In all these features the stridulous catarrh differs from the naembranoue inflammation. In the latter the dyspncea begins gradually and attains its maximum by degrees ; the voice becomes entirely suppressed ; the cough is a hoarse muffled sound which is almost .pathognomonic ; the stridor is as marked in expiration as it is in inspiration ; and albuminuria is some met with. Lastly, in true membranous croup the diphtheritic exudation can often be discovered in the pharynx. Still, absence of exu dation is not to be depended upon as excluding diphtheria, for the mem brane may be limited to the air-passages, and fragments are not always coughed up. In a doubtful case, where the symptoms of spasmodic laryn gitis are exceptionally severe, the points to be relied upon for excluding diphtheritic croup are : The severe and sudden onset ; the comparative absence of stridor in the expiration ; and the quality of the voice, which is not completely muffled or suppressed. The age of the patient is also of some practical value in diagnosis. In a child under twelve months old, or over seven years, the case is very unlikely to be one of stridulous laryngitis.
Laryngitis striclulosa may be also confounded with laryngisnms stridu lus, with retro-pharyngeal abscess, and with oedema of the glottis. The distinctive characters of the first-named complaint are elsewhere described (see page 271). Retro-pharyngeal abscess is at once recognised by the in ability of the child to breathe when lying down, the increase to his distress occasioned by pressure on the larynx, and the presence of a swelling at the back of the throat. (Edema of the glottis is usually the consequence of a scald or burn, or follows an attack of acute specific disease ; the distress is more continuous, without marked remissions in the dyspncea, and the thickened epiglottis can be felt with the finger.
Prognosis.--As a rule, the child has a good prospect of recovery, even in serious cases, if the operation of tracheotomy be not performed. The most urgent dyspncea usually subsides under suitable treatment, and it is very, rare for the child to die. suffocated. When the disease ends fatally, the un favourable issue is usually the consequence of an inflammatory complica tion. Stridulous laryngitis sometimes accompanies the onset of a pneu monia, or from want of proper precautions the tracheal catarrh may be allowed to extend into the finer tubes. In such a case the prognosis is not favourable, for attacks of suffocation occurring in a child the subject of bronchitis or pneumonia are necessarily dangerous. Still, even in these cases the child may recover, for often the spasm becomes less marked when the inflammatory complication declares itself.
Treatment.—In the milder attacks of laryngitis stridulosa the child should be at once placed in a warm bath (95° Fah.) for fifteen or twenty minutes, and should be made to vomit by a dose of ipecacuanha wine. Afterwards a small dose of chloral (gr. iij.–iv. to child of eighteen months old) may be given, with a few drops of sal volatile, to prevent a relapse in the course of the night. In the morning it is well to prescribe a diaphoretic mixture
(such as vini ipecacuanhaa, ; liq. ammonim acetatis, ritxx. ; glycerini, TRx. ; aq. ad 3 j.), to be taken every three or four hours, and to give directions that the child be kept in one room of a suitable temperature. If the tongue is loaded, a grain of calomel should be given with two grains of jalapine.
In the very severe cases a warm bath is also useful. Afterwards the child should be placed in a tent-bedstead, in a warmed and moistened atmosphere, as recommended for membranous croup. An emetic in all these cases produces great relief. A teaspoonful of ipecacuanha wine, or a quarter of a grain of sulphate of copper, may be given every ten minutes until the desired eflect is produced. The vomited matters in all severe cases should be searched for shreds or patches of false membrane. As long as there is fever the child must be kept in bed, and while the voice remains hoarse it is wise to keep the air moistened by means of the steam kettle (see page 103). Tracheotomy is rarely if ever necessary in mere spasmodic laryngitis. The most violent attack of suffocation seldom fails to be relieved by a warm bath, an emetic, and steam inhalations. Graves' plan of applying a sponge wrung out of hot water to the neck, below the chin, is also of service. It must not be forgotten to attend to the bowels, and a mercurial purge is a great help to the other treatment.
If the spasms return repeatedly, which, however, is rarely the case if the above treatment have been adopted, an antispasmodic may be re quired. Chloral is perhaps the best, and may be given to a child of two years of age in doses of three grains three times a clay.
If any inflammatory complication arise, such as bronchitis, pneumonia, etc., special measures must be adopted as recommended for these diseases. If the case be uncomplicated, diaphoretics should be given when the spasm subsides, and the child should be treated for an ordinary pulmonary catarrh, taking care to withhold all stimulating expectorants as long as the cough continues barking and hard. Sometimes a few drops of paregoric added to the saline expectorant mixture seem to aid its effect in reducing the hard ness of the cough. All the time the diet must be regulated as directed for pulmonary catarrh.
In cases where the attacks of laryngitis tend repeatedly to recur, endeavours must be made to strengthen the child and diminish his sus ceptibility to changes of temperature. He should be dressed from head to foot in woollen underclothing ; should pass much of his time out of doors ; and should have a cold douche every morning, given with all the precau tions recommended in a previous chapter (see page 17). Moreover, as children with this tendency often have cold feet, care should be taken that the extremities are thoroughly warm when the child leaves the house. A little alcohol with the dinner is a useful medicine in these cases.