DISEASES OF INFANCY AND CHILDHOOD. BY THE SAME AUTHOR—(Just Issued.) LECTURES ON THE DISEASES OF WOMEN. Complete in one handsome 8vo. volume, extra cloth, of about 500 pages. Price $2 50. As a writer, Dr. "West stands, in our opinion, second only to Watson, the " Macaulay of Medicine;" he possesses that happy faculty of clothing instruction in easy garments; com- bining pleasure with profit, he leads his pupils, in spite of the ancient proverb, along a royal road to learning. His work is one which will not satisfy the extreme on either side, but it is one that will please the great majority who are seeking truth, and one that will convince the student that he has committed himself to a candid, safe, and valuable guide. We antici- pate with pleasure the appearance of the second part of the work, which, if it equals this part, will complete one of our very best volumes upon diseases of females.—N. A. Med.-Chirurg. Review, July, 1858. We must now conclude this hastily written sketch with the confident assurance to our readers that the work will well repay perusal. The conscientious, painstaking, practical physician is apparent on every page.—N. Y. Journal of Medicine, March, 1858. We know of no treatise of the kind so complete and yet so compact.—Chicago Med. Journal, January, 1858. A fairer, more honest, more earnest, and more reliable investigator of the many diseases of women and children is not to be found in any country.—Southern Med. and Surg. Journal, January, 1858. We gladly recommend his Lectures as in the highest degree instructive to all who are in- terested in obstetric practice.—London Lancet. We have to say of it, briefly and decidedly, that it is the best work on the subject in any language ; and that it stamps Dr. West as the facile princeps of British obstetric authors.__ Edinb. Med. Journal. LECTURES ON TIIE DISEASES OF INFANCY AND CHILDHOOD. BY CHARLES WEST, M.D., AUTHOR OF "LECTURES ON THE DISEASES OF WOMEN. FELLOW OP THE ROYAL COLLEGE OF PHYSICIANS: EXAMINER IN MIDWIFERY AT THE ROYAL COLLEGE OP SURGEONS OF ENGLAND: PHYSICIAN TO THE HOSTITAL FOR SICK CHILDREN: PHYSICIAN-ACCOUCHEUR TO, AND LECTURER ON MIDWIFERY AT, ST. BARTHOLOMEW'S HOSPITAL. THIRD AMERICAN, FROM THE FOURTH REVISED AND ENLARGED LONDON EDITION. PHILADELPHIA: BLAN CHARD AND LEA. 1860. km- W5|*Le PHILADELPHIA : COLLINS, PRINTEK. TO SAMUEL STEPHENS MAULING, Esq., OF EBLEY, near STROUD, GLOUCESTERSHIRE, W$m f ettos m iPiaM, IN ACKNOWLEDGMENT OF THE EVER ACTIVE FRIENDSHIP, AND MORE THAN BROTHERLY KINDNESS, WHICH HATE MADE A LIFE-LONG DEBTOR OF HIS AFFECTIONATE KINSMAN, THE AUTHOR. PUBLISHERS' ADVERTISEMENT. Two editions of this work having been called for in Eng- land since the appearance of the last American edition, it has enjoyed the advantage of a double revision on the part of the Author, resulting in its present greatly improved and enlarged form. In addition to this, the publishers have thought that perhaps its value might be still further in- creased by appending some Lectures published by the Author since its appearance in London. These Lectures, treating on subjects not discussed in the work itself, will be found at the end of the volume. Philadelphia, February, 1860. ADVERTISEMENT TO THE FOURTH EDITION. Want of leisure must form my excuse for having allowed these Lectures to remain for more than a year out of print, They now embody the results of 900 observations, and 288 post-mortem examinations made among nearly 30,000 chil- dren, who, during the past twenty years, have come under my care. I have done my best in this edition, which is much enlarged, to supply past deficiencies, as well as to correct former errors; though I know but too well how many of both still remain to call for kind indulgence, and a friendly judgment. 61 Wimpole Street, September 15, 1859. A PREFACE TO THE FIRST EDITION. The substance of a considerable part of the following Lectures was addressed to the pupils of the Middlesex Hos- pital in the summer of 1847, and the form of lectures ap- peared to me to present advantages which led me to retain it, when I determined to publish the results of my observa- tions on Children's Diseases. These observations were made in the large field presented by the Children's Infirmary, which was first thrown open to me in the year 1839, by the kindness of my friend Dr. Willis, then physician to that institution; to which office I suc- ceeded on his resignation in 1842. Very nearly 14,000 chil- dren have thus been brought under my notice during the past nine years; and I have kept accurate notes of the dis- eases of 600, as well as of the results of 180 dissections of cases in which those diseases terminated fatally. The time that has elapsed since the appearance of these Lectures in the Medical Gazette, has been too short to allow me, in preparing them for separate publication, to do much toward supplying those deficiencies in them of which I am Xll PREFACE TO THE FIRST EDITION. fully sensible. If life and health be spared me, it will be my constant endeavor to render these imperfections less numerous. I trust they may not be of a nature to detract seriously from the usefulness of the work; still less of a kind to lead into error those to whom it has been my earnest wish to prove myself a faithful guide. 96 Wimpole Street, September 20, 1848. CONTENTS. LECTURE PAGE I. Introductory: on the Study of Children's Diseases .... 17 II. Introductory: on the Treatment of Children's Diseases ... 27 III. Diseases of the Brain and Nervous System. General remarks upon them, and on their symptoms in early life ..... 37 IV. Congestion of the Brain: its causes, symptoms, and treatment . 45 V. Cerebral Hemorrhage, and Cephalhematoma, or hemorrhage ex- ternal to the skull.........56 VI. Inflammatory Affections of the Brain. Acute Hydrocephalus, its morbid appearances and symptoms......68 VII. Acute Hydrocephalus, concluded: its symptoms and treatment _ . 82 VIII. Simple Inflammation of the Brain. Inflammation succeeding to Dis- ease of the Ear. Inflammation of the Sinuses of the Dura Mater . 97 IX. Chronic Hydrocephalus.........107 X. Hypertrophy and Atrophy of the Brain......119 XI. Hydrocephaloid Disease. Tubercle of the Brain. Hydatids and Cancer of the Brain......... 128 XII. Diseases of the4Spinal Cord. Irritation and Congestion. Inflamma- tion of its Membranes and Substance. Trismus .... 142 XIII. Convulsions, and Spasm of the Glottis......154 XIV. Epilepsy, and Chorea.........169 XV. Paralysis.........., , 186 XVI. Night Terrors. Disorders of the Mindysand Idiocy . . . .201 XVII. Diseases of the Respiratory Organs: general remarks on the respira- tory functions in early life. Imperfect Expansion of the Lungs 220 XIV CONTENTS. LECTURE PAGE XVIII. Collapse of Lung after Birth. Induration of the Cellular Tissue . 230 XIX. Inflammation of Respiratory Mucous Membrane. Catarrh. Coryza. • • 241 Post-mortem appearances of Bronchitis..... XX. Inflammation of Substance of Lung: its post-mortem appearances. Symptoms and treatment of Bronchitis. Influenza . • . 2o0 XXI. Pneumonia: its symptoms and treatment.....2GG XXII. CEdema of the Lungs. Gangrene of the Lung. Pleurisy, acute and chronic...........2'9 XXIII. Croup: its varieties, causes, post-mortem appearances, and symp- toms. Treatment of its early stages......29L XXIV. Croup: treatment of its advanced stages—tracheotomy . . • 307 XXV. Diphtheria, and Croup secondary to Measles. Laryngitis Stridula, or Croup with predominance of spasmodic symptoms. Varieties of Spasmodic Cough . . . . • . • • • .315 XXVI. Hooping-cough: its symptoms and complications .... 336 XXVII. Hooping-cough: its complications, continued—post-mortem appear- ances, and treatment ......... 349 XXVIII. Pulmonary Phthisis: its peculiarities, anatomical characters, and symptoms in childhood. General symptoms of Bronchial Phthisis, and of Phthisis in early Infancy.......366 XXIX. Phthisis, continued: its auscultatory signs, its different forms, dura- tion, and treatment ......... 377 XXX. Diseases of the Heart.........393 XXXI. Diseases of Organs of Digestion and Assimilation. General remarks on the diet of Infants.........406 XXXII. Infantile Atrophy. Thrush. Dentition, and the Management of Children during it ......... 419 XXXIII. Stomatitis—follicular, ulcerative, and gangrenous. Cynanche Ton- sillaris. Hypertrophy of the Tonsils. Retrq-Pharyngeal Abscess. Cynanche Parotidea.........431 XXXIV. Diseases of the Stomach. Indigestion. Softening of the Stomach. Haematemesis and Melaena ........ 450 XXXV. Jaundice. Constipation, and mechanical causes for it, as Imper- forate Anus and Intussusception.......463 XXXVI. Diarrhoea: its symptoms and morbid appearances .... 478 XXXVII. Diarrhoea, continued: its treatment, and that of its complications . 489 CONTENTS. XV LECTURE PAG E XXXVIII. Peritonitis, its acute and chronic forms. Tubercular Peritonitis. Tabes Mesenterica.......... 500 XXXIX. Intestinal Worms. Diseases of the Urinary Organs: albuminuria, gravel, and calculus. Diabetes. Incontinence of Urine . . 51(j XL. Abdominal Tumors. Infantile Syphilis. Discharges from the Vulva in Children...........537 XLI. Fevers: general remarks on them. Remittent or Typhoid Fever: its symptoms and treatment. Intermittent Fever or Ague . . 553 XLII. Smallpox. Modified Smallpox. Chicken-pox.....567 XLIII. Measles and Scarlatina.........577 ADDITIONAL LECTURES. I. On Sudden Death in Infancy and Childhood.....597 II. On Cerebral Symptoms Independent of Cerebral Disease . . . 608 Index to the Subjects ......... 619 Index to the Formulae.........630 LECTUEES OX THE DISEASES OF INFANCY AND CHILDHOOD. INTRODUCTORY. On the Study of Children's Diseases.—Its difficulties, and how to overcome them.— Rules for the examination of sick children, and for taking notes of cases.—Ge- neral plan and objects of the Course. Gentlemen— It is not without hesitation that I have determined on adding another to the already numerous courses of lectures that you are called on to attend while engaged in the study of medicine. My reasons—and I trust my justification—for so doing are furnished partly by the fre- quency of the diseases of infancy and childhood, partly by their fatality, but still more by their many peculiarities. Children will form at least a third of all your patients, and so serious are their diseases, that one child in five dies within a year after birth, and one in three before the completion of the fifth year. These facts, indeed, afford conclusive arguments for enforcing on you the importance of closely watching every attack of illness that may invade the body while it is so frail; but they alone would scarcely be adequate reasons for my bringing these diseases under your notice as objects for special study. The body, however, is not only more frail in infancy than it be- comes in after life, but the sympathies between its different^parts are more extensive and more delicate. One organ seldom suffers alone, but the effects even of local diseases extend to the whole system, and so disorder its workings that it is often no easy matter to determine the seat of the original mischief. Nor is this all; but many important consequences result from the period of childhood being one of un- ceasing development. In the adult the structure of the body is com- plete, and its functions are the same to-day as they were yesterday, but the child learns successively to breathe, to feel, to think; and its body is daily undergoing modifications to fit it for new duties, as well as daily growing in size and strength. Disease, therefore, not merely 2 18 PECULIARITIES OF THE DISEASES OF CHILDREN. disturbs the present, but its influence reaches to the future; it not only interrupts the present function of the organ that is affected, but it puts a stop for a time to the completion of the general machinery of the body, or disarranges the due proportion of one part of that machinery to another. Moreover, there are periods, namely, those of the first and second dentition, when very great changes take place in the organism of the child, and when all these dangers are especially to be feared. Disease is then frequent and serious beyond what it is at other times, and every ailment then warrants a double measure of anxiety; while, on the other hand, if these epochs are safely passed, there succeeds a season of comparative immunity from many affec- tions that before were both common and perilous. But, if this be so, you will at once perceive that something more is essential to the successful treatment of children's diseases than to watch their advances carefully, and to adapt the strength and doses of your remedies to the tender years of your patients. It is not mere hyperbole to say that you have to study a new semeiology, to learn a new pathology, and new therapeutics. Matters of such importance cannot be properly examined at the end of a course of lectures on midwifery. I have therefore preferred making them the subjects of separate consideration during the summer, when the comparative leisure of the season will, I hope, enable you to devote some of your time to the practical as well as the theoretical study of the diseases of children. I must warn you, however, of one difficulty which you will en- counter at the very outset—a difficulty that disheartens many, and makes them abandon in despair the study of children's diseases. Your old means of investigating disease will here to a great degree fail you, and you will feel almost as if you had to learn your alphabet again, or as if, entering a country whose inhabitants you expected to find speaking the same language, and having the same manners as the people in the land you had lately left, you were to hear around you everywhere the sounds of a foreign tongue, and to observe manners and customs such as you had never seen before. You cannot question your patient; or if old enough to speak, still, through fear, or from comprehending you but imperfectly, he will probably give you an in- correct reply. You try to gather information from the expression of his countenance, but the child is fretful, and will not bear to be looked at; you endeavor to feel his pulse, he struggles in alarm ; you try to auscultate his chest, and he breaks out into a violent fit of crying. Some practitioners never surmount these difficulties, and the dis- eases of children are consequently a sealed book to them. After a time they grow satisfied with their ignorance, and will then with the greatest gravity assure you that the attempt to understand these affec- tions is useless. They have fallen into this unfortunate error from not taking the pains to start aright; they have never learned how to interrogate their little patients, and hence they have never received satisfactory replies. I speak of interrogating them ; for though the infant cannot talk, it has yet a language of its own, and this language it must be your first object to learn, if you mean ever to acquire the EXAMINATION OF SICK CHILDREN. 19 character of successful practitioners in the diseases of children. But, if you have not cultivated your faculties of observation, you cannot learn it, for it is a language of signs, and these signs are such as will escape the notice of the careless: if you are not fond of little children you cannot learn it, for they soon make up their minds as to who loves them, and when ill they will express their real feelings, whether by words or signs, to no one else. There is, moreover, a certain tact necessary for successfully inves- tigating the diseases of children. If, when summoned to a sick child, you enter the room abruptly, and, going at once to your patient, you begin to look closely at it, while at the same time you question the mother or nurse about its ailments in your ordinary pitch of voice, the child, to whom you are a perfect stranger, will be frightened, and will begin to cry; its pulse and respiration will be hurried, its face will grow flushed, and you will thus have lost the opportunity of acquainting yourself with its real condition in many respects. Besides this, the child's alarm, once excited, will not subside so long as you are present: if you want to see its tongue, or auscultate its chest, its terrors will be renewed, and it will scream violently; you will leave the room little wiser than you entered it, and, very likely, fully con- vinced that it is impossible to make out children's diseases. Very different would be the result if you conducted this examina- tion properly; and though I believe, where there is real love for chil- dren, the tact necessary for examining into their ailments will not be long in being acquired, still a few hints on this subject may not be out of place in an introductory lecture. The quiet manner and the gentle voice which all who have been ill know how to value in their attendants, are especially needed when the patient is a child. Your first object must be, not to alarm it; if you succeed in avoiding this danger it will not be long before you acquire its confidence. Do not, therefore, on entering the room, go at once close up to the child, but, sitting down sufficiently near to watch it, and yet so far off' as not to attract its attention, put a few questions to its attendant. While doing this, you may, without seem- ing to notice it, acquire a great deal of important information ; you may observe the expression of the face, the nature of the respiration, whether slow or frequent, regular or unequal; and if the child utter any sound you may attend to the character of its cry. All your ob- servations must be made without staring the child in the face; little children, especially if ill, seem always disturbed by this, and will be almost sure to cry. If the child be asleep at the time of your visit, your observations may be more minute: the kind of sleep should be noticed, whether quiet or disturbed, whether the eyes are perfectly closed during it, or partly open, as they are in many cases where the nervous system is disordered: you may, too, if the sleep seem sound, venture to count the frequency of the respiration, and the beat of the pulse, but in doing this you should be careful not to arouse the child. It should be awakened gently by the, nurse or mother, and a strange face should not be the first to meet its eye on awaking. If it were awake when you entered the room, it will probably in a few minutes 20 EXAMINATION OF SICK CHILDREN. have grown accustomed to your presence, and will allow you to touch its hand, and feel its pulse. This must always be done at as early a period in your visit as possible, in order that you may count it while the child is undisturbed, since the pulsations of the heart vary, in young children, as much as twenty in a minute under comparatively slight disturbing causes; and any inferences that you might draw from the pulse of the child, when frightened or excited, would almost certainly be erroneous. Besides the pulse, the frequency of the respira- tion should, if possible, be noticed, since the results obtained by a com- parison of the two are always more valuable than those of either taken alone. But if this be your first visit to the child, do not, for the sake of ascertaining either of these points exactly, persevere in attempts which irritate or frighten it; probably you would, after all, be unsuc- cessful, and even though you were to succeed, the knowlege would not repay you for the loss of the child's confidence, which it must be your grand object to acquire and to keep. With management and gentleness, however, you will comparatively seldom fail, and while you are feeling the pulse, or with the hand on the abdomen are counting the frequency of the inspirations, you will also learn the temperature of the body and the condition of the skin. Supposing your examination has thus far been pretty well borne, you may now, probably, venture to talk to the child, or to show it some- thing to amuse it—as your watch or stethoscope, and while thus test- ing the state of its mental powers, you may pass your hand over the head, and note the state of the fontanelle, and the presence or absence of heat of the scalp. The examination of the state of the abdomen, though too important to allow of its ever being omitted, will often lead to no satisfactory result unless carefully managed. If you allow the nurse to change the child's posture and to lay it back in her lap, in order that you may pass your hand over its stomach, the child will often be alarmed, and begin to cry. Its abdomen then becomes perfectly tense, and you cannot tell whether pressure on it causes pain, or whether the cries are not altogether the consequence of fear. It is therefore the best plan to pass your hand beneath the child's clothes, and to exa- mine the abdomen without altering its posture, while, at the same time, the nurse talks to it to distract its attention, or holds it opposite the window, or a bright light, which seldom fails to amuse an infant. If there be no tenderness of the abdomen the child will not cry on pressure, or if, during your examination, the presence of flatus in the intestines should occasion pain, gentle friction, instead of increasing suffering, will give relief. You must next examine the chest: and for this purpose immediate auscultation is always to be preferred, since the pressure of the stetho- scope generally annoys the child. If the child be not in its bedgown, it will usually be your best course to have the back of its dress undone, and then, while it is seated in its mother's or nurse's lap, to kneel down behind it, and apply your ear to its chest. In all acute diseases of the lungs in infancy the condition of their posterior part is a sure index to the extent of the mischief from which they are suffering ; for, EXAMINATION OF SICK CHILDREN. 