-;yyy ■ •'----—c>"-----^*------« .....•■ ■—* -~—".. ■ CHrYNE *ON CROUP. PUBLISHED BY ANTHONY FINLEY, South East corner of Chesnut and Fourth Stree. Philadelphia. Printed title label from the front cover of another copy, withdrawn from the National Library of Medicine. AN ESSAY CYNANCHE TRACHEALIS, CROUP. BY JOHN CHEYNE, M. D. Fellow of the Royal College of Surgeons of Edinburgh. PHILADELPHIA: PUBLISHED BY ANTHONY FINLEY. Sold also by Bradford and Read, Boston; A. Miltenberger aad J. Cashing, Baltimore; R. Cottom, Petersburgh, and J. and J. Boyce, Richmond, (Va.); Seymour and Williams, Savannah; W. Graydon, Harrisburgh; and A. Montgomery, Frankfort/ (Kentucky). 1813. ^1 t v- PREFACE. When Dr. Harris published his Essay on the Acute Diseases of Children, Sydenham said.to him, " Without flatte- " ry> you are the first man I ever en- " vied ; and it is my firm belief that your " little book will be more useful to man- " kind than all I have written." The book did not in itself, perhaps, merit so high a commendation; but Sydenham foresaw that it would turn the attention of physicians to a part of their profession the most useful, and the most neglected. Still this department is strangely over- looked. Children are not admitted into A 4 public hospitals, and their diseases are ill understood, and superficially treated, or slurred over, by those who profess to teach medicine. The best physicians do not scruple to acknowledge, that they find nothing at first so difficult as the treatment of these diseases; and it is only by careful observation, and after years of practice, that this most inte- resting branch of professional knowledge is to be attained. These things had made a deep impression on my mind when I entered on the charge of an ex- tensive range of practice, in a place where some of the most formidable of the diseases of children are peculiarly fre- quent and dangerous. I devoted my chief attention, therefore, to this subject, and resolved to seek, with unremitting diligence, all occasions of observation 5 and of study in a department so intimate- ly connected with the duties which I had undertaken. I soon found my cases and observations multiply. I have been careful to compare them with the obser- vations and cases of others; and I have arranged them systematically, with the intention of submitting them to the pub- lic, not without hopes of being useful to my profession. My design is to discuss, in separate Essays, the most important of the Dis- eases of Children, beginning with those, as less intricate, to which children, after being weaned, are exposed, and proceed- ing afterwards to those which attack in- fants at the, breast. My hopes of being useful rest upon the fidelity of my obser- vations, and the minuteness and accura- 6 cy of detail, where I may have been en- abled by dissection to elucidate any im- portant points in the nature and history of the diseases of which I treat. In this Essay, which I now venture to publish, I have attempted the dis- cussion of one of the most interesting diseases, the most alarming in appear- ance, and in reality one of the most dan- gerous to which a child can be exposed. These motives might alone have been sufficient to lead me first to the discus- sion of the subject I have chosen ; but in my situation I found an additional motive, of great influence. To this dis- ease children are peculiarly exposed in the town where I practise; and the op- portunities which this frequency has af- forded me of observing it in all its stages, 7 and also of tracing, after death, the ap- pearances and nature of the disease, have given me a confidence in what I have to lay before the public, which I could not otherwise have attained. a2 ESSAY I. ON CYNANCHE TRACHEALIS. THIS ESSAY IS INSCRIBED AS A TESTIMONY OF RESPECT, TO JOHN ROLLO, M. D. SURGEON GENERAL TO THE ROYAL ARTILLERY, &C. &C B YHIS MOST OBEDIENT SER 7ANT, JOHN CHEYNE. ESSAY I. ON CYNANCHE TRACHEALIS. The disease which in this country is called Croup, may be defined an in- flammatory affection of the Trachea, which in the progress of the disease is accompanied with an effusion which be- comes a tubular membrane, lining the inflamed surface. It might seem strange that a disease so striking in the symptoms, and so spee- dy and fatal in the event, should not have been clearly described(0 earlier than the (1) The following passage (transcribed from Ballonius into the Sefiulchretum of Bonetus, Vol, I. p. 484.) may refer to this disease: " iEgri qua- *i tuor mihi noti, qui codem fere tempore interi*- 14 middle of the last century, were it not remembered, that formerly all the ailments of children were much neglected, and that even the most eminent physicians, when called to children, went with re- « ere pene morbo consimili: Omnibus medicis " negotium dedit: Imo ausim asserrere morbum (( non intellexisse : Difficultas erat spirandi sum- u ma, spiritus frequens et parvus ad mortem us- u que: In sicco velut spirare videbantur: Nee " tussis nee sputum, spiritum ne ad momentum " cohibere poterant: Erecto paulum corpore ita u parvum et frequens spirabant: Febris non erat " magna, nee quae istam respirationem require- "ret," &c. " Chirurgus affirmavit se secuisse cadaver pue- " ri ista difficili spiratione et morbo, ut dixi incog- M nito sublati: Inventa est pituita lenta contumax, " quae instar membranae cujusdam arteriae asperse " erat obtenta, ut non esset liber exitus et introi- " tus spiritui externo, sic suflbcatio repentina." « Balloniuay Efiid. et Efthemer. Lib. II. p. 197. « and 201. See also Hildanus, Cent. III. Obs. " 10. Exemp. I. 15 luctance, judging their diseases to form a labyrinth for which they had no clew(2). Yet the descriptions to be met with in every systematic writer of that danger- ous angina, in which no tumour is to be found in the fauces W, however vague (2) u Quapropter medici non pauci, nominis u amplissimi, palam sunt nobis aliquando professi, " se pueris aegrotis, ac praesertim recens natis vi- " sendis advocatos, invita quidem Minerva, tan- " quam ad mysterium nescio quod evolvendum, " aut insanabilem affectum sanandum, plumbeis " pedibus accedere solitos." Harris de Mortis " Acutis Infantum, p. 2. (3) " Etenim angina alia vera, alia notha est: M Verae et legitimae quatuor sunt differentiae. " Una quam omnium periculosissimam censuit " Hippocrates, ubi neque in faucibus, neque in " cervice quicquam apparet." Ftrnelii, Universa Medicina de Partium Morbis et Sym/itomat. Lib. V. cap. 9. " Inter anginae species gravissima est et celer. " rima, quae nee in cervice, nee in faucibus con- " spicuum, aliquid efficit."—" Porro mortifera at- " que omnium horrendissima angina citissime occi- B 16 they may be, afford sufficient evidence that the disease (*) was not altogether overlooked. " dit, quae neque in cervice, neque in faucibus quic- " quam conspicui vel tumoris vel ruboris exhibet, (l simulque summi doloris tormentum, et vehe- " mentem febrem, atque tantum non praesentem " suffocationem infert. Turn profecli oculi ver- " tuntur et rubent et veluti his qui strangulantur " prominent. Vox impedita nihil significat, et " qualis catulorum est," &c. Mcol. Piso de Cog- noscend. et Curand, Morbisy Lib. II. cap. 3, " Si inflammatio interiores laryngis musculos " occupet synanche appellatur. In synanche ma- ({ xima est respirationis laesio, ita ut aegri strangu- " lari videantur. Fauces vehementer dolent, nul- 14 Jus tamen rubor aut tumor, neque in faucibus " intus neque extra in cervice apparet. Haec " species anginae omnium periculosissima est." Lazari, Reverii Cfi. Univerm Prax. Med. Lib. VII. cap. 7. See also the 801. and 802. aphorism of Boer- haave, with Van Swieten's commentary. (4) Perhaps it may be added, that there is ground for supposing the disease more frequent 17 Martin Ghisi (5), an Italian physician, published the first regular history of Croups now than it was formerly. In an inaugui*al dis- sertation, defended at Edinburgh in 1780, by Dr. Ambrose Cookson, there is the following commu- nication from his friend Mr. Fell, of the county of Lancaster : " After diligent search, I have " found some remarks made on Croup at its first " appearance in this place in 1760. I say its first " appearance, because my father, who was an ac- " curate observer of diseases, and practised phy- " sic here for upwards of forty years, could not " recollect that the disease once occurred to him ; ' and none of my medical acquaintances had at " that time the least knowledge of it." " In that spring, six children labouring under " the disease, were committed to my care, to all of " whom it proved fatal. Catarrhal complaints " were then very frequent; indeed in most of " them the disease commenced with symptoms '• of catarrh," Sec. p. 8. (5) Martino Ghisi Lettere Mediche in Cremo- na, 1749. This performance I have not been able to procure; I therefore must rely on the accuracy of Michaelis. 18 but the best and fullest is that of Chris. Frider. Michaelis, De Angina Polyposa she Membranacea, published at Gottingen in 1778. The frequency of Croup in Leith and the neighbourhood, furnished Dr. Home of Edinburgh with materials for an essay on the subject in 1765. From possessing the same, or perhaps better opportunities, I have been enabled to compose the following history, which I trust is a faithful picture of this striking disease (6). (6) I do not allow that the dissertations of Wilcke, De Angina Infantum, (Sandifort, The- saurus, Vol. II.) or those of Millar and of Rush, relate to this disease. The dissection by Dr. Martin in Wilcke's essay appears to have induced Michaelis to say, in p. 6., that it contains one or two examples of the disease ; but I think even that is far from being a- clear case of Croup. The acute asthma of Dr. Millar is evidently a differ- ent disease, and in the Nosology ought to occu- py a place in a different class. 