diphtheria (membranous croup) happens to be frequent, the most
experienced diagnostician will meet with occasional difficulties. The
sound of the barking, explosive, tickling cough locates its origin in
the larynx, but the affection may be very mild or very severe.
Expectoration in small children is not pathognomonic; even when it is
copious it is not brought up, but swallowed. Fibrinous expectoration
would settle the diagnosis of a croupous process. Depressing the tongue
with a spoon or spatula and producing the movements of vomiturition
often reveals the presence of a tough, viscid mucus rising from the
larynx. It renders the catarrhal nature of the laryngitis positively
clear. The frequency or volume of the pulse is of no account in
diagnosis; it is too variable. Of more importance is the temperature,
at least in children. Uncomplicated sporadic croup has no increase, or
very little; catarrhal laryngitis is mostly attended with high fever.
In very many cases this symptom has guided me safely, in spite of the
statements of the books. The stenosis of catarrhal laryngitis comes on
very suddenly, in diphtheritic laryngitis mostly slowly. In the former
it is not of long duration; remission sets in soon, and is more
complete than in membranous croup. An attack of stenosis occurs mostly
in the night, and is apt to return with the same vehemence after a fair
remission after twenty-four hours. The frequency of relapses in
catarrhal laryngitis in children who have been affected before must,
however, not prejudice in favor of the catarrhal nature of an
individual case, for not infrequently will those who have had many
attacks be taken with membranous croup some other time. In the latter
the main symptoms--viz. stenosis, hoarseness (or aphonia), and
cough--will mostly develop simultaneously and in equal proportion; the
unproportionality of these symptoms--for instance, much stenosis and
cough, but little hoarseness, or barking cough and hoarseness with
little stenosis--would speak for catarrh. The laryngoscope, when it can
be used--viz. in the adult and very docile children--reveals redness of
the mucous membrane of the pharynx and all or part of the larynx; also
tumefaction of the epiglottis or fossæ Morgagni or ary-epiglottic
folds. Sometimes the inferior part of the larynx only is affected;
Ziemssen has described a severe form under the name of hypoglottic
laryngitis. The vocal cords can be watched easily. Their proportionate
and parallel contraction is often interfered with.
Tubercular laryngitis, particularly when there is no pulmonary
tuberculosis, is not easily diagnosticated by the local changes only.
The long duration of {96} hoarseness and fever, increasing emaciation,
and the knowledge of the presence of tuberculosis in the family are
more conclusive than local examinations can be.
PROGNOSIS.--The termination of catarrhal laryngitis in the adult is
almost always favorable. Still, relapses are frequent, and it may
become chronic, with permanent tickling of the mucous membrane and
submucous tissue. In children it is mostly favorable; still, it is
doubtful, because of the frequency of complication with, or
transmutation into, bronchitis, pneumonia, or glottic oedema, and
because of the facility with which in a prevailing epidemic the
catarrhal laryngitis becomes diphtheritic. The elevation of temperature
is not a very significant symptom in regard to prognosis. The danger
does not increase with the temperature at all. On the contrary, those
cases which set in with a high temperature will, as a rule, terminate
soon and favorably. When, however, the temperature rises again after
having gone down to the normal or nearly normal standard, complications
or extension of the catarrhal or inflammatory process must be expected.
Catarrhal secretion from the nasal mucous membrane, which was dry in
the beginning, is a favorable symptom; so is the looser and moister
character of the cough.
TREATMENT.--Whatever plays an important part in the etiology of the
disease ought to be carefully avoided. The feet must be kept warm under
all circumstances, nothing being more injurious to health in general,
and to that of the respiratory organs in particular, than cold and
moist feet. Shoes and stockings must be kept dry, the latter changed
when wet, and of slowly-conducting material. No part of the body must
be kept uncovered, and the dresses of children made the particular
object of care on the part of the family physician. Linen must not be
in immediate contact with the skin, cotton--or, still better in all
seasons, wool--being required for the undergarment. At the same time,
the hygiene of the skin requires attention. Regular washing or bathing
need not be mentioned as a requisite, as it is self-understood. What,
however, cannot be insisted upon too much is this, that the skin must
get accustomed to cold water. The whole body must be exposed once a day
to cold water--washing or bathing--and well rubbed off afterward with a
thick towel. Young infants and those who are very susceptible to colds
begin with tepid water, the temperature being lowered from day to day.