21 owing to the infant passing s.o much of its time in the horizontal posi- tion, the blood naturally gravitates towards the back of the lungs, and the secretions are much more likely to accumulate in the bronchi in that situation than elsewhere; hence, if air be heard permeating the lungs throughout the whole posterior part of the chest, and un- accompanied with any considerable amount of crepitation, it may fairly be inferred that their front parts are free from serious disease, even though you should be unable to ascertain the fact by actual observation. When you have listened thoroughly to the back of the chest, you may next percuss it. You must not percuss first and listen after- wards, as you often do in the adult; for even when practised with the greatest gentleness, percussion sometimes frets the child, and makes it cry, whereby any subsequent attempt to listen to the breathing will often be rendered unsuccessful. But you must not neglect percussion : it is of peculiar value in childhood, since auscultation is then unavoid- ably incomplete in many instances, sometimes quite impracticable. In practising it, however, there are some rules without attention to which you will very likely fail of acquiring any information what- ever. You must never, in the child, attempt to percuss the walls of the chest immediately, but should strike on your finger, and even then very gently. The chest of the child is so resonant, that, if you per- cuss smartly, you will fail to perceive the finer variations in sonoriety which would be readily appreciable on gentle percussion. Always compare the results obtained by percussing opposite sides of the chest, - since otherwise you may overlook a very considerable degree of dul- ness. It often happens, too, that the lower lobes of both lungs are involved nearly equally; you must therefore notice the resonance of the lower as compared with that of the upper part of the chest. Sometimes you are compelled, by the fretfulness of the child, or by the tenderness of the walls of its chest, to percuss so gently as scarcely to elicit any sound. It is of importance, therefore, to attend to the sensation of solidity communicated to the finger as well as to the sound of dulness that falls upon the ear, since, if your sense of touch be delicate, it will correct or confirm the evidence of hearing. Having thus examined the back of the chest, you may if the child be likely to tolerate it, try to listen at its sides, and then in front. You can, however, scarcely auscultate the front of the chest in infancy without a stethoscope, and this you will very seldom be able to use; for, if the child be not frightened, it will probably be so exceedingly amused at what it regards as specially intended for its own diversion, that it will join in the game, and disconcert you by playing with the instrument. You will encounter this difficulty in cases of phthisis in early childhood, and will often find it no easy matter to ascertain the character of the respiration in the front of the chest. In such cases you will learn all the value of percussion, which may be practised over the front of the chest as well as the back, while the state of the breathing in the upper and back part of the chest will generally be a correct index to its condition in front. Your examination of the chest will not be complete until you have 22 EXAMINATION OF SICK CHILDREN. noticed the character of the breathing, whether the whole of the chest is expanded by it, or whether the respiration is merely abdominal— whether the child breathes as deeply as it should, or whether it makes frequent short inspirations which cannot fill the smaller bronchi. The time for ascertaining these points must vary in each case; but the earlier they are observed the better, since otherwise you run the risk of drawing your inferences not from the child's ordinary condition, but from its state when excited and alarmed. Some of these points may be noticed though the child be so fretful that you cannot auscul- tate even the back of its chest satisfactorily. An imperfect auscul- tation, however, is better than none; for at the very worst, during the deep inspirations that are made at intervals in a fit of crying, you may ascertain how far the lungs are permeable to air, and whether the bronchi are much loaded with mucus. Independently of auscultation, too, much may be learned from the cry. If its two periods be clearly marked—the long loud cry of expiration, and the shorter, less loud, but perfectly distinct sound that attends inspiration—you may feel convinced that there exists no important ailment of the respiratory organs. It will still remain for you to examine the tongue, and to ascertain the condition of the gums; and it is wise to defer this to the last, since it is usually the most grievous part of your visit to the child. If during any part of your previous examination it had cried, you might seize that opportunity to look at its tongue, and, if necessary, to pass your finger over the gums; thus sparing it any further dis- tress about the matter. If you had not this opportunity, you will generally get a good view of the mouth and throat in young infants by gently touching the lips with your finger; the child opens its mouth instinctively, and then you can run your finger quickly over its tongue, and down towards the pharynx, and thus secure a perfect view of the mouth and throat. With older children a good deal of coaxing is sometimes necessary to persuade them to open their mouth; but, if once you get your finger on the gum, you can usually keep them quiet by rubbing it, and by a little address will then seldom fail in opening the mouth wide enough to get a view of the tongue. If little children be wery ill, all this minute care in the order of your examination is not so much needed, because they will not notice so quickly; but gentleness of tone and manner will be even more necessary to sooth the pettishness and quiet the alarm of the little sufferer. Many of the directions that I have just given you refer to the ex- amination of infants, and become less applicable in proportion to the greater age of the patient. Minute rules for your examination of children from three years old and upwards are not needed; but patience the most untiring, and good temper the most unruffled, are indispensable. The previous history of a patient, the circumstances in which his present illness came on, and the symptoms that at first attended it often help to remove our doubts with reference to the nature of a disease, and sometimes greatly modify our diagnosis and influence our CASE-TAKING. 23 plan of treatment. Eeally trustworthy information on these points, however, is often difficult to be obtained, and the attempt to elicit it is almost sure to be unsuccessful, if the questions put to the patient are proposed at random, and without some previously well-digested plan on the part of the physician. One great object of clinical in- structions is to teach the student so to conduct this as well as other parts of his examination of the sick, as to throw from every source the greatest possible amount of light upon the nature of the disease, and thus to fit himself to decide with some approach to certainty on the means most likely to effect its cure. Such instruction has been amply afforded you in the wards of this hospital; but you must allow me to detain you while I point out the subjects towards which your inquiries must be especially directed in the case of children, since they differ in many respects from the questions that you would propose if your patient were an adult. We will suppose, if you please, that a child is brought to you of whose case you wish to preserve a record. Its name, age, sex, and residence will form of course the first entry in your note-book; but your next inquiries should be as to the number of living children that the parents have had, whether any of those children have died, and, if so, at what age, and of what diseases, and as to the health of both parents, aqd of their immediate relatives. The object of these questions is to ascertain whether there exists any hereditary tendency to disease in the family, since that plays a most important part in many of the affections of childhood, and symptoms that in the child of healthy parents would cause you but little uneasiness, would at once excite serious alarm if you knew that some members of the family had died of hydrocephalus, or of consumption, or had been the subjects of scrofula. Many of the most serious affections of childhood occur within the period of a few years, and after a certain age are comparatively rare in their occurrence, and generally mild in their character. It is there- fore very desirable, when any ailment is coming on the nature of which is not yet quite apparent, to know which of the diseases inci- dental to childhood have already affected your patient. With this view you would ask whether the child has been vaccinated, or has had the smallpox, and whether it has passed through any of those affections—such as chicken-pox, hooping-cough, measles, or scarlatina— which generally come on in early life. If the child had suffered from any other disease, you should learn its nature, the age at which it occurred, and any other point of importance connected with it. In writing out your history of the case, these preliminary matters would naturally be mentioned at the beginning, and though you would not follow any very strict order in proposing your questions, yet it is always desirable to obtain information on these points at an early stage of your examination, since it may guide you in some of the questions that you afterwards propose, or may lead you to pay par- ticular attention to symptoms which otherwise would not seem to be of much moment. Besides, if you postpone these inquiries till you have nearly completed your examination of the patient, the parents 24 CASE-TAKING. will probably apprehend that they are suggested by some doubt and apprehension in your mind as to the nature of the case, and will dis- tress themselves by causeless fears, or perhaps disconcert you by ques- tions to which you are not prepared to return a positive answer. There are two other points which bear on the general condition of the child, to one or both of which your inquiries must in many in- stances be directed. If your patient be an infant at the breast, you must learn whether it lives entirely on its mother's milk, or has other food besides. If it has been weaned, you must ask its age at weaning; whether it was taken from the breast on account of any failure in its own health, or its mother's, and on what diet it has since been fed. The process of dentition is the other subject for examination, and in reference to it you must ascertain how many teeth the child has, and which they are—whether they were cut easily or with difficulty,_the age at which teething commenced, and the time that has elapsed since any fresh teeth appeared. You may now endeavor to obtain a clear and connected history of the present illness; and for this purpose it is well to begin with asking when did the child last seem quite well? since you thus get a fixed starting-point from which-you can make the mother or nurse set out in her detail of symptoms. The date thus assigned, indeed, will often be a wrong one, the disease having begun before with some symptom that was not noticed, or its real origin having been considerably sub- sequent to its supposed commencement. But notwithstanding this possible error, you derive much advantage from thus making sure of the symptoms being told you in something like their chronological order, since otherwise it is very likely that those only would be men- tioned which had chanced to strike the mind of the mother or nurse, while the others would be passed over in silence. Your object in the examination must not be to curtail the garrulity of the nurse, or to suppress the mother's expression of her sometimes imaginary fears, but to get as clear an account as possible of everything that has been observed. You must be careful not to underrate the value of the information they communicate, or even of the opinions they express. Both are much more likely to be correct when your patients are chil- dren than when they are adults. A mother hanging over her sick infant, or a nurse watching the child she has helped to rear from baby- hood, may sometimes see dangers that have no existence, but will ge- nerally be the first to perceive the approach of such as are real. You see the child but for a few minutes, and at distant intervals, and the excitement or alarm which your presence is so likely to occasion may greatly modify its condition during your visit. They tend the little one by day and night, notice each movement, and seize the most tran- sient variations in its expression. I need not say much concerning the necessity of inquiring about the appetite or thirst, the state of the bowels, and the appearance of the evacuations; for these are points which you would investigate in patients of every age. I will just mention, however, that the degree of appetite and thirst cannot be so readily determined in the infant as they may be in the adult, or even in the weaned child; for an infant CASE-TAKING. 25 may suck, not because it is hungry, but in order to quench its thirst. That extreme craving for the breast, which is appeased only so long as the child is sucking, while the milk swallowed is speedily vomited, may be taken as a sign of thirst; but it is always better to record the fact than the inference. It is likewise often desirable to let the infant be put to the breast in your presence, not only for the sake of ob- serving the above-mentioned facts, but also in order to notice the vigor with which it sucks, the ease or difficulty with which it swal- lows, and other similar points, from which very important conclusions may often be drawn. Before you venture on drawing any inferences from the state of the child at the time of your visit, you should ascertain whether it has just before been taking food, or has been recently excited or fatigued by being washed or dressed; since comparatively trivial causes are sufficient to accelerate the pulse and respiration, and to give rise to changes which might, if unexplained, lead you to very erroneous conclusions. Any such circumstances ought of course to be mentioned in your notes, as should also the fact of the child being asleep at the time of your visit, since that would explain even a very considerable diminution in the frequency of the pulse and respiration. But if you are carefully to observe all the points of which I have mentioned, and to make yourselves thoroughly masters of a case, you must be most lavish of your time; you must be content to turn aside from the direct course of investigation, which you would pursue un- interruptedly in the adult, in order to soothe the waywardness of the child, to quiet its fears, or even to cheat it into good humor by join- in its play; and you must be ready to do this, not the first time only, but every time that you visit the child, and must try to win its affec- tions in order to cure its disease. If you fail in the former, you will often be foiled in your attempts at the latter. Nor is this all: you must visit your patient very often, if the disease be serious in its nature and rapid in its course. New symptoms succeed each other in infancy and childhood with great rapidity; complications occur that call for some change in your treatment, or the vital powers falter suddenly, when you least expect it. The issues of life and death often hang on the immediate adoption of a certain plan of treatment, or on its timely discontinuance. Do not wait, therefore, for symptoms of great urgency before you visit a child three or four times a day, but if the disease be one in which changes are likely to take place rapidly, be frequent in your visits as well as watchful in your observation. You will naturally think, that before I finish this lecture I should tell you something definite about the subjects that I mean to bring before your notice, and the manner in which I propose to treat them. The title of these lectures can, I should think, scarcely need any ex- planation, for by the diseases of infancy and childhood you will natu- rally understand all those affections which are either limited in the time of their occurrence to early life, or which though incidental to all ao-es, yet in the child present many peculiarities in their symptoms, and require many important modifications in their treatment. Some of these diseases, indeed, are usually allotted to the care of the surgeon. 