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I1VN JN.3.03W JO ABVBB.l TVNOUVN 3 N I 3 I Q 3 W J O A B V B B I 1 IVNOIIVN JNI3I03W JO / lX> i MiVN 3N.3.03W JO ABVBB.1 IVNOUVN 3 N . 3 > 0 3 W J O A » V B 8 ,1 1 V N O > 1 V N 3NI3.03WJO BRARY OF MEDICINE N A T I O N A I L I B R A R Y O F M E D I C I N E NATIONAL II =. ^ 0.1VN 3N.3,03W JO ABVBBM IVNOIIVN JNI3IQ3W JO ABVBB.l TVNOI1VN 3N.3.a3WJI \ 1 <■ f vj ..CINE3 NATIONAL LIBRARY OF M E D I C . N E NATIONAL L.BRARY OF MEDIC, NE NATIONAL L ,,,»» .......,,...».iiii..oh»..........mnni...ii.. ■»,>...«. r& • .''Si, • 7X •: /^KSa DISSERTATIONS ON CYNANCHE TRACHEALIS <&v Croup; AND ON THE FUNCTIONS OF THE EXTREME CAPILLARY VESSELS IN f^calth airt ©fscaar; TO WHICH WERE AWARDED THE BOYLSTON PREMIUMS FOR THE YEARS 1820 AND 1823. BY WILLIAM SWEETSER, M. D. FELLOW OF THE MASSACHUSETTS MEDICAL SOCIETY. v BOSTON* PUBLISHED BY CUMMINGS, HILLIARD & CO. HILLIARD AND METCALF, PRINTERS. 1823. A^ IS 43 ft»» % <®n Cgnaucfte &racftealt& Cynanche Trachealis has been believed by some medical writers to be a disease of late origin; it appears to me, however, that even a very partial examination into the medical works of the ancients will prove to us that this, or certainly a complaint bearing its characteristic marks, existed long ago. I do not mean to be understood that there are any accurate or clear accounts of it in the writings of the older physicians ; this we could hardly expect, had the disease been common, so little were the complaints of children formerly regarded. Hippocrates, and others who wrote not far from his period, divided quinsy into two species; in the one there was no tumour, nor any manifest disease of the fauces and parts within view; in the other, disease here was evident to the senses. The former species they universally described as being most fatal. Aretaeus, as Van Swieten states, believed it so fatal that he compared it to the mortiferous vapours, which, exhaling from damp pits or caverns in a moment, suf- focate people.* In relation to it, Hippocrates remarks, " there arises an orthopnaea with a great dryness, and * Van Swieten's Commentaries on Boerhaave's Aphorisms 4 the parts within view are slender or without swelling. Likewise the posterior tendons of the neck are con- tracted and seem to be stretched as in tetanus. The voice likewise is disturbed or broken, the respiration is small, and there arises a frequent and violent draw- ing in of the breath." He likewise states that this species of quinsy often induces suffocation on the very day of its attack, and also on the second, third, and fourth. The older writers do not speak of it as being peculiar to children, which affords reason for believing that the Cynanche Laryngea might, in their time, have existed and been confounded, as it has been among ourselves until very lately, with croup. Boerhaave describes a species of quinsy where there is no tumour, nor any manifest disease about the fauces, and which he supposes to have its seat in the trachea. His description of its symptoms corresponds very well with those which are now known to occur in croup. He likewise speaks of it as affecting the upper part of the larynx particularly, and his com- mentator enumerates its diagnostic marks when affect- ing this part, and when especially confined to the ' trachea. We have no reason for believing that the early writers in medicine had any idea of the false membrane so frequently witnessed in those who die of croup. Their limited knowledge, however, of morbid anatomy will sufficiently account for their ignorance on this point. Whether the Cynanche Trachealis is of more fre- quent occurrence now than formerly, cannot with certainty be decided. Many more cases have been recorded of late years, but whether this is owing to 5 the disease being more common, or to its having excited more attention, we do not know, though we should rather be inclined to attribute it to the former cause. In some situations there can be no doubt but that of late it has become more frequent, whilst in others it may perhaps be more rare in its occurrence. In the report of the diseases of Edinburgh for Decem- ber 1807, it is stated that croup at one time was a very common disease there, but that lately it had almost entirely disappeared. Martin Ghisi, an Italian physician, appears to have been the first who gave any thing like a regular his- tory of croup. This was written in 1749. During the same year Doctor Starr, of Great Britain, pub- lished a paper on the same complaint, in which its symptoms were pretty accurately described. He also gave the drawing of a membrane, which had been expectorated in this disease, and which seemed from its shape to have lined the trachea, and some branches of the bronchiae. But the notions of these gentlemen in regard to the nature of the disease were quite vague and unsatisfactory, so that the treatise by Dr Home, of Edinburgh, which appeared in 1767, is now gener- erally considered as having given the first clear account of it. In 1798, Michaelis, of Gottingen, published a paper, De angina Polyposa sive Membranacea, in which he gave a full and pretty accurate history of all that was then known of the disease. Since the pub- lication of this last treatise, the complaint has excited a good deal of attention ; much too has been written about it, a considerable part of which rather serves to confuse, than give us any clear notions of its nature. 6 Even at present we are not entirely agreed in its pathology, many physicians still believing it to be a spasmodic affection. The disease of which we are treating is peculiar to children, who appear to be most subject to its attacks from about the time of weaning until their sixth or seventh year. It does, however, occur both earlier and later than these periods. Dr Ferriar observes that he has seen children affected with it almost at all ages under nine ;* and we have well authenticated instances of its occurrence even still later in life than this. It attacks, though not indiscrimi- nately, children of very different habits; we see it both in the healthy and robust, in the sickly and delicate. Cheyne thinks it occurs most commonly in children of very robust constitutions. Others have believed it to be more peculiar to those of a scrofulous disposition. I have heard a medical gentleman of high eminence state, that he has noticed it to occur most frequently in children of a fair complexion, and light hair, who have large heads, short necks, and naturally full round faces.f Both sexes seem equally liable to it. After children have once been affected with croup, the parts on which it has its seat seem more ready, perhaps, as some believe, from the influence of habit, * Medical Observations and Inquiries. t This remark is made in his Lectures by Dr James Jack- son, Professor of the Theory and Practice of Physic in Harvard University. In the four last cases of this disease which have fallen under my observation, two of very recent occurrence these physical characters in the individuals were very stronglv marked. 7 again to take on this diseased action; and it has been noticed that after having had frequent attacks of it, they will often after a little exposure be affected with cough, having the peculiar sound of this complaint, and slight wheezing during respiration, which symp- toms soon go off, either without any remedies at all, or by the use of the common family ones. It is a very common opinion that the after attacks of the croup are more mild than the first, the danger from the disease seeming to diminish almost in the direct ratio of the frequency of its occurrence. This opinion is, no doubt, correct to a certain extent, but not univer- sally. Parents, too, after their children have once been afflicted with the disease, detect it more readily, and being aware of its dangerous nature, call in assistance at its very onset, which seasonable attention may both shorten and mitigate it in its course. Some instances are adduced by European writers to show that croup does at times prevail as an epi- demic ; but I am incapable of deciding what reliance is to be placed upon them. We certainly have no well authenticated account of its having prevailed epidemically in our own country. Some have asserted it to be contagious, but observation seems by no means to support this assertion. There occasionally appears to exist in some families a predisposition to the disease, so that at times, we find it attacking successively the different children of a whole family. In such instances there may perhaps be an hereditary weakness of the parts on which this affection has its seat. Cynanche Trachealis occurs in almost every cli- mate, but it is by far the most prevalent in cold cli- 8 mates, having a moist atmosphere, and which arc liable to great and sudden alterations. In our own it occurs most frequently in the spring and autumn, those