An inquiry into the nature, cause, and cure of the croup. By Francis Home,:

AN INQUIRY INTO THE NATURE, CAUSE, and CURE OF THE CROUP.

THE Science of Medicine has been, gradually, advancing for these two thousand years by past; and is now brought to a great degree of improve∣ment; perhaps to as great a degree, every circumstance considered, as the difficulty of the art, the limitation of the human facul∣ties, and the continual attempts to further refinement, too often conducted merely by fancy, will admit of.

ONE used to consider the progress of the different arts, their gradual advancement to perfection, and their subsequent decay, may

be apt to contemplate, with some alarm, the present situation of physic. More attention is paid to the classing of diseases, as if they were natural and permanent entities, than to the complete history of each particular one; more to the sub-division and splitting of them into separate species, from some slight difference in the symptoms, than to the general turn and complexion of the whole disease; more to the novelty and change of application, than to the improve∣ment of what is already discovered and in use. These, a speculative mind will be apt to consider as proofs of too great refine∣ment, and distant marks of a future change.

IT is by a close attention to the history of particular diseases, that the science has made such great advances. The accuracy of ancient and modern authors hath left few diseases untouched. By describing every circumstance belonging to them, and the appearances, which occurred, on inspecting the bodies after death, they have ascertain∣ed most diseases, and laid a foundation for arriving at as certain a knowledge of the

rest, as the narrow limits of our powers will allow. For cases in medicine are the expe∣riments of this branch of Natural Philoso∣phy.

THERE is one disease, however, which had entirely escaped all regular examina∣tion; and concerning which, there was lit∣tle to be learned by inquiry, and still less from books; I mean the CROUP. I never have seen any thing written on this subject, except a Thesis, where the author gives us no facts; and classes it amongst the spasmodic distempers, to which it has no resemblance, either in its progress or cure. The Catarrhus suffocativus of Etmuller, tho' it resembles the Croup in many particulars, yet appears to be a very different disease in some symptoms, in the cure, and appearances after deaths.

DR Russel, in his Oeconomy of Nature, describes, in a few lines, a disease very similar to this, in most of its symptoms: But it seems not exactly the same, as it was attended with ulcers about the larynx, and terminated of∣ten in a sphacelus of the lungs. Besides,

had it been the same disease with our Croup, the same appearances must have occurred, upon dissection, to him as to us.

I SHALL, therefore, treat this disease as entirely unknown as to its nature, cause, effects, and cure; and try how far our facts will carry us towards a discovery of these.

How so singular and dangerous a disease has been totally neglected, while such atten∣tion has been paid to most others, is not the least surprising circumstance belonging to it. Its external features ought to have been suf∣ficient to have roused an inquisitive searcher into diseases; its internal appearances, if but once seen, must have raised, from their sin∣gularity, the strongest desire to investigate its nature. But these seem to have been more than counterbalanced by its local situation; the unfrequency of its appearance; the sub∣jects which it attacked, these being general∣ly children, and unable to give a distinct ac∣count of their complaints; the rapidity of its course; the apparent easiness of its symp∣toms; and their similitude to other catarrhal

or peripneumoniac distempers. These seem to be sufficient reasons for its being so long undistinguished and undescribed, without laying us under any necessity of looking on it as a new disease. Probably it has existed more or less in all ages; for the same pro∣ductive causes must have operated formerly, as they do at present.

THIS disease happens, or at least is ob∣served, so seldom in this city, that very few cases must occur to any particular person, during the course of a whole lifetime. To have the power of seeing more, one must put himself in the way of intelligence, especially at places situated on the coast. By that means, I have had an opportunity of attending more cases, than otherwise would have fallen to the share of any one. The danger of the symptoms under such apparent ease, and the singularity of its appearances after death, in the first examination, excited my curiosity. The subsequent cases were sufficient to show me its nature, tho' perhaps not to point out a certain cure. That is not always allowed to mortals. To be able, however, to distin∣guish

it from other diseases; to discover the nature of it; to point out when it is cureable, and when not; perhaps to lay a foundation for improvement in its most desperate state; that is the design of the following pages.

To be the first author in treating a disease; to have no assistance from preceding experi∣ence, is a situation a little uncommon in these modern times. To this cause, and to the rarity of the disease, must be imputed my not bringing it to that degree of improve∣ment, that I could wish; and that has hap∣pened in other diseases. If this can serve for a foundation to excite others to inquire, to preserve, and to communicate facts ob∣served by them, my labour will be well be∣stowed.

THIS disease appears to belong peculiarly to children; and the younger they are, af∣ter they are weaned, the more liable they seem to it. On the breast, they appear less sub∣ject to it; or, which is as probable, as they cannot tell their complaints, it is taken for some other disease. I never saw, or heard of one, above twelve years of age, affected by

it. After this the body gains a strength capable of resisting the cause, or of expelling it when received. About this time, or a lit∣tle after, very great changes happen in the human frame.

It seems, likewise, in a great measure, to have a local situation; and to be very sel∣dom found at any great distance from the sea-shore. It appears much less in Edinburgh than in Leith, or Musselburgh. It is often seen along the coast of Fife; and is very common, I am told, along the coast of Air∣shire and Galloway. Tho' I never heard of it in the neighbouring coast of England, yet probably it is to be found there too. The same causes, that kept it from being so long attended to here, may still make it neglected there. Very wet and marshy situations, sometimes, produce it.

IN the first history of a disease, it becomes absolutely necessary, to set down the cases and the facts, as they really happened. In diseases, that have already been described, it is sufficient to enumerate the symptoms, as they generally appeared, by which the diffe∣rence betwixt that species, and any of the

former, may be observed. But in a new disease, as little ought to be left to the fancy or judgment of the historian as possible; for, from the natural appearance of the symptoms, all our reasoning and conclusions must take their rise. As cases are analogous to the expe∣riments of Natural Philosophy, they ought to be described as circumstantially. Hippo∣rates, that great historian of diseases, treats his epidemics, as they were new distempers, in this way.

CASE I.