26 PROPOSED PLAN OF THE LECTURES. and on their examination I will not enter, since I could tell you nothing more than has already been better said by others. They, however, are but few in number, and most of them are purely local affections ; so that these omissions will not be many, and most of them not important. In the description of the diseases of children, no practically useful end would be attained by following any elaborate nosological system. I shall therefore adopt the most simple classification possible, and shall treat in succession of the diseases of the nervous system, of the respiratory and circulatory, and of the digestive systems and their appendages. There will still remain one very important class of affections, namely, fevers; and these I propose to consider last of all, because much of their danger arises from their complications, and to treat them judiciously you must be familiar with the diseases of the brain, the lungs, and the bowels. In this plan it will be easy to detect a want, perhaps too great a want, of scientific arrangement; but the one object of my endeavors will be to communicate to you, as clearly as I can, such information as may be most useful to you in the dis- charge of 3'our daily duties. With this view I have, while composing these lectures, tried to think over the doubts I felt, the difficulties I met with, and the errors I fell into, when, some years ago, I entered on the office of physician to a large institution for the cure of children's diseases. I have pre- sumed that where I had encountered difficulties there you might meet them too—that where I had made mistakes there you would need a guide—and remembering the many anxious hours I. passed when I hesitatingly adopted some course of treatment which I feared might after all be a mistaken one, it has been my aim to lay down, not only the rules for the diagnosis, but also the indications for the treatment of each disease as minutely as possible. To the task before me I now apply myself, with a deep conviction of the narrow limits of my own knowledge, but still feeling that I have contracted an obligation to impart toothers what I trust experi- ence has taught me. My end will be answered, if you learn it at an easier rate than I did; and if I can be the means of saving you from some of those errors in diagnosis, and some of those mistakes in treat- ment, which, for want of some one to guide me aright, I committed. RULES FOR DEPLETION IN CHILDREN. 27 LECTURE II. INTRODTJCTOKY. On the Treatment of Children's Diseases.—Influence of remedies modified by the age of the patient.—Rules for the practice of depletion, for the use of mercury, autimony, and opium, and for the employment of blisters. Suggestions as to the mode of prescribing for infants and children. In the introductory lecture I tried to point out the main peculiari- ties which distinguish the diseases of early life, and to furnish you with some general rules for their investigation. It may not be time misspent if^ before we begin the examination of any special class of ailments, I endeavor to give you a few general directions for their treatment, though in so doing 1 must of necessity anticipate some things which will require notice hereafter, and must occasionally pre- suppose the possession of that knowledge which it is the main object of these lectures to impart. The importance of great exactness in prescribing for infants and children, and the necessity for regulating the doses of our remedies according to the tender years of our patients, are self-evident. Poso- logical tables, as they are termed, are, however, of very little value for our guidance, since the susceptibility of the young to the action of different remedies varies greatly according to their nature, so that the rule which safely defines the dose of an opiate would be altogether inapplicable as determining the strength of a purgative or of an emetic. The abstraction of blood, the use of emetics and purgatives, the employment of antiphlogistics, and the administration of sedatives are the great weapons with which we endeavor to combat the ad- vances of acute disease. The safe use of each of these in early life implies the observance of certain precautions which I will now attempt to explain, and will then try to furnish you with a few general direc- tions that may be of service in prescribing for infants and children. The early age of our patients imposes of necessity some restriction on the mode fn which depletion can be practised; for venesection in the arm is hardly ever possible before the age of three years, often not till later, in consequence both of the small size of the veins, and of the quantity of fat in which they are imbedded. In cases of ex- treme urgency the jugular vein may be opened, and I have never found any difficulty in the operation, though I believe the necessity for the proceeding very seldom arises, and the only instances in which I have had recourse to it were either instances of violent con- vulsions succeeded by profound coma, or else of very acute inflamma- tory croup. For almost all purposes of depletion in early life we are dependent 28 RULES FOR DEPLETION on the use of leeches, and by this means, if rightly managed, we may attain nearly all the ends of general bleeding. The great objection to the employment of leeches rests on the difficulty of estimating and of controlling the quantity of blood abstracted by them. This objec- tion, however, applies almost entirely to the common practice of putting on a comparatively small number of leeches, and trusting to the application of a poultice, or the employment of fomentations, for obtaining a sufficient quantity of blood. Instead of adopting this plan, than which nothing can be more uncertain, it is far better to apply a larger number of leeches and to allow of no subsequent bleeding. It may then be calculated that each leech takes about two drachms of blood, and we are thus enabled to estimate the quantity removed with a certainty little less than we are possessed of if we employ venesection, while, further, the blood is removed in the course of fifteen or twenty minutes, instead of draining away as in the other case for six or eight hours, weakening the patient, and yet exercising comparatively small influence on the disease. To insure certainty and safety, however, in the employment of leeches, there are several precautions which must not be neglected. Of these, the most important is, that their application should not be left to a nurse, but that, wherever it is at all practicable, the medical attendant should himself superintend it. This is of special moment in all acute diseases in which it is desired to obtain by local bleeding the constitutional effects of general depletion, since according to the result produced, it may, on the one hand, be desirable to put on a larger number, or, on the other, to remove some before they have completely filled themselves. The effects produced by the loss of blood often influence the character of the subsequent treatment. On this account, therefore, as well as with the view of lessening the risk of hemorrhage going on from the leech-bites unperceived, it is desir- able to apply leeches by day, not towards evening, or at bedtime, as is commonly the practice. Attention should further always be paid to apply leeches in situations where they will not alarm the child by being within his sight, and where, also, there is a firm surface beneath against which pressure can be made, so as readily to control the bleed- ing. Behind the ears, therefore, or on the vertex, are the best situa- tions for applying leeches to the head, and under the scapulas when it is necessary to deplete from the chest, while, in many abdominal affections, all the advantages of local bleeding may be most safely obtained by the application of leeches to the anus. The above rules apply to the mode of practising depletion in early life; but, independently of the mere manner of drawing blood there are some still more important cautions which have reference to the general principles which should govern us in resorting to depletion at all. 1st. It should be remembered that large losses of blood are worse borne by the child than by the adult; that if syncope is produced its effects do not pass away so speedily, but leave a much more abid- ing depression. 2d. That the shock consequent on large losses of blood, shows AND EMPLOYMENT OF MERCURY. 29 itself, not merely by causing syncope, but also, not very seldom, by producing convulsions, and such convulsions are specially apt to be excited in cases where the previous disorder of the nervous system was considerable, even though such a disorder depended on conges- tion of the brain which called for depletion to relieve it. It seems in these cases, as in some of comparatively slight disease of the heart, in which, if the equilibrium of the circulation is suddenly disturbed, it altogether fails to recover itself. A child of ten months old was brought to me many years ago with symptoms of cerebral congestion —a hot head, a raised fontauelle, a burning skin, and twitchings of the tendons of the arms and legs. I ordered leeches to the head, which drew freely; but the convulsions, which it was hoped they would ward off, occurred while the bleeding was still going on, and the child sank at once into a state of coma, from which it never rallied completely, and died in the course of forty-eight hours. Now, in this case, the abstraction of blood was indicated, and the appearances dis- covered after death showed that the depletion had not been excessive. It had, however, been too sudden; and probably, had I been present when the leeches were applied, I should have noticed some change in the child's condition which would have warned me to put a stop to further bleeding, and might thus have led to an entirely different re- sult. In proportion, therefore, to the youth of our patient, must be our caution in ordering free depletion, and our care in watching its effects, and these must both be greater when marked disorder of the nervous system forms the indication for our treatment. 3d. Not only are very large losses of blood hazardous, and great shock by its too sudden abstraction, also attended with danger in early infancy, but repeated bleedings are also inexpedient. The system rallies from them with proportionately far greater difficulty than in the adult, and that peculiar class of symptoms, by which exhaustion is apt to simulate congestion of the brain, are specially likely to be induced. It may be added that, to a considerable degree, the same caution holds good with reference to all other antiphlogistic remedies, that free purgation, spare diet, and depressing measures of all kinds, though often requisite, yet require most heedful watching, and gene- rally need to be soon discontinued. Among antiphlogistic remedies, the two which in the child, as in the adult, are of the greatest value and of the most general applica- tion in the treatment of acute inflammatory diseases, are antimony and preparations of mercury. Both, however, are not infrequently used in cases where they are neither not needed, or are positively inju- rious. The peculiar influence of mercury is exerted too slowly to control the first rapid advance of some acute diseases, such as croup and pneu- monia, though in both after previous depletion, and the administration of antimony, mercury often proves more serviceable. In those forms of pulmonary inflammation, also, which sometimes occur in compara- tively weakly subjects, or in which the disease has already advanced unchecked so far as to produce consolidation of the lungs, it is on mercury that our chief reliance must be placed. Mercury, too, is our 30 RULES FOR EMPLOYMENT OF MERCURY great stay in all cases of acute inflammation of the serous membranes of the chest and abdomen, and in severe inflammation of the mucous membrane of the large intestine or dysentery, the disease often admits of control by no other means than by the conjoint employment ot calomel and opium. In cachectic diseases its utility is far more limited. The earlier symptoms of congenital syphilis yield rapidly to the employment ot small doses of mercury; but the tertiary results of the disease are often aggravated, very seldom indeed benefited, by that medicine. In the majority of disorders connected with the tubercular diathesis mercurials are not beneficial; and in tubercular hydrocephalus in particular, in which they are so often given, I never saw even momen- tary improvement from them, apart from their occasional action as purgatives. It must, however, be confessed that, in their powerless- ness to control this disease, they do but stand on the same footing with all other medicines. There is one class of ailments too connected with tuberculosis in which the action of mercury is almost uniformly bene- ficial ; and that is tubercular peritonitis, and those vague disorders of the functions of nutrition so commonly referred to disease of the mesenteric glands. In administering mercury to infants and young children, it must be borne in mind that evidence of the system being affected by it is seldom afforded, as in the adult, by the occurrence of salivation. So rare indeed is mercurial stomatitis in early life, that I have never yet seen an instance of it in a dangerous form, very rarely indeed have met with it in such a degree as to be troublesome; and should there- fore regard the production of gangrene of the mouth by the adminis- tration of mercury, as an evidence of some rare idiosyncrasy on the part of the patient, rather than of want of due care on that of the doctor. In early life, mercury, instead of affecting the mouth, usually acts very speedily as an irritant on the intestinal canal; and the green stools, which are often looked on with satisfaction as a proof of the system being brought under the influence of the medicine, are far from always having that meaning. They prove its action as a local irritant, a result which may be most undesirable, and which often compels us to diminish its dose, sometimes even completely to sus- pend its administration. Sometimes, too, calomel acts as an irritant on the mucous membrane of the stomach, producing nausea and vomit- ing, and giving rise to so great a degree of depression as to necessi- tate its discontinuance. Besides its use in those more formidable diseases to which reference has hitherto been made, mercury is also often employed as a purga- tive and alterative. There is no doubt but that used with either°of these objects it is a remedy of great value, and the objection to its employment is, not that it fails to accomplish these ends, but that it answers them at a greater expense of constitutional power than was necessary. Rhubarb, soda, the mineral acids, aloetic preparations, the taraxacum, and other remedies, exert an alterative power over the secretions, without any of that depressing influence which attends the use of mercurials. In the same manner, there are many purga- AND ANTIMONY. 31 tives no less certain, and no less speedy in exciting the action of the bowels, so that, before prescribing calomel or gray powder, the prac- titioner ought to be satisfied that there is some special end, in pro- ducing an increased secretion of bile, in controlling an excited state of the circulation, or in rapidly modifying the condition of the intestinal mucous membrane, which no other remedy would attain, or at any rate would not attain so certainly or so quickly. A second remedy of great value in early life is antimony, though one which also is not infrequently misapplied. • It is not as a simple emetic that antimony ought to be employed, for, unlike ipecacuanha, its influence is not confined to inducing vomiting, but it also exerts a most powerful depressing action on the circulation, and is therefore specially indicated in acute inflammation of the lungs and air-tubes. When the object is merely to empty the stomach, to produce that revulsion which follows the operation of an emetic, and which leads us often to prescribe it at the onset of a febrile attack for the sake of the moist skin and tranquil pulse which seldom fail to succeed its operation; or when we seek simply to free the bronchi from the se- cretions poured into them in too great abundance, as in catarrh or in simple hooping-cough, every end is answered by the use of ipeca- cuanha. On the other hand, in the onset of croup, in the early stage of acute pneumonia or of capillary bronchitis, when disease is advanc- ing every hour and when its advance directly threatens life, antimony is°the only medicine sufficiently speedy and sufficiently powerful in its action to keep pace with the advances of the disease, and to hold it in check. Even in these cases, however, the administration of anti- mony needs care, and after tolerance of it has been established we cannot so safely as in the adult continue its use. I shall hereafter have to explain to you the liability to collapse of the lung in early life, when feeble inspiratory power is associated with the presence of secretion in the air-tubes. In this state the pulmonary tissue tends by its own elasticity to exclude the air from the air-vesicles; and, if the muscular power be reduced below a certain point, the patient's efforts fail to dilate them, and by degrees more and more of the lung becomes dense, unaerated, and as useless for the time, for all purposes of respiration, as if it had been solidified by inflammation or com- pressed by fluid. This danger is always to be borne in mind in the pulmonary affections of early life, and the vigor of the patient's powers must be the measure of our treatment, as much as the urgency of the disease. As a mere diaphoretic, antimony, when administered in small doses, is as useful in the case of the child as in that of the adult. I am not fond of its use, however, as an antiphlogistic in ordinary febrile affection; for the nausea which it is apt to produce may obscure the approach of cerebral mischief, or lead to an erroneous interpretation of the symptoms. . ... A third great remedy in the diseases of early life is opium in its various preparations; and with it may be classed, though separated by a wide interval, other sedatives, such as hemlock, henbane, hop, and lettuce. Perhaps no remedies