seasons during which the weather is most variable. In the winter months it is less frequent, and we hardly ever witness it in the summer. Its exciting causes, therefore, appear to be the same as those which give rise to other iuflammatory diseases in organs above the diaphragm; as catarrh, pneumonia, &c. and it has been by some observed to occur most commonly when such diseases have been most prevalent. It was the belief of Dr Home, and many other physicians have since held to the same opinion, that this complaint was peculiar to maritime places ; there is abundant evidence, however, to show that it is also common in inland situations. It has likewise been stated to prevail most in the neighbourhood of large bodies of water, and near marshy grounds. In Cheyne's Essay we find the following note—" This disease, we are informed by Dr Crawford, prevailed in the Carse of Gowrie, a plain in Perthshire, bounded by the river Tay ;" but he adds, " Haec planities vero nuper desiccata fuit, et varius occurritur morbus." The more frequent occurrence of this, as well as of other inflammatory affections in such situations, may be accounted for from the greater exposure to their exciting causes. Croup,*in some instances, appears to follow as a consequence of certain other diseases, for which reason some have divided it into symptomatic and idiopathic. It will sometimes succeed to catarrh, cynanche tonsillaris, and cynanche maligna. Dr 9 Ferriar observes he has seen it occur in two cases of ulcerated sore throat, and that he has seen pneumonic inflammation converted into it. In some instances it will follow measles ; I have witnessed one case, which proved fatal, where it occurred in this disease. Imme- diately on the appearance of the symptoms of croup, the eruption disappeared, nor could it afterwards, by any means, be restored. The lungs also, were from the very first, much affected. Dr Rush says he has known it follow small pox, measles, scarlet fever and apthous sore throat. 1 recollect to have seen it some where recorded to have occurred in a case of yellow fever. The proximate cause of croup is now pretty gen- erally agreed to be an inflammation, especially seated on the mucous membrane of the larynx and trachea, but also extending into the bronchiae, and sometimes even into the air cells of the lungs. The usual con- sequence of this inflammation, when continued long enough, is an effusion of coagulating lymph, which often puts on the appearance of a membrane lining a part of the air passages, for which reason it is called false membrane. Sometimes it is seen commencing at the upper portion of the larynx and extending even into the minute branches of the bronchiae. It also com- mences at the upper part of the trachea and extends not even so far as its division. It is generally observed to be thinner in the larynx than in the trachea; but sometimes through its whole extent it is found to be quite thick, and at others very thin. Some writers have recorded instances of its being dry and even hard. It now and then has such consistence that it 10 may be removed entire, when it will be found to cor- respond in shape with the organs to which it was attached. More frequently, however, it is too soft and tender to be removed except in small portions at a time. It usually is of a whitish, or yellowish white appearance, and it has been compared to thin chamois leather. There are some anomalous instances on record in which it was dark coloured, and even quite black, also where it appeared spotted. The adhesion of the false membrane to the mucous coat of the air passages is generally but slight, and m some instances it is partially or almost entirely detached by an effusion of purulent matter under it, which sometimes nearly fills the trachea and bronchiae. The mucous coat of the larynx and glottis is often found to be greatly inflamed, and quite tumid, so much so as to close up the rima glottidis. Some- times this opening is seen to be shut up by an ad- hesion of the lips of the glottis. With regard to the natwe of the membrane formed in croup, a variety of opinions have existed. It has been believed to be an organized substance, also to possess a fibrous swucture. But the most common opinion entertained by the earlier writers on the com- plaint made it to be merely inspissated mucus. This seems to have been the belief both of Home and Michaelis, as well as of many others who have since treated of it. I recollect having seen in a periodical publication a similar opinion advanced by a celebrated physician in our own country. It was that the natural secretion of the parts in consequence of the inflamma- tion, became increased, and growing inspissated from 11 the evaporation of its more volatile parts, the child had not sufficient strength to expectorate it. The reason offered for the disease showing itself in children rather than adults was that they possessed less power to expectorate this secretion, so that what in an adult would be only catarrh, in children would often become croup. It seems now, however, to be pretty well agreed by the best writers on the complaint, that the effused matter is coagulating lymph. But why this is poured out instead of mucus or pus, which are usually secreted on an inflamed mucous membrane, we know not. Mr Hunter thought that when inflam- mation of the mucous membrane of internal canals was unusually severe, this membrane took on the adhesive inflammation and poured out coagulating lymph. The inflammation does generally seem to diminish in severity as it extends down in the air pas- sages, and the consistence of the membrane seems also to become less, and to partake more of the nature of a purulent mucus; in fact as it extends, it is often found to be gradually without any distinct line of demarkation, converted into the same matter as is secreted in catarrh; the inflammation in the lower portions of the air passages appearing, according to the above theory of Mr Hunter, to be reduced down to the catarrhal. The false membrane we have been speaking ot, is not formed in all cases of the disease. Sometimes portions of coagulated lymph only, having none of the characters of a membrane, are seen. At other times no effusion at all takes place. " In two cases, observes Dr Ferriar, "where dissection was per- 12 mitted, I found the internal surface of the trachea, near the larynx, affected with the most violent inflam- mation. The membrane so much talked of by the first writers on this disease, appeared in both of these dissections, to be nothing more than inflammatory exudation." Ghisi, Home, Bard, and others who have wrote since, relate cases of this disease which proved fatal, where the false membrane was not formed. In the New England Medical Journal, Dr Jackson has related four well marked cases of croup, all of which proved fatal, but on examination after death no membrane could be detected. The inner coat of the larynx and trachea were found inflamed and smeared over with mucus. The three first patients all died in less than forty eight hours from their attack, but the last lived sixty hours. It is made plain by the concluding observations of this paper that the rapid progress of the cases, certainly of the last, will not account for the absence of the effusion.* In the majority of cases, however, and of those in a special manner, which run their course most perfectly, the false membrane is formed. In Cynanche Trachealis we find no disease in the fauces; the pharynx and oesophagus have also a healthy appearance. The epiglottis is occasionally a little inflamed and somewhat rigid, and sometimes there is a partial swelling about the glands of the throat. The viscera of the thorax are found in a healthy state, more especially if the complaint has been very rapid in its progress. The lungs, however, * N. E. Journal of Med. and Surg. vol. i. p. 383. 