iSrit.] NATURE AND TREATMENT OF CROUP. 61! d Article VI.- On Croup: Its Nature, and Treatment. By John \y Mom, L.Il.C.P. Edin., etc.; District Medical Officer, West Ham Union, London. (Continued from page 517.)

The general absence of ulceration distinguishes both croup and diphtheria from cynanche maligna, or putrid or ulcerative sore- throat, the angina maligna of Fothergill and the old authors. But they may be found in conjunction with it, or with one another, in- creasing the danger to be apprehended from one alone. Dr Ewing Whittle of Liverpool divides croup-like affections into seven :? 1 st, Cynanche trachealis of Cullen, true croup, with the forma- tion of false membrane, the croup we are here considering, and sup- posed by some, as we have seen, to be always diphtheria; but as We have shown this is not really so, but an allied and distinct disease. 2d} Angina stridula of Bretonneau, pseudo-croup of Guersant, the acute asthma of Miller, characterized by remissions not usual in croup, inflammatory to a very great extent, but without forma- tion of false membrane. 3clj Croup complicated with diphtheria, diphtheritic croup. 4tli, Sympathetic croup occurring in exanthemata, disappearing when the eruption comes out. This was once observed by the Writer in a case of measles in Edinburgh in 18G4. 5th, Croup caused by an ulcerated condition of the larynx, either following the ulcerated sore-throat of scarlatina or variola, or syphilitic (as in a case of tlie late Dr Gregory of Edinburgh). G^/i, Mechanical croup, from a puckered condition of the glottis from oedema, etc. (Murchison on Continued Fevers, p. 504), from scalding from hot fluids, etc. Mason Good. 7th} Nervous croup, laryngismus stridulus of Here, and in most of the other forms not diphtheritic, chloral hydrate is a specific remedy, as croton-chloral hydrate is said to be lr* whooping-cough. The true nature of croup has now been pointed out, namely, that \t is an inflammatory affection of the trachea and larynx, with the formation of a false membrane, distinct from other diseases appar- ently but not really identical, especially so from diphtheria, although the are diagnosis is often by no means easy, and the two affections frequently combined,?distinct also from acute laryngitis, asthma, cynanche maligna, and others above mentioned,?more or less liable to be mistaken for for Dr E. L. in it, particularly laryngitis; uFox, St George's Hospital Reports above quoted, remarks, that a ^he in the torni of croup exists non-membranous, often terminating in his pouring out of pus, and often fatal." Sir Thomas Watson, eai'ly lectures, limited it to " that portion of the air-passages which 614 MR JOIIN MOIR ON THE lies between the laryngeal cartilages and the primary bronchi, in other words, to the windpipe. In a few cases no adventitious mem- brane has formed, the inner surface of the trachea is merely tumid and reddened, and covered with viscid mucus or perhaps a shred or two of concrete albumen here and there; but this must certainly be of rare occurrence in cases of true croup." But in the latest edition (1872) he asserts that, in common with nearly all British he has erred in true croup as non-diphther- physicians," considering " itic. Croup," now says Sir T. Watson, is laryngeal diphtheria, distinguished by the presence of false membranes from inflamma- tory or false croup, called also simple or catarrhal laryngitis, or stridulous laryngitis." Sir Thomas Watson now holds with Sir John Hose Cormack (Edin. Med. Journal, Sept. 187G) and others, that in this country the term croup has been applied to three dis- tinct forms of disease?1st, Spasmodic croup, the seventh of Dr Whittle's series above mentioned; 2d, Inflammatory croup or infantile laryngitis, a catarrhal affection of the larynx, not con- tagious, and not resulting in the exudation of false membrane within the larynx ; 3d, Diphtheritic croup, true croup, or mem- branous laryngitis, tlic, exudation of false membrane being always the result of the specific, general, and contagious disorder diphtheria. True croup, then, accompanied by false membranes in the larynx, is- always diphtheritic, whether in the child or the adult, and simple laryngitis or inflammatory croup is never associated with the exu- dation of false membrane. Our error, then, formerly consisted in combining the history, the symptoms, and the treatment of acute laryngitis with the morbid anatomy of diphtheria. These views, first enunciated by Bretonneau, Empis, Guersant, Trousseau, etc., in