DIAGNOSIS.—It is by no means easy in all cases. When laryngeal diphtheria (membranous croup) happens to be frequent, the most experienced diagnostician will meet with occasional difficulties. The sound of the barking, explosive, tickling cough locates its origin in the larynx, but the affection may be very mild or very severe. Expectoration in small children is not pathognomonic; even when it is copious it is not brought up, but swallowed. Fibrinous expectoration would settle the diagnosis of a croupous process. Depressing the tongue with a spoon or spatula and producing the movements of vomiturition often reveals the presence of a tough, viscid mucus rising from the larynx. It renders the catarrhal nature of the laryngitis positively clear. The frequency or volume of the pulse is of no account in diagnosis; it is too variable. Of more importance is the temperature, at least in children. Uncomplicated sporadic croup has no increase, or very little; catarrhal laryngitis is mostly attended with high fever. In very many cases this symptom has guided me safely, in spite of the statements of the books. The stenosis of catarrhal laryngitis comes on very suddenly, in diphtheritic laryngitis mostly slowly. In the former it is not of long duration; remission sets in soon, and is more complete than in membranous croup. An attack of stenosis occurs mostly in the night, and is apt to return with the same vehemence after a fair remission after twenty-four hours. The frequency of relapses in catarrhal laryngitis in children who have been affected before must, however, not prejudice in favor of the catarrhal nature of an individual case, for not infrequently will those who have had many attacks be taken with membranous croup some other time. In the latter the main symptoms—viz. stenosis, hoarseness (or aphonia), and cough—will mostly develop simultaneously and in equal proportion; the unproportionality of these symptoms—for instance, much stenosis and cough, but little hoarseness, or barking cough and hoarseness with little stenosis—would speak for catarrh. The laryngoscope, when it can be used—viz. in the adult and very docile children—reveals redness of the mucous membrane of the pharynx and all or part of the larynx; also tumefaction of the epiglottis or fossæ Morgagni or ary-epiglottic folds. Sometimes the inferior part of the larynx only is affected; Ziemssen has described a severe form under the name of hypoglottic laryngitis. The vocal cords can be watched easily. Their proportionate and parallel contraction is often interfered with.
Tubercular laryngitis, particularly when there is no pulmonary tuberculosis, is not easily diagnosticated by the local changes only. The long duration of hoarseness and fever, increasing emaciation, and the knowledge of the presence of tuberculosis in the family are more conclusive than local examinations can be.
PROGNOSIS.—The termination of catarrhal laryngitis in the adult is almost always favorable. Still, relapses are frequent, and it may become chronic, with permanent tickling of the mucous membrane and submucous tissue. In children it is mostly favorable; still, it is doubtful, because of the frequency of complication with, or transmutation into, bronchitis, pneumonia, or glottic oedema, and because of the facility with which in a prevailing epidemic the catarrhal laryngitis becomes diphtheritic. The elevation of temperature is not a very significant symptom in regard to prognosis. The danger does not increase with the temperature at all. On the contrary, those cases which set in with a high temperature will, as a rule, terminate soon and favorably. When, however, the temperature rises again after having gone down to the normal or nearly normal standard, complications or extension of the catarrhal or inflammatory process must be expected. Catarrhal secretion from the nasal mucous membrane, which was dry in the beginning, is a favorable symptom; so is the looser and moister character of the cough.
TREATMENT.—Whatever plays an important part in the etiology of the disease ought to be carefully avoided. The feet must be kept warm under all circumstances, nothing being more injurious to health in general, and to that of the respiratory organs in particular, than cold and moist feet. Shoes and stockings must be kept dry, the latter changed when wet, and of slowly-conducting material. No part of the body must be kept uncovered, and the dresses of children made the particular object of care on the part of the family physician. Linen must not be in immediate contact with the skin, cotton—or, still better in all seasons, wool—being required for the undergarment. At the same time, the hygiene of the skin requires attention. Regular washing or bathing need not be mentioned as a requisite, as it is self-understood. What, however, cannot be insisted upon too much is this, that the skin must get accustomed to cold water. The whole body must be exposed once a day to cold water—washing or bathing—and well rubbed off afterward with a thick towel. Young infants and those who are very susceptible to colds begin with tepid water, the temperature being lowered from day to day. Even children of three or four years enjoy, finally, a morning bath at sixty or sixty-five degrees F. in winter. Such as do not get easily warmed up under the succeeding friction may mix alcohol with the water they use for washing and sponging purposes, in the proportion of 1:5–8. Sea-bathing also makes the skin more enduring, to such an extent that exposure to cold air has no longer any damaging influence. In fact, cold air without wind is easily tolerated even by those who have a tendency to respiratory disorders, while wind and draught must be avoided. From this point of view the change of climate sometimes required for such as suffer from catarrhal laryngitis must be instituted. It is not always necessary to select a very warm climate; undoubtedly, many of the winter resorts are badly selected, for the very reason that they are too warm. On the other hand, great elevations are not advisable. The sudden atmospheric changes and fogs of high mountains are injurious.