13 in many cases, are much diseased. Sometimes a serous effusion is discovered in the bag of the pleura ; this membrane is also at times found partially inflam- ed, and here and there coagulated lymph effused upon it. In the lungs themselves there is often the appear- ance of great congestion, and likewise of considerable inflammation; they have a solid feel, and do not recede as usual on opening the thorax. There is occasionally discovered a serous effusion in the reticular substance of these organs. In the bronchial tubes and air cells there is generally found a large quantity of purulent matter, often combined with mucus. The heart is usually healthy in its appearance ; instances, however, have been recorded of considerable serous effusion in the pericardium. The viscera of the abdomen have commonly their natural look ; if the disease, however, lasts long, they may from sympathy become affected. Dr Farre, in a volume of the Med. Chirurg. Trans. relates the history of a rapid and fatal case of croup, in which, on dissection, the stomach was found to be extensively acted upon by the gastric fluid, and in many places in a state of dissolution. Death in croup may be induced in various ways. It may occur in the stage of inflammation, even before any effusion has taken place, from the violence of the constitutional sympathy either completely exhausting the living powers, or bringing on convulsions in which the child expires. It may also take place from asphyxia, induced by the inflammatory swelling of the lips of the glottis closing up the rima glottidis. Death is probably brought on in this way in most of those fatal cases of the disease where, on examination, no 14 effusion can be seen. In the last stage, or that follow- ing effusion, the child often dies from exhaustion, which takes place in consequence of blood, that has undergone only a partial change in the lungs, being circulated through the system, as well as from the great efforts made to carry on respiration. The rima glottidis may also in this stage be closed by the effu- sion on, or swelling of the lips of the glottis. In the first case, there is sometimes perfect adhesion. Some- times life is destroyed by an accompanying pulmonary affection, even after the difficulty in the larynx and trachea has been removed. Disease in the lungs will always aid much the other causes of dissolution. When much effusion takes place in the bronchiae and air cells of the lungs, it is plain that air cannot be received so as to effect the necessary change in the blood, the consequence of which must be asphyxia. The false membrane may, in some instances, so completely close the air passages as to prevent the admission of air to the lungs, but this I conceive is not common. The aspect of the corpse will, for the most part, show whether the child died from suffocation. If death were thus induced, the face will be livid and swoln, the eyes protruded, the muscles rigid, and the whole appearance exhibit marks of violent struggling. " I once," observes Dr Ferriar, " attended the inspec- tion of a fine boy, who had died of the croup, and I observed his struggles had been so violent, that the corpse rested in a great measure on the hind head and heels." Symptoms. The Cynanche Trachealis sometimes makes its attack very suddenly, there having been no 15 previous symptoms of illness. More frequently, how- ever, the child seems unwell for some days before ; he is uneasy, fretful, and his countenance becomes changed from its wonted healthy look. There is occasionally a slight cough, with some dyspnaea, also loss of appetite, thirst, drowsiness, and often more heat on the surface than natural. These appearances very commonly last for some days, when the symp- toms of croup suddenly show themselves. Sometimes the disease comes on after a catarrh, even of some weeks standing; and, as has been before stated, it will at times succeed to, or be combined with other complaints. To aid us in describing the symptoms of this affection, we shall—following Dr Hosack—divide it into three stages; the first, or forming, stage, where the affection is merely local; the second, or inflam- matory, where the constitution sympathises with the local affection; the third, or post-febrile, in which effusion has taken place. In the first, or forming stage, the complaint, to an inexperienced observer, would not generally appear to be very serious, and might easily be mistaken for a slight catarrh only. Even the countenance of the child is not much altered, and sometimes its expression is indicative of perfect health. During this stage, often in the morning and fore part of the day there takes place an evident remission of the symptoms, at which times the little patient frequently becomes play- ful, and sometimes even morbidly exhilirated, so that the physician is very apt to be deceived in regard to the nature of the complaint. These remissions, however. 16 do not last long, but the symptoms soon return, and generally with increased violence. In this stage the heat on the surface is but little, and sometime scarcely at all increased, and the pulse are but slightly accelerated. The appetite, too, often remains unimpaired. There is a manifest difficulty, however, in the respiratory function; we observe an effort, on the part of the patient, to carry on respira- tion, accompanied by an unnatural sound. It is difficult to describe this sound so as to give any clear idea of it, yet it is so peculiar that it is seldom mistaken after having been once heard. Writers on the disease have compared it to the noise made by air passing through a brazen tube, and through muslin. It appears to be produced by air rushing with uncommon velocity through the air tube, which, in consequence of the inflammation, has become narrowed, and unusually rigid. It is most evident during inspiration. The voice also becomes much changed, and as the disease progresses, this change grows more and more evident. It is shrill, hoarse, or squeaking, approach- ing in its sound, as was remarked of it by the ancients, in the worst species of quincy, to the noise made by singers when they try to raise their notes beyond the compass of their voice. Some have likened it to the crowing of a cock. It certainly partakes, in a con- siderable measure, of the sound of the respiration. At times, especially when the disease is much advanced, the child cannot raise his voice above a whisper. The alteration in it is probably owing to the swelling and rigidity of the lips of the glottis. 17 A cough also comes on in this stage, the sound of which has been compared to the barking and yelping of young puppies. It resembles much the sound of the respiration and voice. During the act of coughing, there is commonly expectorated in small quantity, a transparent, glairy mucus. Sometimes the cough is almost perfectly dry. This stage will occasionally continue even for a day or more, but usually in a shorter period the symptoms of general inflammation came on, which, as we should naturally suppose from the disease being seated on parts so essential to life, are greatly disproportioned to the local affection. In the second stage of croup all the symptoms become more aggravated, and the constitutional affec- tion is now very evident. The respiration grows more difficult, is performed at shorter intervals, and its peculiar sound, together with that of the voice and cough, are more strongly marked. The pulse are more accelerated, and usually full and hard. The skin is hot and dry, the face flushed, often partially swollen, and has a livid appearance. The eyes seem protruded, as if starting from their sockets ; are suffused with blood, and have a glaring brightness, and the whole countenance exhibits marks of extreme suffer- ing. If the child is capable of expressing his sensa- tions, he will often complain of heat, and a painful feeling in the larynx, or its immediate neighbourhood. This pain is increased by pressure, and is sometimes felt only when the larynx is pressed upon. Occa- sionally there is a sense of uneasiness about the affected parts, seemingly not confined, or even refer- rible to any particular spot. The fauces, if they 3 18 can be examined, will almost always appear healthy, and deglutition is not accompanied with any uneasi- ness. There is generally a thin white or yellowish coat on the tongue ; commonly great thirst, and total loss of appetite. The urine is passed in small quanti- ties, is limpid, and high-coloured. The bowels are, for the most part, costive, and when discharges do take place, unless provoked by medicine, they are generally small in quantity, and exhibit an unnatural appearance. Occasionally slight delirium manifests itself in this stage, yet it hardly ever lasts long, the patient here, as in the other acute inflammatory affections of the respiratory organs, generally retaining his mental powers, and at times, even in their full vigour, to the last. Pain is frequently felt in the head, and there occurs, now and then, a spontaneous vomiting of offensive matter from the stomach, often affording some temporary relief. As this stage continues, the symptoms go on increasing in severity. The breathing grows still more difficult, and the cough becomes more frequent and distressing. The patient tries to assist respiration by assuming different postures, and calling into action all the different muscles that can aid this function. During his struggles for breath, he throws back his head, thus in some degree, probably, by lengthening out the trachea, increasing its capacity for air. In the excess of his agony there is scarcely any position that he does not assume to get relief; from the lap he goes to the cradle, and from the cradle to the lap, but no position satisfies him, for none affords relief to his sufferings. Sometimes, if old enough, he will start 19 suddenly, and run, or attempt to run towards the door, or