France, are now adopted by Sir T. Watson, Sir W. Jenner, Sn* J. R. Cormack, Dr Semple, Dr George Johnson, and other phy- sicians of the highest eminence, yet they do not meet with much favour in this country, and we cannot, in the face of such opinions as Begbie, Sir W. Gull, Sanders, Fox, Jabez Hogg, Spence, Green- how, Habershon, and a host of others, and confirmed by our own humble experience during the last twelve years, assent to the iden- " is tity of the two diseases. Daviot goes so far as to say Croup non-contagious, and diphtheria and croup are the same ; therefore diphtheria is non-contagious." Surely this is sufficient condemna- tion of the identity theory from one of its most ardent supporters. so We shall also see that the treatment is different, essentially ot that the chain of evidence is complete as to the non-identity croup and diphtheria. Having now shown the nature of croup, of the what it is and what it is not, we pass 011 to the next stage inquiry; II. The Causes of Croup. is a This part of our is involved in obscurity, and it subject great ox matter of difficulty, if not indeed, as far as is at present known, 187!).] NATUKE AND TREATMENT OF CltOUr. 615 impossibility to determine why in this particular inflammatory ?affection an exudation should form differing from that usually found in ordinary inflammatory attacks even of the same parts. -Hie formation of false membrane is, as we have seen, the peculiar characteristic of this disease. It is found in other animals besides man, poultry in particular are very liable to it; and when we see that it is an exudation caused by a local inflammation apparently ?f a peculiar and unique character, the modus operandi of which lias been already described in accordance with the views of Rokitansky, Paget, Carpenter, Burden Sanderson, Wharton Jones, etc., we have now further to consider whether there are "?any predisposing or exciting causes favourable to its production. Here the ground is a little clearer, but by no means certain. J^amp, undoubtedly, is the greatest factor in the production of croup. Dampness, then, cold easterly and northerly winds, pos- sibly also bad drainage,?in fact, all the influences producing ?catarrhal affections must be included amongst the causes of croup. Dr Arthur Mitchell, one of the Commissioners in Lunacy for Scotland, in his valuable tables on Medical Meteorology, con- trasting the results with mean temperature through a long series of years, clearly demonstrates the inverse relation of temperature and mortality, and shows that the law holds apparently without exception for diseases of the respiratory organs. Dr W. Lindsay Richardson, for some years in chief charge of Ballarat hospital, along with other Australian practitioners, holds that dampness is the chief cause of croup in Australia. He found it very common there, particularly on badly-drained lands during the wet season. In Canada, and wherever the disease prevails, this is uniformly the case. Dr Alison found washerwomen's children very liable to Jt; sitting or sleeping in a newly-washed room may cause it. Exposure to the night air is another common cause of croup; the Want of skilful, conscientious, and attentive nursing, insufficient or unsuitable clothing, and the like, may cause an attack in delicate children, although, strangely enough, it often seems more liable to attack robust, ruddy children, and boys rather than girls. It is but yery apt to return on any slight exposure to cold, usually the it is not then so severe, the first attack being generally worst, although in the spring of 18G5 I had a case which succumbed to the second attack, after recovering well from the first. In winter and spring, when the weather is wet, cold, and windy, it is com- nioner than in other seasons, and it is most prevalent near the sea, where the air is full of moisture, and in northern more than ln of a temperate regions ; it is also common in inland districts damp marshy nature, and the estuaries of rivers, in rural more than in urban districts. Croup is peculiarly a disease of infancy from the age of two years to that of ten, one to seven other observers put it; but many cases have been narrated of the affection occurring even in new- '616 MR JOHN MOIR ON THE

