: 
Trne croup always commences gradually, the severer paroxysms never 
occurring until the disease has lasted for at least some short time. 
There is no real contradiction here. I make these ({nota- 
tions to show how the cases apparently run together at the 
very time when the practitioner must decide quickly what to 
do. Dr. Jacobi, of New York, after making the clearest pos- 
sible distinctions between the true and false, uses the follow- NATURE AND TREATMENT OF CROUP. 
7 
ing language: “This much may be stated here, and practice 
will admit the fact, that the affection will frequently (es- 
pecially when there is no epidemic diphtheria) commence 
by pseudo-croup, and afterward assume a more formidable 
character.” He says also : 
You may see in the mouth a catarrhal proliferation, or croupous con- 
densation of the epithelium, on the tonsil a diphtheritic deposit, embedded 
in the tissue, on the larynx and trachea a plain croupous deposit, and in the 
bronchi a muco-purulent secretion, and again, under the same endemic and 
epidemic influence, you will find a case of catarrh, a case of croup, a case 
of diphtheria, a case of follicular exudative amygdalitis, in the same family, 
in the same week. Thus it appears that, in the long list of morbid con- 
ditions met with, catarrh on the one side, diphtheria on the other, are 
but the starting and terminating points, between which all the different 
shapes and forms may be registered according to their dignity; their modi- 
fications depending on individual local, endemic, and epidemic influences; 
the only form which is perhaps, and perhaps only, to be excluded, being 
the necrotizing diphtheria. 
Again, Watson, whose work on Theory and Practice (ex- 
cepting his therapeutics) is one of the best and decidedly the 
most popular that ever was published, so expresses himself as 
to call forth the following criticism from his special admirer, 
Dr. Condie : 
Under the head of Child-Crowing or Spurious Croup, Dr. Watson lias 
confounded two very distinct diseases. One occurs most commonly en- 
tirely independent of inflammation in any portion of the air-passages, and 
consists simply in a spasm of the glottis—the results of a reflex action, 
through the excito-motory property of the nervous system, of various 
irritations of the gums, or digestive apparatus, or of the action of external 
agents, or mental emotions. This is the affection known as laryngismus 
stridulus. The other disease differs in nothing from genuine croup, ex- 
cepting that the inflammation is less intense, and seldom extends into the 
trachea, the exudation is of a more muco-form character, seldom adhering 
long enough to the inflamed mucous surface of the larynx to become con- 
verted into false membrane. This form of laryngeal disease (continues 
Condie) has been termed catarrhal croup—false croup, and, by some, 
spasmodic croup. We prefer the name spasmodic laryngitis given to it by 
Iiilliet and Barthes. 
It is true, then, upon the testimony of Condie, that AVat- 
son, an authoritative teacher in the medical Israel, may and 
actually does confound these different affections. It this be 8 
PEACTICAL REFLECTIONS ON THE 
so, can we expect greater accuracy among those who have less 
knowledge and less experience ? At the risk of seeming pro- 
lix, I must beg you not to understand me as detracting in the 
slightest degree from the importance of those distinctions 
which are made and which actually exist between the purely 
spasmodic and the inflammatory affections of the larynx and 
trachea. I know very well that the simply spasmodic will 
almost always recover, that the mildly inflammatory will gen- 
erally recover, and that those which go on to the formation of 
pseudo-membrane do generally die. I know also that when 
the death or the recovery has taken place, and you have the 
whole history of the case before you, it is almost always the 
easiest matter in the world to say to which class it belonged. 
Moreover, in exceptional cases it is easy to make an early and 
positive diagnosis; but the idea which I wish clearly to ex- 
press in this connection is, that generally, when you are called 
to a case of simple spasmodic croup, with the imperfect history 
that you are able to get, and the imperfect examination that 
you are able to make, you cannot feel sure that there is no 
inflammation; and, if there be inflammation, you cannot feel 
sure that it will not go on to exudation, coagulation, and ul- 
timate suffocation: and the practical point is this, that too 
often the worst is assumed to be probable, and the treatment 
is directed accordingly. 
Proposition II.—True croup is an inflammation of the 
tissues lining the larynx and trachea, and sometimes extending 
to the bronchial ramifications. It may be superficial, involv- 
ing only the mucous membrane, or it may involve the subja- 
cent areolar tissue. 
Remarks.—There is no reason to regard this inflammation 
as in any sense specific;'it is a simple inflammation, arising 
generally from ordinary atmospheric causes. It does not seem 
remarkable that children should be more susceptible to these 
influences, and therefore more liable to croup, than those of 
mature years. Nor is it difficult to see why children at the 
breast are less liable than after weaning ; they are better pro- 
tected from cold and damp. 