19 The Croup (?) is less known in the temperate than in the northern regions of Europe. Peculiar to no season, it how- ever chiefly appears in the winter and spring, in low situations (8) exposed to air passing over large bodies of water; and it is most especially the disease of sea-port towns. It is very prevalent in cold changeable weather, often appearing after a cloudy and hazy day ; insomuch (7) Concerning the etymology of this word, Rosenstein says, " He has not been able to learn " any vulgar name for this disease, except that " the Scots call it Croup." I rather think roup is the word ; it is called Roup in this town ; and, like many of our words, it is I imagine, of French origin, roufiie. (8) This disease, we are informed by Dr. Craw- ford, prevailed in the Carse of Gowrie, a plain in Perthshire, bounded by the river Tay ; but he adds, " Haec planities veronuper desiccata fuit, et " rarius occurritur morbus." Disquidtio Med,. Tnauguralis de Cynanche Stridula, p. 13. B2 20 that I have seen a mother, in whose fami- ly the disorder had been a frequent in- truder, kept in constant anxiety by this condition of the atmosphere. The Croup chiefly prevails in chil- dren from a short time after birth (9) un- til puberty ; attaching itself to particular families; and generaly attacking the most robust and ruddy children. It does oc- cur, but more rarely, in children exhaus- ted by some other disease. The disease C1) generally comes on in (9) I have known this disease in a child three months old, but it does not frequently occur be- fore weaning. It has been observed (I believe by Dr. Home), very justly, that the younger chil- dren are when weaned, they are the more liable to the disease. (1) This description is in the main taken from a very perfect case which I attended the winter before last, and which exhibited the disease as it will often be seen in violent attacks. 21 the evening, after the little patient has been much exposed to the weather during the day, and often after a slight catarrh of some days standing. At first his voice is observed to be hoarse and puling; he shuns his play-fellows, and sits apart from them, dull, and, as it were, foreseeing his danger. His illness, indeed, does not prevent him from going to sleep, but soon he awakes with a most unusual cough, rough and stridulous. And now his breathing is laborious, each inspira- tion being accompanied by a harsh shrill noise, most distressing to the attendants: His face is swelled and flushed, and his eye bloodshot; and he seems in constant dan- ger of suffocation : His skin burns, and he has much thirst; he labours more and more in breathing; still the ringing noise is heard, and the unusual cough: He tries to relieve himself by sitting erect; no change of posture, no effort gives him relief. Generally his sufferings are thus protracted until morning, when per- 22 haps there is a slight remission; his breathing is a little easier, but the anx- iety, the fever, and the cough remain; he is soon as ill again as ever ; and these symptoms continuing, weakened by the violence of his illness, with purpled lips and leaden countenance, he dies in two or three daysW. In other cases, the disease, after continuing some time, ap- pears suddenly alleviated : The breathing is free, the child soon becomes cheerful, his appetite for food returns, he amuses himself, and seems perfectly recovered, and the hope of every one is raised, only to make the disappointment more keen; for the child suddenly gets worse, and (2) There are very distinct histories of the dis- ease ending fatally in 24 hours: Of this Mr. Alex- ander saw four instances. Generally, however, the child does not die before the third or fourth day. Sometimes the disease continues much longer, for several weeks. 23 dies, his livid and swoln face and con- vulsive struggles giving him the ap- pearance of one that is strangled. When Croup is favourable, it termi- nates in various ways. Most commonly, after the disease has arrived at its height, the sequel is as it were a retrogression of the attack; there is poured out a mois- ture on the skin, the fever declines, and the croupiness, and, lastly, the cough, gradually wear away. When bleeding is used upon the commencement of the violent symptoms, the relief is often immediate; and I have scarcely believed that I saw the same child breathing softly, who ten minutes before lay gasping and convulsed. Sometimes, after the disease has con- tinued a few days, a viscid and white substance is expectorated, and the child 24 is relieved (3): Sometimes the Croup is chronic, and does not subside for weeks, when the resolution is very gradual, the child now and then coughing up portions of this white membrane. When, in the urgency of the attack, the fauces and neck are examined^ with a view to investigate the cause of these symptoms, even when a sense of heat is complained of in the throat, the tonsils are not swelled, and but little inflamed. In some instances there is a fullness to be discerned in the swell of the neck ; but the disease is generally unaccompanied with this sign. It may be said of this complaint, in common with Cynanche Tonsillaris, that the first attack establishes a predisposi- (3) This does not always happen. See case 1.0, where the membrane was twice rejected, com- pletely formed, and yet the child died. 25 tion to the disease. I have observed, that after the first attack, a slighter cause will produce Croup a second time than is required originally; nay, I believe that external cold and wet, without any speci- fic state of the atmosphere, will bring on a recurrence of the disorder (4). It is a confirmation of this, that children who have had croup, when they are affected with catarrhal complaints, have more or less of the croupy cough until they arrive at their 14th or 15th year. Upon dissecting the body, the cause of these alarming symptoms becomes suf- ficiently obvious. When the child dies after an illness of three, four, or five (4) Subsequent attacks are supposed to be less violent than the first; but I should, from my own experience, be led to believe that there is some error in this. Perhaps the immediate steps taken in consequence of the alarm excited by £ knowledge of this dangerous complaint, may pre- vent it from forming. I have seen the third at- tack more violent than any former one. 26 days, there is found lining the windpipe a white membrane, of considerable te- nacity. It arises a little under the larynx, and is sometimes prolonged into the di- vision of the trachea; and generally a quantity of white fluid, like matter with which the lungs are filled, is seen gurg- ling up. The attachment of the mem- brane is slight, but the inner coat of the windpipe is inflamed. The inflamation, which is still perceptible, and which of course must have been more violent be- fore this fluid exuded, I hold to be the immediate cause of the bad symptoms in the first stage of the disease; as the ad- ventitious membrane and puriform flu- id C5), the consequence of that inflam- mation, is in the conclusion of it. (5) I have added a case, where the membrane, observed on dissection, was not such as to im- pede the respiration ; it was not more than a few detached crusts : But it would seem that the in- flammation, the effusion in the lungs, and the general affection, had produced the same fatal effect. 27 The pathology of Croup is very sim- ple. When the child dies, the inflam- mation has terminated by effusion. This effusion is of a lymph, strongly resem- bling purulent matter; which exuding on the inflamed surface of the windpipe, thickens there, forming the membrane. That this is the natural explanation, is proved to my conviction by analo- gies from other diseases ; for a similar membrane is thrown out on other secret- ing surfaces, as in diseases of the intes- tines ; and it is one of the most common appearances (6) we find in dissections, being the effect of pneumonia, and the cause of adhesions between the lungs and and pleura. As an argument, I may state, that I have discovered in a dissec- tion of Croup an effusion (7) surround- (6) Morgagni de Sed. et Caus. Efiist. 21 (7) See case 7. In the Psedanehone of Sever- inus there is a similar appearance observed in the C 28 nig the outside of the trachea, resem- bling, in quantity and quality, the white of an egg, and which, if it had been ex- posed to the drying influence of the air in respiration, would probably have as- sumed the very appearance of the mem- brane. I have seen this exudation, in all its different degrees of consistence, gurgling up at the epiglottis, puriform, and quite fluid ; then at the larynx, pos- sessing more tenacity; and, lastly, lining the lower part of the trachea, firm, and completely membranous. But in all these circumstances the colour was precisely the same. That this membrane is not merely inspissated mucus, I likewise conclude from the dissimilarity of ap- pearance from the fluid of which it is dissection of a boy who died of the epidemical angina, of which he treats: " Pervestigafe larynx, " Crustacea quadam pituita, facie exteriore con- " tecta, citra ulceris speciem." De Abscess. Nat. p. 528. 29 composed wanting that resiliency which characterises mucus; from the mem- brane bearing maceration, without hav- ing its structure destroyed; and from their chemical properties being widely different (R). But indeed it is not natural to explain the appearance in this manner ; and certainly it is not necessary to re- sort j to this solution of the difficulty, for similar concretions are found in situations where there are no mucous glands; and I do not think that mucus will in any circumstances assume this structure; if it did, we should see the membrane in those diseases of chil- dren where the secretion of mucus is pro- fuse, but where from weakness the pow- er of expectoration is lost. It is no hard matter to explain the difficulty of breathing in the latter part of this complaint, when the membrane (8) Fide Michaelis, p. 60. et seq. 30 is compleatly formed; but in the begin- ning, the tumor and inflammation (al- though I suspect they are then much more considerable than they are after- wards) will hardly be thought to afford a sufficient explanation of the orthopnoea. I must suppose, therefore, that along with this fullness, and perhaps in some measure occasioned by its stimulus, there is a spasmodic constriction of the larynx. Thisl am the more inclined to believe, because, although in the first stage I have never seen an intermission in the dissease, unless in consequence of bleed- ing (9), I have observed the breathing, which is always laborious, performed at particular times, and for several minutes together, with incomparably more dis- tress. The inflamatory affection of the larynx is doubtless sufficient to account for the alteration which takes place in the sound of the voice and cough. £9) Or some other antiphlogistic remedy. 