MARCH 15th. Was called to Miss****, aged fifteen months, of an inflammatory con∣stitution, and living within a quarter of a mile of the sea-shore. The day before, she had appeared duller and hotter than usual. This morning she was attacked with a diffi∣culty of breathing. Her pulse was strong, and about 135 in a minute; five ounces of blood was immediately taken from her. Af∣ter which, she was seized with the sharp stri∣dolous voice, which I can resemble to no∣thing more nearly than the crowing of a

cock; and which is the true diagnostic sign of this disease. She had a quick and high breathing, and unusual heat in her fore∣head, and palms of her hands. Her feet and hands were swelled, and had an aedematous appearance. As her pulse was still strong, five ounces of blood was again taken from her, which seemed to ease her greatly. The steams of warm water and vinegar made her spit up, and did her service. Her belly was kept constantly loose with magnesia alba; and that night a blister was applied round her neck. On the third day, she was a lit∣tle easier; but the voice still remained shrill, the breathing high, and pulse strong. At night four leeches were applied to her throat; and the orifices, constantly fomented with warm water, continued blooding for four hours. Next morning all the symptoms went off. In this case, the repeated blood∣ings, especially the local one, with internal and external fomentation, did most remark∣able service. I was not so certain about the effects of the blister.

CASE II.

MISS ******, aged eighteen months, healthful, living near a great loch, and a∣bout a mile distant from the sea, was seized, March 30th, with the Croup. She had im∣mediately lost five ounces of blood by leeches, and had got a vomit. Next morning, she had taken a second vomit, after which I first saw her. Her voice had the characteristical shrillness, only, when she raised it, or cough∣ed. Her breathing was quick. Pulse about 130. and rather weak. Dry, rough, short cough. She had no pain in swallowing, but showed uneasiness when she turned about her head. Urine clear, and without sediment. The steams of warm water and vinegar, and a blister round the neck, were ordered. In the evening she was better, and her lungs ap∣peared somewhat moister. That night she rested pretty well; and on the third day her voice was natural, except when she coughed. She had a running at the nose, and there was a cloud in the urine. The vomit repeated. On the fourth day, the voice was still some∣what

unnatural. The urine now deposited a light sediment, which lasted for three or four days, during which she gradually reco∣vered. She had the same disease again six months after, but in a slighter manner.

CASE III.

A CHILD two years old, who had had the small pox six weeks before, had been seized, August 8th, with the croupy voice. Leeches had been applied, and blisters be∣hind the ears, and to the throat: On the 12th, I saw him, and sound his breath∣ing bad, great stuffing, shrill voice, and a swelling externally on the superior part of the trachea. Pulse 140. Every thing look∣ed ill. Steams, external fomentation, poul∣tices, and several leeches were applied to the throat. 13th, the child greatly relieved, more chearful, and voice more natural. 14th, pulse much better, and the peculiari∣ty of voice and the swelling almost gone.

I NEED not relate more cases of this kind, as such like commonly occur, and as

they are sufficient to prove its nature in this situation. The only remark that I shall make is, that the symptoms of these three patients, and their cure, show plainly the Croup, in this state, to be a disease of an in∣flammatory nature, attacking the organs of voice and respiration, particularly the supe∣rior parts of the trachea, and that the local inflammation often ends by resolution. This disease appears to be confined chiefly to the trachea, as the patients have no pain in de∣glutition; as they generally complain, when they are of an age to speak, of a dull pain in the upper part of it; as sometimes an external swelling is seen there; and as the fauces are at most but a little redder.

LET us now see what light other situa∣tions of the disease, and inspection into the morbid body, will give us.

CASE IV.

SEPTEMBER 29th, 1760, was called to a boy of seven years of age, who had been some days sick. He lived on Leith bridge, had

been ill of the chin-cough the preceeding winter, and had recovered of the measles a∣bout six weeks before this. He had been fre∣quently purged, and had been tolerably well, excepting a slight cough, till he was seized, four days before I saw him, with fever, heat, thirst, and the shrill croupy voice. When I saw him, his pulse was quick, with a little degree of hardness, but not strong. He swal∣lowed easily; but complained of a pain in the trachea, when he spoke, or when I pressed it with my fingers. His face had been swel∣led. Great drought. Breathing high, but not very quick. He sometimes expecto∣rated, and had often frothy saliva upon his lips. The urine had a white ouzy sediment. His senses and his head were quite clear and distinct. He was immediately blooded, and at night had leeches applied to his throat, and a blister round it. The next day his pulse was weaker, and beat 175 in a mi∣nute. Breathing quicker, and often altered. Distinct in all his senses. Died that night.

ON laying open the parts, there was no ap∣pearance of any inflammation on the fauces. But, to my great surprise, the whole superior internal surface of the trachea was covered with a white soft thick preternatural coat or membrane, easily separable from it, and generally lying loose upon it, and purulent matter lodged below, and around it. The subjacent parts were red; but no great de∣gree of inflammation. As we searched downwards, the same appearances continued thro' the ramifications of the aspera arteria, tho' the membrane seemed here softer, thin∣der, and to become of a more purulent na∣ture. All the branches of the windpipe and bronchiae were filled with purulent matter; and we could easily squeeze it out, in great plenty, from all these pipes. The substance of the lungs was quite sound, and in a natu∣ral state.

THESE circumstances appeared, at that time, so new and surprising to me, that I looked on them as accidental, and not the natural effects of the disease. But I was soon convinced of the contrary.

CASE V.

OCTOBER 5th. I WAS called-to the last boy's sister, aged five years, who had been observed, only the day before, to complain of a dull pain in the throat. She had been im∣mediately blooded, and had got a mixture of spt. minder. and theriac, with a blister to the neck. She had been in a constant sweat since she began to take the mixture. When I saw her she had the dry shrill voice, and difficult breathing, with great motion of the ribs and scapulae. Her face was a little swel∣led and red; deglutition easy. Her pulse was quick, and of a proper degree of strength. What she expectorated seemed to be of a pu∣rulent nature. Her senses were all in the na∣tural state. Leeches were immediately ap∣plied to her neck, and afterwards a warm fomentation, and the steams of warm water and vinegar: these appeared to give her some ease. At night she seemed worse, and could not ly long in one posture. She was vomited with the syr. scillit. and threw up a great deal of gross ropy defluxion. I tryed her with a

mixture of camphire and nitre. The next day her pulse was 152, and weaker. The amygdalae appeared a little swelled, and cover∣ed with mucus. She had a little difficulty of deglutition. Frequent reachings. She called often for drink, but drunk little at a time. Tongue white and furred. Breath∣ing rather quicker to-day, and often altered. Eat some spoonfuls of panada and wine. She was ordered an emollient injection, and garlick cataplasms to her feet. In the after∣noon, all the symptoms were worse. The injection had operated thrice. Breathing difficult and quicker. Great restlessness and anxiety. Pulse weaker and intermitted. She died in the evening, all her senses being di∣stinct, and having eat somewhat just before. What she spit up appeared thin; but what came up, with the short stiffled cough, was always thick and yellow, like matter.