Stokes, Bouchut, and Guersant, speak of it as contagious, 
or probably so, but the verdict of the profession is against this NATURE AND TREATMENT OF CROUP. 
9 
idea. It has often been epidemic, as we might expect it to he, 
just as influenza is, and from like causes ; but in such a fatal 
prevalence as that reported by Tarrand, where, within a small 
compass and in a short space of time, in 1827, sixty were at- 
tacked, and none escaped death, and also in those cases where 
good observers have pronounced it contagious, I strongly sus- 
pect the disease was a true diphtheria. It is much easier to 
account for so fearful a mortality upon this theory of a specific 
poison entering the system in a necessarily fatal dose, than to 
understand how so many cases of croup could occur, and have 
no mild case among them. 
In speaking to a learned society, such as I have the honor 
to address, it is not necessary that I should detail the symp- 
toms of a disease so familiar. I shall only refer to them inci- 
dentally as I proceed. The spasmodic element exists in all 
cases of croup, though in exceedingly variable degrees. The 
febrile excitement is seldom great, and sometimes hardly ob- 
servable. 
Proposition III.—Effusion of plastic lymph, coagulation, 
and consequent formation of false membrane, occur in about 
one-sixtli of all the cases of true croup. 
Remarks.—It is so common to speak of membranous croup, 
that it is difficult to get out of the unscientific habit of regard- 
ing the occasional symptoms here referred to as diagnostic. 
Bouchut, Good, Guersant, Brettoneau, and many others, so 
regard it. Dickson says it does not always exist even in the 
worst cases. Chapman often failed to find it in the cadaver. 
In a fatal case which I attended eighteen years ago, in con- 
junction with Dr. Sweet, of New York, we made an autopsy, 
and no membrane existed, though a more protracted and pain- 
ful death from suffocation was never witnessed. Dr. Peaslee 
says : 
We need not, for any practical purpose, admit an inflammatory and 
membranous croup, any more than vve should make the same distinction 
in regard to pleuritis or peritonitis. Croup is always inflammatory, and 
some cases are accompanied by the formation of a false membrane. The 
latter should not affect the treatment of the disease as an inflammation, 
but merely because of its mechanical effects. Its occurrence cannot be 
predicted in any case, until it is actually seen, and this is not possible in 
most cases, even when it is developed at the very outset ot the disease. 10 
PRACTICAL REFLECTIONS ON THE 
It may occur in any case of laryngo-tracheitis, and our 
anxiety always testifies to our faith in this fact. It will not 
occur in five cases out of six. Dr. Peaslee is therefore right, 
in my opinion, in maintaining that it ought not to he included 
in the definition of the disease, or he expressed by its name. 
To regard the false membrane as diagnostic, and therefore as 
indicating a disease separate and distinct from inflammatory 
croup, is not only to erect a symptom which is sometimes 
present and sometimes not, into a disease, but it is practically 
pernicious, since it leads us to cry, “ Peace, jpeace, where there 
is no peace,” in the inflammatory cases, and to neglect, perhaps, 
the very means which are necessary to prevent such cases from 
becoming membranous. 
Adults have more judgment in expectorating, and thus 
getting rid of the products of inflammation before they have 
time to become coagulated and solidified. Moreover, I suspect 
that an inflammation of the larynx which an adult would carry 
with him to his daily avocation, and perhaps never speak of to 
any one, would, at the impressible age of two years, cause a 
spasmodic complication which might destroy life. 
Statistics of croup-cases are generally worthless, because 
you cannot tell, unless you have a minute report of each, what 
proportion are mild and what severe ; what kind of cases were 
included as true and what set down as false ; what influence 
early treatment had in preventing fatal symptoms, and in cut- 
ting the disease short before it merited to be called a severe 
case. 
With regard to its fatality, Prof. Ware, of Boston, reports 
90 per cent. ; but, then, it must be remembered that he 
rigidly restricted the title “ croup ” to those cases in which 
that terribly fatal symptom—the formation of false membrane 
—had actually occurred. If all the cases of laryngo-tracheitis 
which he treated of had been included in the estimate, it is 
not probable that the percentage of deaths would exceed 40. 
Dr. Jacobi says 75 is highly favorable; yet it is not cpiite 
clear upon what basis he makes his estimate. Upon the best 
evidence which I can bring to bear on the subject—if I were 
to hazard an opinion—I should say that, including all well- NATURE AND TREATMENT OF CROUP. 
11 
marked inflammatory cases, not 20 per cent, are lost when 
treated judiciously. 
Proposition IV.—The popular treatment of croup, in all 
its phases, has been and still is, in my opinion, severe and full 
of danger. 