are so often needed in the diseases 32 RULES FOR USE OF OPIUM of early life as sedatives, for at no other age is the nervous system so easily disturbed. At the same time the susceptibility to the action of narcotics and sedatives is so remarkable, and the evils which result from their unnecessary employment or from their administration in excessive doses are so serious, that some practitioners altogether ab- stain from their use. To do so, however, is to deprive ourselves ot one of the most important classes of remedies, and of one lor wnicn no substitute can be devised. . . The danger which especially attends the use of opium arises partly from the employment of uncertain preparations, such as the syrup ot poppies; partly from the administration of overdoses, or from their too frequent repetition, of which two errors the latter is more frequently committed. In prescribing for children, preparations of definite strength should always be used, as the compound tincture of camphor, tincture of opium, or Dover's powder. The weaker preparation, the compound tincture of camphor, is often preferable to laudanum, since a slight error in dispensing is of so much less moment. Sometimes the comparative tastelessness of laudanum renders it the more suit- able, but if so, even though only a single dose is needed, it is wiser in the case of infants to order a mixture containing two or three doses in order to lessen the risks of error. But mischief is more frequently done by the frequent repetition of opium, than by the improper pre- scription of overdoses; and I am always averse to the common prac- tice of giving small quantities of opium at short intervals, for the purpose of checking diarrhoea or of soothing restlessness in young infants, and prefer, unless there be some strong reason to the contrary, to give a larger dose of the remedy once or twice in the twenty-four hours. In addition to these general precautions with reference to the mode of administering opium, special care is needed in its employment in some conditions. It must be given charily in all cases where the system has been exhausted by the previous disease, or by the previ- ous treatment; and this caution must be particularly borne in mind during convalescence from fever, where yet the patient's restlessness not seldom requires its employment. In all cases of cerebral excite- ment the use of opium calls for great watchfulness; sometimes it must be given rather as an experiment whereby the real nature of the dis- ease is tested, and when so employed its results must be scrutinized with the most anxious care. In severe diarrhoea, too, the transition from a state of excitability of the nervous system to a condition of coma is often very rapid in its occurrence; an overdose of opium may hasten or induce this catastrophe, or, even though it should not have this result, yet without great care we shall be at a loss to deter- mine how far the disease, and how far the medicine, has induced the symptoms. In mere restlessness, unattended by severe pain, other sedatives are often preferable to opium; thus, for instance, the feverish disquietude of a child during teething is often soothed by henbane, while that which manifests itself by a disposition to carpopedal contraction and to AND APPLICATION OF BLISTERS. 33 spasm of the glottis, is mitigated by small doses of hydrocyanic acid and chloric ether as effectually as by opiates, and with far greater safety. The difficulties in the administration of internal remedies in early life have had no small share in leading practitioners to the employ- ment of outward applications with much greater frequency than in the adult. Fomentations, poultices, and liniments of various kinds relieve pain, abate spasm, or serve as useful counter-irritants, in very many cases which I need not now occupy your time in specifying. But, besides these, blisters are also much used in different inflamma- tory affections, more particularly in those of the lungs and air-tubes, though I think their application is more restricted and is resorted to with greater caution now than formerly; and I see far fewer instances of unhealthy ulceration of blistered surfaces among the children of the poor now, than came under my notice fifteen or twenty years ago. In applying blisters to infants and young children, it must be borne in mind, not only that they vesicate more speedily than in the adult, but that the vesicated surface is apt, especially in some diseases, to pass into a state of ulceration; and, further, that the amount of constitu- tional disturbance produced by blisters is considerable in proportion to the youth of the patient. The ordinary rule, which prescribes four hours as the longest time during which a blister should be allowed to remain on the skin in infancy, is on the whole a good one, but it must be remembered that some parts of the surface are far more sensitive than others. Thus, for instance, the skin on the front of the chest is peculiarly delicate, and a blister applied there for two hours would almost certainly vesi- cate, while it might not produce the same effect in double the time if applied beneath the scapulas. On the other hand, the scalp is re- markably deficient in sensitiveness, and a blister may be allowed to remain on it for eight hours without any risk of mischief ensuing. There are, moreover, some diseases which increase the susceptibility of the skin to the action of irritants; thus, for instance, in all the ail- ments which accompany or succeed to measles, and especially in the pneumonia which often complicates it, a vesicated surface is apt to pass into a state of dangerous ulceration. Nor is this the only hazard which attends their use; but the constitutional disturbance which they produce, the pain while they are drawing, the soreness of the surface while they are being dressed, and the itching and irritation which accompany their healing, often keep up an amount of restlessness, and a state of feverish irritation, that are in every way prejudicial to the child's recovery. On these accounts, therefore, I have almost entirely abandoned the use of blisters in infancy and early childhood, and am always most careful that no extensively abraded surface shall be left by their application. Partly with this object, and partly in order to avoid the inconvenience of the blister being dislodged by the movements of the child, I make use almost exclusively of the blistering fluid, which is painted once or oftener over the surface, according as it is wished to produce a more or less considerable degree of irritation. If vesication takes place, the serum is let out by pricking with a needle, and a 3 31 RULES FOR PRESCRIBING layer of cotton wool being applied over the surface is allowed to re- main there until, healing being completed, it drops off of its own accord. In addition to the avoidance of danger and the lessening ot constitutional disturbance by these means, we have the great advan- tage of being able, if it should be desirable, to repeat the same pro- ceeding in the course of three or four days, while, by the ordinary mode of employing blisters, ten days almost invariably elapse before the sore left by their application is healed. # The whole range of remedies might thus be gone through ; and with reference to each it might be pointed out how its employment requires to be more or less modified according to the age of the patient. But to do this would be more tedious than profitable, and the majority of details will find their fittest place when we notice the disease for the cure of which this or the other medicine is specially indicated. A few general hints may, however, be given with reference to the art of prescribing for infants and children of tender age. But first of all I must remind you of the twofold difficulty which you encounter in the treatment of' the diseases of children, owing partly to the way- wardness of the little patients themselves, partly to the prejudices of their parents, while your success as practitioners will depend on the amount of tact with which you avoid coming into direct collision with either. To prescribe nauseous medicine when with a little care you could order it in a palatable form; to insist on a particular article of diet being given, or on a particular remedy being employed, which the parents fancy will not suit, unless you believe one or the other to be absolutely indispensable to your patient's cure, is needlessly to weaken that authority which in the graver maladies it is absolutely essential that you should be able to exert. As has been truly said by MM. Rilliet and Barthez, it is in the slighter much more than in the serious diseases of children that waywardness, fretfulness, and obstinate refusal of medicine are met with. In the majority of such cases nature alone suffices for the patient's cure, and, while you watch carefully the approach of any serious symptoms, you will lose nothing in the confidence of the parents, and gain much in the love of your patients, by sparing them the nauseous draught, and the agony of tears and fright and temper which they often undergo before they swallow it. The battle with a child to compel it to take medicine, to force it into a bath, or to give it an emetic, generally does far more harm than the remedy so administered can do good; and the many tears saved by it in the nursery are one of the strongest practical recommendations of homoeopathy to the public. But even the most expectant plan of treatment does not leave you without the power of regulating to a great degree the diet of the child, the temperature of its room, the nature of its amusements, and of ex- cluding bright light and loud sounds from its apartment, and nothing beyond these simple measures is needed to remove many of the minor ailments of the young child. Many medicines, too, can be given with- out any trouble either to the child or to its attendants. A few drops of ipecacuanha wine will be unperceived in its drink, a little James's powder may be concealed in some arrowroot or on a bit of bread and FOR YOUNG CHILDREN. 35 butter, or a dose of scammony may pass unnoticed in a little hot and sweetened milk; while, if tonics are needed, the saccharine carbonate of iron, or the steel wine will seldom be refused by the most spoilt and most wilful inhabitant of the nursery. Your own ingenuity will suggest many other remedies which may be given without exciting suspicion, or at any rate without causing disgust; and, believe me, the doctor who brings smiles rather than tears into the nursery, he whom the children love most, the parents will trust most, and that love and trust will stand him much in stead when he has to combat serious illness. As far as may be, then, it is well to avoid formal prescriptions in treating the ailments of early life. Often, however, this is not pos- sible, but something may still be done to make physic at any rate supportable. Let its bulk be small; two teaspoonfuls will be swal- lowed readily by many a child whom no persuasion could induce to take two tablespoonfuls. For the same reason, powders, except when very small, are often worse than useless; and yet one sees powdered bark or powdered calumba, or large doses of rhubarb and soda, prescribed for little children of two or three years old; and they must have been educated with far more than average wisdom, or be possessed of more than average docility, who will be prevailed on to take the nauseous compound. In the heat and fretfulness of fever, when the child would gladly drink any moderately palatable medicine, the solution of acetate of ammonia is not seldom prescribed, and the return of the time for giving ea^h dose of medicine is but the signal for a fresh combat between the child and its attendant, in which, whoever gains the victory, the patient is sure to suffer. A few moments' thoughtfulness would avoid the trial both to the child and its parents, for nothing would be easier than to prescribe a mixture such as it would take eagerly. A solution of carbonate of potash saturated with citric acid and flavored with syrup of mulberries, or a few grains of nitre dissolved in water and rendered palatable with syrup of lemons, forms a febrifuge mixture to which very few children would object. If it is desirable to give antimony, a watery solution of tartar emetic may be substituted for the wine, the unaccustomed taste of which might be disagreeable. If a stimu- lant is needed, milk well sweetened conceals to a great extent the pun- gency of ammonia; while the chloric ether, on account of its sweet taste, is almost always taken readily. Of course it is not possible to make all medicines palatable, and then you must confine yourselves to giving that which is unpleasant in as small a bulk as possible. Still, if you keep this object in view, it is remarkable to how large an extent it is attainable. The com- pound jalap powder is almost the only aperient powder which children do not very much object to, and the small bulk of the jalapine enables us to dispense even with that in the greater number of instances. Scammony, and especially its extract, can be concealed in milk; and even castor oil shaken up in a bottle with hot sweetened milk, in which a piece of cinnamon has been boiled, is so disguised as scarcely to be suspected. The addition of a little chloric ether to the infusion 36 RULES FOR PRESCRIBING. of senna covers its nauseous taste almost completely, and an extra quantity of liquorice makes even the decoction of aloes palatable, while powdered aloes occupying a small space can often be given in brown sugar. Rhubarb is the one medicine which nothing effectually disguises, though a little spirit of nutmeg mitigates the nauseous flavor of the infusion. We seldom, however, need be at a loss in selecting some of the milder laxatives, for the senna electuary, the various syrups and essences of senna, the nursery infusion of senna and prunes, fluid magnesia, and the saccharine carbonate of magnesia, may each in turn be employed. 1,111.1, It is not in general difficult to prescribe a tonic which shall both be suitable for a child, and at the same time not very unpalatable. The ordinary bitter infusions, as gentian, cascarilla, and calumba, are out of the question with young children; but the mineral acids can always be made tolerable, and the infusions of roses, cloves, and orange peel, though perhaps of little value except as vehicles for some other remedy, are by no means unpleasant. The decoction of logwood is very valuable as a tonic and astringent, and a little sugar and a teaspoonful of port wine generally render the dose popular. In spite of its bitter flavor the small bulk of quinine generally enables us to give it without much difficulty, while fortunately the cod-liver oil, disgusting as it seems to be, is comparatively seldom objected to, and orange syrup or orange wine usually conceals its taste very effectu- ally. The steel wine and the saccharine carbonate of iron have been already referred to as the best chalybeates for children; but, if iron is needed in stronger forms, the syrup of orange-peel covers the taste of the muriated tincture of iron, and even the compound iron mix- ture of the London Pharmacopoeia is taken readily if sufficiently diluted with almond emulsion. But enough has probably been said on these preliminary subjects. Your own experience will every year deepen the conviction that in dealing with the diseases of early life nothing can be considered tri- vial. The object of my first lecture was to show you how it is only by attention to little things that you will learn rightly to discriminate their nature; the purpose of this has been to teach you how necessary the same attention is to their successful treatment. FREQUENCY OF DISEASES OF THE NERVOUS SYSTEM. 37 LECTURE III. Diseases of the Brain and Nervous System.—Their extreme frequency in early life favored by the rapid development of the brain, and the wide variations in the cerebral circulation during childhood.—Peculiar difficulties of their study.— Symptoms of cerebral disease in the child.—Convulsions, their symptomatic value very various—their frequency in great measure due to the predominance of the spinal system in childhood—may be excited by many causes—hence attention should always be paid to the precursors of an attack. Description of a fit of con- vulsions. It can scarcely be necessary to assign many reasons for beginning this course of lectures with the study of the diseases of the nervous system. The subject, although beset with many difficulties, has always engaged much attention ; partly, no doubt, from the natural tendency of the human mind to inquire most curiously into those truths that seem most hidden ; but still more from the alarming nature of many of the symptoms that betoken disturbance of the nervous system, and from the frequently fatal issue of its diseases. But besides the gene- ral interest and importance of these affections, at whatever age they may occur, their extreme frequency in early life gives them an additional claim on our notice. It appears from the reports of the Registrar-General, that 16,258 out of 91,225 persons who died in the metropolis during the years 1842 and 1845, of ascertained causes, were destroyed by the various diseases of the nervous system. But 9,350 of these 16,258 deaths took place during the first five years of oxistence ; or, in other words, 57 per cent, of the fatal disorders of the nervous system occurred within that period.1 Even after making a very large allowance for the possible errors of statistical data, this predominance of the diseases of the nervous system in early life is far too remarkable to be over- looked ; though some persons not being able to account for the fact, have affected to doubt its reality. The fact is one which cannot be gainsaid; and though we do not pretend thoroughly to account for it, yet two considerations may help in some degree to explain it. The first is derived from our knowledge of the circumstance, that in an organ whose development is rapidly advancing, many diseased processes also, if once set up, will go on with proportionate activity. 1 These numbers, which yield results differing but very little from those given in the first edition, are deduced from the returns furnished in the Fifth and Eighth Re- ports. The returns for 1846, which are also given in the Eighth Report, are not in- cluded, since, owing to the epidemic prevalence of diarrhoea in the autumn of 1846, they would not yield average results. 