some other part of the room, seeming hurried, and to be anxious to attain something, but what, he does not himself appear to be perfectly aware. It is air of which he is in search. Frequently, from the sever- ity of the constitutional sympathy, and probably also from blood partly venous circulating through the brain, the little patient becomes drowsy, but if he chances to doze, he suddenly starts from his slumber, apparently almost suffocated, gazes wildly about, stretches out his arms, and in a manner the most piti- ful and trying to our feelings, seems to implore assis- tance. At such times the sweat, from the severity of suffering, will often stand in drops about the face, which exhibits an apoplectic appearance. Remissions in this stage are not common, and when they do occur, are very imperfect, and short in their duration. Symp- toms of general inflammation continue for the most part unabated till effusion takes place, after which the third stage may be said to have commenced. In the third and last stage of Cynanche Trache- alis, the inflammatory symptoms subside, and those of irritation come on, combined however occasionally, with signs of inflammation. The pulse almost always become smaller and more feeble, the heat on the sur- face is also diminished, and a moisture often breaks out here. At the commencement of this stage, respiration is frequently performed with more ease, but this relief is of short duration, the difficulty soon returning with all its former violence. The patient still continues to make all the exertion of which he is capable to carry on respiration, but the living powers are now much 20 exhausted, consequently his efforts are more feeble, and there is a longer interval between them, seemingly to give time for the accumulation of sufficient vital energy for a new effort to respire. The lips in this stage become quite purple, and a livid paleness over- spreads the whole countenance. The cough contin- ues, and often with such severity as nearly to exhaust the little strength remaining. In some instances a substance has been expectorated, in small portions, resembling coagulated lymph ; this expectoration, however, is not common. Sometimes there is appar- ent difficulty in deglutition, owing, probably, to the delay this action produces in the performance of respiration. The urine becomes increased in quantity, and a copious sediment is deposited from it. As the stage advances, jactitation comes on, the child also becomes comatose, and at times a low muttering delirium manifests itself, during which he appears hurried, but from this state he can generally be arous- ed. The tongue and whole mouth are often much coated, quite foul, and the breath fetid. A diarrhaea, and profuse sweats sometimes make their appear- ance, soon closing the scene. The patient seldom holds out long after this stage has commenced, and the younger he is, other things being equal, the sooner is death induced. As the fatal termination approaches, the countenance has a deathly hue, or is hippocratic, the pulse increase in frequency, are small and fluttering, the respiration is irregular, and performed at still longer intervals, a cold, clammy moisture breaks out over the body, the extremities grow cold, and the little sufferer expires. Death may 21 take place at any period of this stage from suffocation, when the child is carried off in violent struggles. Frequently before death the cough will wholly cease, the respiration also will seem to be performed with more ease, and without the peculiar sound which before accompanied it; but the livid paleness of the countenance, the small, frequent, fluttering pulse, and the coldness of the extremities, show us too plainly the fallaciousness of these symptoms. Sometimes in this stage of the disease, the child will be suddenly relieved, respiration will be performed with much comparative ease, and it is said that in some instances he even becomes playful, but on a sud- den the difficulty returns with increased severity, and he dies with every symptom of suffocation. This has been explained by supposing a portion of the false membrane to become detached, and after a certain time to be forced by the air into such a situation as, like a valve, to close up the air passage. It is stated by writers on the disease, that the stage of effusion does occasionally last for days, or even weeks, the patient every little while expectorating portions of the false membrane, and ultimately recov- ering. Sometimes through the whole disease, great insensibility to the action of medicines is witnessed. In the 29th vol. of the London Medical and Physical Journal, there is recorded a case, in which, in the space of forty eight hours, a boy of two years old took forty-nine grains of antimonial powder, and in less than three days, forty-seven grains of calomel, and the bowels were never opened more than twice any day 22 during the disease, the salivary glands not at all affected, and the breath not in the least tainted. On the prognosis in croup little needs be said. It we see the patient in the first stage, there will be a pretty good chance of effecting a cure, and the earlier we are called to him in this stage, the greater will the probability be of our success. If the physician is not called in until the second stage, the cure becomes quite doubtful, and the longer it has continued, the smaller is the chance of success. There are instances, how- ever, recorded, where the disease had continued, so long as two days, and still a cure was effected, and apparently by resolution. We must be greatly influ- enced at any period, in forming our prognosis, by the severity of the symptoms. Though when effusion has taken place, we can scarcely hope for a recovery, }'et, in some rare instan- ces, the effused matter, or false membrane, has been expectorated, and a perfect restoration to health fol- lowed. Some instances are recorded where the mem- brane was expectorated entire, but it has been oftener coughed up in small portions at a time. Recovery does by no means always follow its expectoration, for it is plain that when the disease is extensive, and the lungs much affected, this can do but little good. The disease too may have so exhausted the living powers, that even should the cause of the disorder be removed, its effects on the system could not be recovered from. Cheyne, in his Essay on the complaint under consid- eration, gives a case in which the membrane com- pletely formed, was coughed up twice, and still the child died. In this last stage, as well as through the 23 whole course of the disease, we must be much gov- erned in forming our prognosis, by the respiration, pulse, and general powers of the patient. Diagnosis. In the first place we will attempt to point out the distinctive characters between croup and cynanche laryngea. It was not until very lately that a line of distinction was drawn between these two diseases; the ancients probably described them both under that species of quinsy, sine apparente tumore. Boerhaave and his commentator both remark, that a quinsy from inflammation of the windpipe is attended with the greatest danger when the seat of it is espe- cially about the larynx and its muscles. In such cases, too, they also notice that there is great pain and diffi- culty during the act of deglutition, which symptom is not mentioned by them as occurring when the disease, in their belief, principally affects the trachea. Within a few years cynanche laryngea has excited in Europe a good deal of interest, much of which was at first owing to the circumstance of two distinguished physicians* having died of it at about the same period. Instances of it have also occurred in our own country, and the two first on record, in individuals whose names are intimately connected with the history of our country.f Late dissections have shown that the cynanche laryngea differs considerably from croup. Many of its symptoms, too, are different, as well as the subjects whom it attacks. * Dr David Pitcairn, and Sir John Macnamara Hayes. t George Washington and Samuel Dexter. 24 Cynanche laryngea attacks, so far as observation has extended, only adults, and it has generally made its appearance in persons somewhat advanced in life. Cynanche trachealis attacks children only, or those under the age of puberty, and we have no well marked case on record of its occurrence in the adult. Both these affections appear to be -produced by the same, or nearly the same exciting causes, and they are both attended with great danger to life. Many symptoms, too, are common to them both. Some have asserted that in cynanche laryngea there is pain felt in a small spot about the larynx, but that in croup there is rather a diffused sense of uneasi- ness, or the pain is more extensive. Little depen- dence, however, can be placed on this diagnostic mark, for in the former affection there is generally rather a sense of uneasiness about the larynx than acute pain, and in the latter, when there is pain in the affected parts, it is most usually referred to the larynx or its immediate neighbourhood. As in cynan- che laryngea the inflammation about the parts which are immediately concerned in forming the voice, is generally more severe than in croup, the disease being more concentrated in the larynx, we should infer, a priori, that the voice would be more uniformly, and in a greater degree affected. In some of the few cases recorded, we find it noticed that the patient was una- ble to raise his voice above a whisper, and in all that great pain accompanied efforts to articulate, so that the patient endeavoured to avoid speaking as much as possible. 