DEP/DUA/1/30/14 (Normalised version)

Arabella Wallis

(1782-1783)

---

Arabella Wallis.

With regard to this case have very great difficulty both as to name & nature.

And not altogether without suspicion that this difficulty somewhat increased by patient herself.

Have some suspicion that if be not capable of altogether inducing can at least aggravate most considerable & obvious part of affection.

Affection viz of respiration, particularly as attended with peculiar noise.

If this really the case, hard to say what can be motive for it.

Here no advantage from it.

Perhaps even no other than by showing it in worst state the more readily to obtain most effective aid.

But whatever be in it, some grounds at least for suspicion.

Particularly from its having been repeatedly observed that affection much less considerable when sits in waiting [room] than when called in for report.

But whether affection real or fictitious is in several respects such a one as have not before met with in practice.

And for my own part although [inclined] to suspect that appearance somewhat aggravated yet look upon it as being principally a real disease.

To this opinion the rather induced from difficulty which conceive, there would be, in entirely feigning it.

At least for my own part find, that cannot by any voluntary effort, emit such sound in respiration as here takes place.

At same time, where from diseased state of parts, such sound in some degree emitted, can easily conceive, that by voluntary effort, may be augmented.

Taking this view of case then, if not principal, at least most remarkable [symptom] of disease consists in peculiar sonorous respiration.

This of such a nature that cannot pretend to convey any idea of it by words.

May only observe to those who have ever had opportunity of seeing patient labouring under that disease, which in this [country] commonly known by name of Croup, that approaches more nearly, to noise then emitted by respiration, than anything else with which I am acquainted.

This peculiar noise which as occurring in Croup has by some been compared to crowing of cock, though resemblance by no means accurate is by many considered as a certain pathognomonic of that disease.

That is as a symptom always present in croup never occurring in any other affection.

In that view then, would be disposed to give to present disease the name of croup.

But if has this one mark of that affection, wants almost every other.

And still more difficulty from that affection in progression.

For while Croup so rapid in progression as to prove fatal, sometimes in space of few hours, seldom continues for many days, present, from continuation which has already had, may pronounce to be in some degree even a chronic affection.

Probably different from it not less in degree of danger.

For Croup a most alarming affection, unless speedily terminated by proper interposition of art.

Here however must observe that with regard to nature of this disease, practitioners by no means agreed.

And hardly two who have written with regard to it, entertain same sentiments as to immediate cause of principle & characteristic symptom viz peculiar sonorous & difficult [respiration]

Croup a disease known only in few places of Britain.

Or at least, if has in others sometimes taken place, [confused] with different affection.

Hence nothing said with regard to it, by any of older practitioners of eminence

First publication on subject with which I am acquainted, an inaugural dissertation published by Dr James Simson of St Andrews, in the year 1762 entitled De Asthma Infant Spasmodica, cum ranca voce & respiratione sibilio.

In that, as you will indeed infer from title, considered disease as being entirely of spasmodic kind.

And looks upon affection of respiration, as well as peculiar noise with which attended, as proceeding totally from stricture taking place in muscles of Larynx.

Not long after this, viz in the year 1765, Dr Home published at this place his inquiry into nature, cause, & cure of the Croup¹.

In that, gives very different view of principal affection.

Ascribes both difficulty of respiration, & peculiar sound in breathing, to a membrane formed in the inside of Trachea.

A few years after Dr Homes publication, an inaugural dissertation [appeared] at this place by Dr Crawford De Cynanche Stridula².

In that dissertation great part of which taken from lectures of late Dr Gregory the author contends that the disease entirely an inflammatory affection.

And ascribes both difficulty of breathing & peculiar noise, to inflammation of Trachea.

In this, adopted also the sentiments of Dr Cullen who has styled the Disease Cynanche Trachealis.

Besides these, several other authors have since written upon this subject.

Particularly Millar. Rush, [ Mease], [ Miha] etc.

But have adopted one or other of opinions already mentioned those viz of Spasmodic, Inflammation, or Membrane.

Into this controversy cannot here propose to enter.

And the rather as have never in my own practice seen many instances of these affections.

But from all that have seen, am most inclined to sentiments of those who hold it to be principally a spasmodic disease.

Would not indeed pretend to deny that white membrane is not frequently formed on inside of Trachea.

This however considered not to be cause but merely consequence of disease

And from all that I have seen am inclined to consider it as nothing else but viscid mucus.

And as when does take place can only be late in the disease, while in some cases entirely wanting, although may undoubtedly augment difficulty of breathing yet can neither look upon it as principal cause of this symptom nor of peculiar noise in Respiration.

My sentiments with respect to inflammation nearly the same.

Have no doubt that inflammation of Trachea often exists in Croup.

