518 CROUP veloped gradually. The first local symptom is hoarseness, which may exist for one, two, or three days before distress from obstruction ensues. The latter at length becomes marked, and progressively increases, the labor of breath- ing and the suffering from a sense of the want of air increasing in proportion. The voice becomes extinct. The cough is croupal, but in a degree less than in the so-called spasmodic croup. Spasm, however, is an element in true croup, as it is in the several varieties of false croup, but not to the same extent. Death takes place from slow suffocation, or apnoea, in from four to six days. In the cases which end in recovery, the false membrane is thrown off and expectorated. Portions of the membrane are sometimes expectorated in fatal cases, but a renewal of exudation takes place. The ex- udation sometimes extends to the bronchial tubes, and this lessens the few chances of re- covery. Pneumonia not infrequently occurs as a complication. The suffering from the sense of suffocation generally becomes less toward the close of life, owing to the perceptions hav- ing become blunted, and the spasmodic ele- ment being less marked. Sometimes, owing to these causes, there is an appearance of im- provement which is apt to lead to a delusive hope that the patient is essentially better. In treating cases of true croup, the great object is to expedite the separation of the false mem- brane. The inhalation of warm vapor or steam is the most effective measure for this object. The presence of lime is supposed to be useful by giving to the vapor a solvent property. Slacking lime in the room is a convenient method of producing a warm vapor, and se- curing whatever benefit is to be derived from the presence of lime in the vapor inhaled. In addition, the room should be kept filled with vapor from boiling water, and the temperature should be between 80 and 90. Emetics may be useful when the false membrane has been thrown off, by effecting its expulsion from the larynx. The application of cold to the neck is rep ommended, with a view to lessen the inten- sity of the inflammation and prevent spasm. A highly important part of the treatment con- sists in giving nutritious food, together with tonic remedies and perhaps alcoholic stimu- lants, in order to prolong life until the separa- tion and removal of the false membrane have been effected. The measures of treatment which were formerly in vogue, bleeding, mer- curialization, counter-irritation, and the fre- quent repetition of powerful emetics, are now generally regarded by physicians as injudicious. Opening the trachea (tracheotomy) is to be employed when it is apparent that the disease will otherwise in all probability prove fatal. The chances of saving life by means of this operation are not many ; but it cannot be doubted that tracheotomy sometimes rescues patients from impending death. If not suc- cessful, it affords relief from the distress of suffocation, and substitutes an easier mode of dying ; it is therefore justifiable on the ground of euthanasia. True croup, as a rule, affects children between two and seven years of age. Exceptionally it occurs at other periods of childhood and after adult age. The varieties of false croup in which spasm is exclusively the cause of the temporary obstruction of breathing call for measures of treatment which relieve the spasmodic condition, namely, warm applications to the throat, the inhalation of warm vapor, and anodynes. When dependent on indigestion, a mild emetic is promptly effi- cacious. Simple acute laryngitis in the child claims mild measures designed to diminish the intensity and duration of the inflammation, together with remedies to palliate spasm. None of the varieties of false croup have any tendency to eventuate in the membranous variety or true croup. Considering this fact, and the great danger in cases of true croup, it is extremely important to discriminate between these different affections, which have unfor- tunately been grouped together. Anxiety on this score may often be relieved by bearing in mind that if the voice or the cry be unaffected, that is, if there be no hoarseness, the affection is purely spasmodic, and without danger. It is also important to be borne in mind that the dangerous affection, true croup, is generally developed gradually ; and in a child, especially between two and seven years of age, hoarse- ness should always excite apprehension, and still more if with the act of inspiration the nostrils dilate, although there may be no evi- dence of distress from obstructed breathing. An affection analogous to spasmodic croup, consisting in spasm of those muscles of the larynx which close the glottis, occurring chiefly in infants, is known as spasm of the glottis or laryngismus stridulus. It has been called thy- mic asthma, from a fancied dependence on en- largement of the thymus gland. It occurs in paroxysms, during which respiration is greatly obstructed. Sometimes, although very rarely, it causes death by suffocation. It exists in a mild form when infants are said to have " spells of holding the breath." The holding of the breath, however, is due not to mental per- verseness, but to an involuntary contraction of the muscles of the glottis. A tendency to spasm of these muscles exists in some children as an idiosyncrasy. Severe paroxysms are apt to arise from the irritation of teething. The milder paroxysms are quickly made to cease by a sudden impression on the nervous system, as by slapping the back, or sprinkling a little cold water on the face. If the paroxysms are severe, it is important to ascertain and remove the ex- citing causes (for example, dividing the gums), and to employ measures to improve the gene- ral health and vigor. Spasm of the glottis, al- though one of the affections belonging espe- pecially to infancy, may occur at any period of life. It is among the varied nervous mani- festations embraced under the name hysteria, and it may be caused by a tumor so situated
