symptoms of catarrh, sometimes without them. Nasal, pharyngeal, and
laryngeal catarrh may precede it a few hours or a week, with or without
fever and with {102} a certain sensation of pain or uneasiness in the
throat and a moderate amount of cough and hoarseness. This condition
has been called the prodromal stage of membranous laryngitis, though it
is just as natural to presume that the changes in the mucous membrane
merely facilitated the deposit of false membrane. The latter is more
apt to develop on a morbid than on a healthy mucous membrane. The
membranous laryngitis proper dates from the time at which, with or
without an elevation of temperature, a paroxysmal cough makes its
appearance--first in long, afterward in shorter intervals--which is
increased by a reclining posture, mental emotions, or deglutition. At
an early period this cough, which is very labored and gives rise to
dilatation of the veins about the neck and head, is complicated with
hoarseness, which gradually increases into more or less complete
aphonia. Respiration becomes audible, sibilant, with the character of
increasing stenosis. Inspiration becomes long and drawn; expiration is
loud; head thrown back; the scaleni, sterno-cleido-mastoid, and serrati
muscles are over-exerted; above and below the clavicles and about the
ensiform process deep recessions take place in the direction of the
lungs, which are expanded with air, but incompletely; dyspnoea becomes
the prominent symptom, and occasional attacks of suffocation render the
situation very dangerous and exciting indeed. These sudden attacks of
suffocation are due--besides the permanent narrowing of the larynx by
the membranes, which gradually increase in thickness--to occasional
deposits of mucus upon the abnormal surface of the larynx and vocal
cords, by partly-loosened false membrane, which now and then become
audible, yielding a flapping sound, by oedema in the neighborhood, and
by secondary spasmodic contractions. They are mostly met with in the
evening and night; there is often a slight remission in the morning,
which rouses new hopes, which soon, however, prove unfounded.
Meanwhile, the pulse becomes more frequent in proportion with the
increase of dyspnoea, and finally irregular; the temperature rises but
little, and usually only when the throat or other organs, which are in
more intimate connection with the lymph circulation than the larynx,
are participating in the exudative process; and the laryngeal sounds
become so loud as to render the auscultation of the lungs impossible.
The glands of the neck are not swollen when the process is confined to
the larynx. Now and then small or larger, rarely cylindrical, pieces of
false membranes are expectorated, with or without any amelioration of
the condition. In this condition the patient may remain a few hours or
a few days.
Then the dyspnoea will rise into orthopnoea; the anxious expression and
bearing of the little patient--for the vast majority of the sufferers
are children--becomes appalling to behold; cyanosis increases; the head
is thrown back; the larynx makes violent excursions upward and
downward; the abdominal muscles work in rivalry with those of the
thorax and neck; the surface is bathed in perspiration; still,
consciousness is retained by the unhappy little creature tossing about
and fighting for breath, and in complete consciousness he is strangled
to death. Now and then the carbonic-acid poisoning renders the pitiful
sight a little less appalling to the powerless looker-on by giving rise
to convulsions or anæsthesia and sopor, which finally terminate the
most fearful sight, the like of which the most hardened man, the most
experienced medical attendant, prays never to behold again.
Besides the brain symptoms just mentioned, but few other organs give
rise to abnormal function. In the kidneys the stagnant circulation
results in albuminuria--in the bronchi and lungs, in hyperæmia,
inflammation, and oedema.
The symptoms described above are the same both in those cases which are
strictly localized and those which descend from the pharynx. In the
latter there is fever only when the pharyngeal diphtheria was attended
with it. The process descending into the trachea and bronchi changes
the symptoms {103} but little, as far as the laryngeal stenosis is
concerned, for it is the latter which destroys by suffocation. Only
when tracheotomy has been performed, and the immediate danger of
suffocation has been removed, the further progress in a downward
direction gives rise to a new series of symptoms. After the temporary
relief procured by the operation dyspnoea will set in anew, not always,
however, of that intense degree of the laryngeal stenosis; respiration
will become dry and loud again, and a little more frequent than in the
uncomplicated laryngeal cases. Death will finally also result, either
from suffocation or from the symptoms I enumerated above.
