PATHOLOGY OF CROUP For description of Plate see page 93. OBSERVATIONS 
ON THE 
PATHOLOGY OF CROUP: 
WITH 
REMARKS ON ITS TREATMENT 
BY 
I 
TOPICAL MEDICATIONS. 
By HORACE GREEN, M.D., LL.D., 
PRESIDENT OF THE FACULTY, AND EMLERITUS PROFESSOR OF THE THEORY AND PRACTICF 
OF MEDICINE IN THE NEW ' ORK MEDICAL COLLEGE ; CORRESPONDING 
FELLOW OF THE LONDON MEDICAL SOCIETY; MEMBER OF 
THE AMERICAN MEDICAL ASSOCIATION, ETC. 
NEW YORK: 
JOHN WILEY, 56 WALKER STREET. 
1859. Entered according t© Act of Congress, in the year 1859, by 
HORACE GREEN, 
In the Clerk’s Office of the District Court of the United Suites, for the Southern District of New York. 
W. H. Tin son, Stereotyper and Printer, 
Rear of 43 & 45 Centre street, N. Y. CONTENTS. 
Page 
Preface ix 
CHAPTER I. 
Nature and Pathology of Croup 13 
Frequent fatality of Croup 14 
Opinions as to the nature of Croup 15 
Essential Characteristic of Croup 1G 
Albuminous Exudation of Croup 17 
Spasmodic Croup 19 
Opinions of Guersent, Williams, and others 21 
Varieties of Croup by Dr. Ware 22 
Laryngismus Stridulus of Dr. Cheyne 23 
Division of Croup into Laryngeal, Tracheal, and Bronchial Croup... 24 
Source of the Exudation in Croup 26 
Commencement of the Morbid Action 29 
Age at which Children are most liable to Croup 32 
Stage of the disease when the Exudation commences 34 
Repeated formation of the Adventitious Membrane 35 
Great extent of the False Membrane 36 
Experiments of Jurine, Schmidt, and others 37 
CHAPTER II. 
Laryngeal and Tracheal Croup 39 
First employment of the topical Remedy in Croup 41 
Case of Membranous Croup 43 
Case successfully Treated 4V 
Cases of Membranous Croup treated early 49 
CHAPTER III. 
Membranous Croup complicated with Bronchial Inflammation. .. 56 
Commences with Catarrhal Symptoms 56 
Case of Bronchial Croup 57 CONTENTS. 
Page 
Symptoms and their progress 58 
Application of the nitrate of silver to the Bronchial Membrane..... CO 
Affects children less than adults Cl 
Case of Bronchial Croup successfully treated 02 
CHAPTER IY. 
Membranous Croup complicated with Spasmodic and Bronchial 
Symptoms C5 
Life destroyed by Spasm of Croup Co 
Case of Croup with spasmodic symptoms 66 
Severe case of Bronchial Croup. V 09 
The false membrane removed by the applications '12 
Employment of Hydrocyanic Acid. .5 '14 
Successive layers of albuminous matter .' Vo 
Case of Croup by Dr. Bryan *76 
Cases of Croup by Dr. Blakeman 80 
Cases of Croup by Dr. Ware 82 
CHAPTER V. 
Of the Treatment of Croup 86 
Topical Medications 86 
Its employment by Bretonneau 87 
Method as practised by M, Gucrsent 88 
Method as practised by M. Trousseau 89 
Danger of the application as considered by M. Bouchut 90 
Strength of the Solution as ordinarily employed. 91 
Method of making the application 92 
Description of the Instrument employed 93 
The insidious nature of Croup 96 
Importance of detecting first symptoms 97 
CHAPTER Y I. 
Diphtherite, or the Croup of Adults 1D1 
Not identical with the Croup of children.. 101 
Diphtherite frequently fatal 101 
Diphtherite occurs often as an epidemic 102 
Cases recorded by Ryland ... 1<>2 
Cases of Diphtherite following Measles 1 >5 
Applications of a strong solution of the nitrate of silver through the 
rima glottidis lit.) 
The removal of the false membrane, not the only indication in the 
treatment of Croup 11) 
Extent and Fatality of Croup Ill 
Dr. West on the Treatment of Croup 116 CONTEXTS. 
CHAPTER YI I. 
Page 
Experience of Eminent Medical Men in the treatment of Croup 124 
Opinions and Experience of Dr. Ware 124 
Cases reported by Dr. Ware 126 
Employment of heroic remedies 127 
Milder remedies advised 128 
Opinions and Experience of Dr. May 183 
Topical Treatment by Dr. Yedder 138 
Treatment of Croup by Dr. Peaslee 143 
Cases treated at EHopita.1 des Enfants 145 
Opinions and Experience of Prof. Watson of Glasgow 146 
Discussion in the Academy of Medicine of Paris 149 
Method employed by M. Loiseau 150 
Opinions of the Editors of the French Medical Journals 154 
Case of Diphtherite under M. Trousseau 155 
Treatment of Croup in America 162 
Case of Croup successfully treated (Smith) 163 
Case of Croup treated by Homoeopaths .' 165 
Cases of Croup in which tracheotomy was indicated ... 168 
Cases of Croup treated by Dr. Yedder 
Cases of Croup treated by Dr. IT. G. Clark 171 
Trousseau’s method of practising Tracheotomy 172 
Interesting case of Croup by Dr. G. II. Gay. 175 
CHAPTER VIII. 
Treatment of Croup continued 187 
General Remedies 187 
Emetics 187 
Antimonial Preparations 188 
Tartar Emetic—its effects upon the pulse 189 
Tartar Emetic—its effects upon young Children 190 
Blood Letting 192 
Opinions of different authors 193 
Mercury... % 195 
Mercury first employed in Croup by Dr. Rush 195 
Calomel the best preparation 196 
Hydrocyanic Acid 197 
First employed by the Italian Physicians 197 PKEFACE TO EIBST EDITION. 
"When, about eighteen months ago, the author brought 
before the medical public, in a work on Diseases of the 
Air-Passages, the subject of the treatment of disease of 
the larynx and trachea, in the adult, by means of the 
direct application of therapeutical agents to the lining 
membrane of those cavities, the proposition was received 
with distrust by a large proportion of the profession; 
whilst another part publicly and peremptorily declared 
that it is practically impossible to convey medicinal 
agents, in the manner proposed, below the epiglottis. 
Less than two years have passed, and that practice 
which, as the British and Foreign Medical Be view has 
remarked, was received by “ some of the author’s coun- 
trymen with a sneering incredulity,” and was by them 
declared to be an “unwarrantable innovation,” an 
“ anatomical impossibility,” as well as “ physiologically 
impracticable,” has been adopted, not only by distin- 
guished medical men in almost every part of this 
country, but by the highest medical authority of 
Europe ; and by the latter has been commended as 
a method of treatment which is not only the most 
effectual and certain in some forms of pulmonary dis- 
ease, but as one that “ will lead to important changes 
in the prophylaxis and cure of pulmonary phthisis.” PREFACE. 
Less reluctantly, therefore, does the author now advo- 
cate—as ho has done in the following pages—the 
practice of making topical application of medicinal 
agents into the larynges of young children, for. the 
treatment of membranous croup. Nor does he hesitate 
to declare, although the proposition may be received 
by many with allowance, that it is a plan entirely 
practicable, safe, and, when judiciously employed, in 
the highest degree efficacious. 
The first successful attempt to introduce a solution 
of tbe nitrate of silver into the larynx of a child affected 
with croup, was made by the author, in November, 
1842. During a period of nearly four years, previous 
to this time, he had been constantly employing this 
remedy, locally, in chronic, laryngeal and bronchial 
diseases of adults. But, up to the above period, such 
were the prejudices against its employment, and such 
the skepticism of a large proportion of the profession 
on the subject of topical applications to the larynx, in 
tbe cases of adults even, that, hitherto, he had not 
ventured on its use in the treatment of diseases in 
young children; although the happy effects which in 
so many instances had followed the application of a 
strong solution of the nitrate to the diseased pharyngo- 
tracheal membrane and its follicles, had long before 
convinced him that the same remedy must prove 
highly efficacious in a disease so strictly local, and of a 
nature so peculiar, as is that of Croup. 
The history of one of the earliest cases of Croup 
which came under his observation, and was treated by 
topical applications to the larynx, was given at a meet- 
ing of the New York Medical and Surgical Society, 
November 1st, 1845, and the members present wTere PREFACE. 
desired to make trial of the local remedy, whenever an 
opportunity for employing it in Croup might occur. 
Several cases were thus treated subsequently, and with 
success, by other medical men in this city; a notice of 
some of these will be found in the subsequent pages. 
In describing, in this work, the application of the 
nitrate of silver to the mucous membrane, the term 
cauterization is frequently employed. It is not strictly 
correct; for, a solution of the crystals of nitrate of 
silver, of the strength.of from two to four scruples of 
the salt to an ounce of distilled water, when applied 
freely to the mucous membrane, does not act, as has 
been supposed, by burning, or as a cautery; it effects 
no destruction whatever of the textural matter, but 
forms, immediately, a union with the albumen,- and 
other secretions of the mucous lining; whilst it operates 
at the same time to produce a most favorable change in 
the vital action of the parts. 
In conclusion, this little work, and the practice herein 
advocated, are commended to the candor of that portion 
of the profession who have the liberality to admit that 
improvements in the practice of our art can be made; 
and the energy and honesty to test such proposed im- 
provements before condemning them. 
12 Clinton Place. 
JVeio York, Sept. 1848. PREFACE TO SECOND EDITION. 
“ It is my firm belief,” said Sydenham to Dr. Harris, 
the author of an essay on the Acute Diseases of Child- 
ren, “that your little book will be more useful to man- 
kind than all I have written.” “The book did not in 
itself, perhaps, merit so high a commendation,” said 
Dr. Cheyne, in alluding to this remark, “but Sydenham 
foresaw that it would turn the attention of physicians 
to a part of their profession the most useful, and the 
most neglected.” 
In the publication of the first edition of this Essay, 
it was the sincere desire of the author to awaken in the 
profession an increased interest in that most frequent, 
and frequently fatal, disease of children, membranous 
Croup; and if any merit appertains to the work, it 
arises from this fact more, perhaps, than from all 
others, that its publication has served to call the atten- 
tion of physicians to a method of treatment which, 
in their hands, as the author has reason to believe, 
has already been the means of saving the lives of many 
children. 
The present edition has been carefully revised, and 
has received many important additions; which addi- 
tions consist principally of observations made by ex- PREFACE. 
perienced practitioners in this and other countries, on 
the treatment of Croup by topical medication. This 
method of treatment is employed, at the present day, 
more- extensively in Europe even, than in our own 
country. The subject of direct medication of the 
larynx, in the treatment of Croup, was first brought 
before the profession of France in 1857, in a paper 
presented to the Imperial Academy of Medicine, by 
M. Loiseau, and which was entitled, “A simple and 
easy method of entering the air-passages, in order to 
cauterize them, or to extract false membranes j to dilate 
the (glottis / to introduce substances used in the treatment 
of Croup, either in the form of liquid or powder, and 
finally to take the place of tracheotomy” 
A most interesting discussion on the subject of cau- 
terization of the larynx and bronchi followed the read- 
ing of this paper, in which MM. Velpeau, Trousseau, 
Piorry, Loiseau, De Paid, and others, participated; 
and a commission was appointed to investigate the 
subject,-of which M. Trousseau was made chairman. 
At a subsequent meeting, a very favorable report on 
the treatment of laryngeal diseases by this method was 
adopted, the commission declaring that cauterization 
of the air-passages, -in the treatment of Croup and 
kindred affections, is not only practicable, but is of 
great utility ; and M. Velpeau declared, in the discus- 
sion, that to M. Loiseau “ belonged the merit of having 
called attention to this subject.” “Thanks to his 
memoir,” he continued, “ we know Croup can be 
cured without operating for tracheotomy. That is a 
great deal. ... I believe the method recommended 
by M. Loiseau is a good one. While diphtheritis is at 
the opening of the air-passages it is curable, and M. PREFACE. 
Loiseau lias ascertained that it is not difficult to carry 
medications into the larynx.”* 
In alluding to this discussion of the Academy, the 
learned editor of the Gazette Medicate de Paris says of 
laryngeal cauterization : “ As a therapeutical means, it 
merits a more serious attention. What is the relation 
of cauterization to Croup? It is a powerful, energetic 
means, the only one which up to this time has really 
succeeded. When the disease is limited to the upper 
part of the air-passages we cauterize, and all practi- 
tioners agree that this means is truly of great benefit. 
What is laryngeal cauterization other than carrying 
beyond the limits of ordinary cauterization a remedy 
recognized as good, efficacious, not only against the 
essence of the disease itself, but also against the patho- 
logical secretion? Laryngeal cauterization is, then, in 
this respect, much superior to tracheotomy. Experience 
seems to have already confirmed these theoretical 
hopes—future experience will say much more of it.”f 
In the Gazette llebdomadaire for August 27, 1857, 
the editor, after calling attention to what has been 
done in America in the treatment of Croup by cauteri- 
zation, adds : “These experiments should be repeated 
by us, with that attention which the authority and the 
honorable position of our American confreres command. 
M. Loiseau, anticipated, as it is seen, in every particu- 
lar, gives us, however, a useful example, and his merit 
will still be great if he succeeds in introducing into use 
a practice worthy of more attention than it has yet 
received.” 
Hot only in France are cauterizations extensively 
* Union Medicale, August 27, 1857. 
f Gazette Medicale de Paris, August 29, 1857. PREFACE. 
employed, at the present day, in the treatment of mem- 
branous Croup, but, during the last year in particular, 
Topical Medication has been much relied upon in 
Great Britain, in the management of all forms of diph- 
theritic inflammation. Many of these important addi- 
tional observations, on the advantage of local remedies 
in the treatment of Croup, to which reference has been 
made, will be found recorded in the present edition of 
this work. 
HOEACE GKEEK 
12 Clinton Place. 
New York, June, 3859. OBSERVATIONS 
ON THE 
PATHOLOGY OF CROUP. 
CHAPTER I. 
Nature and Pathology of Croup. 
The distressing nature of croup—its frequent 
fatality, and the interesting class of patients 
who, ordinarily, are the subjects of its attack, 
invest with a peculiar interest any plan of treat- 
ment which promises to mitigate its horrors, or 
in any degree to lessen its fatality. 
Notwithstanding that the energies of some of 
the most distinguished medical men of the pre- 
sent century have been given to an investigation 
of the nature and the treatment of this disease, 
yet it is admitted at the present day by the 
best authorities, to be not only progressively on 
the increase, but so far uncontrolled by the ordi- 
nary remedial measures, as to prove fatal in 
13 14 
NATUKE AND PATHOLOGY OF CEOCP. 
nearly one-half of the whole number of those 
who are attacked by the disease ! * 
With emphasis, then, may it be said, that no 
member of our profession has discharged his 
duty, until he has at least made earnest efforts 
to add something to our stock of knowledge, 
respecting the pathology or the treatment of this 
formidable malady. 
Not until after the middle of the last century, 
was croup recognized and described as a distinct 
disease. Until that period it was confounded 
with catarrh, and other diseases of the respi- 
ratory apparatus ; but in 1765, Dr. Home of 
Edinburgh drew up and published an Inquiry 
into its nature and treatment, and gave to 
the disease the name of Croup;—an appellation 
by which it is universally designated at the pre- 
sent day. 
The celebrated general order issued by Napo- 
leon, in 1807, from the head-quarters of Fin- 
kenstin,—“ d’ouvrir un concours sur la maladie 
eonnue sous le nom de croup,” with the offered 
prize, awoke a new interest on this subject in 
Europe, and was the means of calling forth, from 
the savans of the continent, many elaborate and 
able essays on the disease, in which, says Dr. 
Cheyne, nothing was omitted in illustration of NATURE AND PATHOLOGY OF CROUP. 
15 
that disorder which industry could collect, or 
method arrange. These learned inquiries of the 
aspirants for the prize at concours, have been fol- 
lowed, during the last forty years, by numerous 
and valued essays on the pathology and treat- 
ment of croup, contributed by some of the most 
distinguished medical men of both Europe and 
America : and yet the views respecting its essen- 
tial nature, and the opinions regarding the most 
certain and efficacious mode of its treatment, 
* 
are not uniform, or well settled with the pro- 
fession. 
Diverse, moreover, are the opinions of the 
different writers on croup, with regard to the 
unity or the division of the disease into distinct 
varieties ; some, on the one hand, making seve- 
ral species of the affection, according to the views 
entertained of its nature ; others, again, consider- 
ing the disease to be essentially one and the same 
in all cases, and as being modified only by exter- 
nal circumstances, or by difference of constitution 
in the subjects attacked. 
These varied opinions of different pathologists 
on this and other affections, serve to embarrass 
the inexperienced, and to hinder our progress in 
the knowledge of disease. 
Without attempting to settle any of the ques- 
tions involved in these different opinions, I shall 
proceed to state that, after having given much 16 
NATURE AND PATHOLOGY OF CROUP. 
attention to the study and treatment of the dis- 
ease whilst actually engaged in a general practice 
through a period of more than twenty years, I 
have come to the following conclusions : 
1. That true croup, pathologically considered, 
is a special or single disease ; being dependent 
for its existence, like tubercular phthisis, on a 
peculiar or specific cause. 
2. That its distinctive and essential charac- 
teristics consist in an inflammation of the secret- 
% 
ing surfaces of the fauces, larynx, and trachea, 
which is always productive of a membranaceous 
or an albuminous exudation. 
3. That the membranaceous concretion, which 
is found coating the inflamed mucous surface of 
the parts in croup, is an exudation—not from 
the membrane itself, but is secreted principally 
by the muciparous glands, which so abundantly 
stud the larynx and trachea. 
4. That the exudative inflammation com- 
mences invariably in the superior portion of the 
respiratory passages, and extends from above 
downwards—never in the opposite direction. 
1. The opinion that croup, in its access, is 
essentially one and the same disease—being only 
modified by epidemic influences, by difference 
in constitution, or by other fortuitous circum- 
stances, is founded principally on the pathological 
fact, that the inflammation peculiar to this dis- NATURE AND PATHOLOGY OF CROUP. 
17 
ease is always attended with an exudation of 
plastic lymph. 
Not that I would here maintain with MM 
Guersent and Bretonneau, that the perfect form- 
ation of a false membrane is necessary to con- 
stitute the distinctive character of croup, and 
that the cases where this is not formed are, as 
they declare them to he, instances merely offalse 
croup ; but this I affirm, that inflammation of 
the respiratory mucous membrane—whatever 
may he its grade—if unattended with an albu- 
minous exudation—can no more constitute croup, 
than any of tire various diseases of the lungs, or 
of their tissues, which are unaccompanied with a 
tuberculous deposition, can constitute true pul- 
monary phthisis. 
I agree fully with Prof. Hasse,* that the exuda- 
tion of croup may present various gradations, or 
different degrees of density. In some instances 
it consists of a tenacious mucus, wherein are 
suspended thin, membranaceous flocculi—or, in 
other words, the viscid mucus is blended with 
fibrin in various proportions ; sometimes, again, 
of a layer, resembling both in color and consis- 
tency that which settles upon scalded cream ; 
and sometimes of a firm and tough false mem- 
* An Anatomical Description of the Diseases of the Organs of Circula- 
tion and Respiration. By Charles Ewald Ilasse, M.D., etc. Sydenham. 
Society Edition, p. 2'78. 18 
NATURE AND PATHOLOGY OF CROUP. 
brane of considerable thickness, and which 
extends not unfrequently from the fauces, 
throughout the greater portion of the air-pas- 
sages. Not that this concrete albuminous mem- 
brane will be found to be present in all cases of 
croup, but it is here maintained, that the effusion 
of coagulable lymph is the essential pathological 
character of the disease ; and that the degree of 
density of the plastic exudation will depend upon 
the intensity of the inflammation, and the dura- 
tion of the disease. When a child dies very 
early in the malady, says Dr. Copland,* instead 
of the formation of a concrete false membrane, 
the parts will be found coated only with a tena- 
cious mucus, or fibrinous exudation. As the dis- 
ease advances, this glutinous secretion becomes 
more condensed, and moulded into a false mem- 
brane, or it may be found having assumed a but 
partially concrete condition. “La presence de 
cette fausse membrane est le caractere ana- 
tomique fondamental de cette affection. Sans ce 
produit nouveau, il n’y a pas de croup 
“ Les fausses membranes sont exclusivement 
formees de fibrine.” f 
That form of the affection which has been 
termed Spasmodic Croup by some writers, is a 
* Dictionary of Practical Medicine. Article Croup, 
f Manuel Pratique des Maladies des Nouveaux-Nes, et des Enfants a 
la mamelle. Par M. Bouchut. Article, Croup. NATURE AND PATHOLOGY OF CROUP. 
19 
variety of this malady, and not a distinct dis- 
ease. 
When children of a nervous temperament, or 
of weak and irritable habits, are exposed to the 
ordinary exciting causes of croup, and become 
the subjects of the disease, we then have the 
spasmodic variety of the affection; or, in other 
words, the inflammation, under such circum- 
stances, is of a sub-acute character ; the albumin- 
ous secretion is more tardilv effused ; but there 
is present, from the commencement of the disease, 
a great predominance of spasmodic and nervous 
symptoms. The stricture of the glottis which 
attends this form of the malady is spasm caused 
by inflammation, occurring in weak children of 
the above nervous temperament. 
This inflammation, Dr. Cheyne * observes, is 
often spontaneously resolved, the spasm depend- 
ing upon it subsiding at the same time ; and 
this has given rise to the opinion that there is 
a purely spasmodic species of croup—an opin- 
ion not sustained by the pathology of the dis- 
ease. “With respect to the inflammatory and 
the spasmodic varieties of croup,” says Mr. Ry- 
land, “I have before stated that this division 
can refer only to the predominance of either 
set of symptoms. The nature of the disease is 
* Cyclopaedia of Practical Medicine. Article, Croup. 20 
NATURE AND PATHOLOGY OF CROUP. 
essentially inflammatory, but in weakly, leuco- 
phlegmatic children, who are always more subject 
to nervous affections than the more active and 
healthy race, it sometimes assumes a spasmodic 
form, inasmuch as the vascular excitement is 
comparatively trifling, whilst spasm of the glot- 
tis and general convulsions occur frequently 
during the disease, and the remissions are singu- 
larly long and complete.”* The occurrence of 
short intervals of natural breathing, which take 
place suddenly, every now and then, in spas- 
modic croup, has been adduced by some writers 
as characterizing this form of the disease, and 
as indicating, they suppose, the noil-inflamma- 
tory nature of the affection. But these remis- 
sions, which take place for the most part in the 
early stage of the disease, occur, not because 
there is no degree of inflammation present, and 
consequently, no obstructions from albuminous 
secretions, but for the reason that this last mor- 
bid condition is not of sufficient extent, at this 
period of the malady, to embarrass respiration, 
whenever perfect relaxation from the spasm 
takes place. As the disease advances, and the 
membranaceous exudation increases, and be- 
comes denser, the remissions are less complete, 
and of shorter duration—the exacerbations more 
* A Treatise on the Diseases and Injuries of the Larynx and Trachea. 
By Frederick Ryland, p. 127. NATURE AND PATHOLOGY OF CROUP. 
21 
prolonged, and the cough and difficulty of respi- 
ration more severe. 
M. Guersent, and other pathologists, have 
shown from the dissection of cases, where this 
spasmodic form of croup has terminated fatally, 
that “ albuminous concretions—sometimes ex- 
tensive, but more frequently consisting of small 
isolated patches, are found in the larnyx ;* and 
Dr. Williams, in a Treatise on Diseases of the 
Respiratory Organs, also affirms that “although 
the albuminous effusion is generally thickest and 
most tough in sthenic cases of croup, yet it is 
pretty abundant in asthenic cases ; so much so, 
that Andral and Gendrin consider plastic in- 
flammation of the mucous membranes to be 
rather of the sub-acute, than of the most acute 
kindffif 
Dr. John Ware of Boston, who, in his ad- 
mirable “ Contributions to the History and 
Diagnosis of Croup,” has done more to elucidate 
the true pathology of membranous croup than 
any other writer in this country, makes two dis- 
tinct varieties of the affection, in the pathology 
of which he thinks there is an original and 
essential difference. 
These two forms of croup, Dr. Ware has dis- 
tinguished as membranous and inflammatory 
* Dictionary of Practical Medicine. Article, Croup, 
f Ut supra, p. 140. 22 
NATURE AND PATHOLOGY OF CROUP. 
croup—the former being characterized by the 
presence of a false membrane in the air-passages, 
while the latter differs from the first variety only 
in the supposed absence of this adventitious 
membrane. 
According to Dr. Ware, the severe form of 
the disease occurs much less frequently than the 
milder variety, is but little affected by any form 
of treatment, and is almost always fatal. Of 
one hundred and thirty-one cases of croup, ob- 
served by Dr. Ware, in the course of twenty - 
five years, twenty-two only of these were cases 
of true or membranous croup ; of which number 
nineteen died. 
The principal grounds, with Dr. Ware, for 
believing that the two forms of croup are patho- 
logically different from each other, are thus 
stated : “The very great preponderance of fatal 
results, in the membranous croup, and a similar 
preponderance of recoveries in the inflammatory; 
and the evidence which exists that in the few 
cases of recovery from the former, the membrane 
has been formed, and in the few cases on record 
of death from the latter, that a membrane has 
not been formed—afford strong reason for believ- 
ing that the diseases are essentially different.”* 
And yet Dr. Ware, with much candor, observes 
* Contributions to the History and Diagnosis of Croup. By John 
Ware, M.D., p. 12. 23 
NATURE AND PATHOLOGY OF CROUP. 
on another page, ‘ ‘ that with our present amount 
of knowledge, he would not be understood even 
to assert positively, that they are not different 
manifestations of the same disease.” * 
In the above form of the disease—which has 
been considered as a single affection, it is not 
intended to include that hysterical affection of 
adult age, described by Dr. Cheyne, which not 
unfrequently assumes the character of croup ; 
nor that disease of infancy, termed laryngis- 
mus stridulus, which, the above writer observes, 
ought never to be called croup, inasmuch as it 
is not attended with cough, and leaves, on dis- 
section, no trace whatever of inflammation of 
the larynx. 
The membranaceous exudation consequent 
upon violent inflammation of the air-passages 
during measles and scarlatina, and which some- 
times appears about the fauces, and in the upper 
portion of the larynx, differs, according to modern 
pathology, from that which takes place in croup. 
The fluids having become vitiated in these dis- 
eases, there is secreted a much less amount of 
fibrin than takes place in primary croup ; hence 
the false membrane is less consistent—less uni- 
formly spread over the involved part, is friable, 
and prone to decomposition. 
Although it is maintained that croup is essen- 
* Loco citat. p. 3. 24 
NATURE AND PATHOLOGY OF CROUP. 
tially a single disease, being only modified by 
difference in constitution, epidemic influences, 
and other circumstances ; yet it may with pro- 
priety be divided into laryngeal, tracheal, and 
bronchial croup, according to the seat of the 
greatest intensity of the inflammatory action ; 
and inasmuch as “the treatment and the prog- 
nosis may be in some measure influenced by the 
locality of the disease,” croup, moreover, may be 
complicated with, or be consecutive to, other 
affections of the air-passages. It may be asso- 
ciated with chronic bronchitis, and there is then 
presented that form of the disease which Dr. Rush 
denominated, Cynanche Trachealis Humida. In 
many cases, symptoms of acute bronchitis are 
predominant, but ordinarily in this form of the 
affection, the bronchial disease is consequent 
upon the exudative inflammation. In a large 
proportion of the cases of croup which terminate 
fatally, the inflammation will be found to have 
extended into the bronchi, filling, indeed, the 
terminal branches, and even the interstitial cells, 
with an effusion of serum, and it is this bronchial 
effusion which in some instances is the final cause 
of the fatal result. 
2. The truth of the second proposition stated ; 
namely, that the essential pathological character 
of croup is inflammation of the lining membrane 
of the larynx and trachea, attended by a concrete NATURE AND PATHOLOGY OF CROUP. 
25 
albuminous exudation, is unanimously admitted 
by the best pathologists of the day. 
The plastic exudation which is poured out 
upon the surface of the mucous membrane in 
croup, forms with great rapidity. It consists 
mainly of fibrin blended with mucus in various 
proportions ; and it presents different degrees of 
density, and varies much in thickness and extent 
of surface over which it is spread. In some 
cases, it consists of a tenacious mucus blended 
with a small proportion of fibrin ; sometimes of 
a dense, albuminous concretion ; and, again, it is 
found in the form of a thick adventitious mem- 
brane, extending from the epiglottis without 
breach of continuity to the extremities of the 
bronchial ramifications.* 
3. With respect to the source of that peculiar 
exudation which is poured out upon the inflamed 
mucous surfaces in croup, I have before expressed 
the opinion that it is an exudation from the 
diseased follicles of the tonsils, larynx, and 
trachea. 
Anatomy has revealed to us that the tonsillary 
glands are composed, almost entirely, of an 
aggregated mass of follicles, enveloped in folds 
of the mucous membrane ; that the lining mem- 
brane of the larynx is studded with mucous fol- 
* A Treatise on the Diseases and Injuries of the Larynx, etc. By 
F. Hyland, p. 134. 26 
NATURE AND PATHOLOGY OF CROUP. 
licles, especially that portion of it which occupies 
the upper part of this organ. These glands, 
indeed, are very numerous in the thickness of 
the superior vocal cords, within the ventricles of 
the larynx, and in the folds of the mucous mem- 
brane, in front of the arytenoid cartilages. The 
lining membrane of the trachea is supplied still 
more abundantly than that of the larynx with 
the mucous cryptae. 