Even children of three or four years enjoy, finally, a morning bath at
sixty or sixty-five degrees F. in winter. Such as do not get easily
warmed up under the succeeding friction may mix alcohol with the water
they use for washing and sponging purposes, in the proportion of 1:5-8.
Sea-bathing also makes the skin more enduring, to such an extent that
exposure to cold air has no longer any damaging influence. In fact,
cold air without wind is easily tolerated even by those who have a
tendency to respiratory disorders, while wind and draught must be
avoided. From this point of view the change of climate sometimes
required for such as suffer from catarrhal laryngitis must be
instituted. It is not always necessary to select a very warm climate;
undoubtedly, many of the winter resorts are badly selected, for the
very reason that they are too warm. On the other hand, great elevations
are not advisable. The sudden atmospheric changes and fogs of high
mountains are injurious.
Patients suffering from catarrhal laryngitis or a tendency in that
direction must avoid all irritation of the pharynx and larynx. They
must not smoke, or talk too much or too loud. Those few clergymen who
suffer from clergymen's sore throat in consequence of speaking only
will remember that they can speak just as forcibly when speaking less
vehemently. The use of alcoholic beverages, unless greatly diluted, is
prohibited. Catarrh of the nares and pharynx must get cured. The former
will get well in most cases under the use of salt water. A tepid
solution of 1 or ½ per cent. of table-salt {97} in water, snuffed up
copiously (a tumblerful) from the hand of an adult patient, or a
similar solution in a small quantity injected through each nostril of a
child, twice or three times a day for weeks and months in succession,
will often remove a laryngeal as well as a pharyngeal catarrh. Care
must be taken that the fluid passes the whole length of the nasal
canal. It must be applied in the fauces, and will then be ejected
through the mouth or a small portion of it swallowed. Many a severe
nasal catarrh requires no other treatment. Some chronic ones require
the use of a spray of nitrate of silver in a solution of ½-1 per cent.
every other day, or of a 2 per cent. solution of alum daily. Where both
the pharyngeal and nasal catarrh are complicated with, or kept up by,
enlarged or ulcerated tonsils, these organs must be resected. The
combination of these two measures, exsection of the tonsils and nasal
injections, has proved very beneficial in a great many cases.
The treatment of an acute case requires great care. Avoid injurious
influences. The patient must keep silent and quiet in bed. The
temperature of the room is to be about 70° F., the air moistened by
vapor, which must not be allowed to get cold before it reaches the
patient.
When swelling and dyspnoea are considerable, particularly in those
grave cases attended with swelling of the submucous tissue, the
application of an ice-bladder or ice-cloths will be found beneficial
and agreeable. But the cases in which these applications are
indispensable are but few. In most of them the necessity of subduing
intense inflammation is less urgent than the advisability of increasing
the secretion of the congested larynx. For that purpose warm poultices,
but of light weight, act very favorably. Inhalation of warm vapors
either constantly or at short intervals, or of muriate of ammonium or
spirits of turpentine, will prove beneficial. The latter is evaporated
from the surface of boiling water, on which a small quantity, from a
teaspoonful to a tablespoonful, may be poured every one or two hours.