25 The sound of the respiration differs somewhat in this disease from that in croup ; nor is the breathing so difficult at its commencement, but it goes on increasing in difficulty, even with greater rapidity than in the last mentioned disease. In all the cases of cynanche laryngea which have been given to the pub- lic, difficulty of deglutition accompanied the other symptoms, owing to an inflammation and swelling of the fauces. Different morbid appearances are exhibited in these diseases after death. In cynanche laryngea, the fauces are somewhat inflamed and swollen. The uvula, and velum palati, are often found oedematous, and at times, the tonsils likewise. The upper and fore part of the pharynx are inflamed, and this inflammation is found extending on the mucous membrane common to these parts, to the epiglottis, glottis, upper part of the larynx, and sometimes, though with abated severity, to the trachea and bronchiae. It would seem that the inflammation commences in the pharynx, because difficulty of deglutition is noticed as one of the first symptoms, showing itself before the respiration be- comes manifestly affected. In those who have died of cynanche laryngea, serous effusion has generally been found in the cellular membrane behind the larynx, and also under the mucous membrane of the glottis and upper part of the larynx. The epiglottis, too, is occasionally oede- matous. Sometimes coagulable lymph is effused on the mucous membrane of the glottis. Now in croup, as may be seen by referring to its proximate cause, there is no disease of the fauces or pharynx, there is 4 26 no serous effusion, or certainly it is more rare in the cellular membrane of the affected parts. The inflam- mation is more extensive, and likewise more severe in the trachea, where is usually found a false membrane, and generally more purulent effusion in it and in the bronchiae, than in cynanche laryngea. The lungs, too, so far as observation has extended, are more frequently affected in croup. In cynanche laryngea, death from suffocation is more common than in cynanche trachealis, the rima glottidis becoming so closed, either in consequence of the inflammatory swelling of its mucous membrane, of the oedematous tumour, or from adhesion following the effusion of coagulable lymph, as to obstruct the passage of air to the lungs. From the accounts we have had of cynanche laryngea, it would seem that, for the most part, it runs its course more rapidly, and is more fatal than croup. There are two other species of cynanche with which croup may possibly be confounded ; they are the cynanche tonsillaris, and cynanche maligna. First, Cynanche Tonsillaris. The seat of this dis- ease is in the fauces, but when severe it extends, also, to the pharynx, and even to the oesophagus. On inspect- ing the fauces, the tonsils will be seen swollen, and of a more florid red than usual; sometimes one only is affected, at others both. All the parts about the fauces look inflamed and somewhat tumid, and often have portions of coagulable lymph effused on them, exhib- iting the appearance of ulcerations. The tongue, too, at times, becomes much swollen. In some instances in which the disease is very severe, the tongue and 27 fauces are so much swelled that it is with much diffi- culty that the air can pass to the larynx, and even suf- focation may be induced from this cause. In the ex- ternal fauces considerable tumour is usually manifest to the feel. Now in cynanche trachealis none of these phenomena are exhibited, but as in young children we cannot always examine the fauces, we are often under the necessity of distinguishing the diseases by their symptoms only. In mild cases of cynanche tonsillaris the respi- ration and voice are but very slightly affected; as the disease, however, increases in severity, the affection of these becomes more strongly manifested. But the respiration is never accompanied by that peculiar wheezing noise which is the attendant of croup ; the voice also is hoarser, and has not the shrill sound of this last disease. It has been remarked that in cynan- che tonsillaris the patient speaks and breathes as if there was some foreign substance in the mouth, par- tially obstructing the air in its passage through it, and giving it a direction through the nasal passages, thus the patient often seems to speak, as is commonly expressed, through his nose. The peculiar cough of croup is also absent in this species of cynanche. Great difficulty and pain attend deglutition, especially when the patient attempts to swallow his saliva, or foreign liquids, so that much distortion of the countenance is frequently witnessed during this act. This difficulty is increased when the individual lies on his back. In croup, deglutition is not attended with any difficulty until a late period of the disease, and then the diffi- culty arises from a cause altogether different. 28 In common cases of cynanche tonsillaris, the con- stitutional affection is quite mild, and the symptoms of general inflammation are hardly ever so violent as they are in croup. When the inflammation of the fauces extends to the larynx and trachea, as sometimes happens, symptoms of croup, of course, show them- selves. Second, Cynanche Maligna. Nearly the same ma»ks distinguish this as the former disease, from cvnanche trachealis. The fauces are inflamed and swollen, in addition to which, there is ulceration and sloughing of these parts, giving rise to a disagree- able fetor of the breath. The stomach also is much disordered, and the tongue and mouth very foul. The powers of the system are more prostrated, and delir- ium is more frequent than in croup. The cynanche maligna often prevails as an epidemic, and at such times is much more severe than when sporadic, so that there is hardly a possibility of mistaking it for croup. The inflammation in this disease may also extend to the larynx and trachea, inducing symptoms of cynan- che trachealis. " In the unfortunate circumstance," observes Dr Ferriar, " of the croup's supervening to the ulcerated sore throat, from the extension of inflam- mation to the trachea, it is extremely difficult to direct our practice, and if the symptoms of croup run high, it becomes scarcely possible to save the patient. To discontinue the bark, while the ulcerations are gain- ing ground, would be to devote the patient to certain death, and general bleeding is expressly prohibited by the same circumstance. Large blisters to the throat, leeches and repeated emetics, are the only means of 29 relief reserved to us; and I must own, that I have found these ineffectual, in this perplexing coinci- dence." Acute spasmodic Asthma of Children. This disease seems to have been very commonly confounded with croup, and in fact, until very lately, there appears to have been no accurate line of distinction drawn between them; which may in part account for the division of croup into a spasmodic and inflammatory species, so frequently met with. Many physicians even now do not seem fully aware of the different nature of the two affections. Dr Rush at one time thought them to be the same disease ; he afterwards, however, treated of them as distinct. The diagnosis here, is unquestionably difficult, yet a careful atten- tion to the different symptoms of each, will in a great measure do away this difficulty. Acute spasmodic asthma and croup affect children at about the same age, and they are not unfrequently produced by similar exciting causes. Dr Rush, and some others, state that this species of asthma, like croup, most usually makes its attack in the night. It generally, however, comes on more suddenly than croup, at times the symptoms appearing almost instan- taneously. The difficulty of respiration, which is for the most part very great, seems almost at once to arrive at its height, whereas in croup it is at first slight, and goes on in a more gradual manner to increase. The respiration, also, is more rapid, cer- tainly, than at the commencement of the last men- tioned disease. The breathing is often accompanied by a wheezing noise, but it is not usually so loud as 30 in croup nor has it the