Synonyms.—Membranous Croup; Laryngeal Diphtheria.
Definition.—An inflammation of the larynx, characterized anatomically by the formation of a false membrane; clinically, by a shrill, piping respiration, dry, metallic cough, the voice sinking to a whisper.
Etiology.—There has been much discussion as to whether membranous croup and laryngeal diphtheria are one and the same disease, and although it is now generally recognized by the profession as one disease, and although health officers require membranous croup to be reported as infectious, I am sure that I have seen cases where there is no evidence of infection and no symptom of diphtheria; hence it may be classed a non-contagious membranous croup.
As proof I report a recent case: I was called to see a child two years old who had been suffering, as I learned, for five days with cough and difficult breathing. Home remedies had been faithfully used, but the child grew gradually worse. At my first visit I found the child laboring for breath, interrupted by the dry, metallic, croupal cough; the cry was piping, and the labored breathing showed the opening of the larynx was very small. The tongue was but slightly coated, appetite good, no odor from breath, skin moist, secretions from kidneys and bowels good. In fact, had it not been for the labored breathing and croupal cough the child would have needed no medical aid. The membrane gradually lessened the caliber of the larynx, and, despite steam inhalations and internal medication, the child grew gradually worse so that intubation was required to preserve life. Within ten minutes after the tube was in place, the child dropped into a quiet sleep, the breathing was as quiet as that of a healthy babe, and, to all appearance, the disease was at an end. The tube was allowed to remain four days, during which time the child drank freely of milk, slept quietly, and made no complaint. There was not a single symptom of diphtheria.
The cause of non-contagious membranous croup is no doubt the same as that of catarrhal croup, although just why in the one case a plastic exudate is formed, it is impossible to say.
Pathology.—This is a true inflammation of the mucous membrane, which is attended by a plastic exudate, forming the pseudo-membrane, which varies in thickness from one-sixth to one-fourth of an inch, and consists of mucus, epithelial cells, and an obscure fibrous structure. In some cases it is but loosely attached, while in others it is removed with difficulty.
Symptoms.—"The coming on of an attack of pseudo-membranous croup may sometimes be recognized for three or four days, or even a week. The child does not seem sick, and plays about the house as usual, but has some cold, and the parents notice some hoarseness of voice and cough. We will notice, however, a peculiar metallic resonance to the voice, cry, and cough, but more especially that there is a dry and whistling respiration. This is so marked that the breathing may be heard across the room.
"The attack of croup most frequently comes on at night, as in other cases. In the evening it is noticed that there is more hoarse-ness of the voice and the cough is somewhat croupal, but as the child breathes pretty well and does not seem sick, the parents flatter themselves that it is but a cold, and will give no trouble. The mother has told me of going to the child's bed or crib, attracted by the peculiar whistling respiration, impressed that there was something wrong, but fearing ridicule if she sent for the physician.
"As the time passes, the child becomes restless from difficult breathing, has slight attacks of cough in his sleep, which are clearly croupal. In another hour or two he awakes with a start, and assumes a sitting position, evidently suffering much from difficult respiration, which is increased by the attacks of coughing.
"The symptoms are now very marked, the respiration is sibilus or whistling, and difficult, the cough hoarse and metallic, the voice roughened or sunk to a whisper, and the cry shrill and piping; the skin is dry, the pulse hard and increased in frequency, the urine scanty, and the patient restless and uneasy.
"As the disease progresses, there is a gradual increase of all these symptoms, but especially of difficult respiration, which is constant. The cough is spasmodic in its character, and when it comes on, the patient suffers very greatly from want of air. After a time, evidences of asphyxia appear in the bluish lips, distended veins, leaden appearance of the surface, cold extremities, dullness of the nervous system, and finally coma and death.
"The entire duration of the final attack will be from six to forty-eight hours."
Diagnosis.—The constantly increasing difficulty of respiration, the whistling, sibilant sound of the air as it passes through the narrowed larynx, the dry, ringing, metallic cough, and the piping cry can hardly be mistaken for any other form of croup.
Prognosis.—This is a grave disease, and the prognosis must be guarded. In very young children the outlook is unfavorable, owing to the small size of the larynx. An unfavorable prognosis will be made where the pulse becomes small and feeble, the skin relaxed, extremities cold, the respiration gasping, and the face cyanotic.
Treatment.—I can not do better than reproduce the treatment as given in Scudder's "Diseases of Children," which is as follows:
"The indications of treatment in this case are: To produce relaxation of the intrinsic muscles of the larynx, and thus give freedom to the respiration while we pursue the main treatment; to lessen inflammatory action and obtain free secretion of mucus, for the purpose of effecting the detachment of the false membrane; and, finally, to effect the removal of this.