Remarks.—I by no means intend to assert that I alone 
treat this disease on conservative and safe principles; it is so 
treated by thousands throughout the world. Nevertheless, 
the great number of cases are vomited before the doctor sees 
them (often with tartar-emetic), and approved text-books on 
practice say “ That’s right, give the child another dose.” Cheyne 
says tartar-emetic is the sheet-anchor. Dr. John Elliotson 
has “ no doubt that he has generally failed with antimony, be- 
cause he has used it timidly, and quotes almost approvingly the 
experience of a medical man who gave it till twenty-seven grains 
were swallowed, and tetanic spasms produced. In Braith- 
waite's Retrospect, January, 1857, several English physicians 
indorsed Dr. Elliotson’s views, but Dr. Prior, of Tewksbury, 
says that “ as the result of extensive experience he can testify ” 
that, “ if such heroic practices be carried out, the deaths from 
this cause would be immensely increased.” 
As an emetic in croup, Condie says a majority of phy- 
sicians prefer tartar-emetic. 
Watson begins his remarks, on the treatment of croup, with 
this sentence : “ The three remedies most requiring considera- 
tion are bloodletting, tartarized antimony, and calomel.” 
Mr. President, I join in no tirade against these time-hon- 
ored and valuable agents, but I believe the time has come 
when we have better means at command to meet the indica- 
tions which arise in the course of this disease. Bloodletting, 
though by common consent abandoned, was almost as uni- 
versally recommended even into the present century. Calo- 
mel is hardly ever given now, except in a cathartic dose ; but 
antimony, the most dangerous of all, still clings to its false 
reputation. The people give comp, syrup of squills, and call 
it croup-syrup. If the child dies by syncope, of absolute 
prostration and exhaustion, as I have seen them die after do- 
mestic treatment, the friends say, “ What a terrible thing this 
membranous croup is ! ” and the doctor arrives in time to 12 
PRACTICAL REFLECTIONS ON THE 
give a certificate, when perhaps laryngismus stridulus is the 
worst name that he can conscientiously write. Dr. Horace 
Green says : “ The injudicious use of tartarized antimony in 
the diseases of young children has destroyed more lives than 
it has been instrumental in saving.” Dickson begins mildly— 
gives a dose of paregoric; “ afterward,” he says, “ an emetic is 
demanded, and if not relieved by the first emetic and the 
lancet, repeat the emetic ; then comes the cathartic, salines 
preferred.” lie says, “ The invading stage of croup is under 
domestic control.” Twenty years ago Prof. Ware, of Harvard 
University, after deploring the loss of thirty out of thirty-three 
cases of “ membranous croup,” wrote as follows : “ The method 
in common use of treating this disease requires careful recon- 
sideration.” He also asks: “ If the mode of treating croup 
commonly adopted does no good, are we sure it does no 
hurt?” Many authors advise that, besides the occasional 
emetic, nauseating doses of antimony or of ipecac, be con- 
tinually given. This somewhat anticipates the subject of— 
Proposition Y.—Emetics and nauseants, as a rule, do 
harm. 
Remarks.—The only exceptions that I would make to this 
rule are, that ipecac, may be given in a single emetic dose, 
when the stomach is full, particularly if indigestible food has 
just been taken, and sulphate of zinc or sulphate of copper, or 
some other non-depressing emetic, when death threatens from 
simple laryngeal obstruction, and when there seems reason to 
hope that the false membrane may be detached and thrown 
off by its mechanical action. Kauseants and emetics, except 
for the purposes just indicated, cannot reasonably be expected 
to do good ; surely the spasmodic efforts and temporary cere- 
bral and cervical congestions which attend the act of vomit- 
ing cannot lessen the laryngeal inflammation. Again, they 
debilitate and rapidly unfit the little sufferer to contend suc- 
cessfully with his great enemy, for Watson says that “in fatal 
cases the false membrane is sometimes found detached from 
the larynx, so that it might have been expelled without much 
forcing or difficulty, if the child could have sufficiently inflated 
its lungs, and the requisite muscular power had remained.” 
Conserve, then, this muscular power. Again, emetics, nau- NATURE AND TREATMENT OF CROUP. 
13 
seants, and expectorants, till the lungs with mucus, at a time 
when it is extremely difficult to get rid of it, and when it can 
have no other effect than to act as an additional barrier to the 
little oxygen which reaches the blood. I have made an excep- 
tion in favor of certain mechanical or non-depressing emetics in 
the last stages of croup, with a view to the detaching and ex- 
pelling of the false membrane. I will finish here what I have 
to sav upon that point. It is true that the dilatation of the 
larynx occasioned by the act of vomiting is well calculated to 
favor the detachment of the dreaded false membrane. Dr. 