born children, and in children at the breast. There are, not- more the withstanding, very few cases in the first year of life, in second, probably owing, ccctcris paribus, to changes in the diet after weaning. Diphtheria, on the contrary, is more generally a disease of adolescent and adult life, but there are exceptions, and even croup is not unknown after the age of puberty. Trous- seau performed tracheotomy in croup in a woman forty years of age; Dr J. Warburton Begbie in 1861, Sir T. Watson, Dr Robert Bruce of Edinburgh, etc., have met with cases of it in adult life. Washington is said to have died of croup. Similar cases are recorded by Jurine of Geneva and Albers of Bremen, who divided the great prize offered by Napoleon I. for the best memoir on croup, 011 account of the death of his young nephew, son of Queen Hortense and grandson of Josephine, from this affection. But these last may have been cases of laryngitis. Croup is essentially a sporadic affection, then, arising from damp ; diphtheria is a contagious disease not specially caused by damp, but, like scarlatina and typhoid fever, a specific fever of a zymotic nature, arising from special insanitary conditions, as Dr Wynter Blyth, medical officer of health for North Devon, has pointed out in the Brit. Med. Journal 1876, and as held by Dr Carpenter, Dr West Walker, Dr W. Roberts, Farr, Allen Thomson, etc. This is the direction in which we believe the only progress \ as to the production, nature, etc., of diphtheria can be made, and a rational system of treatment founded thereon be established. It in may be too much to say that croup never occurs as an epidemic this country, but I have never seen it in that form or heard of it, although I have seen it in not a few instances attacking children in the same family, either from the above exciting causes of damp- ness, etc., or from some idiosyncrasy predisposing certain children of of one family to take this affection more readily than children another family differently constituted, namely, hereditary tendency, of which I have already given an instance in the practice of Mr Jabez Iiogg. This tendency is never observed in diphtheria. On this point Mr Hogg adds, " I will only venture one other remark by way of answer to Professor M. Roger's incongruities, that while both diseases are highly contagious and inoculable, they are one and the same disease, neither peculiar to children nor adults, as they are equally sporadic, epidemic, and endemic. In so far as my experience enables me to speak authoritatively, and with, I hope, the authority of a large number of the pro- fession, I answer, that while one disease?diphtheria?is decidedly epidemic and endemic, attacking persons of all ages, but mostly after early childhood is passed, the other?croup?is essentially not or where there is a family pi'p" sporadic, communicable, only in and is seen after childhood is that is, disposition, rarely passed, brief children much above seven years of age. From this very the charac- inquiry into the causes, we now proceed to point out teristic symptoms of croup. 187!).] NATURE AND TREATMENT OF CKOUP. 617

III. The Symptoms of Ckoup. Of course all the symptoms hereafter mentioned do not occur at once or altogether in every case, or perhaps in any case of the malady, for many may be absent or occur differently in different oases, still, there is one or more always present sufficient to in- dicate the nature of the attack, so that without loss of time the proper means may be used to get rid of the false membrane and to alleviate such other symptoms as may be likely to require either the ordinary or special treatment. Croup usually comes on in the night, and is generally quite sud- den in its onset; or a day or two before the attack the child is languid and fretting, inclined to sleep, with the eyes full and heavy, and there is cough, which from the first is of a peculiarly shrill character, and in a day or two becomes more violent and troublesome as well as much shriller. The symptoms of true sporadic croup, however, differ materially in this point from spas- modic croup,?laryngismus stridulus (the affection for which it is most apt to be mistaken, or vice versa),?in that in this affection the Respiration itself is not difficult from the very beginning, whereas ln spasmodic croup this is invariably the case. In the spasmodic oi'oup fever and inflammation are not present, there is no hoarse- ness, it is intermittent, the breathing is quite free during the re- missions, there is no sonorous sound in the windpipe during sleep, the glands of the neck are often swollen,?in all these points, and also in the treatment, it differs most essentially from true croup, -^ot to mention others, Dr Marshall Hall, and