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poison. The following was a case in which croup was apparently idiopathic, produced by that common cause of inflammations of mucous surfaces; to wit, exposure to sudden atmospheric changes:
CASE.-At midnight, on October 22, 1884, I was summoned to a child, aged twenty-five months, who had been in the street until nearly nightfall, when the weather suddenly became much cooler and he was brought home. At 11.45 P. M., he awoke with a harsh voice and croupy cough, which alarmed the family. I found the axillary temperature normal, but the fauces were injected, and the diagnosis was made of spasmodic or catarrhal croup. Emesis was produced by sirup of ipecacuanha, and the croup-kettle and a mixture of potassium chlorate and ammonium chloride were ordered.
On the following day, he walked about the room and seemed better; but the inhalation of the vapor of lime from the croupkettle was continued. At 7 P. m., the symptoms became aggravated, the cough was frequent and hoarse, temperature (axillary) 1003°, pulse 120, and respiration noisy. At the time of my visit, the post-clavicular, supra-sternal, infra-mammary, and epigastric regions were depressed with each inspiration, although only in a moderate degree ; the face was flushed, and the fauces injected, but without pseudo-membrane. The aspect was now more serious on account of the increasing dyspnea. The pulse was strong, and no pseudo-membrane was visible. The temperature in the groin was scarcely 100° Fabr. Emesis had been produced before my arrival, and, in the matter vomited, there was a pseudo-membrane with ragged edges, about one half an inch in length. Examined under the microscope within an hour, it was found to consist of fibrillæ, evidently fibrous, some of them wavy, and inclosing many puscells. Ten grains of calomel were placed on the tongue, and inhalation of the following was almost constantly employed by means of the steam atomizer :
R Liq. potassæ, 3 ij;
Aq. calcis, 3 xij.
Misce. On the following day the respiration was easier, and within twenty hours the patient bad so far convalesced as to be out of
danger. There had been no case of diphtheria in the house, or recently, as far as I could learn, in the immediate neighborhood.
That this was a local disease, non-specific and quite distinct from the croup of diphtheria, can not, I think, be doubted.
In considering the ætiology of croup, and recognizing diphtheria as by far its most common cause wherever the latter disease prevails, an interesting theory is suggested, to which Heubner alludes, who affirms that inflammations, even with the characteristic membranous exudation, may be set up without the micrococci and that then inoculation by micrococci may occur and “induce the general disease” (“Die experimentelle Diphtherie,” Leipzig, 1883, quoted in Ziegler's “ Pathological Anatomy," New York, 1884, part ii, p. 249). The point alluded to is that inflammations arising from causes other than diphtheria now and then become intensified and are rendered more protracted and dangerous by the reception of the diphtheritic virus after the inflammations have become established. In support of this opinion, it is well known by all who have had much experience with diphtheria, that those surfaces are likely to be attacked by the specific inflammation which are already irritated or inflamed when diphtheria is contracted. Hence the occurrence of the pseudo-membrane on recent wounds, upon the eyelids in cases of catarrhal conjunctivitis, upon the uterine surface after parturition, and upon the laryngeal, tracheal, and bronchial surfaces, if they be already inflamed, as in measles.
Scarlatina is so often complicated with diphtheria, that there seems to be a close affinity between the two diseases. It is a very common observation in New York city, that scarlet fever continues two or three days in its usual form, when the symptoms become suddenly aggravated and the aspect of the disease more severe. On inspecting the fauces, a pseudo-membrane is discovered covering this region, and it generally appears also upon the nasal surface. Although severe scarlatinous inflammation may cause a fibrinous exudation, yet that diphtheria has supervened upon scarlet fever, in a considerable proportion of cases which have the above history, can not, I think, be doubted. In a few instances in my practice (four), the fact that scarlet fever was complicated with true diphtheria and that the scarlatinous inflammations, first in order, were intensified by the presence and influence of the diphtheritic poison, was shown by the occurrence of diphtheria without scarlet fever in other members of the family.
In accordance with the above law, we may assume that a child who has laryngo-tracheitis, which is so common from taking cold and is manifested by cough and hoarseness, is more likely to have diphtheritic croup than one whose air-passages are in their normal state when diphtheria begins. A supposed error of diagnosis is often made by physicians, always to their discredit, who diagnosticate catarrhal laryngitis, but who find, after two or three days, that their patients really have diphtheritic croup. A considerable number of such instances have come to my notice, always with the ill-will of families toward their physicians. Now, it seems to me that, in many of these cases, the physicians have been right in their first diagnosis, and that diphtheritic croup had supervened on the catarrhal inflammation.