Meigs, of Philadelphia, prefers for this purpose alum, which 
may be given in five to ten grain doses. Dr. Hubbard, of 
Maine, uses and has great faith in turpeth mineral, yellow sul- 
pliuret of mercury, two to three grains repeated in fifteen min- 
utes if it fails to operate. Sulphate of copper, first introduced 
by Serlo, has been given by Schwabe in fifty cases, a grain and 
a half to four grains every hour, eight to twelve doses. Ilorner 
Koff reports ninety-nine cases, with seventy-seven recoveries, 
in which he used this remedy. It is also highly recommended 
by Berrignier, Trousseau, and Luzinsky. The sulphate of 
zinc is also recommended by many, dose five to fifteen grains. 
Thus far, my remarks on treatment have had reference 
mainly to what should not be done, and I cannot sum up this 
branch of my subject by any words more apt than those of 
Prof. Ware, published twenty years ago. After the fearful 
experience to which I have already alluded, he proposed to 
treat croup without depletion (except, perhaps, a few leeches), 
without vomiting, without purging, without blistering, with- 
out antimonials, without ipecac., and without any of those 
nauseating remedies which had been usually resorted to. Al- 
though Dr. Ware was the highest living authority at that 
time, the world was not ready for so great an innovation. 
Had the treatment which he proposed been as sound as 
this negative proposition, it would probably have exerted a 
more abiding influence upon the profession. 
It has excellent features, and, as it consists of three points 
only, I will rehearse them : 1. Full influence of opium, com- 
bined with calomel. 2. Constant application of warmth and 
moisture to the neck, and of mercurial liniment, slightly stim- 14 
PRACTICAL reflections on the 
ulating. 3. Constant inhalation of the vapor of water. A 
vast improvement on the general practice of his day. 
The course of treatment which I adopt, and heartily 
recommend, may be stated in a few words : 
Proposition YI.—If the stomach he full, or indigestible 
food have been recently taken, a single emetic may be given. 
It is, however, in my experience, rarely required. 
Remarks.—The emetic here is not so objectionable as un- 
der any other circumstances, because the form of disease which 
arises from reflex action after a full meal is generally spas- 
modic. If, however, there should chance to be inflammatory 
action commencing, the expectorant effect of the remedy will 
be mainly over before the height of the disease would be 
reached. Even here three to ten grains of the sulphate of 
zinc would probably be a better choice than ipecac. 
Proposition YII.—Give a dose of bromide of potassium 
sufficient to quiet all spasmodic action—four to twenty grains, 
and repeat every six hours. 
Remarks.—It is supposed this remedy may also be useful, 
to some extent, in retarding or preventing the deposit of false 
membrane, its solvent action upon such deposits being well 
known to the profession. Two grains in an ounce of water 
will liquefy a false membrane in a few hours. If restricted 
to its antispasmodic property only, I would never omit it, 
since the spasmodic element is more or less marked in all cases 
of true croup. 
Hydrocyanic acid, first introduced by the Italian physi- 
cians, is recommended by Horace Green. Wenett gives one 
grain of musk every hour. Dickson relies upon paregoric. 
I regard the bromide as more reliable than either of these. 
Proposition YIII.—Give one-half to one teaspoonful of 
liquor calcis every hour or every half-hour. 
Remarks.—The alkalies, generally, are solvents of false 
membrane, and lime-water is one of the pleasantest and most 
manageable for internal use. Eggert regards carbonate of 
o ©o O 
potassa as almost a specific. J. D. Griscom, of London, gives 
the iodide of potassium. J. Gottstein, of Breslau, speaks of 
using repeated injections of lime-water into the nares in diph- 
theria. I do not know whether the lime-water which I ad- NATURE AND TREATMENT OF CROUP. 
15 
minister acts through the circulation directly upon the inflamed 
surface, or whether its action is restricted to the epiglottis and 
the parts above; at any rate, I would not he willing to relin- 
quish it, except, perhaps, for its equivalent in the carbonate of 
potassa. 
Proposition IX.—Allow the patient to inhale the vapor of 
slacking lime. 
Remarks.—The credit of this last expedient is due, I be- 
lieve, to Dr. Geiger, of Dayton, Ohio, who reports great suc- 
cess. 
Dr. B. B. Wilson, of Pennsylvania, with the same remedy, 
saved two cases while in articulo mortis. Dr. Wilde, of this 
society, reports two terrible cases, which I saw with him, and 
which were saved by the lime inhalations and the bromide of 
potassium. The best method is to slack the lime in an open 
pail or tub. Care is requisite not to annoy, frighten, or scald 
the patient. Some children are so much pleased with the re- 
lief it affords, that they seek it voluntarily after the flrst expe- 
rience ; others oppose its use, as they do every thing else. The 
confidence and cooperation of the patient are important, since 
all excitement increases the circulation, and the necessity for 
greater quantities of oxygen to properly arterialize the blood. 
