medical men who have studied croup. The pneumonia, primarily in the state of bronchitis in the first stage, only assumes the character of pneumonia towards the end of the second; it almost invariably leads to a fatal termination.

Descrete lobular pneumonia and confluent pneumonia are met with. In some children they exist concurrently with a pseudo-membranous capillary bronchitis. In these cases the disease is beyond all the

resources of medicine.

Croup has been sometimes observed in connection with hooping cough, phthisis, eruptive fevers, &c. Amongst these diseases there is only scarlet fever which has a direct relation with that which we are now considering. It is, as is known, very often accompanied by pseudomembranous angina; then the manifestation of croup is very much Je to be dreaded.

DIAGNOSIS.

The diagnosis of croup sometimes presents difficulties, for there are other diseases of the larynx which are accompanied by symptoms very like those which it presents.

In simple laryngitis the cough and cry are hoarse, but the rough, smothered, hissing, ringing cough of croup is not observed; the respiration is not accelerated, and there are no fits of suffocation as in this disease.

The symptoms of oedematous laryngitis, or of oedema of the glottis, much more resemble those of croup. The cough is equally rough and hissing, the respiration is laborious, and suffocation imminent, but the fundamental character of croup does not exist. There is no expectoration of false membranes. Fidis This product does not exist at the back of the mouth. However, as it is not always possible to be assured of its existence it is easy to make a mistake, and there is a liability of mistaking one of these diseases for the other. The progress of the symptoms must also be taken into It is much more rapid in oedema of the glottis than croup. But after all there is little chance of error, for, as we have observed, oedema of the glottis is a very uncommon disease amongst young children. The mistake can never be prejudicial, the treatment in both cases is alike; there is only one resource against asphyxia, which is the opening of the trachea.

account.

It is much more difficult to distinguish croup from pseudo-membranous tracheitis. The anatomical character is the same; there may be in both cases expectoration of false membranes; but, as M. Guersant has remarked, the symptoms which are observed in these two conditions are essentially distinct. "The pseudo-membranous tracheitis presents none of the symptoms of the first stage of croup; it commences by a more or less intense fever and a dry acute cough,

Book IV, Chap. I.]

ON CROUP.

to Jus, with The produs. 265 lucu

which causes a more or less tearing pain; the voice is low, but it is in nubrau not extinguished as in croup; the respiration is not hissing; it is

evident that the larynx is free. In the second stage the cough has she become more moist; the respiration, although obstructed and rattlinguis after the fits of coughing and between the fits, presents nothing to

be compared to the dry and metallic rales of croup, and to the fits of croupal suffocation. In the third stage of this disease the obstruction

increases, and after strong fits of coughing the patients reject mem- tive branous, riband-like layers of various dimensions. They then become

convulsed, if in the meantime an attack of bronchitis or pneumonia does Croupal

not cause a prolongation of the symptoms.'

The disease which has been most frequently confounded with croup, and which has been the cause of fatal mistakes, is false croup or stridulous laryngitis. It is important that a precise distinction be established between these two diseases which require entirely else different therapeutical means. M. Guersant has contributed more than brenk any one to clear up this subject, which so long remained confused and obscure.

Like croup, stridulous laryngitis is accompanied by a dry, hoarse, hissing more or less sonorous cough. The obstruction to respiration ^ is extreme; it seems as if the child must perish of suffocation; yet the larynx is free, and there can be no expectoration of false membranes. The phenomena which are observed are entirely nervous; they are soon quieted; their progress is quite peculiar. They suddenly appear in a very high degree of intensity in subjects otherwise in a good inte state of health or labouring under slight cold. They come on in the middle of the night. The attack lasts about two hours, and reappears the following nights for two or three times; but it is more feeble and disappears.

on.

Croup presents nothing like this. The symptoms gradually increase in intensity and it is at the end of several days that suffocation comes The fits appear during the day as well as by night; they reappear as long as the false membranes enclosed in the larynx have not been ejected. Far from diminishing in intensity they become on the contrary more terrible each minute, and terminate by carrying off the patient.

There exists, as has been observed, a very great analogy between the manifestation of these two diseases, between the cough, the dyspnoea, and the suffocation; but the similitude is only apparent. When the progress of these symptoms is carefully observed, this changes their character and necessarily modifies the interpretation which may be drawn from it. This progress is so different that it appears to me difficult henceforth to confound croup with false croup, pseudo-membranous laryngitis with stridulous laryngitis.

* Dict. de Méd; t. ix.

імний

PROGNOSIS.

Croup is a very serious disease which always threatens life.

It is a disease which it is difficult to overcome and to arrest in its progress. It is very often fatal.

Some differences must however be established, according to the seat and extent of the alterations. When the false membranes developed in the mouth only exist on the epiglottis and the superior opening of the larynx, the disease may be cured by means of appropriate treatment. The same is also the case when they do not extend beyond the limits of the larynx. But if these products penetrate into the trachea and bronchi, the croup is almost invariably fatal. ally The complications of this discase add still further to the unfavourWe rest is a most serious symptom, as has been already observed, A Cableness of the prognosis. Pseudo-membranous coryza in children at licatio since it exposes them to death from inanition. Lobular pneumonia increases the dyspnoea, and if the obstruction of the larynx is not of such a nature as to produce fits of suffocation, the difficulty of breathing which accompanies pulmonary inflammation very readily provokes them. In this case, if the child does not perish by the larynx, it will succumb in consequence of the disease of the lungs.