Lastly, when membranous laryngitis is but the terminating development
of extensive membranous bronchitis, the symptoms differ from those
described above in this, that the laryngeal symptoms last but a short
time. For days or weeks no symptoms but those of an ordinary bronchial
and tracheal catarrh were observed: all at once the process reaches the
larynx; in a few hours the very last stage of croupous stenosis is
reached; even tracheotomy does not relieve the symptoms. Or the
fibrinous bronchitis was extensive enough to give rise to a sufficient
number of symptoms before the larynx was reached. Amongst them is,
foremost, frequency of respiration, because of its insufficiency;
diminution of respiratory murmur over the area supplied with the
affected bronchi; sometimes localized absence of respiratory murmur,
while the percussion sound is sonorous. Another complication is
emphysema, either subpleural or pulmonary. It is not frequent, except
in combination with fibrinous bronchitis. The increase of respiratory
movements is quite sudden, percussion sound tympanitic, and
auscultation negative. Pulmonary oedema is quite frequent; it is the
result of the rarefaction of air in the bronchi, the consecutive
dilatation of the blood-vessels, and the effusion of serum by
intravascular pressure. Every severe case is accompanied with it; in
every tracheotomy it is met with coming up into the incision. Oedema of
the glottis is less common, but it is met with in the same manner and
with the same symptoms which characterize the glottic oedema of
catarrhal laryngitis.
PROGNOSIS.--It is not favorable even in the simple and uncomplicated
cases. Infants and children under two years almost invariably die. The
percentage of average mortality rates very high--from 80 to 90 and
more. It is probable that some recent therapeutical advances have
reduced it, will reduce it, considerably. Tracheotomy is known to do so
certainly, as from 20 to 45 out of 100 operations prove successful. The
previous condition of the patient is of very little account in regard
to the course and termination of the disease; no constitution protects
or saves. The more the disease is local the better the prognosis. When
fever makes its appearance, it means a complication, such as extending
diphtheria or bronchitis or bronchi-pneumonia, and impairs the chances
of recovery. The expectoration of membranous shreds or whole membranes
does not improve the prognosis much, as the new formation of membranes
may be very rapid indeed. I have seen new membranes rising to a
formidable extent in from two to seven hours. The prognosis is improved
when the cough becomes looser, expectoration more purulent, pulmonary
respiration become audible again after having been covered by the
laryngeal noises, rhonchi become moist, and portions of lungs which
before were inaccessible to air by clogging membranes are reopened.
Increasing debility, frequent and irregular pulse, are ominous
symptoms. Even more so is the failure on the part of emetics to take
effect.
DIAGNOSIS.--It may be quite difficult to diagnosticate croupous from
catarrhal laryngitis, particularly in those cases where the former is
not complicated with any visible exudative process in the fauces. In
membranous laryngitis stenosis begins gently (except in those cases
which ascend from the bronchi) and increases gradually; there are, it
is true, remissions in the {104} morning (mostly), but they are but
slight, and the subsequent evenings are worse than the previous ones.
It increases from day to day until a slight cyanotic hue of the lips is
followed with more general cyanosis. There is no fever or very little,
except in the cases of generalized diphtheria. The character of the
cough does not change; perhaps it becomes more dry and suppressed after
a while. Hoarseness does not improve, but increases steadily into
aphonia. Expectoration is but scanty; now and then a small portion of
mucus from the lower portion of the respiratory tract, now and then
shreds of membrane, are expelled.
In catarrhal laryngitis stenosis begins abruptly and suddenly, and is
often at its height a few minutes after the commencement of the attack.
Remission sets in soon, is more marked, sometimes complete, and a new
attack, just as sudden as the first, may occur in the next night. Real
cyanosis is but rarely developed; when it is, it changes soon into a
more normal condition. Catarrhal laryngitis in the child is a febrile
disease. In it the cough changes after a little time, some moisture
mixes with the expectoration and changes both cough and articulation;
also, the voice is not equally husky; now and then a clear note comes
in. Close inspection of the throat exhibits sometimes a thick, viscid
mucus floating up and down with the excursions of the larynx in
catarrh. It never has any membranous expectoration.
Local oedematous swelling of the ary-epiglottic folds, with or without
membranous deposits in some other parts of the larynx, yields all the
symptoms of membranous croup with its dangers and death-rate. The
effect of this oedema is partial paralysis of the vocal cords. Thus,
inspiration is impeded, as in membranous obstruction; expiration,
however, is free and the voice intact to a certain extent. This local
oedema may be detected by palpation.