peculiar shrill, clangorous sound of that disease. Occasionally a cough is present, but it differs somewhat in its sound from that of croup, so that it may be readily distinguished by one accustomed to witness the two diseases. The voice is described as being dull and hoarse, rather than shrill. The patient also breathes better in the sitting posture with the head bent forward, but in cynanche trachealis the head is generally thrown back to get relief. The remissions, too, or perhaps they may with more pro- priety be called intermissions, are generally more per- fect, frequent, and regular. The constitutional affection in acute spasmodic asthma is by no means so constant, nor so violent as in croup; neither is any pain induced by pressure upon the larynx. The entire relief often given in this disease by a spontaneous vomiting of undigested food, and the immediate good effects following the action of emetics, would lead us to infer that it originates in many instances from a disordered state of the digestive organs. According to the observation of some authors, it now and then takes a chronic form, continuing for weeks, or more, with frequent and well marked inter- missions. In some instances it appears like a family complaint, the younger members being very subject to its attacks, especially from any irregularity of diet, or undue exposure; in such cases, however, the diag- nosis becomes much less difficult. It is pretty gener- ally allowed, that there is no false membrane formed in it. Dr Rush, in the first volume of his Medical Observations and Inquiries, gives the dissection of a 31 case, in which the larynx, trachea, and lungs were found perfectly healthy. Catarrh. The proximate cause of this disease is an inflammation of the mucous membrane of the nasal passages, extending back into the fauces ; and if severe, into the larynx, trachea, bronchiae, and even air cells of the lungs. The same parts then, which are affected in croup, here take on diseased action, and they are both inflammatory complaints. In catarrh, however, the inflammation is usually quite mild, and it also goes through different processes. We observe in it only the ordinary phenomena consequent to inflammation of a mucous membrane ; an increase of the natural secretion of the parts, or a secretion of pus. But in croup the inflammation seems to dimin- ish or check the natural secretions, and in their stead a new matter, or coagulating lymph, is commonly poured out. As the complaints differ in their proxi- mate cause, so do they in their symptoms. In catarrh, except when it prevails as an epidemic, the constitu- tional affection is quite mild, and even in its epidemic form, it is seldom, if ever, so severe as in well marked cases of croup. An attention, however, to the respi- ration, voice, and cough will enable us most readily to distinguish it from this latter disease. Though in catarrh a wheezing often accompanies the respiration, yet it differs from the respiration of croup; it is neither so hard nor shrill, but rather gives the idea of loose matter, partially obstructing the pas- sage of air. The increased secretion of mucus, also, about the nasal passages does not admit the air to pass freely through them, from which cause the peculiar 32 noise which we call snuffling, arises. Sometimes they seem almost entirely obstructed, more especially after the patient has been asleep, the mucus then having become accumulated and inspissated. Now in cynan- che trachealis there is no obstruction to the air above the larynx. In catarrh the respiration is less rapid than in croup, and there is often a sense of fulness or oppres- sion about the pulmonary organs, but no symptoms of any mechanical obstruction to their functions. When the larynx is affected, the voice becomes dull' and hoarse, but not shrill as in croup. The cough when present differs from the hard, barking cough of this latter disease, it being attended with a rattling noise. There is also expectorated a proper mucus, or a puru- lent mucus, and in large quantity, whereas, in croup, a thin, glairy mucus is coughed up, and in very small quantity. Pneumonic Inflammation. In inflammation of the lungs there is pain, and a feeling of oppression in the chest, accompanied, also, by a manifest difficulty in the respiratory function. These symptoms are often much augmented by certain postures of the body; thus they will generally be more severe when the body is horizontal, than when the head and shoulders are so raised that the chest forms an inclined plane. Some- times the breathing is easiest in the erect position. In some cases the patient can only lie on one side with any kind of ease, in others only on the back. In croup the child throws himself into almost every posi- tion without obtaining any relief; at least no farther 33 than as one may favour the action of more muscles in aiding respiration. In pneumonic inflammation, the breathing is shorter and more rapid than in croup, and the sound accompanying it is altogether different, approaching that which often follows a sudden blow on the chest, or epigastric region. There seems to be no mechan- ical obstruction to the air in its passage to the lungs, as in the latter disease; the effort on the part of the patient to carry on respiration is apparently but slight, yet by observing him attentively, we perceive that he breathes short, and with a degree of timidity, seeming afraid to take a full breath; and if at any time the attempt is made, checks himself suddenly as if from acute pain. The cough, also, differs from that of croup. As coughing produces considerable pain, the patient makes evident attempts to avoid, or check it, and during a paroxism, exhibits signs of much suffering. Its sound, too, is very different, having none of that peculiar shrillness attending the cough of croup. There are instances recorded of polypi forming both in the larynx and trachea. They are dis- tinguished from croup by the gradual manner in which their symptoms come on, and the comparative mild- ness of the constitutional sympathy. The peculiar sound, too, attending the respiration, voice, and cough in croup, is here absent. It has been observed, like- wise, that the breathing is free at certain times and difficult at others, and that occasionally after an expi- ration the patient seems to be suffocating, but becomes immediately relieved by an inspiration. 5 34 Foreign substances received through the mouth, into the larynx and trachea, may give rise to symp- toms analogous to some which occur in croup, so that an inexperienced observer, not aware of the accident, might, in some instances, be led by them into a serious, and even fatal error. Michaelis thought the diagnosis here to be attended with much difficulty, and Dr Home mentions an instance related to him of a for- eign body received into the trachea, which, from the similarity of the voice, was mistaken for croup. When an extraneous substance is received into the air passage, the symptoms are more or less urgent, and varied, according to its nature, size, and situation. But we may, in almost every instance, distinguish such a case from cynanche trachealis by the following marks. The symptoms make their appearance in a very sudden manner, the respiration at once becom- ing extremely difficult, and at the same time there is a violent convulsive cough. The repiration and cough, however, both differ from croup, being usually attended by a kind of hissing and rattling in the throat. The voice generally becomes hoarse, but is less shrill than in the last mentioned disease, and sometimes it entirely fails. There is difficulty, too, in deglutition, this act often producing great distress. We occasionally observe, after the foreign body has remained some time in the air tube, an emphysematous tumour above the clavicle. I do not know that this appearance is ever witnessed in croup. If the sub- stance is loose in the trachea, it will often be felt by the patient to change its situation : the seat of the pain, too, will become altered, and at times the symp- 35 toms have evident remissions, the cough and difficulty of respiration occurring at intervals only. Dr James Jackson speaks, in his lectures, of a peculiar affection} of which he had witnessed two cases, attacking children, and almost exactly resem- bling croup. In both of these, the symptoms were so similar to those of croup as to deceive him with regard to the nature of the disease. The patients con- tinued sick for some weeks, but finally recovered. The diagnosis of such cases must of course be difficult or almost impossible. Dr Ferriar has distinguished the genuiue from what he calls the spurious croup. " Children," says he, " who are subject to attacks of the croup, are sometimes seized with the deep, barking cough, which will increase to such a degree as to create much alarm about the usual time of the dangerous