38 DISEASES OF NERVOUS SYSTEM —THEIR STUDY DIF Now there is no organ in the body, with the exception of the pregnant womb, which undergoes such rapid development as the brain in early childhood. It doubles its weight during the first two years ot^ lire, and reaches nearly, if not quite, its maximum by the end ot tne seventh year. This same active state of the nutritive or vegetative processes in the brain of the child renders the organ liable to nave disease set up in it by causes which would produce little or no injurious effect on the brain of the adult. In the second place, the brain in infancy is much more exposed to disorder than that of the adult, owing to the far wider variations ot which the cerebral circulation is susceptible in early life than subse- quently. Nor is the cause of this difficult to discover. The cranium of the adult is a complete bony case, and the firm substance of the brain affords a comparatively unyielding support to the vessels by which it is nourished. It has been proved, indeed, by Dr. Burrows' that the quantity of blood which these vessels contain is not always the same, as some have erroneously supposed: still its variations must needs be circumscribed within far narrower limits than in the child, whose cranium, with its membranous fontanelles and unossified sutures, opposes no such obstacle to the admission of an increased quantity of blood, while the soft brain keeps up a much slighter counter-pressure on the vessels than is exerted by the comparatively firm parenchyma of the organ in the adult. If the circulation in the child be disturbed, whether from difficulty in the return of venous blood as during a paroxysm of hooping-cough, or from increased arterial action, as at the onset of a fever, or during the acute inflam- mation of some important organ, the brain becomes congested, and convulsions often announce the severity of the consequent disturbance of its functions. The same causes, too, which expose the brain to be overfilled with blood, render it possible for it to be drained of that fluid more completely than in the adult. This fact, which you should always bear in mind when treating the diseases of infants, is one reason why excessive depletion induces a far more serious train of symptoms in young children than succeed to it in the grown person. It happens, unfortunately, that while there are special reasons for studying the diseases of the nervous system in childhood, their study is beset with special difficulties which we do not meet with in the adult. Disordered intellect, altered sensation, impaired motion, are the three great classes to which the symptoms of disease of the nervous system may be referred. If our patient be an adult, he tells us of his altered feelings; he perhaps experiences some disorder of his intellectual powers even before it has become observable to others, and thus timely warned, we can often take measures to prevent the advance of 1 In his Lumleian Lectures, published in the Medical Gazette, April 28 and May 6, 1842, and subsequently in his work on Disorders of the Cerebral Circulation, Sec. 8vo. Lond. 1846. The general accuracy of Dr. Burrows's conclusions, though called in question by the late Dr. John Reid, in the London and Edinburgh Monthly Journal for Aug. 1846 ; and more recently by Dr. Hamernjk, of Prague, in the Vierteljahrschrift filr die praktische Heillcunde, vol. xvii. p. 38, seems to be placed beyond doubt by the very careful experiments of Dr. Berlin, published in the Nederlandsche Lancet, Feb. 1850; and in Schmidt's Jahrbiicher for 1851, No. 1, p. 14-16. SYMPTOMS OF CEREBRAL DISEASE. 39 disease and to ward off that impairment of the motor powers which in his case we know usually indicates the occurrence of some grave organic lesion. In the child things follow a very different course. At first it cannot express its sensations at all, while, long after it has acquired the power of speech, it knows too little how to shape its ideas into words to give a correct account of what it feels; and we cannot expect to learn much from the disturbance of an intellect which as yet has scarcely asserted its claim to be anything higher than the instinct of the animal. The value of the symptoms, too, is different; for disturbance of the motor power, which is comparatively rare in the adult, except as the consequence of some serious disease of the brain, takes place in the child in cases of the mildest as well as of the most serious ailments; and we may even observe convulsions recur- ring several times a day for many days together, apparently without adequate cause, and not leading to any serious impairment of the child's health. How, then, are we to attain in the child to anything beyond the merest guesswork in our diagnosis of diseases of the nervous system, when we are deprived to so great an extent of that information which the state of his intellect and the description of his sensations afford us in the adult? What meaning are we to attach to that symptom— the impairment of the motor power, which in the adult we look on as of such grave import, but which we meet with in the child under such varying conditions and.in by far the greater number of cases? The task, indeed, is attended with difficulty, and the solution of these inquiries will need that you should devote to it some time and some careful observation ; but if you do this you need not despair of learn- ing much about an infant's sensations, and the state of its mind, and will at length become able rightly to interpret the meaning even of a fit of convulsions. It may be well to pause here for a moment, and briefly to pass in review the symptoms by which disease of the nervous centres, and especially of the brain, manifests itself in infancy and early childhood. The painful sensations which the infant experiences soon show themselves in the haggard, anxious, or oppressed look, which takes the place of the naturally tranquil expression of its countenance. It often puts its hand to its head, or beats or rubs it, or while lying in its cot, bores with its occiput in the pillow, owing to which, in children who have suffered for any time from uneasy sensations in the head, you will often find the hair worn quite off the occiput. It turns its head away from the light, and lies much with its eyes half closed, in a state of apparent drowsiness, from which it often arouses with a start, and cries. The cry, especially in inflammatory disease, is pecu- liar; it is generally a low almost constant moan, very sad to hear— interrupted occasionally by a sharp, piercing, lamentable cry, almost a shriek. If the child be young it will often seem relieved by being carried about in its nurse's arms, and while she is moving will cease its wail for a time, but begin it again the moment she stands still. You will sometimes observe, too, that if moved from one person's arms to those of another, or even if its position be but slightly altered, 10 SYMPTOMS OF CEREBRAL DISEASE. a sudden expression of alarm will pass across its features; the child is dizzy, and afraid of falling. You see, then, that even in the infant there is a language of signs by which we learn with certainty the existence of pain in the head, and the connection of this pain with dizziness and intolerance of light. You must beware, however, of concluding from any one set of symp- toms that the head is the seat of real disease. The child, as well as the adult, may have sick headache; and the degree of febrile disturb- ance, of heat of surface, and of heat of head, together with the state of the digestive organs, are all to be taken into account in forming your diagnosis. Something may be learned of the state of the mental powers and of the feelings even in early infancy. Have you never watched an infant on its mother's lap, and noticed the look of happy recognition with which its eye meets that of its mother? An early result of cere- bral disease is to interrupt this intercourse : the child now never seems to catch its mother's eye, but lies sad and listless, as if all persons were alike indifferent to it; or at other times even familiar faces cause alarm, the child apparently not recognizing those who yet have al- ways tended it. This disturbance, however, is but momentary, and the child subsides into its former condition, and allows itself to be taken by those at whom a minute before it seemed frightened. But these symptoms are to be interpreted by the light thrown on them from other sources, and by the information, both positive and negative, thus obtained. You fear that disease is going on in the brain; but is the skin hot?—is there heat of head?—are there fre- quent flushings of the face, and does the accession of each flush seem connected with an increase of agitation and distress, or followed by a deepening of the drowsiness? Is the fontanelle prominent and tense, or are the pulsations of the brain to be felt with unusual force through it?—are the veins of the scalp full, or do the carotids beat with un- usual force? What is the character of the pulse?—is it not merely increased in rapidity; but even when examined under exactly similar conditions, does it afford a different result each time? Do you find it irregular in frequency, or unequal in the force of its beats, or even distinctly intermittent? Again, what is the state of the pupil ?—is it generally contracted, as if to exclude light as much as possible from the oversensitive retina? or is it usually dilated, and does it act slowly, as though disease had deadened the sensibility of the nervous system; or do the pupils of the two eyes not act simultaneously, but one more readily than the other? Do the pupils oscillate under the light, at first contracting, then dilating, and either remaining dilated or continuing to oscillate, though within narrower limits, and with a tendency to remain more dilated than at first? Or, lastly, do you find, when the child is roused, this oscillation of the pupil going on under the ordinary amount of light that enters the chamber? Now all of these are indications of disordered function of the brain and many of them point to disorder of a very serious kind. But there are yet other sources from which we must not neglect to seek for information. Much may be learned from the state of the PRECURSORS OF AN ATTACK. 41 digestive functions. The bowels are almost always disturbed ; usually, though not invariably, constipated, while nausea and vomiting are seldom absent. I am not acquainted with any one symptom which should so immediately direct your attention to the brain, as the occur- rence of causeless vomiting, and especially its continuance. At first, perhaps, the child vomits only when it has taken food ; but before long the stomach will reject even the blandest fluid, and then the efforts at vomiting will come on when the stomach is empty, a little greenish mucus being rejected with no relief, the retching and vomit- ing soon returning. I shall have occasion to dwell again upon the importance of this symptom, which I have known continue for several days before any other indication of cerebral disease could be dis- covered. In children of three or four years old this occurrence would scarcely be overlooked; but the case is different with infants, who so often vomit the milk when ill, that the mother or nurse might fail to mention it to you, if you did not make special inquiries with reference to that point. The manner in which the functions of the respiratory organs are performed is also not to be overlooked. That peculiar, unequal, irre- gular breathing, to which the name of cerebral respiration has been applied, though of considerable value when present, is sometimes not observed, or not until the disease of the brain is already so far advanced that all questions of diagnosis have long been set at rest. There is,, moreover, a short, hard, hacking cough, which you may sometimes hear, and the import of which you ought to be acquainted with, since it betokens disease of the brain, not of the lungs. There are peculiar sounds, too, which sometimes attend respiration, and are known as indicating disturbance of the nervous system. To these, however, I shall have to return hereafter, since they betoken a disease of a serious nature, known by the name of spasmodic croup, and which I must in the course of these lectures describe in full. I have purposely delayed till now of speaking of the indications of cerebral disease afforded by the occurrence of convulsions. The symp- tom is one undoubtedly of great importance, since it is observed in almost every case of serious disease of the brain, at some stage or other of its progress. The very frequency of the phenomenon, how- ever, and the great variety of the circumstances in which it occurs, render it difficult for us rightly to interpret its meaning. Perhaps it will help us to understand it, if we bear in mind that in a large pro- portion of cases convulsions in the infant answer to delirium in the adult. In early life the superintendence of the motor power is the chief function of the brain, which has not yet attained to its highest office as the organ of the intellect. Hence the convulsions which you may observe to come on in infancy in the course of some acute diseases, such as inflammation of the lungs, do not import that any new mala- dy has invaded the brain, but simply that the disease is so serious as to disturb the due performance of all the functions of the organism, and of those of the brain in common with the rest. Convulsions at other times take place in infancy, not as the result of any abiding disease of the brain, but simply in consequence of those anatomical 42 CONVULSIONS —PREDOMINANCE OF SPINAL SYSTE peculiarities which allow of a much more sudden and more consider- able congestion of the cerebral vessels than can occur in the adult. Of this kind are frequently the convulsions that come on during a paroxysm of hooping-cough, which are induced by the impediment to the return of blood from the head, and which often cease so soon as that impediment is removed by the child taking a deep inspiration. But these two considerations are, it must be owned by no means^ade- quate to explain the very great frequency of convulsions in children, though they account for much that otherwise would be inexplicable. The grand reason of their frequency is no doubt to be found in tne predominance of the spinal over the cerebral system in early life. In tne adult, the controlling power of the brain checks the display or'tn°se reflex moments which become at once evident if disease heighten the excitabilitv of the spinal cord, or cut off the influence of the brain from the paralyzed limb, or even if sleep suspend that influence tor a season. When the child is born the brain is but imperfectly de- veloped, its functions are most humble, and convulsions are then so frequent that they are computed to occasion 73.3 per cent, ot all deaths which take place during the first year of existence, from dis- eases of the nervous system. In the next two years the brain more than doubles its weight, and deaths from convulsions sink to just a third of their former frequency. In proportion as the-brain increases in size, and its structure acquires perfection, and its higher functions become displayed, convulsions grow less and less frequent, until from the 10th to the 15th year they cause less than 3 per cent., and above 15 less than 1 per cent., of the deaths from diseases of the nervous system.1 But a little observation will show you, that though convulsions are often the immediate cause of death, yet this fatal event is rare during childhood in comparison with those instances in which they pass off without any serious result; and that in proportion to there frequency they less often betoken grave disease of the brain in the child than in the adult, while any cause which greatly excites the spinal system may be attended by them. The disturbance of the spinal system, which ushers in fever in the adult, shows itself by shivering, while in the child the same disturbance often manifests itself not by shivering but by convulsions. Convulsions may be induced in early life by a constipated state of the bowels, by the presence of worms in the in- testinal canal, or of a calculus in the kidney, or by the pressure of a 1 The first line in the accompanying table shows the proportion per cent, of deaths from diseases of the nervous system at different ages, to the deaths from all causes at the same ages, in the metropolis ; and the second line the proportion borne by deaths from convulsions to deaths from diseases of the nervous system in general. Under 1 year. From 1 to 3 years. From 3 to 5 years. Total under 5 years. From 5 to 10 years. From 10 to 1 j years. Total above 15 years. 30.5 73.3 18.5 24.9 17.6 17.8 24.3 54.3 15.1 9.9 10.6 2.4 10.4 0.8 Deduced from the Fifth and Eighth Reports of the Registrar-General. CONVULSIONS — THEIR EXCITING CAUSES VARIOUS. 