General oedema of the larynx (glottis) is fortunately rare. The attack
is very sudden; there is no cold, no hoarseness, no choking cough, no
membrane; there is only dyspnoea, gasping, asphyxia, sopor, and death,
unless relief is given almost instantaneously.
The presence of a foreign body has been mistaken sometimes for
membranous laryngitis. The history is a different one; there was no
prodromal catarrh; the children were taken suddenly while playing or
eating.
The laryngoscope would be a great aid in diagnosis if it could be used
during the distress of a membranous laryngitis. Still, it has been
employed by Ziemssen, Rauchfuss, and others. But the opportunities are
rare.
TREATMENT.--The objects of treatment differ with the various stages of
the disease. The inflammatory symptoms of the commencement, the
completed exudation, the maceration and disintegration, and also the
expectoration of the pseudo-membranes, and, finally, the asphyctic
stage, have each their own indications. If there is anything which must
not be recommended, it is depletion. Fortunately, there are but few
practitioners left who still apply leeches or employ more general
depletion, but these few are still doing too much harm by their
practice and teaching. The application of ice, however, in bags over
and near the larynx, and of iced cloths frequently changed, combined
with the swallowing of small pieces of ice from time to time, is apt to
be beneficial in well-nourished, hearty children. Such as have been
anæmic, with thin muscles and pale mucous membranes, do not bear it so
well.
The most powerful and reliable preventive and solvent, thus far, is
hydrargyrum. It is true that many voices have been raised against it,
but from Bard, Bretonneau, and Billard to Rauchfuss, Ch. West, Lynn,
Pepper, and others, the remedy has had its admirers. Large single doses
of calomel have been given by some, amounting to 15-30 grains (gramme
1.0-2.0), but that treatment has not found many friends. In small and
frequent doses it has been of good service to me both in fibrinous
laryngitis and bronchitis, {105} particularly in the latter; gr. ¼-½
may be given every half hour or every hour. Tartar emetic is liable to
develop so many unfavorable effects that even doses--in combination
with calomel--of 1/100 of a grain require great caution. The most
reliable mercurial preparation, in my experience, and the least
hurtful, is the corrosive chloride. In the stomach it combines with the
chloride of sodium, is absorbed without being changed, and transmuted
into an albuminate during its circulation in the blood. Babies of
tender age bear one-half of a grain and more, daily, many days in
succession. Salivation and stomatitis are exceedingly rare after its
use. Gastro-intestinal disturbances are not at all frequent; diarrhoea,
if observed at all, is very moderate, and can be avoided or removed by
the administration of mucilaginous and farinaceous food or a mild dose
of an opiate. But the administration of the bichloride requires care in
regard to its solution. A fiftieth of a grain may be safely given to a
baby a year old every hour, but it must be dissolved in one-half of a
tablespoonful or a whole tablespoonful of water. The solution of a
grain in a pint of water is about correct. In those very rare cases in
which no preparation of mercury is borne internally the inunction of
sufficient and frequent doses of the oleate of mercury may take the
place of the internal administration or alternate or be combined with
it. The blue ointment is not so effective as the oleate. The
subcutaneous injection of the corrosive chloride may be added to the
modes of administration if no time must be lost in introducing as much
as possible of the drug into the system. Now and then, however, the
subcutaneous tissue of the child does not tolerate it well in that
form, though the solution may be not larger than 2 per cent.[3] The
cyanide of mercury, in doses of a hundredth of a grain every hour, has
been warmly praised by A. Erichsen and C. G. Rothe.
[Footnote 3: _The Medical Record_, May 24, 1884.]
The large mortality in croup and the inefficiency of remedial treatment
have been the reasons why the recommendations of remedies have been
very numerous. Alkalies were held in great favor during different
periods of our literature, mainly the carbonate and bicarbonate of
potassium (and sodium), in daily doses, to a child, of ½ drachm or 1
drachm or more; also the chlorate of potassium or sodium. As an
adjuvant it may be useful; as an antidiphtheritic or antimembranous
remedy it must not be regarded. What it can do is to heal or prevent a
catarrhal stomatitis and pharyngitis. The best and most reliable is
probably the iodide, in larger doses than are usually given. One or two
drachms daily (grammes 4.0-8.0) are well tolerated when sufficiently
diluted. Benzoate of sodium was recently recommended for its supposed
antifermentative and antibacteric effect; its practical utility is but
very limited; not even its antifebrile effect is anything but reliable.