WHEN she was opened by Mr Gibson Sur∣geon, we perceived the glands at the root of the tongue turgid, covered with mucus, and their excretories open. The amygdalae were larger than usual; but neither they,

nor the neighbouring parts, were inflamed. All about the glottis was covered with a tough viscid mucus. When the trachea was open∣ed no inflammation appeared; but all its su∣perior internal surface, particularly the back part, next the oesophagus, was covered with a soft half-dissolved-like-membrahe, detached from the subjacent parts, lying loose like the blankets of a bed that has been lain in, and matter like pus on each side of it, and betwixt it and the membrane of the trachea. Some of the small glands about the glottis were turgid. The farther down we searched, the more purulent matter we found; but no mem∣brane appeared here. When we came to where the trachea enters the lungs, by squeez∣ing them, we could force out thro' it a great deal of whitish glutinous liquid. The same matter appeared in all the ramifications of the lungs, and they seemed to be intirely full of it, as we could squeeze it our, mixed with a little blood, from the smallest divisions of that canal. The substance of the lungs ap∣peared quite sound. The internal coat of

the stomach seemed, likewise, very soft, and covered with a great quantity of mucus.

CASE VI.

JUANUARY 3d. I was called to a boy of seven years of age, at Musselburgh, who had gone about till this morning, but had com∣plained for four days of a great difficulty in his breathing, and of a constant dull pain a∣bout the head of the trachea, attended with a shrill voice. As his pulse was quick, and his breathing difficult, the Surgeon had that morning taken twelve ounces of blood from him, and given him Gum. Ammon. Sal. C. C. gr. iv. When I saw him, at night, his pulse was very frequent and weak, his breathing quick; still a little pain about the head of the trachea; no inflammation to be seen in the fauces, and his urine deposited an ouzy sedi∣ment. His voice was feeble, and the shrill∣ness had gone off. As I saw he would soon die, I desired the Surgeon to open him, and to be particularly attentive to every circum∣stance in the whole course of the trachea, as

some unusual appearances, there, had occur∣red to me in this disease.

HE told me, afterwards, that the lungs were not in the least inflamed; that he found, a little below th•• aperture of the glotttis a quantity of what appeared to him pure mat∣ter; but had not observed whether or not there was any membrane, nor whether the ramifications of the trachea were filled with the matter. This, however, must certainly have been the case, as matter was actually found in the superior parts of the trachea, as his lungs appeared otherwise sound, and could not be the cause of his death; and as he had the same purulent sediment in his urine, which I had observed in the former cases, and which attends all collections of matter, in whatever part of the body they are contained. To our purpose, it is suffici∣ent, that matter of a purulent kind, was found in the trachea.

CASE VII.

A BOOKBINDER'S child, four years old, in this town, was seized with a cough and

quick breathing, Saturday October 5th, 1763. As it appeared of the croupy kind, he was blooded with leeches that day, and blistered next day. After this he seemed better, and went coughing thro' the house that week. Sunday 13th, I first saw the child. The voice was rather more hoarse than usual in the croup; the pulse very quick, and the breathing very laborious, with a little pain in the throat in swallowing. Dry short cough. I suspected that there was a considerable mixture of the angina with the croup here. Leeches were applied to the neck, with fomentation and steams. 14th, Breathing much better, and all the symptoms easier. 15th, All the symptoms worse. Pulse and breathing very quick. Died the 16th.

The trachea, when opened by Mr Wood surgeon, was covered, for half an inch from the glottis downwards, with a firm white thick membrane, from which, for an inch further down, was a soft yellowish purulent-like matter, not yet hardened. All the mem∣branes of the trachea were entire under these, but much inflamed and red. In some parts

of the lungs, the vesicles contained the same kind of matter, but in no great quantity.

CASE VIII.

OCTOBER 20th, 1763. A girl, aged four years, coughed a little, was out the day fol∣lowing, and, at night, the cough increased with hoarseness. On the 22d, Mr Wood, the family-surgeon, by accident, saw her play∣ing, and observing her breathing laborious, and her pulse quick, tho' she was otherwise well, he blooded her. 23d, She was worse, and had a blister applied to her throat and back, and got an injection. 24th, I saw her first; her breathing quick, and hoarse; pulse 180; urine with an ouzy sediment; and was told, that she had coughed up, what seemed to the family, pure matter. By her breathing, more of the same kind still seemed to be left be∣hind. She eat and drank without any pain. To expel the matter, if possible, she got a vomit of squills; but nothing came away. 25th, She was much in the same way; and I ob∣served some matter mixed with the saliva,

that she had coughed up. Breathing ex∣ceeding quick, and laborious. Ordered the steams of warm vinegar to be drawn into the lungs, on purpose to produce a fit of cough∣ing; but it had no such effect, and she died in the evening.

WHEN the trachea was opened, by Mr Wood, the whole internal surface was cover∣ed with a membrane for three inches down∣wards from the glottis. This membrane was compleat all around, did not adhere to the trachea, and came off in the shape of a hol∣low tube. The natural coats of the trachea seemed entire, and not ulcered. The substance of the lungs was quite sound; but the vesicles of the left lobe were filled with yellow thick pus, which sunk in water. The new formed membrane had some degree of tenacity; and, when steeped in milk-warm water for two days, did not dissolve, but preserved some degree of cohesion. Mo fibres could be observed in it.

THE preceeding facts excited the curiosity of some gentlemen, and have been confirmed

from similar observations made by them, and which they lately transmitted to my hands.

CASE IX.