When exists will undoubtedly produce some affection of respiration in different ways.

At same time reason to believe, that in many common catarrhs, & in other species of Cynanche, such inflammation takes place without any of characteristic symptoms of Croup.

And certainly no reason to believe, that such inflammation confined to that early period of life during which alone Croup can be said to occur as a disease

Infants however well known to be subjected to spasmodic affections from very slight causes, which afterwards would have no influence.

Where inflammation of Trachea takes place in tender & irritated habits, spasmodic affection of Larynx will much more readily be induced, than in any other circumstance.

Thus I apprehend croup often supervenes to inflammation, or rather [complicated] with it

Thus by removal of inflammation, croup also removed.

But apprehend that without spasm of Larynx can neither give difficulty of breathing, nor peculiar sound.

That from such spasms alone, croup often arises corroborated by many circumstances

But particularly proved from manner in which disease makes attack.

For in many cases with those [before] in perfect health, arises suddenly to greatest height at once.

Proved from manner in which often disappears

For in some instances as instant attack so also instant recovery.

And lastly from its being observed in some cases at least, that this affection of respiration alternates with spasmodic affection taking place in other parts.

To these may also add, that by a voluntary, contraction of muscles at head of Larynx, can produce a sound somewhat similar to that in croup.

May therefore reasonably infer, that a stronger & involuntary contraction, most ready cause of producing that mode of respiration which characterises this disease.

May likewise observe that although most successful practices, not hitherto [perfectly] ascertained, yet many remedies employed with greatest advantage, such as will [counteract] spasms.

For from some late trials, by different practitioners appears, that warm bathing, opium, & aether employed with great advantage.

As removing & counteracting spasm also may account for good effects of Emetics.

And as far as my experience goes no mode of cure, attended with equal benefit in this affection.

In most urgent circumstances where oppression of breathing almost [insupportable] have seen from Emetics most remarkable relief.

And at least much more [concomitance] to what we observe in common practice to suppose that operates by removing spasm than by counteracting inflammation.

Must here however observe that for my own part, at least, am disposed to attribute principal benefit from emetics to their operation as expectorants.

And relieve respiration by discharging large quantity of viscid mucus.

Which however suppose to be [retained] there by spasmodic affection of the larynx.

From these considerations [then] in place of referring croup to genus of Cynanche my opinion is that should be placed under that of Asthma.

And when consider how much is confined to particular period of life, perhaps best distinguished by title of Asthma Infantile.

These observations on Croup seemed rather necessary that might state opinion as to nature of present affection.

And how far seemed to me to differ from that disease.

Here also as in Croup am inclined to think, that peculiar noise in respiration is principally effect of inordinate action of [muscles] of Larynx.

And this the rather probable when consider that here evident symptoms of inordinate action in other respects.

For among other particulars mentioned in case, is often affected with globus hystericus.

And probable that not only contraction in fingers & legs, but flying pains also in head, ears, & breast, symptoms of the hysterical kind, & depending on inordinate action.

At same time can hardly [illegible] cause of this kind to have constantly existed producing such affection of respiration for so great length of time.

Am therefore inclined to think that [here] there must also take place some local morbid affection of Larynx.

And that by this means inordinate action or even voluntary effort of these muscles, produces sonorous respiration to that remarkable degree which with this patient have often had occasion to observe

My idea then of disease of present patient is that she is a female of peculiarly irritable habit.

And although only in very early period of life, yet subjected to distinctly marked Hysteria

While from this cause inordinate action takes place even without any obvious circumstance exciting it in many different [parts] of body is more especially apt to affect muscles of Larynx.

As probably these there exist about parts concerned some local morbid affection.

This opinion however cannot pretend to offer with any great degree of confidence.

And at that you will not be surprised after what already said as to suspicions of appearance at least of affection being intentionally aggravated.

But even supposing conjecture to be strictly well founded, still very uncertain as to prognosis.

Regarding case which have not before met with in practice cannot form any opinion on grounds of former experience.

And as far as can judge from [former] experience are in little less doubt.

Supposing local affection to exist may yet be of such a nature as to be easy removable.

More probable however, that if ever, will not be speedily accomplished.

With regard to hysterical affection as little reason to look for expedient cure.

Well known to be a disease which when once rooted in constitution very difficult to be overcome.

And here reason to fear will be peculiarly obstinate from having taken place at so early period of life.

At same time from this circumstance some ground for hopes.

As constitution in progression of life soon subjected to many changes inducing very great alteration.

Some of these however such for example as appearance of menstrual flux often tendency rather to aggravate than diminish hysteria

On these grounds then reason I think to fear that affection will be obstinate.

Will not be less so, if patient as we suspect has any particular reason for wishing to appear worse than she is.