Now, it will be found, that wherever these 
glands are the most numerous in the air-pas- 
sages, there, ceteris paribus, will the albuminous 
exudation be the most abundantly poured out in 
the inflammation of croup, and the adventitious 
membrane will be the densest and the most per- 
fectly formed. 
The fluid secreted by the mucous follicles of 
the air-tubes, being intended to lubricate these 
passages, is, in the normal condition of the 
glands, bland and transparent, not abundant in 
quantity, and possesses no qualities of an acrid 
or adherent nature. 
It consists, according to late microscopic ob- 
servations, of water combined with a viscid sub- 
stance, which is termed mucus, and which con- 
stitutes about five per cent, of the whole amount. 
When the mucous membrane of the larnyx 
and trachea becomes the seat of the exudatory in- 
flammation of croup, the glands which in health NATL’EE AND PATHOLOGY OF CKOUP. 
27 
lubricate its surface, are now found, from some 
peculiarity of irritation, to elaborate a vitiated 
fluid, or a fibrinous exudation, which, sooner or 
later, if the disease continues, is changed into 
an adherent false membrane, having generally 
its greatest degree of thickness in the larnyx 
and trachea, but becoming thinner as it descends 
towards the bifurcation. 
The opinion here adduced, that the plastic 
exudation in croup is poured out by the mucous 
glandulse of the part, where the disease is located, 
finds confirmation in the interesting fact re- 
corded by Prof. Hasse ; namely, that ‘‘filamen- 
tous bands are sometimes found between the 
plastic exudation and the mucous membrane, 
consisting merely of delicate fibrous threads 
which dip into the orifices of the muciperous 
glands ” * 
In 1854, several years subsequent to the publi- 
cation of this work, my colleague, Prof. E. R. Peas- 
lee, published a most valuable and original Mono- 
graph on Croup, in which he maintains that the 
“ false membrane is, in all cases, formed from the 
plasma of the blood, and consists principally of its 
fibrinthat the plasma, in inflammation of 
membranes, is exuded from the engorged ves- 
sels of the part, and upon the surface of the 
membrane ; that, in membranous croup the exu- 
* Op. citat. p. 280. 28 
NATURE AND PATHOLOGY OF CROUP. 
elation is most abundant, and therefore the result- 
ing membrane is thickest, on the surface where 
the mucous follicles are most abundant, because 
these cryptce being “ merely an inversion of the 
mucous membrane, here is a great amount of free 
surface, and a vast number of small blood-vessels 
inclosed within a very small space.* 
4. I have, on a former occasion,f expressed 
the opinion that the physiological and pathologi- 
cal relations which exist between the throat and 
the respiratory tubes, are not justly regarded by 
medical writers, in describing the nature of those 
diseases which affect these different parts. 
Affections of the throat are ordinarily ar- 
ranged by nosologists in connection with those 
of the oesophagus : or are treated independently 
of those diseases which occur in the larynx, 
trachea, and bronchi. 
Pathologically considered, the relation which 
exists between the fauces, tonsils, and pharynx, 
on the one hand, and the respiratory tubes on 
the other, is much more intimate and important 
than the connection which exists between the 
throat and the oesophagus. 
In almost all the inflammatory affections of 
the air-passages, whether primary or consecu- 
* On the Pathology and Rational Treatment of Croup. Dr. E. R. Peas 
lee, American Medical Monthly, Aug. 1854. 
f See Treatise on Diseases of the Air-passages, etc. p. 24. NATURE AND PATHOLOGY OF CROUP. 
29 
tive, the diseased action has its origin in the 
fauces and pharynx, and extends, by continuity, 
from thence to the respiratory tubes. This is 
especially true with regard to the origin and 
progress of the exudatory inflammation of croup. 
Here, the morbid action commences primarily 
about the fauces and the upper portion of the 
respiratory passage, and extends, universally, from 
above downward. Hr. Porter, I am aware, ob- 
serves in his work on the “ Surgical Pathology 
of the Larnyx and Trachea,” * the effusion of 
coagulated lymph is very generally confined to 
the larynx alone ; but still, in a number of cases, 
the inflammation commences in the bronchial 
cells, and proceeds upwards in the windpipe. 
But this view of the course of exudative in- 
flammation is not sustained by the observations 
of modern pathologists. Professor Rokitansky, 
who is undoubtedly one of the first pathologists 
of the age, says, that the exudative process pro- 
gresses from the epiglottis downwards, extending 
in some instances to the very minutest branches 
of the bronchi; and that bronchial croup is a 
disease of youth and early manhood, and when 
occurring in the terminal branches of the bronchi, 
is always simultaneous with pneumonia,f and 
* Ut supra, p. 36. 
\ Treatise on Pathological Anatomy, translated by Dr. J. 0. Peters, 
pp. 22, 23. 30 
NATURE AND PATHOLOGY OF CROUP. 
consequently in such cases cannot be true croup. 
Prof. Hasse also, whose late work on Patholo- 
logical Anatomy has been translated and pub- 
lished by the London Sydenham Society, ob- 
serves with regard to the exudatory inflamma- 
tion of croup, that its progress is invariably from 
above downward, and that it never spreads in 
the opposite direction. This law is so univer- 
sal, that where plastic inflammation occurs in 
the bronchi of the adult, as the concomitant of 
pneumonia, it can only descend to the pulmonary 
cells, never mount to the larynx. * 
This view of the progress of the disease has 
been confirmed by other pathologists, since the 
issue of the first edition of this work. In an 
excellent dissertation on the “ History, Nature 
and Treatment of Croup,” by Dr. Albert New- 
man, which obtained the “ Fiske Fund Prize,” 
awarded in 1855, the author says of'the inflamma- 
tion of croup, that “ it commences generally in the 
fauces, sometimes in the larynx ; but at whatever 
point it may commence, it extends always down- 
ward, never upward.”f Prof. Peaslee says, also, 
in the essay to which I have referred : “ The pro- 
gress of laryngo-tracliitis is invariably from above 
* An Anatomical Description of the Diseases of the Organs of Circu- 
lation and Respiration. By Charles Ewald Basse, M.D., etc., Sydenham 
Soc. Edition, p. 2*76. 
f American Journal of the Medical Sciences, Jan. 1856, p. 114. 31 
NATURE AND PATHOLOGY OF CROUP. 
downward. The observations of the best pathol- 
ogists have established this point. Generally, or 
at least very frequently, a catarrh commences in 
the nasal passages, and extends backward into 
the pharynx, then, descending into the larynx, 
continues such for a time, or at once merges into 
an inflammation. Often the pharynx becomes 
inflamed, and a false membrane appears upon it 
before the inflammation descends into the larynx 
and trachea. In some cases, the larynx may be 
the part first affected ; but if so, such cases are to 
be regarded as exceptional, and the inflammation 
never extends upward, but always downward, 
from that organ.’7* 
Let this important point, advanced in this last 
proposition, with reference to the pathology of 
the disease, be fully established, and universally 
understood by the profession, and it will be at 
once perceived what important results may fol- 
low the topical employment of appropriate re- 
medial agents, in the early treatment of true in- 
flammatory croup. 
In the preceding brief observations on some 
manifestations in the especial pathology of croup, 
reference has not been had to other important 
points in its general pathology, to which it may 
be well briefly to allude. 
From an examination of the tables given by 
* American Medical Monthly, August, 1854, p 98. 32 
NATURE AND PATHOLOGY OF CROUP. 
M. Caillon, Ryland, and other foreign authors, 
it appears that croup is a disease of childhood, 
and attacks children most frequently between 
the second and tenth years. In this country, the 
age at which children are most liable to this 
disease, is probably from one year to eight years 
old. 
There are few cases on record where it has 
occurred as early as the sixth month. In the 
table given by Ryland,* embracing the experience 
of some fourteen authors, it had been observed 
only once at the age of seven months, and never 
at an antecedent period. 
With the morbid changes which are revealed 
by an examination of the bodies of children who 
have died of croup, medical men are now gene- 
rally familiar. Ordinarily, the lining membrane 
of the air-passages, particularly that of the larynx 
and trachea, is found inflamed, its tissues tumid, 
and the entire surface of these parts is coated, 
either with an adventitious membrane, or a less 
densely formed albuminous exudation, varying in 
consistence according to the duration of the 
disease, and the intensity of inflammation which 
had been present. This exudation is composed 
almost entirely of fibrin blended with mucus, 
in various proportions. 
In the first stage of the disease the plastic 
* Loc. citat. p. ISO. NATURE AND PATHOLOGY OF CROUP. 
33 
exudation consists of a tenacious mucus, wherein 
are suspended shreds of coagulable lymph. In 
the second stage, the mucous surface of the 
larynx and trachea becomes partially or wholly 
coated with a membranaceous exudation of con- 
siderable density, and which is finally molded, 
in the last stage, into a firm, false membrane, 
extending sometimes throughout a greater por- 
tion of the air-passages, and pervading even the 
minute ramifications of the bronchial tubes. 
This membranaceous product, when first formed, 
adheres with considerable firmness to the mucous 
membrane ; but after an interval, and as the 
inflammation abates, a mucus, or a muco- 
purulent excretion, becomes deposited beneath 
the plastic layer, which serves to loosen and to 
assist in detaching the adventitious membrane, 
when it is sometimes expelled by violent cough- 
ing, either in fragments or in a cylindrical mass, 
which represents the parts upon which it has 
been molded. 
It is a mistake to suppose, as many do, that 
the secretion of the characteristic discharge of 
croup begins in the early stages of those catarrhal 
symptoms, which precede, frequently, for many 
hours, the development of true inflammatory 
croup. In the most violent and acute forms of 
the disease, the plastic exudation commences 
nearly simultaneously with the inflammation, to 34 
NATURE AND PATHOLOGY OF CROUP. 
be poured out upon the inflamed mucous surface ; 
but in some instances a preexisting catarrhal 
stage, of several days’ duration, may be present, 
before the occurrence of that peculiar inflamma- 
tion which disposes the vessels of the membrane 
to exude the albuminous deposit. “No sooner, 
however,” says Prof. Hasse, “does the catarrhal 
irritation merge into inflammation, than the 
plastic lymph is thrown out, and the parts 
immediately suffer that disturbance of nervous 
energy, which results from all violent inflamma- 
tions.” * Instances, too, may arise where the 
early occurrence of violent spasms shall destroy 
the patient, while as yet the exudation has 
assumed no degree of density, and it wTill then 
be found in the air-passages, presenting the 
appearance of a layer of viscid, whitish mucus ; 
or, at most, there may be perceived irregular 
fragments of adherent lymph in the glottis and 
larynx, but more particularly about the tonsils. 
“ This glutinous exudation,” Dr. Copland re- 
marks, “becomes more and more condensed and 
molded into a false membrane, or partially 
assumes this state, as the disease advances.” f 
The membranaceous exudation differs much, 
not only in its density, but in its depth, and the 
extent of surface over which it is spread. It is 
commonly thickest in the upper and posterior 
* Op. citat. p. 277. f Dictionary of Prac. Med. p. 531. 35 
NATURE AND PATHOLOGY OF CROUP. 
part of the trachea. Dr. Ryland * observes that 
it ranges from half a line to a line and a half. 
Dr. Copland *j* considers a line and a half or two 
'lines to be its utmost thickness, and Professor 
Hasse J remarks that its depth is extremely 
variable, but nowhere exceeds three lines. 
Croup usually subsides after the occurrence of 
a single process of exudation • but cases are 
recorded where the inflammation has continued 
until the formation of a second, and even a third 
adventitious membrane. It is not therefore 
improbable, in the examples given by authors, 
where the albuminous deposit equalled two or 
three lines in thickness, that several successive 
layers had been poured out, during the severity 
and continuance of the inflammation. 
Examples of the great extent of the false 
membrane are given by different writers. Bre- 
tonneau § gives several instances of its extending 
in a connected and uniform layer, from the epi- 
glottis to the rami of the bronchial tubes. Bri- 
cheteau, || Dr. and Prof. Horner, ** of 
our own country, give instances of a similar ex- 
tensive pervasion of the plastic exudation. 
The post-mortem appearance of the mucous 
* Op. citat. p. 135. § Traite de la Diphtherite. 
f Dictionary of Prac. Med. p. 531. || Precis du Croup, p. 274. 
t Ut supra, p. 278. T Ryland, p. 134. 
** Pathological Anatomy, p. 310. 36 
NATURE AND PATHOLOGY OF CROUP. 
membrane, subjacent to the membranaceous 
deposit, varies according to the intensity and 
duration of the disease. In the acute form of 
the affection, and particularly where death takes 
place early, the lining membrane of the larynx 
and trachea is inflamed, and sometimes even of 
a vermilion hue, throughout the greatest part of 
its extent. In other; instances, and at a later 
period, it is found paler, and presenting in color 
a rosy tint only. Still later, as in the last stages 
of the disease, the redness of inflammation will 
have disappeared, and the mucous membrane 
will present its natural pale color. On this 
point, Dr. Ryland * has very properly observed : 
“It is not always possible to determine, from 
the results of an examination of the dead body, 
what was the state of parts before the final 
change took place, and this is especially the 
case with regard to inflamed membranes; in 
puerperal peritonitis, for example, which is un- 
questionably an inflammatory disease, and one 
the symptoms of which cannot readily be mis- 
taken, how often do we find the peritoneum 
free from redness ! The same observation holds 
good with regard to inflammation of the skin, 
the redness which exists antecedent to death 
vanishes most completely on the occurrence of 
that event 
* Op. citat. pp. 135-36. NATURE AND PATHOLOGY OF CROUP. 
37 
“ It happens but very rarely that we have an 
opportunity of examining the state of the mem- 
brane in the first period of croup, before the for- 
mation of the albuminous concretion ; and it is 
on this account, in a great measure, that we 
seldom find any vivid injection of the parts, for 
the secretion of the lymph weakens the inflam- 
mation most commonly, and in the end puts a 
stop to it entirely.” 
It has before been stated that croup is a dis- 
ease of childhood, that it is essentially inflam- 
matory in its nature, affecting especially the 
secretory surfaces of the larynx and trachea. 
But the question here occurs, and it is one 
which many able pathologists have endeavored 
to elucidate,—why does the inflammation of 
croup differ from the laryngeal and bronchial 
inflammations incident to childhood, and which 
affect the same parts with this disease ? Since 
the experiments, instituted by Jurine, Schmidt, 
and other essayists at the concours of Napoleon, 
to produce artificial croup in the lower animals 
(they having succeeded in producing a false 
membrane in the air-passages of young animals 
only), many pathologists have adopted the 
opinion that the peculiarity of the product in 
the inflammation of croup, is attributable to an 
excess of albumen in the blood of young child- 
dren. 38 
NATURE AND PATHOLOGY OF CROUP. 
Dr. Copland, who strongly advocates this 
theory, affirms that he has “ uniformly observed 
the fact: namely, that the quantity of fibrine 
and crassamentum in the blood taken from the 
patient, and of albumen in the urine, have been 
great in proportion to the inflammatory type of 
the disease, and the disposition to form a false 
membrane.” On the other hand, Hyland, Wil- 
liams, and other writers on the disease, attribute 
the peculiarity of the product of croup to the 
circumstance of the inflammation being more 
deeply seated than that of bronchitis ; namely, 
in the cellular tissue that enters into the compo- 
sition of the mucous membrane—from the secer- 
nent arteries of which the albuminous exudation 
is secreted. Although in most cases of croup 
the sub-mucous cellular tisue is infiltrated with 
serum, the effect of inflammation, yet according 
to Rokitansky/15 it is not so, in all fatal cases of 
the disease. It is therefore an unsettled ques- 
tion in the pathology of croup, whether the 
albuminous product is owing to some peculiarity 
in the nature of the inflammation, or in the 
structure which is the subject of it. 
* Op. citat. p. 22. CHAPTER II. 
LARYNGEAL AND TRACHEAL CROUP. 
In the preceding pages, I have taken a brief 
view of the opinions entertained by some of the 
best authorities, with regard to the nature and 
pathology of croup. 
I have also alluded to my own views as to 
the unity of the disease, and the nature and ori- 
gin of the product which constitutes its distinc- 
tive characteristic ; and I have endeavored to 
show, that the commencement of that exudative 
inflammation of the respiratory passages that 
occurs in true croup, is invariably in the upper 
portion of these tubes, and that the morbid ac- 
tion extends only from above downwards. 
Guided by this view of the seat, progress, and 
pathology of croup, and an extensive experi- 
ence in the topical treatment of other diseases 
of the air-passages, I adopted the determination 
several years ago to make the attempt in croup 
whenever opportunity should offer, to arrest the 
exudatory inflammation, and thus prevent the 
formation of a false membrane ; or, when formed, 
to promote its separation and consequent ex- 
39 40 
LARYNGEAL AND TRACHEAL CROUP. 
pulsion by the employment of topical applications 
to the mucous surfaces of the fauces, larynx, and 
trachea. 
A part of the results of these efforts will be 
found in the history of the following cases. 
In the treatment of croup with topical reme- 
dial measures, I have always employed a so- 
lution of the nitrate of silver, as, in my opinion, 
there is no known therapeutic agent, which for 
safety, efficiency, and certainty of action, can 
compare with the crystals of the nitrate of sil- 
ver, in the local treatment of laryngeal, tracheal, 
and bronchial affections. 
In preparing the solution, the pure crystals 
should be employed, and not the fused or solid 
nitrate, as the latter is much more likely than 
are the crystals, to contain the nitrate of potash, 
or copper, or lead in combination. A solution 
of the crystals, of the strength of from two to 
four scruples of the salt to an ounce of distilled 
water, when applied freely to the mucous mem- 
brane, does not act, as has been supposed, by 
burning, or by a destruction of the textural mat- 
ter. It forms, immediately, a union with the 
albumen, and other secretions of the mucous 
lining ; whilst it operates, at the same time, to 
produce a most favorable change in the vital 
action of the parts. 
The first favorable opportunity which pre- LARYNGEAL AXD TRACIIEAL CROUP. 
41 
sented itself for the employment of nitrate of 
silver, as a topical remedy, in croup, came un- 
der my notice in November, 1842. 
CASE i. 
On the evening of the 20th of November, 
1842, I was called to see John S , aged 
three years, the son of a widow woman in this 
city. He was in the last stage of croup, hav- 
ing been attacked with the disease about a 
week previous to the time of my being called. 
Catarrhal symptoms had preceded, for several 
days, the full development of the croupal stage. 
The ordinary remedies had been employed, 
but without arresting in any degree the pro- 
gress of the disease. The great prostration, the 
stridulous respiration, and other symptoms of 
threatened suffocation, which were present, in- 
dicated the stage of collapse, and that no re- 
lief could be expected from the employment of 
common means. Under these circumstances, I 
proposed the cauterization of the larynx, with 
the hope that some relief might be obtained 
from this operation. 
The proposition being acceded to by the 
friends of the little sufferer, I proceeded at once 
to apply a solution of the nitrate of silver, of 
the strength of twenty grains to the ounce of 42 
LARYNGEAL AND TRACHEAL CROUP. 
water, freely to the fauces, and into the cavity 
of the glottis. The application was followed 
by a violent expulsive cough ; by which a large 
quantity of ropy mucus was discharged. Con- 
siderable relief followed this operation ; the re- 
spiration became much less embarrassed, and 
so continued during a greater part of the fol- 
lowing night. Towards morning, however, the 
croupal symptoms recurred with much violence, 
and when I saw my patient at an early hour 
the next day, the prognosis appeared so un- 
favorable, that I did not deem it advisable to 
renew the application. 
The patient died the same day. No examina- 
tion of the body was made. 
This case is adduced as being the first in- 
stance, in my practice, where a successful at- 
tempt had been made to introduce the nitrate of 
silver into the larynx of a child affected with 
croup. During a period of nearly four years, 
previous to this time, as may be seen by refer- 
ring to my work on Diseases of the Air-Passages, 
I had been constantly using this remedy, locally, 
in chronic laryngeal and bronchial diseases of 
adults. 
But up to this period, such were the preju- 
dices against its employment, and such the 
skepticism of a large proportion of the profes- 
sion on the subject of topical applications to LARYNGEAL AND TRACHEAL CROUI*. 
43 
the larynx in cases of adults even, that hitherto 
I had not ventured upon its use in the treat- 
ment of disease in young children. The marked 
relief which for a time followed its employment 
in the above case, although adopted as the “ ul- 
timum remedium,” in the hopeless stage of the 
disease, and the small amount of irritation caused 
by the application, encouraged me to repeat the 
remedy on subsequent occasions. 
CASE II. 
Oct. 19, 1845.—I received a message to meet 
two medical gentlemen in this city in consul- 
tation, in the case of an interesting little daugh- 
ter of Mr. H., who was reported to be dying of 
croup. 
On repairing to the house, I found the medi- 
cal attendants in waiting, from whom I received 
the following history of the case. The little 
patient, who was three years old, had been suf- 
fering, for several days previous to the attack of 
croup, from a hoarse cold, which was attended 
with a dry, barking cough. ISTo alarm, however, 
was awakened in the minds of the parents 
until the evening of the 18th, when the child 
was suddenly and violently seized with croup. 
The family physician was immediately called, 
by whom the usual remedies were promptly em- 44 
LARYNGEAL AND TRACHEAL CROUP. 
ployed. No relief, however, following these 
measures, a consulting physician was called the 
next day, 'and other active measures were 
adopted. But the disease progressed with great 
rapidity until the evening of the 19th, at which 
time I was called. 
On entering the room, I found the child 
struggling for breath, for respiration seemed to 
he performed with the greatest difficulty. The 
head was thrown back ; the lips and face were 
livid ; and the whole countenance was expressive 
of the greatest anxiety. It was proposed that I 
should attempt to cauterize the larynx ; hut so 
near suffocation did the child at this time ap- 
pear to be, that I declined attempting to perform 
the operation, unless the attending physician 
would state to the friends of the patient its 
present hopeless condition ; for I feared that the 
impending fatal termination, which seemed so 
likely to follow, might be attributed to the 
effects of the application. This was done ; 
and, at the request of the father of the child, 
and the medical attendants, I proceeded to apply 
a strong solution of the crystals of nitrate of sil- 
ver (forty grains to the oz. of water), to the in- 
terior of the larynx. To effect this the head of 
the child, thrown back, was held firmly by an 
assistant, the tongue depressed, and a small, 
round sponge, fastened to a bent probang of LARYNGEAL AND TRACHEAL CROUP. 
45 
whalebone, and dipped in the solution, was passed 
over the top of the epiglottis, and pressed sud- 
denly downwards and forwards, into the cavity of 
the larynx. A convulsive cough followed this 
operation, and a large quantity of dense, adhe- 
sive mucus was discharged, in which traces of 
the false membrane were observed ; and, ad- 
hering to the sponge, also, were found fragments 
of the same albuminous concretion. The re- 
spiration, soon after this, wras in some degree re- 
lieved, the countenance was not so livid, and 
there wTas less jactitation. After a delay of 
nearly two hours, during which there wTas no in- 
crease of the distressing symptoms, the applica- 
tion was repeated. The same results followed 
the second application, that attended the first; 
and the embarrassed respiration was decidedly 
more relieved. 
The second cauterization was made at eleven 
o’clock in the evening. One grain of calomel 
was ordered every three hours during the night, 
and I was requested to meet the attending physi- 
cian at an early hour the next morning, and 
renew the application. 
At seven o’clock, the hour of consultation, the 
next morning, although we found our patient 
still oppressed by the impeded respiration, yet 
the breathing was slower, the countenance less 
anxious, and in no respect was she worse than 46 
LARYNGEAL AND TRACHEAL CROUP. 
when we left her the night previous. It was 
concluded to repeat the cauterization, and the 
nitrate of silver was again applied freely about 
the fauces of the child, and to the interior of the 
larynx ; and at this time the operation was fol- 
lowed with even more relief than had attended 
the previous application. 
I did not see the patient after this time, and 
the subsequent history of the case was furnished 
me by the attending physician, who stated, in 
substance, as follows :—That after the applica- 
tion of the nitrate of silver, in the morning, the 
child discharged a great quantity of ropy mucus, 
and appeared more relieved of the croupal 
symptoms than at any time before. At twelve 
o’clock, when he called, he found the little pa- 
tient sitting up in the cradle, breathing with 
more freedom, and “ looking as if she might re- 
cover.” These favorable symptoms continued 
until three o’clock, when the hour came for ad- 
ministering the grain of calomel, which, at longer 
intervals was still continued. 
In doing this, the child resisted with consider- 
able violence ; and, caused either by the efforts 
of the patient, or the irritation of the medicine, 
this was followed by a spasm, and a return of 
all the unfavorable symptoms ; and these con- 
tinuing to increase, the death of the child took 
place a few hours afterwards. LAEYNGEAL AND TEACHEAL CEOUE. 
47 
I have always been of the opinion that this 
case would have terminated favorably if it had 
not been for the occurrence of the above unto- 
ward circumstance. 
An examination of the body was requested, 
but could not be obtained. 
It is well known that marked remissions of 
the unfavorable symptoms will not unfrequently 
occur in some cases of croup • and this is par- 
ticularly true with regard to that form of the 
disease which early assumes the spasmodic cha- 
racter. 
But the almost entire relief which for a time 
followed the employment of topical medication 
in the suffocative and hopeless stage of the two 
preceding cases, was certainly unusual, and led 
to the conclusion that the same measure might 
prove quite successful if adopted in the access 
of the disease, or before the exudative .inflam- 
mation had extended into the trachea and the 
bronchial divisions. By the occurrence of the 
following cases the opportunity was presented 
for the local employment of nitrate of silver in 
the early stage of the affection. 
CASE III. 
Several years ago, a son of Mr. and Mrs. W., 
p Franklin street, a fine healthful child of four 48 
LARYNGEAL AND TRACHEAL CROEP. 
years old, was attacked with membranous croup, 
and, notwithstanding the most energetic mea- 
sures were adopted, died of the disease after a 
few days7 illness. Some time after this, another 
son, only a little younger than the first was at 
the time of his death, was similarly attacked, 
and died of the disease in about the same period 
of time. In November, 1847, the only remain- 
ing child of these parents, an interesting daugh- 
ter of eighteen months old, was violently seized 
with the same disease of which her brothers 
had previously died. Several hours after the 
occurrence of the croupal symptoms in this case, 
very late in the evening of Nov. 20th, 1847, I 
was called to see this child, and found her ex- 
hibiting all the symptoms of a severe attack of 
membranous croup. The heated skin, the fre- 
quent, oppressed, and stridulous respiration, the 
dry and ringing cough, “ tussis clangosa,” and 
the appearance of the tonsils and pharynx, 
which were highly inflamed, and coated with 
an albuminous exudation, left no room to doubt 
the nature and the stage of the disorder. 
For two or three before the disease had 
merged into true croup, the child had been la- 
boring under catarrhal symptoms, which were 
attended with hoarseness, and a dry, hard 
cough. 
Immediately on my arriving at the house, and LARYNGEAL AND TRACHEAL CROUP. 
49 
finding the patient in the above condition, I 
determined to try the effect, in this early stage 
of the disease, of remedies applied directly to 
the inflamed mucous surfaces. But in order, at 
the same time, to secure the aid of general re- 
medies, I ordered the administration of a few 
grains of ipecacuanha, and, after waiting several 
minutes, followed the medicine with the appli- 
cation of the sponge dipped in solution of 
nitrate of silver, of the strength of forty grains 
to the ounce of water. With this, the fauces, 
pharynx, and the laryngeal face of the epiglottis 
were well cauterized, and at the same time the 
sponge, wet with the solution, was carried into 
the larynx. 
As in the preceding cases, this operation was 
followed by a cough, and an effort at vomiting ; 
by which a large amount of glairy, adhesive 
mucus was discharged, commingled with which 
shreds of the false membrane were distinctly visi- 
ble. Within fifteen minutes the child breathed 
with more freedom, and there was an equally 
favorable change in the dry and ringing cough. 
Expecting to repeat the application, I remained 
a short time with the patient; but there was 
such an improvement in all the croupal symp- 
toms, that no further application of the caustic 
was made that night. Five grains of calomel 
were directed to be given to the child ; an eme- 50 
LARYNGEAL AND TRACHEAL CROUP. 
tic of ipecacuanha and tartarized antimony was 
ordered to be administered in the course of the 
night, if at any time there should be an increase 
of the peculiar symptoms of the disease. 
At an early hour the next morning I visited 
my patient, and found she had passed a night 
of comparative comfort. The respiration was 
not so laborious as when I left on the previous 
evening, the cough was less croupal, and the 
heat of the surface was greatly diminished. The 
calomel had moved the bowels, and as the pa- 
tient continued to improve during the night, the 
emetic was not given. 
The same favorable indications continued 
during the day ; but about nine o’clock that 
evening a message was received from the alarmed 
parents, requesting my immediate attendance, 
for their child, as the messenger reported, was 
suffering from a return of the croup. I found a 
recurrence of the same symptoms that had been 
present the preceding evening ; but they were 
much less in degree, and a single application 
of the nitrate of silver to the larynx, which I 
made at once, relieved, in a short time, the em- 
barrassed respiration, and lessened the croupal 
cough. 