[The following abstract from the Report of the Registrar General shows the number of deaths from croup in London during the years 1845-49, and the number in each quarter.

Total of the
quarter.

112

79

67

77

425

277 295 295

TREATMENT.

The treatment of croup has been advantageously modified in this age in consequence of the researches of two eminent physicians, MM. Bretonneau and Trousseau. It is composed of two parts, one medical, the other surgical. Formerly the first was the only one in favour; the second is now definitely accepted. We owe it to the two above-named physicians.

Abstractions of blood, revulsions, alteratives, emetics, and sternutatories form the basis of the medical treatment. Topical applications and tracheotomy belong to the surgical part of the cure.

Before the examination of the value of these various means it will be useful to understand what aim it is proposed to fulfil in making use of them. The knowledge of indications forms the basis of therapeutics, which, without it, is only a blind and dangerous empiricism.

The inflammation of the mucous membrane of the larynx must be moderated and the specific nature of this inflammation destroyed by abstractions of blood, by revulsives, and by alteratives. Tartar emetic, employed as an emetic, equally conduces to this result; but it possesses, like the sternutatories, a different action. It acts in a mechanical manner, and by the efforts which it occasions it provokes the expulsion of the false membranes which obstruct respiration.

5 2

It is by means of topical applications that we hope to favour the detachment of the false membranes, and when we cannot succeed, and suffocation is imminent, tracheotomy then finds its application. It is a desperate remedy, by means of which the lives of the little patients are momentarily saved, before their definitive cure is realized. Abstractions of blood. There was a time when it was thought that the specific inflammation, which existed in croup, could not be better treated than by means of bleeding. Experience has singularly Experience has singularly demonstrated the incorrectness of this idea. Bleeding does not succeed in this case as in the usual inflammations. It is only useful amongst strong and vigorous children, when the reaction is very intense, and Excel when from the commencement the respiration is observed to be so obstructed that suffocation is imminent. It is in general dangerous in children at the breast, who are far from having the same strength of constitution. However, if it is thought necessary to have recourse to this means, it is preferable to employ bleeding from the arm to

local abstraction of blood. This last method possesses the very greatly

inconvenience of exciting the little patients who are frightened by the leeches, and who agitate themselves in a way which is prejudicial C to them. The internal spasm, to which they are a prey, impedes the exercise of respiratory functions, and determines asphyxia more ( rapidly. Then, in order to apply them, the children must be made to lie

on the back, with the head thrown backwards, a position which of itself antings

alone is sufficient to occasion suffocation. Lastly, the neck is that Gouri region of the body of the child where it is most difficult to stop the flow from the leech bites. They cannot be compressed in this att disease without the danger of still more obstructing the entrance of air into the chest. The leech bites then bleed abundantly; thence results a very serious anæmic condition, and sometimes even syncope, followed by death.

The greatest caution should then be used in the employment of abstraction of blood in children at the breast attacked with croup. Bleeding from the arm is preferable to the bleeding by leeches. If, however, this latter means be decided on, care should be taken to proportion the loss of blood to the strength and age of the patients. Three or four leeches ought to suffice; it is much better to repeat them than to put life in danger by too extensive an application.

Revulsives. The employment of blisters to the neck, and to different parts of the body, is not followed by that advantage which might be expected from them. Besides the uncertainty of their action, they are likely to give rise to serious danger. The wound which they cause is often covered by a false membrane, similar to that of the larynx, which may extend itself very far. This constitutes a second very dangerous disease, which it is necessary to attend to. Now, as the utility of blisters cannot compensate for such an inconvenience, it is, in my opinion, best to banish them from the treatment of croup. They may be of service in the exceptional cases, pneumonia for example; but they would then be employed less against the affection of the larynx than against the complication. We shall return to this subject further on.

Alteratives. Alterative treatment has been employed with the object of modifying the organism, and, at the same time, the nature of the diphtheritic inflammation. M. Bretonneau has sanctioned the employment of this method by numerous cases, and since, MM. Trousseau, Guersant, Blache, and the greater number of physicians have derived great advantage from it.

Mercury, sulphuret of potassium, and sulphate of copper, have been successively employed. The first of these medicines is the most useful

Atruly of all. нинигу

Mercurial frictions upon the superior part of the chest, the axillæ, the internal surface of the arms and thighs, and calomel internally, are usually prescribed. The friction should be performed night and morning, and calomel should be given to children at the breast, in the doses of from three quarters, or one and half, to three grains a day.

This medicine favours the expectoration and detachment of the false membranes. The cough diminishes, and loses its special character in proportion as the difficulty of the respiration ceases.

In those children submitted to this plan of treatment, numerous stools are remarked, and a congestion of the gums which is salutary when not carried too far. When the alvine evacuations are too considerable, the use of mercurials must be stopped, in order that the patient may not be thrown into a too decided state of weakness. Salivation is difficult to bring on in children at the breast. When it exists, we may judge that the mercurialization is very intense, and the use of the medicines must be interrupted, that we may not witness those serious results, such as gangrene of the mouth and necrosis of the maxillary bones, accidents which have been observed by M. Bretonneau.

The internal administration of sulphuret of potassium has also been recommended in the dose of from nine to eleven grains a day, in a demulcent draught, and of sulphate of copper, in the dose of three grains