43 tooth upon the swollen gum—causes wholly inadequate to occasion so serious an occurrence in the grown person. Hence your first duty is, in every case, to ascertain where is the seat of the irritation which excited the nervous system to this tumultuous reaction. If the fits come on in an advanced stage of some serious disease, they are pro- bably only the indications that death is busy at the centres of vitality; if they occur during hooping-cough, they point to a congested state of the brain, the consequence of the impeded circulation through the lungs; if they attack a child apparently in perfect health, they pro- bably indicate that the stomach has been overloaded, or that some indigestible article of food has been taken; or, if this be certainly not the case, one of the eruptive fevers is perhaps about to come on; most likely either smallpox or scarlatina. To determine the cause of the convulsions you must acquaint your- self with the history of the child's health for some time before any threatening of them had appeared; you must learn whether the child has ever suffered from worms, whether its digestive functions has long been out of order, or whether the process of dentition, which is now perhaps going on, has been attended with much constitutional disturbance. But, besides all these points, your inquiries must be still more carefully directed to ascertain whether any cerebral symp- toms preceded the attack, and if so, what was their nature, since it is seldom that acute disease of the brain sets in with convulsions. You will sometimes, indeed, be told that the child was well until a convulsive seizure suddenly came on; but on inquiring minutely it * will usually be found that some indications of cerebral disease had been present for days, though not sufficiently severe to attract much attention. In cases of apoplexy, of intense cerebral congestion, and of phrenitis convulsions occur at a very early period; but even then, extreme drowsiness, great pain in the head, and vomiting, usually precede for a few hours the convulsive seizure. When the brain is thus seriously involved, the recovery from the convulsions is very imperfect; coma perhaps succeeds to them, or other evidences of cere- bral disease are so marked as to leave no doubt of the brain being affected. Tubercle sometimes remains for a long time after its deposi- tion in the brain, without giving rise to any well-marked symptoms, till its presence is at length announced by a fit of convulsions. These convulsions are seldom at first very severe, but you will learn to dread them more than those which assume a more formidable appearance, from noticing either that one side of the body is exclusively affected, or, at least, that there is a marked preponderance of the affection on one side. It is well to bear in mind, too, that convulsions may occur from a want of blood in the brain as well as from its excess, and that the convulsions which come on in some ill-nourished infants may in- dicate a state of atrophy of the brain. I must, however, have said enough already to impress upon you the importance of narrowly scrutinizing the meaning of every attack of convulsions. But though so important, there are few tasks more difficult. You have to maintain your own self-composure at a time when all around you have lost theirs; to extract truth as you best 44 DESCRIPTION OF A FIT. may from the imperfect, often exaggerated, accounts of anxious rela- tives; to observe not only minutely but quickly, and to come to a speedy decision: since while in those cases which require active treat- ment delay is almost synonymous with death, there is at least as great danger of destroying your patient by that "nimia diligentia" to which the prejudices of the nurse and the fears of the friends will often con- spire to urge you. It is well to watch closely the first indications of that disturbance of the nervous system which will be likely to issue in convulsions. And here let me recommend you not to listen with too incredulous an ear to old nurses, who may tell you that a child has been much convulsed, while you find upon inquiry that it has not had any fit. When they say that a child has been much convulsed, they mean usually that it has shown many of the symptoms which forebode an attack of general convulsions.' These forebodings are often induced by dyspepsia, or by disorder of the bowels in young infants, and have been described by writers under the name of "inward fits." A child thus affected lies as though asleep, winks its imperfectly closed eyes, and gently twitches the muscles of its face—a movement especially observable about the lips, which are drawn as though into a smile. Sometimes, too, this movement of the mouth is seen during sleep, and poets have told us that it is the " angel's whisper" which makes the babe to smile—a pretty conceit of which we can scarcely forgive science for robbing us. If this condition increase, the child breathes with difficulty, its respiration sometimes seems for a moment almost stopped, and a livid ring surrounds the mouth. At every little noise the child wakes up; it makes a gentle moaning, brings up the milk while sleeping, or often passes a great quantity of wind, especially if the abdomen be gently rubbed. When the intestinal disorder is relieved, these symptoms speedily subside, nor have we much reason to fear general convulsions so long as no more serious forebodings show themselves. There is more cause for apprehension, however, when we see the thumbs drawn into the palm either habitually, or during sleep; when the eyes are never more than half closed during sleep; when the twitching of the muscles is no longer confined to the angles of the mouth, but affects the face and extremities; when the child awakes with a sudden start, its face growing flushed or livid, its eyes turning up under the upper eyelid, or the pupils suddenly dilating, while the countenance wears an expression of great anxiety or alarm, and the child either utters a shriek or sometimes begins to cry. When a fit comes on, the muscles of the face twitch, the body is stiff", immovable, and then in a short time, in a state of twitching motion, the head and neck are drawn backwards, and the limbs vio- lently flexed and extended. Sometimes these movements are confined to certain muscles, or are limited to one side. At the same time neither consciousness nor sensation is present. The eye is fixed and does not see; the finger may be passed over it without winking; the pupil is immovably contracted or dilated; the ear is insensible even to loud sounds ; the pulse is small, very frequent, often too small and CONGESTION OF THE BRAIN. 45 too frequent to be counted ; the breathing hurried, labored, and irre- gular; the skin bathed in abundant perspiration. After this condition has lasted for a minute, or ten minutes, or an hour or more, the convulsions cease; and the child either falls asleep, or lies for a short time as if it were bewildered, or bursts into crying, and then returns to its senses, or sinks into a state of coma in which it may either be perfectly motionless, or twitching of some muscles may still continue; or lastly, it may die in the fit. This, however, is not usual except when the convulsions have come on in subjects ex- hausted by previous disease, or when they are the result of apoplexy or of intense cerebral congestion, such as takes place occasionally in hooping-cough, or when they are associated with that closed state of the larynx which occurs sometimes in spasmodic croup. This preliminary examination of the symptoms of disturbance of the nervous system has placed us in a position to commence our in- vestigation of the different forms of cerebral disease ; on which we will enter at the next lecture. LECTURE IT- Congestion of the Brain.—Active congestion may come on at the onset of eruptive fevers, or be induced by exposure to the sun, or may attend dentition, or be ex- cited by various other causes.—Symptoms in each of its three stages.—Treatment. —Special rules for depletion and the application of cold.—Active measures not always appropriate. Passive congestion may supervene on hooping-cough, or be connected with disorder of the digestive organs in weakly children, or be induced by unfavorable hygienic causes.—Its symptoms and treatment. In my last lecture I endeavored to point out to you some of the reasons for the greater frequency of affections of the nervous system in infancy and childhood than at other periods of life. I dwelt es- pecially upon certain structural peculiarities of the brain, and of its bony case, which render the cerebral vessels liable to become over- loaded with blood, under the influence of causes that would be wholly inadequate to produce such an effect in the adult. With the advance of the ossification of the skull, and the closure of its fontanelles and sutures, these peculiarities are rendered fewer and less important; but still a remarkable liability to congestion of its vessels continues to characterize the brain through all the years of early childhood. A late distinguished German physician, Dr. Mauthner, of Vienna, on examining the bodies of 229 children who had died at different ages and of various diseases, found a congested state of the vessels of the brain in 186 of the number. In some of these cases it is probable that this i Die Krankheiten des Gehirns und Riickenmarks bei Kindern. 8vo. Wien, 1844, p. 12. 46 ACTIVE CONGESTION OF THE BRAIN. condition had come on only a short time before the patients' death, since in them no symptoms of cerebral disturbance had appeared during the progress of their illness; but in many it was not so; and I shall have occasion to warn you over and over again to be on the watch against congestion of the brain, as a condition which is very likely to come or in the course of affections even of distant organs. Nor is it merely as a serious complication of many other diseases that this cerebral congestion deserves your notice; its importance depends still more on its constituting the first and curable stage of many dis- eases of the brain, which, unless arrested at the outset, soon pass be- yond the resources of our art. Neither, indeed, must it be forgotten, that although inflammation, hemorrhage, and the effusion of serum, are the three results to one or other of which congestion of the cere- bral vessels tends, yet the exceptions to their occurrence are by no means few, even when that congestion has been very considerable or of long continuance; and that not only may the functions of the brain be seriously disordered, but the life of the patient may be destroyed, without the anatomist being able to discover any one of these results, or, indeed, anything more than a general repletion of the vessels of the organ.1 Any cause which greatly increases the flow of blood to the head, or which greatly impedes its reflux, may give rise to a congested state of the brain; and, according as this state is induced by the one or the other cause, it is said to be active or passive. The head symp- toms which sometimes usher in the eruptive fevers, depend, in a measure, upon the former cause; the convulsions which frequently occur during a fit of hooping-cough result from the latter. The brain may become actively congested at the time of teething, or from ex- posure to the sun, or from a blow on the head; or a state of passive congestion may be induced by some mechanical impediment to the return of blood from the organ—such as the pressure of a hypertro- phied thymus, or enlarged and tuberculated bronchial glands upon the jugular veins: or it may be merely the result of a languid circu- lation from the want of pure air, or of nourishing and sufficient food. Active cerebral congestion is a not very unusual consequence of the disturbance of the circulation at the outset of the eruptive fevers. Con- vulsions and apoplectic symptoms sometimes come on suddenly in a child previously, to all appearance, in perfect health, and may even terminate in death in less than twenty-four hours. The brain is found loaded with blood, but all the other organs of the body are quite healthy. Some years ago I was requested to be present at the examination of the body of a boy not quite two years old, who had been in perfect health until the day before his death, which took place in such circumstances as I have just mentioned. The congested state of the cerebral vessels gave but little satisfactory information; but the same evening the brother of the child was taken ill with 1 Dietl's Anatomische Klinik der Gehirnkrankheiten, 8vo. Wien, 1846, contains, at pp. 53—73, a very able exposition and defence of views concerning cerebral congestion in many respects similar to those expressed in this lecture. CAUSES PRODUCING CONGESTION OF THE BRAIN. 47 vomiting, intense fever, and eore throat. In a few hours a red rash appeared: the case was one of scarlet fever, and ran its course with considerable severity, though, happily, to a favorable termination. It is probable that the poison of the fever had affected the blood of both children, and that the consequent disturbance of the cerebral circula- tion was so violent as at once to destroy the life of the younger, while the elder brother survived the shock, and in him the disease soon presented its usual features. The history of most epidemics of scarla- tina would afford'many instances of a similar nature.1 But, alarming though these symptoms are, it is comparatively seldom that they end in death ; for when they occur at the onset of the exanthemata they generally vanish almost as if by magic on the appearance of the eruption. I was called one day to see a little girl two years old, who, until the day before, had never had an hour's illness. She had eaten a hearty dinner; and, though she vomited soon afterwards, did not seem otherwise indisposed, and slept well in the night. Immediately on waking in the morning, however, she had a fit, during which she was insensible, squinted, threw her limbs about, and occasionally screamed aloud. She continued very ill through the whole day ; was hot and feverish during the night, having occasional attacks of con- vulsions, in which she stretched out her legs, threw back her head, now and then uttered a wrord or two, and then relapsed into a state of insensibility. This was her condition at half-past 10 A. M.—about twenty-fours after the occurrence of the first fit. I bled her to liij, and would have drawn more blood if it had continued to flow; and then put eightleeches on her head, employed cold effusion, and gave active cathartics during the day, but without much benefit; and at midnight she was still insensible, rolling uneasily from side to side, boring with her head in the pillow, squinting, and making automatic movements with her mouth and tongue. I now put eight more leeches on the head, which bled profusely, and the bleeding was followed by great diminution in the convulsive movements. About 4 A. M. of the next day, the child fell asleep, and dozed for a few hours. She awoke sensible, and continued so. On my visit in the morning, I found her quiet and sensible, without any sign of convul- sion ; her face was very pale ; her head, before so hot, was now quite cool; her pulse had sunk in frequency, and lost its fulness. An erup- tion of a papular character had appeared on the hands, arms, inside of the thighs, and slightly on the face. This eruption was the small- pox, and the disease ran its course with no unfavorable symptom. It would not be right, indeed, to attribute the symptoms of disturb- ance of the nervous system that sometimes occur at the commencement of the eruptive fevers entirely to derangement of the cerebral circula- tion, for something is probably due to changes in the blood itself; but we see similar results produced by other causes, the immediate effect 1 See Armstrong's notice of this suddenly fatal form of the disease, at p. 30 of his work on Scarlet Fever, &c. 2d edit. London, 1817 ; and Von Amnion's mention of it in his description of the epidemic of malignant scarlatina at Dresden in 1831-2, in the Analekten iiber Kinderkrankheiten, lltes Heft, p. 42. Stuttgart, 1836. 48 CEREBRAL CONGESTION. of which is to disturb the circulation and to favor congestion of the brain. Thus, exposure to the heat of the sun, even though the head had not been unprotected from its rays, may be followed by convul- sions or by other indications of an overloaded state of the brain, and these symptoms may all subside so soon as the excited circulation has recovered its wonted balance. Of this I remember a striking instance in the case of a delicate boy, who, when a year old, was taken out by his nurse during one of the hottest days in June. He was quite well and cheerful when he left the house, but, after being out for some time, he began to breathe hurriedly and irregularly, and his nurse, in consequence, brought him home. I saw him about two hours after- wards. He was then restless, fretful, and alarmed; his surface gene- rally hot, and his head especially so, the brain pulsating forcibly through the anterior fontanelle; the pulse too rapid to be counted; the respiration hurried, labored, and irregular, and there were constant startings of the tendons of the extremities. The child was on the eve of an attack of convulsions; but the tepid bath relieved the heat of the skin, and the pulse fell, and the subsultus diminished. Light and sound were excluded from the room; he fell asleep, and awoke in a few hours refreshed and tranquillized, and on the next morning a little languor was all that remained of an illness which had seemed likely to prove so formidable. Disorders of the nervous system are very frequent during the period of teething. Many of the symptoms which then occur are the direct result of irritation of the trifacial nerve, but others are the immediate consequence of congestion of the brain. Febrile disturbance almost always attends upon the process of dentition, and you can easily un- derstand that when the circulation is in a state of permanent excite- ment, a very slight cause may suffice to overturn its equilibrium, and occasion a greater flow of blood to the brain than the organ is able to bear. But I need not occupy more time in pointing out to you the various circumstances which may give rise to active congestion of the brain. Let us now pass to a more minute examination of its symptoms. Cerebral congestion may, as you have seen, come on very suddenly, its symptoms from the first being alarming, and such as to call for immediate interference; or general uneasiness, a disordered state of the bowels, which are generally, though not invariably constipated, and feverishness, may have for a few days preceded the more serious attack. The head by degrees becomes hot, the child grows restless and fretful, and seems distressed by light, or noise, or sudden motion, and children who are old enough sometimes complain of their head. One little boy, nearly three years old, who died of congestion of the brain, had seemed to suffer for some days before any alarming symp- tom came on, from severe pain in the head. He sometimes awoke crying from his sleep, or when awake would suddenly put his hands to his ears, exclaiming, "Oh, hurt! hurt!" Usuallv, too, vomiting occurs repeatedly; a symptom on the importance of which I have already insisted, since it is not only confirmatory of others, but also may exist before there is any well-marked indication of the head being ITS SYMPTOMS. 