The simple vapor of wrater has been and is extensively used 
and recommended, and some have seriously questioned whether 
any thing but moist air reaches the larynx when we employ 
the slacking-lime. I am not alone in contending that lime is 
inhaled, and that its effect is superior to that of vapor alone. 
Even at the temperature of 212° F., a pint of water will hold 
in solution five and a half grains of lime, and this is sufficient 
to give an alkaline reaction to the vapor which arises there- 
from. If the patient resist violently, so that its immediate 
inhalation is rendered impossible, lime may be freely slacked 
in the room to such an extent as to keep the air constantly 
moist. I have used lime-water atomized by the spray-pro- 
ducer, and believe it objectionable in this disease. It annoys 
the patient, and condenses frigidly upon the face and neck. 
Proposition X.—Take equal parts of impure carbolic acid 
and glycerine. Pour upon a teaspoonful of this mixture, in an 
open basin, a pint of boiling water. Renew this every four 16 
PRACTICAL REFLECTIONS ON THE 
hours, and allow the patient to inhale its vapor for a few min- 
utes. Let the preparation stand in the room till renewed. 
Remarks.—Lime-water and carbolic acid, though possess- 
ing opposite chemical properties, are both useful, and both at 
the same time, though not at the same instant. I have ob- 
served, while using carbolic acid in surgical practice, that, 
whenever venous blood was touched by it, it instantly became 
arterial. Lime-water dissolves the false membrane, to use a 
paradox, before it is formed, while it is also gently stimulating 
and alterative to the inflamed surface. Carbolic acid acts, 
directly upon the nerves and vessels of the larynx, trachea, 
and bronchi, aiding in the oxygenation of the blood and in the 
exfoliation of the diphtheritic deposit. It is also a valuable 
disinfectant, and will destroy any diphtheritic poison that may 
be lurking about unawares. 
Proposition XI.—Give an enema of strong hop-tea, at 
least twice a day. If the child be costive, add to the first 
enema one or two teaspoonfuls of table-salt. 
Remarks.—The injection is given to unload the vessels, 
and to give the diaphragm free play. 
Hop-tea is chosen on account of its sedative and antispas- 
modic influence. I avoid cathartics because of their disturbing 
and debilitating effects. A simple cathartic dose of calomel— 
ten to twenty grains—has been highly recommended; and, 
though I would not ordinarily give it, I can see no great objec- 
tion to its use. I have been told that the late Francis "W. 
Johnston, of Hew York, would not treat a case without it. 
lie never repeated the dose. Had not Rush seen some good 
effect from its use, he could hardly have said, “ Calomel is as 
efficacious in croup as bark in fever.” 
Proposition XII.—Use externally some gently stimulating 
and anodyne liniment. I prefer linimentum saponis, slightly 
ammoniated, ij ; tinct. rad. aconiti, 3 ss. Apply this with a 
camel’s-hair pencil. 
Remarks.—Do not bind the liniment to the neck with 
cloths of any kind; it is not only liable to vesicate, but it 
adds greatly to the discomfort of the little sufferer to have 
the neck in any way pressed upon, or restricted in its move- 
ments. On this account the weight of poultices makes them NATURE AND TREATMENT OF CROUP. 
17 
objectionable. Tincture of iodine, either simple or compound, 
may be substituted for the liniment. Turpentine is a good 
application. My friend Dr. W. W. Rees uses kerosene-oil 
and prefers it to every thing else. I have had no experience 
with it, but am favorably impressed with the recommendation. 
The popular application of snuff and tobacco I regard as dan- 
gerous. Blisters are intolerable. 
Proposition XIII.—Let the diet be meat, broths, and 
milk, or milk-punch and wine-wliey. Give water ad libitum. 
Remarks.—I only intend to indicate by this proposition 
that we should sustain the patient. As an inflammatory 
affection it is of slight extent, and all experience goes to show 
that powerful antiphlogistic remedies are of no avail. On the 
contrary, an element of asthenia is often manifest at an early 
stage. 
The amount of stimulation and support necessary must of 
course be left to the judgment of the physician in each case. 
Children at the breast should generally depend upon their 
natural aliment, but even with them stimulation is sometimes 
necessary. 
Proposition XIY.—As a rule, I am opposed to topical 
applications. 
