COMPLICATING MEASLES. 429 This variety of croup seldom begins until the eruption of measles is on the decline, or till the process of desquamation has commenced. Its occurrence is most frequent from the third to the sixth day from the appearance of the eruption, but it oftener occurs at a later than at an earlier period. It is sometimes attended with well-marked symptoms from the very first; but it often happens that the character of the disease is masked, and its course insidious, and that the degree of suffering during life affords no correct index to the amount of mischief which may be revealed by a dissection after death. Of itself it is highly dangerous, and its hazard is increased by the frequent coexistence with it of inflammation of the lungs, which serves moreover to throw the symptoms of croup into the shade. When the laryngeal affection comes on three or four days after the appearance of measles, its presence is usually betokened by much more obvious symptoms than when it occurs after the lapse of a longer period from the febrile attack. Sometimes, however, it developes itself unnoticed, simultaneously with the measles, and causes a fatal issue when the medical attendant is least prepared to expect it. The child in such cases is evidently more seriously ill than can be accounted for by the mere existence of measles; but he makes no definite complaint, neither are there any obvious indications of the special suffering of any particular organ. There are considerable drowsiness, disinclination to swallow, and reluctance to speak; but the cough may be very slight, and the respiration free from distinct croupy stridor, while the child speaks in so low a tone that it is almost impossible to appreciate any alteration of the voice. In such circumstances, the most careful observation is needed to avoid error. The loss of voice should of itself direct attention to the state of the larynx; the cry should be listened to attentively; pressure should be made on the larynx, to ascertain whether much tenderness exists, and examination of the fauces should never be neglected. But little less obscure, and of much more frequent occurrence, are those instances in which the laryngeal affection attends the process of desquamation. Recovery up to a certain point has probably gone on well, when sometimes with, sometimes without, an increase of the cough and morbillous catarrh, the febrile symptoms become exacerbated, and the child droops again, apparently without any adequate cause. Sometimes a loud sonorous cough, succeeded or accompanied by alteration of the respiratory sounds, betrays the nature of the disease; but at other times there are no 430 DIPHTHERIA COMPLICATING MEASLES. symptoms besides unusual drowsiness, reluctance to speak, or alteration in the tone of the voice, with disinclination to swallow, or difficulty in the act of deglutition. In many instances deglutition is scarcely at all impeded; and I remember only one case in which the difficulty of swallowing was so great that fluids returned by the nose. But even though these symptoms be but slight, it will usually be observed, on examining the mouth, that the gums have a spongy appearance, or are actually ulcerated, that the tongue is preternaturally red and raw, and that small aphthous ulcers have formed upon its edges and on the lining membrane of the mouth. The soft palate will usually be seen to be red and swollen, and specks of false membrane will be observed on the velum or tonsils. In such a case, if it terminate fatally, the duration of life is very variable; though the disease, for the most part, runs a somewhat chronic course. The child's strength declines daily, and emaciation makes rapid progress; yet no acute symptoms appear. There is great restlessness, and no posture seems easy to the child; or else it sits constantly upright in bed, distress and dyspnoea following any attempt to place it in the recumbent position. The alteration of the voice is succeeded by complete aphonia; the frequent hacking cough, which had previously caused much annoyance, ceases altogether; and, although evidently thirsty, the child often refuses drink, or swallows with difficulty. Diarrhoea, or pneumonia, usually supervenes, and hastens death; though in some instances exacerbation of the croupal symptoms, coupled with the increasing weakness of the child, are the only causes of the fatal termination. On examining after death the bodies of children who have died of this affection, not only is the mucous membrane of the mouth found inflamed and ulcerated, but the soft palate, fauces, epiglottis, and the upper part of the pharynx are seen to be more or less intensely congested, and coated more or less extensively with false membrane. The epiglottis is often ulcerated on both its surfaces, and partially coated with false membrane; and the mucous membrane of the larynx is generally eroded by numerous small ulcerations, as well as covered with a similar deposit. I have in no instance observed false membrane extending below the larynx ; and although the trachea is usually congested, sometimes intensely so, yet this is by no means of invariable occurrence. Bronchitis and pneumonia, especially the latter, are frequent complications of this affection. The peculiar sound that characterises the cough of croup, the stridor of the respiration, and the urgent dyspnoea which attend the progress of the disease, result, as I scarcely need remind you, almost entirely from the spasmodic action of the muscles of the larynx, and not from the mechanical obstacle which the presence of false membrane offers to the free admission or exit of air. We have seen that these symptoms are, on the whole, less marked in cases where croup appears as a secondary affection, and the larynx becomes involved by the extension to it of disease beginning in the throat, than in those where the air-passages themselves are primarily affected. Still they vary much, both in the period of their occurrence and the degree of their severity, even in those cases that most resemble each other; and they bear no certain relation to the intensity of the inflammation any more than to the amount of the deposit of false membrane. The diversities in this respect depend on constitutional peculiarity rather than on any essential differences in the nature of the disease. 