49 affected, and when, though the child seems ailing, there is nothing definite about its illness. The degree of fever which attends this con- dition varies much, and its accessions are irregular; but the pulse is usually much and permanently quickened; and if the skull be unos- sified, the anterior fontanelle is either tense and prominent, or the brain is felt and seen to pulsate forcibly through it. The sleep is disturbed, the child often waking with a start, while there is occasional twitching of the muscles of its face, or of the tendons of its wrist. The child may continue in this condition for many days, and then recover its health without any medical interference; but a slight cause will generally suffice to bring back the former indisposition. You will sometimes see striking instances of this in children while teeth- ing; the fever subsiding, the head growing cool, and the little patient appearing quite well, so soon as the tooth has cut through the gum, but the approach of each tooth to the surface being attended by the recurrence of the same symptoms. But though the disturbance of the brain may pass away of its own accord, yet we cannot reckon on such a favorable result occurring, for symptoms such as I have mentioned are often the indications of the organism generally having begun to suffer from mischief which has been going on for months unnoticed, and which is now about to break out with all the formidable characters of acute hydrocephalus. Or should they have no such grave import, yet congestion of the brain is itself a serious, sometimes a fatal malady. Even though no treatment be adopted, indeed, the heat of head may diminish, and the flush of the face grow slighter and less constant; but the countenance becomes very heavy and anxious, the indifference to surrounding objects in- creases, and the child lies in a state of torpor or drowsiness; from which, however, it can at first be roused to complete consciousness. The manner, on being roused, is always fretful; but if old enough to talk, the child's answers are rational, though generally very short; and, murmuring " I am so sleepy, so sleepy," it subsides into its former drowsiness. The bowels generally continue constipated, and the vomit- ing seldom ceases, though it is sometimes less frequent than, before. The pulse is usually smaller than in the other stage, and it is often irregular in its frequency, though not actually intermittent. An attack of convulsions sometimes marks the transition from the first to the second stage; or the child passes, without any apparent cause, from its previous torpor into a state of convulsion, which, subsiding, leaves the torpor deeper than before. The fits return, and death may take place in one of them, or the torpor growing more profound after each convulsive seizure, the child at length dies comatose. This second stage, if so it may be called, is usually of short duration, and if relief be not afforded by appropriate treatment, death is seldom delayed beyond forty-eight hours from the first fit, though no graver lesion may be discovered afterwards than a gorged state of the ves- sels of the brain and its membranes, and perhaps a little clear fluid in the ventricles and beneath the arachnoid. Occasionally, indeed, death does not so speedily follow these symp- toms; but they continue slightly modified for days, or even weeks, and, 4 50 TREATMENT OF CEREBRAL CONGESTION. contrary to all expectation, recovery now and then takes place. This protracted course of the affection is, I believe, met with only in the case of very young children, in whom, the congestion having relieved itself by a copious effusion of serum into the ventricles, the yielding skull accommodates itself to its increased contents. The symptoms, though to a great extent the same as before, are now due to the pre- sence of water in the brain—a disease which, though dangerous and often fatal, is yet chronic in its course, and may even admit of cure. If active congestion of the brain may come on under so great a va- riety of circumstances, it is evident that there can be no invariable rule for its treatment, adapted alike to every case, but that the pecu- liarities of each must be taken into your most careful consideration. The little girl I have mentioned in whom convulsions preceded the attack of smallpox, would most likely have died from apoplexy if she had not been bled very freely; and it is probable that in her case the depletion might have been carried still further with advantage. On the other hand, the boy who had been exposed to the heat recovered under the tranquillizing influence of a tepid bath, and there can be no doubt but that to him depletion would have been injurious. You must, then, always endeavor to make out what has been the antecedent of the attack. If violent convulsions have come on suddenly, and without apparent cause, in a child until a short time before in perfect health, inquire whether your patient has had the eruptive fevers, especially scarlatina and smallpox, or whether he has been recently exposed to their contagion, and examine the arm to see whether there is a good cicatrix as evidence of successful vaccination. When head symptoms usher in the exanthemata, the danger for a time may be imminent, but you know that if you can relieve the gorged vessels of the brain, and thus ward off the immediate peril, nature herself will come to your assistance, and the outbreak of the eruption will probably be followed by the cessation of the cerebral disturbance. Or it may be that the child has greatly overloaded its stomach, or has partaken of some indigestible substance, in which case you would give an emetic, though in any other circumstances the attempt to induce vomitino- would be not only useless, but dangerous. If the symptoms had suc- ceeded to a blow, you would not lose sight of the danger of inflamma- tion of the brain supervening; while if the head affection had been preceded by long-continued gastric or intestinal disturbance, or if it had come on during teething, you would bear in mind that a more cautious treatment must be pursued, lest you cause as serious mischief by doing too much, as might in other cases result from your doing too little. There are, however, but few exceptions to the rule which prescribes the abstraction of blood, either locally or generally, as one of the most important remedies in cases of active cerebral congestion. If the symptoms set in violently, as they did in the case of the little girl whose history I mentioned to you, you must deplete freely, and will find that relief will follow more speedily on the abstraction of blood from the jugular vein than on venesection or the application of leeches. It is not easy to define exactly the quantity of blood which may be RULES FOR DEPLETION—APPLICATION OF COLD. 51 drawn, but from two to three ounces are probably as much as you would ever be warranted in taking from a child a year old; and the appearance of manifest relief to the symptoms should be a signal to you for stopping its flow, even before that quantity had been obtained. The removal of too large a quantity of blood would be at least as mischievous as the abstraction of too little, while you would run some hazard of confounding the effects of loss of blood with those of its excess, and might thus be led further into error. It is, therefore, better (although children bear repeated bloodletting ill) to take but a moderate quantity of blood at first; to watch its effects, and to repeat the bleeding in a few hours, if it be necessary, rather than to subject the system to the shock of an excessive loss of blood. In children under three years old, bleeding from the arm is seldom practicable; and without the case be very urgent, it is inexpedient to open the jugular vein. At this early age, however, almost all the good effects of general bleeding may be obtained by the proper appli- cation of leeches. But their proper application in cases such as these, in which too little and too much are alike attended by most serious danger, implies something very different from ordering a certain num- ber, and leaving the management of them to the nurse, and the regu- lation of the subsequent bleeding to accident; and requires that you should remain with your patient, and watch the effects they produce. It is generally estimated that a healthy leech will draw about 3ij of blood, and that if the subsequent bleeding be encouraged, about as much more will flow afterwards; but it is, as I observed in the second lecture, by far the better and safer course, whenever it is wished to produce a decided influence on the system, such as, in the adult, we should seek to exert by general depletion, to put on a larger number of leeches at once; to remove them the moment they seem to have produced a decided effect, and not to allow of any bleeding subse- quently. Eight leeches applied to a child one year old, will under these regulations do much more good, and with an actually smaller loss of blood, than will follow from half that number applied without such precautions. If, on your second visit, you find that the child, although manifestly relieved for a time by the depletion, is relapsing into a state of coma, or that convulsions, checked for a season, are returning, or that the head is nearly as hot, and the pulse nearly as accelerated as before, and quite as hard, you may be warranted in bleeding again. You must not, however, resort to a second bleeding without the most evi- dent necessity, nor without having tried all those subsidiary means by the diligent employment of which you will often be able to render further depletion unnecessary. Many of these means, indeed, are so simple that their value is frequently underrated; and it is so often said, almost as a matter of course, "Keep the child quiet and the room cool, and apply cold to the head," that it does not strike the parents how much depends upon those directions on which the doctor seems to lay so little weight. You must learn, however, that, in the treatment of children's diseases, none of these things are trivial, but that on their due performance often hangs the life of your patient. Do not content 52 TREATMENT OF CEREBRAL CONGESTION. yourselves, then, with merely giving directions, but stay to see them attended to; and do not leave the house till the chamber is darkened, the cool air freely admitted, the cold application to the head properly adjusted ; nor till all persons who are not actually waiting on the child have left the apartment. At the outset of the affection the bowels are usually constipated, so that an active purgative is in most cases called for. You may give a dose of calomel and jalap, or the calomel may be administered alone and followed by the infusion of senna, which may be repeated every three or four hours till the bowels act. Should the stomach be very irritable, a larger dose of calomel may be given, and after the lapse of a couple of hours an attempt may be made to quicken its action by administering a purgative enema, or by dissolving some sulphate of magnesia in the child's drink, and giving it at short intervals. In many cases the disorder will be speedily removed by this treatment, and the child, whose life had seemed to be hanging by a thread, will, in the course of twenty-four hours, be almost well. But it may happen that though the symptoms are increasing in severity, though the convulsions are unchecked, or though coma is evidently coming on, yet the state of the pulse forbids a repetition of depletion; or it may even be that you dare not bleed at all, for fear of altogether putting out the life which is in such urgent peril. For- tunately we have another and very powerful remedy in store, which we may try in cases where, otherwise, we should be without resource: this remedy is the cold affusion. There is something, however, appa- rently so formidable in taking a child from its bed and pouring a stream of cold water on its head for several minutes together, that you will be wise to explain what you are about to do to the child's friends, and to obtain their consent to the experiment, lest you be compelled by their alarm to desist before you have done any real good. When you have determined to resort to it, the child must be taken out of bed, wrapped in a blanket, and laid upon the nurse's lap with its face downwards, while you pour a stream of water from a little height, upon its head. The most effectual way of doing this, though one "not always practicable, is to place the child under the cock of a water cistern, or the spout of a pump, since you can then continue the stream, uninterruptedly, for five or six minutes. I have seen some remark- able instances of convulsions arrested and of children aroused from coma, by these means; but you must bear in mind that the agent is one of great power, and you must feel the pulse from time to time during its employment, lest you should, by its long continuance, pro- duce too great a depression of the vital energies. But besides those cases in which you want to produce a sudden effect by the application of cold with a shock, you often need the sedative influence of cold constantly applied. A very intense degree of cold may be kept up by allowing cold water to drip constantly upon the patient's head, which may be managed, as suggested by Dr. Watson, by means of a sponge and funnel placed a little above the head. This plan is, however, objectionable on account of its being almost impossible, when it is adopted, to prevent the patient's person COLD AFFUSION. 53 from becoming extremely wet; and, moreover, it is but seldom that so powerful an agent is needed in the case of children. Few methods of applying cold to the head are better than that which consists in half filling two bladders with pounded ice or cold water, and placing them, each wrapped in a napkin, the one under, and the other upon the child's head. By pinning the corners of the napkins to the pillow you can secure them from being displaced, and can also prevent the weight of the upper bladder from resting too heavily on the child's head, while all danger of the bed or the dress becoming wet is avoided. Supposing, now, that by the employment of these means you have removed the imminent danger, and that your patient is going on favor- ably, still it will be generally desirable to continue treatment for a few days. Free action of the bowels must be secured; for which purpose small doses of calomel may be given two or three times a day, and it may be desirable to accompany each powder with a dose of a mixture containing nitre and sulphate of magnesia.1 You must, however, bear in mind that you will do less harm by allowing a child to go without medicine than by forcing on it remedies which it dislikes and resists taking. Calomel, indeed, can almost always be given; and even sulphate of magnesia will very often be taken if mixed with the drink, or dissolved in a little veal broth. But how much soever a child may resist medicine, the abstraction of blood, a spare diet, a cool and dark and quiet chamber, are remedies always at command, the value of which you must not underrate. I need not tell you that all cases do not admit of this active treat- ment. When the disease creeps on with febrile symptoms, occasional vomiting, constipation, loss of appetite, and restless nights, with com- plaints, if the child be old enough to speak, of pain in the head or limbs, or vertigo, and with a quick and variable pulse, you must treat it gently. If you deplete, it must be only by leeches, and then not in Targe number, while you trust much to quiet and the careful regu- lation^ the diet. In such cases you will often find a tepid bath night and morning soothe the child and tranquillize the circulation far more than you might have 'expected from so simple a remedy. Drastic purgatives must be avoided, but small doses of mercury and chalk, or of calomel, either alone or combined with rhubarb, may be given with advantage pnce or twice a day. Half a grain of calomel, or two grains of the hydr. c. creta, with four of rhubarb, would be a proper dose for a child a year old. If there be much feverishness and restlessness during the day, you may give a mixture of bicarbon- ate of potash not quite saturated with citric acid, and containing small doses of ipecacuanha wine, if the stomach be not extremely irritable, and of the tincture of hyoscyamus; the value of which last medicine as a sedative in the diseases of children can scarcely be too 1 (No. l.) ty.—Potassse nitratis gr. x. Magnesia? sulph. ^j. Syr. limonum 5iij- Aquae destil. 3ix.— M. Jjij ter quotidie. For a child a year old. 54 PASSIVE CONGESTION. highly estimated. The addition of a little syrup of mulberries will render the above mixture extremely palatable.1 You will sometimes meet with cases of cerebral congestion that appear to have been brought on by exposure to the heat of summer, and in them it often happens that the bowels are not constipated, but somewhat relaxed. You must not, however, aim at checking the diarrhoea by direct astringents, but should rather pursue an alterative plan. In most instances there is irregularity of the bowels rather than diarrhoea; the child having five or six unhealthy motions, for the most part destitute of bile, in the course of one day, and passing the succeeding twenty-four hours without any evacuation at all. In such cases you will find the treatment I have just indicated very useful. If the bowels be much disturbed, half-grain or grain doses of Dover's powder may be combined with the mercurial with advantage. There is not time to enter into more minute details with reference to the management of every variety of active cerebral congestion, but we must' briefly notice those cases in which the condition exists in what may, perhaps not improperly, be called the passive state. In the paroxysms of hooping-cough the brain becomes congested by the impediment to the return of the blood from the head: and cerebral congestion is induced in a similar manner when the larynx becomes spasmodically closed in the disease known by the name of Laryngis- mus Stridulus. But we likewise meet with cases where the passive succeeds to the active form of cerebral congestion, or becomes more or less gradually developed out of some disorder of the abdominal viscera; or, lastly, where it supervenes towards the close of life in weakly children, whose vital powers have at length become too feeble to propel the blood. In children who have suffered long and severely from hooping- cough, you often notice a general lividity of the face and lips, a puffed and anxious countenance, and the child makes grievous complaints about its head, while the skin is moist and cool, and the pulse soft, though frequent. Many of these symptoms indicate an overloaded state of the cerebral veins ; and if a paroxysm of coughing occur, and the circulation be thus further disturbed, the child may die in a fit, or may sink after some convulsive seizure into a state of coma, which sooner or later proves fatal. In such a case you will find the vessels of the brain and its membranes universally gorged with black blood, the choroid plexuses of a deep purple color, and more bloody points than natural will present themselves on a section of the brain being made. Both the symptoms during life, and the appearances after death, are only a rather exaggerated illustration of what occurs in all 1 (No. 2.) I£.—Potassse bicarbonat., Acidi citrici, aa gr. xx. Vin. ipecac. Tt^xij. Tree, hyosc. WLxviij. Syr. mori 3iij- Aquse destill. 5ix.—M. 3>j 6ta quaque hora. For a child a year old. ITS SYMPTOMS AND TREATMENT. 