Dr F. Pauli, Wurzburg, have given good descriptions of this laryngismus stridulus, or child-crowing. There is in croup more feverishness and hoarseness than in catarrh, and the patient is more severely agitated by every attack of cough; the face swells and flushes, and the eyeballs protrude; the frame trembles all over; and at the end of each coughing fit there is a sort of convulsive and noisy effort to renew respiratory Action. As the malady increases there is greater difficulty of breathing, accompanied with much pain, and usually or occasion- ally slight swelling and inflammation of the tonsils, uvula, and velum but the fauces are not usually swollen in this ;it palati; affection, least not to any extent such as is the case in laryngitis. Then we have a feverish expression ; the countenance is very much injected ; the head is thrown backwards in agony to escape the ?f danger suffocation. We have also not only an unusual brassy Gi- gging sound produced by the cough itself, but after either, the Cxpiration is of a and is with a ringing kind, inspiration performed hissing noise, as if the windpipe were filled up with some light, sponge-like substance, producing the characteristic crow like the Rowing of a cock, or, as some have said, like the sound of a piston torced a up dry pump. The cough is generally dry, harsh, and V?L. XXIV.?NO. VII. "1 1 G18 MR JOHN MOIR ON THE brassy; tlie voice either entirely lost or much altered, with great dyspnoea; no expectoration, or if anything is spat up, it is generally pus-like, or oftener filmy shreds, resembling pieces of a mem- brane. But where, from great nausea, there is frequent vomiting, coagulated membraniform matter is thrown up along with glairy mucus, and sometimes streaks of blood, though the latter is most unusual. Combined with these characteristic symptoms, as they may be called, we have great thirst, uneasiness, and a feeling of heat and increase of temperature all over the body, extreme rest- lessness and disinclination to remain in one position or place, with frequency and hardness of the pulse. Sometimes, but not so frequently as in spasmodic croup, the symptoms undergo slight remissions and exacerbations. There is usually no difficulty in swallowing, though deglutition undoubtedly^ may aggravate the symptoms, especially in an advanced stage of the disease. In the advanced and in the last stages of the disease, we have the pulse irregular or intermittent, the respiration becoming more stridulous, and being performed with still greater difficulty, with spasms of ineffectual coughing, constantly increasing obstruction to the breathing, tossing, anxiety, and extreme suffering, finally succeeded by or convulsions, followed by gradual insensibility" death after an inspiration. The breathing having been for some time seriously interfered with, and aeration of the blood imper- fectly performed, untoward results begin to manifest themselves in both lungs and brain congestion, followed by serous effusion. The threatening of asphyxia is aggravated by threatened super- vention of coma."?(Miller, late Professor of Surgery, Edinburgh University.) The paroxysms of croup and dyspnoea are doubtless caused, as Schlantinann asserted, by paralysis of the laryngeal the muscles, and not by spasm of these muscles. This is also opinion of Dr Alfred Yogel, Professor of Clinical Medicine (Uni- versity of Dorpat, .Russia), and others. The condition of a patient with croup is compared to that of an animal whose pneumogastrics u in are divided or paralyzed. This takes place by a reflex action, the of which the superior laryngeal is the incident, and performance s the inferior laryngeal is the motor nerve." (Dr John Reid 1812) Researches, p. 114.) Legallois (Sur le Principe dc la Vie, ?" says C'est done bien rdellement en paralysant les muscles arytdno'idiens et en relachant par la les de la glotte, que ligaments Ur la section des nerfs recurrens produit la suffocation." In it lS Marshall Hall's Lectures on the Nervous System, 1836, p. 76, stated that it depends on spasm of these muscles b) " produced of a irritation- of the recurrent nerves, and is obviously a part from more general spasmodic affection." It is apparent, however, experiment, that severe dyspnoea amounting to suffocation ma) arise from both causes. At death the bottoms of the feet have become black and hard, and the face is either pallid or bloatec according as the disease has terminated either in syncope or apnee^* 1879.] NATURE AND TREATMENT OF CROUP. 619

