CROUP AND MEMBRANOUS CROUP.

BY SAMUEL A. VISANSKA, M.D., ATLANTA.

Three years ago, when this Association met in Savannah, I had the pleasure of reading a paper on membranous croup or diptheritic laryngitis, and you will perhaps ask yourself, why I have chosen the same subject. The answer is, that, in my opinion, the general practitioner does not give this particular subject sufficient thought, study or attention, and hence a number of errors of diagnosis are made, proper treatment is often given too late, and lives that could be saved are no doubt lost in this way. Children have suffered from these diseases from time immemorial, and until recently we were unable to make a differential diagnosis or treat cases successfully. The bacteriologist tells us that in treating membranous croup we are dealing with the Klebs-Loeffler bacillus of diphtheria, and that other organisms (the streptococci) are often found with the Klebs-Loeffler. The spasmodic form is usually due to taking cold, changes in the weather, kicking off the cover, etc. There seems to be a predis position in some children, especially those suffering with catarrh of the upper air-passages, scrofulous, weak, anemic children with proneness to coryza and to inflammatory affections of the tonsils, are more especially liable to attacks of pseudo-croup. In membranous croup my experience has been that the healthiest child in the house is usually stricken, they are usually stout and chubby, with short necks. Being called to a case, the first thing we

must do is to distinguish between false, or spasmodic croup, and true or membranous croup, and from the history of the case and symptoms present we are to decide. Spasmodic croup usually comes on at night and suddenly, the cough is dry and barking, there is hoarseness, the child is restless, wants to be taken up and held upon the arm, there is little or no fever, and with proper treatment in from twelve to twenty-four hours the patient is entirely well. In membranous or true croup of course the only positive proof would be the finding of the KlebsLoeffler bacilli, but in laryngeal diphtheria it is difficult to obtain the membrane unless coughed up. Constitutional symptoms are usually absent, partly on account of the protection afforded by the very numerous mucous glands and the supply of lymphatic vessels. These vessels connect with the bronchial glands. The main danger comes from the mechanical obstruction to respiration and the extension of the disease to the bronchi. In uncomplicated cases of membranous laryngitis excluding the ascending ones, there is little or no fever, and I desire to impress upon you the fact that the onset of the disease is gradual, and that it grows progressively worse; the membrane is seldom seen, because it is below the epiglottis and it is difficult to get a laryngeal picture; there is hoarseness, and after a short time complete aphonia, the stenosis is at first slight and present only on inspiration. As the disease progresses the inspiration becomes more hurried, with dilatation of the alæ nasi and recession of the chest. The skin and mucous membranes are of a blue or leaden hue, there is great restlessness, the eyes seem to have a bulging appearance and the face a most pitiful expression, almost begging for oxygen. If nothing is done to relieve the obstruction, in a short time the child dies from asphyxia. Such is the sad picture usually presented

to us at the bedside, and it is our duty to be able to relieve these little sufferers. When I am called to see a case of croup, which is usually at night, unless I find the symptoms warrant a more radical cure, I treat them all alike; that is, for false croup I order the following prescriptions; calomel gr. 1⁄2, soda bicarb gr. 1⁄2, salol gr. 4, every half-hour until four doses are taken. For the croupy cough and for its relaxing effect I give apomorphine hydrochlorate gr. 1, acid hydrochlor, dil. min. 30, syr. senega dr. 4, syr. pruni virg. oz. 11⁄2, aq. anisi q. s. oz. 4. A teaspoonful every two hours for a child three years of age is ordered, or another preparation which I am very fond of is, potassii carbonas grs. 4, vin ipecac dr. 3, spt. chloroform dr. 2, syr. pruni virg. oz. 1, aq. anisi q. s. oz. 3, one dram every two hours. A cloth wrung out in cold water is applied around the throat, with a dry cloth on top; this is repeated every hour. Another useful adjuvant is medicated steam; the child is placed under a tent, the medicated steam, which consists of carbolic acid, turpentine and eucalyptus oil, or menthol-camphor, is passed from a Holts croup kettle. One steaming usually suffices if you are dealing with false croup, but in membranous croup it has to be repeated according to circumstances. When you return in the morning and find your patient very little or no better, the cough of a deep barking or rasping tone, hoarseness progressing, anxious expression, then what is the next step? By all means use antitoxin and give a large dose. To a child two years of age with progressive croup I do not hesitate to give three to four thousand units, and the dose should be repeated every eight hours if necessary. If you are called to a case of croup of two or three days' standing, as we are in most cases, and it seems to be of a malignant type, use at least five thousand units the first dose. In all these

cases we should be governed more by the severity of the disease than by the age of the patient. I wish to repeat again, that unless you use antitoxin in these cases you are guilty of criminal negligence. In the meantime the child should receive concentrated, nourishing food, and if the pulse gives indication of a weak heart, strychnine and whiskey should be given; it is surprising the amount of whiskey these little patients can stand. If there is constipation give calomel and use enemata to cleanse the lower bowel. After employing this treatment (or if you are called after the disease has progressed for several days), suppose we find in the place of the membrane becoming detached, respiration easier, and hoarseness decreasing, the reverse state of affairs, with symptoms of aphonia, hurried respiration, cyanotic face, retraction of the ribs, etc., what step shall be taken next? We must choose between two operations-intubation and tracheotomy. My mind is so made up between the two that I seldom consider the latter, though bear it in mind in case circumstances call for it; that is, if intubation does not relieve the stenosis immediately, tracheotomy should be performed at once. Intubation or the procedure for the relief of dyspnea depending upon croup was first employed by Bouchut of Paris, in 1858, but it is due to the careful work of O'Dwyer of New York, that the operation has become recognized as a legitimate procedure in the treatment of the symptoms arising from laryngeal obstruction. Having performed intubation successfully a number of times I can recommend it to every physician, and with proper fitting tubes believe little injury can be done. With the proper amount of experience the operation is over in a few minutes, the child breathes easier, cyanosis disappears and in a short while the little patient, almost exhausted, falls asleep. The instruments I use are

the latest made by Ermold of New York. The tube can remain in the larynx for seven or ten days or longer without any discomfort to the patient, as the longer it remains the more accustomed the larynx is to the foreign body. After inserting the tube the question arises how to feed the child? If the food is given with the child sitting upright it will run into the larynx, causing the child to cough and possibly the expulsion of the tube. To overcome this difficulty the head of the child should be held over the nurse's arm and lower than the body, so that the food will not run into the larynx. Only concentrated food should be given, and even then it should be semi-solid. Ice cream is the ideal nourishment, but milk, soft custard and gelatine can be given in this way. Some times we will find a patient so sensitive that food can not be given in this manner; then we must resort to rectal feeding. Before the introduction of antitoxin, treatment by inhalation was almost universally adopted, and the fumes most destructive to the Klebs-Loeffler bacilli are those generated by the sublimation of calomel, and even to this day many physicians use it with good results. Usually forty to fifty grains is sufficient, and it should be burned every two or three hours, according to circumstances. This treatment was first suggested by Corbin of Brooklyn. In conclusion, will state that we should try as soon as possible to make a diagnosis between simple and membranous croup; that if antitoxin is used early in the latter disease. there will be very few intubations performed, and the death-rate will be reduced from 80 per cent. to less than 15 per cent.

DISCUSSION ON DR. VISANSKA'S PAPER.

Dr. E. C. Cartledge: I remember the first case I ever saw treated with antitoxine, and I was disappointed with it. Another case was very severe, and we did an intuba