Lime-water has not fulfilled in my hands the promises made by
others--neither its internal use nor spray nor inhalation. The most
certain mode of introducing lime particles into the larynx is, after
all, the inhalation of slaked lime, which allows a quantity sufficient
to be somewhat effective to enter the respiratory organs. Its
comparative inefficiency has been acknowledged by those who add 1 per
cent. of the liquor of caustic potassium or sodium to the lime-water.
Quinia, in doses of 15 or 30 grains (grammes 1.0-2.0) daily, has been
recommended by Monti for the same indications, mainly in the
commencement of febrile cases. It has been claimed that cold
applications, to be changed every hour or two according to the
Priessnitz or hydropathic plan, had a great power in macerating and
disintegrating mucous membrane. Many of the successful cases of these,
as of all other specialists, are undoubtedly the result of the
convenient substitution of a grave diagnosis for a milder one. The
effect of such applications in laryngeal catarrh, like that of warm
applications, is undoubted. Vesicatories applied to the neck over the
larynx are never {106} useful--frequently injurious by the sore surface
becoming the seat of a pseudo-membrane.
Inhalations of warm vapor are decidedly beneficial, but atomized water
is not of equal value. Thus, Richardson's atomizer is not so useful as
Siegle's inhaler or other apparatuses working on the same plan.
Lactic acid, in solutions of 1:10 or 25 (Monti's solution of 1:200 is
certainly too weak), has been applied by means of a sponge, inhaled, or
thrown in from an atomizer for the same purpose. Good results have been
reported, failures also; and still, recoveries are rushed into print
much more readily than failures. The same may be said of the local
applications of glycerin, boric acid, carbolic acid in solutions of 1
or 2 per cent., salicylic acid, iodoform, and hypermanganate of
potassium; also of bromine (bromine and potas. bromid. _aa_) 1:water
500, or a stronger solution.
Tannin, dry or with glycerin, is rather more injurious than it can be
useful. It is apt to coagulate the mucus contained in the pharynx and
the upper part of the larynx, and to render the dyspnoea graver than
before. Such an aggravation of symptoms must be carefully avoided,
though it be but temporary. The same must be said of alum, which has
been used solid, in finely-powdered condition, down to a 3 per cent.
solution in water.
Spirits of turpentine are inhaled either from an inhaling apparatus or
by saturating the air of the room. Water is kept boiling constantly on
a stove, oven, or alcohol lamp (not on gas, which consumes a larger
quantity of oxygen), and a tablespoonful of the spirits of turpentine
is poured hourly or in shorter intervals upon the boiling surface.
Hydrochlorate of ammonia can be used in the same manner as described in
the article on Catarrhal Laryngitis.
Hydrochlorate of pilocarpine was introduced into the treatment of
diphtheria and pseudo-membranous croup some years ago, and recommended
as no less than a specific. It increases, physiologically, the
secretion of the skin, the mucous membranes, the lachrymal and
muciparous glands, the kidneys. It also depresses the heart's action.
In all cases in which the latter effect is to be feared the drug is
contraindicated; thus in septic diphtheria, in pseudo-membranous croup
with great asthenia, in general debility and anæmia. By increasing the
secretion of the mucous membranes it is expected to macerate the
pseudo-membrane and raise it from its bed. This can be accomplished
wherever the membrane is deposited upon the mucous membrane--that is,
whenever the number of muciparous follicles is large and the epithelium
is cylindrical. This is not so on the vocal cords, and thus the
floating effect of pilocarpine cannot be obtained exactly where it is
most needed--that is, on the vocal cords, where the pseudo-membrane is
more intimately imbedded into the tissue than, for instance, on the
posterior wall of the fauces or the trachea and bronchi. Still,
pilocarpine may be tried, in combination with other modes of treatment,
as long as the heart's action is competent and the general condition
satisfactory. It is dissolved in water; its dose, for a child a year
old, 1/30 grain (2 milligrammes = 0.002) every hour. A subcutaneous
injection every four or six hours of 1/60 grain (three drops of a 2 per
cent. solution) will prove very effective for good and evil. I believe
it has rendered me good service in some well-marked but mild cases of
pseudo-membranous laryngitis, which it either aided in healing or
prevented from getting worse.
