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A CASE OF MEMBRANOUS CROUP.
Read before the Gibson County Medical Society,
BY W. H. CONNELL, M.D., EDMUNDS, TENN.
The previous history of O. N. up to the attack of the case shortly to be described is as follows: Age, 2 years; the first child of a strong, healthy young mother, its father also being a vigorous man. Notwithstanding the vigor of the parents, the child seemed never to be up to a good standard of health, having been troubled more or less for the last year with derangement of the bowels, and narrowly escaping death during the last week of August from an attack of enteritis, after which it gained strength and health rapidly up to the 4th of December, when it was taken with croup. The home remedies having all been exhausted with no effect, on the 5th I was called in, and the mother informed me that on the previous day the child was very fretful, ate but little, had smothering sensations, a dry, ugly cough, and spoke with difficulty. Upon examination I found the description very accurate, and the same symptoms existed at that time, but were greatly intensified.
Membranous croup being suspected, I examined closely but could discover no membrane. Knowing that the child had taken deep cold, and hoping that the disease might be arrested at that stage, I gave at once a dose of calomel to act upon the bowels, which were then very constipated, and three-grain doses of sulphate of quinine every four hours for the next twenty-four hours.
Upon the morning of the 6th I again visited my patient, and learned that the purgative had acted splendidly, but no appreciable effects from the quinine. The symptoms observed then were labored breathing, excessive perspiration, some fever, redness of the face, a wild, anxious look out of the eyes, and a hoarse, stridulous cough immediately followed an inspiration by a sharp, crowing noise. As on my previous call I still suspected membranous croup, and after another close examination I discovered no membrane. The treatment given at this visit was steam inhalation, which was accomplished by placing a spread over the cradle in which the child
was lying, and placing a kettle of boiling water under the tent thus formed. This gave partial relief, and the patient took a short sleep, but was soon awakened by a paroxysm of coughing and dyspnea, after which mucus collected in the throat and further obstructed breathing. I immediately administered ipecacuanha, which emptied the stomach and removed the mucous collection. The tonsils and neighboring parts showing considerable congestion and irritation, I prepared a solution containing carbolic acid and chlorate of potash for a throat wash and sedative to the irritated surface.
This treatment being instituted I left, directing that it should be continued until I returned. During my visit in the afternoon of the same day I saw no changes for the better, and on examining found that a whitish-yellow membrane covered the inner posterior portion of the tonsils and the epiglottis. I ordered the steam inhalation to be kept up at intervals, and for the nurse to continue keeping the room warm and well ventilated, and to give the patient all the sweet milk it would take. On the 7th I visited my patient twice, and remained some length of time each call, but could see no changes for the better. During the day paroxysms of coughing were more frequent, and the dyspnea more threatening. The tongue, lips, and finger nails and tips were livid ; deglutition was very difficult, and aphonia complete. The pulse was weak and extremely rapid, reaching 180 to 200, and the temperature was 1020.
Seeing that no course of treatment which I adopted had any effect further than to palliate for a time, I withdrew all except the steam inhalation, which seemed to make respiration easier, and the paroxysms of coughing and dyspnea less severe.
On the 8th, the fifth day from the attack, the vital forces had become almost exhausted; the patient fell into a stupor, the face became pale and livid, the pulse almost imperceptible, and death ensued without a struggle.
Such is briefly the case as I treated it. I know there are many remedies and modes of treatment, extolled by good authority, that might have been adopted, and very prominent among them is tracheotomy. This was not left unconsidered
in my course of treatment, but my honest judgment is that it would have been of no effect further than to have lengthened the period of suffering a few hours, as the membrane seemed to be extended a considerable distance down the trachea. I now submit the case to your consideration, and earnestly request that no reasonable criticism be withheld nor valuable modes of treatment kept back.
DISCUSSION. Dr. J. C. Moore reported that he had treated in all about fifteen cases, all fatal. That he had used many different remedies, but all to no purpose. Dr. A. W. Stephenson said that he had treated but few
That all of them had been fatal except one. Dr. J. D. Butler stated that he had lost two cases, all that he had treated.
Dr. Robinson of Eaton had treated three or four cases-all died.