The hydrochlorate of ammonium is evaporated, 10 or 20 grains (1.0
gramme), every one or two hours by heating it on a hot stove or
otherwise. The white cloud penetrates the air of the whole room, and,
while not uncomfortable to the well, serves a good purpose in
liquefying the viscid and tough secretion of the mucous membrane. The
internal administration of liquefying and resolvent remedies may
properly accompany the external applications and inhalations. Amongst
them I count the alkalies, mainly bicarbonate and chlorate of potassium
or sodium and the hydrochlorate of ammonium. A child of two years will
take daily a scruple (gramme 1.0-1.5). The iodide of potassium will
also have a good effect and counteract many a predisposition to
chronicity. A child may take from 8 to 15 grains a day (gramme
0.5-1.0). Hydrochlorate of apomorphine, gr. 1/50-1/30 (0.001-0.002),
dissolved in water, a dose to be given every two hours or every hour,
is quite sufficient to act as a fair expectorant without being enough
to produce emesis. Antimonii et potassii tartras has been used more
extensively in former times than at present. An adult would take gr.
1/20-1/15 every two hours. Children ought to be spared the drug, as it
is depressing, produces unnecessary vomiting now and then, even in
small doses, and, what is still worse, diarrhoea. The other antimonial
preparations, such as kermes mineral and the oxysulphuret of antimony,
are less depressing and less purging, but also less effective; and
there are but few cases where a good substitute could not be found. For
the purpose of increasing secretion the hydrochlorate of pilocarpine
has been recommended. It certainly has that effect, but its indications
become doubtful in many cases where the saving of strength is of
paramount importance. I shall return to this subject in my remarks on
the therapeutics of membranous laryngitis.
Derivation is of great service when well directed. Local depletion must
be avoided. A purgative in the beginning is beneficial--a dose of
calomel {98} as good as, or mostly better than, anything else.
Diaphoretics and diuretics act quite well; the best of them all are
warm beverages of any kind. They need not come from the apothecary's
nor be very unpleasant to take--water not too cold, Apollinaris,
Selters, or Vichy, hot milk, tepid lemonade in large quantities and
very often. Sinapisms have a good effect. When not kept on longer than
a few minutes--long enough to give the surface a pink hue--they may be
applied every hour or two.
Some urgent symptoms may require symptomatic treatment. When secretion
is copious, but too tough, and expectoration insufficient because of
both the character of the mucus and the incompetency of the respiratory
muscles, ipecac in small doses or camphor is indicated. A child's dose
of the latter would be gr. ¼-½(gramme 0.015-0.03) every one or two
hours. In these cases the hydrochlorate of ammonium may be combined
with the carbonate (ammon. chlorid. drachm ss. (2.0); ammon. carbonat.
scruple j (1.25); extr. glycyrrh. pur. scruple ij (2.5); aq. pur.
fluidounce iij (grammes 100.0)--teaspoonful every hour). When the
difficulty of expectoration is excessive an emetic may be resorted to.
It is true that infants and children vomit with less straining and
difficulty than adults, but, still, the practice of flinging emetics
around is too common. The unpleasantness of getting up in the night
because of a pseudo-croup in a distant patient's baby is not a correct
indication for encouraging the indiscriminate use of emetics. When they
are required, antimonials ought to be excluded from the list. Ipecac,
sulphate of zinc, sulphate of copper, turpeth mineral are preferable.
In urgent cases the hydrochlorate of apomorphia may be used
hypodermically (six or ten drops of a 1 per cent. solution in water).
Cases of such urgency, and so excessive dyspnoea coupled with cyanosis,
as to necessitate tracheotomy are but very rare. But once in thirty
years and in many more than four hundred tracheotomies have I been
compelled to operate for a case of catarrhal laryngitis. Still, a few
such cases are on record. The best-known amongst them is that of
Scoutetten, who operated successfully on his own daughter six weeks
old.
Narcotics prove quite beneficial, particularly in complications with
pharyngeal catarrh. A dose of gr. j-jss of Dover's powder (gramme
0.05-0.1) at night will secure rest for several or many hours to a
child of two or three years; an adult is welcome to a dose of 10 or 12
grains (0.6-0.75). When the irritation is great during the day, it is
advisable to add a narcotic (acid. hydrocyan. dil., min. j; vin opii,
min. viij-xij; codeine gr. 1/3-1/2, or extr. hyoscyam. gr.
ij-iij--daily) to whatever medicine was given. I am partial to the
latter, giving it up to gr. viij-x (0.5-0.6) to adults daily in their
mixture, retaining the single dose of opium or morphine to be taken for
the night. At that time a single larger dose is rather better than
several small ones. Narcotics cannot be dispensed with in all those
cases in which--as, for instance, in tubercular laryngitis--deglutition
is very painful because of the catarrhal and ulcerous pharyngitis.