Remarks.—Dupuytren, Trousseau, Guiet, Bouchut, Ware, 
Eben Watson, Gottstein, and many others have applied and 
recommend a solution of nitrate of silver, forty or sixty grains to 
the ounce of distilled water. Horace Green, of Xew York, was 
the first to insist upon its introduction into the larynx. It has 
little or no effect directly upon false membrane, and must, 
therefore, to do good, be applied early, that it may exert its 
alterative influence upon the inflamed surface. Many acids 
and alkalies have also been used with the probang—the acids 
hardening and shrinking, and the alkalies softening and dis- 
solving the membranous deposit. Iodine, and the subsulpliate 
and sesquichloride of iron, with their blackening and accumu- 
lating presence, have also been used; but I am happy in the 
belief that the inhalations of the vapors already alluded to ren- 
der all these distressing expedients not only inexpedient, to use 
a paradox, but positively harmful. 18 
PRACTICAL REFLECTIONS ON THE 
Proposition XV.—Tracheotomy is unjustifiable, except as 
a dernier ressort, and even then it is generally a forlorn hope. 
Remarks.—I do not doubt that lives have been saved by 
it, yet I strongly suspect, though I dare not assume, that an 
equal number have been destroyed by it. It has many advocates 
and defenders, while very few say any thing in its detraction. 
I shall, therefore, speak the more earnestly, because I know not 
who are to be my supporters. Jacobi says, “ The omission of 
it is homicide.” Some of its most enthusiastic friends are 
named among the following statistics of the operation, which 
are all that I have been able to lay my hand upon : 
Operation. 
Recov. Deaths. 
Bretonneau, .... 
20 
6 
14 
Trousseau, .... 
150 
39 
111 
Lothar Voss, .... 
43 
9 
34 
Waldemar von Roth, . 
48 
11 
37 
ICrackowizer, 
56 
15 
41 
Jacobi, 
62 
13 
49 
Gilfillan, .... 
3 
2 
1 
George Buchanan (Glasgow), 
26 
9 
17 
408 
104 
304 
Eberle says, “ All experience lias decided against trache- 
otomy.’' 
Dickson lias little faith in it, and Dr. Frank H. Hamilton 
no more than I, as he himself has told me. 
Hyland says: “ With regard to the general results of tra- 
cheotomy when performed for the cure of croup, I have no 
hesitation in saying that they are so unfavorable as to warrant 
us in the strongest condemnation of it, under almost every 
conceivable circumstance.” Dr. Cheyne contends, and his 
argument applies to a certain proportion of cases, “ that death 
does not occur because there is an insufficiency of air admitted 
into the lungs to effect the arterialization of the blood, for,” 
he says, “ three eighths of the aerial canal is always open, con- 
stituting a space quite sufficient for the transmission of all the 
air necessary to the maintenance of the process of respiration.” 
Dr. Eben Watson, of the Glasgow Royal Infirmary, sums up his 
experience in the following words: “ Tracheotomy should on no 
account be performed during the exudative stage of croup; for 19 
NATURE AND TREATMENT OF CROUP. 
it is either useless in the worst cases, or positively hurtful in 
those where there is any hope of recovery.” In an excellent 
article contributed by this Society to the Society of the State 
of New York in 1863, Dr. William Gilfillan says: “Tracheot- 
omy is an operation in which every thing is to be gained and 
nothing can he lost.” The italics are his own. And yet in 
this very communication he enumerates “ certain causes of 
death which are incident to the operation,” and, of those 
causes of death which arise subsequent to the operation, 
“ some,” he says, “ spring from the operation, and some are 
accidental.” 
I quote again: “Haemorrhage during the operation may 
cause death, or greatly weaken the already depressed vital 
powers; ” again, “ Haemorrhage into the trachea may cause 
obstruction of the respiration, or even suffocation.” Of course 
he gives directions for avoiding these accidents as far as pos- 
sible. Yet the fact, that they may occur, shows that the 
operation is one in which life may be jeopardized beyond the 
risks incident to the disease itself. Again, we are told that 
the proper introduction of the canula “ is a nice point and 
only to be acquired by practice.” Again : “ It is a matter of 
vital importance that the tube inserted, and through which 
the patient respires, should he as large as possible Trous- 
seau first drew attention to this point, that many persons died 
after tracheotomy, from the tube introduced being too small 
to permit air enough to enter the lungs for the oxygenation 
of the blood.” 
Another fact which Dr. Gilfillan records (and I do not 
question the accuracy of any of his statements) is, that “the 
lungs” are sometimes “ affected by the direct admission of cold 
air, and pneumonia and bronchitis follow.” lie says also: 
“ After every case of tracheotomy, there is, I think, more or 
less bronchitis when the patient survives the first few hours.” 
“ A more serious form of the disease may occur, or pneumonia 
may arise.” After these dangers are past, he tells us, very 
truly, that our next solicitude will have reference to the re- 
moval of the tube. “ If this is not done soon, the larynx from 
disuse contracts so as to be too small for respiration.” lie says 
(and who will question it?) that “it is a grievous affliction 20 
PRACTICAL REFLECTIONS ON THE 
to be condemned to breathe through a canula for the term of 
one’s natural life.” I have known a case, Mr. President, in 
which every attempt to get rid of the tube was attended with 
such serious symptoms, that it was worn for twelve years, and 
then I lost sight of the patient. 