31 There is a circumstance mentioned in the history of the disease, which I have not seen satisfactorily resolved: I allude to the sudden extinction of our hopes when they are at the highest, consisting first in a wonderful remission of the dis- order, and soon after in a fatal exacer- bation. Perhaps this ought to be at- tributed rather to a mechanical than to a spasmodic affection of the parts." It some- times takes place after the expectoration of part of the membrane ; and I suppose that the connection of the remainder with the trachea may be loosened ; so that in taking a full inspiration, this detached portion acts as a valve, completely shut- ting up the tube, and thus suddenly suf- focating the child. Michaelis (l) supposes this disease to occur as frequently in adults as in chil- (1)" Suspicor nempe, morbumin adultioribus " non rarius quam in infantibus occurrere j cum C2 32 dren, with this difference, that adults have the power of expectorating the lym- phatic exudation before it becomes a so- lid membrancc. But if this were the case, we should at least hear the croupy cough, and peculiar voice and breathing, for these precede the formation of the " autem adultiores, materiem lymphaticam, pri- " mo statim tempore, quo in asperam arteriam " effunditur, antequam m solidum coagulari con- " crementum possit, ore rejiciant, morbum in eis, " primis jam plerumque in incuaabilis , suffocari, a et sub communis affectionis catarrhalis specie, Ct observatorum oculis se subtrahere. " Infantum autem plane alia est ratio; isti enim a initio materiem in asperam arteriam effusam, " mollem adhuc paucamque, rejicere negligunt; " mox autem ilia ita inscrescit, ut vires jam infan- " tis ad earn rejiciendam non sufficiant. Credo " itaque rudimenta, initiumque morbi nostri, in '* adultis non minis frequenter, ac in infantibus a occurrere; perfectum autem, atque completum '' morbum, cujus naturam membrana polyposa " declarat, ob mox expositas rationes, in adultiore n state rariorem esse." P, 177. 33 membrane. Children of all ages up to puberty have died of Croup ; and yet a boy of ten, twelve, or fourteen years of age, has, as perfectly as ever he can have it, the power of expectoration. I have heard of no example of this disease after the fifteenth year ; and I have imagined this to depend on that change which hap- pens in the constitution at puberty, and perhaps, in a more peculiar manner, on the change which the upper part of the windpipe undergoes. That a very mate- rial alteration does take place, is evident from the change in the voice, which now becomes firm and manly. I therefore suppose, that the greater degree of tone with which the trachea is endowed, ena- bles it to resist those excitements which would have operated on the same organ in a lax and less perfect state. Hence it may be seen, that I consider the debility of the trachea as the predisposing cause to Croup. 34 The obvious exciting cause of this disorder, the inflamed trachea, the throb- bing and accelerated pulse, the great thirst, burning skin, and high-coloured urine, together with the pain in the diseased organ, point out that it legiti- mately belongs to the order of inflama- tions; an order of diseases of which the general treatment is peculiarly applicable to the disease under review. With a view to the formation of a plan of cure, it is proper to consider the disease as consisting of two stages—the incomplete, or inflamatory; and the com- plete, or purulent. In the former the membrane is not yet formed; in the lat- ter it is fully formed. It is in the first stage that every effort for the cure of the disorder is to be made. In the first stage, our practice is bold, as it is simple; and unless the summary measures taken in the beginning succeed, all success, let 35 the management afterwards be ever so skilful is very problematical. In the first and second days of illness, when the signs above enumerated W are distinctly before us, when we find the croupiness attended with much pyrexia, it is our duty to let blood freely ; and to do it effectually, it must be done with the lancet. Venisection is easily performed, as, from the nature of the disease, the jugular veins are always tumid; and in a child is easier to let blood from these than even from the veins of the arm. If, indeed, the child is very young, and worn out by a former illness, or of a ten- der constitution, it may be proper to ap- ply leeches; but it will very rarely hap- (2) To these might be added the buffy coat on the coagulum of the blood; but this is not al- ways found. The parched tongue, likewise, al- though very common, and often a most excellent index to the inflammatory nature of a disease, is not pathognomic. 36 pen that we cannot use the lancet; and it is of much consequence to take away a large quantity of blood C3) without delay, it being well known, that to do this sud- denly, is of the utmost importance in in- flammatory diseases. After bloodletting, I have been accus- tomed to order an emetic. I have obser- ved the best effects from emetics, whe- ther used before or after the bloodletting. The warm bath is another very une- quivocal remedy ; but as it is a popular and simple application, it is generally used, along with an emetic, before the physici- an is called; and together or separately, by their antiphlogistic powers, they in (3) It is not easy to establish a rule, but I should account from three to five ounces a full bleeding in a child under five years of age. I never at one bleeding took more than eight ounces of blood in this disease, and in every in- stance it will be found a free bleeding. 37 very many instances prevent the forma- tion of the disease. Brisk purges, when the bowels are inactive, and indeed in most attacks, are so obviously proper, that it is sufficient merely to mention them. The solution of tartarised antimony, given every three or four hours, in naus- eating doses, I have used with so much ' advantage, that I have no hesitation in recommending it. The vinegar of squills may be used for the same purpose. The antimonial solution may, in com- bination with laudanum, be administered as a diaphoretic; but when the febrile symtoms run high, I should prefer giving the solution by itself, so as to occasion a continued nausea. I have seldom omitted the application of a blister to the neck, and I believe it. i 38 is a valuable addition to the plan of cure, although I cannot affirm this upon my own experience. Blistering has proved, however, so useful in simiiar diseases, and is so strongly recommended in this, that it is well entitled to every attention. That part of the plan of cure upon which I would chiefly dwell, is bloodlet- ting. If in the inflammatory stage it is not in the first instance, attended with an abatement of the bad symtoms, it must be repeated according to the strength of the patient. Should the physician dislike the use of the lancet a second time (and indeed in this repetition he will not at all times have the concurrence of the pa- rents), I recommend the application of a number of leeches to the neck. The ma- ny opportunities which I have had of ob- serving the advantage decidedly gained by such treatment, have overcome the repugnance I had to the employment of this remedy in the beginning of my prac- 39 tice : and had I no other reason for affirm- ing that the acute asthma of Millar is not synonymous with Croup, this alone were sufficient, that he dissuades us from bloodletting, and recommends assafoetida, musk, and Mindererus's spirit(4). The second stage of the disease is known by some remission in the phlogis- tic appearances, such as a change in the countenance from a florid to a leaden co- lour ; by the pulse getting smaller; and by the difficulty of breathing continuing or increasing, the child frequently breath- ing easiest in postures which might be thought most unfavourable (5) to respira- (4) These medicines, says the Doctor, though children loath at first, they afterwards, when for- ced to take, even acquire a relish for ! (5) This, as a symptom peculiar to the second stage, I have frequently observed. I find it taken notice of in two instances, but without any conclu- sion having been deduced from it. D 40 tion; and by a sediment in the urine. From having observed in dissections that the thyroid veins are very turgid, I have " Malgre son oppression il avoit toujours mieux v aime avoir la tete basse qu' elevee." Observa- tion sur une Maladie analogue a I'Angine Polyfieuse ou Croup, des Enfans, par M. Mahon Associe Reg- ?iicole a. Chartres. Histoire de la Sociite Royale de Medicine, p. 207. " Mitior respirationis difficultas, si capite paul- " lulum reclinato lecto incumberet, quam si se- " dentis potius sedem imitaretur." Observat. a CI. Baeckac Salomon. Michaelis, p. 285. I apprehend the explanation of this to be, that the trachea, stuffed with the membrane, has its capacity increased, by being stretched out to the full extent, which happens when the head is lean- ed backwards; whereas when the patient sits tsrect, which generally is the easiest posture in difficult breathing, the head falls somewhat for- ward, and the membrane, being doubled together in the trachea, becomes impervious. I am inclined to rank a preternatural drowsi- ness as a pathognomic of the second stage ; it cc- *ninly js often to be observed. 41 been induced, in this stage of the dis- ease, to apply leeches to the neck; I have also used emetics, to procure, by the agitation which they produce, the expectoration of the membrane, should it occupy, as sometimes happens, only a small space in the trachea. The bowels are to be kept open by glysters; and the low regimen observed in the first stage is to be laid aside ; and the strength of the patient supported. It has been proposed to give children calomel under this disease, throwing it in quickly, with a view of bringing on sali- vation. I have ordered it in the second stage, but I never found it to be of any service. In a chronic state of the dis- ease C6), I think this medicine promises success. In the first stage, the remedies we already possess arc so valuable, that (6) A case of this kind will be found in the last vol. Medical Annals. 42 I should be unwilling to relinquish them, unless the superior powers of a substitute were demonstrated. Some physicians have proposed a scheme, absurd, because impracticable, namely, to pull out the adventious mem- brane, after having performed the opera- tion of bronchotomy (7). This operation cannot be done in the usual way, by making an aperture between two of the rings of the trachea ; a longitudinal slit must be made, cutting the cartilages di- rectly across. In the first instance, the bleeding from the thyroid veins is to (7) This operation was proposed by Dr. Home; has abettors in Drs. Crawford and Michaelis; and, we are informed by Dr. Rush, was actually per- formed in Philadelphia by a gentleman of well known skill in physic and surgery !