Emetics have their distinct indication. It is irrational to expect any
relief from them when the larynx is narrowed by firmly-adhering
pseudo-membranes. Their indication depends on the possibility of
removing something which acts as a foreign body. This something can be
either mucus or loose or partially loose membrane. The peculiar
flapping sound produced by the latter admits of or requires the
administration of an emetic. Above I have stated which {107} of them
ought to be selected. Turpeth mineral in a dose of from 3 to 5 grains,
repeated in six or eight minutes, acts quite well. Hypodermic
injections of apomorphine may be required in urgent cases.
The introduction of catheters into the larynx, according to the methods
of Horace Green, is a dangerous proceeding and ought not to be indulged
in. It gave the idea to Loiseau and Bouchut to force a tube into and
through the larynx, full of pseudo-membrane, for permanent use until
the pseudo-membrane would have disappeared. This tubage was rendered
ridiculous at once by the assertion of Bouchut (1858) that children
suffering from croup who were supplied with this laryngeal tube were
not only relieved at once, but expressed their gratitude in audible
oratory. Still, there are some cases on record of more recent date in
which tubage is reported to have been attended with success. It is not
very probable, however, that a larynx which admits of no air, because
of its being clogged with firm pseudo-membrane, should be willing to
admit and endure the presence of a tube.
Massage of the larynx has been recommended by Bela Weiss. It consists
in systematical gentle pressing and kneading of the larynx by the
physician while sitting behind the patient. He asserts its satisfactory
influence not only in catarrhal but also in diphtheritic (croupous)
laryngitis.
The inhalation of oxygen has proved rather advantageous in my hands in
a few instances. The most memorable case of the kind I have mentioned
elsewhere. It was that of a child on whom tracheotomy had been
performed. The pseudo-membranous process, however, invaded the bronchi,
with the result of producing dyspnoea, cyanosis, and convulsions.
Whenever a current of oxygen was introduced into the lungs through the
canula both cyanosis and convulsions would cease, and returned when its
supply was stopped.
But if no medication will have proved successful, the symptoms of
stenosis, dyspnoea, cyanosis, and the supra- and intraclavicular and
epigastric recension increase steadily to an alarming extent. When the
pulse becomes frequent and intermitting, even without the presence of
asphyxia and anæsthesia, air ought to be introduced into the lungs by
tracheotomy. No positive rules can be laid down as to the length of
time one ought to wait before performing it. No subdivision of the
disease into several stages is of any benefit in selecting the exact
period in which the trachea must or may be opened. No alleged
contraindication to the performance of tracheotomy, whether the tender
age of the patient or a complication with either an inflammatory or an
infectious disease, must be considered valid. The one strict indication
for the performance of tracheotomy is when the diagnosis of
pseudo-membranous laryngitis is undoubted, the increasing dyspnoea,
cyanosis, and approaching asphyxia, with the certainty that a
well-directed and sufficient medicinal treatment has been, and in all
probability will be, useless. Even under these circumstances there is
no mathematical certainty. The matured experience of a well-informed
and thoughtful physician will commit but few errors. If there be the
slightest doubt, the operation ought to be preferred to suffocation.
The operative procedure and the surgical treatment after the
performance of tracheotomy will form the subject of a special article
in this work. In this place a few remarks upon the medicinal and
dietetic treatment in that period of the disease must suffice.[4]
[Footnote 4: Cf. _The Med. Rec._, May 24, 1884.]
The nutrition of the patient has generally suffered much. Before the
operation but little food was taken, still less was digested, and the
operation itself and the anæsthetic have added to the previous weakness
or exhaustion. Moderate feeding and stimulation are therefore to be
commenced soon. Vomiting after chloroform I have seldom seen to last
long or to be embarrassing under these circumstances. Feeding and
stimulation are the more necessary {108} the more the hungry
lymph-vessels are liable to absorb injurious material when not supplied
with healthy food.