6 This view, indeed, is not taken by all writers, but some observers of deservedly high repute-such, for instance, as M. Guersant*— have conceived that there are differences sufficient to warrant our placing in a separate category those cases of croup which are marked by the predominance of spasmodic symptoms. They have proposed to designate this form of the disease by the name of laryngitis stridula, to distinguish it from ordinary croup, the laryngitis pseudomembranacea. It was doubtless the observation of some cases of this kind that led Dr. Millar,† more than ninety years ago, to describe under the name of the acute asthma' a disease resembling croup in many respects, but presenting a mixture of spasmodic and inflammatory symptoms-the former predominating at the commencement of the disease, the latter towards its close. Dr. Millar appears, indeed, in some measure to have confounded two very different affections,-the true spasmodic croup, or laryngismus stridulus, with the inflammatory croup, or cynanche trachealis, under the idea that they constituted the two stages of one disease. But, nevertheless, cases are sometimes observed that bear a very close resemblance to Millar's description, though no advantage seems to me likely to arise from constituting a new species of croup out of a modification in its symptoms produced by the idiosyncrasy of the patient. &c. * In the article 'Croup,' in vol. ix. of the 2nd edition of the Dictionnaire de Médecine, Paris, 1835. Observations on the Asthma and on the Whooping-Cough,' 8vo. London, 1769. In some children there is a greater tendency to spasmodic affections than in others: in such the laryngeal nerves will take the alarm at the very outset of the disease, and the paroxysms of dyspnoea will consequently commence at an early stage, and will soon attain great intensity, but may become masked by the permanent distress of breathing to which the disease in its progress gives rise. In other instances, the symptoms of inflammatory disease, and those of spasmodic disturbance, may be so commingled, or may so alternate with each other, as to render it hard to tell from which the child suffers most. This was the case with a little boy, ten months old, who some years since came under my care, suffering from what seemed at first to be ordinary inflammatory croup. The symptoms, though not very urgent, were plainly marked, and the active employment of antimony soon dissipated them. During the whole course of the disease, however, the child, who seemed highly nervous and excitable, suffered from fits of dyspnoea far more severe than could have been anticipated from the general mildness of the attack, or than would have been supposed to exist by any one who had seen the child only in the intervals of the paroxysm. The cough and respiration had for forty-eight hours entirely lost all croupy character, and nothing but catarrh seemed left behind; when the child was suddenly seized with extreme difficulty of breathing, attended with slight croupy noise, and lay stiff in his nurse's arms with his thumbs drawn into the palms of his hands, and his great toe separated from the others. Four-andtwenty hours had elapsed from the supervention of these new symptoms before I was able to visit the child. He was then extremely restless; his face was flushed, his thumbs were drawn into the palms of his hands, and his feet were forcibly extended; his breathing was laboured, and attended with a hoarse croupy sound, which became still more distinct whenever the child coughed. The bowels had not acted for a couple of days; but an hour after my visit some purgative medicine, of which large doses had been given during the previous six or eight hours, began to act, and produced three very copious evacuations, with perfect relief to all his symptoms. The carpopedal contractions disappeared, the respiration became easy, and the face ceased to be flushed or anxious. The child slept well through the night, was cheerful on the following day, and slight hoarseness attending his occasional cough was the only remaining symptom. In a day or two that also disappeared, and the child perfectly recovered. The influence of that spasmodic element which enters so largely SPASMODIC AFFECTIONS OF THE LARYNX. 433 into the production of the symptoms of cynanche trachealis, is seen in many cases in the long persistence of a croupy sound with the cough, and in its subsequent recurrence when a patient who has once had croup catches cold. In these cases the nerves have doubtless not thoroughly recovered from the effects of the previous inflammation. Before closing this lecture, one or two additional illustrations may be adduced of spasmodic affection of the larynx in connection with disease seated elsewhere; though the remarks made at an early period of the course, on spasm of the glottis as a frequent attendant on the convulsive affections of infancy, must have made you thoroughly familiar with its occurrence.† * See Lecture xiii. p. 187. + There is a form of spasmodic affection of the larynx, which, under the name of Thymic Asthma, has attracted considerable attention among continental writers, though my own experience concerning it is confined to a single case which I observed many years ago. The spasm of the glottis which is the most prominent symptom in this affection is supposed to be due to the pressure of the hypertrophied thymus on the larynx, and the consequent irritation of its nerves. The essay of Haugsted-Thymi in homine, etc.: descriptio anatomica, pathologica et physiologica, 8vo. Hafniæ, 1832—may be consulted with advantage by any one desirous of becoming thoroughly acquainted with the subject. I owe to Professor Gairdner, of Glasgow, the obligation of his having directed my attention, in a note at p. 263 of his Lectures on Clinical Medicine, by which he has left all members of our profession largely his debtors; to the memoir by Dr. Hood, of Kilmarnock, on Spasm of the Glottis from enlarged Thymus, published in the Edinburgh Medical Journal for January 1827. He who proves, discovers,' is an old adage, but a true one; I am glad that it should find a fresh verification, as in Dr. Hood's case, among our northern countrymen. I will merely relate the case to which I have referred, and do so rather on account of its rarity than of any important practical inferences which I am prepared to deduce from it. The subject of the observation was a little boy, who was brought to me at the age of six months, suffering from symptoms which his mother said had existed, though in a less aggravated degree, almost from the time of his birth; but which had not much alarmed her until they were followed by an attack of general convulsions a day or two before I saw the child. These symptoms consisted in the occasional occurrence of great difficulty in breathing, attended with considerable livor of the surface, continuing for a very short time, and returning every two or three weeks without any assignable cause. From the sixth month the child seemed very liable to catch cold, and had frequent cough and wheezing; but a little rhonchus was all that was ever perceptible in the lungs; and febrile symptoms were at no time apparent. The attacks of difficult breathing often occurred at night, the child waking from sleep with them, or they were sometimes produced by deglutition, which process always seemed to be attended with slight difficulty whenever the child attempted, as it grew older, to swallow semi-solid substances. It was remarkable that no distinct crowing sound ever attended the inspiration; but that the child having turned extremely livid during the paroxysm of dyspnoea, gradually recovered its breath, and the livor and anxiety of the countenance disappeared by degrees. Profuse perspiration about the head generally followed these seizures; and sometimes the child would pass into a state of general convulsions, in which, however, it did not struggle much, but continued to FF |