MR Wardrobe Surgeon related to me the the following case. A boy, eight years of age, and healthful, had been ill two days. His breathing was difficult; his voice was croupy; he was feverish, and had all the o∣ther symptoms of the disease. He was blood∣ed, blistered, &c. but all to no purpose; and died the fourth day.

THE whole trachea, externally, appeared swelled, and rather oedematous than inflam∣matory. When he opened it, the whole in∣side was covered with a soft, thick, pale-co∣loured membrane, which easily separated from the parts below; those had a slight degree of inflammation. When he pursued the ra∣mifications of the trachea thro' the lungs, there was found, there, a considerable quantity of real pus, which seemed to fill all those pipes. The lungs themselves were sound. Nothing can be liker the former cases than

this; and as Mr Wardrobe had no occasion of ever seeing it again, he had concluded, as I had done before, in similar circumstances, that it was an anomalous case. It now ap∣pears to be the common course of nature, in that disease, when mortal.

CASE X.

THE following case, in confirmation of the preceeding, was communicated to me by Mr Balfour Surgeon, and which I shall de∣liver in his own words. November 1st 1763, I was desired to visit a child, between two and three years old, living at the Canonmills. His face was flushed; his breathing laborious; his cough of the hard croupy kind; his pulse was frequent; his tongue clean; with little drought, and no pain. I was informed by the parents, that the child had been very healthful; but for eight days past had been troubled with a cough, which did not put on the present appearance till the night be∣fore I was called; and that the child had, till that time, gone about, and eat his meat heartily. They had then applied leeches to

his neck, which bled a great deal, and had with difficulty been stopt. I immedi∣ately took away, from the jugular vein, two cupfulls of blood more, which was sizy; and being informed, that he sometimes reached, I ordered a vomit of tinct. ipecacuanh. with an addition of acet. scillit. which was given about an hour after he was blooded, and brought up a great deal of tenacious mucus. That night, he got a blister to his back, and the saline mixture every two hours. Nov. 2d, His Pulse was as frequent, but not so firm. All the other symptoms rather worse. He was ordered a decoction of the bark; the oily saline mixture, to be taken internally; and the camphorated volatile oil, to be ap∣plied externally. The child took two or three doses of the decoction and mixture; but towards the evening, the symptoms grow∣ing worse, the medicines were discontinued. The child died next morning.

WHEN the trachea was laid open, I thought that a suppuration had happened; but, upon nearer inspection, found, that it was only the mucus which had acquired a pu¦rulent

colour; and that it was formed into a membranous crust, which every where lined the internal membrane of the trachea, from the larynx, to its entrance into the thorax. This preternatural membrane appeared thick∣est about the middle of the trachea; and, there, seemed almost to fill up the passage. It was so firm, that a considerable portion separate∣ed, at once, leaving the natural membrane of the trachea bare and sound, and with the appearance of a slight inflammation. I put a considerable portion of the preternatural membrane into water; and, after that, it still retained a degree of tenacity, but had too little firmness to be preserved.

CASE XI.

MR Wood Surgeon gave me the following. A child, about sixteen months old, was seiz∣ed with the Croup, and died the seventh day. On opening the body, there was found in the lower part of the larynx, and beginning of the trachea, a substance of a membranous appearance, adhering slight∣ly

around the inside of these parts. When it was removed, the membranes of the trachea were found entire, and somewhat redder than usual. Along the trachea and bronchial branches, there was a considerable quantity of mucus. It was frothy, and somewhat tenacious. This mucus ex∣tended as far as the membranous appear∣ance, and downwards into the minutest branches of the bronchiae, in which it had a yellowish purulent appearance. The surface of the lungs was somewhat reddish.

CASE XII.

THE following case, which was communi∣cated to me by—, I think worth relating; as it shows the disease in a different situ∣ation from all the preceeding; indeed, under such circumstances, as I never had an opportunity to see, and must appear very seldom in, for it is the only one of its kind that I have heard of.

MISS ******, about nine years old, was seized with a slight cough, on the 25th of

October, owing to rainy weather, and wet feet. On the 26th, when I saw her first, the scarcely had any heat, thirst, or sickness, and no pain of any kind, except when she cough∣ed, or was fretted, which bringing on a quick inspiration, she then felt some slight pain in the windpipe, a little below the rima glottidis. Her voice was shrill, like that of a young cock. She was blooded; got a gentle vomit; emolient cataplasms to her feet; and a blister to her back. 27th, Symptoms no better. No difficulty of deglutition, and no redness to be seen in the throat. She never expec∣torated any thing like pus or phlegm, during the whole course of the disease. Steams of warm water were tried. 28th, Her cough was incessant for some hours, during which, she coughed up a piece of a membrane. This I believed to be a part of what lines the trachea, as it had a mortified appear∣ance, and was like black shagg silk. She died soon after this.

UPON opening the body, the disease seem∣ed seated, solely, in the head of the trachea, as its membrane appeared to me mortified

two inches downwards. Below that, the trachea, and its branches, seemed quite sound.

IT was very natural for one, who had never any opportunity of seeing this disease in its natural situation, to think, that a mor∣tification had seized on the coats of the tra∣chea. But to one who has been accustom∣ed to inspect bodies, in this disease, it must appear probable, that it was only the preter∣natural and morbid membrane become black, which gave the trachea the appearance of be∣ing mortified. No wonder that the coats of the trachea were thought to be in a gangre∣nous state, when I imagined they had suppu∣rated in the first case, that I met with. The coughing up a piece of the membrane, shows that it was this loosely adhering one, and none of the natural ones, which are so firm∣ly attached; and which, having no fleshy parts below, could not have been so easily se∣parated. This, then, appears to differ in no other point from the others, but only that here the morbid membrane had dryed

and turned black; whereas, in all the former, it was moist and white.

THESE are all the cases, that I have kept an account of, or received from others. Tho' few, they are leading ones, and sufficient to establish many material facts and circumstan∣ces, that have hitherto been unknown, with regard to this disease. We will now draw, from them, some conclusions; which, as we have proceeded so cautiously, will be the more certain. If we add any reasoning, to set these conclusions in a clearer light, we shall keep as close as possible to settled experi∣ment; and shall give it only as probable con∣jecture, finding fault with no person who may reason differently.