The patient again passed a comfortable night, 
and the next day when I called, she appeared 
quite cheerful, and apparently almost free from LARYNGEAL AND TRACHEAL CROUP. 
51 
disease. From this time no further medication 
was needed ; the child has since passed through 
a severe winter without the recurrence of any 
symptoms of laryngeal disease. 
The above case occurred in a family whose 
children were predisposed to the disease ; and in 
its access and development, the affection pre- 
sented all the symptojns of true, membranous 
croup. With the exception of the small doses 
of ipecacuanha and calomel which were given 
on the evening of the attack, no other means 
were used but the local employment of a strong- 
solution of the crystals of nitrate of silver to the 
seat of the disease. 
During the months of February and March 
of the present year (1848), the occurrence of 
croup among children, in this city, has been 
more than ordinarily frequent. This is to be 
attributed, undoubtedly, to the epidemic influ- 
ence of the atmosphere, which, for some cause, 
has been in a condition to favor the develop- 
ment of influenza, and other diseases of the 
respiratory organs, in adults, and of croup in 
children. 
The following cases appeared during this 
period ; they took place in a family where croup 
had before occurred, and in one or two instances 
had proved fatal. 52 
LARYNGEAL AND TEACIIEAL CROUP. 
CASE iv. 
At a late hour in the evening of the 23d oi 
February, the Rev. Dr. B , of this city, 
called at my office and desired me to accompany 
him to see his little daughter, a child three years 
of age, who that evening had been violently 
seized with an attack of croup. 
She had been hoarse, and had had a rough, 
dry cough for several days previous to the full de- 
velopment of the affection. When I saw her a 
few hours after the occurrence of the disease, 
the symptoms of croup, which were present, 
were marked and severe—indeed, as I entered 
the hall of the house, the ringing cough and 
stridulous respiration of the child—sounds which 
no physician ever desires to hear a second time, 
were distinctly audible through the closed doors 
of the chamber above. 
With the aid of Dr. J. Hancock Douglas, 
who was in the office when the father of the 
sick child called, and who accompanied me to 
his house, I succeeded in obtaining a good 
view of the throat of the little patient. The 
parts were highly inflamed, and the tonsils were 
covered with an albuminous exudation. The 
barking cough and the embarrassed and tracheal 
respiration plainly indicated the stage of the dis- LARYNGEAL AND TRACHEAL CROTJP. 
53 
ease, and that the inflammation had extended to 
the larynx, and about the vocal chords. 
As no time was to he lost, I immediately ad- 
ministered ten grains of ipecacuanha, and after 
waiting fifteen minutes, prepared to cauterize the 
diseased parts. 
Assisted by Dr. D , I applied a solution of 
the nitrate of silver (forty grains to the ounce), 
to the fauces and pharynx, and also introduced 
the sponge saturated with the solution, into the 
cavity of the larynx. The introduction of the 
instrument was followed by a free discharge of 
muco-fibrinous matter, in which, and also on the 
sponge, were shreds of the membranous deposit. 
The little patient, very soon after the opera- 
tion, appeared greatly relieved. 
"We remained nearly an hour after the appli- 
cation, in order to repeat it if the symptoms 
should indicate its necessity ■ but the child con- 
tinuing to improve, we left for the night, after 
giving directions to have an emetic of ipecacu- 
anha administered should there be any increase 
of the embarrassed respiration. Soon after we 
left, the child fell asleep, and although the breath- 
ing was labored, and the cough, which occurred 
often during the night, was croupal, yet she 
slept for several hours, and when I called the 
next morning, I found a great improvement in 
all the above symptoms. The emetic had not 54 
LARYNGEAL AND TRACHEAL CROUP. 
been given. As there still appeared to be some 
inflammation about the throat, and the cough 
retained the peculiar sound of the disease, I had 
fears that there might be a return of all the un- 
favorable symptoms before night, and therefore 
concluded not to wait, but to repeat the appli- 
cation of the nitrate of silver to the diseased 
organ. This was done, and I feel confident 
the operation was attended with much advan- 
tage, for instead of having a recurrence of the 
croupal symtoms on the second night, as had 
occurred in a former instance (Case 3), and 
which is so likely to follow a remission of the 
disease in most cases, there was a constant im- 
provement of all the croupal symptoms during 
that day, and the following night was passed 
with equally favorable indications. 
In short, after this date no further medication 
was needed, for the child rapidly recovered. 
CASE Y. 
While in attendance upon the above case, a 
second child in this family, a little daughter, 
nearly eight years of age, was likewise attacked 
with the disease. 
It had been observed by the mother, that she, 
like her younger sister, had been hoarse with a 
severe cough for a number of days. For these LARYXGEAL AND TEACHEAL CROUP. 
55 
symptoms, occasional doses of syrup of ipecacu- 
anha, or of hive syrup, had been administered 
by the parents. But- notwithstanding the use 
of these expectorants, croup supervened on the 
above symptoms, which, although well marked, 
was not developed with quite that degree of 
severity that attended the onset of the disease 
in the preceding case. Being at the house soon 
after the access of the disease, I applied the 
cautery immediately to-the inflamed mucous sur- 
face of the throat and larynx. 
It will be unnecessary to repeat the details of 
the treatment in this case. Two applications 
only were made on the evening of the attack, 
and one on the following day. The only gene- 
ral remedy administered, was a laxative dose of 
calomel. The eroupal symptoms, which were 
greatly lessened by the first and second applica- 
tions, disappeared altogether after a single em- 
ployment of the local remedy on the second day. CHAPTER III. 
MEMBRANOUS CROUP, COMPLICATED WITH BRON- 
CHIAL INFLAMMATION. 
The preceding cases of croup, with the ex- 
ception perhaps of the first, may he termed in- 
stances of laryngeal, or tracheal forms of the 
disease. The bronchial variety, or that form of 
croup which is complicated with inflammation 
of the bronchial tubes, is described by most 
authors as commencing with catarrhal symptoms. 
There is, soon after the access, and in some in- 
stances from the invasion of the disease, a 
croupy character of the voice, dependent upon 
the exudative inflammation which distinguishes 
it from a purely catarrhal or bronchial affection. 
This distinction, be it remembered, is not founded 
upon any pathological difference in the nature 
of croup, for it is maintained that the peculiar 
inflammation of croup has its origin in the su- 
perior parts of the respiratory passage ; and 
that this inflammation, if continued, will extend 
not only along the trachea, hut into the ramifi- 
cations of the bronchi ; and we then have the 
sibilous respiration, the suffocative cough, and 
56 57 
MEMBRANOUS CROUP. 
the lividity of the countenance, which distinguish 
this complicated form of the disease. 
The danger of an unfavorable termination, it 
is considered by Ryland and others, will be in 
proportion to the rapidity with which these 
several stages follow each other. 
Although the chances of success, in the em- 
ployment of the nitrate of silver as a topical 
remedy, are greatly diminished when the exuda- 
tive inflammation has extended into the bronchi, 
yet, as the application of it does not preclude 
the adoption of other measures, its employ- 
ment, even when there is a predominance of 
bronchial symptoms, should in no wise be 
neglected. 
In the following case, though unsuccessfully 
employed in the advanced stage of a case of 
bronchial croup, yet such was the effect of the 
nitrate of silver, in mitigating the croupal symp- 
toms, and in relieving the oppressed and stridu- 
lous respiration, as to encourage perseverance, 
and awaken hopes of final success, in some cases 
of the complicated variety. 
CASE VI. 
Feb. 28, 1848.—Was requested to meet Dr. 
Spears, in consultation, in a case of croup, in the 
daughter of Mr. 1ST., of Sidney Place, Brooklyn; 58 
MEMBRANOUS CROUP, COMPLICATED 
This child, aged two and a half years, had ex- 
hibited, as I learned from the attending physi- 
cian, symptoms of croup complicated with ca- 
tarrhal or bronchial disturbance, for nearly a 
week before the full manifestation of the disease. 
During the last twenty-four hours all the symp- 
toms had become greatly aggravated, notwith- 
standing appropriate and energetic measures liad 
been employed, by the attending physician, to 
check the progress of the disease. 
I found the child oppressed with a most diffi- 
cult and laborious respiration ; there was great 
restlessness ; the voice was reduced to a whis- 
per ; whilst the choking cough, the livid lips, 
the constant heaving of the thorax, and the 
sibilous respiration, indicated the complicated 
nature of the case, and the advanced stage of 
the disease. 
After examining the case, I expressed my 
fears that permanent benefit would not follow 
the employment of topical remedies at that stage 
of the affection, especially as applications could 
only be made to a portion of the diseased mem- 
brane. As the attending physician and the 
parents were anxious to have a trial made, I 
applied a strong solution of the nitrate of sil- 
ver to the fauces, phaiynx, and on both faces of 
the epiglottis; and then, after a delay of ten 
minutes, I passed the sponge of the probang WITH BRONCHIAL INFLAMMATION. 
59 
through the aperture of the glottis, and freely 
cauterized the interior of the larynx. For a few 
moments the cough was more violent, and the 
respiration appeared more embarrassed. But 
during this time, a large quantity of muco-puru- 
lent matter was discharged, or was wiped from 
the mouth of the patient, commingled with which 
were many patches of false membrane. 
The respiration, soon after this, was much 
easier ; but more especially was this the case, 
after a second application, which was made in the 
course of half an hour, and which was followed 
by a like free discharge of viscid, yellow mucus, 
and a decided improvement in the choking, 
croupy cough and respiration. Indeed, although 
this patient did not ultimately recover, the 
s}unptoms of tracheal croup were at no time 
thereafter so severe, as before the nitrate of sil- 
had been applied to the parts. 
These applications, conjoined with appropriate 
general treatment, were repeated at intervals for 
several days, and always with more or less relief 
to the embarrassed respiration ; but the bron- 
chial affection continuing, pulmonic inflamma- 
tion supervened, and the child sank under the 
disease, and died on the thirtieth of the month, 
although the peculiar symptoms of croup, as the 
attending physician informed me, had nearly dis- 
appeared before the death of the patient. 60 
MEMBRANOUS CROUP, COMPLICATED 
I have alluded to the difficulty of reaching 
the whole surface of the diseased membrane, 
where, as in the preceding case, the exudatory 
inflammation has extended through the larger 
bronchi into their minute ramifications. But, 
even when this is the case, wTe should not be 
deterred from the employment of the nitrate of 
silver as a topical remedy, if it shall be found 
that, when it can be applied, its influence upon 
the mucous membrane is always salutary ; for, it 
is now an established fact, that a solution of 
nitrate of silver, of sufficient strength to arrest 
inflamed action, may be introduced in consider- 
able quantities below the epiglottis of adults, 
and thus be diffused with certainty over the sur- 
face of the bronchial membrane. 
Among the patients who during the last few 
years have come under my care, for the treat- 
ment of chronic laryngeal and bronchial disease, 
are a number of intelligent physicians. Several 
of them have informed me, that after 
having a few applications of the solution of ni- 
trate of silver into the larynx, they have felt the 
fluid distinctly extending down the bronchial 
tubes. Often, in these cases, no taste of the 
medicine would be observed, until matter, by 
coughing, was expectorated from the air-passages, 
when the peculiar flavor of the nitrate of silver— 
a most acrid bitter—would be perceived ; and WITH BRONCHIAL INFLAMMATION. 
61 
this would continue to be observed, whenever 
the individual expectorated, for many hours after 
the operation ; thus conclusively demonstrating, 
as it did, to those gentlemen, that the solution 
had pervaded the bronchial divisions. Another 
point, connected with this matter, is the inter- 
esting fact, that much less mechanical irritation 
is produced by the application of the nitrate of 
silver into the larynges of young children, who 
are suffering from croup, than when it is intro- 
duced into those of adults, who are affected by 
chronic diseases of the larynx. 
In applying this remedy, in the preceding 
case, it was observed by Dr. Spears, with much 
surprise, and the same fact has been remarked by 
myself in other cases, that after the first appli- 
cation of the solution to its larynx, this child, 
as if fully conscious of, and seeking for the re- 
lief it afforded, would open her mouth to receive 
the probang, whenever the physician approached 
for the purpose of repeating the operation. 
In the treatment of croup, therefore, where 
the plastic exudation has extended into the rami- 
fications of the bronchi, or where the primary 
affection is complicated with bronchial disease, 
a still more free use of the solution should be 
employed, in order that some part of the fluid 
may find its way over the diseased mucous sur- 
face of the lesser branches of the air-tubes. 62 
MEMBRANOUS CROUP, COMPLICATED 
Acting upon this plan, the following case of 
croup, complicated with bronchial disease, was 
successfully treated by the topical employment 
of the nitrate of silver. 
CASE VII. 
In the early part of the spring of the present 
year, M. M., of this city, called on me, and re- 
quested me to visit his little daughter, who, un- 
der the care of his family physician, had been 
sick with the croup for nearly a week, and was 
then dangerously ill. 
One or two of his children had already died 
of croup, and the array of symptoms which I 
found here presented, indicated an equally un- 
favorable termination of the disease in the case 
of this child. From the history given, as well 
as from the symptoms present, I found that 
bronchial inflammation had become complicated 
with the croupal affection soon after the attack. 
The symptoms present at this stage of the dis- 
ease were not.dissimilar to those that existed in 
the latter stage of the case last recorded. There 
was oppressed and stridulous respiration ; the 
voice was reduced to a whisper ; the character- 
istic croupy cough was present, but more suffo- 
cative and bronchial than when occurring in 
simple croup ; and complicated with these WITH BRONCHIAL INFLAMMATION. 
63 
S)rmptoms were further indications of extensive 
bronchial disease. Throughout the left lung, 
especially, of this patient, the sibilant respiration 
and other evidences of the affection were most 
apparent. 
The ordinary general treatment usually 
adopted in such cases had been judiciously and 
perseveringly employed for several days by the 
attending physician, apparently without arrest- 
ing in any degree the progress of the disease. 
I proceeded at once to cauterize the diseased 
organs, and having applied a strong solution of 
the nitrate to the fauces, pharynx, and about the 
glottis, passed the sponge well filled with the 
fluid into the cavity of the larynx. As had oc- 
curred in other cases, this operation was fol- 
lowed by a free expectoration of muco-purulent 
matter, large quantities of which adhesive dis- 
charge were wiped from the mouth of the 
patient, in which, and adhering also to the 
sponge of the probang, were many small frag- 
ments of the false membrane. 
These first applications were made about four 
o’clock in the afternoon ; at eleven o’clock at 
night they were repeated, when other portions 
of the adventitious membrane were ejected ; and 
within half an hour after the last application, 
there was a decided improvement in all these 
unfavorable symptoms. 64 
MEMBRANOUS CROUP, ETC. 
As the child was greatly enfeebled, not only by 
the severity of the disease, but from the ener- 
getic practice which had been employed, a stimu- 
lating expectorant was the only remedy ordered; 
anodyne and slightly irritating fomentations were 
applied to the chest ; and a bland, supporting 
diet was directed. 
On calling at an early hour the next morning, 
the attendants reported the patient as having 
passed a better night than had occurred to her 
since the first attack of the disease ; and the 
appearance of the child indicated a favorable 
change in all the unpromising symptoms. The 
breathing was much less embarrassed, the pulse 
and respirations were diminished in frequency, 
and the cough had nearly lost its croupy cha- 
racter. 
The same plan of treatment was continued, 
and from this period the patient recovered 
rapidly ; and although it was several days before 
the voice was restored, yet vocalization returned, 
and the child was ultimately restored to robust 
health. CHAPTER IV. 
MEMBRANOUS CROUP COMPLICATED WITH SPASMODIC 
AND WITH BRONCHIAL SYMPTOMS. 
It has been stated in the preceding pages, 
that that form of croup which some writers 
have denominated the spasmodic variety, is in 
fact different from the true inflammatory croup 
only in this respect, namely, that in such cases 
there is a greater predominance of spasmodic 
and nervous symptoms, whilst, on the other 
hand, there is a tardier tendency to the forma- 
tion of an adventitious membrane 
There is not a doubt, that in such instances 
as the following, patients are frequently cut off 
by the violence of the spasm before the plastic 
exudation has become in any degree condensed 
into a continuous membrane ; and it is from an 
examination of the morbid appearances mani- 
fested in similar cases that some writers have 
been led to adopt the conclusion, that there 
exist two distinct forms of the disease, in the 
pathology of which there is an original and 
essential difference. 
65 66 
MEMBRANOUS CROUP COMPLICATED 
CASE VIII. 
On the night of the 1st of April, 1848, I was 
desired by Mr. Hall, of Amos street, to visit his 
son, a fine healthy fat boy, five years of age, 
who had an attack of croup. The disease had 
come on after an unusual exposure to the cold 
easterly wind which had prevailed during the 
preceding day. Early in that day the child 
had been allowed to stand for an hour or more 
at an open window, engaged in watching some 
boys who were flying their kites near by, until 
he was quite chilled by the cold atmosphere. 
The attack of croup, as might be anticipated, 
in one predisposed to the complaint, followed 
this exposure. This case was first seen by me 
about three hours after the development of the 
disease. The symptoms at this stage of the 
affection were uncommonly violent. The cough 
was croupal ; the face flushed ; the respiration 
was accelerated, stridulous, and greatly op- 
pressed ; so much indeed was the breathing em- 
barrassed, and so great were the struggles for 
breath, it was with much difficulty that the child 
could be held in his mother’s arms. 
On examining the throat of the patient no 
patches of the false membrane could be dis- 
covered about the tonsils, but the whole faucial WITH SPASMODIC SYMPTOMS. 
67 
region was coated with a viscid exudation, and 
was, moreover, in the highest state of inflamma- 
tion. Here then was a case where severe spasm 
existed in the early stage of exudative inflam- 
mation, before the fibrinous dejiosit had assumed 
a concrete form. Every physical or rational 
symptom of true membranous croup was mani- 
fested in this case in a prominent degree, except 
the formation of the pellicular membrane, and 
this unquestionably would have been deposited 
in a short time if the morbid action had not been 
arrested. 
In order to excite vomiting, the syrup of ipe- 
cacuanha had been administered to the patient 
before my arrival, and at the suggestion of an 
officious neighbor, this had been followed by an 
infusion of lobelia, but no effect had been pro- 
duced by either of these remedies. 
Finding the symptoms so urgent—for imme- 
diate suffocation seemed impending—I deter- 
mined to try at once and relieve the spasm by 
local applications to the larynx of the patient. 
Directing the child’s head to be properly con- 
fined, I depressed the tongue, and passed a sponge 
saturated with a strong solution of the nitrate 
about the fauces and into the cavity of the larynx. 
A large quantity of ropy and adhesive mucus was 
quickly thrown off after the application. In a 
few minutes the respiration was less suffocative, 68 
MEMBRANOUS CROUP COMPLICATED 
but not until after a second application, which 
was made within twenty minutes of the first, 
was the relief marked and decisive. In less than 
half an hour after the second thorough applica- 
tion of the solution to the diseased parts the 
child fell asleep, breathing comparatively with 
but little difficulty. 
On calling the next morning to see my patient, 
he was found looking pale but cheerful, and was 
engaged at his play. He had passed the latter 
part of the night in a quiet sleep. His voice, 
although sounding hoarse when he coughed, 
was nearly restored ; his pulse was natural, and 
his respiration almost wholly unembarrassed. 
The emetic had not been administered, nor was 
any other medical agent whatever employed in 
this case after I was called but the local appli- 
cation of the argentine solution to the mucous 
surfaces of the fauces and larynx. The recovery 
was rapid and permanent. 
In this connection, I shall detail the treatment 
of but one other case of membranous croup as 
having come under my own immediate observa- 
tion. 
The interest connected with the following 
successfully treated case of membranous croup 
is enhanced by the fact that besides being one 
of the most severe and complicated cases of the 
disease that I have ever encountered, its pro- WITH SPASMODIC SYMPTOMS. 
69 
gress, treatment, and the effect of the treatment 
employed, were observed by several intelligent 
physicians, not one of whom considered it pos- 
sible to save the life of the child by means ordi- 
narily employed in the treatment of croup. 
CASE IX. 
The daughter of Mr. Griffin, of Hudson street, 
came under my care for the treatment of croup, 
April 26th, 1848. 
This child, who was three years and one 
month old, had been affected with a severe cold, 
which was attended by a hoarse cough for a 
whole week before the occurrence of the suffo- 
cative and alarming symptoms which character- 
ize the full development of the disease. I was 
called to see this child on the morning of the 
26th, and found the catarrhal symptoms present 
as above named. The hoarse cough, the heated 
skin, the restlessness, and the increased respira- 
tion of the child, awakened in my mind the sus- 
picion that the patient was threatened with an 
attack of membranous croup. 
Small doses of calomel and ipecacuanha were 
ordered every three hours during the day, these 
to be alternated with a weak solution of tartar- 
ized antimony. But I failed to do what should 
not have been omitted at this visit, namely, to 70 
MEMBRANOUS CROUP COMPLICATED 
examine the throat for the purpose of ascertain- 
ing the presence of the false membrane, if it 
existed • for I doubt not from the subsequent 
course and character of the disease, that its pre- 
sence about the tonsils could have been detected 
at this stage of the affection. 
About 8 o’clock of the following evening, I 
was sent for in great haste to see the child, and 
found her laboring under a most violent and 
fully developed attack of membranous croup. 
The flushed countenance, the accelerated pulse, 
the ringing cough, the oppressed and stridulous 
respiration, and the appearance of the fauces, 
which were entirely coated with a membrana- 
ceous deposit, made it impossible to mistake the 
nature or the grade of the disease. 
The medicine being at hand, I immediately 
administered an emetic dose of ipecacuanha and 
antimony, and after a delay of fifteen minutes, 
the patient not vomiting and the respiration be- 
ing greatly embarrassed, I proceeded to employ 
cauterization. A sponge dipped in a strong so- 
lution of nitrate of silver was applied to the 
tonsils, the mucous membrane of the pharynx, 
and then passed rapidly over the laryngeal face 
of the epiglottis and into the larynx itself. This 
operation was followed by immediate vomiting, 
and the ejection of a large quantity of tenacious, 
glairy mucus from the air-passages, in which WITH SPASMODIC SYMPTOMS. 
71 
could be seen many broken portions of the false 
membrane. 
After a few minutes, the patient breathed with 
more freedom ; but this partial relief continued 
for a brief time only, for at the end of half an 
hour the cough became more stridulous, and the 
respiration more embarrassed than it was before 
the application of the topical remedy. An eme- 
tic of sulphate of zinc in combination with ipe- 
cacuanha was now administered, by which full 
vomiting was produced. 
As no permanent relief, however, followed 
these measures, but the disease, on the, contrary 
appearing to advance, I proposed a consultation, 
and Dr. Cox, of Union Place, was called. 
It was concluded in consultation to continue 
the topical applications, to administer small and 
frequently repeated doses of tartarized antimony, 
and to give two grains of calomel every second 
hour. The second cauterization was made at 
10 o’clock, which brought away an increased 
amount of the adhesive mucus, and many 
shreds of the pellicular formation. The anti- 
mony, although given in large doses during the 
night, did not produce vomiting. This was 
only effected by administering the zinc and 
ipecacuanha, and whenever the above combi- 
nation was given, it never failed to act as an 
emetic. 72 
MEMBRANOUS CROUP COMPLICATED 
A third application of the caustic was made 
a little before midnight, and my assistant, Dr. 
Douglas remaining with the patient through the 
night, repeated the cauterization for the fourth 
time, about two o’clock in the morning. At 
each application much mucus was discharged, 
commingled with which were many portions of 
the adventitious membrane. In every instance 
the operation was certain to be followed by a 
mitigation, to a greater or less extent, of all the 
distressing symptoms—the difficulty of breath- 
ing, the quickened pulse and respiration, would 
be for a time greatly diminished ; but not until 
after the fourth application, did this relief con- 
tinue for any length of time. When I returned 
to the patient at five o’clock the next morning, 
I observed a marked change in the symptoms 
that were present. The croupal cough and the 
stridulous breathing were much lessened, but on 
the other hand, the increased heat of the surface, 
the bronchial cough, and the widely diffused 
rfdes, which were revealed by auscultation, 
throughout both lungs, indicated too plainly 
that the exudative inflammation had extended 
into the bronchial terminations. 
At the consultation held soon after my first 
visit this morning, it was concluded to have a 
few leeches applied between the shoulders of the 
patient with the hope of arresting the bronchial WITH SPASMODIC SYMPTOMS. 
73 
inflammation : to continue the calomel, and to 
repeat the topical measures during the day should 
there be an increase of the croupal symptoms. 
During the early part of the day, the case ap- 
peared to be somewhat improved by th6 bleed- 
ing and the other measures adopted ; but towards 
night, the croupal symptoms returned with more 
violence than ever ; and complicated with this 
we had extensive bronchial disease, occupying 
both sides of the chest. A blister was applied 
over the sternum, the topical applications were 
renewed, and the patient again vomited with 
the mineral emetic. Many portions of albu- 
minous matter were again ejected by these 
measures, which served to relieve greatly the 
stridulous breathing ; but by 10 o’clock at 
night, the respiration became more bronchial 
and rapid, the pulse was increased in frequency, 
and feeble : and although the croupal symptoms 
were decidedly relieved by the local applications, 
yet the little patient appeared to be fast sinking 
under the suffocating effects of the bronchial 
disease. In consultation with Dr. Cox it . was 
concluded that depletion even by vomiting, 
could he carried no further, and that the spasm 
and bronchial irritation must be relieved, if at 
all by other measures. It was decided, there- 
fore, to continue the cauterizations as required, 
and to administer the hydrocyanic acid, in drop 74 
MEMBIIANOUS CEOUP COMPLICATED 
doses, every two hours. The excellent effects 
of this latter remedy were soon apparent. After 
two or three doses had been swallowed, the great 
restlessness, the almost constant suffocative 
cough, subsided greatty, and the ejection, after 
an application of the caustic, of a much larger 
amount of fragments of the false membrane than 
had before been discharged, afforded the greatest 
relief; so that towards morning, the child fell 
asleep, and for two hours slept quietly, and 
breathed with considerable freedom. 
The next day the child appeared much pros- 
trated, but the croupal symptoms had nearly dis- 
appeared, and the bronchial irritation was greatly 
lessened. 
The hydrocyanic acid was continued for 
several days. Appropriate supporting means 
were employed, under the use of which the little 
patient was gradually restored to health and 
strength. 
But notwithstanding convalescence took place 
in other respects, yet vocalization did not return 
till nearly eight weeks after the attack of the 
disease. 
Pathologists have observed that croup usually 
subsides after the occurrence of a single process 
of exudation ; but cases are recorded where the in- 
flammation has continued until the formation of a 
second, and even a third adventitious membrane. WITH SPASMODIC SYMPTOMS. 
75 
Such was the severity and persistence of the 
exudative action in the preceding case, that, as 
we had every reason to suppose, several succes- 
sive layers of albuminous matter were formed 
in the larynx, and removed by the applications. 
Repeatedly, during the period of the greatest 
severity of the disease, after these cauterizations 
were made, many patches or fragments of the 
false membrane, some of considerable size, were 
at each time ejected from the air-passages. This 
occurrence was always followed with relief to 
the patient, and this relief would continue until 
the. deposition of another membranous coating 
had taken place. 
I shall conclude, for the present, my record of 
observations, by noticing a few cases of membran- 
ous croup which, in the hands of other members 
of the medical profession, have been successfully 
treated by means of the topical application of the 
nitrate of silver. 
Within a few days the subsequent highly in- 
teresting case was communicated to me by my 
friend, Dr. James Bryan, of Philadelphia. 
CASE X. 
“Dear Doctor: 
“ The following case of membranous croup, 
cured by the application of nitrate of silver, I 
send to you in accordance with your request. 76 
MEMBRANOUS CROUP COMPLICATED 
You are at liberty to make whatever use of it 
you may think proper. 
“ On the 21st of April of the present year, I 
was called upon by my friend, Dr. T. Beasley, to 
see with him the only child of Thomas Hutchin- 
son, aged 14 months, laboring under an attack of 
croup. 
“Dr. B. informed me that this was the third 
day of the disease, and that the child had gradu- 
ally grown worse, until the disease assumed the 
features presented at this visit. 
“ I fastened on the extremity of a properly 
bent whalebone a conical piece of sponge, and 
prepared a solution of the nitrate of silver, forty 
grains to the ounce of water. At seven o’clock, 
p.m., the child was lying on its back with the 
head thrown backwards spasmodically, and 
breathing with the greatest difficulty ; the lips 
livid, the pulse small, thready, and very quick ; a 
peculiar whistling sound was produced by the 
imperfect act of respiration. The fauces and 
throat, as far as vision, aided depressing the 
tongue, would extend, were covered by a white, 
milky, sheet-like covering. The child was placed 
on the father’s lap, the head supported by Dr. 
B., when I depressed the tongue by means of the 
bent handle of a silver spoon, and introduced 
rapidly into the larynx the sponge, saturated 
with the solution. WITH SPASMODIC SYMPTOMS. 
77 
“ For an instant the spasm of the glottis 
produced apparently complete closure. This, 
however, wTas followed by relaxation, and a 
copious discharge of mucus, with long membran- 
ous shreds, which relieved the respiration very 
much. 
“ o’clock, p.m. : The child has vomited freely 
in the interim, and respiration is some better. 
