On Croup: Its Nature, and Treatment

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 formation 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 formation 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 apparently 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 membrane 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 inflammatory 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 distinct 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 contagious, and not resulting in the exudation of false membrane within the larynx ; 3d, Diphtheritic croup, true croup, or membranous 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 exudation 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 physicians 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.

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