Bromide of potassium has a fair effect, but frequently fails, and the
administration of morphia before each meal is sometimes an absolute
necessity.
That complications, such as bronchitis, have their own indications is
self-understood. The general rules controlling the treatment of
laryngitis are not interfered with by them. Oedema of the glottis,
however, when occurring during an attack of laryngitis, has its own
indications, and very urgent ones indeed in all acute cases. In chronic
cases a causal treatment is required according to the etiology of the
affection as specified above. In acute cases it is not permitted
because of want of time. The danger of immediate strangulation is often
averted only by a deep scarification or the performance of tracheotomy.
Chronic cases require all the preventive measures enumerated above and
{99} the internal use of iodide of potassium or sodium (scruple
j-scruple iiss = gramme 1.25-3.0 daily, for adults), and tincture of
pimpinella saxifraga three or four teaspoonfuls daily. When it is given
it ought to have an opportunity to develop its local effect on the
pharynx also by giving it but little diluted, and not washing it down
afterward (tinct. pimpinella saxif., glycerin. _aa_, teaspoonful every
two hours). In these cases, while the local salt-water treatment
recommended above is indispensable, the nitrate-of-silver spray
mentioned in that connection is here again referred to as very
beneficial indeed. But the solution of 1 per cent. is the highest
degree of concentration allowable. Conducted through the nose, it will
reach the larynx better than through the mouth. When both accesses are
rather difficult the application must be made directly to the larynx.
{100}
PSEUDO-MEMBRANOUS LARYNGITIS.
BY A. JACOBI, M.D.
PATHOLOGY.--Pseudo-membranous laryngitis is characterized by the
presence, on and in the mucous membrane, of a pseudo-membrane of a
whitish-gray color, various consistency, and different degrees of
attachment. It has been called croupous when it was lying on the mucous
membrane without changing much or at all the subjacent epithelium and
could be removed without any difficulty. It has been called
diphtheritic when it was imbedded into the mucous membrane and was
difficult to remove. This difference exists, but it does not justify a
difference of names except for the purpose of clinical discrimination;
for the histological elements of the two varieties are the same, and
the difference in their removability is explained by the anatomical
conditions of the territory in which they make their appearance. The
membrane consists of a net of fibrin studded with and covering
conglomerates of round cells, mixed with mucus-corpuscles, epithelial
cells more or less changed, and a few blood-cells. The fibrinous
deposit is either quite superficial or lies just over the basal
membrane or on layers of round cells originating from the basal
membrane. It is continued into the open ducts of the muciparous
follicles, filling them entirely in the worst cases, or meeting the
normal secretion of mucus in the interior of the duct. The principal
seat of the pseudo-membrane is that mucous membrane which is covered
with pavement epithelium; thus it is that the tonsils are the first,
usually, to exhibit symptoms of diphtheria. But cylindrical epithelium
is by no means excluded. However, while pavement epithelium is
generally destroyed by the diphtheritic process, the cylindrical
epithelium is frequently found unchanged, or but little changed, on top
of the mucous membrane under the pseudo-membrane.
The nature and consistency of the pseudo-membrane in the larynx is best
studied by the light of the study of its anatomy. There is a great deal
of elastic tissue in both epiglottis and larynx; the mucous membrane of
the latter is thin, and sometimes folded on the vocal cords. The
epithelium of the epiglottis is pavement; only at its insertion it is
cylindrical. In the larynx it is also pavement on the true vocal cords
and in the ary-epiglottic folds, and fimbriated toward the fossæ
Morgagni and trachea. Lymph-vessels are but scanty on the epiglottis,
still more so in the larynx. Of acinous muciparous glands there are
none on the epiglottis, none on the true vocal cords; they are more
frequent in and round the fossæ Morgagni, with cylindrical epithelium
in the glandular ducts. The trachea and bronchi contain a good many
elastic fibres, less connective tissue, fimbriated epithelium, some
lymph-vessels, but no lymph-glands, and acinous muciparous glands in
large numbers. Wherever the pavement epithelium membrane is abundant
the membrane is firmly adherent and imbedded into the mucous membrane.