The application was made again, and was fol- 
lowed by a temporary spasm, and a copious 
discharge of a flaky and stringy mucus, as white 
almost as milk. A little blood was found mixed 
with it, which came apparently from the nose, 
which has been discharging blood every now 
and then since the commencement of the disease. 
“ 22d, 8 o’clock, a.m. : The child has passed a 
tolerably easy night. Free bilious discharges 
have taken place from the bowels, produced by 
the use of two grains of calomel taken every 
two hours since yesterday morning. Respira- 
tion now is comparatively easy, the head is not 
thrown back as before, nor are .the lips so livid. 
The child is enjoying a quiet sleep. The pulse 
is about 90, and regular. Ever since the first 
application, it has drunk freely of cold water, 
which it did not before. 
‘ ‘ The third application into the larynx pro- 
duced less spasm, and very little irritation, but 
it was followed by a very free expectoration 78 
MEMBRANOUS CROUP COMPLICATED 
of the same kind of shreddy and membranous 
substance, with a large amount of mucus. Con- 
tinue the calomel two grains every few hours. 
“ 7 o’clock in the evening: The child has had 
four stools during the day, is now lying languidly 
on the pillow with its chin raised, but cjuiet. 
Respiration dry and difficult. 
l< On account of the excitement of the child, 
the first attempt to cauterize the larynx was not 
successful, and it produced, which in fact is al- 
ways the case, considerable spasm. The second 
attempt was perfectly successful, the sponge 
passing down more than two and a half inches, 
bringing up with it a quantity of white mem- 
branous mucus, and followed by a discharge of a 
large amount of the same kind of matter, almost 
without any effort of the child, who threw his 
head back, breathed easily, and went to sleep in 
a very few seconds. 
“ 23d, 82 o’clock a.m. : The respiration com- 
paratively easy, slept well last night, has had 
four bilious stools. It is so much easier that 
we resolved not to apply the caustic at present, 
but to hold ourselves ready to do it during the 
day, should there appear immediate necessity 
for it. 
“ G o’clock r.M. : The child was sitting up on 
its mother’s lap, amusing itself with toys. A 
quantity of coagulated blood fills up the right WITH SPASMODIC SYMPTOMS. 
79 
nostril. Respiration but slightly stridulous ; has 
eaten bread and milk; had three stools since 
morning, and has slept very comfortably. The 
throat, as far as can be seen, is perfectly free 
from the diphtlurite deposit. Continue calomel, 
half a grain every four hours, with one grain of 
quinine. 
“ 24tli: Saw the child this morning with Dr. 
Beasley. It was lying comfortably in the cradle ; 
very little impediment to the respiration ; has 
slept well during the night, taken nourishment, 
and passed three stools. The throat shows no 
appearance of deposit. The calomel diminished 
to one-eighth of a grain every four hours. The 
consultation to cease. 
“ It will be recollected that no emetic or other 
remedy than a few grains of calomel and the 
nitrate of silver has been administered in this 
case until last night, when the quinine was added. 
The patient recovered without an unfavorable 
symptom.” 
The history of Case 2 which is recorded on 
page 31 of this work, was given at a meeting 
of the “New York Medical and Surgical So- 
ciety,” November 1st, 1845, and the members 
present were desired to make trial of the local 
remedy whenever opportunity for employing it 
in croup might occur. 80 
MEMBRANOUS CROUP COMPLICATED 
The next year a member of the Society, Dr. 
Wm. N. Blakeman of this city, reported to the 
Society two cases of croup which had been treated 
successfully by topical medication. 
The details of these cases are recorded in the 
twenty-third number of the New York Journal 
of Medicine. . 
The first case, which is that of a large fat 
child two years old, and of a leuco-phlegmatic 
temperament, was seen by Dr. B. five hours 
after the attack. The skin at this time was hot 
and diy, the pulse quick, with great restlessness, 
laborious breathing, and the hoarse barking or 
crowing sound peculiar to croup. The tincture 
of sanguinaria with squills, and ipecacuanha, 
were first given, by which vomiting was pro- 
duced, with no relief; six grains of calomel 
were then administered and the former mixture 
repeated, with the addition of five grains of tar- 
tar emetic ; free purging and vomiting were pro- 
duced, but with no relief. On the second day 
persulphate of mercury was given in doses of 
a quarter of a grain every hour, by each dose of 
which vomitingi was excited, but without relief. 
In the afternoon of the same day Dr. Blakeman 
resolved to try a strong solution of nitrate of 
silver. The application was made by means of 
a sponge, and the solution used contained a 
drachm of the nitrate to an ounce of water. WITH SPASMODIC SYMPTOMS. 
81 
The application brought away a quantity of 
tenacious membranous matter, and a larger 
quantity by the vomiting which soon followed. 
A second application was made ten minutes 
after, by which a still larger quantity was 
brought away, to the great relief of the symp- 
toms. In five hours a third application was 
made with the same effect as to the discharge of 
membranous matter and the vomiting. The next 
morning the child was found entirely relieved 
from the disease. 
In the second case, that of a boy six years old, 
with frequent pulse, skin hot and dry, breath- 
ing hurried and difficult, and loud crowing, the 
same application was made two hours after the 
commencement of the attack, when a discharge 
of tough phlegm took place and vomiting. 
After a second application the relief was com- 
plete. 
Within the last year several other cases of 
croup have been communicated to me by medi- 
cal gentlemen residing in different parts of the 
country, in which they have succeeded perfectly 
and with great satisfaction to themselves in 
arresting the disease, by the use of the topical 
measures I have recommended. I shall, how- 
ever, in this connection subjoin the history of 
but one other case of membranous croup ; one 
which was successfully treated by Dr. C. E. Ware, 82 
MEMBRANOUS CROUP COMPLICATED 
of Boston, and was by him communicated to 
the Boston Medical and Surgical Journal. It 
may be found in the fourth number for Decem- 
ber, 1847. 
“ I was called,” says Dr. Ware, “ to this pa- 
tient, a boy five years old, Saturday, November 
20th. The mother said that he began to 
breathe hard just a week previous, but as he 
had been subject to attacks of spasmodic croup, 
in several of which I had attended him, and 
usually found ready relief, she felt no great 
anxiety, especially as there was less constitu- 
tional affection than he had in former attacks. 
His tonsils, also, had been for a year or more 
somewhat enlarged, and often gave a huskiness 
to his respiration and voice. On Tuesday he 
began to cough, and evinced other signs of a 
cold. These symptoms continued, he playing 
about, and having appetite without anything 
very characteristic till Friday afternoon, when 
the cough began to have a ringing tone, and the 
respiration to be very labored. I was not called 
to him till the next afternoon. Then there was 
the characteristic breathing of croup well marked. 
It had become sufficiently distressing to oc- 
casion great restlessness and jactitation, but 
was not accompanied by much febrile excite- 
ment, nor as yet prostration. The general ex- 
pression of the child. wras good. On examin- WITH SPASMODIC SYMPTOMS. 
83 
ing the fauces they appeared red, and the tonsils 
presented distinct patches of lymph. On the 
backs there was an almost entire absence of re- 
spiratory sound, and no rales whatsoever. The 
breathing and cough were both dry, with very 
little rfde in the trachea. 
“He was ordered strong mercurial ointment, 
and fomentation to neck, and pills of Dover’s 
powder and blue pill once in four hours, and a 
syrup with opium and ipecac, at intervals be- 
tween. Under the influence of the opium he 
got more sleep than during the previous twenty- 
four hours, but in the morning was no better, nor 
essentially different. 
“I now commenced the application of the ni- 
trate of silver to the larynx, using a solution of 
the strength of a drachm to the ounce, and ap- 
plying it with one of Dr. Green’s whalebone 
staffs. I applied it twice in the course of the 
first day. The child the first time resisted vio- 
lently, and I was obliged to use much force. 
But after having been persuaded once to submit 
quietly, the operation occasioned so little irrita- 
tion that he never afterward made the least 
objection to it, but allowed me to perform it as 
effectually as I could have done upon a grown 
person. The first applications were followed by 
so much excitement that it was difficult to see 
what was the immediate effect. But afterward, 84 
MEMBRANOUS CROUP COMPLICATED 
when he was more tranquil during the operation, 
it was obvious that it produced an increased 
dryness of the cough and respiration, without 
immediate relief or aggravation of the labor in 
breathing. In the course of the day he raised 
twice considerable pieces of false membrane, 
very well marked, and stained with blood, to- 
gether with a great deal of very thick, tenacious 
mucus, which was also occasionally stained with 
blood. After the discharge of the false mem- 
brane the breathing became much easier, and 
was never again as labored as it had been before. 
“ The next day, Monday, the respiration, al- 
though improved, was still very laborious. There 
was yet great deficiency of respiratory sound in 
the backs, and absent of rales. After the appli- 
cation of the caustic, which was applied twice 
this day, the fauces appeared red, but there wTas 
no lymph visible. From this time the amend- 
ment, although slight, from day to day was con- 
stant, till Friday, the 26th. No lymph was 
seen upon the tonsils. The caustic was applied 
once a day. Friday night, the breathing was 
more labored than the night before, and Satur- 
day morning I again saw lymph on the tonsils. 
Through Saturday and Sunday, however, he 
continued to improve, and Sunday evening 
uttered the first loud word which he had been 
able to speak since I had seen him. The WITH SPASMODIC SYMPTOMS. 
85 
caustic was now omitted, as well as all his 
medicines. His appetite, which had never en- 
tirely disappeared, became more urgent, and he 
was allowed to eat freely. Indeed, his diet had 
been liberal throughout. The respiratory sound 
gradually returned to the backs, but continued, 
as it had done throughout, free from rales. The 
voice continues to improve, but still retains its 
huskiness. The caustic was applied twice the 
two first days ; afterwards but once a day, the 
sponge never being introduced more than once at 
the same visit.” CHAPTER Y. 
OF THE TREATMENT OF CROUP. 
As these contributions to the pathology and 
treatment of croup are not intended to consti- 
tute a complete essay upon the disease, I shall 
not stop to describe the symptoms or to discuss 
the etiology of membranous croup, hut shall 
proceed to a more critical examination of both the 
topical and the general remedies which are indi- 
cated in the treatment of this affection. 
Topical Medication.—Believing as I do, that 
topical medication is a measure of the highest 
importance in the treatment of membranous 
croup, I shall make no apology for giving to it 
a more extended consideration. 
M. Bretonneau was among the first to recom- 
mend and employ the nitrate of silver as a 
topical remedy in the treatment of membranous 
croup. He made use, however, of a very weak 
solution (four grammes of the salt to thirty-two 
grammes of water), and directed its application 
to be made to the throat and the opening of the 
glottis. The instrument he employed, and his 
method of application, are thus described in a 
work by M. Berton, which has recently been 
86 TREATMENT OF CROUP. 
87 
published in Paris.* “ L’appareil est compost 
d’une eponge fine de la grosseur environ d’une 
noix, fixee au bout d’une baleine assez forte et 
recourbee, a la chaleur d’une bougie, a 5 ou 6 
centimetres de son extremite et presque a angle 
droit. L’eponge est imbibee d’une solution de 
nitrate d’argent (au degre de 4 grammes de ce 
sel pour 32 grammes d’eau distillee). Elle est 
introduite dans le fond de la gorge ; l’epiglotte est 
soulevee et la solution au-dessus de la 
glotte.”f 
It will be observed from the above extract 
that M. Bretonneau makes no attempt to pass 
the instrument below the epiglottis. The sponge 
attached to the probang, being saturated with 
the solution, is introduced into the throat, “the 
epiglottis is elevated (soulevee) and the solu- 
tion expressed into the glottis.” J 
The topical application of a solution of the 
nitrate of silver in membranous croup, has also 
been recommended by MM. Dupuytren, Trous- 
seau, Guersant, Guiet, Bouchut, and other French 
practitioners. 
M. Guiet, in his Thesis published in 1843, 
* Formulaire Therapeutique, etc. Concernant les Maladies de L’En- 
fance. Article, Croup. 
\ If the French anatomists will acquaint themselves with the position 
of the living epiglottis when in situ, they will find that this cartilage is 
always raised, except at the moment of deglutition. 
X Ut supra, p. 81. 88 
TREATMENT OF CROUF. 
on the treatment of croup,* thus describes the 
method—as practised by M. Guersant in the 
Hopital des Enfants—for applying the caustic 
solution to the fauces, pharynx, and to the open- 
ing of the glottis in such a manner as to cause 
some drops of the solution to penetrate into the 
larynx : “ convenablement imbibee de 
la solution causticjue, et le malade solidement 
maintenu par une ou deux personnes vigoureuses, 
l’operateur abaisse la base de la langue, avec la 
main gauche, armee dame cuiller ou de tout 
autre instrument ; en meme temps il porte avec 
la main droite, la baleine dans la bouche ; lui 
fait traverser rapidement cette cavite ; porte 
l’eponge dans le pharynx apres l’avoir prome- 
nee sur les piliers et les amygdales, s’il y existe 
des fausses membranes ; la fait glisser profonde- 
ment dans cette cavitd le long de sa paroi 
posterieure, de maniere a la loger, si c’est possi- 
ble, entre cette paroi posterieure et Pepiglotte ; 
puis, quand il se sent arrete par Torifice sup6- 
rieur du larynx, il presse un peu sur cette 
eponge, de maniere a en faire suinter quelques 
gouttes de solution caustique, et a en faire par- 
venir un peu dans le larynx.”* 
The same author informs us that Professor 
Trousseau at the Hopital Neckar has employed 
* Considerations Pratiques sur le Traitement du Croup. Par P. R. L. 
Guiet, p. 22. f Op. citat. p. 22. TREATMENT OF CROUP. 
89 
with success a solution of the nitrate of silver 
as a topical remedy, in the treatment of a case 
of croup occurring in an infant of twenty months ; 
but to what extent the applications were made, 
or of the exact' strength of the solution employed, 
we are not informed. 
M. Bouchut, whose work on Diseases of 
Children* was published in 1845, alludes to this 
case of M. Trousseau, and adds that two other 
well marked cases of membranous croup in pri- 
vate practice had been successfully treated, by 
means of the above local remedy. The strength 
of the solution as recommended by Bouchut, is 
ten grammes of the nitrate of silver to thirty 
grammes of distilled water. The instrument of 
the operator, and the manner of applying the 
caustic in pseudo-membranous croup, is thus de- 
scribed : “II faut avoir une petite eponge fine, 
solidement fix5e au bout d’une baleine courbee 
en crochet ; lorsque l’eponge est imbibee, on 
exprime legerement et on la porte dans le pha- 
rynx et sur la glotte, afin cjue quelques gouttes 
du liquide caustique puissent penetrer dans le 
larynx.”*)* 
The application of the caustic, says the above 
writer, should be made in the commencement of 
* Manuel Pratique des Maladies des Nouveaux-Nds, et des Eufants a la 
Mamelle. 
f Op. citat. p. 271. 90 
TREATMENT OF CROUP. 
the disease, or as soon as we perceive patches 
of the false membrane about the pharynx, and 
it should be repeated at least twice in the twenty- 
four hours. But he observes, and recommends, 
great caution in making the applications to 
the pharynx and over the glottis, lest too 
large a quantity of the liquid should drop into 
the larynx, and produce suffocation and death ; 
or, at least, render it necessary to practise im- 
mediate tracheotomy. The following are the 
author’s remarks on this subject : “Si la cau- 
terisation de l’arriere-bouche et cle la partie 
superieure du larynx est avantageuse, elle a 
aussi ses inconvenients qu’il faut connaitre pour 
tacher des les eviter. La suffocation immediate 
pent en etre la consequence, si l’on a laisse trop 
longtemps l’eponge sur la glotte, et si une trop 
grande quantity de liquide a penetre dans le 
larynx. Cet accident est fort grave, car il peut 
determiner la mort, ou au moins la necessite de 
pratiquer aussitot la tracheotomie.”* 
Bearing in mind these dangers, and advising 
great caution in its use, M. Bouchut commends 
the employment of the nitrate of silver as an 
important medication in the treatment of croup. 
And yet, neither Bouchut nor his confreres, to 
whom allusion has already been made, derived 
that benefit from the use of the nitrate which 
* Op. citat. p. 272. .TREATMENT OF CROUP. 
91 
they might have obtained, by carrying their ap- 
plications directly into the diseased larynx, in- 
stead of making them, as they do, only to the 
pharynx and the superior opening of the larynx 
—“ harriere-gorge et l’ouverture superieure du 
larynx.” 
In employing the nitrate of silver as a topical 
remedy in the treatment of diseases in young 
children, I have not deemed it prudent or neces- 
sary to use a solution of the caustic of the 
strength recommended by Bouchut or Guiet. 
The former employed a solution in the propor- 
tions of one of the salt to three of water ; the 
latter, in the treatment of membranous croup, 
made use of a still more concentrated solution ; 
namely, equal parts of the nitrate of silver and 
distilled water. Ordinarily, I have applied in 
croup, a solution composed of from two scruples 
to a drachm of the salt, dissolved in one ounce 
of distilled water. A remedy of this strength I 
have applied freely to the fauces, pharynx, and 
into the larynx of young children, in a large 
number of cases during the last eight years, and 
in no single instance have I observed any indi- 
cations of the danger of suffocation from its 
employment. On the contrary, I have repeat- 
edly observed, and have once before remarked, 
that much less bronchial irritation is produced 
by the application of the nitrate of silver into 92 
TREATMENT OF CROUP. 
the larynges of young children who are suffering 
from croup, than when it is introduced into 
those of adults who are affected by chronic dis- 
ease of the larynx. 
In cauterizing the cavity of the larynx in the 
above disease in adults, I have advised on a for- 
mer occasion,* that the aperture of the glottis 
should not be passed until after the parts in the 
faucial and pharyngeal region had been prepared 
by having the solution applied for a few times to 
the pillars of the fauces, the epiglottis, and about 
the opening of the glottis. Proceeding in this 
manner, it has been shown that the instrument 
may then be passed into the larynx without 
producing half the amount of that irritation 
which its introduction below the epiglottis would 
have awakened without these pareparatory steps. 
Happily, it is not necessary to take these 
precautionary measures before employing the 
topical remedy, in the treatment of croup in 
children ; for, as we have seen, applications of 
the argentine solution of a proper strength may 
be employed without apprehension in these 
cases ; and these applications should be made 
promptly to the tonsillary and pharyngeal 
regions, whenever the symptoms present indi- 
cate the commencement of the exudative in- 
* Treatise on Diseases of the Air-passages, etc. p. 199. TREATMENT OF CROUP. 
93 
flammation in the mucous membrane of these 
parts. 
The instrument which I have ordinarily em- 
ployed for making direct medicinal applications 
to the fauces, and into the cavity of the larynx, 
in the topical treatment of croup, is one com- 
posed of whalebone, about ten inches in length, 
slightly curved at one end, to which curved 
extremity is securely attached a small round piece 
of fine sponge. {See plate.) 
Care should be taken that the sponge be not 
only firmly fixed to the rod of whalebone, but 
that it be not of a size too large to pass the 
aperture of the glottis. Anatomists are aware 
that there is but a very slight difference in size 
between the larynx of a child of two years, and 
twelve years of age ; and that, at this period of 
life, the calibre of the tube is from three-eighths 
to half an inch in diameter ; consequently, if the 
sponge be' formed so as not to exceed one-third, 
or one-half of an inch in diameter, it can be 
made, with slight pressure, to pass the aperture 
of the glottis, and to enter the laryngeal cavity. 
The instrument being prepared, by suitably 
saturating the sponge with the solution to be 
applied, and the head of the child being firmly 
held by an assistant, an<*f\the base of the tongue 
depressed with a spoon, or any other suitable 
instrument, the operator carries the wet sponge 94 
TREATMENT OF CROUP. 
quickly over the top of the epiglottis, and on the 
laryngeal face of this cartilage • then, pressing 
it suddenly downward and forward, passes it 
through the opening of the glottis, into the 
laryngeal cavity. If any patches of false mem- 
brane are to be observed upon the pillars or ton- 
sils, the sponge should be passed freely over 
these parts, and also upon the posterior wall of 
the pharynx. 
Not unfrequently, if topical measures are em- 
ployed in the very onset of the disease, and 
before the exudative inflammation has extended 
much into the larynx, the affection may be 
arrested by one or two applications of the caus- 
tic solution to the fauces, and the opening of the 
glottis, without ever passing the instrument 
upon the mucous surfaces of the larynx. 
In March, 1847, Dr. P., of this city, called at 
my office, and requested me to visit, with him, 
a young child, about two years old, who that 
evening had been attacked with croup. This 
child had been indisposed for several days, with 
a cold, and some slight affection of the bowels, 
but not until that afternoon and evening had 
symptoms of croup been present. 
We found the patient with a croupal cough, 
stridulous and laborious respiration ; and, indeed, 
presenting unequivocal indications of the pre- 
sence of the disease. The attending physician TREATMENT OF CROUP. 
95 
had administered an emetic, and had adopted 
other ordinary measures, before calling for me. 
Discovering evidences of plastic inflammation 
about the throat, I advised the immediate appli- 
cation of the caustic to these inflamed parts, 
and, at the request of Dr. P., I applied a solu- 
tion of the strength of forty-five grains of the 
salt to the ounce of water, to the tonsils, the 
posterior wall of the pharynx, and about the 
aperture of the glottis. Intending to follow this 
application with a second, and to carry the 
sponge into the larynx, if necessary, I remained 
a short time for this purpose ; but, in less 
than half an hour after the first cauterization, 
the respiration became less embarrassed, the 
cough less croupal, and I left without repeating 
the local remedy. The next day, Dr. P., who 
remained with his patient all night, called and 
informed me that the child breathed with con- 
siderable freedom, and slept well a part of the 
night ; that early in the morning, the respira- 
tion becoming again more stridulous, he deemed 
it advisable to make a second application of the 
caustic solution. After this was done, the croupal 
respiration and other symptoms of the disease 
subsided rapidly, and, by afternoon of that day, 
had all, or nearly all, disappeared. 
Having seen, on several occasions, the local 
application of the nitrate of silver act promptly 96 
TREATMENT OF CROUP. 
and efficiently in arresting exudative inflamma- 
tion in its formative stage, I have been led to 
consider it of the highest importance in the 
treatment of membranous croup, that the first 
indications of the disease should be observed, in 
order that, by the early employment of this local 
remedy, the specific inflammation may be arrested 
before it shall have extended into the larynx and 
bronchial divisions. 
It is well known to the experienced prac- 
titioner that in many cases of membranous croup, 
the disease will come on in a manner so stealthy 
that plastic lymph will be found in some in- 
stances coating the tonsils and pillars of the 
fauces, before alarm has been awakened by the 
patient having manifested any rational symptoms 
of croup, unless it be those merely of a common 
cold, or slight hoarseness of the voice. It is 
seldom, indeed, that much hoarseness attends the 
ordinary cold of young children. When, there- 
fore, this symptom is observed to be present, in 
catarrhal disease, especially if the child exhibit- 
ing it is of a family predisposed to croup, the 
physician should never omit to examine the 
throat of such a patient, in order to detect, and, 
if necessary, to be able to combat the earliest 
manifestations of exudative inflammation. Dur- 
ing the more than ordinary prevalence of croup 
in this city last winter, a physician of my ac- TREATMENT OF CROUP. 
97 
quaintance, whilst attending, in consultation, a 
fatal case of the disease in a family where one 
or two had already died of this affection, ob- 
served that another child, although apparently 
perfectly well, and engaged at his play, ex- 
hibited a slightly raucous condition of the voice ; 
and, calling the child to him, found, on examina- 
tion, the throat to be inflamed, and the pillars 
and tonsils to be coated with several distinct 
patches of albuminous deposit. 
The attention of the attending physician was 
called to these facts, and the threatened danger 
from such indications, pointed out. But, as the 
child had made no complaint, and the parents 
on being questioned, had observed no cough, or 
any other symptoms of indisposition in their 
child, the doctor believed that no cause of alarm 
existed, and, in a pleasant way, was disposed to 
laugh at the apprehensions of his professional 
brother. They proved, however, to have been 
too well founded, for, in less than three da}rs 
from that time, the child was dead of croup. 
If we admit that the peculiar inflammation of 
croup has its origin, ordinarily, about the tonsils 
and the opening of the air-tubes, we can under- 
stand how readily the application of the nitrate 
of silver to the parts about the larynx, may arrest 
the disease, if the topical remedy is employed 
in the commencement of the exudative process. 98 
TREATMENT OF CROUP. 
After the inflammation has advanced, and the 
surfaces of the larynx have become involved in 
the disease, the argentine solution should not 
only he applied to the tonsils and to the faucial 
region generally, but the applications must be 
extended into the laryngeal cavity. 
If the exudations are not already formed into 
adventitious membrane, the employment of a 
few successive applications below the epiglottis 
may be sufficient to arrest the plastic inflamma- 
tion altogether. But even in a more advanced 
stage of the disease, when, from its continuance, 
and the severity of the disease, we have reason 
to apprehend the formation of a false membrane 
or “ tubular mold,” throughout the larynx 
and trachea, we should not despair of removing 
the obstruction or of arresting the inflammation. 
Mr. Hyland, who advances the theory that the 
inflammation in croup has its origin chiefly in 
the cellular tissue that enters into the composi- 
tion of the mucous membrane, and not in the 
muciparous follicles themselves ; and that the 
albuminous exudation is poured out by the 
secernent arteries of the cellular structure, ad- 
mits that “after an uncertain interval, the mu- 
cous glands become consecutively affected by the 
inflammation, and secrete a quantity of their 
proper fluid, which assists in loosening and de- 
taching the false membrane, and, except in a case TREATMENT OF CROUP. 
99 
of relapse, puts a stop to its further forma- 
tion.” * 
Now, it is to secure and expedite this very 
sanative process, that I would recommend the 
prompt application of the caustic solution to 
the diseased mucous surfaces within the larynx, 
in order to effect an expulsion of the false mem- 
brane which may have formed in that cavity ; 
for pathologists, who have been accustomed to 
post-mortem examinations of children who have 
died during the latter stages of croup, have gene- 
rally found that the lymph is partially detached 
from the lining membrane by an intervening 
layer of mucus; “and it has, therefore,” adds 
the writer just quoted, “ been considered an im- 
portant indication to excite the action of the 
muciparous follicles, that by largely secreting 
their peculiar fluid, they may loosen the adventi- 
tious membrane and render its expectoration 
easy.f 
When called, therefore, to a case of croup in 
this its second or developed stage of the disease 
—and unfortunately, it is not until this period of 
the affection that medical aid is resorted to in a 
large proportion of the cases of croup—the local 
employment of the nitrate of silver, conjoined 
with other appropriate measures, should be 
entered upon at once. 
* Op. citat. p. 144-5. f Op. citat. p. 155. 100 
TREATMENT OF CROUP. 
An application may first be made to the ton- 
sils, and about the opening of the glottis. After 
a delay of from fifteen minutes to an hour, the 
operation may be repeated, and the sponge, wet 
with the solution, should then be passed into the 
glottis. The cauterizations may be repeated 
once in two, four, or six hours, according to the 
effect produced, and the intensity of the disease. 
When the symptoms indicate that the disease 
has extended into the tracheal divisions, or when 
the affection is complicated with inflammation of 
the bronchi, the applications should be repeated 
more frequently, in order that some of the solu- 
tion may find its way over the mucous surface 
of the larynx and trachea into the bronchial 
divisions. CHAPTER YI. 
DIPHTHERITE, OR THE CROUP OF ADULTS. 
There exists a form of exudative inflamma- 
tion which M. Bretonneau calls Diphtlierite, or 
croup of adults, but which is not exactly iden- 
tical with the croupal inflammation of children. 
The same parts, however, are affected in both 
diseases, and they both end in the effusion of 
plastic lymph ; but true croup ordinarily com- 
mences with catarrhal symptoms, is more sthenic 
in its nature, and is confined in its attacks to 
children and persons before the age of puberty, 
whilst the above form of disease commences 
with pain, redness, and swelling of the tonsils 
and back of the throat generally, and attacks, 
moreover, individuals of all ages, but those 
especially who have become debilitated by other 
diseases. 
The diphtherite proves frequently fatal. M. 
Louis, who, under the name of “ Croup chez 
l’adulte,” describes the disease, records only one 
case in which a cure was obtained by medical 
treatment. “ It causes death,” Mr. Ryland re- 
marks, “very rapidly, when the morbid action 
101 102 
CEOCr OF ADULTS. 
has reached the air-passages, because the larynx 
is always affected in Louis’s cases the patients 
never lived longer than from eighteen to thirty- 
six hours after the moment when we might 
presume, from the alteration of the voice, that 
the false membrane had reached the larynx. 
Diplitherite occurs frequently as an epidemic, 
and is considered by M. Bretonneau as decidedly 
contagious, especially when combined with scar- 
latina, which is one of its most frequent com- 
plications. 
Still further to illustrate the nature and cause 
of this disease, and the effects of topical reme- 
dies in its treatment, I shall here introduce the 
two following cases of diphtherite, which have 
been recorded by Ryland,* together with a third, 
which came under my own observation, and 
which was brought to a successful termination 
by means of the topical application of the nitrate 
of silver to the diseased parts. 
CASE XI. 
The patient, a strong boy ten years old, be- 
gan to experience some difficulty of swallowing 
on the 1st of January. On the 4th, the tonsils 
were greatly swollen, and, as well as the uvula, 
were covered with a greyish concretion ; respi- 
* Op. citat. p. 164-6. CROUP OF ADULTS. 