Patients suffering from catarrhal laryngitis or a tendency in that direction must avoid all irritation of the pharynx and larynx. They must not smoke, or talk too much or too loud. Those few clergymen who suffer from clergymen's sore throat in consequence of speaking only will remember that they can speak just as forcibly when speaking less vehemently. The use of alcoholic beverages, unless greatly diluted, is prohibited. Catarrh of the nares and pharynx must get cured. The former will get well in most cases under the use of salt water. A tepid solution of 1 or ½ per cent. of table-salt in water, snuffed up copiously (a tumblerful) from the hand of an adult patient, or a similar solution in a small quantity injected through each nostril of a child, twice or three times a day for weeks and months in succession, will often remove a laryngeal as well as a pharyngeal catarrh. Care must be taken that the fluid passes the whole length of the nasal canal. It must be applied in the fauces, and will then be ejected through the mouth or a small portion of it swallowed. Many a severe nasal catarrh requires no other treatment. Some chronic ones require the use of a spray of nitrate of silver in a solution of ½–1 per cent. every other day, or of a 2 per cent. solution of alum daily. Where both the pharyngeal and nasal catarrh are complicated with, or kept up by, enlarged or ulcerated tonsils, these organs must be resected. The combination of these two measures, exsection of the tonsils and nasal injections, has proved very beneficial in a great many cases.
The treatment of an acute case requires great care. Avoid injurious influences. The patient must keep silent and quiet in bed. The temperature of the room is to be about 70° F., the air moistened by vapor, which must not be allowed to get cold before it reaches the patient.
When swelling and dyspnoea are considerable, particularly in those grave cases attended with swelling of the submucous tissue, the application of an ice-bladder or ice-cloths will be found beneficial and agreeable. But the cases in which these applications are indispensable are but few. In most of them the necessity of subduing intense inflammation is less urgent than the advisability of increasing the secretion of the congested larynx. For that purpose warm poultices, but of light weight, act very favorably. Inhalation of warm vapors either constantly or at short intervals, or of muriate of ammonium or spirits of turpentine, will prove beneficial. The latter is evaporated from the surface of boiling water, on which a small quantity, from a teaspoonful to a tablespoonful, may be poured every one or two hours. The hydrochlorate of ammonium is evaporated, 10 or 20 grains (1.0 gramme), every one or two hours by heating it on a hot stove or otherwise. The white cloud penetrates the air of the whole room, and, while not uncomfortable to the well, serves a good purpose in liquefying the viscid and tough secretion of the mucous membrane. The internal administration of liquefying and resolvent remedies may properly accompany the external applications and inhalations. Amongst them I count the alkalies, mainly bicarbonate and chlorate of potassium or sodium and the hydrochlorate of ammonium. A child of two years will take daily a scruple (gramme 1.0–1.5). The iodide of potassium will also have a good effect and counteract many a predisposition to chronicity. A child may take from 8 to 15 grains a day (gramme 0.5–1.0). Hydrochlorate of apomorphine, gr. 1/50–1/30 (0.001–0.002), dissolved in water, a dose to be given every two hours or every hour, is quite sufficient to act as a fair expectorant without being enough to produce emesis. Antimonii et potassii tartras has been used more extensively in former times than at present. An adult would take gr. 1/20–1/15 every two hours. Children ought to be spared the drug, as it is depressing, produces unnecessary vomiting now and then, even in small doses, and, what is still worse, diarrhoea. The other antimonial preparations, such as kermes mineral and the oxysulphuret of antimony, are less depressing and less purging, but also less effective; and there are but few cases where a good substitute could not be found. For the purpose of increasing secretion the hydrochlorate of pilocarpine has been recommended. It certainly has that effect, but its indications become doubtful in many cases where the saving of strength is of paramount importance. I shall return to this subject in my remarks on the therapeutics of membranous laryngitis.
Derivation is of great service when well directed. Local depletion must be avoided. A purgative in the beginning is beneficial—a dose of calomel as good as, or mostly better than, anything else. Diaphoretics and diuretics act quite well; the best of them all are warm beverages of any kind. They need not come from the apothecary's nor be very unpleasant to take—water not too cold, Apollinaris, Selters, or Vichy, hot milk, tepid lemonade in large quantities and very often. Sinapisms have a good effect. When not kept on longer than a few minutes—long enough to give the surface a pink hue—they may be applied every hour or two.
Some urgent symptoms may require symptomatic treatment. When secretion is copious, but too tough, and expectoration insufficient because of both the character of the mucus and the incompetency of the respiratory muscles, ipecac in small doses or camphor is indicated. A child's dose of the latter would be gr. ¼–½(gramme 0.015–0.03) every one or two hours. In these cases the hydrochlorate of ammonium may be combined with the carbonate (ammon. chlorid. drachm ss. (2.0); ammon. carbonat. scruple j (1.25); extr. glycyrrh. pur. scruple ij (2.5); aq. pur. fluidounce iij (grammes 100.0)—teaspoonful every hour). When the difficulty of expectoration is excessive an emetic may be resorted to. It is true that infants and children vomit with less straining and difficulty than adults, but, still, the practice of flinging emetics around is too common. The unpleasantness of getting up in the night because of a pseudo-croup in a distant patient's baby is not a correct indication for encouraging the indiscriminate use of emetics. When they are required, antimonials ought to be excluded from the list. Ipecac, sulphate of zinc, sulphate of copper, turpeth mineral are preferable.
In urgent cases the hydrochlorate of apomorphia may be used hypodermically (six or ten drops of a 1 per cent. solution in water). Cases of such urgency, and so excessive dyspnoea coupled with cyanosis, as to necessitate tracheotomy are but very rare. But once in thirty years and in many more than four hundred tracheotomies have I been compelled to operate for a case of catarrhal laryngitis. Still, a few such cases are on record. The best-known amongst them is that of Scoutetten, who operated successfully on his own daughter six weeks old.