—without suc- cess. Dr. Michaelis has many arguments to this point, which leave no impression with me, but that he was a novice in the disease when he wrote this part of his book. 43 be encountered, which to my thinking, would suffocate the child. But suppose this difficulty overcome, and the forceps introduced into a tube not half an inch in diameter, (for such is the trachea at two years of age) the membrane may not, af- ter the incision is made, be found to pos- sess that tenacity which will enable it to bear the pulling out. Such I have found it after death, at the very place where the operation must have been done (8): And if we loosen the membrane from the trachea, without extracting it, it will meet the (8) I have separated the membrane from the trachea down to its bifurcation, in a case where this substance extended into tubes whose diame- ter did not exceed the eighth part of an inch, and then I have endeavoured gently to pull it out, but it broke off short. In this instance, the connec- tion of the membrane with the inner coat of the trachea, at the part where it yielded, was stronger than the cohesion of the membrane itself; and in this child the membrane was stronger than I had seen it in any other dissecion. 44 first inspiration like a valve, and the child must immediately be suffocated. But farther, is the child to be cured by ex- tracting the membrane from the trachea ? Certainly not; for there are instances where the child has sunk, even after the mem- brane had, by the use of emetics, been ex- pectorated (9). Not only the membrane but the frothy and puriform matter with which the lungs are stuffed, must be re- moved before he can be saved ; for this must be instrumental in the death of the child: I do not indeed believe that any prudent surgeon will be found to perform this operation. Previous to the detail of a series ol cases, I have only to say, that the means of preventing croup are still more obvious than the plan of cure, and the object is in most instances attainable. I have observed, in the first place, that (9) See case 10. 45 some families are much more liable to this complaint than others. It is difficult to say whether this arises from a particu- lar mode of education, or is owing to a peculiarity of constitution, which children of the same family often have in com- mon ; but I have had the clearest proofs of this fact, that very often where one child in a family takes the disorder, the the other children are sooner or later af- fected in a similar way. I have known more instances than one where three or four children of the same father and mo- ther have been attacked by this disease ; and authors C1) have mentioned the cir- cumstance of two children of one family being ill about the same time. In the second place, I have observed, that in Leith the danger is greater or less, in ex- act proportion to the nearness or distance from the sea-shore ; and I conclude that the observation would hold good else- (l) Home and Rosensteiv. 46 where. Of all the instances I have seen of the disease this year, amounting to ten or eleven, not one of the children li- ved a stone-throw from the sea-shore or harbour. In Edinburgh, which is only a mile and a half distant from the sea, nay, in the skirts of Leith the farthest from the beach, although not a quarter of a mile removed, the disease is rare : I there- fore warn parents to take the alarm as soon as the disorder appears ; and,.where practicable, I recommend a change of ha- bitation. This will generally be precau- tion sufficient, unless where the children have already sustained an attack; in which case it will be necessary, in this uncertain climate, to guard against an in- discriminate exposure to the air, particu- larly in damp weather, from December to the middle of the summer ; and to adopt all those precautions with respect to regimen, so well known, and so strongly recommended as preventives in catarrhal complaints. CASES OF CROUP. These cases will show the nature of Croup better than any general history of the disease. The four first will place in a favour- able point of view the advantages of bloodletting, in producing a resolution of the inflammation. The fifth, from Michaelis, shows a termination of the disease by expectoration of the mem- brane, effected by the use of emetics. I may observe, that all the children whose cases are given from my own prac- tice, except the second, were of a san- guine temperament. 48 CASE I. October 15. As I was walking along Bath-street, a woman called me to visit a child who was ill of a cold. I found a fair complexion- ed boy, sixteen months old, who appear- ed in perfect health, and I was about to pronounce him so, when I heard him cough very croupily. Being aware of the insidious way in which this disease sometimes steals on, I ordered an emetic and the warm bath, and that the utmost care should be taken of the child, not without hopes that the disease might thus be prevented from forming. The next evening the same woman came, quite breathless, to inform me that the child was at the point of death ; and 49 although she wished me to hasten to her house, she did not expect we should find him alive. On my way thither, she informed me that the emetic had so much relieved the boy, that, thinking him well, she had quite forgotten his danger, and exposed him to the weather in the morn- ing, which was very raw. r When I arrived, I saw the boy so much oppressed, that truly I stood some time without the power of asking a question, or presence of mind to re- collect what was to be done. He was struggling sadly from a difficulty of breathing; his inspiration was peculiarly difficult, and performed with a grating noise ; his voice was hoarse ; his face was florid, and much swelled; the caro- tid arteries were throbbing violently ; and he seemed in danger of immediate suffo- cation. Though doubtful whether it .were possible to save this child, I opened the 50 external jugular vein, and took a small cup full of blood, and ordered the warm bath again to be got ready for him. In the mean time, I visited a patient in an adjoining street, and was absent about ten minutes. When I returned, I found to my great joy, the boy breathing easily, his face less florid, and the fever already abating. The cough was, however, still ringing and frequent. After the bloodletting every circum. stance was favourable. Next morning the child was cheerful and easy ; but such was the severity of the attack, and so great the accumulation of blood in his head, that a violent opthalmia, which last- ed many days, was the consequence. The warm bath and a blister were both used, and during the night an antimonial 51 preparation; but the friends of the child were satisfied he was already recovering before these remedies were prepared; and I have no hesitation in saying his re- covery is to be attributed to the blood- letting. The croupy cough continued several days. F. 52 CASE II. May 16.....One o'clock, P.M. Mr. H----'s son, eight years old,— dark eyes and complexion. He has had several attacks of this dis- ease; one very severe, exactly three years ago, when he was relieved by bleeding in the neck. Last night at bed-time he was taken ill. His mother gave him an emetic, and, as usual in slight attacks, he was a good deal relieved by the sickness and vomit- ing. He continued free from all the symp- toms of the disease, except the ringing cough, until about half an hour ago, when his breathing became so difficult as to excite great alarm. 53 His breathing is now laborious, and the sound resembles the hissing of confi- ned air through a narrow opening ; it is rather slower than natural; he has a vo : rauca and the ringing cough in the greatest perfection; his skin is warmer than is na- tural ; his countenance is flushed; a.iu his eyes are very heavy ; his pulse is 120; he has had no passage from his bowels for two days. He had been a good deal exposed to damp hazy weather ; and I remember to have remarked, the night before he was seized, that I was afraid the weather would produce some more instances of this disease, a child I then attended being about to die of it. Four o'clock. With this boy Croup always occasi- ons much apprehension ; and at my last visit he readily allowed me to bleed him from the arm, whence I took four oun- ces of blood, and ordered him imme- 54 diately a dose of infusion of senna with tincture of jalap. His breathing was not relieved ; and about half an hour after the bleeding it was much oppressed, but he soon became easier. The purge has just operated, after sickening him very much. Evening. His pulse, which in the morning was 120, is now only 100; his breathing is free; he has had a profuse perspiration ever since the purge operated; and he is again cheerful. He was ordered a spoonful of the fol- lowing solution every four hours: &. Sol. Antim. Tart. ^vi. Aq. Cass. |i. Aq. lui. "I. May 18. He has been quite well, since last re- port : His cough is still a little rough : Yesterday and to day he has been run- ning about the room, and amusing him- self as usual. 