103 
ration frequent, and attended by a guttural 
sound ; tumefaction of the cervical glands near 
the angle of the jaw. Pulse 94 to 96. Appli- 
cation of concentrated muriatic acid to the 
fauces, and a grain of calomel to be given every 
hour. 
On the 5th and 6th, the state of the patient 
continued the same, except the swelling of the 
glands increased. 
7th. Deglutition performed with greater ease ; 
tonsils less swollen, but still covered with false 
membrane ; tumefaction of the cervical glands 
remarkably diminished. The calomel was dis- 
continued. 
8th. Swelling of the glands again augmented ; 
inspiration attended by a hissing noise ; croupal 
cough. At eleven o’clock the dyspnoea increased, 
/ 
and death took place. Twenty minutes after 
death tracheotomy was performed, and artificial 
respiration had recourse to, but with no bene- 
ficial effects. 
Dissection.—The lungs were healthy ; the mu- 
cous membrane of the bronchi pale ; that of 
the trachea, toward its middle parts, partially 
reddened, and covered with a tubular membran- 
ous concretion, which was loose at its lower 
extremity, but became thicker and more ad- 
herent in the larynx, and less so again on the 
epiglottis. 104 
CEOUP OF ADULTS. 
The whole of the back of the fauces, the upper 
part of the pharynx, and the posterior orifice of 
the nostrils, were covered with membranous con- 
cretions, having a most intimate adherence to the 
parts on which they lay. 
CASE XII. 
A woman, aged 72, had, when she was first 
seen, suffered for some days from sore throat, for 
which leeches had been applied. On the follow- 
ing day her countenance was flushed and anxious, 
respiration difficult, and accompanied by a hoarse 
sound, voice scarcely audible, deglutition impos- 
sible, pulse developed, and skin hot. 
A few hours after, on examining the throat, a 
whitish false membrane was observed on the an- 
terior part of the velum palati, and on this be- 
ing raised, the mucous membrane beneath was 
bloody ; the other symptoms were in no respect 
relieved. 
On the following morning the patient was 
dying, the respiration shorter and more sonorous, 
and death occurred soon after the visit. 
Dissection.—A very thick false membrane 
covered both surfaces of the velum palati, ex- 
tended into the nasal fossse, and penetrated into 
the larynx, trachea, and bronchi ; it adhered 
more strongly to the larynx than to the trachea. CKOTP OF ADULTS. 
105 
CASE XIII. 
Early in May, 1847, Mrs. B., of Forsyth street, 
about 23 years of age, was attacked with measles. 
She was healthy and robust, before contracting 
the disease, and was seven months pregnant at 
the time of her attack. 
Nothing unusual occurred during the progress 
of the measles, until toward the close of the 
eruptive fever, when Mrs. B. was seized with pain 
and inflammation of the throat, attended with 
swelling of the tonsils and fauces generally, 
and with dyspnoea and great difficulty of deglu- 
tition. Her attending physician, Dr. Belcher 
(Sen.), was immediately called, and finding the 
above symptoms present, employed both general 
and local bleeding, and such other antiphlogistic 
measures as were deemed advisable. But the 
disease continuing to advance, another physician, 
Dr. M., of this city, was called in consultation, 
and other measures were adopted, but without 
arresting in any degree the progress of the disease. 
On the 18th of May, one week after the at- 
tack of the diphtheritic inflammation, I was re- 
quested to see this patient, in consultation with 
the attending physician. 
The following was the condition in which I 
found her at this period : She wTas supported in 
an upright position in her bed, with her head 106 
CROUP OF ADULTS. 
thrown back and breathing with the greatest 
difficulty ; the lips and face were livid, the coun- 
tenance anxious ; the pulse small and frequent, 
and the extremities cold ; there was a hoarse, 
croupal cough, with great difficulty of swallowing, 
and an entire suppression of the voice. On in- 
specting the throat, the fauces, tonsils, and the 
uvula, and indeed every part that could be 
brought into view, were found to be completely 
coated with a dense false membrane. By depress- 
ing the tongue, nearly the whole of the epiglottis 
was exposed, and that cartilage, as well as the 
pharynx low down, could be seen covered with 
the same adventitious deposit, leaving no doubt 
from the condition of the voice and the circula- 
tion, that the exudative inflammation had not 
only entered the larynx and trachea, but had 
reached even the bronchial terminations. 
At the consultation it was agreed that as all 
other means had failed, an attempt should be 
made to relieve the larynx by topical applica- 
tions of the nitrate of silver to the diseased mu- 
cous surface, and I was requested to make these 
applications. 
Employing a solution of the strength of forty- 
five grains of the salt to the ounce of water, 
1 applied it freely to the whole faucial region, 
and also passed the sponge, wet with the solu- 
tion, into the larynx. The patient manifested CROUP OF ADULTS. 
107 
no uneasiness whatever from the application, 
and, on being questioned, declared she did not 
feel it in the least degree. The strength of the 
solution was now increased up to sixty grains to 
the ounce of water, and a second and third cau- 
terization was made deep into the cavity of the 
larynx, all in the space of fifteen or twenty 
minutes. 
It was not until the last application that the 
patient complained of any irritation having been 
produced by the caustic solution. Many shreds 
of the false membrane were brought away by the 
sponge, and were also ejected by the cough and 
expectoration that followed the last two applica- 
tions. So decided was the relief obtained by 
these operations that the patient begged to have 
them repeated before we left the house. 
A supporting plan of treatment was advised 
for the patient, and it was agreed to return at 
six o’clock and repeat the applications/ 
At the above hour in the afternoon, we found 
the patient exhibiting symptoms more aggravated 
than those which were present in the morning ; 
the lips and countenance were of a livid aspect, 
the respiration was more stridulous, and the 
breathing was being performed with still greater 
difficulty. The relief that followed the first ap- 
plications had continued for several hours, but 
for some time before our return in the evening, 108 
CEOUP OF ADULTS. 
the above symptoms had been coming on with 
constantly increasing violence. 
At this visit, the applications of the sponge, 
wet with the solution of sixty grains to the ounce 
of water, were made into the larynx at intervals 
of five minutes, care being taken at each appli- 
cation to convey below the epiglottis as much 
of the fluid as the sponge could contain. A large 
quantity of muco-purulent matter, containing 
many particles of the false membrane, was ejected 
by coughing after each cauterization. 
Soon after these operations, the patient ex- 
pressed herself greatly relieved, and we left her, 
with her respiration much less embarrassed than 
it was on our arrival; and the following night 
was passed by the patient with less distress, rest- 
lessness, and oppressed breathing, than had been 
present during either of the two preceding 
nights. 
May 19th. There is still great prostration, 
anxiety, and stridulous respiration present. The 
countenance is yet livid, the cough is croupal, 
and the voice is reduced to a feeble whisper. 
But it is concluded, notwithstanding, that our 
patient has lost nothing, on the whole, during 
the last twenty-four hours. Some patches of 
albuminous secretion can be seen about the ton- 
sils, the uvula, and the epiglottis ; but it has 
been detached and removed from many parts of CROUP OF ADULTS. 
109 
the throat, leaving the mucous membrane be- 
neath thickened and inflamed. 
A solution of four scruples of the nitrate of 
silver to the ounce of water was made, and three 
cauterizations of this strength were employed 
during the day. The effect of each application 
was to produce a free expectoration of albumin- 
ous matter, which was sure to be followed with 
great relief for a longer or shorter period. 
May 20th. But little change occurred in our 
patient throughout yesterday and last night. 
Four cauterizations were employed during the 
day and night, which caused the ejectment of 
much adhesive mucus, with membranous frag- 
ments. Some rest was obtained, but great rest- 
lessness, feeble pulse, cold extremities, and 
oppressed respiration, were present during the 
greater part of the night. 
On examining the patient’s throat to-day, it 
wras found that the coriaceous deposit was almost 
entirely removed from the tonsils, uvula, and 
epiglottis, yet the embarrassed and sibilous re- 
spiration, the great anxiety, and the livid coun- 
tenance of the patient, plainly indicated that the 
false membranes were still obstructing the air- 
passages below, and were thus preventing the 
perfect arterialization of the blood • it was there- 
fore determined to carry the cauterizations 
deeper into the trachea than had yet been done, 110 
CROUP OF ADULTS. 
In the presence of Dr. Belcher, the attending 
physician, and my friend Dr. S. Conant Foster, 
who had accompanied me to see the case, I 
passed a sponge, saturated with a strong solu- 
tion of the nitrate of silver—eighty grains to 
the ounce—through the rima glottidis, and along 
the whole length of the trachea. The with- 
drawal of the probang was followed by a severe 
fit of coughing, and the expectoration of a great 
quantity of muco-purulent and membranaceous 
matters. 
Soon after this last operation, the patient ap- 
peared greatly relieved, and breathed with more 
freedom than she had done at any time since 
her first attack. The same application was re- 
peated at evening, and from this time her re- 
covery was rapid. The cauterizations were con- 
tinued every day for nearly a week longer, when 
the consultations were discontinued, as the pa- 
tient was considered out of danger. 
Mrs. B recovered perfectly, and was de- 
livered of a healthy child at her full term ; but 
vocalization did not return until many weeks 
after her restoration to health. It has since been 
fully restored. 
I am quite sensible that, in the treatment of 
croup, the removal of the false membrane sim- 
ply is not, after all. the only indication of im- EXTENT AND FATALITY CROUF. 
111 
portance ; for, it has been shown repeatedly, 
from the dissections of those who have died of 
the disease, that death has not occurred as the 
result altogether of the obstruction presented by 
the adventitious membrane, inasmuch as it has 
been found in many such cases, that within the 
membrane a space was left for a current of air, 
sufficient to support life. But, the same exuda- 
tive process which results in the spreading of a 
false membrane over the mucous surface of the 
larynx and trachea, will, if allowed to progress, 
inflame the whole bronchial divisions, and block 
up and distend the ramifications of the bronchi 
and the lungs with serum and puriform matter ; 
and in this way will effectually prevent the arte- 
rialization of the blood. To arrest, therefore, 
this morbid condition of the mucous membrane, 
which causes the generation of these albuminous 
exudations, is an indication of the highest im- 
portance. JSTow, from the well-known thera- 
peutic effects of the nitrate of silver upon in- 
flamed mucous tissues, and from my own experi- 
ence in its use, which is not a limited one, I 
can with confidence recommend it as the most 
efficient and certain of all topical agents for 
effecting this very purpose. So salutary, indeed, 
have I been led, in my experience, to consider 
the effects of the nitrate of silver when topically 
applied to the mucous membrane, and its cryptee, 112 
EXTENT AND FATALITY OF CEOUP. 
in plastic inflammation, that for several years I 
have not hesitated to employ it, in combination 
with appropriate general remedies in all stages 
of both simple and complicated membranous 
croup. 
Since the publication of the first edition of this 
work, I have watched with much interest the 
results of the “ received mode of treating croup,” 
as this method is generally employed in the 
management of the disease, in this and other 
cities. 
The extent of the fatal cases of croup which 
have occurred among children in the city of New 
York, during the last few years, is almost with- 
out a parallel in the history of this or any other 
disease of childhood. This holds true with 
regard to those seasons in which no epidemic in- 
fluence has prevailed. The number of deaths 
from croup in this city during the year 1858—a 
year that has been unusually temperate—amount- 
ed to four hundred and seventy-eight. But in 
1854, from a statement published by the City 
Inspector, it appears that during that year, which 
ended February 28th, 1854, the number of fatal 
cases of the disease that occurred in New York, 
was six hundred and eighty! The subjoined 
table contains a statement of the number of 
deaths from croup, in each of the months of the EXTENT AND FATALITY OF CEOEP. 
113 
above-mentioned year ; and, also, columns to 
exhibit the relative proportion of males and 
females out of the six hundred and eighty fatal 
cases. 
Males. 
Females 
Total 
1858 March. 
....81.. 
....86... 
....70 
“ April. 
...29 .. 
26.. 
....55 
“ May... 
. ..27.. 
22... 
....49 
“ June... 
. ...28.. 
...14... 
....42 
“ July... 
....13.. 
15... 
,...2S 
“ Aug ... 
....21.. 
11... 
....32 
“ Sept... 
15.. 
21.. 
....36 
Males. 
Females. 
Total. 
1853. October. 
..38... 
...43 
..SI 
. 31... 
...89 
. .70 
“ Dec 
. .47... 
...42 .... 
..89 
1854. Jan 
..2S... 
...39 
. .07 
“ Feb 
..33 .. 
...2S 
..61 
844 
336 
CSO 
We have no means of comparing the preced- 
ing statement of the fatal cases of croup, with the 
statistics of deaths from this disease in other places 
during the same time ; but, on referring to an 
article published in the London Medical Gazette, 
for 1850,* on the subject of croup, we find that, 
in a population nearly fourfold greater than that 
of this city,*)* the average number of deaths from 
croup, during a period of eight years, in London, 
was less than three hundred and eighty a year. 
The number of deaths from croup in the whole 
State of Massachusetts, in 1851, according to the 
Registration Report for that year, in a popula- 
tion, at that time, of about one million, J amounted 
to four hundred and eleven. During the same 
year, in Suffolk County (which county includes 
* London Medical Gazette, vol. x. p. 542. 
f The number of the inhabitants of London, at the last census, was 
2,362.236. In New York, in 1850, it was 515,547. 
t At the census in 1850, the population of Massachusetts was 994,514. 
That of Boston proper, 136,881. 114 
EXTENT AND FATALITY OF CROUP. 
Boston, Chelsea, etc.), with a population amount- 
ing to 145,000, the deaths were ninety-two. 
It will be recollected, that at the census of 
1850, the population of Kentucky was very near 
the same in amount with that of Massachusetts.* 
It is a little remarkable, diverse as are the 
climates of these States, that, with a population 
nearly equal, the number of fatal cases of croup 
should be so uniform. In 1852, according to the 
Annual Report of the Registration of Births, 
Marriages, and Deaths, in Kentucky, for the above 
year, the deaths from croup were four hundred 
and sixty-one ; just fifty more than occurred in 
Massachusetts during 1851. 
In Philadelphia, the mortality from croup, in 
the five years preceding 1846, was seven hun- 
dred and fifty-six ; or an average of one hundred 
and fifty-one a year, f in a population which, at 
the census in 1850, amounted to 121,376. 
These brief statistics will afford us some idea 
of the ordinary annual mortality from croup in 
some of the larger cities, and in different climates, 
and will exhibit, also, especially in comparison 
with London, the frightful mortality caused by 
the disease in New York during the year named. 
It is now over fifty years since Napoleon’s 
offered prize for the best essay on the nature of 
* The population of Kentucky was 985,405. 
f Dr. Meigs on the Diseases of Children, p. 84. EXTENT AND FATALITY OF CKOUP. 
115 
this disease, served to awaken a new interest on 
the subject throughout the whole of Europe ; and 
was the occasion of eliciting many learned, ela- 
borate, and highly interesting works on the 
nature and treatment of this terrible malady. 
From that time to the present, these inquiries 
have been pursued, in this country and in Europe, 
by eminent medical men, and the results pub- 
lished to the world ; but, has a plan of treatment 
yet been discovered, recommended, and adopted 
generally, that has had the effect to abate the 
severity of the disease, or, in any considerable 
degree, to lessen its fatality ? 
In that excellent treatise on Croup to which I 
have alluded, by Dr. Ware, the author declares, 
that “ the received mode of treating the disease,” 
which is very much the same for all varieties, 
“ has come down to us by a sort of tradition 
from our predecessors in the profession, and 
varies but little, if at all, from that which was 
originally adopted when the disease first became 
the object of attention. ... In the main, 
emetics and bleeding, blisters and calomel, have 
been the principal remedies. The depleting, 
reducing, and perturbating method is that upon 
which dependence has been chiefly placed.7’ * 
This is, indeed, true, for it must be admitted 
that whilst in the management of many other 
* Boston Medical and Surgical Journal, vol. xiii., p. 261. 116 
DR. WEST ON THE TREATMENT OF CROITP. 
diseases great improvements have been made 
during the last half century, in the traditionary 
treatment of this affection no modifications have 
been generally adopted which have served, to 
diminish, in any amount, the number of fatal 
cases. On the contrary, the disease is admitted, 
as I have before stated, to be so far uncontrolled 
by the ordinary therapeutic measures, as to prove 
fatal in nearly one half of the whole number of 
those who are the subjects of this affection. 
These unfortunate results, which, in the statis- 
tical records of croup, have followed the ordinary 
mode of treatment, will be found to have been in 
no degree more favorable in the history of the 
disease as it has occurred in our city and county 
during the past few years, and we do not hesitate 
to avow our firm conviction, that the employ- 
ment of the reducing and perturbating plan of 
treatment, a plan recently recommended by more 
than one eminent writer, and still employed by 
many practitioners, has destroyed more lives, 
among young children, altogether, than it has 
been instrumental in saving. A work, by an 
eminent English writer, has recently been repub- 
lished in this country, which has met with a very 
favorable reception from the profession generally, 
and has received the commendation of the re- 
viewers, in our medical journals ; and yet, the 
method urged by the author, in his “ Lectures on DE. WEST OX THE TREATMENT OF CROUP, 
117 
the Diseases of Infancy and Childhood,’7 * as the 
appropriate plan for the management of mem- 
branous croup, if fully carried out in the treat- 
ment of the disease, would prove fatal in its 
results, as we conscientiously believe it has done, 
in more instances than it has proved remedial. 
That we may not be misunderstood in our re- 
marks on this heroic plan of treatment recom- 
mended by Dr. West, and employed, to a great 
extent, by many practitioners in this country, we 
shall take the liberty of giving a brief statement 
of the therapeutic measures by him adopted. 
In cases where an attack ’of croup “is 
merely apprehended, but where catarrh exists, 
attended with a slight, ringing cough,” Dr. West 
recommends that the child “ be confined to the 
bedroom, be placed on a spare diet, and should 
take an emetic of ipecacuanha and antimony, to 
be followed by some mild diaphoretic medicine 
containing small doses of antimonial wine.” f 
But, should the disease have attained its full 
development, before the patient comes under the 
notice of the physician ; or, should its access be 
violent, a far more energetic plan of treatment is 
advised by Dr. West. “ The abstraction of blood, 
* Treatise ou the Diseases of Infancy and Childhood, by Charles 
West, M.D. 
f Diseases of Infancy and Childhood, by Charles West, M.D., p. 221, 
Philadelphia edition. 118 
DK. WEST ON THE TREATMENT OF CROUP. 
and the administration of tartar emetic, are the 
two measures on which your main reliance must 
he placed ; and you must bleed largely, and give 
tartar emetic freely, remembering that if relief do 
not come soon it will not come at all—that there 
is not danger only, but death in delay. I have 
never met with an exception to the rule which 
prescribed the free abstraction of blood in every 
case of severe idiopathic croup, when seen at an 
early period, and before the purple lips, and livid 
countenance, and failing pulse, announce the 
long continuance of a serious obstacle to the free 
admission of air into the lungs. Even in very 
young children, local depletion forms, in these 
cases, but a poor substitute for general bleeding ; 
for it is not merely the abstraction of a certain 
quantity of blood that is needed, but its removal 
in such a manner as most speedily to produce an 
effect on the system. Bleeding from the jugular 
vein is preferable, under these circumstances, to 
venesection in the arm, since the latter often fails 
in children under three years old ; and the blood 
never flows so freely as when taken from the 
jugular vein.” * 
Ajfter bleeding “largely” from the arm—or, 
what Dr. West considers preferable, “ in very 
young children,” from the jugular vein, because, 
in children under three years of age, “ the blood 
* Ut supra, p. 221. DR. WEST ON THE TREATMENT OF CROUP. 
119 
flows more freely when taken from the jugular 
vein ”—the free administration of tartar emetic 
is recommended. To accomplish any real good 
by means of this medicine, “ it must be given,” 
says Dr. West, “ in doses of an eighth, a quarter, 
or half a grain, every ten minutes, until vomit- 
ing is produced ; and the same doses should after- 
ward be continued every half hour, until decided 
and permanent relief has been afforded.” If the 
medicine, when administered in the amount as at 
first, fails after a little to excite vomiting, it is 
advised by the author to increase the dose until 
this effect is fully produced. The antimony thus 
administered, is to be continued for four or six 
hours, when, if “ no satisfactory measure of im- 
provement should have yet appeared, local de- 
pletion may be resorted to, or possibly a repeti- 
tion of general bleeding may in some cases be 
ventured on.”’ * 
Later in the disease, calomel m combination 
with ipecacuanha, is administered every hour 
or two hours, “ but interrupting its use at inter- 
vals in order to give an antimonial emetic ;” and, 
finally, these active therapeutical measures above 
enumerated having been thoroughly tried, and 
tried in vain, Dr. West advises that a totally 
different plan of treatment be at once adopted. 
“ If antimony cease to vomit,” he remarks, “ or 
* Op. citat. p. 222. 120 
DE. WEST ON THE TEEATMENT OF CEOEP. 
if it be rejected immediately, and without effort, 
the fluid thrown up being unmixed with phlegm 
or false membrane, while the temperature sinks, 
the lips grow more livid, the pulse more frequent 
and feeble and the paroxysms of dyspnoea are 
undiminished in severity ; or, if the respiration, 
though less laborious, be attended with a sibilant, 
instead of a stridulous sound, it is evident that 
by continuing the medicine we may destroy the 
patient, but shall fail to cure the disease.” 
Under such circumstances, “ an attempt must 
be made to arouse the child from the state of 
collapse into which it is sinking, by placing it for 
a few minutes in a hot mustard bath, and emetics 
of the sulphate of copper should at once be ad- 
ministered.” * If to the therapeutic measures 
already enumerated, we add that of the use of 
mercury, which, in addition to its occasional ad- 
ministration at an earlier period, is to be em- 
ployed at that stage of the disease when the 
patient “seems sinking into a state of collapse,” 
and under these circumstances to be fully em- 
ployed, by means of its internal administration, 
every hour, “ while at the same time a drachm 
of strong mercurial ointment may be rubbed into 
the thighs every twTo hours,” in order to bring 
the system as speedily as possible under the in- 
fluence of mercury,” together with the applica- 
* Op. citat. p. 224. DR. WEST ON THE TREATMENT OF CROUP. 
121 
tion of “ a blister to the throat ”■—if these mea- 
sures are included, we repeat, they constitute 
the plan of treatment strongly advocated by Dr. 
West, and employed by many practitioners, both 
in Europe and in this country, for the cure 
of membranous croup. “ Emetics and bleeding, 
calomel and blisters,” Medicma agens et pertur- 
bans, the Sangrado, traditionary treatment of 
the last half-century! We can hardly imagine a 
plan more likely to pbove- unsuccessful, when 
fully carried out, than the method of which we 
have spoken ; and if we'icoiisult the records of 
this plan, we shall find that, where it has been 
adopted, this opinion of itS1 effects will be entirely 
sustained by the results'-Which have followed its 
employment. ■ &yz'o\> 
A similar method, though in some degree less 
heroic, is advocated by DivMeigs, of Philadelphia, 
in his work on “ ThSP'Diseases of Children.”* 
In a “summary of thd'treatment,” Dr. Meigs 
suggests “the following plan of treatment to be 
pursued in childreniab'CWtfbt* over two years old, 
when we are called imgotjd time : to take from the 
arm three or four once, twice or 
three times in two daysj'&CCbrding to the strength 
of the child, and the degree-'and obstinacy of the 
fever. In both forms of the disease, emetics, and 
* A Practical Treatise on the Diseases of Children. By J. Forsyth 
Meigs, M.D , etc. Second edition. 122 
DR. WEST OX TIIE TREATMENT OF CROUP. 
I would recommend alum in preference to any 
other, should be given once at least, very often 
twice, and, in violent cases, three or four times 
in the twenty-four hours, so as to produce vomit- 
ing attended with a good deal of effort. To give, 
at the same time, from one to two grains of 
calomel, with a quarter or half a grain of Dover’s 
powder, every two hours, taking care not to give 
a dose for an hour before nor after the time 
selected for the exhibition of the emetic. In 
cases in which there is loud stridulous respiration, 
heard both in the inspiration and expiration, in 
which previous treatment has had no effect, and 
in which there is threatening of speedy death, 
we may give two grains of calomel every hour, 
until three or four doses have been taken, and 
direct the exhibition of an alum emetic after the 
last dose, or resort to tracheotomy.” * 
Certainly, in one respect, this “plan of treat- 
ment ” is characterized by a great improvement 
on the wholly reducing and prostrating method 
ordinarily adopted ; namely, in substituting alum 
for antimony as the emetic in the treatment of 
the disease. His reasons for this are as follows : 
“ Antimony, when resorted to as frequently in 
the disease as I am of the opinion emetics ought 
to be, is too violent in its action ; it prostrates 
many children to a dangerous degree, and is, 
* Op. citat. p. 103. DE. WEST ON THE TREATMENT OF CEOUP. 
123 
I fear, in some cases, itself one cause of 
death.” * 
If, then, these positions, with regard to the 
generally-adopted reducing plan of treating croup 
are tenable—and in confirmation of these views 
we challenge inquiry into its history—is it not 
time for the thinking, progressive portion of the 
profession to conclude with Dr. Ware, “ that the 
methods of treating this disease in common use, 
require a careful reconsideration ?” CHAPTER VII. 
EXPERIENCE OF EMINENT MEDICAL MEN IN THE 
USE OF TOPICAL MEDICATION, AND THEIR OPINIONS 
OF ITS VALUE IN THE TREATMENT OF DISEASE. 
As a difference of opinion still obtains, to some 
extent, among the profession, with regard to the 
propriety of employing topical applications of 
the nitrate of silver in exudative laryngitis or 
croup, I shall examine, with care, the opinions 
and observations of some of those practitioners 
who have had extensive opportunities, both in 
this country and in Europe, to test its efficacy 
in the treatment of this often fatal malady. 
Since the publication of this work, the author 
has received from medical men, in different parts 
of the United States, as well as from numbers in 
Europe, the history of many cases of membran- 
ous croup, wherein topical measures, in their 
hands, have proved effectual in arresting the dis- 
ease. In view of the great fatality, on the one 
hand, which constantly attends this disease, as 
ordinarily treated, and on the other, of the pre- 
judice against the local treatment, which is still 
entertained by many, especially of the older 
124 DE. WAKE ON THE TREATMENT OF CEOUP. 
125 
members of the profession, the author does not 
feel at liberty to withhold from his professional 
brethren this abundant and most conclusive tes- 
timony in favor of topical medication in the treat- 
ment of croup. 
It will not avail, for the cavilling opposer of 
this method of treating the disease, to rebut all 
testimony in its favor, as many in the profession, 
who, having always refused to try the plan, have 
persisted in doing,* with the assertion, that the 
cases of croup which have recovered rapidly un- 
der local treatment “ were not cases of true 
membranous croup, but those of a spasmodic or 
catarrhal nature, such as would have recovered 
under almost any treatment for, in many in- 
stances, the employment of nitrate of silver, in 
the treatment of croup, has been adopted with 
great success, by eminent practitioners, who pre- 
viously had had extensive experience in the man- 
agement of the disease, but who, before the em- 
* In a case of membranous croup that occurred in this city, the his- 
tory of which was received from the attending physician, a prominent 
surgeon was called, by request of the family, in consultation. The case 
had advanced, until the symptoms were very urgent, and prompt mea- 
sures were demanded, to save the life of the child. The physician in 
attendance proposed cauterization of the parts, rather than tracheotomy. 
The consulting surgeon positively refused to accede to the adoption of 
this plan, on the ground that it was a dangerous, and, in such cases, a 
worthless measure. The physician, however, persisted in his proposal, 
and the surgeon retired. Cauterization of the larynx was then promptly 
and perseveringly employed, and, by this means, the life of the child was 
saved. 126 
DR. WARE OX THE TREATMENT OF CROUP. 
ployment of topical medication, had treated, un- 
successfully, a large number of cases by the ordi- 
nary “ depressing, depleting, and disturbing 
remedies.” This was the case, as with many 
others to whom we could refer, with Dr. Ware, 
to whose experience, in the different modes of 
treating this disease, and the conclusions to 
which he has arrived, we shall now briefly 
allude. 
Dr. Ware, in his papers on the “History and 
Diagnosis of Croup,” refers to thirty-nine cases 
of what he denominates membranous croup, 
which were noticed in his own, or in the practice 
of his friends. Of these cases the state of the 
fauces was observed in thirty-three instances, and 
“in thirty-two a false membrane was present; 
most frequently, and sometimes only on the ton- 
sils, sometimes on other parts also, as the palate, 
uvula, and pharynx. In one case no such mem- 
brane was present; but it was found to exist in 
the larynx after death. These thirty-three cases 
were treated by the ordinary therapeutic mea- 
sures ; and of the whole number, three only 
recovered—in thirty, the disease proved fatal.” 
It is not at all surprising that, under these cir- 
cumstances, Dr." Ware, eminent for his careful 
investigation and conscientious inquiry after 
truth, should have become “ confirmed in the 
opinion,” as he subsequently declares himself to DR. WAKE OX THE TREATMENT OF CROUP. 
127 
have been, that the methods of treating this clis- 
ease, in common use, require a careful recon- 
sideration ;” nor that he should have propounded 
the question—“ If the mode of treating croup 
commonly adopted, does no good, are we sure 
that it does no hurt ?” 