"To fulfill the first indication, we employ inhalations of. the vapor of water, or water and vinegar, or lime-water, as will be hereafter named. With this we direct the continuous application to the throat of flannel cloths wrung out of hot water, in the meantime bathing the throat with the compound stillingia liniment. These are important means, and should never be neglected.
"There are two plans for accomplishing the second indication. The one is by the use of the tincture, of veratrum viride or aconite, aided by inhalations of lime-water, and is very good treatment and much pleasanter than the use of nauseates. I prescribe the veratrum in the proportion of ten drops to water four ounces, a teaspoonful every fifteen minutes, until it produces a marked influence upon the pulse; then in smaller doses, to continue its effect.
"Aconite is preferred where the pulse is small and frequent, and it is administered in the usual small doses: Tincture aconite. 2 drops; water, 4 ounces; a teaspoonful every fifteen minutes. If the child is very sensitive to the action of the remedy, the dose should be still further reduced, and if we find the lips dry and contracted, and the child grasping at its mouth with its hands, it should be suspended and veratrum administered.
"If the tongue is pallid, and shows small spots of red, phytolacca may be combined with the medicine. If the little patient is dull and stupid and wants to sleep, give belladonna. If there is a sharp stroke of the pulse, and the child moves its head restlessly backward and forward, throwing it backward as if it would bury the occiput in the pillow, give it rhus. This remedy is also indicated by the shrill cry as if frightened, and sudden starting from sleep. Gelsemium is indicated by the flushed face, bright eyes, and contracted pupils, with restlessness and great irritation. These remedies are secondary, it is true, but it is a case that requires all that we can do, and if by one of these we strengthen the aconite and veratrum, we give our patient an additional chance.
"What the physician needs most of all is a steady hand. The treatment requires time, and we must not get excited. If the patient is growing no worse, we should feel satisfied for a time; if there is but slow improvement, as marked by more ease of respiration, a better circulation, warmth, and moisture of the feet, legs, and forehead, we feel encouraged, and hold fast to the treatment.
"The use of lime-water as an inhalation is a very important part of the treatment. It is claimed that it alone is sufficient to arrest the inflammatory action and cause the detachment of the membrane; and I have employed it with success when other means have failed. The veratrum has also proven very successful alone, and the two will fulfill the first two conditions.
"The other and older plan of treatment is by the use of the nauseant emetics, and, if properly used, will give excellent results. I may add that if improperly used—i. e., so as to irritate the stomach with retching and ineffectual efforts to vomit—they will hasten the fatal termination.
"Of these remedies I prefer: Acetous tincture of lobelia, acetous tincture of sanguinaria, 1 ounce use; molasses, 1 ounce; chlorate of potash, finely powdered, ½ ounce; let them be combined with heat, and add the potash. We give this in doses of a teaspoonful every ten or fifteen minutes, until nausea is induced; then in smaller doses, so as to continue the nausea without vomiting. The greater and more constant the nausea without efforts at vomiting, the greater the success of the treatment.
"Using the hot applications to the throat, and the inhalations of vinegar and water, we continue the nausea for some hours, at least until we have evidence of secretion, and the commencing detachment of the false membrane. This will readily be detected by the moist sound of respiration, and a gurgling, napping sound in the act of coughing. If the child is breathing pretty freely, we may wait for the removal of the membrane by the cough, as it will be brought away by shreds.
"But if, with the loosening of it, it seems to be drawn upward in expiration, and downward with inspiration, tending to block up the passages and producing evident symptoms of asphyxiation, we carry our remedies to thorough and prompt emesis.
"Generally it will be well enough to prepare an infusion of the compound powder of lobelia and capsicum for use at this time, as we will have established a degree of tolerance for the other preparation. Occasionally we will meet with a case requiring prompt relief. Here the child will be turned on its abdomen; and a finger introduced into the mouth, drawing the tongue forward, and exciting the fauces, will be followed by a forcible expulsive effort, and the membrane will be detached. A case of this kind occurred in my practice; the membrane became detached and entirely stopped the larynx, the child was asphyxiated, and would have died in five minutes. I snatched it from the mother, turned it on its face, inserted my finger as far down as the larynx; a forcible effort at vomiting ensued, and the whole membrane was removed at once, being a perfect cast of the larynx. The child recovered.
"To the above treatment I would add the nitrate of sanguinaria when the membrane becomes loosened and is coughed up in small shreds: Nitrate of sanguinaria, ⅛ grain; rub in mortar with boiling water, 4 ounces; when dissolved, add a teaspoonful of good, sharp cider-vinegar. The dose is a teaspoonful every hour.
"Where the child grows worse despite the above treatment, and struggles for breath, intubation should be performed. The tube should remain three or four days.
"Convalescence demands much care. The child should avoid draughts of air. A good tonic should be administered and stillingia liniment or potassium bichromate given for hoarseness that follows, and to strengthen and tone up the weakened laryngeal tissues."