COROLLARY I. It seems easy, in general, to distinguish the Croup from all other diseases hitherto described. A peculiar sharp shrill voice, not easily described; a remark∣able freedom from all complaints, when in imminent danger, so that they will eat a mi∣nute before they expire; a quick laborious breathing; a frequent pulse, sometimes strong at first, but always soft and weak to∣wards

the end; scarce any difficulty of de∣glutition, or remarkable inflammation in the fauces; a dull pain, often, and sometimes an external swelling in the upper part of the trachea; senses quite distinct to the last; and all the symptoms most rapid in their progress, characterise sufficiently this disease. I have not mentioned a cough, as that symptom is sometimes absent; and when it attends the Croup, it is not of the common kind, but more short and stiffled, and less convulsive, with little or no expectoration.

THE other symptoms, that often attend it, such as a red swelled face, oedematous feet, drought, urine sometimes with, and, at other times, without a sediment, reachings, &c. are not so constant as the former; and therefore, are not so characteristical.

THOSE not conversant in this disease, of∣ten mistake peripneumoniacal complaints, and severe colds, for it; and, as they frequent∣ly cure these, they are apt to look on it as not so dangerous. But we have seen, that the lungs are totally free from any inflam∣mation, and are not the seat of the disease.

The Catarrhus suffocativus of Etmuller seems, likewise, to have been a peripneumony. And, as he describes no peculiarity in the voice; as the symptoms seem to have been, apparently, severer; and as it returned, at stated and re∣gular periods, we must consider them as dif∣ferent diseases, tho' similar in many points.

As this disease has different vulgar names, for I am told, that on the west coast, they call it the Chock, or Stuffing, a technical one becomes absolutely necessary. A name is best given from the apparent symptoms, which are al∣ways conspicuous, while the cause is general∣ly hidden, and often doubtful. The lead∣ing symptoms here, are, the shrill voice, and difficult breathing. It, therefore, may pro∣perly be ca••led Suffocatio stridula.

COROL. II. As it appears peculiar to a certain age, and local, in a great measure, as to its situation, so it seems to attend certain seasons of the year. All the preceeding cases showed themselves during the course of the winter, from the month of October to the month of March, except one in August, which was probably owing to the antecedent

small-pox; for long catarrhs from the small pox, measles, or chin-cough, are strong pre∣disponent causes to this disease. The moist and cold weather in winter, seems to have great power in producing this disease.

COROL. III. Very different have been the opinions, with regard to the seat of the Suf∣focatio stridula. Some placing it in the glot∣tis and its muscles; some in the coats of the trachea; while others have fixt its seat in the lungs themselves. None of all these opini∣ons appear to be true. The glottis is never found contracted or inflamed; the lungs are quite sound; and the coats of the tracked seem to suffer only by second hand.

THE seat of this distemper appears to be the cavity of the wind-pipe. The place first, and most particularly, affected, is the upper part of the trachea, about an inch below the glottis; for in that part they complain of a dull pain; the external swelling has been ob∣served there; and the morbid membrane we have found stretching from that place down∣wards. The back part of the trachea, where there are no cartilages, seems, from the in∣spection

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spection of those that die of this disease, to be its first and principal seat, as this morbid membrane is often found there, when it is in no other part.

No wonder that the morbid appearances are chiefly found there; for, there, are lodg∣ed the greatest number of glands, designed for the secretion of mucus. This fluid is se∣parated from glandular bodies, deposited be∣twixt the different membranes, which are per∣forated by an infinite number of almost im∣perceptible small holes, that give a passage to the excretory ducts of these glands. The largest of these lye on the outer, and poste∣rior surface of that membrane, which serves, on the back part, to make up the deficiency of the cartilages, as they are not compleat circles.

IN some of the former cases, the whole glands, at the root of the tongue, and the amygdalae were turgid, and the parts covered with mucus. In the mucous glands, in general, this distemper ought to be considered, as ori∣ginally seated; but, from particular causes, more directed to those of the trachea;

where, from the nature of the part, it be∣comes visible in a different shape.

COROL. IV. Various have been the the∣oretical opinions of people, who never had the opportunity, or gave themselves the trouble, to search into the real cause of this distemper. Some have attributed it to spasms of the muscles, that contract the glottis. That it was not occasioned by spasms of the muscles, that contract the larynx, might have appeared from the symptoms them∣selves. Had this been of the class of spas∣modic nervous diseases, it would have come in paroxysms, with remission and exacerba∣tion; the urine would always have been pale; convulsions would have come on before death; and antispasmodics, instead of evacuants, would have been the remedies.

HAD these muscles, or any of the coats of the trachea, been inflamed or mortified, as others have thought, the pain would have been greater than it is, before the mortifica∣tion; and the pulse would have been strong∣er, than it generally is, as the parts are membranous.

IF, according to the opinion of many, the lungs had been inflamed and suppurated; the cough would have been more incessant and violent; the pulse full and soft; with a sen∣sation of weight in the breast, sizy blood, dry tongue, and delirium.

BUT all these fanciful erroneous opinions fall to the ground, when we once inspect the morbid body. From that true source of knowledge, we learn, that the cause of this disease is a preternatural white, tough, thick membranous crust, covering, often for many inches, the inside of the trachea. This mem∣brane is of so tenacious a consistence, that it can remain soaking in warm water, for ma∣ny days, without dissolving. It is not at∣tached to the parts below, but is easily se∣parable from them, as there is always mat∣ter behind it. When it ends, the trachea is covered with good pus, or purulent mucus; as are, generally, the ramifications of the bronchiae and vesicles, which, in some cases, were quite filled with it. To account how this matter, as there is no ulceration; and how this membrane are formed, we must trace things from their source.

THE blood consists of three principal parts, the crassamentum, serum, and lymph; the last of which is a diaphanous liquor, full of ge∣latinous and nutritious particles. This liquor very similar to the white of an egg, is coagulable by heat, alkohol, acids, and by every method which attracts or evaporates the watery particles. This coagulable part, probably, is the nutritious part of our blood.