exacerbation, yet it will decrease again, and at length go entirely •off, without any other remedies than common demul- cents." Such cases as these are supposed by him to have been described as genuine croup, and to have been the occasion of the use of trifling remedies in the disease. The diagnosis is to be drawn from the fol- lowing circumstances. The cough in this spurious kind of croup, is different; it has not the shrill whin- ing sound of the genuine disease, but is hoarser, and has longer intervals. There is less difficulty also manifested in the respiration, and it has not the sound peculiar to croup, the affection of it seeming more like a common dyspnaea. "The spurious croup is not attended with restlessness, trembling, and palpitation of the arteries, which characterize the other. I must 36 observe, however, that these distinctions are only to be learned, from much attention to the different cases of the disease ; for the sound of the cough is so similar in both, as to inspire even the mosf experienced with some degree of doubt. I have sat by the child's bed- side repeatedly, watching for the moment of danger, while the cough was increasing in violence ; and have been only undeceived, by finding that no tremor or palpitation came on towards midnight, that the restlessness abated, and that sleep seemed to become more composed."* Some writers have thought it necessary to point out the distinguishing characters between croup and some other diseases which we have not noticed, among which are hooping cough, hydrophobia, and hysteria; but the line is so distinctly drawn here, that it would seem almost impossible for any physician having a tolerable acquaintance with his profession to mistake these for croup.f * Medical Histories and Reflections. t In the Med. Chirurg. Trans, vol. 12th, part 1st, Dr Marshall Hall has published four cases of an affection which was produced in children by their attempting to drink through the spout of a tea-kettle containing boiling water, having symptoms similar to those which occur in croup. Out of the four cases recorded by him, one only recovered. Bronchotomy was performed in one instance, and gave immediate, and very manifest relief. The patient died, however, in about thirty four hours after the oper- ation, exhausted, as was thought, by the irritation from the pri_ mary affection. On dissection of this case, the epiglottis was discovered to be swollen, blistered and corrugated, and the inter- nal mouth, tongue, and fauces affected in the same way. A little mucus was seen in the larynx, but no morbid condition of the stomach or oesophagus. The trachea was not at all inflamed- 37 Treatment. The pattralogy of croup which has been given by the latest and most distinguished medi- cal writers, and of which we have already spoken, shows it to be a disease of inflammation iu the strict- est sense of the term. Our indications of cure then are strictly antiphlogistic. I feel persuaded that serious errors in the manage- ment of this complaint have often arisen from the belief in its spasmodic nature, and that Dr Ferriar does not err from truth when he says, " many valua- ble lives have been sacrificed to the imaginary powers of assafoetida, or small repeated doses of antimonials, from unfounded theories of spasmodic constriction attending the disease." He believes croup to be as strictly an inflammatory complaint as pleurisy, or peripneumony, and to be equally free from spasm. Many physicians, undoubtedly, who have viewed croup as a spasmodic affection, have, from not duly attending to its diagnostic marks, confounded it with the acute spasmodic asthma of children, a disease, as has been already shown, very different in its nature. But even admitting its pathology to be doubtful, it would be much the safer way to treat it as an inflam- matory disease, since it is well known that our antiphlo- gistic remedies act powerfully as antispasmodics ; but the reverse of this is not true, for the greater number of antispasmodic medicines in common use, not only In an appendix to this article, Edward Stanley Esq. relates two more cases of this affection, each of which exhibited the symptoms of croup. They both proved fatal. In one, the interior of the mouth, the fauces, pharynx, and the oesophagus, to within a short distance of the cardiac orifice of the stomach,, manifested the common appearances of a scald. 38 do no good, but their employment is attended with much danger in inflammatory affections. The disease of which we are treating has its seat ou organs in the highest degree essential to life, and its whole force is generally concentrated in a very small space. It runs its course, too, with great rapid- ity. Our remedies, therefore, should be prompt and powerful; the delay even of a few hours may be attended with the most fatal consequences, and to tamper with inefficient remedies is sure death. The words of Hippocrates, " Ad extremos morbos, extrema exquisite remedia optima esse/7 may be well applied to this disease. General Bloodletting. To effect a cure in croup the course of the inflammation must be checked; and what remedy have we so likely to do this, as general bloodletting? This then should generally be our first remedy employed, for we are seldom called to the child so early in the complaint that it can safely be dispensed with ; ignorant and officious friends too frequently tampering with common family medicines until the inflammatory symptoms appear with all their violence. Under such circumstances, bleeding is most urgently demanded, and is the remedy upon which we are to place our chief reliance. The ancient writers on medicine, in treating of that species of quinsy which corresponds with our defini- tion of croup, have agreed almost universally, that bloodletting is the sole remedy upon which we can rely for a cure. Hippocrates and Galen, both strongly urge its employment. Aretaeus advises that the blood be taken from a larger orifice than usual, and in such 39 quantity as nearly to produce fainting. Among the medical writers who come nearer our own period, we find Boerhaave strongly insisting on this practice. In Aph. 809, referring to this kind of quinsy, he observes, " In the first place a speedy, large, and repeated blood- letting, must be put in practice, until the weakness, paleness, coldness, and collapsion of the vessels, denote that the remaining strength is not able to increase the tumour and turgescence, or rigidity of the vessels." " That kind of inflammatory quinsy," observes Van Swieten, "which is seated either in the windpipe itself, or about the larynx, is of all the worst and most suddenly fatal, and requires the most efficacious reme- dies to be applied at one and the same time." Among the first and principal of which, he ranks bloodletting. He recommends the blood to be drawn until the patient faints, and if the threatening symptoms return, again to have immediate recourse to it, the disease admitting of no delay ; since, as he remarks, " It is much better for the patient to languish some time by a loss of blood, than to be unhappily suffocated." Home, Cullen, Michaelis, and many others of note who have written on the disease we are treating, speak most decidedly in favour of this remedy. If, then, we are called to the patient at any period previous to the last stage of the disease—perhaps with the exception of the early part of the first stage—we should begin our treatment with general bloodletting. In relation to the quantity of blood to be taken, it is impossible to state any certain and invariable rule, as this must be varied according to the age of the patient, his habit of body, the severity of the symp- 40 toms, and length of time they have lasted. In a child from two to six years of age, a quantity of blood vary- ing from five to eight ounces, taken at once, would be a pretty free bleeding. In the first stage of croup it will not often be requisite to employ bloodletting to the same extent, as when symptoms of general inflammation are present. But even in this stage, especially if the child is robust and plethoric, and the difficulty of respiration consid- erable, we should let blood pretty freely. When the patient is not seen until the sympathetic inflammation has occurred, more especially if it has continued for any length of time, runs high, and is attended with great difficulty of breathing, we ought to bleed even till fainting is induced, as under such circumstances the child's safety seems to depend in a special manner on the result of this remedy. It is almost universally allowed that in acute inflammations, more particularly where it is so important to produce a speedy effect on the disease, that the blood should be drawn from a large vessel and from a large orifice. It is not unusual to meet with considerable diffi- culty in obtaining blood from young children in suffi- cient quantity to be