On the other hand, it occasionally happens that the tube 
creates so much irritation that it has to be dispensed with 
from the first; in which case, unless wre can keep the wound 
open by means of a simple wire dilator, such as Marshall Ilall 
describes in Braithwaite’s Retrospect, part xxxv., wre can, of 
course, expect no benefit from the operation. 
The advocates and champions of tracheotomy are con- 
stantly urging us to operate earlier, that wre may have a larger 
percentage of recoveries. How, to my mind, the only justifica- 
tion for this operation is in its use wdien all else has most sig- 
nally failed. Even then, it is hardly safe to assume that the 
few cases which recover are saved by it, for no practitioner 
of experience can have failed to see cases recover without 
operation, after all hope had been relinquished. Indeed, I 
cannot help recognizing the probability that some of the fatal 
cases after operation -would have recovered, but for the ad- 
ditional risk incurred by it. 
How, I have no doubt that, by resorting to tracheotomy 
at an earlier stage of the disease, we should have a greater 
apparent success. We should, of course, include a greater 
number of those cases which would recover if let alone; and 
a sufficient percentage of these would live in spite of both dis- 
ease and doctor, to increase very considerably the proportion 
of successful operations. When the enthusiastic advocates of 
tracheotomy succeed in persuading the whole profession to 
operate early, we may be very proud of the record, as we read 
recoveries forty per cent, instead of twenty as now, but wdio 
shall answer for the other sixty, thirty of whom would have 
recovered but for rash interference ? 
Operate early? Why, Mr. President, there was never a 
more dangerous exhortation. Yon cannot early know that 
there is any necessity for such an act. It is admitted by the 
most zealous operators that death may occur as a direct con- 
sequence of tracheotomy—by syncope from haemorrhage, bv NATURE AND TREATMENT OF CROUP. 
21 
suffocation from haemorrhage, by a tube too small, by irrita- 
tion, by bronchitis, by pneumonia—and we may increase the 
list by reference to all those accidents which are occasioned 
by the struggling of the patient, and by the constant moving 
up and down of the part to be operated on (unless well se- 
cured by the hook). These accidents I need not dwell upon, 
nor need I claim that they are unavoidable ; the oesophagus 
and the pleura have been opened in this way. 
Again, is it not probable that many a child has died be- 
cause of the greater quantity of oxygen required, while, under 
violent exercise and fright, striving to escape the operation? 
In view of these undoubted facts, have we any right or 
reason to assume that the one out of four or five, who has 
lived through this ordeal, was saved by it ? Indeed, have we 
not reason to suspect that, if all the cases which have been sub- 
mitted to the knife had been mildly treated without it, we 
should have had from fifteen to twenty per cent, more ot re- 
coveries. 
I close this paper, which has already far exceeded the limit 
which I prescribed to myself, with a report of all the fatal 
cases of croup which I have seen during the last three years : 
Case I.—A little German boy, four years of age, living in Atlautic 
Street, became hoarse May 1G, 1869, but was allowed to run about as 
usual, in and out of doors. May 17th, ivas so much worse that his parents 
vomited him profusely with ipecac, and purged him with oil. Steadily the 
disease advanced, till, on the 18th, Dr. Skene was called. lie found the 
patient weak ; pulse rapid ; breathing short and laborious; countenance 
anxious; skin and lips slightly livid. He ordered, at once, the plan of 
treatment sketched in this paper. This treatment was rather inefficiently 
carried out till the child died, on the twenty-fourth day from the seizure. 
I was in consultation from tlie second day, and this is the 
first case of croup which I have seen die in over three years. 
I report it, because it confirms my views of the proper treat- 
ment of croup, as certainly as did the recovery of all the other 
cases. A powerfully perturbing treatment was instituted 
here before the doctor was called. A nauseant and emetic 
was given, with all its prostrating effect; the lungs were filled 
with mucus, which the child had no power to throw off; the 
alimentary canal, from one end to the other, was irritated and 22 
PRACTICAL REFLECTIONS ON THE 
excited to such peristaltic action as would necessarily disturb 
every natural function. The child grew rapidly worse after 
the emetic. The breathing was much relieved by the subse- 
quent treatment, and finally the death was more from asthenia 
than apncea. On the day before his death an accident oc- 
curred in the treatment, which should be mentioned, though 
I suppose it did not alter the result. The nurse gave a tea- 
spoonful of turpentine instead of lime-water, and, being fright- 
ened, ran to the nearest apothecary, who directed a teaspoon- 
ful of sweet oil. Some irritation of the bladder and urethra 
was the consequence. 