55 case m April 19. Mr. W----'s daughter, set. 12. This girl is exceedingly robust and big of her age, of a florid complex- ion. She has been threatened with this complaint two or three times, and was taken ill yesterday evening. She had the day before been much exposed to the weather, which was damp and chilly. Though her cough was very rough, she went out to day. I saw her at tell o'clock at night. Her respiration was performed with the utmost difficulty; she breathed so high, that I heard her immediately on E2 56 entering the house, although she lay above stairs. Her friends, tremblingly alive to the danger of her situation, were supporting her in bed, for she could not lie down. Her cough resembled the barking of a lap-dog, very hoarse and sharp ; she was much flushed, and com- plained of pain, or rather great heat in the windpipe; her tongue was white ; the tonsils and uvula were not inflamed nor swelled in the slightest degree; she swallowed easily; there was perhaps a fullness in the throat; her pulse was about 130, and pretty strong: She had an evacuation from her bowels this after- noon. I took from five to six ounces of blood from the arm, and should have taken more, but she nearly fainted under the operation: She got very sick in con- sequence of it, and vomited; but she could breath in the recumbent posture 57 immediately after the Weeding, though her cough was still very frequent. Observing that while the sickness continued, she breathed, comparatively speaking, easily, I was willing to keep it up, and gave her an emetic, which emptied her stomach, about half an hour after the bleeding. When the sickness went off, I had her put into the warm bath, where she remained about a quar- ter of an hour. I then gave her, to be taken during the night, a nauseating so- lution, similar to that ordered in the last case. A large blister was applied to the sternum. Soon after I left her last night, she fell asleep, and slept softly for two hours. The medicine made her very sick during the early part of the morning. Since she was in the bath she has constantly had a moisture on her skin, which is cooler. The blister rose very well. She had 58 during the night considerable thirst, which still continues. Her breathing is easier, but often is interrupted by trrtS cough. Her pulse is 100, and some- what irregular. The blood is rich and florid, but not sizy, She has had no passage from her bowels. I was somewhat surprised to be again sent for in the evening to visit this girl. Her complaint had returned about four o'clock, and in expectation that it would soon abate, I was not sent for until ele- ven. Her cough was worse than ever; it was ringing and incessant; the effort it occasioned resembled the convulsions of the whooping cough. Her breathing was quicker than last night, although not so difficult; her pulse was 110, and pretty full; her tongue foul. I found her sitting in the warm bath, and there I bled her to eight ounces. Before I could get the arm bound up she fainted. When she recovered, her breathing was 59 manifestly easier. I continued sitting by her for half an hour, during which time she was not two minutes free from a con- vulsive shudder, which sometimes made her even start up in bed. Her pulse was now, however, under 100, and not very weak. As she was still faint and sick, I gave her a small tea cupful of weak port wine negus. I ordered the volatile lini- ment, to rub her neck. April 21. When I left her last night, her cough became much less frequent, and she has not coughed since one o'clock in the morning. Her pulse is 70; and she breathes like a person in perfect health. She had a very severe fit of convulsive shuddering about two hours after the bloodletting. I called in the evening, when she had rather more feverishness, and some cough, but it had quite lost the croupy sound. She has started much much during the day. Her bowels are 60 open, in consequence of using the laxa- tive powder, which was not given before this morning. April 24. .She is quite free from all her com- plaints. 61 CASE IV. " A girl 15 months old, living a mile " distant from the sea, appeared in the " evening to be somewhat indisposed, her " skin being a little more hot than usual. " Dr. Home, who went to see her in " the morning, found her breathing la- " borious, the pulse hard, and beating " one hundred and thirty-five times in a " minute. He ordered five ounces of " blood to be drawn off immediately: her " voice then grew sharp, and resembled " that of a cock ; the breathing frequent "and deep; her forehead and inside of " her hands very hot; both hands and feet k< swelled, but without any redness. The " pulse now being hard, she was bled " again, which gave her much ease. She " was made to drink and breathe the va- '* pours of warm water mixed with a little 62 " vinegar: this had a good effect, and pro- " moted expectoration. The body was " unbound with the magnesia alba; in the u evening a blister was applied round the " neck : The third day she was somewhat " better; but the voice the same as before, u the pulse hard, and the breathing deep. " In the evening four leeches were applied " under the chin, just at the top of the " windpipe; and they having left off " sucking, the place was fomented with " warm water, so that the blood continu- " ed to ooze out for some hours. The " child was well the next morning." 63 CASE V. " Infantis unius et dimidii anni, qui " nutricis adhuc lacte spissiore jam aleba- " tur, lectulum cum mutato loco fenes- 11 trae apposuissent, aeri liberorem justo " transitum concedenti, die 29 Novem- " bris habitum alacrem cum tristi muta- " vit, accedente noctis praecipue tempore, " graviori tussi: Nee insequente die etsi " obambularet melius valuit. Cum febris " observaretur nulla, nil nisi laxans accep- " it. Insequente media nocte cum aliqua " tussi, spiritus ducendi apparuit difficul- " tas, anxia erat et celer respiratio, quae " suffocationis metum induceret, praeter- " naturale clangori stridenti juncta. Forti- " ter movebatur pectus, fortiterque pul- " sabant arteriae. Per bihorium haec con- " tinuavit aegrotae ratio ; tunc autem tur- " bas istas placida excepit quies. Primi " Decembris, tempore matutino, pulsus " plenus erat ac celer, facies rubra, in- ;< quietudo summa ; increverat interea et F 64 " respirationis dinicultas et raucedo. " Cum de morbo nostro jam cogitaretur, " vena in brachio secta quinque sanguinis " unciae mitte bantur ; quo facto et pul- " sus minuebatur vehementia et respi- "rationis difficultas; vesicatorium nunc " colli anterioris lateri applicabatur, nee "enemata omittebantur. Attamen spei " eventus minus respondit; exacerbaban- " tur enim versus vesperam et pulsus ve- " hementia et spiritus ducendi difficultas, " facillimumque jam erat stridorem istum •'peculiarem distinguere atque agnoscere. " Diversa nunc aceti vapores ratione, in " usum trahebantur; nam non solum " spongia aceto calido immersa, ori ae- " grotae admovebatur, sed vas etiam ace- " to ebulliente repletum, tenuique solum- "modo linteamento tectum, lecto appone- " batur, et itaque aer quern aeger duce- " bat aceto impregnebatur. Nee quid- " quam hoc remedio, aegrotae majus afferre " videbatur levamen; respirationis enim " inde minuebatur difficultas, et placidus ■' plerumque mox insequebatur somnus. 65 Infusum nunc florum sambuci theifor- me, copiosumque oxymel simplex exhi- bebatur. Vespertino tempore collects urina, a primo jam initio alba apparuit, frustulisque mucosis quam plurimis fundum neutiquam petentibus, sed ei innatantibus, commixta. Prima inse- quentis diei luce, aliquando melius va- luit, et sponte muci aliquid rejecit. Quae omnia cum ante meridiem bene se haberent, imminutaque deprehende- retur morbi vis, emeticum exhibere muci spontanea ejectio jussit. Repeti- tis itaque vicibus oxymel propinabatur squilliticum, usque dum vomitus cie- retur. Accedente vomitu insignis nee muco remixta membranae albae, diver- sae magnitudinis, in frustula divisas, a muco ordinario ob majorem tenacita- tem facillime distinguendae copia excer- nebatur. Felicissimus ille prioris eme- tici successus aliud exhibere suasit. Nee illud quoque levamine caruit; li- berabatur enim asger a membranacea materia aeque ac muco omnium tenacis- 66 " simo. Gratissima nunc in infante ap- " paruit mutatio; pulsus aeque ac respi- " ratio naturali similior evasit, et placido " sopitus somno per totam jacebat vespe- " ram, maximamque insequentis noctis " partem, sine ulla pene febre vel aliis •* pathematibus transegit. Tertii Decem- " bris diei initio bene valuit, nee de alia " re nisi de vesicatorio questus est. Nunc " laxans propinabatur, cujus ope larga " educebatur muci copia. " Abundans nunc quoque ex naribus " stillare ccepit humor. Nee minus in- " sequente nocte bene se habuit, etsi tus- u sis, nee molesta tamen, per inter valla " rediret. Clangor specificus post pri- " mum jam evanuerat vomitum, et rau- " cedo in dies minuebatur. Quarto De- " cembris mane aliud exhibitum fuit erne- "ticum, quod vero paullulum modo muci " ejiciebat. Quinto jam cibum appetere, et " pristinam recuperare alacritatem ccepit. " Laxantia, quorum adhuc continuabatur 67 " usus, magnam semper muci quantita " tern evacuarunt." I shall now proceed to detail five Cases which terminated fatally. The four first occurred in my own practice, the fifth is taken from Michaelis. In the first and fourth the membrane was most completely formed, but there was least inflammation. In the second, the membrane, of which perhaps part had been expectorated, was less complete, but the inflammation was greater. In the third the inflammation was very great, but the membrane was less perfect than in any of the other cases. In the fourth case a con- siderable quantity of calomel was given, without producing any good effect. The fifth case ended fatally after the expec- toration of the membrane, the boy dy- ing hectic. F2 68 CASE VI. On the 22d of February, in the same house where I saw the first case, I found a second in a child of a similar tempera- ment. The character of the disease, however, was quite different. The inspi- ration was very difficult, but not hoarse ; the cough was stridulous ; the child was pale rather than'flushed. When his mo- ther took him on her knee, he struggled for breath, and seemed to be easiest when lying on his back, with his head low. His eye was heavy ; he was afraid to cry; But was extremely fretful and irritated when I laid hold of his arm, insomuch that it was long before I got his pulse numbered. In the five seconds it beat 14 strokes, and was weak. His hands were chilly; he had great thirst, and swallowed easily : He had eaten nothing for two days : He had no fullness in the upper part of his neck, and it was not in 69 my power to examine the fauces: He had three stools this morning; and his urine, which has much sediment, he voids frequently. Ten days ago he took a diarrhoea, at- tended with griping, which his mother imagined proceeded from detention. This disorder continued till Wednesday the 17th, when it entirely left him, and the croupy cough came on that afternoon; but the mother was not at all alarmed before the 20th, when his breathing had become very high ; still she thought his illness proceeded from his teeth. This morning he was cheerful and easy; but the respite was granted only for a short time; his disease became much more threatening, and her fears were seriously awakened. Of her own accord she had applied a blister two days ago, and she gave the boy a vomit this morning, which brought away much viscid expectoration and bile. 70 I ordered an emetic and two leeches to be applied to the neck. February 23. I called early this morning, and found that the child had died an hour before. The leeches were not applied. DISSECTION. There did now appear a fullness in the neck; but this was not an occasional fullness, but rather a thickness and na- tural shortness of the neck. The face, and skin of the neck, were peculiarly pale, like marble; the cellular mem- brane and fat were white, and most deli- cately transparent, and free from a stain of blood ; the thyroid veins on the ante- rior part of the trachea were turgid, as were the external and internal jugulars. The incision was made from the chin to the sternum, and the tongue, trachea, and gullet, were cut out, and pulled from the cavity of the thorax. There 71 was no inflammation of the fauces, nor any apparent affection of the throat; but upon looking into the glottis, a fluid like pus was observed working up from the trachea. The oesophagus was cut away, and the trachea slit up upon the back part, where there is a deficiency of the cartila- ginous rings, and then the membrane presented itself fully formed. The trachea was cut away near its branching off; and here, upon careful examination, the membrane was found most complete, and very strong; but gradually, as it stretched upwards be- hind the thyroid cartilages, it degenera- ted into a puriform matter, which loose- ly adhered to the rima glottidis and sac- cuius laryngeus. This matter was not like the natural secretion of the mucus of these parts ; it was not the mucus thicken- ed and become tough ; much of it was flu- id as the natural mucus is, but it had no other resemblance to it; it was like that mutter which at first flowed out of the 72 larynx; it was of the consistence of cream, or rather the fluid part of it was thin and watery like whey; and in this the firmer matter, curdy, and like the discharge from a scrophulous joint, floated.' Upon taking up the membrane from the lower part of the trachea, where it was firm, the inner coat was seen inflamed, the vessels red, enlarged) and distinct. 