of service in this disease, their veins being small, and, for the most part, lying deeply imbedded in adipose substance. " In the case of young children," says Dr Ferriar, " we must almost despair, for it is extremely difficult to procure any blood from them by the lancet." Generally, however, we may obtain considerable blood from the veins on the back of the hand, if wre immerse it in warm water, but still more reliance can be placed on the jugular 41 vein. There are, in fact, several reasons which should, on a general principle, induce us to give the prefer- ence to this last. It is tke most prominent of the superficial veins, and can consequently be opened with the greatest facility. Commonly, too, from its greater size, the blood may be drawn more rapidly, and in larger quantity than from any other. And perhaps there may be some advantage in taking this fluid from the immediate neighbourhood of the diseased organs. To be sure there have been objections urged against it. The operation has been thought hazardous in consequence of the extreme restlessness of the patient in this disease. It has been urged, too, that we can- not always ascertain the exact quantity of blood taken, it being difficult from the situation of the vein to receive it all as it flows. There has been supposed, likewise, to be constant danger of the orifice made in the vein being opened afresh by the child's continued motion and violent fits of coughing. And finally it has been opposed on account of the unpleasant effect it produces on the by-standers. But there seems to be little force in these objections. It can be no very dif- ficult matter for one or two attendants to keep the child quiet for so short a time as the operation will occupy, and the vein is so large and prominent that it may readily be opened by any one possessing a com- mon share of surgical skill. The blood, as it flows, may be received in a sponge, or in small vessels, as teaspoons, or teacups, so that the quantity may be pretty accurately ascertained; and by bringing the lips of the orifice together, with common adhesive or court plaster, they very soon became united so as to 6 42 be out of all danger of being forced open ; or if they are, the bleeding may be very easily checked by slight pressure over the opening. The effect the operation may have on the feelings of the by-standers, when compared with the welfare of the individual, scarcely deserves any consideration ; still this may be much lessened by doing the operation neatly, having a care to receive all the blood as it flows, so that it may make as little show as possible. Sometimes after one full bleeding, all the danger- ous symptoms subside, and the little patient, who, a short time before, seemed every moment about to suf- focate, now breathes easily, and appears nearly restored to health. Still he is far from being secure, as the symptoms, in spite of these propitious signs, not unfre- quently reappear, and sometimes even with increased violence. If the threatening symptoms subside in a considerable degree after the first bleeding, it will not be requisite to repeat it, unless they return ; still it ought to be followed by other remedies about to be mentioned, which should be continued as long as we conceive there is any danger of a recurrence of the disease. If by the first bleeding in combination with the other remedies, the symptoms are not mitigated, but remain the same, continue to increase in violence, or even should they subside only in a slight degree, it ought to be repeated, in fact even to the third and fourth time, if the urgency of the symptoms require it and the strength of the patient will admit. A knowl- edge of the rapidity of the disease makes it plain to us, that to gain benefit from this remedy, it must be 43 repeated at short intervals, as of six or seven hours, or oftener if the violence of the symptoms demand. Of course we cannot safely continue to take so large quantities of blood as at the commencement of the treatment; the physician, however, must be guided here by the general powers of the child, and the urgency of the symptoms. Local Bloodletting. In cynanche trachealis, this is a remedy of great value, especially as the strength of the child may become so exhausted from the vio- lence of the constitutional sympathy, and from the first general bleeding, as to render the repetition of this dangerous, although the inflammatory symptoms continue; under such circumstances we must rely principally on local bleeding. A small quantity of blood, drawn from the capillary vessels in the immediate neighbourhood of an inflamed part, will not unfre- quently have as great an influence on the disease as even a much larger quantity when taken from the general circulation. The effects, however, are not so imme- diate ; the blood is obtained more slowly, and in much less quantity; consequently, in the disease under con- sideration, local is to be considered as merely an auxiliary to general bloodletting, where the latter can be safely resorted to. Instances may sometimes occur in which all the veins, even the jugular, lie so deeply imbedded in the adipose substance, that it becomes almost impossible to open them with the lancet; here local bleeding must be immediately re- sorted to, and carried to the greatest possible extent. Very soon, then, after blood has been taken from a large vein, unless the symptoms are so much alle- viated, as in our judgment to make it unnecessary, topical bleeding ought to be employed, which not unfrequently will prevent the necessity of repeating the general bleeding. This is usually effected by means of leeches applied to the external fauces ; and to produce the desired effect, they ought to be applied in considerable number, as from a dozen to twenty. This is generally a very convenient mode of obtaining blood, and is productive of but little pain to the patient. It has also been thought to unite, to a certain extent, the advantages of general bloodletting and blistering; the blood drawn by a considerable num- ber of these animals being sufficient to affect the whole circulation, whilst their bites keep up a counter-irritar tion. The flow of blood may generally be kept up for some time from the orifices made by the leeches, by bathing the part with warm water; in this way considerable blood may often be obtained.* * It is of much importance to acquaint ourselves with the proper method of managing leeches, since they do not always bite so readily as we could wish; at times, in fact, we find it extremely difficult to make a sufficient number of these animals take hold. " In order that leeches may bite readily and suck well, they should be made to fast for a few hours before they are applied__ that is, they should be taken out of the water, and put into a cup, tied over with linen, for four or five hours in winter, and three or four in summer. They are then to be put into a dry and fine napkin, and gently rubbed, which irritates them, and makes them bite keener. If it be winter, they are the better to be breathed upon, for a minute or two, before application, the warmth of the breath making them more lively; or the ves- sel in which they are kept may be placed near a fire for a short time, so as to raise the temperature of the water a little, a great 45 Emetics.—Almost all writers on croup attach great value to emetics; in fact there are but few remedies concerning which we are so well agreed, as in the use of these in the complaint under considera- tion. They have, however, met with a little opposi- tion, and Dr Home was averse to their employment. Our experience, however, still continues to give them their deserved rank in the disease. Emetics, in addition to the benefit arising from their evacuation of offensive matter often contained in the stomach, have a powerful influence in restoring to the inflamed organs their natural secretions, and also in promoting expectoration, which is here of great importance. They aid, also, to allay the inflammation by diminishing the action of the heart, and by their tendency to restore to the extreme vessels their nat- ural functions. The system also feels a peculiar shock from their operation, which seems in many cases to destroy morbid catenation, and to excite a new and healthy set of actions in the constitu- tion. When an emetic is employed at the very onset of the disease, that is, within the first few hours of the attack, it will not unfrequently restore to the diseased parts their healthy actions, and without the aid of any other remedy, effect a perfect cure; but even if the degree of cold rendering them torpid." Paper on the use of Lavemens and Leeches; extracted from the Med. Chir. Jour. into A~o. 1, vol. xi, of the New Eng. Med. Jour. The part where leeches are to be applied ought to be first Avet with milk and water, or sweetened water; or it may be rubbed with a piece of frc