THIS gelatinous lymph abounds more in young animals, than in those come to matu∣rity. Geoffroy le Cadet, in the Mem. Acad. des Sciences, for the year 1730, by many ex∣periments shows us this fact; and makes it appear, that there is twice as much nutritive jelly in veal, as in beef. The final reason for this is self-evident; for young creatures, on account of their growing, require a greater supply of nourishment. Children must, there∣fore, abound more with it than men.

The mucus separated from glands, in diffe∣rent parts of the body, viz. nose, fauces, oeso∣phagus, stomach, guts, trachea, and bronchiae, appears to be very analogous to this lymph.

The former differs from the latter, only, in its greater spissitude; and this alteration is brought about after its secretion, the more watery parts being volatilized and dissipated, while the more heavy and viscous remain be∣hind. This mucus is extremely disposed to inspissation, as appears from experiments. Even the admission of cold air into the tra∣chea thickens this mucus, often, to such a de∣gree, that it stagnates in the glands, and all secretion is entirely stopt.

IN children, as well as in old people, this secretion is plentiful, owing to the great quantity of it they contain, and to the laxity of their vessels. This evacuation is particu∣larly increased during the cold and moist weather of winter, when the perspiration is diminished, and the glandular secretions in∣creased.

THIS evacuation is promoted by all sti∣mulants, operating on the trachea and lungs, as we observe from the effects of snuff, and the smoak of tobacco. The maritime air supplies a stimulus, calculated to increase the secretion from the mucus glands of the trachea

and lungs. Along with the moisture, sweep∣ed from the sea by the winds, is carried likewise, a great quantity of sea-salt; as every thing, at some distance from the shore, tastes salt. This inspired into the lungs, stimu∣lates the orifices of the tracheal glands, and increases the mucous secretion. This effect will happen more particularly in children, as their nerves are more irritable, than those of people advanced in years. Hence we find, that, in moist winter weather, particularly a∣long the sea-shore▪ children should have an unusual secretion of mucus, from the glands of the wind-pipe. Diseases, such as the small∣pox, measles, chin-cough, &c. and other na∣tural causes, have the same effect in increasing this discharge. When these are combined, there exists the greatest predisposition to this disease.

WHEN there happens a very great secre∣tion of this coagulate fluid from the glands of the trachea in children, they are either not sufficiently attentive, or often too young, to spit it up. The thinner parts are carried off during expiration, while the remainder is

thickened and compressed, by the obstruction, that the narrowness of the glottis must make to the exit of the air from a larger canal. Every circumstance encourages its concre∣tion into a solid firm membrane, while the more internal parts of the mucus, continuing still fluid, and the continual secretion of more, keep it separated from the parts be∣low.

BUT how happens it that we find pure matter, which sinks in water, behind the membrane, and in the different ramifications of the trachea, when there is no ulceration? Matter does not seem to be formed, as was generally thought, by the vessels of the ulcer; but to exist in the blood, particularly in the serous and lymphatic liquors, nearly in the fame state; and to be, probably, the true nu∣trititious, nay, perhaps, the coagulable part of our fluids. Dr Pringle, in his ingenious, useful, and accurate experiments, upon sep∣tic and antiseptic substances, found, that the serum, when stagnating, and exposed to heat, let fall a white substance like pus; and, from thence, justly, concludes, that the pus of ulcers is formed, in the same way, by the evapora∣tion

of the more watery particles, and the subsiding and inspissation of this part. This fluid shows a great tendency to become solid, by restoring quickly all loss of substance.

THERE cannot be a fitter situation, for the formation of pus from the mucous secre∣tion, than the trachea and lungs. There the same secretion, evaporation, stagnation, and heat exists, as in an ulcer; and, therefore, the same consequence should, and does, hap∣pen. We often see real pus spit up in the end of a cold. Perhaps this change from mucus to pus, happens before the membrane is formed, as pus shows such a tendency to assume a solid form, and is designed by Na∣ture to repair all deficiencies in the solids.

THIS disease now appears of a very singu∣lar nature, and unlike any other that we know. Du Haen has, indeed, lately told us, that he has sometimes found, in dissection, the viscera covered, externally, with a white tough crust. I wish he had given us the history of some of these patients. He ima∣gines, that it was formed from the inflam∣matory crust in the blood; but, here, these never is found any.

I HAVE lately met with a description in the Philosophical Transactions abridged, Vol. 3d, page 68th, of a membrane formed in the inside of the trachea."

"A boy five years old, died of a consumption. A year be∣fore his death, he was troubled with a dry cough, which continued ever after, spitting, now and then, a little quantity of blood. Ten or twelve days before he died, his nurse took notice of some thick skins he spit up. His Physcian, having exami∣ned one of them, sound, it had the shape and consistence of a vessel, which made him think it might perhaps be some ves∣sel of the lungs. The child being dead, I opened the body. In the left side of the lungs, I found a little purulent sanies. The inside of the trachea was incrustated with a slimy membrane, which I took off from the trachea, and the branches in the lungs, insomuch that that pellicula made a perfect vessel, from the larynx to the ve∣ry extremities of the bronchiae, from which it came off very easily, without breaking ei∣ther the trunk, or the branches. It adhered

to the inward coat of the trachea, only by some small filaments, which were so ten∣der, that they broke off easily; and made me think, the production of that extraor∣dinary vessel was nothing but the mucila∣ginous humour, continually discharged by the glands of the trachea, grown more clammy by the distemper, and so dry that it could not be spit out; this incrusting the inside of the trachea and bronchiae, and growing thicker, was at last shaven off by the violent fit of coughing the child was sometimes taken with, and then was re∣newed again by the succeeding mucus. This new vessel would not dissolve in hot water. The vessels of the lungs, that is the tra∣chea and bronchiae, the pulmonary arteries and veins, were as whole as could be."

IT appears, by the dissection, that there was no imposthume formed in the lungs; and that the child died from this preternatural membrane. Perhaps, many of the polypus's, thrown up from the bronchial vessels of grown up people, might have the same origin.

These cases show, how apt the mucus is to ac∣quire a solid form.