Having concluded, after the experience to 
which we have referred, to treat the disease 
“without the persevering use of the heroic 
remedies,” Dr. Ware subsequently adopted a 
method in which “ the treatment consisted— 
“1. In the absence of all reducing, depleting, 
and disturbing remedies. 
“ 2. Keeping the patient under the full influ- 
ence of opium combined with calomel. 
3. Constant external application of warmth 
and moisture [to the neck], and of mercurial 
liniment, slightly stimulating. 
“ 4. Constant inhalation of watery vapor.” 
In March, 1850, Dr. Ware read before the 
Suffolk District Medical Society, “ Additional 
Remarks on the Treatment of Croup,” in which 
paper he refers to five cases of membranous 
croup, three of which were treated on the 
method indicated in the preceding propositions. 
The history of these five cases, as briefly nar- 
rated by Dr. Ware, with the conclusions to which 
he has arrived, we shall take the liberty of giving 
in his own words : 128 
DR. WARE OX TIIE TREATMENT OF CROUP. 
“The first case was that of a male, four years 
old, who was taken with membranous sore throat, 
accompanied by high constitutional irritation, 
Oct. 14, 1845. No croupy symptoms occurred 
till Oct. 18, when they were manifested in a per- 
fectly distinct manner. On the 20th and 21st, 
patches of false membrane, with bloody sputa, 
were raised—and one piece of four inches in 
length. The raising of the latter was accom- 
panied by a severe and suffocative paroxysm of 
coughing. On the 22d he died, eight days from 
the commencement of the disease and four from 
the access of croup. The suffering in this case 
was very considerable, but far less than I have 
been accustomed to witness in cases of croup 
treated according to the ordinary method. 
“The second was that of a female, four years 
of age, taken with croup on the 8th of Nov., 
1845. No depleting or reducing remedies were 
employed. Patches of membrane, and one piece 
of considerable size, were brought up on the 10th, 
and a few following days. She never suffered 
much, improved steadily, and on the 15th seemed 
well in all respects except the voice, so that on 
the 16th I did not see her. On the 17th, there 
was a return of all the croupy symptoms, includ- 
ing the appearance of lymph upon the tonsils, 
and she died on the night of the 19th, eleven 
days after her first seizure. During no part of DE. WAEE OX TKE TKEATMENT OF CEOUP. 
129 
the disease was the suffering from dyspnoea very 
intense for any continued period. 
“ On dissection, the usual appearances were 
found, and in one lung the false membrane 
extended for some distance into the bronchi in 
the substance of the organ. 
“ The third case was a female, six years of age, 
who was seized with the disease Oct. 31, 1847. 
The onset of the disease was gradual, yet quite 
distinct. Nov. 2d, the symptoms had become 
quite severe ; and Nov. 3d, there was bloody 
expectoration, and pieces of membrane were spit 
up. Pieces of membrane continued to be found 
in the sputa for several days, and she was very 
comfortable and breathed with tolerable ease, yet 
never losing the distinct croupy sound of respira- 
tion and voice. She retained some appetite and 
sat up and amused herself as usual. On the 8th, 
she became rapidly worse, but without distress, 
and died on the 9th, quite easily ten days from 
the first attack of the disease. 
“ It will be admitted, I think, that these cases, 
especially the two last, exhibited certain differ- 
ences from the common course of this disease, 
which indicated a favorable influence from dif- 
ference of treatment. 
“ In all of them the membrane was thrown up 
in considerable quantities. 
“In all of them the disease was attended by 130 
DR. WARE ON THE TREATMENT OF CROUP. 
very much less distress than is usual in croup, 
and, in two, there was so decided a mitigation of 
symptoms following the separation of the mem- 
brane, as to lead to considerable hope of a favor- 
able termination. 
“ In two, at least, the disease was prolonged 
to twice its average duration under the usual 
treatment. 
“In the two other cases, to which reference 
was made, the same general course of treatment 
was followed, with the addition of the introduc- 
tion of a sponge, wet with a solution of the nitrate 
of silver, into the larynx. In each of these cases 
the application was made as early in the disease 
as I became satisfied of its distinct character. It 
was repeated morning and evening. It decidedly 
gave relief to the breathing, soon after each 
application, and both cases ultimately recovered 
perfectly. For the suggestion and adoption of 
this valuable addition to our means of treating 
this formidable disease, we are indebted, as is 
well known, to the enterprise of Dr. Horace 
Green, of New York. The profession, I think, 
owe to him a large debt of gratitude, for the 
energy and perseverance manifested in the intro- 
duction of this remedy, and I am the more dis- 
posed to render this tribute to him, because so 
many attempts have been made to detract from 
his merit in relation to it.” BE. WAKE OX THE TEEATMENT OF CKOT7P. 
131 
“ I am well satisfied from wliat I have now 
seen of this method of treating croup, as com- 
pared with that which has been followed for so 
many years, that it has the advantages which 
were pointed out in one of the preceding papers. 
It is a disease which I would treat without deple- 
tion—except, perhaps, by a few leeches—without 
vomiting, without purging, without blisters, with- 
out antimonials, ipecac., and all those other 
nauseous remedies which have been usually 
resorted to. I would trust to opiates, perhaps 
calomel, emollients, and the local application of 
the nitrate of silver. 
‘ ‘ I ought to add that many of my friends in 
the profession have informed me of cases in their 
practice, treated on these principles, which have 
recovered in a favorable manner.” 
Since the publication of Dr. Ware’s papers, 
cauterization of the larynx, in the treatment of 
membranous croup, has been adopted by large 
numbers of medical men in New England, from 
many of whom we have received communications 
on this subject, expressing their full confidence in 
this therapeutic agent, when timely and appropri- 
ately employed in the management of croup. 
Should we give the history of a tithe of these 
cases, which have been thus reported to us, they 
would occupy a much larger space than can be 
appropriated to this subject. In many instances 132 
DE. WAEE OX THE TREATMENT OF CROUP. 
—and this is the testimony of large numbers of 
practitioners, experienced in the disease—the 
morbid process has been promptly arrested, by 
topical medication to the surface of the tonsils 
and pharynx without the introduction of the 
sponge-probang into the larynx. 
Some time ago, a physician from the interior 
of one of our southwestern States, called on us 
to state his experience in the treatment of croup 
by local measures. Two or three years before, he 
had passed several weeks in our city, and had 
then seen, for the first time, the employment of 
topical medication for the treatment of laryngeal 
and bronchial diseases. Returning to his home 
in the West—a region noted for the frequency 
with which croup occurs among children—he 
commenced at once to put into practice the new 
method of treating disease, with which he had 
recently become acquainted. During his previ- 
ous practice, he had treated many cases of croup 
in the ordinary method, and the proportion of 
deaths, in his experience, as he stated, had been 
quite equal to one-third of the whole number 
attacked. But since the adoption of topical medi- 
cation, during the two or three years after his 
return, some fifteen cases, he affirmed, had come 
under his observation, and were treated by cau- 
terization of the fauces and larynx, every one of 
which recovered. The plan adopted by this physi- Dll. MAY ON THE TREATMENT OF CROUP. 
133 
cian was the same as that which is recom- 
mended in this work. 
As before asserted, since the publication of this 
work on croup, we have received similar verbal 
statements, in favor of topical medication, from 
physicians resident in almost every State in the 
Union ; but we have also abundant written testi- 
mony bn the subject. 
The following cases from Prof. May, of Wash- 
ington, who is one of the most distinguished of 
American surgeons, will be read with much 
interest: 
Washington, April 80th. 
“ My dear Sir : 
“I herewith inclose you a hasty and brief 
account of the cases of cynanclie trachealis, in 
which I have used the strong solution of nitrate of 
silver, as recommended by you in your work on 
croup. The statement of these cases is not as 
full and satisfactory as I could have desired, 
owing to the partial notes hastily taken by me at 
the time of their occurrence j but the result, 'in 
several of them, fully sustains the great value of 
the local agent recommended by you, to arrest 
this formidable disease, and which you have been, 
I believe, the first to bring fully to the considera- 
tion of the profession, 
“I am very truly and respectfully yours, 
“ Jno. Fred’k May. 134 
DR. MAY OX THE TREATMENT OF CKOUP. 
“ Case 1. On the 2d of January I was called on 
to visit a son of Mr. C., of this city, aged about ten 
years, whom I found laboring under symptoms 
of croup. The child had been complaining 
of some uneasiness about the throat, with hoarse- 
ness and slight cough, a day or two before I saw 
him. At my visit, his respiration was difficult, 
and there was a good deal of tenderness about 
the tonsils and fauces,' 'which were inflamed. 
There was considerable febrile action, and the 
little patient was very restless, and the voice 
quite hoarse. I directed an emetic, to be fol- 
lowed by an active mercurial cathartic, his bowels 
being constipated, and such local applications, 
both internal and external, as I thought most 
likely to give relief. 
“ At my visit next I found my little patient 
no better, but, on the contrary, his symptoms 
were more unfavorable and alarming. His res- 
piration was very difficult, and his countenance 
expressed great suffering and anxiety. He could 
not remain more than a few moments in a hori- 
zontal position, but was raising himself up con- 
tinually, and stretching backward the head to 
obtain relief. In a word, the difficulty of respira- 
tion was extreme. He was very hoarse, his pulse 
very hurried, and the throat and tonsils more 
inflamed than at my previous visit. The symp- 
toms of diphtheritic croup, which had been epi- DR. MAY OX TIIE TREATMENT OF CROUP. 
135 
demic in our city the year previous, were very 
decided. I at once resolved to try your method 
of introducing a strong solution of argent, nitrat. 
into the larynx—everything else having been 
tried by me, in this disease, the year previous, 
not excepting tracheotomy, with but little success. 
The symptoms were very urgent. I felt satisfied 
that, unless soon relieved, the case would proba- 
bly end fatally. I had no instrument sufficiently 
small for the object I had in view, and I there- 
fore bent a small piece of ash stick to the proper 
curvature, and secured to the end of it a small 
piece of sponge, which I saturated thoroughly with 
a solution of the crystallized nitrate, of the strength 
of forty grains to the ounce, and introduced it 
fairly into the larynx. This I repeated once or 
twice, on the spot, the child being forcibly held 
by the father. There was considerable irritation 
produced in the throat, for a few moments, but I 
believe it was caused as much by the effort, on 
the part of the child, to resist, as by the action of 
the caustic. 
“ I remained some time after using this remedy, 
and in half an hour the improvement in his 
breathing was manifest to all present. I left 
him breathing decidedly better, and when I re- 
turned in the morning I found the child had 
passed a quiet and comfortable night, having 
slept a considerable portion of it. The caustic 136 
DK. MAY ON THE TREATMENT OF CROFT. 
solution was again used by me, in the same way, 
at this visit, his breathing having again become 
somewhat more difficult, and with the same im- 
provement in his condition. My visits to him 
were soon after discontinued, the little patient 
having entirely recovered. 
“ Case 2. I was requested in May, by my friend, 
Dr. Dawes, to visit, in consultation with him, in 
the country, a little girl of two years of age, the 
daughter of R. S. Wood, Esq. 
“Dr. D. had been in attendance on the child 
for several days, and had administered the usual 
remedies in her disease, which was membranous 
croup. Having mentioned to him, some time 
before, the success of the argent, nitrat. solution, 
in the case which I have already stated, he was 
desirous of having it used in the present in- 
stance. 
“ When I saw the child the breathing was ex- 
tremely difficult, and the cough tight and ring- 
ing. The little patient was much exhausted, 
having slept but little during the twenty-four 
hours which had passed. It was constantly held 
by the mother in her lap, or by some of her 
friends, as the respiration became more labored 
when she was placed in the bed. I at once used 
the solution of crystallized nitrate of silver, in- 
troducing it into the larynx, and cauterizing also 
the back part of the throat, freely. The solu- DE. MAT OX THE TEE ATM EXT OP CEO UP. 
137 
tion was of the strength of fifty grains to the 
ounce. 
“ The respiration became easier before I left 
the house. This was apparent to all, and at the 
same time the pulse improved, and the skin be- 
came more natural and warm. On our return, 
early in the morning, we found the little patient 
had passed a much more comfortable night, and 
her breathing had decidedly improved. The 
caustic was, however, • again used, and with an 
equally satisfactory result. The symptoms of 
the disease gradually yielded, and the child re- 
covered. As I was not aware, or had forgotten 
the treatment which had been pursued in the 
commencement of her case, I applied to Mr. 
Wood, who had formerly pursued the study of 
medicine, for a statement of it. I received the 
following reply: 
V ‘ M*y daughter, about two years old, was at- 
tacked with croup in the month of May last. 
She had never suffered previously from any dis- 
ease, and her constitution was good. After try- 
ing the usual domestic remedies, such as hot 
baths, emetics, local applications, and small doses 
of calomel and ipecac, frequently repeated, we 
were induced to send for our family physician, 
Dr. Dawes, who prescribed mercury to the full 
extent warranted by her critical situation. On 
the third day, the doctor proposed consulting 138 
DR. VEDDER ON THE TREATMENT OF CROUP. 
with you, in regard to the propriety of introduc- 
ing a strong solution of the nitrate of silver 
into the larynx. I readily gave my consent, 
and the operation was performed twice within 
twelve hours. The character of the respiration 
was perceptibly changed on the first trial, but 
we felt doubly sure of success on its repetition ; 
the pulse rallied, and the color of the skin be- 
came more natural. 
“ ‘ She is now enjoying.perfect health.’ ’J 
Other cases have been treated by Dr. May 
with equal success, the history of which have 
been furnished by him; but, as our object has 
been to give the testimony of different members 
of the profession, from various localities, these 
may with propriety be omitted. 
Dr. A. M. Yeddcr, Lecturer on Anatomy and 
Physiology, at Union College, has treated many 
cases of membranous croup by topical measures. 
The subjoined cases were communicated by Dr. 
Yedder. 
Even at the present day, there are medical 
men who will not admit that the passage of an 
armed probang into the larynx of the adult can 
be accomplished. Much more emphatically do 
these men deny the possibility of cauterizing the 
larynx of the young child. Within the last year, 
an astute professor in one of our medical colleges DE. VEDDEE OX THE TEEATMENT OF CEOUP. 
139 
declared, before his class, his firm belief that the 
operation had not been, and never could be, per- 
formed! To such “blind guides,” we would 
commend the interesting fact recorded in the 
second case reported by Dr. Yedder. 
“ Case 1. A little girl, aged six years, was under 
treatment by a neighboring practitioner, who 
called me in consultation. She was first taken 
with what we supposed to be slight catarrhal 
symptoms ; after a few days, the cough became 
stridulous, aind was accompanied with some fever. 
These symptoms continued for three weeks, 
gradually increasing in severity. At this time I 
saw her, in the evening, and found her laboring 
under the characteristic symptoms of inflamma- 
tory croup ; pulse rapid, and small; voice re- 
duced to a whisper ; respiration high and la- 
bored ; tonsils red and inflamed, but not covered 
with false membrane. The attending physician 
had treated her with sinapisms, calomel, and tar- 
tar emetic, the latter in emetic and nauseating 
doses. 
“I suggested the topical application of nitrate 
of silver, which was readily acceded to. Two 
applications were made ( 3 ii. to §j. aqua). The 
probang was found covered with a thick, tena- 
cious secretion. Respiration became somewhat 
more free. On the following day, there was a 
marked increase of all the symptoms, the silver 140 
DR. TEDDER OX THE TREATMENT OF CROUP. 
was again applied three or four times during the 
clay, entering the glottis each time. There was 
now a gradual improvement of all the symptoms, 
and no further applications were made. During 
this time, calomel and James’ powder were also 
administered. 
“ Case,2. Louisa —:—, aged six years, general 
health previously good, came home from school 
(Nov. 1st) complaining of sore throat and cough, 
which was followed by vomiting. A homoeopathic 
doctor was sent for, who treated the case as ‘ sore 
throat ’ for five days ; during this time, she was 
not wholly confined to the bed, and was about the 
house a part of the time. On the afternoon of 
the fourth day, she became very hoarse, with loss 
of voice and decided croupy cough. Nov. 6th, 
confined to bed, with considerable heat of skin 
and thirst. I saw the patient this day, for the 
first time, at 6 o’clock, p.m. Expression of coun- 
tenance anxious, skin pale, voice reduced to a 
whisper, respiration extremely difficult, high and 
characteristic, pulse frequent, skin above natural 
temperature, cough frequent; applied the nitrate 
of silver with the probang, which did not produce 
any unpleasant symptoms, her breathing became 
somewhat easier ; during the night her respira- 
tion became more difficult, and an emetic was 
administered, which was followed by some relief. 
Nov. 7th, a.m., countenance still anxious, color of DR. TEDDER ON THE TREATMENT OF CROUP. 
141 
skin inclining to blue, respiration not much im- 
proved, almost complete aphonia ; prescribed the 
following powder, to be taken every three hours. 
“R. Tart. Antira., gr. -J, 
Hyd. Chlor., M. gr. 
M. 
“Applied the silver three times during the day. 
Nov. 8th, no improvement j sweats now freely, 
and has done so all night; on coughing expec- 
torates a little mucus, particularly after applying 
the sponge ; continue powders and apply cold 
water to the neck by means of a towel. Nov. 9th, 
no improvement ; applied the sponge, and on 
removing it the false membrane was found attach- 
ed to the sponge ; and on examination found it 
to be a membranous tube two and a half inches 
in length, and about one half the thickness of 
milliner’s pasteboard. Her respiration became 
immediately easier and she continued to improve ) 
from this time the sponge was not again applied ; 
her cough remained * croupy ’ for several days 
longer ; her voice did not become natural for more 
than a week after j the cold water and expecto- 
rants were continued for several days. Her health 
has been good since ; her voice becomes hoarse, 
occasionally, on taking cold. I should have 
remarked, that at my first visit, I saw patches of 
lymph on the tonsillary glands. On taking charge 142 
DR. VEDDER OX TIIE TREATMENT OF CROUP 
of the patient (which I did with great reluc- 
tance), I had very little hope of a favorable ter- 
mination, on account of the advanced stage of 
the disease, and must attribute the cure to the 
application of the silver. 
“ Since treating this case I have used the silver 
with varying success. In two cases, in which I 
was called early, and in which the lymph could 
be seen in the upper part of the fauces, the 
patients recovered. In one case where I was 
called in consultation, the patient was in articulo 
mortis. We used the silver without an}~ relief. 
In two other cases, I was called late in the dis- 
ease ; the nitrate of silver, and other remedies 
were employed; but both cases terminated 
fatally.” 
Believing, as we conscientiously do, that the 
reducing, perturbating, plan of treating young 
children for croup, is in a large proportion of 
cases, not only useless, but worse than useless : 
and that, on the other hand, we have, in the topi- 
cal treatment, when judiciously combined with 
mild general measures, an entirely practicable, 
and in most cases, an effectual means of arresting 
the disease, we are solicitous to remove the objec- 
tions, which, for various reasons, exist in the 
minds of many practitioners, and hinder their 
adoption of this method. We have alluded to the DE. PEASLEE OX THE TEEATMEXT OF CEOUP. 
143 
dogmatic skepticism of one class, but fortunately 
this class of “unbelievers in the earth’s rota- 
tion,” is very small. Still, there is a much larger 
class, who, whilst they admit both the practica- 
bility and utility of the treatment, reject its 
employment because of the supposed difficulty of 
medicating the larynx in disease. This difficulty, 
we can assure the profession, does not exist. It 
is neither really difficult to accomplish, nor is it 
in any degree a hazardous operation. Any medi- 
cal man who understands the relative anatomy of 
the parts, can, with very little practice, readily 
pass the sponge probang into the larynx ; and, 
as benefit comes from the attempt (for the parts 
cauterized thereby are those first affected in 
croup), no time should be lost in putting the 
method into practice, in the onset of the disease. 
Dr. E. It. Peaslee, judicious and experienced, 
as a medical practitioner, in the monograph on 
croup, to which I have referred, says : “In our 
judgment there is no local application for arrest- 
ing the inflammatory process in this disease to be 
compared with the solution of the crystals of 
nitrate of silver. It should be at first applied 
to the fauces and pharynx only ; and then, in 
15 to 30 minutes, the probang may be passed 
into the larynx, and through the rima glottidis 
if required. The operation should be repeated, 
in some cases, three or four times daily, in 144 
Bit. PEASLEE ON THE TREATMENT OF CROUP. 
others only once. Other solutions or fluids, 
thus applied, may also be found useful—such as 
glycerine, olive oil, etc. ; but none will probably 
be found to possess the efficacy of the nitrate of 
silver. Applied to the pharynx and fauces, 
indeed, as soon as the false membrane has 
appeared in these parts, it has frequently arrested 
the inflammatory process at once, and thus pre- 
vented its extension iflto the larynx and trachea. 
“ We should, therefore, feel it an unpardonable 
omission, at the present day, should we fail early 
to cauterize the pharynx (and the larynx and 
trachea, if already invaded by the disease), and 
to repeat the operation as circumstances might 
require in every case of laryngo-traclieitis. The 
objections sometimes raised, that this is a diffi- 
cult operation, and also, if accomplished, a 
dangerous one, were always too puerile, and are 
now too generally known to be entirely un- 
founded, to require a refutation here.”* 
Still farther to sustain these views, not only of 
the nature of the disease, but of the positive 
efficacy of topical treatment in every stage of 
membranous croup, we shall proceed to adduce 
further testimony on these most important 
points. 
In a recent number of the “ Archives Gene- 
rales de Medecine,” is an interesting memoir by 
* Op. Citat. pp. 200-1. DK. WATSON ON THE TREATMENT OF CROUP. 
145 
M. Vouthier, on the history of croup, as it oc- 
curred in an epidemic form in DHopital des 
Enfants Malades de Paris. 
In this paper are the details of several well- 
marked cases of membranous croup, which were 
treated successfully by “emetics and cauteriza- 
tions and although in these instances the 
argentine solution was not conveyed into the 
larynx, but was applied only to the fauces and 
pharynx, yet the patients recovered perfectly 
under the treatment.* Although the cases thus 
treated are characterized as having been very 
severe—“ tres-intense ”—yet, as the treatment 
was early adopted, it is probable that the exuda- 
tive process had not extended to the larynx ; for, 
in the same paper is a history given, of five other 
cases of membranous croup, in which the disease, 
having reached the larynx, was not arrested by 
cauterizations. This measure was employed, as in 
the other cases, but no attempt was made to pass 
the instrument below the epiglottis. Trache- 
otomy, however, was resorted to in all these live 
cases, but every patient died. Efficient cauter- 
ization of the larynx, we maintain, would have 
saved three, if not more of these last cases. 
Among the English practitioners, of whose 
works, on topical medication, we have spoken, a 
few only appear to have employed this remedy 
* Archives Generates de Medecine, tome xix. art. 1st, 146 
DK. WATSON ON THE TREATMENT OF CROUP. 
in the treatment of true exudative croup. The 
experience of Dr. Watson, in the treatment of 
the few cases he has reported in his work, has 
led him to the conclusion, “that the topical 
treatment is unsuitable during the acute stage of 
exudative croup.” 
Having been unsuccessful in the management 
of a single case of membranous croup,* in which 
he employed the treatment through the acute or 
inflammatory stage of the disease, Dr. Watson 
adopts and promulgates the above opinion. In 
the commencement of the disease, or in that stage 
of the affection denominated by him “the pre- 
exudative stage of croup,” Dr. Watson highly 
recommends the application of the solution of 
nitrate of silver to the throat and larynx. Omit- 
ting the applications during the acute stage of 
the disease, he renews the topical measures, as 
soon as the inflammatory process has been sub- 
dued by appropriate reducing measures. But 
his view on this subject will be best understood 
from the following brief extract from his work : 
* The only other case mentioned by Dr. Watson, as one not benefited 
by the topical treatment, is that of a gentle nan past the middle period 
of life, “ who on a winter evening,” was suddenly seized with difficult 
respiration, tightness in the throat, harsh, dry, whistling cough, and high 
fever, “ whilst the physical signs were: Inspiration long in the trachea, 
and accompanied by a harsh sound of the air passing along the dry and 
narrowed tube.” Symptoms, manifestly indicative of acute laryngitis, 
and not, as Dr. Watson supposed, of “ acute tracheal croup, accom- 
panied by exudation.”—Op. citat. p. 51. DR. WATSON ON THE TREATMENT OF CROUP. 
147 
“ There is a large class of cases, in which the 
croup commences by a longer or shorter stage of 
simple, though severe inflammation of the laryn- 
geal membrane. This inflammation differs in 
nothing from the most intense degree of catarrh, 
formerly described ; but it speedily ends either 
in exudation upon the surface of the membrane, 
or in serous effusions beneath it. 
“ The suddenness of the attack, the anxiety of 
the patient, the severity of the constitutional 
fever, and, above all, the stethoscopic signs of 
a dry and tense glottis, never fairly released at 
any stage of respiration, are the chief diagnostic 
marks of the danger to be expected in the next 
stage of the disease. No one who has ever 
listened attentively to the peculiarly harsh sounds 
transmitted through the stethoscope placed over 
the thyroid cartilage of a patient in the critical 
state we are now considering, can either forget 
or mistake the prolonged and dry, but vibratory 
sound during inspiration, immediately followed 
by less noisy, though still grating murmur of 
obstructed expiration by which it is characterized. 
Then the stifling and painful cough, without 
expectoration, and the whispering, not hoarse 
voice, are equally characteristic. 
“ In children, or in adults predisposed to the 
disease, such a group of symptoms as that just 
referred to, may be considered as certainly indica- 148 
DR. WATSON ON THE TREATMENT OF CROUP. 
tive of the first stage of exudative croup. But 
no exudation lias yet been poured out, and 
according to my experience, the disease may 
here be checked by the application of an appro- 
priately strong solution of the nitrate of silver ; 
and I will venture to assert, it is in the treat- 
ment of this preexudative stage of croup, if I 
may be allowed so to name it for sake of brevity, 
that Dr. Horace Green has also been success- 
ful.” * 
This abortive treatment of croup by topical 
application, is further illustrated by Dr. Watson, 
in his relation of the subjoined case : “ It is that 
of a family of young children,” he says, “all of 
whom are remarkably subject to croup, and, 
notwithstanding the utmost care in their manage- 
ment, some of them have suffered once or twice 
from the disease during the winter, for some years 
past. In the beginning of the present year, I 
attended two of them, and, within the last few 
days, a third, when attacked by the disagreeable 
visitant. 
“ Whenever a croupy cough is heard in this 
family, the throat and larynx are at once touched 
with the solution of caustic. A warm bath, a few 
drops of antimonial wine, and, if necessary, a 
dose of laxative medicine, are next had recourse 
to, and very little else is generally required. 
* Op. citat. pp. 49, 50. Mi. WATSON ON THE TREATMENT OE CROUP. 
149 
The throat is touched for the two or three suc- 
ceeding days, by which time the child is usually 
quite well. 
“ Only once that I remember did this abortive 
treatment fail in my hands, and it was in the case 
of a member of the family here referred to. The 
weather was at the time very severe, and the 
subject of the disease, a strong little boy about 
six years of age. For some reason or other, it 
was longer than usual, too, before the topical 
application was made to the larynx, and it failed. 
Exudation was thrown out, and the boy passed 
through a critical illness, during the intensity of 
which I laid aside the topical treatment, and 
employed leeches, calomel, and antimony. But 
when, as happily occurred in this case, the exuda- 
tion had separated in due time, I renewed the 
stimulant applications to the windpipe, with 
marked benefit, and the child made a speedy and 
perfect recovery.” 
In one other respect Dr. Watson differs from 
most practitioners in this country, namely, in the 
strength of the solution which he employs in the 
treatment of croup. He has found in practice, 
he says, that a solution “of fifteen or twenty 
grains to the ounce of water, is abundantly 
successful in fulfilling the indications of the dis- 
ease.” 
In the Academy of Medicine of Paris, a discus- 150 
TROUSSEAU AND LOTSEAU. 
sion took place quite recently on the subject of 
topical medication of the air-passages in croup, 
in which Velpeau, Trousseau, Piorry, Depaul, 
and others were engaged, and this method of 
treatment was emphatically indorsed by that 
body. At a previous sitting of the Academy, 
M. Loiseau had presented a paper entitled, “A 
simple and easy method of entering the air-passages 
in order to cauterize them, or to extract false mem- 
branes, to dilate the glottis, to introduce substances 
used in the treatment of croup, either in the form 
of liquid or powder, and finally to take the place of 
tracheotomy 
On this pajDer MM. Trousseau and Blache 
were appointed to report ; and their report, and 
the discussion that followed, may be found in the 
Union Medicale for August 27tli, 1857, and also 
in the Medical Monthly for November, 1857. In 
this report M. Trousseau sa}7s : “It was after 
M. Loiseau had seen several children attacked 
with croup die, upon whom tracheotomy, although 
indicated, had not been performed, that he 
invented some instruments and a method of 
operating for entering the larynx as the pharynx 
is entered. His invention dates from 1840. 
“ Hr. Green, of New York, had already made 
use of a stiff curved whalebone, armed with a 
sponge, for entering the larynx, and the opera- 
tion was facilitated by a tongue-depresser, which OPERATION OF M. LOISEAU FOR CROUP. 
151 
is in itself an excellent instrument 
The method of M. Loiseau is simple and infallible, 
lie protects the metacarpal phalanx of the left 
index finger by a metallic ring two or three cen- 
timetres in height, and introduces it rapidly and 
deeply into the mouth, so that the ring may be 
placed between the molar teeth, and keep the 
jaws apart. 