IV. The Terminations of Croup.

When croup terminates favourably it is by resolution of the inflammation from the tree expectoration of the false membrane, thus relieving the dyspnoea and spasms, and restoring the natural tone to the voice. With regard to the causes of death in croup, I here quote the very able description of Dr Richardson:?" In croup of the inflammatory type death may and does occur either Irom an obstruction in the heart (syncope), arising from the right cavities of that organ being the seat of a fibrinous deposit, or from an obstruction in the windpipe (apncea) arising from over-secre- tion ; or, lastly, from a combination of these causes, as happened in a case related to the Medical Society by Dr Hawksley, where the local mischief produced death, while yet the fibrinous concretion Was becoming developed, and before it had materially impeded the circulation. Holding, then, these views on the causes of death in croup ... I maintain . . . the symptoms about to terminate in syncope, the result of cardiac obstruction, are distinct from those arising from obstruction in the air passages. The differences are these:?In the cases of syncope from arrested circulation, the dyspnoea is not caused by obstruction in the larynx, but by the peculiar anxiety and gasping desire to breathe, incident to the "Want of blood in the pulmonic circuit. In this case, therefore, if the stethoscope be carried from the upper part of the windpipe downwards, and over the whole chest, the respiratory murmur is audible, and, it may be, clear throughout, so that the observer is prepared to say that there is here no such deficiency of respiration will account for the severity of the symptoms. Again, the ^ost common physical pulmonic sign in these cases is that of emphysema, which is often accompanied in very young children by a peculiar prominence in the anterior part of the chest; this er>lpJn/scma when present is strictly diagnostic of fibrinous obstruction, aild is altogether subversive of the idea that the cause of the symp- toms is an obstruction of the windpipe. In addition, there are in Jjhese cases the definite signs which mark the cardiac obstruction. ?ie is cold, and pale, almost marbly, but mostly so at body generally the extreme parts. The lips are slightly blue, the cheeks are the same. The veins are distended ; the pulse lfiOccasionally jugular irregular; the body is painfully restless. The heart beats are eeble, quick, and irregular; the sounds muflled, with a bruit in ^onie cases. No real convulsions of the limbs occur, but intense j^ixiety and constant movement. In those cases, on the other \and, where the death is really due to apncea?the effect of obstruc- |?n in the air-passages?the symptoms are widely different. In lese cases there is some point in the respiratory canal where an ? struction can be detected. The lungs show signs of congestion, out never of emphysema. The difficulty of respiration arises from absolute inability to fill the chest. From the fact of the obstruc- 620 MR JOHN MOIR ON TIIE [JAN.

tion being in the respiratory circuit, sucli blood as passes through it is not arterialized, and the surface of the body, instead of being pale, as in cases of cardiac obstruction, is generally of a dark hue, with the veins more decidedly turgid. The muscles are not simply restless, but actually convulsed violently, the patient being uncon- scious of the fact; the heart sounds are clear, and its motions, though feeble, are rarely tumultuous. Lastly, the breathing is the first to stop at death, while in the former case the heart takes the precedence in this respect. These broad and definite diagnostic signs can never be mistaken, except in instances where there is a clot in the heart coincidently with obstruction in the windpipe. Here some difficulty may arise, but a careful inquiry into all the facts will indicate the existence of the complication." In some few cases the disease has terminated fatally in from twenty-four to thirty hours after its commencement, but when it terminates fatally it is most usually on the fourth or fifth day, while a fatal issue in diphtheria is usually more protracted. Dr Craigie affirms that croup never goes beyond the eleventh day, and Dr Cheyne states that the younger the child is when weaned, the more liable is it, cccteris paribus, to the malady, and the greater the danger of an early fatal result. Where portions of false membrane are thrown up, even when new false membrane forms, it has occasionally happened that life in these cases has been protracted for a day or two longer than it would otherwise have been.