73 CASE VII. March 20. G. D----'s daughter, two years and a half old. She is extremely stifled in her breath- ing, which is rather frequent; the expi- ration is performed as if the tube were shut up by a valve, and this forced back with a flap when the air returns from the lungs. There is no tumor in the fauces, no redness ; her cough is very croupy and frequent; her neck is not swelled; her countenance is of a death-like pale- ness, and her extremities chilly; her pulse is very quick, but still firm and regular. She had a stool this evening. This child some days ago, her friends say four or five, took the croupy cough, 74 and for two days her breathing has been affected; but as she had some appetite for food, and drank easily, they appre- hended nothing. The child was visited some hours ago for the first time. She seemed suffocating, and five ounces of blood were taken from her neck. Before the compress could be applied to the ori- fice, she nearly fainted ; she then vomit- ed very freely, and derived temporary ease in her breath from the bleeding ; but soon after the dyspnoea returned. The warm bath was ordered, and a blis- ter, which was immediately applied to the neck. In addition to this, when I saw the child, I recommended an emetic, from a notion that the membrane of croup was formed. March 21. I saw the child at eight o'clock this morning ; she was writhing and twisting about, of an ashy paleness, and was just 75 dying. The vomit brought away a quan- tity of mucus, but notwithstanding my injunctions, it was not kept. The first mouthful, which seemed like the white of an egg, she rejected with great vio- lence. I think there is reason to suppose it might contain in it part of the mem- brane. The urine passed since last visit had a most copious sediment. The child died at nine o'clock. DISSECTION. Upon making the first incision in the neck, and fat and cellular substance re- sembled very much, in whiteness and transparency, that of the last patient. The thyroid veins were not peculiarly distended, but the internal jugulars were very turgid. The thyroid gland was large, and the lobes of the thymus gland extended upwards to the thyroid carti- lage, in two distinct slips. Although there appeared no active inflammation, yet the effect of an increas- G 76 ed action was very manifest, from the quantity of a gelatinous effusion which surrounde'd the lobes of the thyroid gland, and passed behind them round the trachea. Upon lifting the sternum, the thy- mus, of a monstrous size, lay extended over the pericardium. The lobes of the lungs, which projected, were of a pale greyish colour O3). Upon raising them from the thorax, the posterior part was of as darker red, not, however, as if in- flamed, but as if more gorged by the gravitation of the blood in the supine posture of the body after death (>X (3) I suspect this appearance had led to an er- ror in the first case described by Michaelis ; for he says, " Pulmonum dextro aeque ac sinistro « in latere, facies inferior ac posterior colore in- " signis erat livido, unde ad inflammati >nem ha- " rum partium concludere fas est. Facies autem " pulmonum anterior ac superior, naturali gau- « debat colore." P. 256.—And agah, in the Ob. 1 servations par M. Mahon, " La portion des lo- 77 Having taken out the trachea and part of the lungs, the trachea was opened upon the back part at the bifurcation ; but here there was no membrane. The trachea was then slit upwards, and on approaching the back part of the great cartilages of the larynx, the membrane was found distinct, fully formed, but not so strong as in the last instance. It was of less extent, as well as possessing a less degree of firmness. A streak of the membrane passed down a considerable way, attached to the fore part of the tra- chea. In general, it has been observed, that the membrane extended farther down, and was firmer on the back and membranous part of the trachea. The membrane, which extended « bes du poumon qui, s'est pr6sentee la premiere « i la vue, lorsqu'on a enleve le sternum, etoit "dans son etat naturel.—II n'en a pas ete de " meme du reste du poumon. II etoit rouge et ' engorge," &c. 78 about an inch and a half downwards from the glottis, was in a manner float- ing in a milky-like fluid, white and opaque. Upon tracing the branches of the bronchise, there was no membrane ; but in cutting into the substance of the lungs, a frothy mucus was observed in the minute branches of the bronchia?. 79 CASE VIII. May 14. M, D----'s daughter, 18 months old, was the day before yesterday seized with a croupy cough. Yesterday, with the cough, she began to have much dif- ficulty of breathing, which towards noon increased to a great height; and this symtom has not once intermitted since. Yesterday and this morning she had her usual apetite for food. At present she labours inexpressibly in her breathing; her nostrils are inflated; and every inspi- ration raises her chest from the bed. If she is at all fretted, in crying her voice is very stridulous, and then she takes the ringing cough. Her face is of a leaden paleness, her eyes are languid, and she is very lethargic. When she is lifted up, G2 80 she struggles and tosses about till she again gets to lie down on her back, and then when her head is low, she appears easier, and is inclined to dose. She has vomited several times this afternoon. Her pulse is rather full and quick, and her skin warm ; her bowels have been loose; her fauces are without swelling or redness; and there is no swelling in the neck. The treatment in this case was simi- lar to that already mentioned, only that I used no internal medicines but an emetic and calomel. The child died in nine or ten hours after I first saw her. DISSECTION. During this dissection I was much an- noyed-by the jealous watchfulness of the attendants, so that the operation was hurried. On the fore part of the neck there was nothing particular to be observed; 81 there was neither swelling nor any ap- pearance of inflammation ; but upon ma- king an incision, separating the larynx from the pharynx and root of the tongue, and then folding down the trachea and oesophagus, a viscid tenscious froth was seen to fill the upper part of the pharynx and opening of the windpipe. Upon cutting out and carefully ex- amining the trachea in its whole length, the inner coat was observed to be consi- derably inflamed. The epiglottis was in- flamed, and somewhat tumid. The swelling of the epiglottis was not consi- derable, but it was red, and its vessels were distinct and turgid ; and upon its concave surface films of a membranous crust adhered : When these were remo- ved, slight ulcerations were observed on each side of the little ligament which runs down the middle of it. The membrane covering the cornua of the os hyoides and the thyroid cartilage was swelled and red, 82 and had that purplish or bluish cast,' with lake-coloured turged vessels, which would incline me to say that the inflam- mation was of an erythematous kind. Within the cartilages of the larynx tie membrane was distinctly formed, but irregular, perhaps displaced in some measure in the hurry of dissection. There was little inflammation lower in the trachea ; and there was none of the membranous pellicles or crusts to be ob- served lower down than the crecoid car- tilage ; but the internal membrane had the vessels distinct, and slightly turgid. I was not allowed to open the breast. S3 CASE IX. Sunday, June 7. A. R----'s daughter. She has had catarrhal complaints since Sunday last, with a rough cough. On Thursday her breathing became affec- ted in the manner it is at present, namely, frequent and laborious. During the night there is an aggravation of the dyspnoea. Her cough and her voice are croupy; her eye is heavy; her pulse is moderate in strength, and not much quicker than , usual; she has no thirst; her appetite for food is natural; she is generally re- served, but sometimes amuses herself as if nothing was the matter; and is at no time fretful. The tonsils and velum are slightly inflamed; the submaxillary glands are full, but not painful. He ex- 84 pectoration is copious ; her urine is high coloured, depositing much sediment. The disease is well marked, but it has been less active in the attack than usual. Evening. In the morning I ordered a vomit, which brought away a great deal of mu- cus; and she had afterwards leeches, and then a blister applied to her throat. After the vomit had operated, she had a grain of calomel, which has been repeated every two hours since. This medicine has pro- cured her several stools. I think her breathing is more difficult now than it was in the morning, and indeed she has more pyrexia. I ordered the warm bath, and a continuation of the calomel every hour and a half during the night. Monday Evening. She has had 10 grains of calomel, but without any abatement of the disease. This morning she got another vomit, 85 which caused the expectoration of much mucus, mixed with puriform flakes, re- sembling portions of the membrane. I ordered another vomit for this evening, and a continuation of the calomel. Tuesday. The