“With the extremity of the finger which is 
free, he depresses the tongue, seizes the epiglottis, 
raises it and presses the end of the finger between 
the aryteno-epiglottic folds. There is, then, 
nothing more easy than to make the end of the 
tube, which is only the tube of Chaussier, glide 
over the finger. The air which escapes through 
the exterior extremity of the tube proves that it 
has really entered into the larynx. Through this 
tube, serving as a conductor, a caustic, the nitrate 
of silver, for example, or any other medicated 
substance, may be carried in the curette of a 
flexible metallic shank 
“ This operation of catheterism of the larynx, 
which is the principal point in the memoir of 
M. Loiseau, is considered as a very good means for 
taking the place of tracheotomy, and at all events 
to be tried before that operation.” The professor 
proposed, in consequence, that the thanks of the 
Academy be given to the author, and that his 
paper be sent to the committee of publication. 152 
OPERATION" OF M. LOISEAU FOR CROUP. 
In the discussion that followed, M. Depaul, in 
alluding to the declaration of M. Trousseau that 
‘ ‘ the process of catheterism of the larynx as pro- 
posed by M. Green, was very difficult, even upon 
the cadaver, ”said he, “but I maintain that nothing 
is easier than this catheterism for those who have 
performed it a certain number of times.” 
“The operations [of tracheotomy] upon the 
larynx,” said M. Piorry, “for diseases which are 
most frequently only secondary, are perhaps too 
much esteemed. In these cases the operations 
only shorten life, for they are useless in curing 
the primitive lesion. .... The operation of 
M. Loiseau, which, at least, is exempt from the 
dangers of tracheotomy, is preferable to the last.” 
M. Velpeau declared that to M. Loiseau “ be- 
longed the merit of having called attention to the 
subject.” “ Thanks to his memoir,” he continued, 
“ wre know that croup can be cured without ope- 
rating for tracheotomy. That is a great deal. 
.... I believe the operation recommended by 
M. Loiseau is a good one. While diphtheritis is 
at the opening of the air-passages it is curable, 
and M. Loiseau lias ascertained that it is not 
difficult to carry medications into the larynx.” 
The learned editor of the Gazette Medicate de 
Paris, in alluding to the discussion of the Aca- 
demy, says of laryngeal cauterization: “As a 
therapeutical means it merits a more serious OPERATION OF M. LOISEAU FOR CROUP. 
153 
attention. What is the relation of cauterization 
to croup ? It is a powerful, energetic means, the 
only one which up to this time has really succeeded. 
When the disease is limited to the upper part of 
the air-passages, we /cauterize, and all practi- 
• tioners agree that this means is truly of great 
benefit. What is laryngeal cauterization other 
than carrying beyond the limits of ordinary cau- 
terization a remedy, recognized as good, effica- 
cious not only against the offence of the disease 
itself, but also against the pathological secretion. 
Laryngeal cauterization is, then, in this respect, 
much superior to tracheotomy. Experience seems 
to have already confirmed these theoretical hopes, 
—future experience will say much more of it.” * 
In the Gazette llebdomadaire for August 27, 
1857, the editor after calling attention to the 
fact that cauterization in croup has been employ- 
ed in America, adds; “The Gazette Hehdoma- 
daire has translated or analyzed papers upon this 
subject, published in America and England ; it 
has been careful in making the most express 
reserves both upon the possibility of the opera- 
tion itself and its practical value ; but all these 
reserves are an additional reason for desiring 
that these experiments should be repeated by us 
with that attention which the authority and the 
* Gazette Medicate do Paris, August 29, 1857; also, translation in 
Medical Monthly, Not. 1857, pp. 321, 2. 154 
CATIIETERI3M IN CROUP. 
honorable position of our American confreres com- 
mand. M. Loiseau, anticipated, as it is seen in 
every particular, gives us, however, a useful 
example, and his merit will still be great if he 
succeeds in introducing into common use a prac- 
tice worthy of more attention than it has yet 
received.” 
In describing the instruments employed by 
Loiseau, in the following number of the Gazette 
Hebdomadaire (September 4), and his method 
of operating, the editor remarks: “ M. Loiseau 
affirms that he penetrates with these instruments 
much further than the larynx, even to the bifur- 
cation of the trachea ; as Dr. H. Green also pro- 
fesses to do. It is seen that this is a repetition 
(extended and perfected) of the American pro- 
cesses, so much the more remarkable that it dates, 
in the knowledge of many persons, from a period 
when the labors of Dr. H. Green were not known 
in France, and perhaps even not commenced.”* 
Still later, in November, 1857, the French jour- 
nals contain the history of a case of diphtheritis, 
* In the introduction of my work on “Diseases of the Respiratory 
Organs,” it is stated that: “On the 26th of November, 1838, the Rev. 
Mr. Tilden of Vermont, who had suffered many months under follicular 
laryngitis, came under my care and was treated successfully by topical 
applications of the nitrate of silver to the pharynx and larynx. During 
the year 1839, I treated many cases of chronic laryngitis, by cauteri- 
zations of the larynx and treachea. These cases were reported before 
the “ New York Medical and Surgical Society,” as the records of that 
Society will show. CATHETERISM IX CROUP. 
155 
treated successfully by catheterism and cauteriza- 
tion of the larynx, in the practice of Prof. Trous- 
seau. The Medical Monthly for Jan, 1858, con- 
tains the following case translated from the 
Gazette Hebdomadaire, of the Gth of November, 
the successful treatment of which is termed by 
the editor a “ Therapeutical conquest of great 
importance.” 
“ An application of the instruments of M. Loi- 
seau has just taken place in the service of M. 
Trousseau, who made a very favorable report 
upon it at the Academy The 
application of the instrument was upon a little 
girl four years old, who entered Hotel l)ieu, Octo- 
ber 9th, for diphtheritis, affecting exclusively the 
tongue, and accompanied by a slight engorge- 
ment of the sub-maxillary ganglions. The weak 
voice and hoarse cough, however, announced that 
the larynx was beginning to be affected. The 
cauterization of the tongue, at first with a stick of 
the nitrate of silver, and afterward with a solu- 
tion of the sulphate of copper, insufflations of 
tannin, and of alum in the pharynx, the inter- 
nal use of the chlorate of potass, brought about 
some diminution in the extent of the false mem- 
branes. The other symptoms persisted, and 
some fever arose. On the evening of the 23d, 
according to the instruction left by M. Trousseau, 
the chef de clinique, M. Blondeau operated for 156 
CATHETERISM IX CROUP. 
catheterism of the larynx, after the process of 
M. Loiseau. 
The first phalanx of the index finger of the 
left hand being armed with a metallic thimble, 
the operator opened the mouth of the child, by 
means, of a spoon. 
This was the most difficult part of the operation, 
on account of the resistance of the little patient. 
Having, however, separated the jaws, M. Blon- 
deau took advantage of this moment for carry- 
ing his finger quickly down the throat as far 
as possible, so as to reach the base of the tongue 
and the epiglottis. He succeeded in doing this 
quite easily, and the epiglottis was for an instant 
elevated by the finger ; unfortunately, the pro- 
tecting ring was not large enough, so that he 
was obliged to withdraw the finger, it having 
been severely bitten by the patient. 
Upon the second trial he was more fortunate, 
although the finger was not completely protected 
against the bites of the child. Along this finger 
the operator carried rapidly a metallic sound, 
supplied with two fenestrse, and properly curved 
at its extremity. In this manner he readily 
reached the larynx, when the finger, holding the 
epiglottis raised, permitted easy access. The 
fact that the sound had actually penetrated into 
the air-passages was announced by the noise 
which the air made in escaping through the in- CATHETERISM IX CROUP. 
157 
strument. Through this was immediately thrown 
a caustic injection (a saturated solution of the sul- 
phate of copper), then the sound was withdrawn. 
The whole operation—the introduction of the 
finger, the catheterism, the injection—required 
hardly a few seconds. 
A remarkable fact, and which M. Blondeau, 
who performed the operation for the first time, 
did not anticipate, was, that the operation did 
not appear at all painful to the child except at 
the moment when the finger was introduced into 
the mouth and the epiglottis raised. It was only 
then that the child struggled, and seemed 
agitated. As to the catheterism, and the injec- 
tion itself, she bore them wonderfully well. 
Another proof that the sound was really in the 
larynx, and even in the trachea, is that the in- 
jection of a considerable quantity of the caustic 
solution produced neither vomitings nor nausea ; 
and it is well known that a very small quantity only 
of the sulphate of copper, taken into the stomach, 
is necessary for provoking not only painful de- 
sires to vomit, but excessive vomitings. No- 
thing of the kind, however, took place, and the 
patient rejected by the canula only a little viscid 
mucus, evidently coming from the bronchial 
apparatus. 
The next morning, the 24th, the voice had re- 
gained in a great degree its clearness. 158 
CATHETERISM IX CROUP. 
A second catheterism was nevertheless made, 
this time by Prof. Trousseau himself, who was 
also bitten by the child, yet succeeded in making 
the operation. In the evening the operation was 
again repeated, but this time the finger was bet- 
ter protected, by a slight modification in the 
form of the ring, the superior face of it being 
increased in size. The catheterism performed by 
M. Trousseau, was witnessed by Dr. Boucliut, who, 
as well as all the assistants, acknowledged not 
only the facility, but the harmlessness, you can 
say the benignity even of this operation. 
On the morning of the 25th, the catheterism 
was performed for the last time. The condition of 
the patient very much improved, the voice was 
clearer, the lingual diphtheritis had almost en- 
tirely disappeared. 
The 28th, the child was in a state of convales- 
cence, although the voice remained a little hoarse. 
Quite recently, in a number of the Gazette 
Hebdomadaire, as late as that of the 17th of Sept. 
1858 is an account of several cases of membran- 
aceous croup treated by cauterization of the 
larynx. One case, which is reported by M. Gros, 
and is represented as having been one of great 
severity, was that of a child five years of age ; 
robust, and of an excellent constitution. 
The employment of emetics, and other reme- 
dies, together with cauterizations, with a solution C ATII ETEliISM IX CKOUP. 
159 
of nitrate of silver to the fauces and pharynx, 
afforded for a time some relief, by a removal of 
portions of the false membrane. But notwith- 
standing, the symptoms increased in severity, for 
the diphtheritic inflammation had reached the 
larynx and treachea, as was indicated by the 
intense tracheal rale, the croupal cough, and the 
frequent accessions of threatened suffocation. 
MM. Trousseau and Loiseau were called in 
consultation. M. Loiseau immediately practised 
cathctherism of the larynx, introducing the sound, 
and injecting into the larynx and trachea a solu- 
tion of nitrate of silver. “ This operation,” says 
M. Gros, “was accompanied, neither by suffoca- 
tion nor by any other accident ; and on with- 
drawing the sound it wras found to be fdled with 
thick, white false membranes.” The following 
night was passed much more calmly than the pre- 
ceding ; respiration much easier and the attacks 
of suffocation almost entirely absent. But on the 
next day the fauces and pharynx presenting an 
appearance less favorable, M. Loiseau practised 
a second catheterism, followed by an injection, of 
a solution of tannin. At 4 o’clock, on this day 
the patient was seen by M. Trousseau, who, 
although highly gratified with the improved con- 
dition of the case, still believed, inasmuch as the 
voice and cough were yet croupal, that notwith- 
standing the amelioration of the symptoms, this 160 
CATHETERISM IN CEOUr. 
condition would not continue, and that the opera- 
tion of tracheotomy would he required. The 
improvement, however, continued, and on the 
day subsequent to the visit of M. Trousseau, and 
the one on which he proposed to operate, many 
portions of false membrane were expelled which 
presented the appearance of having come from 
the air-passages. As a precaution, M. Loiseau 
practised a third catheterism of the larynx, fol- 
lowed, as in the last instance, by an injection of 
tannin. From this moment no further medi- 
cation was employed • the nourishment of the 
patient was gradually increased, and she soon 
perfectly recovered. 
“This fact,” says the learned editor of the 
Gazette Hebdomadaire, “has an important prac- 
tical signification, and speaks loudly in favor of 
the advantages which may be derived from cathe- 
terism of the air-passages, and from topical appli- 
cations, carried by this measure directly into the 
larynx and trachea.” * 
I\row it is this plan of topical medication, 
denominated by the French journalists all along 
as “ the method of M. Loiseau,” and described by 
them as a new manner of treating diseases of the 
air-passages, that Prof. Trousseau commends as 
a most important measure in the treatment of 
* Gazette Hebdomadaire, Sept. 17, 1858, p. 660. CATHETEKISM IN CROUP. 
161 
diphtheritic inflammation, and recommends its 
adoption. Indeed, this eminent practitioner now 
discourages the employment of all the ordinary 
violent remedies, such as, severe vomiting, blis- 
ters, leeches, etc., and depends upon direct cathe- 
terism or cauterization of the air-passages, fol- 
lowed, if this measure is unsuccessful, by trache- 
otomy. 
In an interview which I had, several yea.rs 
ago, with M. Trousseau, in Paris, he kindly 
described to me, very minutely, his method of 
performing this last operation in croup, and this 
description I shall presently give. But the rea- 
der, I trust, will pardon me, if I first ask his 
attention, in a brief reference, to what has been 
done in our own country, in the advocacy and 
employment of topical, therapeutical measures 
in the treatment of croup—measures which have 
recently been claimed, very generally, by the 
French profession as peculiarly their own; 
albeit, many of those French practitioners and 
journalists, who now advocate the practice, 
were but quite recently, among the number, who 
doubted, and even denied the possible practica- 
bility of these same measures. 
It will be recollected that over ten years ago, 
namely in 1848, the first edition of this book was 
published in which the declaration was made, 
that “ the practice of making topical applica- 162 
CATHETEKISM IN CKOUP. 
tions of medicinal agents into the larynges of 
young children, for the treatment of membranous 
croup, is a plan entirely practicable, safe, and, 
when judiciously employed, in the highest degree 
efficacious.” 
In this work the history of eleven cases were 
given, in the treatment of which, cauterizations 
of the larynx were employed, and were relied 
upon as among the most efficient of the measures 
adopted. The date of the first case of croup, 
recorded as having'been thus treated, is on the 
20th of November, 1842 ; although cauterizations 
of the larynx and trachea, in the treatment of 
diseases of these organs in adults, had been em- 
ployed as early as November, 1838. Since the 
publication of the work in which this mode of 
treatment is advocated, the author has had the 
opportunity of treating many cases of croup 
on the plan deduced from these views of its 
pathology, the histories of many of which have 
never been published, and with an amount of 
success that has afforded a high degree of en- 
couragement and satisfaction. 
I have also received from medical men, in 
different parts of the United States, as well as 
from numbers in Europe, the history of many 
cases of membranous croup, wherein topical 
measures, in their hands, have proved effectual 
in arresting the disease. To compare the Ameri- TREATMENT OF CROUP CONTINUED. 
163 
can method with that employed by M. Loiseau, 
and to show that in both plans, the cauterization 
of the air-passages is the end aimed at, and 
that this end was attained in this country a long 
time antecedent to the French operations, I shall 
give, in a very brief manner, the history of a few 
recent cases which have been thus treated. 
Having relinquished some years ago (as it is 
generally known to the profession), my attend- 
ance upon out-door patients, there have not 
fallen consequently many cases recently of this 
disease under my notice. A few, however, of 
great interest have been observed, and to these I 
shall refer. 
CASE XIV. 
On tlie morning of the 31st of Dec., 1855, 
Dr. I. 0. Smith, a member of the Academy of 
Medicine, called at my office, and requested me 
to visit with him the daughter of Mr. Hachagne, 
of Prince street, who was very ill of membran- 
ous croup. To my invariable objection, that I 
visited no patients away from my office, Dr. 
Smith urged the severity and danger of the case, 
and the distress and anxiety of the parents. In 
short, I was taken into his carriage, and carried 
to the house of the patient. The child, four 
years of age, who had been four days sick, was 
exhibiting all the characteristic symptoms of true 164 
TREATMENT OF CROUP CONTINUED. 
croup, in an advanced stage, and of a very severe 
grade. The countenance of the patient appeared 
anxious, the face had lost its natural color, the 
voice was stilled, the respiration very difficult, 
and of a hissing character ; and the whole symp- 
toms indicated imminent danger from approach- 
ing asphyxia. 
The ordinary remedies having been faithfully 
tried by Dr. Smith, he requested that cauteriza- 
tion of the larynx should be immediately em- 
ployed. Assisted by the doctor, I passed a small 
sponge-armed probang, saturated with a so- 
lution of nitrate of silver ( 9 ij. to 5j. of water) 
into the larynx and trachea. After a delay of 
some ten or fifteen minutes, the operation was 
repeated, in the same manner. I am not aware 
that any other medical treatment was employed. 
The next morning, Jan. 1st, Dr. Smith called on 
me, and stated that the symptoms had some- 
what improved during the day, and that the 
following night was passed with less distress 
than had occurred on the preceding ; but, that 
the child was still dangerously sick, and the 
operation must be repeated. I accompanied Dr. 
Smith, and found his patient as he had stated 
—certainly no worse, but still presenting a 
very unfavorable appearance. Cauterizations 
were again employed as on the preceding 
day. After the second application of the TREATMENT OF CROUP CONTINUED. 
165 
caustic, the symptoms soon diminished in se- 
verity ; and during the day and night, of the 
the 1st of January, the improvement continued. 
At 10 o’clock on the morning of the 2d, when we 
called, we found a marked and most favorable 
change had taken place in our patient. A single 
application was made on this day, and ultimately 
the child recovered perfectly. 
case xv. 
I was called, Dec. 18, 1853, to visit a case of 
croup, which had been treated nearly a week, 
by two homoeopathic doctors of this city. I re- 
fused to go. The father of the patient then 
stated, that his child had been abandoned by 
the doctors, who considered the case quite hope- 
less ; but that his son was still living, and he 
begged I would visit him and endeavor to save 
his life. I stated to my assistant, Dr. Richards, 
that I would see the patient with him once, if he 
would then take charge of the case. We found 
the child, a little boy, four and a half years of 
age, struggling for breath, in the last stage of 
membranous croup, apparently dying of the dis- 
ease. It is unnecessary to describe at length the 
symptoms. The difficult, stridulous respiration, 
the suppressed cough, the pallid countenance, 
and livid lips, exhibited at once the urgency of the 166 
TREATMENT OF CROUP CONTINUED. 
symptoms, and the danger of suffocation. The 
previous medication we could not ascertain, ex- 
cept that antimony* had been freely given, and the 
child had been repeatedly and severely vomited. 
A small armed probang, the sponge saturated in 
strong nitrate of silver solution, was passed with 
some difficulty into the larynx and trachea. 
Some minute fragments of the false membrane 
were dislodged by this operation, but no marked 
mitigation of the symptoms followed the applica- 
tion ; and after a delay of ten or fifteen minutes, 
the operation was repeated. If any relief fol- 
lowed the second application, it was of short 
duration. All the unfavorable symptoms soon 
returned ; the struggling for breath, the dry and 
harsh tracheal respiration, the frequent and 
weak pulse, pointed, as we thought, to a speedy, 
fatal termination, and I left the case believing 
that such would soon be the result. Dr. Rich- 
ards remained with the patient, and several times 
during the night, applied the caustic solution. 
Some relief followed each application, but the 
next day, the 19th, the case appeared so desperate 
that Dr. Richards, fearing the case was hopeless, 
after repeating the application thoroughly to 
the larynx and trachea, left the patient, with 
* I was handed the prescription given to this patient by an eminent 
homoeopath of this city. It consisted of a homoeopathic quantity of 
belladonna and an allopathic quantity of tart, antimony. TREATMENT OF CKOTTP CONTINUED. 
167 
directions to be sent for in a few hours if the 
child continued to live. He was not called for 
again, and nothing more was heard from the 
patient, who was supposed to be dead, of course, 
until several weeks after this, when the father 
came into my office, “to settle the doctor’s bill 
for attendance upon his boy.” Dr. Richards 
ventured to ask the father, how long the poor 
boy lived after he left him, when he was assured 
that his son was alive and in good health. That 
after the last application he began to improve 
and was soon so much better that it was not 
thought necessary to recall the doctor. In the 
course of a week he quite recovered. 
In the early edition of this work, I expressed 
the opinion, with reference to the operation of 
tracheotomy, that we are not justified in having 
recourse to this measure, until the means now at 
our command, both topical and general, have 
been exhausted. Although subsequent experi- 
ence has confirmed these views, yet, my opinion 
with regard to the propriety of the measure, 
when adopted as a last resort, has considerably 
changed within a few years past. 
When topical measures, as ordinarily employed, 
have failed ; when, the larynx having been 
relieved, the coriaceous deposit is found having 
extended into, and is blocking up the bronchial 
ramifications, and the patient appears threatened 168 
TREATMENT OF CROUP CONTINUED. 
with suffocation, then, is tracheotomy, followed 
by caustic injections through the artificial opening, 
of the highest importance. But even in such 
cases of severe membranous croup, where the 
disease has passed on to the last stage—the stage 
of asphyxia, in which a resort to tracheotomy has 
been considered as the one which can afford the 
only means of relief—at this stage, we still main- 
tain, patients have been, and may be saved, by 
other operations than that of tracheotomy. Let 
me illustrate : 
CASE XVI. 
A few years ago, January 5th, 1850, I met a 
member of this Academy in the treatment of a 
case of croup, of much interest. It was that of a 
son, and I believe the only son of a clergyman 
(Rev. Ansel Leo) of this city—a boy of five years 
of age. He too had been subjected to Hahne- 
mannic treatment several days before any effi- 
cient measures were adopted. The case threat- 
ening to prove fatal, was either abandoned by the 
homoeopathic doctor, or he was dismissed, I can- 
not say which, and Hr. S was called to attend 
the case. He found the child in the advanced 
stage of membranous croup ; almost in the stage 
of collapse. Among other measures employed 
by the doctor, an attempt was made to vomit the 
child, by administering an emetic of sulphate of TREATMENT OF CROUP CONTINUED. 
169 
copper, with a hope of dislodging the false mem- 
brane from the trachea, but the effort failed 
entirely : no emetic effect was produced by this 
measure. I was called to visit the patient on the 
5th of January, and saw the case for the first 
time at 11 o’clock, a.m. of that day. I found the 
boy lying in a state of asphyxia. The face and 
lips were purple, extremities cold, the surface 
clammy, violent efforts at inspiration were occa- 
sionally made, but the anesthesia was complete. 
Dr. S stated that he had administered while 
the patient could swallow a strong emetic, with- 
out producing any effect whatever. Tracheotomy 
had been considered as presenting the only pos- 
sible chance of relief, but this chance was deemed 
too doubtful to warrant its adoption. 
At my request, Dr. S took the patient on 
his lap, and sustained him there, with his head 
thrown back on the doctor’s shoulder. In this 
insensible condition, the lower jaw fell, the tongue 
was readily depressed, and nearly the entire epi- 
glottis brought into view. A small sponge pro- 
bang, wet with the nitrate of silver solution, was 
easily passed into the larynx, through the rima, 
and carried down the entire length of the trachea. 
This was done without the child’s exhibiting any 
opposition, or apparent consciousness. On with- 
drawing the instrument, which appeared to 
enlarge mechanically for the moment the calibre 170 
TREATMENT OF CROUP CONTINUED. 
of the air tube, the chest was expanded by a full 
inspiration. The sponge was again wet in the 
solution, and the same operation immediately 
repeated. This time the operation was followed 
by some struggling, and a cough, and consider- 
able quantities of viscid fibrinous mucus and 
broken portions of membrane, were thrown up 
by the cough and vomiting. After a delay of ten 
or fifteen minutes, the probang was introduced the 
third time into the trachea. The child, still 
insensible, was then placed in bed ; and it was 
arranged to meet Dr. S in two hours again, 
and see the patient. 
2 o’clock p.m. Found the patient at this hour 
still insensible, but the countenance was not as 
livid, the surface and extremities were warmer, and 
respiration was somewhat less difficult. At this 
visit, cauterization of the larynx and treachea was 
twice performed in the same manner as at the 
first visit; and directions were given to adminis- 
ter, if possible, some stimulus and nourishment, 
when the child could swallow. 
6 o’clock p.m. Four hours later, we met again 
at the bedside of our patient. As we entered 
the room, the little fellow raised his head, and 
smiling, thrust out his hand to the doctor, 
whom he recognized, and attempted to speak ! 
A great change had taken place in our patient. 
Soon after the applications at 2 o’clock were TREATMENT OF CROUP CONTINUED. 
171 
made, quantities of viscid mucus and patches of 
fibrinous matter were ejected, after which the res- 
piration considerably improved, and the child 
was able to swallow nourishment and some weak 
stimulus. From this hour the croupal symptoms 
began to disappear. No further topical applica- 
tions were made, and the patient, under appropri- 
ate nourishment, recovered perfectly ; but it was 
three weeks before his voice was restored to a 
sound above that of a whisper. 
Within a few weeks I have received the Bos- 
ton Medical Journal, for January 6th, 1859, 
which contains a report read before the Boston 
Society for Medical Improvement, by Dr. H. G. 
Clark, of three cases of membranous croup, 
treated successfully by “the introduction of a 
solution of nitrate silver with the probang into 
the larynx.” In the first case, a boy seven and 
a half years of age, “ the appearances were so 
alarming, that at first sight tracheotomy ap- 
parently offered the only means of saving him 
from immediate suffocation.” The probang, 
says Dr. Clark, was passed into and through the 
larynx ; it came out loaded with ‘ ‘ false mem- 
brane.” Brandy and water and beef tea ad 
libitum, and other light food, were permitted, 
and the patient recovered. In the second case, 
a little girl two years old, with “well-developed 
croup,” in which “ the treatment consisted of 172 
TREATMENT OF CROUP CONTINUED. 
the local use of the nitrate of silver, Dover's 
powder, steam, etc., and wine whey. The child 
made a good recovery.” 
The third case, a child two years and four 
months old, was very severely affected with 
diphtheritic inflammation. “ The tonsils, and 
indeed the whole of the parts about the entrance 
of the larynx, were heavily coated with the 
diphtheritic effusion.” The sponge probang was 
employed, and “ a solution of the nitrate of sil- 
ver was injected quite into the larynx, with the 
Warren syringe.” But in this case tracheotomy 
was required ; it was performed, and the patient 
recovered. 
When, therefore, cauterization or catheterism 
fail in the treatment of croup, I believe with 
M. Trousseau, that we should have recourse to the 
operation of tracheotomy. This distinguished 
physician, who has operated in more cases, pro- 
bably, and with a greater amount of success, 
than any other practitioner, has been accustomed 
to perforin tracheotomy in croup, “as soon as 
he can feel tolerably certain of the presence of 
false membranes in the larynx,” and before the 
accession of symptoms of asphyxia. 
But Prof. Trousseau now advises, as I have 
before stated, that topical applications should be 
resorted to before the employment of trache- 
otomy, and he announces in the Union Medicate, TREATMENT OF CROUP CONTINUED. 
173 
of November, last, which I have just received, 
his conviction, that many lives have been saved, 
of those “who would infallibly have died, had 
not cauterization been employed.7’ In perform- 
ing this operation in those cases in which trache- 
otomy is indicated, Prof. Trousseau uses a double 
canula. The inner tube, which is a little the 
smallest, is made to fit perfectly to the outer one, 
and so fitted, that it can be removed without 
disturbing the external tube, which is not to he 
withdrawn, if possible, until the disease has sub- 
sided, To prevent the canula from exciting vio- 
lent inflammation, from the chafing of the wound, 
a small piece of oiled silk, with an opening of 
the size of the tube, through which this instru- 
ment is passed, is interposed between the head 
of the tube, and the edges of the wound. The 
incision being made into the trachea, the edges 
of the wound are kept apart by the dilator, the 
child is raised from its recumbent posture, and 
when the hemorrhage ceases, the canula is im- 
mediately introduced. In order to render the 
air breathed by the child, as near as possible, 
like the naturally respired atmosphere, M. Trous- 
seau covers the opening of the tube with a re- 
spirator■, which is composed of several folds of 
gauze, and which soon becoming moist, conse- 
quently imparts vapor to the inspired atmos- 
phere. M. Trousseau is convinced that his sue- 174 
TREATMENT OF CROUP CONTINUED. 
cess lias been greater since he has adopted these 
improvements. As often as respiration becomes 
difficult, from an obstruction of the tube, the 
inner canula must be removed and cleansed, and 
this may be done without in the least disturbing 
the patient. 
During three or four days, after the operation, 
M. Trousseau employs topical remedies, arid these 
consist of dropping into the trachea, several times 
in the twenty-four hours, a small amount of a 
solution of nitrate of silver in distilled water, of 
the strength of about five grains to the ounce ; 
and, in some instances, the canula is removed, 
and the trachea is cleared out with a sponge 
dipped in the nitrate of silver solution.* 
Within the last year, tracheotomy, in the 
treatment of croup and diphtheria, has been 
employed more in some parts or this country than 
ever before in the same period of time. During 
the past winter these diseases have been more 
* 4i In 1849,” says M. Trousseau, “ I performed in l’Hopital des Enfants, 
the operation of tracheotomy in a case of croup, which was perfectly suc- 
cessful. From that moment, the repugnance to the operation, which my 
colleagues had before entertained, vanished, and it was then established 
among ourselves, that thereafter, the operation should be performed in all 
those cases, where every other chance had failed. From that time to the 
present, tracheotomy has been performed in this hospital, under this rule. 