Where it is cylindrical and plenty of acinous glands secrete their
mucus, they are loosely spread over the mucous membrane, from which
{101} they can be easily removed; while the histological condition of
both the imbedded and the loose membrane is exactly the same.
Before the membranous deposit takes place the surface is in a condition
of catarrh. Round the membrane the mucous membrane is red and slightly
swollen. Not always, however, is that so. Particularly, the epiglottis
may be covered on its inferior surface with a solid membrane or be
studded with tufts of membrane, without much or any hyperæmia. The same
can be said of the larynx, which is supplied with but a scanty
distribution of blood-vessels and a sufficient network of elastic
fibres to counteract the dilatation of blood-vessels peculiar to the
catarrhal and inflammatory processes.
In uncomplicated cases of membranous laryngitis the membrane is
confined to the larynx. Dozens of years ago--viz. before 1858, when
diphtheria began to settle amongst us, never, it appears, to give up
its conquest again--that took place in most cases. But since that
period we meet with few such simple cases. As a rule, the membrane
makes its appearance in the pharynx first, from there to descend into
the larynx, and not infrequently into the trachea and bronchi. In
other--fortunately, but few--cases the membrane is formed in the
bronchi and trachea first, and invades the larynx from below.
Other organs suffer but consecutively and from the results of impeded
circulation only. Thus, in post-mortem examination hyperæmia of the
brain, liver, and kidneys, and bronchitis, broncho-pneumonia, or
pulmonary oedema, are met with. Only those cases of membranous
laryngitis which are complicated with general diphtheria yield the
additional changes of the latter.
ETIOLOGY.--Intense irritants will produce an irritation on mucous
membranes. In the larynx the product is, according to the severity of
the irritation, either a catarrhal or a phlegmonous or a croupous
laryngitis. The irritating substances may be mechanical, chemical, or
thermical. Heubner produced diphtheria of the bladder by cutting off,
temporarily, the supply of circulation. Traumatic injury of the throat
and larynx will soon show a croupous deposit. Caustic potassium,
sulphuric acid, caustic ammonium, corrosive sublimate, arsenic,
chlorine, or oxygen, applied to the trachea or larynx, produce croupous
deposits.[1] Inhalations of heat, smoke, and chlorine have the same
effect. These, however, are not the usual causes of croup. Cold and
moist air is a more common cause, mainly during a prevailing epidemic
of diphtheria. In former times, which are unknown to the younger
generation of physicians, when no such epidemics existed, the only form
of diphtheria occurring now and then was the local laryngeal diphtheria
called pseudo-membranous croup. It was then a rare disease, while at
the present time it is of but too frequent occurrence. In my _Treatise_
I have explained at some length the relations of the two (p. 128).
[Footnote 1: A. Jacobi, _Treatise on Diphtheria_, p. 111.]
Age has some influence in its development. The disease is not frequent
in the first year of life; between the second and seventh years almost
all the cases are met with. There are families with what appears to be
a general tendency to croupous laryngitis. It may return. Even
tracheotomy has been performed twice on the same individual.[2] It is
contagious. In the same family, from a case of croup, either another
case of laryngeal croup may originate or another form of diphtheria
will develop in other members of the household. It is not so
contagious, it is true, as generalized diphtheria must be, for the
infecting surface is but small in uncomplicated membranous croup, and
the membrane not so apt to macerate and be communicated. Boys appear to
be affected more frequently than girls. But the previous constitution
makes no difference.
[Footnote 2: _Treatise_, p. 27.]