emetic had a powerful effect, bringing up a considerable quantity of pulmonary secretion. The child, howe- ver, died this morning. She had taken 12 grains of calomel. DISSECTION. Instead of examining the trachea by dissecting it from the neck andrcutting it up upon the back part, it was determin- ed to open it on the forepart, and to trace the diseased appearance through its whole length, and to follow its branches in the lungs. When the integuments of the neck were dissected back, though there did 86 not any where appear marks of inflamma- tion, there was a turgidity of the great veins. This, however, was evidently oc- casioned by the difficult respiration af- fecting the circulation of the heart, the impeded action of the heart causing a remora in the cavas and right sinus. Accordingly, upon opening the tho- rax, we found the right auricle and the superior cava turgid with blood, as if the irritability of the heart and general sys- tem had been gradually exhausted by the laborious forcing respiration through the tube of the windpipe, which was pro- gressively diminishing in capacity. When the trachea was slit up on the lore part, from the thyroid cartilage to the division in the lungs, the membrane appeared completely formed in all this length, and of a firmer body than in any of the cases which have been given. It was more delicate behind the great car- tilages of the throat, was firmest about 87 the middle of the neck, and again be- came more soft and liquid after the du vision of the trachea in the lungs ; and gradually as I traced the bronchia?, it lost its consistency. Although I obser- ved a slight affection of the membrane of the bronchia, the adventitious mem- brane could be traced but a very little way into the lungs. The lungs were distended with air in such a manner as if the air had escaped from the cells into the cellular membrane of the lungs. This I conceive to be the effect of the violent play of the lungs, and which must have obstructed the natural functions. Li 88 CASE X. " Puer novem annorum, habitus cor- " poris tenuis delicatuli, adfectionibus ca- " tarrhalibus ssepe obnoxius, ceteroquin " sanus, tempore vernali anni 1775 febri- " cula cum levi tussi et tonsillarum tu- " more correptus est. Hunc morbum ab " aere frigido vespertino, in quo obam- " bulaverat puer, ortum duxisse ratus, " potum theiformem calidum, pulveres- " que camphoratos et linctum pectoralem " praescripsi. Satis bene inde se habuit *' asgrotus, febris disparuit, tussis metuit, " tumor faueium fere evanuit. Cum vero " nulla adesset expectoratio, hanc ut pro- " moverem, oxymel squilliticum addidi " linctui pectorali. Verum in eodem sta- " tu per benas septimanas remansit tussis, " ita tamen ut asgrotus genio puerili late 89 " indulgeret, cibos appeteret, nocturna " quieta frueretur. " Neque febris sub eo tempore re- " cruduit, neque respirationis difficultas, " aliudve incommodum supervenit. Quin- " decimo autem die accersitus res inveni " quam maxime mutatas. Quippe puer " moribundi instar facie pallida, oculis " labiisque diductis immobilibus, cute " frigido sudore perfusa, anhelitu difficiU " limo, stridulo, lento, respirabat. Pul- " sus parvus erat et cellerrimus. Ver- " bo quovis momento misellum animam " efflaturam esse putabant adstantes. Un- " de vix obtinui a parentibus ut venam " secari sinerent. Quatuor sanguinis un- " ciis absque levamine eductis, periculo " magis magisque increscente, emeticum " praescripsi; tartari nempe stibiati ali- •* quot grana in aqua simplice soluta, re- " fracta dosi porrigenda, donee invertere- tc tur stomachus. Secundus remedii haus- " tus, vomitum excitavit tussimque. Quo- 90 " rum unita vi, non sine summo suffoca- " tionis periculo ex faucibus protrusum J* forasque demum rejectum est concre- " mentum membranaceum, firmum, ra- " mosum, totoque tractu cavum, arte- " riae asperae bronchiorumque conforma- " tionem satis apte referens. Post sin- " gularem hanc excretionem, pauculas " sanguinis guttas secum vehentem, ces- " sarunt omnia, quae infanti mortem mi- " nata erant symptomata, spiritum liber- 14 rime traxit puer, calorem naturalem u ciborum adpetitum, mentis hilaritatem u recuperavit, laetusque cum parentibus " laetis, ceu a morte ad vitam revocatus " prandium cepit. Neque tamen restitu- u turn sivi relinquere linctus camphorace- " orumque usum ; suasi etiam vaporis le- lt nientis inhalationem. At breves atque " deceptrices fuerunt illae induciae. Quip- *' pe tertio a dicta mutatione die respiratio " denuo fit anhelosa, stridula, gallinae gra- u cillantis sono similis; pulsu tamen non " adeo depresso et languido, quam in pri- 91 " ori mali accessu. Hinc venam iterum " secui, sed absque sensibili levamine. " Circa vesperam, aucto suffocationis pe- " riculo, tincturam ipecacuanhae aceto " scillitico mistam ad excitandum vomi- " turn propinavi, et quidem cum succes- " su. Alterum enim concrementum pri- " ori plane simile ejecit seger moxque " sublata est spirandi difficultas. " Remanebat autem febris lenta, ver- " sus vesperam exacerbans, sputum hac- " tenus mucosum mutatum est in puru- " lentum, accesset dysphagia, nee obsti- *" tit corticis Peruviani et aquarum selte- " ranarum lacti additarum usus, quo mi- 4t nus sudores et diarrhoea supervenirent, " viresque aegroti penitus exhaurirent. " Sic decimo tertio post alteram rejectio- u nem die animam efflavit. Valde desi- u deranti non concessum est cadaver seca- 11 re, tracheae que cavum inspicere." H2 92 Extract from the note of the dissection of a singular case, as occurring in an adult 0). The Thoracic and Abdominal Vis- cera, in situ, appeared natural; there was rather more fluid in the Cavity of the Chest than usual, and of a brownish co- lour ; the posterior and inferior portions of both Lobes of the Lungs had evident marks of inflammation, but more particu- larly the latter; the fluid found in the Cavity of the Thorax coagulated when exposed to heat; the Tonsils were enlarg- ed, more particularly the left; and both Tonsils were covered with a thick mem- brane of coagulable lymph. About three inches of the Trachea from the Larynx (1) He was a gunner, and had, previous to the attack of Croup, of which he died, suffered se- verely from a catarrh* 93 was taken off; it was covered with the same kind of membrane, and had the same appearance as in cases of Croup. Upon a farther examination of the re- maining portion of the Trachea, we found a continuation of this membrane, but of a firmer texture than that in the superior part, accompanied with an appearance of inflammation of the natural membrane of the Trachea and its divisions ; and this membrane, as well as the inflammation, prevaded the smallest ramifications of the Bronchiae, which upon pressure were found plugged up with a bloody frothy kind of matter. Upon opening the Heart, polypi and coagulable lymph were found in the right Auricle and Ventricle. ' ;V« APPENDIX. In Newhaven, on the 30th of May last, I saw a boy of twelve years of age, whose breathing was very difficult; it was attended with a sense of constriction at the larynx ; the inspiration was frequent and croaking, and his voice was rough and harsh : His breathing was so alarm- ingly difficult, that, according to the cus- tom of the common people, all the wo- men living in the neighbourhood were assembled to witness his death, which was hourly expected. His pulse was quick, but not strong; and he was much flushed. Since the attack commenced, he once or twice, unexpectedly, became easy, and continued so for a quarter or half an hour, and then the symptoms again returned in all their violence. In 96 these paroxysms he had many belchings, but I could not learn whether they reliev- ed him. His illness came on early this morn- ing; and it was imagined to have arisen from his having gone off in an open boat yesterday, which was a very cold day, to fish. I ordered him an emetic immediately, which sensibly relieved him. He was blistered, and he continued getting bet- ter under the use of a strong solution of assafoetida. This I conceived to be a case of the acute asthma of Millar, and under this impression I treated it successfully as a spasmodic disease. I have never seen another instance »of the disorder; but from its supposed indentity with croup, I shall shortly point out the distinctive symptoms. 97 In croup, the cough, which I have so often noticed, is constantly ringing in our ears; in acute asthma there is little or no cough. In croup there is very sel- dom any remission; the remission in acute asthma is one of the most striking phenomena of the disease ; and it is at- tended with some evacuation, as bel- ching, vomiting, or purging. In croup the pulse is strong, the urine is high co- loured, the fever is much greater, the voice is sharp and small; in acute asth- ma, the pulse, though perhaps equally quick, is less full, the urine is limpid, and the voice is croaking and deep. By attending to these symtoms, we shall be able to determine the question of bleeding, which is safety in the one in- stance, and supposed to be improper in- the other. When there is sufficient time deliberately to consider the progress of croup, it is hardly possible that it should be mistaken for any- other disease. 98 It may not be amiss to state the error in the genera morborum, which gave rise to this diagnostic. As synonymous to Cynanche Tra- chealis, Dr. Cullen {Synop. Nos. Meth. g. x.) mentions, Suffocatio Stridula, Scotis The Croup, CI. Home on the Croup. Asthma Infantum, Millar on the Asthma and Chincough. Asthma Infantum Spasmodicum, Rush, Dissertation, London, 1770. Cynanche Stridula, Crawford, Dissert. Inaug. Edinb. 