During this period, from 1849 up to the present time (November 2d, 
1858), there have been treated 562 patients, attacked with croup; of this 
number 466 were operated upon for tracheotomy, and with success in 126 
cases, that is to say, 27 per cent.; notwithstanding,” says M. Trousseau, 
“ the deplorable condition of the hospital.” TREATMENT OF CROUP CONTINUED. 
175 
than ordinarily prevalent. In some of our larger 
cities, particularly in Boston, Mass., many very 
severe cases of diphtheritic inflammation have 
occurred, and some almost hopeless cases have 
been saved through the employment of these two 
combined measures—tracheotomy, followed by 
repeated injections of a solution of the nitrate of 
silver, through the artificial opening, into the 
trachea and bronchi. I cannot better illustrate 
this method of treatment than by giving the 
details of the following highly interesting case 
of croup, the history of which, and its treatment, 
I find recorded in a late number of the Boston Med- 
ical and Surgical Journal. The report of the case 
was read before the “ Boston Society for Medical 
Improvement,” January 10, 1859, by Dr. George 
H. Gay. 
CASE XVII. 
“ Lizzie S set. 4h under the care of Dr. 
Perry. During the absence of Dr. P., and while 
the symptoms of the disease were making rapid 
progress, Dr. Bowditch was sent for. He has 
given the following account of the case, up to 11, 
a.m., December 26th, 1858. 
“ About 104, p.m, December 24th, was called 
to Lizzie S . Found all the symptoms of 
croup—noisy respiration, hoarseness, paroxysms 
of dyspnoea, no membrane on tonsils, fever, rest- 176 
TREATMENT OF CROUP CONTINUED. 
lessness. Disease had commenced the preceding 
night (23d), and was thought to be only a severe 
cold. Mother stated that she had often had simi- 
lar attacks in the West, only this was more 
severe. An emetic of ipecac, and sub. mur. 
hydrarg. was given, a solution of nit. argent, was 
twice applied to the throat, and pulv. Doveri, 
gr. ij., p. r. n., to check restlessness ; steam in 
room ; cloths in cold water around the throat. 
No relief, except less restlessness from the Dover’s 
powder, and partial ease after the application of 
nit. argent. The next day, Saturday, Dr. Perry 
used steam, and opium and hydrarg. cum creta. 
The disease seemed relieved during the opiate 
effect, but there was no real change in the char- 
acter of the breathing. Saturday night there were 
violent paroxysms of dyspnoea, and on Sunday 
morning, December 26th, all the croupy symp- 
toms and their effect had increased.” 
“ When I saw the patient for the first time,” 
continued Dr. Gay, “ on Sunday, December 26th, 
1858, 11h a.m. the following symptoms were pre- 
sent : great restlessness, with constant change of 
position and tossing about of the arms ; head and 
neck thrown back ; great distress of the counte- 
nance ; lividity of both lips and a portion of both 
cheeks ; pallor of the rest of the face (this 
asphyxiate condition was permanent and not par- 
oxysmal) ; the breathing very much labored, and TREATMENT OF CROUP CONTINUED. 
177 
such as exists iu the most advanced stages of 
membranous croup ; the voice merely a faint 
whisper; absence of the cough, noticed since the 
morning ; pulse very rapid, at times 160, feeble 
and intermittent ; no membrane could be seen in 
any part of the throat. Although in an extreme 
condition, an operation was immediately advised. 
“ Operation at 12, m., with ether, and the assist- 
ance of Drs. Lewis, Perry and Bowditch. 
“ The neck was short and fat, and the veins very 
numerous and prominently distended, so much so 
that the dissection was carried on slowly and 
cautiously. But little blood was lost, and, just 
before the trachea was opened, the patient was, 
to all appearances,, dead. JSTo pulse could be 
felt, and there was no apparent breathing. Arti- 
ficial respiration was attempted, by rolling and 
pressure of the chest. As no change was observed, 
the trachea was opened, and the same measures 
continued. Soon there was a jerking inspiratory 
act, as when a child is born, and the respiration 
began gradually to be established, the wound of 
the trachea being kept open by the dilator. 
Shortly afterward, she revived so much that she 
was able to expel, by coughing, several long 
strips of membrane, and much tenacious mucus, 
through the opening of the trachea. The pulse, 
120, could now be felt distinctly, and the breath- 
ing having become more easy and quiet, the tubes 178 
TREATMENT OF CROUP CONTINUED. 
were inserted and secured. After a few minutes1 
rest, the solution of nit. argent, was injected 
through the opening of the tube into the trachea, 
and several strips of membrane, some of them 
two and a half inches long, were expelled through 
the tube, together with some viscid mucus. 
Some of the membrane was grooved, and some 
of it was in very small rings, evidently from a 
small bronchus. As soon as she was compara- 
tively quiet and comfortable, the following writ- 
ten directions were given to the nurse : to have the 
air of the room constantly moist from steam ; to 
have the temperature between 70° and 75°, never 
below 70° ; to clean the tube at least every two 
hours, and oftener if it was obstructed, and if the 
obstruction still continued, to remove the tubes, and 
inject into the trachea some of the solution of 
nit. argent. ; to inject through the tube into the 
trachea, every four hours, about one-third of a tea- 
spoonful of the solution of nit. argent, (gr. xx. 
to water S j.) ; to give a Dover’s powder (gr. ij.), 
p. r. n., and iodid. potass., gr. ij., every two or 
three hours ; lace cravat to be constantly in front 
of the tubes. In the evening she was as well as 
could be expected. 
“ Monday, Dec. 27th.—Had a very good night. 
Coughed, and expelled much membrane and 
mucus. her countenance is very good, 
and at times bright. Pulse 108, stronger than at TREATMENT OF CROUP CONTINUED. 
179 
any time yesterday. Complains of soreness of 
the chest, externally. No labor, and but little 
noise in breathing. The swallowing of liquids 
produces a paroxysm of coughing. Membrane is 
always expelled after the injection of the nit. 
argent, Slept two hours at one time in the fore- 
noon. Up to that time, the tube was cleared 
every hour, on account of the obstruction. Had 
a nap of two hours’ duration in the afternoon. 
At 5, p.m., she was not so well. The cough and 
breathing became more dry, and labored, there 
was more febrile action and restlessness. Pulse 
120. The solution of nit. argent, was thrown 
into the trachea, and in a very short time several 
strips of membrane, from two to three inches 
long, were expelled through the tube, and large 
quantities of mucus flowed from the mouth, 
enough to wet three or four handkerchiefs. She 
expressed herself as greatly relieved, and shortly 
after slept quietly for a long time. At 10, p.m., 
the nit. argent, was used again, with similar 
results. She then slept till 12i- Afterward, 
there was some dryness in the breathing and 
cough, and the nit. argent, was again us<?d at 
4, a.m. A very large quantity of membrane, in 
strips, was expelled. She then slept quietly till 
Qh a.m. 
“ Tuesday, 28th, 9 a.m.—Still raises much mem- 
brane. Pulse 108. Not much thirst nor heat 180 
TREATMENT OF CROUP CONTINUED. 
of skin. Tongue looks pretty well. Some of 
the mucus from the tube looks yellowish. Cough 
more frequent, with a flapping sound. There 
was also a troublesome retching, which had been 
previously noticed in efforts to raise membrane, 
situated between the upper part of the tube and 
the epiglottis. The breathing was also obstructed 
and there was a more anxious look to the coun- 
tenance. On removing the inner tube, cleaned 
two hours previous, it was found lined through- 
out.with a thick, firm membrane. This gave but 
little relief to the breathing, and a flapping 
sound was heard, as if something fell from above, 
and the father had felt an obstruction in replac- 
ing the tube. The coughing being almost inces- 
sant, the other tube was removed, and the cough 
became sharp and ringing. As no great relief 
followed, the solution of nit. argent, was injected 
into the trachea, and after a pretty long and hard 
paroxysm of coughing, in which much membrane 
and mucus were expelled, she became suddenly 
easier. On taking away the lace cravat, its sur- 
face covering the opening of the trachea was 
found patched over with masses of thick viscid 
mucus and a very large piece of membrane. This 
membrane, from its shape and general appear- 
ance, evidently came from the epiglottis, larynx 
and upper part of the trachea. A portion of it, 
at the base of the tongue-shaped epiglottis, was TREATMENT OF CROUP CONTINEED. 
181 
very thick, hard and firm ; below this there was 
nearly a solid cord, half an inch in length, with a 
very minute opening, just large enough to admit 
a small wire, and below this the membrane was 
tubular, softer and almost transparent, with the 
impression of the posterior part of the trachea 
where the rings are absent. This piece of mem- 
brane was between two and three inches long. 
Some bloody mucus was then expelled. Though 
much exhausted by this effort, patient took some 
wine whey, rallied, felt a very decided relief, and 
slept very quietly for two hours after the tubes 
were replaced. In the afternoon and evening, 
the breathing was very quiet, and without labor. 
The cough was loose, and the membrane was ex- 
pelled with much less difficulty. In the evening, 
she sat up in bed, and took, with great relish, 
some milk and tea and soda cracker. Treatment 
as before. 
“ Wednesday, 29th.—But little membrane, in 
strips, was raised after the large piece of yester- 
day morning, till early this morning. During 
the night, she had but little long sleep. The 
cough was loose and frequent, and the expectora- 
tion very viscid, with some of the membrane in 
granules or like boiled tapioca. There was con- 
siderable effort to force it through the tube. 
Early this morning the cough was looser, and 
several strips of membrane stained with blood, 182 
TREATMENT OF CROUP CONTINUED. 
and some yellow purulent masses of mucus, were 
expelled. At 9, a.m., the cough is loose and the 
expectoration easy. Ate a good breakfast of soda 
cracker, milk and tea. Felt better afterward. 
Pulse 108. Tongue moist and cleaning. Is sit- 
ting up in the bed, playing with her slate and pen- 
cil. Takes much notice of what is going on in 
the room. Countenance very bright. Respira- 
tion easy, without noise or hurry. Comfortable 
in the afternoon and evening. Membrane and 
purulent mucus expelled through the tube. 
“Thursday, 50th.—Passed a remarkably good 
night, sleeping easily and quietly most of the 
time, awaking occasionally to cough. Expecto- 
rated without difficulty through the tube, mostly 
a purulent mucus and some membrane in 
granules. This morning, she is amusing herself 
'with her play things. Pulse 100 to 108 ; stronger. 
Respiration easy, quiet, and generally vesicular. 
Some moist, flapping rales. Asked for her break- 
fast very early this morning. Appetite suffi- 
cient. 
“Friday, olst.—Took considerable nourishment 
yesterday. Had a good day and night; slept 
well. This morning, still improving. Pulse 
100. Cough not so frequent ; expels a thin, 
purulent liquid through the tube. Scarcely any 
membrane in strips or granules has been seen 
since yesterday. TREATMENT OF CEOUP CONTINUED. 
183 
‘Saturday, Jan. 1st, 1859.—Yery comfort- 
able during yesterday and last night. This 
morning she is playing with her New Year’s 
presents. She breathes without noise, effort or 
hurry. Pulse 100. No membrane expelled ; 
nothing but a thick, purulent mucus. Appetite 
good. Voice hoarse and whispering. 
“ Sunday, 2d.—Tube removed this morning 
and re-inserted in the evening. 
“Wednesday, 5th.—Both tubes removed. 
“ Tuesday, 11th.—External wound firmly cica- 
trized. She is daily gaining in every respect, 
and can speak aloud ; voice hoarse. 
“ It would seem as if the recovery, so extraordi- 
nary in many points of view, of this patient, 
would be the strongest convincing proof to the 
profession, of the propriety and benefit of the 
operation and subsequent treatment, even though 
the patient is in extremis. It appeared more 
like raising a person, so to speak, from the dead, 
than in any other case of tracheotomy for mem- 
branous croup that I have as yet performed. It 
is a proper question to ask, what power there 
was to get up the membrane in so advanced a 
stage of asphyxia, when the cough was ex- 
tinguished. 
“ The disease had not reached its height at the 
time of the operation, as is evidenced by the 
membrane approaching more and more to a solid 184 
TREATMENT OF CEOEP CONTINUED. 
cord, which of course would have increased one 
of the main causes of the asphyxia, supposing no 
operation had been performed, and added a 
greater hopelessness to any chance of expelling 
the membrane. 
“ The mere operation of tracheotomy will ulti- 
mately avail but little, if the after treatment is 
slighted, or not rigorously attended to. A large 
tube, inserted in the trachea after tracheotomy, 
serves the purpose of an artificial rima glottidis, 
allowing a sufficient passage of air to and from 
the lungs, and, like the natural rima, it may have 
its opening lessened and obstructed by membrane 
and liquids, but unlike it in the facility with 
which an obstruction may be removed by with- 
drawing the tube. The artificial rima can be 
kept of a more unvarying and permanent size. 
Death may follow an obstruction in the artificial 
as in the natural rima, and as quickly. 
“Through the tube, there is a more free and 
accessible way for the introduction of local reme- 
dial measures. After tracheotomy and the in- 
sertion of the tube, the injection of a solution 
of nit. argent, through the tube into the trachea 
and bronchi is our strongest dependence, and 
most of the other measures are mere auxiliaries. 
The strength of the solution may vary with the 
circumstances of the case. Three successful cases 
in succession, in almost as many weeks, are wit- TREATMENT OF CROUP CONTINUED. 
185 
nesses of its usefulness. It seems to act in the 
following way :—cauterization ; a very free mucus 
secretion in the trachea and bronchi (which pro- 
bably pushes off the membrane in part) ; cough- 
ing, and an easier expulsion of the membrane 
and mucus. The mucous secretion is as free in 
the mouth as if the nit. argent, had been applied 
there. Other substances may act as well as the 
nit. argent., but at present I see no reason to sub- 
stitute any different agent. 
“In conjunction with this, a faithful attention 
must be given to the steam, the temperature, the 
cleaning of the tube, the lace cravat, the Dover’s 
powder and iodide of potassa, the nourishing 
regimen, and stimulants if called for. 
“It is well to have one person constantly by 
the bedside, to wipe away, with a sponge or cloth, 
any membrane or mucus that is expelled out of 
the tube, before it is drawn back again into the 
trachea. Another person should be present to 
perform any other duties that may be required. 
“No membrane was voided by the mouth at 
any time. Some of the membrane evidently came 
from some small bronchus. The large piece was 
expelled from the opening of the trachea, about 
forty-six hours after the operation. 
“There was no sign of pneumonia at any 
time. 
“The tubes were removed in ten days after the 186 
TREATMENT OF CROUP CONTINUED. 
operation, and the external wound was fully 
cicatrized six days afterward. 
“In the seven cases that I have performed 
tracheotomy for decided membranous croup, in 
about twelve months, and in which the membrane 
was expelled through the tube, there have been 
five recoveries and two deaths11 
In conclusion, after this brief review of what 
v 
has been done in this country, and in Europe, 
for the treatment of true croup, are we not war- 
ranted in adopting, to a great extent, the conclu- 
sions of our own eminent and experienced country- 
man Dr. John Ware, of Boston, to which I have 
before referred, on the treatment of croup ? “It 
is a disease,” says Dr. Ware, “which I would treat 
without depletion, except, perhaps, by a few 
leeches—without vomiting, without purging, 
without blisters, without antimonials, ipecac., 
and all those other nauseous remedies which 
have been usually resorted to. I would trust to 
opiates, perhaps calomel, emollients, and the 
local application of the nitrate of silver.1'1 CHAPTER YIIT. 
TREATMENT OF CROUP CONTINUED. 
General Remedies.—Notwithstanding the im- 
portant consideration which has been given to 
topical medication in these pages, I would not 
have its use preclude the employment of ap- 
propriate general remedies in the treatment of 
membranous croup. I shall only remark, how- 
ever, in this connection, upon some of the most 
important of the many remedies which have been 
advised by different authors in the treatment of 
this disease. 
Emetics.—To fulfill the first intention of cure, 
in the treatment of croup, which is to arrest in- 
flammatory action, and to prevent the forma- 
tion and accumulation of albuminous matter in 
the air-passages, emetics, more than all other 
general remedies, have been recommended and 
employed by different writers and practitioners. 
“ When given during the first stage of croup, 
they disembarrass the air-passages of the gluti- 
nous secretions that clog them, and often pro- 
duce such a shock to the system as to termi- 
nate the disease at once. This shock, and the 
187 188 
TREATMENT OF CROUP. 
perspiration that follows it, are among the most 
important effects of the remedy ; for even when 
no mucous or albuminous matters are expelled 
from the lungs during the action of the emetic, 
the patient is generally much relieved after hav- 
ing vomited.” * 
From among the various substances employed 
to produce emesis in croup, the antimonial pre- 
parations are the most frequently selected. 
They appear to be very generally recommended 
by writers on this disease, both in England 
and in France ; and American practitioners em- 
ploy this class of remedies to a great extent, in 
the treatment of croup. “ The tartarized anti- 
mony,” says the author above quoted, “is the 
best medicine of this kind, and it should be given 
at short intervals, till vomiting is effected ; after 
which it should not be discontinued, otherwise the 
reaction might prove injurious, but nauseating 
doses must still be administered.” 
Now, with regard to the use of this remedy 
when employed to a certain extent, and with 
that caution which should always be observed 
when administering so powerful an agent, 
emetic-tartar is an invaluable remedy in the 
treatment of exudative inflammation. But, not- 
withstanding all this, and the high authority for 
its use, I have no hesitation in declaring my firm 
* Hyland, p. 153. GENERAL REMEDIES. 
189 
conviction, and this too, after many years of ob- 
servation, that the injudicious use of tartarized 
antimony, in the treatment of diseases in young 
children, has destroyed more lives than it has 
been instrumental in saving among this class of 
patients! 
With the young subject it not only acts as a 
direct and powerful sedative, but as a local irri- 
tant upon the mucous surfaces. In the observa- 
tions recorded by Lepelletier on the effects of 
frequently repeated doses of tartar-emetic upon 
the human system, it is stated that the pulse was 
reduced from 120 to 34 beats per minute, and 
in one from 72 to 44 beats per minute, under 
the use of continued doses of tartarized anti- 
mony.* 
In a recent number of the New York Journal 
of Medicine, j* Prof. John B. Beck, of this city, 
has published a highly interesting and instructive 
paper, “On the effects of Emetics in the 
young subject.” In this article he has collected 
the testimony of many eminent medical men, to 
show the uncertain, energetic, and dangerous 
effects of tartarized antimony, when administered 
in continued doses to young persons. 
In one instance recorded by him, “the one- 
* Medicines, their Uses and Modes of Administration, by J. Moore 
Nelligan, M.D., etc., p. 157. 
f Vol. vii. No. 20. 190 
TREATMENT OF CROUP. 
thirtieth part of a grain of tartar-emetic given 
to a child a year old, laboring under croup, pro- 
duced such severe and protracted vomiting, to- 
gether with general prostration, as to require 
stimulants to save life.7’ In another, “small 
doses of tartar-emetic,77 were administered to 
a child about three years old, in a case where 
no danger was apprehended from the' disease. 
Alarming symptoms of prostration came on, and 
notwithstanding the use of stimulants, the child 
died in an hour or two after Dr. Beck saw it. 
From these facts, therefore, and others which 
have fallen under his own observation, and from 
the recorded opinions of many eminent medical 
men, Dr. Beck has come to the conclusion, that 
as a general rule, emetic tartar ought never to 
be used in children under one year of age ; and 
that in all cases, “ the preparations of antimony 
ought to be resorted to with great caution in 
very young children, and should never be used 
except in those cases where a sedative effect is 
required, and can be borne with safety.” * 
As inflammatory excitement is, ordinarily, 
present in the commencement of croup, and the 
indication being to arrest this action, an emetic 
of tartarized antimony, either alone or in com- 
bination with ipecacuanha, may, generally, be 
* Loc. cit. pp. 158-9. GENERAL REMEDIES. 
191 
administered with safety, at this stage of the 
disease. But, great caution should be observed 
in continuing the medicine, after the manner 
which has been recommended by many medical 
writers. Should a repetition of emetics be re- 
quired, or medicines to be continued in nauseat- 
ing doses, other remedies, equally efficacious, 
after the stage of excitement has passed, and 
altogether safer, may be employed. 
If called during the first stage of croup, I am 
accustomed to commence the treatment of the 
disease, by exhibiting an emetic dose of tar- 
tarized antimony and ipecacuanha, from half 
of one grain, to a grain of the former, with ten 
to fifteen grains of the latter, according to the 
age of the child, and, after a delay of ten or fif- 
teen minutes, to follow its administration with 
the topical application of a solution of nitrate of 
silver to the tonsillary and faucial regions. 
This operation has the effect to excite, almost 
invariably, immediate and free vomiting ; and if 
the emesis and application be repeated in the 
course of half an hour or an hour, they not un- 
frequently arrest the further progress of the exu- 
dative inflammation. 
When it becomes necessary to repeat the 
emetic operation, in the course of the progress 
of the disease, I have found the sulphate of 
zinc, in combination with ipecacuanha, to be the 192 
TREATMENT OF CROUP. 
most certain, efficacious, and safe emetic that can 
be administered.* 
Dr. Copland recommends, as the best emetic, 
on the increase of the disease, tartarized anti- 
mony, and the oxymel of colchicum. 
“ Whilst vascular excitement continues,” he 
remarks, “either this combination, or the anti- 
mony only, in repeated doses, as suggested by 
Cheyne and Michaelis, is the best emetic ; but 
when we wish to detach the membranaceous exu- 
dation, the preparations of squills alone, or with 
ipecacuanha, are preferable.” f 
Blood Letting.—“If the patient is in the 
first, or inflammatory stage of croup,” says Dr. 
Cheyne, “no experienced physician will omit 
bleeding ; if in the second, or that of suppura- 
tion, no physician will propose it.” J M. Bre- 
tonneau, a physician of equal eminence and ex- 
perience, makes the following observations on 
this subject: “I am forced to declare, contrary 
to the received opinion, that bleeding in croup 
has done harm, and accelerated rather than re- 
tarded the spread of the coriaceous inflammation. 
* $ Zinci Sulphatis gr. x 
Ipecacuanhas pulv 3j. 
Aquas tepidae § iv. 
Misce.—A dessert spoonful may be administered every five minutes, 
until vomiting occurs. 
f Dictionary of Prac. Med., Article Croup. 
J Cyclop, of Prac. Med., Article Croup. GENERAL REMEDIES. 
193 
I did not abandon this measure till after reiterated 
proofs of its injurious effects.’7 
It is difficult to reconcile these adverse opin- 
ions with reference to bleeding—opinions which 
are not only entertained by the above authors, 
but likewise by many other distinguished writers 
and practitioners. Much the larger portion of 
these, however, advocate bleeding, either gene- 
ral or local, in croup, if resorted to in the first 
stage of the disease, and in case, of an un- 
equivocally inflammatory type. “ In the more 
inflammatory states,” says Dr. Copland,* “ it 
should be promptly and fully performed f but 
he adds, “ little will be gained by resorting to 
it before inflammatory action is manifested, or 
after excitment has subsided.” 
Mr. Ryland, who is an advocate for blood- 
letting when the febrile excitement is great, the 
patient strong and plethoric, and the disease in 
an incipient state, remarks: “ in town practice, 
and especially amongst the pauper class of the 
community, bleeding even by leeches, generally 
does harm, unless in the very earliest stages of 
the disease ; it weakens the patient, and in most 
instances without putting a stop to the tracheal 
inflammation.” j* 
Dr. Home likewise declares that bleeding em- 
ployed in the second stage of this disease, or 
* Loc. citat. f Loc. citat. p. 149. 194 
TREATMENT OF CROUP. 
when the membrane is formed, cannot possibly 
be of advantage.* 
In my own experience, I have not been favor- 
ably impressed with the effects of blood-letting 
in croup ; having met with cases where this 
measure being employed freely, not only failed 
to arrest the disease, but evidently proved posi- 
tively detrimental. 
I would not, however, be understood to dis- 
card altogether bleeding in croup. Cases there 
are, where a timely and judicious employment of 
this remedy will produce the happiest results. 
When the affection occurs in strong and ple- 
thoric children, and is attended with a high 
degree of vascular excitement, depletion in the 
access of the disease by either local or general 
bleeding, is a most efficient means of arresting 
the exudative inflammation. But if this favor- 
able period, which Dr. Cheyne calls “ the golden 
opportunity,” be lost, and the first stage is al- 
lowed to pass, blood letting will only have the 
effect in the second stage to weaken the patient, 
and to check that muculent secretion which 
serves to loosen and detach the adventitious 
membrane, and render its expectoration more 
certain. Blood-letting, then, if employed at all, 
in the treatment of croup, let it he remembered 
by every practitioner, must be adopted before 
* An Inquiry into the nature of Croup, p. 57. GENERAL REMEDIES. 
195 
the adventitious membrane has formed, for its 
use after this process has taken place, will, as 
M. Bretormeau has remarked, accelerate rather 
than retard the coriaceous inflammation. 
Mercury.—Dr. Rush, of Philadelphia, was 
amongst the first to recommend the employment 
of mercurial preparations in the treatment 
of croup. “ Our principal dependence,’7 Dr. 
Rush remarks, “ must be placed on calomel ; 
the bark is scarcely a more certain remedy for 
intermittents, than calomel in the humid cynan- 
che trachealis.” * 
Many other physicans place great dependence 
on this remedy, exhibited every few hours in 
croup. Some writers consider it a specific in 
the disease, if administered in large and fre- 
quently repeated doses. Calomel has been 
given alone, and in combination with the anti- 
monial preparations, with antispasmodics, with 
James’s powder, with the oxide of zinc, and 
with opium. Of all the mercurial preparations 
calomel is undoubtedly the best form for inter- 
nal administration in the treatment of croup. 
In my own experience, I have had undoubted 
evidence of its great utility in this disease. In 
all cases of exudative inflammation, where topi- 
cal measures and emetics fail in the first stage to 
arrest the disease, prompt recourse should be 
* Medical Inquiries and Observations, vol. i. p. 145. 196 
TREATMENT OF CEOLtP. 
had to mercurial remedies. Under such circum- 
stances, I am accustomed to administer calomel 
in combination with opium and ipecacuanha.* 
The dose should be varied according to the age 
and condition of the patient. From one to three 
grains of calomel, with half a grain of ipecacuanha, 
and from the tenth to the twentieth of a grain of 
opium, may be given every two or three hours 
until the disease yields, or the constitution is 
affected by the remedy. “ Directly that the 
patient becomes influenced by the calomel, 
lymph ceases to be effused in the trachea and 
though it is doubtful whether the false membrane 
is ever absorbed again into the system, it soon 
becomes detached by the secretion from the sub- 
jacent mucous follicles, and will be coughed up 
by degrees.”f 
Cold Applications.—The constant application 
of cold water externally, is considered by Dr. 
Peaslee a means of the greatest value and im- 
portance in the treatment of croup. “Cold,” 
he remarks, “ must be continuously applied to 
produce the desired effect. Applied at intervals, 
indeed, it rather promotes than retards the in- 
flammatory process ; since, during the intervals, 
* IJ. Hydrargyri Submur 3j. 
Ipecacuanha pulv gr. x. 
Opii pulv gr. i. 
Mbce bene et divide in pulv. x. 
f Ryland, p. 148. GENERAL REMEDIES. 
197 
the temperature rises above the normal standard, 
in consequence of the reaction of the chill on the 
surface. Cold water may be constantly dropped 
from a sponge upon a compress laid over the 
throat of the child, and the latter should be of 
only one or two thicknesses of linen, that evapo- 
ration may go on as rapidly as possible.” * The 
applications of hot, early in the disease, as some- 
times practised, is considered objectionable by 
Dr. Peaslee ; and that of rapid vesicants—such 
a§ aqua ammonia, etc., still more unwarrantable. 
Hydrocyanic Acid.—The sedative powers of 
hydrocyanic acid when medicinally employed, 
its influence in reducing the force and frequency 
of the pulse, and in allaying the sensibility of the 
mucous system, serve to render it a valuable 
remedy in the treatment of some of the forms of 
croup. 
Hydrocyanic acid was first employed as a 
therapeutic agent by the Italian physicians, near 
the commencement of the present century. 
Soon after its introduction into the Materia 
Medica, it obtained some celebrity as a remedy 
in disease of the pulmonary organs, and it has 
since been employed with more or less repute 
in other morbid conditions of the air-passages. 
It is the most valuable remedy we possess, for 
the treatment of hooping-cough. “ Cautiously 
* Op. citat. p. 200. 198 
TREATMENT OF CROUP. 
administered,” remarks Dr. Granville, “ this 
medicine has seldom failed to remove the dis- 
ease, and it is singular that children bear the 
action of this sedative medicine in small doses, 
better than adults.” * 
In the treatment of the latter stage of croup, 
particularly when this disease has been compli- 
cated with bronchial inflammation, I have found 
the hydrocyanic acid invaluable in allaying the 
great restlessness—the spasmodic and harass- 
ing cough, symptoms which often attend this 
complicated form of the affection. 
Various other remedies have been advised, 
and are employed for the treatment of croup ; 
but, for an account of these, I shall refer the 
reader to the more general treatises on the dis- 
ease. 
* Historical and Practical Treatise on the Internal use of the Hydro- 
cyanic Acid. 
THE END.