NOT TO BE CONFOUNDED IN THEIR TREATMENT.

389

spite of my field of observation having shifted to a district in which disease generally, and croup among the rest, presented a more sthenic character than it wore in the low-lying district to the south of the Thames. I notice less frequent employment of depletion, and at the same time recourse to cauterisation of the throat, a proceeding to which I was led in a measure by Dr. Horace Green's remarks on cauterisation of the larynx in croup, and which therefore had by no means constant reference to the presence of false membrane about the fauces.

For some years past I have given up the charge of out-patients at the Children's Hospital, and almost all the cases of croup which I see in private I see in consultation, and consequently when some symptom of special gravity has already arisen. It may perhaps be due in part to these circumstances that I have met with no occasion for depletion during the past five years. I have, however, met with not a few instances of idiopathic laryngeal croup, which, in the hands of younger practitioners who thought of nothing but diphtheria, were being plied with stimulants and sesquichloride of iron, and were saved by antimony, by emetics, and the use of mercurials.

In Germany, in spite of the prevalence of diphtheria there as well as here, the old form of inflammatory croup still prevails; and some of the older practitioners have raised their voice against the tendency to ignore its existence, to assume that diphtheria is the one only form of croup, that the observers of five-and-twenty or fifty years ago committed a mistake in supposing that antiphlogistic treatment was ever called for, or that stimulants could possibly be out of place.

My object is to warn against the same errors, to insist on the difference in character between cynanche trachealis and diphtheria, and, as a consequence, on the necessary difference between their

treatment.

There is, however, one point which it is important to remember in the management of the severer cases of croup, lest you fall into the error of over-treating your patient; an error not less hazardous than the opposite one of too great inertness. The disease, as you know, has a marked tendency to exacerbations and remissions, even independently of any physical change in the condition of the respiratory organs. You must not, therefore, allow the return of more difficult breathing, after a period of comparative tranquillity, to

* Among them is especially deserving of notice a short paper by Dr. Clemens of Frankfort, in J. f. Kinderkrankh.' vol. xxxvi., June 1861, p. 359.

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TREATMENT OF CROUP.

lead you at once to the inference that the child is worse, and that necessity exists for renewed and increased activity of treatment. It is very possible that the increased dyspnoea may be merely spasmodic; that immersing the child in a hot bath will give immediate and most signal relief; and that if you auscultate the chest afterwards you will find the air entering the lungs in as large a quantity as before, and unattended by any increase of morbid sounds.

The administration of calomel is not necessary in every case of croup, for when seen early, and treated with due activity, its symptoms are sometimes completely removed in the course of a few hours. But though we may sometimes be warranted in suspending all active treatment for a season, yet we must watch our patient with most untiring care for some days after the decline of the acute croupal symptoms, and at each visit our attention must be directed to the condition of the lungs, in order that we may at once put a stop at its very commencement to that inflammation of the smaller bronchi and of the pulmonary substance which so often disappoints the fairest prospects of recovery. Its treatment does not differ from that of ordinary bronchitis or pneumonia, except that depletion is not generally indicated, and that it not infrequently becomes necessary to support the patient's strength, even from a very early period.

Your own good sense will suggest to you the care and watching which are required during convalescence from croup; the necessity of withdrawing your remedies cautiously, and of awaiting the complete disappearance of all hoarseness, and the cessation of all cough, before you allow the child to breathe the external air. In cases where the peculiar croupal sound continues with slight cough, long after every other sign of mischief about the larynx has subsided, you will often find it of service to paint the neighbourhood of the windpipe every day with the tincture of iodine; a mild, but in the circumstances a very efficacious form of counter-irritation.

It still remains for us to enquire into the treatment of cases in which we have not the good fortune to encounter the disease at its outset, but in which we have to combat it when it has already reached the second stage.

This subject, however, must be reserved for our next lecture.

LECTURE XXIV.

CROUP continued-Treatment of the more advanced stages of the disease-Tracheotomy-the difference between the result obtained by it in England and in France, and its probable cause-objections to its performance-reasons for not regarding them as conclusive-Enquiry into the object of the operation-indications for its performance-its dangers-and how they are to be obviated.

In the last lecture we were occupied with the consideration of the management of those cases of croup in which the patient is seen early, and in which his condition warrants the employment of powerful antiphlogistic measures. He may, however, be seen too late for such means to be allowable, or they may have been tried in vain. If antimony cease to vomit, or 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 becomes 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. A totally different plan of treatment must at once be adopted, though with but slender hope of success.