1771. The first and last of these desserta- tions treat of Croup, the intermediate two of the Asthma Infantum, the disease which occurred to the fisherman's boy. 99 Dr. Cullen, by departing from his usual accuracy and discrimination, has obliged me, in the first paragraph of the Essay, to state precisely the nature of the disease of which I was about to treat, a thing in the present instance of the last importance in a practical point of view, and to define it from the morbid organic condition, rather than from the symptoms, which, in a regular book of nosology, is unquestionably the preferable mode. My definition, therefore, is to be consi- dered rather as an enunciation of the sub- ject; for had I not been compelled by this mistake, I should not have thought it necessary to give any definition of a disease, which is particularly described in the next page. The advocates for the operation of bronchotomy, which, I find, is still recommended, will do well to at- tend to the distinction between the two diseases. I imagine I need hardly say, that in the asthma infantum there is no inflammatory membrane. I 100 In the present state of surgery, I scarcely thought it necessary to add much in support of my opinion as to the unfitness of the operation of bronchoto- my : But as I have been blamed for re- jecting this operation in the cure of croup, I shall consider it in another point of view. At the same time I should hope, that what I have already said will have influence with most physicians. Although in some instances, where the membrane has been formed and ex- pectorated, and the child in consequence has recovered, the affection appears not to have extended much beyond the larynx (4), yet I am convinced, that in nine cases out of ten, the immediate cause of death is not so much the narrowing and obstruction of the stream of air occasion- (4) This too must in a great measure be the case in the peculiarity explained in p. 30. 101 ed by the membrane (5), as the puriform fluid with which the bronchiae are filled ; for in most of my dissections, the puri- form fluid has been found so completely to gorge the lungs, that the air would have been met by this fluid, and prevented from finding its way into the air cells, even had it passed the larynx easily, or had the membranous effusion which lines the larynx been removed. This pu- riform fluid I conceive to be a mixture of the lymphatic effusion of the minute branches of the trachea, of the natural exhaltation of the lungs, and of mucus. He who imagines that the disease is al- ways confined to the larynx, takes a li- mited view of croup; for by continuous sympathy, or from the exciting cause acting as violently there as at the larynx, (5) In Case VIII. there was no mechanical ob- struction in the trachea. It was indeed inflamed ; but the immediate cause of death might be sought in the effusion of the lungs, and the general af fection. 102 the inflammation often, perhaps always in some degree, extends to the more minute branches of the windpipe ; and I have actually seen the membrane regu- larly formed in branches, not a line in diameter, which proves that inflamma- tion had subsisted as violently in these branches, as it usually does in the larynx. Suppose, then, in performing this operation, that the thyroid veins, and all the neighbouring blood-vessels, could be so commanded, that not one drop of blood should be poured out to embarrass the operator; that the membrane, as it lines the larynx, were extracted; and, to avoid any difficulty from the spasm of the larynx, that a tube we*e introduced into the trachea, and that the child were breathing through his tube, By what means could we promote the expectora- tion of the puriform matter which so ge~ nerly fills the lungs? 103 Is it a consideration entirely to be overlooked, that the operation is to be performed upon an organ in a state per- haps of high inflammation? It is alleged, that one child did es- cape from this operation (6). When the (6) Burscrius, Vol. V. § ccccxxxvn. Inst. Med. Pract. Burserius, like every other system- maker, must depend upon the observations of other men for the greater part of the intelligence which he is to communicate ; and accordingly he follows Michaelis (sequar CI. Christ. Frider. Mi- chaelium, qui hujusce morbi historiam prse aliis accuratissime conscripsit, § ccccxxiv.}, who has in some measure made up for his want of experi- ence in this disease by his industry. The imper- fect case which Burserius gives from his corres- pondent Locatellius, cannot be admitted in evi- dence, until the history of the disease previously to the operation be known. That the impression made by this operation upon the mind of Burse- rius himself was very faint, may be inferred from the manner in which he proposes bronchotomy. n In extremo suffocationis periculo, sola tracheo- t 12 104 surgeons of former times were perform- ing operations for the iliac passion, there may perhaps be an instance on record, where the patient has survived. But surely this would not be reason enough, why such an attempt should again be " tomia, reliquis irritis spem aliquam facit quan- " quam non ab omnibus probetur." L. c. Were it judged right to perform this operation, a more hopeless way of doing it (so far as I re- collect, for I have not the book by me), could not have been thought on. There was a transverse incision made between the second and third ring, and another between the fourth and fifth. Then there were two longitudinal incisions made, one on each side of the trachea, which joining the transverse ones at right angles, freed a quadran- gular piece of cartilage two rings in length, and in all probability at least a third of the circumfer- ence of the trachea in breadth, which was removed. I have known this operation performed in two instances, both of which were fatal, one of them under the most favourable circumstances, for the patient was an adult. 105 made. I must still maintain, that it be- comes the surgeon, for the credit of his profession, to decline an operation so im- probable, and which proceeds from a mechanical and contracted view of the disease. Dr. Rollo's case, .although in an a- adult, does not invalidate my opinion, that debility of the trachea predisposes to croup ; for in his patient, the upper part of the trachea was previously reduced to a state of debility, by a severe attack of catarrh, a precursor to croup, which is daily observable in children. Before concluding, I may observe, that, in the second stage of croup, I have had no success in administering ca- calomel, which I have done in many in- stances since the foregoing Essay was written ; that my opinion of its virtues is diminished by an extended experience \ 106 of its effects C?). During the first stage, in violent attacks, I should think myself (7) The praise given by some physicians to ca- lomel I was at a loss to explain, when I found it accounted for in a paper on Croup, by Dr. Fcrriar of Manchester ("Medical Histories and Reflections, Vol. III.)) which I lately read with more satisfac- tion than any thing that I have seen upon the sub- ject. He observes, that " children who are liable " to attacks of the croup, are sometimes seized " with the deep barking cough, which will in- " creased to such a degree, as to excite much " alarm, about the usual time of the dangerous " exacerbation; yet it will decrease again, and at " lengh go entirely off, without any remedies but " common demulcents. Cases of this kind, I sus- " pect, have been described as genuine paroxysms " of croup, and very trifling methods of cure have " been recommended, in consequence of their ap- " parent efficacy in the spurious croup, which al- " ways cures itself." The spurious croup is that croupy cough which I have mentioned, p. 25. The only expectation from calomel which oc- curs to me, is, that it will occasion a new action in the trachea, and thus prevent the disease from 107 criminal, were I to neglect blood-letting and the antiphlogistic regimen, in favour running its fatal course to effusion. Jn this view, calomel can be of no use in th* second stage, where the inflammatory action is completed, and where our sole hope is from expectorants. In the first stage, I have given it as my opinion, that the way to succeed, is to endeavour to obtain a resolution of the inflamation; and indeed where there is nothing peculiar in an inflammation, this is a preferable design to that of inducing a new action in a part. The physician whom I have al- ready quoted in this note, says, that the disease will generally be fatal, if the alarming symptoms be not mitigated within the first six hours. To this I do not accede ; for I have more than once relieved children, where croup had come on alarmingly, by bleeding, on the morning after. But I may venture to affirm, that the disease, i£ not within the twelve or sixteen hours from the invasion of the alarming symptoms, will not be cured at all; and this, doubtless, allows too limit- ed a period for the influence of colomel, which, it is a common observasion, is even more tardy in affecting the system of children, than that of grown people. HoweVer, should calomel be pro- posed on any other principle, I shall willingly 108 of any other measure; for I am more and more convinced, that previously to the formation of the membrane, the disease is certainly to be cured by the means (8) give it every farther consideration. For the pre- sent, I must decline using it, unless in such a va- riety as is mentioned/!. 41. note 6. (8) It was stated to me as a serious objection to the foregoing Essay, that, in the cure of Croup, I had brought forward nothing new. This it was not my intention to do. I found the practice un- fixed, when I first entered on the consideration of this disease ; and my object, in the first place, was to determine, for my own satisfaction, what course I should follow, under circumstances which occured so frequently. My opinion is esta- blished, that this is an inflammatory disease, which, in the first stage, is to be treated by a strict antiphlogistic regimen, by emetics, and the warm bath: when violent, by blisters, large bleed- ings, and other evacuations, p. 24. et seq. In the se- cond stage, by emetics, expectorants, and blis- ters ; and that, while we have agents so powerful, we should neither trust to calomel, asafcetida, not 109 which I have recommended. But when, by the paleness of the visage, the lividity of the lips, and the ghastliness of the eyes ; by the cough evidently becoming more stridulous, although less sonorous (9); and by the changes which I have pointed out, we discover that the inflammatory stage is over ; I have no objection to of- fer against calomel; so that it does not preclude the use of expectorants, among any other drug which has been hitherto offered as a specific for croup. Should I have been success- ful in bringing other physicians to think that these are fair conclusions, my object is granted in its fnllest extent, and my time has been as usefully employed, as if I had been experimenting in or- der to produce a new remedy, which, as is shown by daily experience, however excellent in the sense of the innovator, is generally found only to involve the physician in fresh doubts. (9) A hoarse, deep, parking cough is not so alarming as a shrilly crowing and stridulous one. The latter always characterises the second stage. 110 which I may rank medicated vapours; j but I particularly allude to emetics, which I prefer to all other remedies in the com- j plete stage of croup. T. TOWN, PRINTER.