Dr. Happel stated that he had seen but few cases. That as a rule all had been fatal, but that recently he had treated a case in consultation with Dr. Faucett of Trenton in which the diagnosis of membranous croup was sustained by every symptom except the membranes themselves. At the time he was called that it was impossible, on account of the resulting dyspnea produced, to make a careful and thorough examination of the child's throat; the child's age about 4 years ; rebelling at any attempted investigation. The treatment in this case up to the time of his visit had been bichloride of mercury in small doses, about 4 gr., repeated every two to four hours, quinine, ammonia, alcohol, and nutrition, together with spraying and an occasional emetic. The treatment was continued, except the spraying, which was changed from the solution used to pure peroxide of hydrogen, and belladonna (f. e.) was used when needed. The room was kept constantly saturated with the vapor of lime-water, and impregnated with listerine. Almost from the first spraying with the peroxide of hydrogen the symptoms began to ameliorate, and in the course of ten days the child was discharged well. Dr. Happel suggested that theoretically peroxide of hydrogen ought to be the very best local application in any such cases, though when commenced very late in the disease it could not be expected to do any good.
A CASE IN PRACTICE. Editor Medical Monthly :
If you will allow space in your valuable journal, I will give 'you a case that occurred in practice: April 16, 1887, I received a note from Dr. T., which read as follows : “ Please come as soon as you can and bring such instruments as you deem necessary; Mrs. Mc.'s womb has come out to the world.” I armed myself with chloroform, antiseptics, and such instruments as I could command. On arriving, I found the following condition of affairs :
Brunette, 45 years of age, nervous temperament, lying on her back with a bloody tumor about the size of a large cocoanut lying on the perineum. On closer examination I found it to be attached to uterus by a pedicle one inch in diameter. The pedicle was so short and so completely filled the vaginal outlet that I could not get my finger into the vagina sufficiently to ascertain its exact attachment to uterus, but decided at once that it was not an inverted uterus, and so informed Dr. T. After some persuasion we induced the patient to have it cut off. We ligated the pedicle as close to the vaginal outlet as possible, and cut it one-half inch from point of ligation. The ligated end receded at once and we syringed vaginal cavity with warm solution carbolic acid. She made a rapid recovery, and has enjoyed good health ever since.
The previous history of the case is as follows: For four or five years she had been troubled with falling of the womb (as she expressed it), with irregular hemorrhage, and on that morning while making up bed the tumor was expelled, while emerging from rather a stooping posture. It was a fibroid, and I think it must have lain in vaginal cavity for some time, as the distal end from pedicle had almost the appearance of ordinary cuticle, and she said she had frequently pushed her womb (the tumor) back with her fingers when it would come low down. Comments are in order. Moody, Mo.
JOE. A. SIGLER, M.D.
MEMPHIS MEDICAL SOCIETY. Dr. Crofford reported three very recent abdominal sections, and exhibited the specimens. The first was the tubes and ovaries of a virgin thirty-five years old, who had been a great sufferer for fifteen years.' She was examined one year ago by the Doctor, and pronounced incurable except by the operation. She had fought this one year longer, but was forced by her constantly increasing invalidism to yield. The case illustrates that diseased tubes and ovaries do occur in the virgin.
Case 2. The specimens in the second case taken from a married woman who had borne two children show beautifully, after hardening in alcohol, the line of demarkation between the adherent and the non-adherent portions. This case also was examined one year ago by the Doctor and pronounced incurable except by Tait's operation, so enlarged and adherent were the tubes and ovaries. She had persistently grown worse, until an attack of peritonitis in January last came near ending her life, and determined her to have the operation performed as soon as practicable, notwithstanding wider adhesions rendered the operation more difficult and hazardous. This casé had been treated by electricity with no permanent benefit, by the electrician who promises to relieve most if not all of such cases. This case uneventfully recovering from the operation illustrates the delusion of the electricity where an operation is indicated, and the danger of the delay.
Case 3 is an ovarian tumor weighing ten or fifteen pounds, of interest in being of six years growth, and so closely simulating a fibroid as to make a diagnosis impossible. It was quite tense, and filled with a fluid looking like pus, although the microscopists find no pus cells in it. The case is interesting also on account of the almost universal adhesion ; those of the anterior abdominal wall were quite strong. The omentum was spread out like a fan upon its surface, and the small intestines were so strongly attached as to require an enterorrhaphy after their separation from the tumor; but the point of greatest interest in the case is the unorthodox method of