Case II.—Lizzie C., aged four years; hoarse several days; really no 
other symptom, except an occasional slight, croupy cough; bright, playful; 
appetite good; skin natural; tongue moist; patient but little disturbed 
at night. On the third da)', toward evening, exacerbation of all the 
symptoms, with profuse coryza. Difficulty of breathing increased through 
the night, but was not very great till the morning of the fourth day. 
Dr. Mitchell saw her at 9 a. m., and advised twenty grains of calomel in 
addition to my usual treatment. Steadily the symptoms progressed. The 
amount of air which entered the chest was enough to sustain any child, if 
the processes of endosmose and exosmose had not been prevented by the 
condition of the mucous membrane in the air-cells ; and yet no bronchitis 
was discoverable by any physical sign. She died, not from laryngeal ob- 
struction, but from want of power In the lungs to absorb oxygen and emit 
carbonic-acid gas. There was no struggle during the last two hours, but 
a gradual sinking, such as you would expect, as the effect of carbonic acid 
upon the brain. 
Tliis was no ordinary case of croup, as the sequel showed, 
for six days later an aunt, in the same house, had a severe at- 
tack of diphtheria; then the grandmother, also in the same 
house, had acute laryngitis, losing her voice entirely ; and in 
less than another week a cousin in the same house had well- 
marked scarlatina. They all recovered. 
A fatal case of laryngo-tracheitis having occurred under 
my observation, since the reading of the above paper, I ap- 
pend it here: 
I was invited on Tuesday, the 14th instant, to see a little daughter of 
Dr. Caldwell, who is an active member of this Society. The patient was 
three years of age, and of good constitution. 
I learned that, for about ten (lays, she had suffered with subacute bron- NATURE AND TREATMENT OF CROUP. 
23 
chilis, of not very severe character, yet sufficiently grave to have been un- 
der treatment much of the time. Had vomited several times, as the effect 
of ipecacuanha, and had taken as an expectorant a mixture of squills, 
ipecac., tolu, and ammonia. Castor-oil was given as a cathartic once or 
twice, and her chest was enveloped in oiled silk. At three o’clock on the 
morning of the 14th, symptoms of laryngitis declared themselves—croup- 
ous cough, labored perspiration, and marked aphonia. The expectorant 
mixture was now given, and occasioned free emesis. A dose of castor-oil 
was also administered, which operated late in the day. Flaxseed and mus- 
tard poultices were applied to the chest, and flannels wet with liniment 
about the neck. I first saw her ten hours after the attack. She was pro- 
fusely catarrhal, and continued so all the afternoon. Both lungs were 
loaded with mucus, at times producing loud mucous rales. I recommended 
the plan of treatment which I have detailed to you, but had little faith in 
the efficacy of any plan that could be adopted. The preceding and accom- 
panying bronchitis had called for and received a course of treatment which 
I believe to be injurious in croup. I am not criticising the course pursued; 
it was orthodox, and the croup could not be anticipated. Drs. Byrne, 
Whaley, and Shuttleworth, all saw the case, and made valuable suggestions, 
but gradually the little sufferer sank, apparently expanding sufficiently the 
chest, and receiving air enough, but for the wall of mucus between it and 
the blood. 
I have not thought it worth while to report successful 
cases, because it is almost essential to see a case of croup in 
order to judge of its importance or significance. The follow- 
ing will suffice to illustrate a class of cases which I think are 
not only saved from suffocation, but are prevented from reach- 
ing that stage of deep distress with which we are all too 
familiar: 
Iltirry II., Schermerhorn Street, November 25, 1860, was taken sick 
with feverishness and slightly croupy cough ; grew worse in the night, aud 
on the morning of the 26th was profusely vomited with syrup of ipecac.; 
but no improvement took place. At 11 a. m. I was sent for, and from 
that time until evening the dyspnoea was of that persistent character which 
marks the generally fatal case. I administered at once a ten-grain dose of 
the bromide of potassium, and put in requisition all the other means set 
forth in the above paper. A peck of lime was slacked lump by lump, in 
an open wash-bowl. Half a teaspoonful of lime-water was taken every 
half-hour. The carbolic acid and glycerin mixture (equal parts), one tea- 
spoonful to half a pint of boiling water, also gave otf its vapor every three 
hours, and at 9 o’clock p. m. we felt that the prospect for recovery was 
good. The bromide was continued in five-grain doses every six hours, and 
in all other respects the treatment, through that night and the next day, 
was as at first. The convalescence was gradual but uninterrupted. A 11 V ERJISESf ENTS. 
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