History

The word croup is derived from the Anglo-Saxon word kropan, meaning "to cry aloud." Croup was first used in medical writing in 1765 by Francis Home, a Scottish physician. Until this century virtually all crouplike illnesses were confused with diphtheria.

Daniel Slade in 1864 traced the clinical history of diphtheria to the time of Homer, and A. Sanne in 1887 believed that the writings of Hippocrates demonstrate knowledge of diphtheria. Aretaeus of Cap-padocia, in the second century A.D., noted extension of the disease to the lower respiratory tract, which resulted in death by suffocation. Galen noted the expectoration of the pseudomembrane. At this time, the disease was common in Syria and Egypt and was called ulcus Syriacum or Egyptiacum by Aretaeus. Aetius of Amidu, in the fifth century, added his experiences to the previous descriptions of Aretaeus. Although both Aretaeus and Aetius were describing diphtheritic croup, it is clear that there was confusion with other illnesses such as Ludwig's angina and streptococcal tonsillitis.

The historical trail of diphtheria disappeared in the fifth century and did not reappear until the sixteenth century: First, in 1557, Peter Forest described an epidemic in Alkuaer, Holland. Then in 1576, Guil-laume de Baillou described an epidemic in Paris and specifically commented on false membrane. In 1771 Samuel Bard published the first U.S. report on the nature, causes, and treatment of suffocative angina. Pierre Bretonneau named diphtheria in 1826 and recognized its infectious nature. T. A. Edwin Klebs in 1883 noted the diphtheria bacillus in smears from pseudomembranes, and a year later Friedrich Loffler established the organism as the etiologic agent.

From 1920 to 1940 the incidence of diphtheria in the United States fell from approximately 200 cases to 20 cases per 100,000 population as a result of the use, first, of toxin-antitoxin and then of toxoid. In association with this decline in diphtheria, and also predating it, there was a general realization of other cases of croup in this century. Prior to 1900, only occasional notations of illnesses suggesting nondiph-theritic croup appeared. For example, E. Bouchut in 1852 described false croup, Stridalous laryngitis, which seems to have been spasmodic croup. In his treatise (1887), Sanne referred to an epidemic of simple croup in Germany, and Home (1765) noted two forms of croup. Bretonneau differentiated diphtheria from spasmodic croup in 1826.

In the United States during the first half of the twentieth century, severe croup was called laryngo-tracheal-bronchitis. It was recognized that it was caused by C. diphtheria bacteria and by other bacteria as well. In 1948, Edward Rabe described three types of croup infections: diphtheritic croup, H. influenzae type B croup (epiglottitis), and "virus" croup. Shortly thereafter, with the widespread use of tissue culture techniques, the viral etiology of croup was confirmed. During a period of approximately 30 years (1950-79), croup due to bacteria other than C. diphtheria was overlooked in medical papers and textbooks. In 1976, nondiphtheria/bacterial croup was rediscovered, and since then it has received considerable attention in the literature.

The history of spasmodic croup is not clear because the clinical and pathological aspects of the entity are poorly defined. In the 1940s spasmodic croup was separated from other more severe forms of croup by Francis Davison; however, since then the pathogenesis of this entity has received little attention.

James D. Cherry

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