WE have an account, in the Philosophi∣cal Transactions abridged, vol. 2d, of a dis∣ease in Cornwall, called the morbus strangula∣torius, which, from the pustles, petechiae; and putrid disposition of the fluids, appears more nearly allied to the malignant sore throat, altho' it sometimes attacked the aspera arte∣ria. A case is, there, related, where a hol∣low membranous coat, of the shape of the trachea and its branches, was coughed up, and supposed to be the natural membrane of these parts. Another similar to the former came up afterwards. The patient lived about a day after this.

COROL. V. There appears, from the pre∣ceeding facts, two very different situations of the Suffocatio stridula; the former more in∣flammatory, and less dangerous; the latter less inflammatory, and highly dangerous. In the former, the pulse is generally strong; the face red; drought great; and they agree with evacuations: In the latter, the pulse is very quick, and soft; great weakness; tongue

moist; less drought; great anxiety; and evacuations hasten death. The former may be called the inflammatory; and the latter, the purulent state.

THESE are two very different stages of the distemper, and must be carefully distin∣guished by the practitioner, that he may know how to direct his applications; or, at least, how to form a just prognosis; as he is, generally, not called till the patient is in the latter stage. If this disease comes on with an old habitual cough, or by slow de∣grees, the inflammatory stage will scarcely be perceivable.

IF the pulse is very soft and feeble, especi∣ally after being strong; or any purulent mat∣ter comes up with spitting, vomiting, or coughing, which happened in some of the former cases, we have a proof that the pu∣rulent state is, already, formed. Experi∣ence has taught me another mark, by which I can distinguish these different states. I have observed, that the urine, which, du∣ring the inflammatory state, is thin, had always, after the purulent state came on, a

light ouzy purulent sediment, such as people have from matter collected any where, that has no vent outwards.

NO wonder, that the matter is speedily absorbed, in this situation, as it is contained in the bronchiae and vesicles, and of course im∣bibed by the whole internal surface of the lungs and trachea; a surface infinitely great∣er than any imposthume can have. Hence the blood will be suddenly filled with it; and the urine have that white purulent sediment, which arises from absorption of matter.

IN the latter stage, we find the membrane compleatly formed. Is it so in the former? I suspect that it has not yet got a firm con∣sistency; otherwise evacuations would not have so sudden and salutary an effect, as they produce in this stage. Perhaps, the turgid and inflamed glands are but yet expelling the thick mucus, which is circulating thro' the vessels in too great a quantity, and in too in∣spissated a state. This is strongly confirmed by the great quantity of mucus, sound in the stomach, and the swelling of the mucous glands at the root of the tongue. Even af∣ter

death we perceive some degree of inflam∣mation in the coais of the trachea, which probably has been greater at the beginning, when the flux of humour commeneed, and the irritation was stronger.

COROL. VI. It seems to be no very dif∣ficult matter to account, from the cause, for all the symptoms of this disease. A strait∣ening of the trachea, and dryness of the parts, will mechanically alter the voice, and make it more shrill; for we find in all wind instru∣ments, the notes are acute in proportion to the smallness of the bore. Mr Balfour sur∣geon told me, that he attended a child in a disease, which, from the similarity of voice, appeared to him the Croup. The child died. When opened, a piece of shell, which the child had sucked in with it's breath, was ly∣ing across the trachea, about an inch below the glottis, and the membrane was infla∣med and dry. Here was an artificial Croup raised, from which we may evidently per∣ceive how the voice is altered in the natural disease.

WHEN there appears to be a great quan∣tity of mucus circulating in the vessels; when there is, often, so much mucus or pus in all the pipes of the lungs; when there is a preterna∣tural membrane formed in the trachea; no wonder that Nature excites a fever, her ge∣neral and constant resource, when she is vio∣lently attacked and in danger.

CONSIDERING the acuteness of the fever; considering the obstruction in the trachea, bronchiae, and vesicles; with what difficulty the air must gain admission to distend them; and what hindrance that must give the blood circulating through the lungs; a laborious breathing must, necessarily, attend the other symptoms.

AS the blood passes with some difficulty thro' the lungs, an unusual weakness must certainly come on, the face become swell∣ed, and the extremities appear oedematous.

TO account for that total want of pain, or so slight a one that they don't attend to it, unless when asked, is a matter of some difficulty. That the membrane of the wind∣pipe, in general so very irritable from every

slight cause, should calmly bear the presence of such a quantity of matter, and of so thick a membrane, is not the least surprizing cir∣cumstance of this uncommon distemper. The mucus being a humour natural to these parts; its slow and gradual collection and inspissa∣tion; fresh mucus constantly separated, which hinder the membrane from hurting the tra∣chea, unless in motions of the neck; these reasons may account, in part, for the dimi∣nution of that natural irritability, which re∣sides in these places. But they do not satisfy me altogether. We cannot expect to have all our doubts removed.

COROL. VII. This disease appears, in ge∣neral, to be a very dangerous one, and the more so, as it is silent in its progress, and gives no visible alarm, till death is near at hand. The first stage of this distemper, of∣ten, passes unobserved; and, before we see it, is beyond all remedy. As it happens, fre∣quently, to young children, who are unable to speak or describe their feelings, we have double reason to be afraid.

IF we be not called till the third or fourth day; if the breathing appears much affected, the pulse quick and weak, the face red, great anx••ety, and frequent tossing, the dan∣ger is great and pressing. But if we see the patient the first or second day of the attack; if the breathing is not very bad; the pulse, though frequent, strong, and firm; and more especially, if the voice is only altered, in its stronger exertions of crying or cough∣ing, but more natural in its common state, we may entertain hopes of a recovery. The first sign commonly of safety, is the cough becoming stronger and less dry, with that peculiar sound which attends moistened lungs; for this shows that the membrane is not formed, or is already dissolved, and that the inflammatory state is abated.

THE case seems very desperate, when the membrane is once formed, and the lungs filled with matter. In the latter case, the patient is soon suffocated, as effectually, tho' more slowly, as if he was immersed over the head in it.

IT appears, from the preceeding cases, that the membrane, alone, is sufficient to kill, as there was but little matter found in the lungs of some of them.

DESPERATE as the case is, the patient's recovery is, perhaps, not altogether impos∣sible. Nature, by the means of a critical cough, may eject the membrane and matter; though, indeed, the sensation of these parts, by which it must effectuate this, seems al∣most altogether destroyed. If that happen∣ed, the patient would recover, as the lungs are quite sound.