Another point relating to the ætiology of diphtheritic croup requires notice. Many physicians who have had ample opportunities to observe diphtheria believe that the common way in which diphtheritic croup begins is as follows: The faucial or nasal surface is first affected, becoming covered by the pellicular exudation; and, during inspiration, detached particles of the pseudomembrane containing the specific principle lodge in the larynx. At the point of inoculation, the specific inflammation arises and extends. This may be the manner in which the croup of diphtheria begins in certain cases; but this explanation certainly does not apply to a considerable number of patients. Thus, both the faucial and nasal pseudo-membranes may be treated, every second or third hour from the time of their formation, with the best disinfectants which we possess, so as to destroy all the micrococci, and yet croup not infrequently occurs during the progress of such a case. Again, in certain cases cronp begins at the outset of the diphtheritic attack. The laryngitis
occurs as early as the pharyngitis and therefore does not result from it. Sometimes the inflammation of the air-passages is the predominant lesion from the first, the pharyngitis being subordinate or even trivial. Thus a boy of two years and ten months, whom I attended, died of croup lasting about four days. He lived in the suburbs of the city, where the houses were scattered, and where there had been no recent diphtheria. The attack began with hoarseness, which gradually increased and was followed by a fatal obstruction in the air-passages. Close and repeated inspection of the fauces revealed only redness and some swelling of the parts, and the symptoms indicated only a slight coryza. The diphtheritic nature of the disease was rendered certain by the occurrence of diphtheria, in its usual form, in the two nurses, immediately after the death of the child. In this case, croup occurred at the beginning of the sickness, and it is evident from the history and the lesions that the contagium was not transferred to the larynx from any of the other surfaces. In view of the number of such cases, I see no propriety in assigning to diphtheritic croup a mode of origin different from that of other diphtheritic inflammations; but the possibility, and perhaps probability, in some instances, of an auto-infection, I do not deny.
Anatomical Characters. - It is important to acquaint ourselves with the anatomical characters of croup, especially the nature of the pseudo-membrane, so that we may know what measures to employ in order to remove it and to prevent, so far as possible, the laryngeal stenosis from which so many perish. The surfaces of the larynx, the trachea, and, in severe cases, the bronchial tubes, is hyperemic and swollen, and the inflammatory action more or less involves the submucous connective tissue, causing infiltration or ædema. The relation of the exudation to the mucous surface varies according to the kind of epithelium present. Where the epithelium is of the flat or squamous variety, the fibrinous exudation from the blood-vessels is poured out around the epithelial cells, which perish. If the inflammation extend more deeply, the underlying connective tissue is also embraced in the coagulation and perishes. Professor Ziegler, of
Tübingen, who has made repeated microscopic examinations of the pseudo-membrane, says: “It sometimes happens that the dead epithelial cells become saturated with the exuded liquid and then pass into a peculiar condition of rigidity akin to coagulation. The seat of this change appears to the naked eye as a dull, raised, grayish patch surrounded by red and swollen mucous membrane. The exudation is rich in albumen, and the transformed cells take on the appearance of a kind of coarse mesh-work, almost or altogether devoid of nuclei.” This is superficial diphtheria; and Professor Ziegler next describes deep, or parenchymatous diphtheritis as follows: “It is characterized by the coagulation, not merely of the epithelium, but also of the underlying connective tissue. The affected patch is swollen and assumes a whitish or grayish tint, the discoloration extending through the epithelium to the connective-tissue structures. The epithelium in some cases is lost altogether, and then the diphtheritic patch consists of dead connective tissue only. . . . The dead tissue is separated from the living by a zone of cellular inflammation. Fibrinous filaments are seen here and there through the mass. The lymphatics in the neighborhood contain coagula and leucocytes."
Squamous epithelium covers the nostrils, the buccal cavity, the fauces, and the larynx upon and above the superior vocal cords, with the exception of its anterior aspect. The pseudomembrane, therefore, upon all these surfaces lined with this form of epithelium, consists of the exudate from the blood, which surrounds and permeates the epithelium alone or the epithelium and the subjacent connective tissue. These two distinct elements, that poured out from the blood-vessels and the normal tissue of the mucous surface now dead, incorporated into one mass, therefore constitute the pseudo-membrane. Its intimate relation with the surrounding living tissue is such that we can not detach it without lacerating the latter and causing bleeding
The anterior aspect of the larynx, from the middle of the epiglottis downward, all that part of the larynx below the superior vocal cords, the entire trachea, and the bronchial tubes, are lined