CROUP.
Definition and Varieties.—Confusion still exists in the classification and no menclature of diseases of the larynx in children. This is due largely to the fact that those diseases are not well defined, but merge into each other. In young i children two elements are to be detected I in laryngeal affections: catarrh and spasm. Two forms of croup have, there fore, been described: the catarrhal and the spasmodic. Such a classification seems, however, unnecessary and confus ing. Catarrh and spasm are present in all cases, one being predominant in one instance, the other in another. A slight degree of catarrhal inflammation is in variably present. The form of spas- i modic croup marked only by spasm with no evidence whatever of catarrh, as de scribed by some authors, is extremely rare, if it ever occurs. There is invari ably present a more or less decided ca tarrhal element; tracheitis and bronchitis are prone to follow. In most cases, at the outset, the laryngeal spasm overshad OWS the catarrhal element; later, the ca tarrhal becomes more prominent. The disease may be mild or very severe. Many authors, therefore, describe two forms— a mild and a severe type; but these forms differ in degree rather than in kind.
Catarrhal Croup.
rare instances the on set of catarrhal croup is sudden, with no premonitory symptoms. More commonly the child has a slight cough and coryza and becomes hoarse during the afternoon and perhaps feverish in the evening. Late in the evening the cough becomes loud, dry, and hoarse, its characteristics being peculiar and distinctive. In the great majority of cases this occurs be tween the hours of nine and twelve. The child wakes suddenly with the character istic cough and begins to struggle for breath. He frequently becomes alarmed at his inability to breathe, and his fright adds to the severity of the symptoms.
In attacks of ordinary severity the respiration is loud and noisy; the voice is hoarse, but rarely lost; the dyspncea is sometimes extreme and the respiration so noisy that it can be heard in an ad joining room. The loud metallic cough is very different from the stridulous, sup pressed cough of a well-developed case of pseudomembranous laryngitis. There
is frequently extreme recession of the various thoracic spaces. The tempera ture is usually somewhat elevated, but rarely reaches 102°. The lips and nails frequently assume a purplish hue, but are rarely cyanotic. There is often a dis charge from the nose, and the eyes are sometimes congested and watery; con ditions not usually present in pseudo membranous croup. After two or three hours the symptoms usually subside. Oc casionally they appear in less severe form later in the night, but, as a rule, all urgency is passed by early morning. In some instances the child is almost as well as usual during the following forenoon and shows but little evidence of the ex periences of the night. The attack, how ever, is usually repeated during the fol lowing night, and may recur for several nights, becoming less severe with each succeeding attack. In my experience, however, this freedom from symptoms on the following day is extremely rare. _More commonly the child continues to be feverish and has a troublesome cough, although it may not be croupy in char acter. In the damp climate of New York and vicinity an attack of croup, as a rule, is but the initial symptom of a bronchial or laryngeal catarrh, which requires sev eral days or a week or more to run its course. Attacks more mild in form, but similar in nature, are of frequent occur rence and must be considered as simply mild attacks of croup. In other in stances the attack appears to be really one of bronchitis, with a dry and croupy cough at night.
Differential Diagnosis. — In typical cases of catarrhal croup the diagnosis is evident at a glance. The sudden onset during the early hours of the night; the immediate development of extreme symptoms; the loud metallic cough; the noisy respiration; and the terror of the child, all combine to form a very char acteristic clinical picture. In less typ ical cases, however, the diagnosis is some times difficult.