IN one of the former cases, part of the membrane was thrown up, but the patient died. I was told by Mr Gibson surgeon, that a patient of his escaped, after throw∣ing up a great quantity of matter, and coughing up large pieces of a membrane.

THE following curious case was commu∣nicated to me, lately, by Mr Rae surgeon. A boy betwixt five and six years of age, was seized, August 5th, 1764, with a slight cold and hoarseness. On the 8th, had a dif∣ficulty of breathing, the shrill voice, and a

little fever. As the boy was in a natural sweat, he ordered a mixture with Spt. Minder. 9th, Pulse quicker, and no expectoration. Was blooded, got an injection, and had a blister applied to his throat. 11th, This morning he was told, that, after a severe fit of cough∣ing, a membrane-like substance, about two inches long, pretty tough, and resembling a piece of thin white leather, had been thrown out. In the evening, some pus was obser∣vable in the phlegm expectorated up, and ea∣sily distinguishable from it. The boy did not recover his voice for three months.

ART, though not in the way of internal medicine, may attempt effectuating the same end.

COROL. VIII. We have had occasion to see, in the preceeding cases, great variety of different applications, and their good or bad success. Let us deduce some general rules with regard to practice. In the inflam∣matory state, bleeding appears to have been attended with immediate good effects, and to be a powerful remedy in this situation. This ought to be done expeditiously and plentifully, while the pulse will allow it. It

is best to take blood at first, with the lan∣cet, so that a sufficient quantity may soon b•• drawn off; and, afterwards, by leeches, appli∣ed to the upper and fore part of the throat. Their orifices, when kept open by the appli∣cation of warm wet-cloths, will allow the blood to onze from them for many hours.

IT seems necessary to keep the patient's belly constantly loose, by such medicines as children will take; for we ought to be ve∣ry attentive not to set them a-crying, as that may suddenly suffocate the child. For this purpose, I generally use tablets of magnesia alba, made palatable with sugar. Some of the cooling resolvent salts, such as the chry∣stalised sal polychrest, dissolved in whey, will be of service, provided the patient will peace∣ably take them.

BLISTERS; applied round the neck, af∣ter the vessels are well emptied, do great service. They seem to do none, when ap∣plied before this time; nay, if the state is very inflammatory, must do much hurt, from their violent stimulus on the vessels. Emollient fomentations and cataplasms, ap∣plied

round the neck, are of considerable use, and keep up a local evacuation.

THESE evacuations operate in several dif∣ferent ways, viz. by thinning the dense mu∣cus, while yet circulating in the blood; by diverting its flux from the parts affected, as there is a great communication and consent betwixt the different mucous glands thro' the body; but, particularly, by increasing the absorbent power of the vessels on emptying them; by which means the purulent mat∣ter will be sucked in from the lungs. It was found in the urine of one of the foregoing convalescent patients.

THE resolvent and gently stimulating steams of warm water and vinegar, drawn in with the breath, seemed always to have an immediate good effect. Is it from dissolving the thick mucus, and so opposing its concre∣tion? That is probably the case, as the pa∣tient always spits a great deal after it, and the lungs appear moister.

VOMITS are, frequently, given in this stage of the disease. They are, generally, thought to be of use; but I never saw any

advantage arising from them. I rather su∣spect that they must be often pernicious, as they increase the secretion of mucus in the lungs, without expelling it, which is the ve∣ry circumstance that, if possible, we ought, to guard against. The evacuation that they make otherways is but small.

GENTLE sudorifics may be of service, as they divert the flux from the more internal parts to the external. Others think that these are of use; and prescribe the Vin. emet. in small quantities. I cannot say that I ever saw any great advantage from them.

BUT when the membrane is once form∣ed, or the purulent matter, in great quantity, collected in the lungs, evacuations can be no longer of any use; they rather hurt, as the pulse is then weak. Hence the reason, why people differ about the effects of evacu∣ations in this disease; some deeming them the only certain remedy, while others hold them to be destructive. Both have built their opinion on fa••ts and observation. But as their applications were made in different stages of the distemper, the effects behoved

to be different. What was the only remedy in the inflammatory state, must appear hurt∣ful in the purulent.

IN this state of purulency we plainly see, that nothing can do service, but what brings up the matter from the lungs, and that spee∣dily too. And pray what medicines can do this? Vomits only evacuate, immediately, the stomach; but by means of the sympa∣thy of the nerves, they often bring on a coughing, during their action. They might be of service, if they had this salutary effect; but I never saw them answer this purpose, though often given with that design. The nerves are, indeed, so unactive, that we can entertain no reasonable hopes from this quarter.

SHALL we endeavour to excite a cough, by the means of effluvia, or steams inspired into the lungs? That has been tried, to no purpose; for the membrane which covers the trachea, and the mucus or matter which co∣vers the lungs, render these parts insensible to any external irritation.

To effectuate a solution of the morbid membrane, after it is once completely formed and consolidated, seems to me impossible by any internal or external medicine that I know. To effectuate its expulsion appears equally impossible. We have, then, no method re∣maining to save the patient's life, but that of extraction. That cannot be done thro' the glottis. When the case is desperate, may we not try bronchotomy? I can see no weighty objection to that operation, as the membrane can be so easily got at, and is ve∣ry loose. Many a more hazardous opera∣tion is daily performed. I would propose, however, that it should be first tried on a dead subject, that we may proceed with all manner of caution and assistance. But something ought to be tried in this dange∣rous situation.

WE have now brought our Inquiry to a conclusion. The facts, we hope, will ap∣pear curious, exact, and sufficiently nume∣rous for our purpose; the method such as as is used in mathematics and natural philo∣sophy, for discovering unknown truths; and

the conclusions new, surprising, and natu∣rally arising from the facts. If we have not brought this Inquiry to that degree of per∣fection, in every point, that we could have wished, we have the satisfaction, at least, to think, that, so far as we go, our discoveries are certain, as they are built on the foun∣dation of Nature. Shunning, with all ima∣ginable care, fruitless and deceitful specula∣tions, however entertaining, we have con∣stantly kept our facts and experiments in view, as the only road to the improve∣ment of medicine, and the good of man∣kind.

FINIS.