Upon whole then shall not be surprised if after all efforts, leave her in no better situation than have found her.

Or even with affection rather aggravated than diminished.

At same time see no reason to fear that will suddenly or rapidly increase.

And still less to apprehend that in the end will be attended with fatal consequences.

For hysteria in all its different [modes] much more alarming than dangerous.

If therefore does prove fatal, will probably be by local affection of Larynx disturbing vital function of Respiration.

This however only to be dreaded from gradual increase by long duration.

And if does take place disease will probably before then have put on other appearance.

Although therefore in this case have no sanguine hopes of accomplishing speedy cure, yet if patient continues regular attendance may at least afford opportunity for trial of different practices.

Here however must own am much at loss to think what can be tried with any great prospect of success.

Have already without effect had recourse to different remedies.

And these too such as in my own practice have before found most successful in cases of genuine Croup.

Have tried without any benefit repeated Emetics.

And have had recourse with no better success to application of blisters at different times.

From this have since been led to other practices of which have less experience.

Some of these meant to counteract & remove spasms when had already taken place.

Others to prevent return.

Was with first of these intentions that had here recourse to Vitriol Aether.

This article [well] known to be one of most powerful antispasmodics with which we are yet acquainted.

And on this the activity of mixture [first] prescribed entirely depended

For water & mucilage with which was combined intended merely to give proper formula for introduction.

While this however employed with view of alleviating affection had recourse to another remedy as means of removing disposition to it.

That was the Calx of Zinc.

For introduction of internal use of Zinc as means of removing spasmodic affections are principally indebted to late celebrated Dr Gaubius.

And for first account of it may refer to Chapter of Adversariorum where trials of Luna Fixata Luddemanni ³.

For this [appears] that an Empiric in Holland of name of Luddemanni had employed with great success a nostrum of his in cure of different nervous affections even of Epilepsy.

From Chemical Analysis of this medicine Dr Gaubius led to conclude that active article the flowers of Zinc.

This led him to try these in different affections.

And having found use attended with remarkable success, thought it his duty to publish account of it.

On his authority tried by many practitioners.

And am sorry to say that have not all agreed in opinion with regard to efficacy.

Some from repeated disappointment considered them even as of no effect.

And no one I apprehend who has used them much can pretend to say that have never disappointed him.

For my own part have often found them fail, where regularly employed for due length of time & to as great extent as could easily be borne.

This however has in general at least happened in affections which found [incurable] by any other means.

And if sometimes have failed, on other occasions have succeeded even where did not expect it.

From this success which have often experienced look upon Zinc to be useful & powerful article in different affections of the spasmodic kind.

And my sentiments in this respect corroborated by testimony of different practitioners now published, in Medical Commentaries & other periodical works.

With these two medicines then began treatment of this case after selected as patient for Collegium Casuale⁴.

From Aether had at least no inconvenience & at first imagined that product of some benefit.

But Calx of Zinc which was given combined with Valerian had effect of in general exciting vomiting.

This however ascribed more to Valerian than to Zinc itself.

With continuation therefore of Vitriol Aether as before only increased quantity [taken] had recourse to Zinc in another form.

That viz of pills.

These though at first excited some sickness have since been found to sit upon stomach without inconvenience.

A circumstance augmenting probability of opinion that former sickness principally effect of Valerian.

Although however now retained with ease yet not product of desired effect.

For disease very little if at all mitigated.

And now became subjected to another symptom which consider also as Hysteria.

viz Frequent deliquium Animi.

In this situation changed aether for Spirit Saline Aromatic.

As from combination of Volatile Alkaline with essential oils affords more warm & grateful stimulation to the stomach.

Still however have persisted in use of Zinc to which desirous of giving fair trial.

And under these medicines at last report, symptoms upon whole found to be somewhat easier.

In this situation medicine ordered to be continued.

And while affections continued alleviated will probably persist at least for some time in same course.

If appearance changed hard to say to what practices may have recourse.

But if in present form shall find [them] aggravated trials which have chiefly in view are use of, Electricity Assafoetida & Peruvian Bark.

And if farther reason to suspect that complaint in any degree feigned, may [here] have recourse to renewal of the blisters.

But if these practices tried, & if case has termination in our hands [without] success or otherwise shall probably again make it the subject of few observations.

At present therefore shall say nothing farther with respect to it.

---

Explanatory notes:

1) Francis Home, An Inquiry into the Nature, Cause and Cure of the Croup (1765).

2) Thomas Crawford, Disquisitio medica inauguralis de cynanche stridula (1771).

3) Hieronymus David Gaubius, Adversariorum varii argumenti (1771).

4) A term used in the 1700s in Leiden, Padua and elsewhere to describe clinical teaching, using demonstrations of outpatients.