An attempt should 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 administered. The sulphate of copper has been considered by some writers to be possessed of a specific influence over croup. I cannot, however, take this view of its action. It has seemed to me to be nothing more than an emetic of great power, and therefore especially applicable in cases where considerable depression exists, where the stomach has consequently lost much of its irritability, and where tartar emetic would probably not act at all, or if it did, would be injurious from its depressing action. Alum has been recommended in similar circumstances, and I dare say would answer equally well, though perhaps there is some

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TREATMENT OF SECOND STAGE

advantage in the smaller bulk of the sulphate of copper. I am accustomed to give it dissolved in water in quarter or half-grain doses every quarter of an hour till free vomiting has been produced, but have never trusted to it alone, in the same way as in an earlier stage of the disease I am used to rely on tartar emetic. I employ it with a two-fold purpose: first, to obtain the stimulant action of an emetic; second, to prevent, if possible, the accumulation of false membrane in the larynx. Hence, if the child seem again sinking into a state of collapse, or if coma appear coming on, or if the dyspnoea become much aggravated, the sulphate of copper may again be employed to induce vomiting. If, however, in these cases, or in others in which, though some degree of improvement has followed the previous treatment, yet the child has been much reduced by it, emetics should not act, I would not advise you to attempt to compel vomiting by irritating the fauces, or by other similar proceedings. On one occasion I saw these endeavours succeeded, not by the vomiting, which they were intended to excite, but by general convulsions, followed by a comatose condition, in which death took place an hour and a half afterwards. Examination of the body discovered some congestion of the brain, but showed at the same time that the affection of the air-passages had not reached such a degree as to have precluded the possibility of recovery, and that the patient's death had been caused not by the disease, but rather by the ill-judged employment of the remedy.

In this stage of croup the decoction of senega is a medicine of great value, and may be given in combination with the carbonate of ammonia and tincture of squills, every two hours. The pungency of the ammonia is best concealed by sweetening the medicine with treacle or with coarse sugar, and mixing it with about a third of milk; and in this form children will seldom refuse it. No other remedy or combination of remedies has appeared to me to be so useful as a stimulant expectorant in the advanced stages of croup or bronchitis. The patient's strength must be supported by beef-tea, and a generally nutritious diet; and even wine may be indicated; though small, indeed, are the hopes that remain when the vital powers have sunk so low as to require its employment. While by these means you try to keep your patient alive, there is

• Alum has been used and strenuously recommended in these circumstances by Dr. Meigs of Philadelphia; and the experience of his son, Dr. J. Meigs, as recorded in his work on 'Diseases of Children,' seems fully to bear out his father's recommendation. He gives a teaspoonful in honey or syrup, every 10 or 15 minutes, till free vomiting is produced.

† See Formula No. 12, p. 325.

OF CROUP.-TRACHEOTOMY.

393

still one remedy that you may use, and use actively, though I fear it must be admitted with no great prospect of success. You employ mercury, or you increase the dose in which you have previously prescribed it. A grain of calomel may be given every hour to a child from two to three years old, unless the existence of profuse diarrhoea should contraindicate its use; while, at the same time, a drachm of strong mercurial ointment may be rubbed into the thighs every two hours. If diarrhoea be present, the calomel must be given more sparingly, or must even be altogether omitted.

Much difference of opinion prevails among writers of high repute as to the proper time for employing counter-irritation in cases of croup, and still more as to the part to which this counter-irritation should be applied. I believe that when the disease has been checked by antiphlogistic measures, and the symptoms have lost something of their severity, much good is done by the application of blisters to the upper part of the sternum. But, on the other hand, if croup have reached an advanced stage, unchecked by previous remedies, blisters to the sternum have seemed to me nearly, if not altogether useless; while, from the application of a large blister to the throat, covering the larynx and reaching down nearly to the sternum, I have often observed the paroxysms of dyspnoea to be much alleviated, the respiration to be rendered far more easy, and expectoration for the first time to accompany the cough. In any case, if very manifest relief were not observed within six hours after the abstraction of blood and the administration of antimony, while further depletion did not appear justifiable, I should apply a blister to the throat.*

It was to be expected that the probable utility of bronchotomy in cases of croup should suggest itself to the earliest observers of the disease. For many years, however, after it was first advocated on theoretical grounds by Dr. Home, the value of the operation was not put to the test; and even for a long time after it had been tried, but one instance was recorded of any other than an unsuccessful result. In the year 1825, M. Bretonneau, of Tours, saved

*This opinion being opposed to that of men such as Dr. Stokes and Mr. Porter, I feel it necessary to appeal in support of it to the authority of Gôlis, lib. cit. p. 118, and Albers, De Tracheitide Infantum, p. 127; and not to rest it solely on the results of my own experience.

In this case the operation was performed in the year 1782 by M. André of London, on a little girl five years old. The particulars are related in a dissertation published at Leyden in 1786, by Mr. T. White, whence they are extracted by Dr. Farre, and appended as a note to a paper of his on Croup, at page 338 of vol. iii. of the Medico-Chirurgical Transactions.