V. The Complications of Croup. The most serious complications of croup are undoubtedly exten- sion on the pharynx, or general diphtheria, and cardiac fibrinous obstruction. it With regard to the first, diphtheria, we have throughout held to be distinct from croup, and given our reasons for so doing, admitting that it is held in high quarters worthy of all respect not and to be so, and that the diagnosis is in some cases difficult, occasionally well-nigh, or perhaps quite, impossible, at least during Mi" life. In Guy's Hospital Reports 1877, Dr Hilton Fagge and Lamb arrive at the following cautious conclusions:?"We find- that the attempt to separate from diphtheria a membranous croup in which the fauces remain free from false mem- entirely be brane, is beset with difficulties. The cases (which must, then, called cases of diphtheria) in which the air-passages are attacked, the palate and tonsils being but slightly affected, occur almost exclusively in children, and they are seldom, if ever, infectious, whereas pharyngeal diphtheria is highly infectious. But when one has once admitted that the different forms of diphtheria pi'e~ them sent different degrees of infectiousness, and that each of one is occurs with special frequency at a particular period of life, debarred from insisting on the sporadic character of membranous 1879.] NATURE AND TREATMENT OF CROUP. 621. laryngitis, and tlie fact that it never arises in the wards of a general hospital, as proof that it is distinct. It is otherwise if we allow that the non-specific, simply inflammatory, affection may be attended with the formation of false membranes, even in the fauces. Such a view does away with the very improbable supposition that laryngeal diphtheria differs from the ordinary form of the disease in being peculiar to children, and in possessing little or 110 infec- tiousness, and, we think, commends itself to us on other grounds ?also." Nevertheless, I. believe with Sir William Gull, that the two diseases differ clinically; Avith Jabez Hogg also, that they differ anatomically, histologically, and pathologically; and thera- peutically with Warburton Begbie, etc., etc. With regard to the next most serious and frequent complication, cardiac fibrinous obstruction, Dr Bouchut, in a lecture at the Hopital des Enfants, on the frequency of myo- and endocarditis in these cases, says the endocarditis was valvular and parietal, of a proliferating character, and was followed by fibrinous deposits 011 the diseased walls, and of large ventricular clots. The fibrinous deposits adhering to the diseased valves may become loose, and be carried away by the blood into the aorta or pulmonary artery, and there give rise to embolisms. These embolisms form infarcti of the lungs, followed by metastatic abscesses and infarcti of the brain, which may produce cerebral softening. Bronchitis is also frequently observed concurrently with croup, and though generally unfavourable, is not always so, as it some- times facilitates the separation of the false membranes, or forms a kind of solution of them, enabling them to come away more readily. Whooping-cough, if present, also sometimes acts in the same way by promoting the excretion of the false membranes, by the repeated shocks of the coughing, and by the vomiting which so frequently accompanies it. Gastritis and enteritis are occasionally met with as complica- tions of the disease, and it has been found associated with menin- gitis. Phthisis is also said by Guersant to be amongst the number of complications of croup, sometimes to such an extent as even to mask the characteristic croupy cough. The exanthemata, as measles, smallpox, and scarlet fever, must also be reckoned amongst the possible complications of croup, or one or more of these may be combined, as in some cases where croup was complicated with both bronchitis and measles, adding, of course, considerably to the risk of the patient. Coryza may also be found at times as a disagreeable and not unfrequent accompani- ment. True sporadic membranous croup, as we have seen, although Usually confined, as in its simplest form, to the trachea and larynx, also varies in its intensity, duration, and the extent and seat of the surfaces it occupies ; it is sometimes, though very rarely, found '622 NATURE AND TREATMENT OF CROUP. [JAN.

extending to the pharynx, but more frequently, unfortunately too frequently, it is found extending downwards into tlie bronchi and their ramifications, then accompanied, or rather followed, by con- gestion of the lungs, etc. Bretonneau and Yelpeau found the false membrane penetrating the bronchi in one case out of every nine, but this was in the last stages of the disease, and in remarkably severe epidemics, so that this proportion is not quite exact, and other observers have met with a better, because smaller, proportion. Be the number, however, what it may, a fatal result is of course more likely to ensue when this, or indeed any other, complication is present than when we have only to deal with a simple case of croup confined to the trachea and larynx. Having endeavoured as briefly and clearly as possible to describe the nature and symptoms of true sporadic croup, it now only remains for me, as thoroughly as I can, to point out the treatment, prophylactic, medical, and surgical, which is required for success- fully overcoming the attacks of this at all times to be dreaded malady. (To be continued.) \ I