55 cases of passive congestion of the brain. It is not, however, always easy to explain why this condition comes on. Among the poor you often find it connected with general disorder of the digestive organs, and occurring as one of a long train of ills induced by destitution and neglect. It was so in the case of a little boy four months old, whom I saw some years ago. His parents were young and healthy people, but they had already lost three children, apparently in consequence of their inhabiting one of those narrow courts so numerous in London, into which the sun never shines, and where young children pine and fade like tender plants shut up in a cellar. When tenweeks old, this little boy was taken with pain in his bowels and diarrhoea, and at three months old he began to suffer from fits, which came on daily, sometimes several times a day. No efficient treatment had been adopted when he was brought to me. He was then as large as most children of his age, and by no means emaciated; but his flesh was flabby, his face unintelligent, puffed, and livid, his head hot, the veins of the scalp and eyelids turgid, the eyes prominent, lustreless, covered by mucus, and the pupils not acting under light. He lay in his mother's lap, uttering a constant hoarse moan; his head thrown rather back, and in incessant rotatory motion; his mouth was open, his tongue red and parched, and the papillae on its surface were very prominent; his abdomen was rather full, and his legs were constantly drawn up towards it. He vomited much; his bowels were open three or four times a day, the motions being green and offensive; his pulse was frequent, but without power. In this, as in many instances of passive congestion of the brain, local depletion was resorted to at first, and, benefit° resulting from it, was repeated more than once. It is not however, every case that will admit of even local depletion, which, whenever employed, must be practised only with the view of afford- in «• relief to the gorged cerebral vessels, not with the idea or curing the patient by bleeding. The greatest attention must in every case be paid to diet and to the state of the bowels, and you will find no means of inducing their healthy action better than the employment of small doses of mercury and chalk two or three times a day. It the child be not weaned, you may find it desirable, if there be constant sick- ness, to take it almost, or entirely, from the breast for a day or two and to substitute barley-water, sugar and water, or a weak solution ot isino-lass with the addition of one-third of milk, which should be given in quantities of one or two spoonfuls at a time till the stomach becomes more settled. A stimulating bath, as a hot salt-water bath or a bath into which a handful of mustard has been put, and in which the child is to be kept for four or five minutes, night and morning, will often be found a valuable auxiliary to the general treatment as well as very useful, if combined with the application of cold to the head, in cutting short the convulsive seizures. . If the case be associated with much diarrhoea and general impair- ment of nutrition, the extract of bark, with a few drops of sal volatile, or of the compound tincture of bark, should be given two or three times a day, and you should not let the head symptoms lead you to 56 CEREBRAL HEMORRHAGE. keep the child on a low diet.1 Eemember, too, that when nutrition is much impaired, farinaceous food is not usually well digested ; you must, therefore, be sparing of arrowroot, and give milk and water, or milk and water with isinglass, or veal-tea. If the broth should purge, as it sometimes does, the white decoction of Sydenham2 will form a cheap substitute for isinglass. As the child improves, the ferrocitrate of quinine will be one of the best remedies you can give,3 and through- out the whole progress of the case you will remember the tonic influ- ence of pure air; and may even find the removal to a healthier spot and a purer atmosphere absolutely necessary to the recovery of your patient. Lastly, I will just allude to the head symptoms that sometimes for a few days precede death in children who have been long ill. You may in such cases find the vessels of the brain turgid, and be disposed to reproach yourselves for not having adopted active treatment. Such self reproach would be unmerited; the streams have stagnated because the vital powers were all too feeble to keep them in motion. LECTURE Y. Cerebral Hemorrhage.—The rupture of any large vessel in childhood very rare, but effusion of blood into arachnoid frequent—reasons for its especial frequency in new-born infants—its symptoms and treatment.—Blood sometimes effused exter- nal to the skull in new-born infants.—Cephalhematoma, its characters, changes in the effused blood, and process of cure—its treatment.—Hemorrhage into arachnoid in childhood—changes in the effused blood—obscurity of the symp- toms—occurs sometimes in very feeble children, or in connection with changes in the blood—illustrative cases.—Hemorrhage into cerebral substance in child- hood extremely rare—cases in illustration of its causes and symptoms—capillary hemorrhage in connection with tubercle in the brain. When we last met, I called your attention to the very important consequences that may result from the vessels of the brain becoming 1 (No. 3.) R>.—Extr. cinchonse 3j. Trse. cinch, co. 3ij- Aquae carui 3x.—M. 5j ter quotidie e lacte. For a child a year old. The taste of the above mixture is best concealed by sweet- ening it, and mixing it with twice the quantity of milk. 2 This, the Decoction Blanche of the French Pharmacopoeia, is made by boiling half an ounce of hartshorn shavings, and the inside of one French roll, in three pints of water, till reduced to two ; when it may be sweetened, and given either alone or with the addition of one part of milk. 3 (No. 4.) R_.—Syrupi quinae ferro-citrat. 3iss. Syrupi aurantii 3iiss. Aquas flor. aurantii gj.—M. 3j ter die. For a child a year old. CAPILLARY HEMORRHAGE. 57 overloaded with blood. I pointed out to you a train of symptoms, rising, in severity, from mere pain or heaviness of the head to con- vulsions or coma, according to the degree of the cerebral congestion; and told you that death itself might take place, without any mischief being discoverable afterwards, more serious than a general turgescence of the vessels of the brain and its membranes. Simple apoplexy, indeed, is by no means rare in childhood, and the knowledge of this fact may furnish encouragement to us in cases where the symptoms of present danger are most alarming. We may hope, that if the instant peril can be averted, the blood, which has not burst its vessels, will flow again tranquilly through them, and the functions of life once more go on in their wonted course. In the adult we could scarcely indulge such an expectation, for the import of apoplectic symptoms is generally far more serious. If the patient die, we look for, and seldom fail to find, blood poured out into the brain, compress- ing its substance, and lacerating the delicate fibres along which the nervous influence travels. Or, even should he survive, it often is to pass through a tedious convalescence, with palsy, and weakened senses, and impaired mental powers—the sad and standing evidence of the grievous injury which the brain has sustained. You may naturally inquire how it happens that in the child, the very structure of whose skull favors the occurrence of cerebral con- gestion, hemorrhage into the brain is comparatively so rare; while in the adult, whose unyielding cranium and firmer brain tend to check congestion, the extravasation of blood into its substance takes place so often ? The changes which advancing age induces in the structure of the cerebral vessels are probably the chief cause of this difference. In early life, the arteries are yielding, and admit of being greatly dis- tended without giving way : but in th$,course of years they lose their elasticity, their calibre becomes diminished and unequal, and their coats grow brittle by .the deposit of fatty or earthy matter in their tissue. But though the larger arterial trunks withstand the constantly re- curring variations in the cerebral circulation during infancy and childhood, the smaller and more delicate vessels of the brain are very liable to give way, and capillary hemorrhage, or hemorrhage by ex- halation, as it has been often, though incorrectly, termed, takes place with greater frequency than in adult age. All periods of childhood are not equally exposed to this accident, but it is oftenest met with immediately after birth: and no circum- stances can be imagined more favorable to its occurrence than those which then concur to produce it. The head of the infant has been subjected to severe and long-continued pressure during its progress through the mother's pelvis; immediately on its birth, the course of the circulation is altogether changed, and should any difficulty occur in the establishment of the new function of respiration, a long time will elapse before the blood flows freely through its unaccustomed channels. No one will wonder that death should frequently take place during this transition to a new kind of existence. The tumid scalp and livid face of many a stillborn child point to one of its 58 INFANTILE ASPHYXIA. most important causes, since they are but the measure of that ex- treme congestion of the vessels within the skull that has at length ended in a fatal effusion of blood upon the surface or at the base of the brain. There would be reason to fear that this occurrence had taken place, if an infant, when born, were to present great lividity of the surface, and especially of the face; and if the heart were to beat feebly, and at long intervals, although the pulsations of the cord were slow and faint, or had altogether ceased. In these circumstances, death some- times takes place without any effort at respiration being made, the beatings of the heart growing feebler and fewer till they entirely cease; but at other times the child breathes irregularly, imperfectly, and at long intervals. The hands are generally clenched, and spas- modic twitchings are of frequent occurrence about the face, or these twitchings are more general and more severe, and amount almost to an attack of convulsions. The symptoms, however, are by no means uniform, and probably are in some degree modified by variations in the seat as well as in the quantity of the effusion; for it sometimes, happens, even in cases where a very large quantity of blood has been poured out into the arachnoid cavity, that the breathing is little or not at all disturbed, and that after living for a few hours in a state of weakness and torpor, with chilliness of the whole surface, the child dies without any sign of convulsion. Instances of this form of asphyxia will be sure to come under the notice of those of you who engage in midwifery practice. I need hardly remind you that the first indication to fulfil in their treatment is to relieve the overloaded vessels of the brain, by allowing of the escape of half an ounce or an ounce of blood from the divided um- bilical cord. When the diminished lividity of the surface shows that this end has been attained, the cord should be tied, and the child may now be plunged for a minute or two in a hot bath at 100° or 102°; but prolonged immersion in a warm bath at a less elevated tempera- ture is likely to depress the nervous energy. While the body is in the bath, cold water may be dashed rather smartly on the face or chest, by which means the inspiratory muscles are often excited to action, or the infant may be plunged into a hot and cold bath alternately. If, however, the child do not soon begin to breathe, you must not con- tinue too long the use of these or of other subsidiary measures, such as the application of ammonia to the nostrils, tickling the throat or nares with a feather, &c; for you would thus fruitlessly consume that time which would be much more usefully spent in making a perse- vering trial of artificial respiration. This is scarcely the place for long details with reference to the best mode of exciting respiration, or of restoring it when suspended, but it would not be right to pass unnoticed the suggestions of Dr. Mar- shall Hall,1 with reference to this subject. It would, indeed, appear as if the inflation of the lungs with air must needs be the simplest and 1 Prone and Postural Respiration, &c, by M. Hall, M.D. 12mo. London, 1857. See p. 25 and 56. INFANTILE ASPHYXIA. 59 most effectual mode of exciting respiration, but every one who has attempted it must'have found-great and unexpected difficulties in its performance. It needs, indeed, a degree of dexterity for its accom- plishment such as frequent practice alone can give, and such as it is vain to look for among even the most intelligent attendants in the lying-in room, while the condition of the mother herself often calls for the personal care of the doctor, and prevents him from doing more than giving directions to others as to the best means of resuscitating the child. These circumstances give all the greater value to Dr. M. Hall's plan for exciting respiration, not by forcing the air into the lungs directly, but by drawing the air into them by changes of posture, which imitate the respiratory movements, but which are so simple in their nature that they can be easily carried out by any person of moderate intelli- gence. He directs that, in the first instance, the infant should be placed on its face, in order to allow of the escape of any fluids from the windpipe; and that, if sprinkling the general surface briskly with cold water should fail to excite respiration, what he terms postural respiration should then be commenced. This consists in first turning the child on its face, at the same time pressing gently on the back, and then removing that pressure, and turning it gently on the side, and a little beyond, and so on, perseveringly, until respiration is established. The turning the body from the prone position produces an inspiratory effort, while expiration follows of necessity when it is placed upon its face; and the repetition of these movements about thirty times in a minute introduces air into the lungs as certainly, more safely, and in many instances more effectually, than would be done by its direct insufflation into the mouth, or by means of a tube placed in the tra- chea. If no occurrence have taken place more serious than a very great degree of congestion of the cerebral vessels, you will generally suc- ceed, by the use of these means, in restoring "the child. Often, how- ever, it will happen that your attempts at resuscitation will fail com- pletely, or that, after breathing imperfectly for a few hours, without having ever seemed thoroughly restored, the child will die, and you will then find blood poured out into the cavity of the arachnoid. The extravasation is sometimes limited to the neighborhood of the cere- bellum, but at other times it covers a considerable part of the convex surface of the brain, and even occupies the spinal canal; as you see in this by no means exaggerated representation of a case of infantile apoplexy in Cruveilhier's great work on Morbid Anatomy.1 It fortunately happens that the overcharged vessels of the head in the new-born infant do not always relieve themselves by pouring out blood within the skull, but sometimes the capillaries of the scalp give way, and blood is extravasated into its tissue; or, at other times, the effusion of blood takes place between the bone and pericranium. When this last accident occurs, it often gives rise to the formation of a tumor upon the head, that presents peculiarities sufficient to call for some notice. 1 Anatomie Pathologique, liv. xv. pi. 1. 60 EFFUSION OF BLOOD EXTERNAL TO THE SKULL; This tumor (cephalhcemaioma, as it has been called, from w^ox?, head, and alfiat^a, from ol^o, blood) makes its appearance within forty-eight hours after birth, often much sooner, on one or other parietal bone, most frequently on the right, as a circumscribed, soft, elastic, slightly fluctuating, painless swelling, beneath the unchanged integument On a careful examination, it is generally felt to be bounded by a firm apparently osseous ridge, which usually encircles it completely, though more distinct at one part than another. On passing the finger over the summit of this ridge, and down towards the base of the tumor, the impression is at once conveyed of the parietes of the skull being deficient at this point, and of the ridge being the edge of a hole in the bone. When first discovered, the tumor is usually small, but increases in the course of two or three days, from the size of a marble to that of a chestnut, or of half a hen's egg. As it grows larger, it generally becomes tenser, but still seems to cause no pain, and the child's health continues good. After it has attained its full size, it often remains stationary for a few days, and during this time a gradual increase in the distinctness of the ring which surrounds it is the only change that it undergoes. A slight diminution in the size of the tumor at length becomes perceptible, and then it slowly disappears, though its removal occupies a month, six weeks, or more, and a slight elevation of the skull at the point where it was situated sometimes remains even longer. The centre of the tumor generally retains its soft and fluctuating cha- racter nearly to the last, but occasionally it loses this, and communi- cates to the finger a sensation of crackling such as we should experi- ence if we pressed on a piece of tinsel. Although once the subject of much difference of opinion, the mode of formation of these tumors, and the nature of the changes they undergo, are now tolerably well understood. The edges of the os uteri, compressing the foetal skull during labor, just as, in this engrav- ing,1 the hands are represented compressing it, often produce an effect similar to that which you see depicted here, and occasion an oozing of blood from its surface; or the same result may follow from undue pressure of the fcetal head against the pelvic walls. The quantity of blood thus poured out is usually small, and is then speedily absorbed, without having at any time produced a perceptible swelling. If, how- ever, it be more considerable, a tumor is formed on the exterior of the skull, and this tumor may continue to enlarge for some time after birth, owing, possibly, to the influence of causes calculated to keep up a congested state of the brain, and to favor the effusion of blood.2 1 In Valleix's Clinique des Maladies des Enfants Nouveaux-nes, Paris, 1839, planche i. fig. 2. z The various questions relating to the mode of formation of these tumors are fully discussed by Feist, Ueber die Kopfblutgeschwulst der Neugebornen, 4to. Mainz, 1839; and by Burchard, De Tumore Cranii recens natorum sanguineo, 4to. Vratislavise, 1837 ; where are likewise mentioned various exceptional cases in which the swelling formed on the parietal bone that had been directed towards the sacrum, and not, as is usual, on the bone which had presented during labor. The recent investigations of Professor Levy, of Copenhagen, published in the Journal filr Kinderkrankheiten, March, 1852, show fresh exceptions to this, which had been supposed to be the general rule, and prove that sudden pressure, however exerted, is quite adequate to occasion this acci- dent. CEPHALHEMATOMA. 61 The blood thus effused speedily coagulates, and the edge of the coagulum sometimes conveys to the finger an indistinct sensation of a raised border surrounding the tumor. The elevated ring that is after- wards plainly felt circumscribing it, is, however, mainly the result of a reparative process, in the course of which a fibrinous exudation is poured out over that part of the skull whence the pericranium has been detached, and is heaped up in great abundance just where the bone and its investing membrane come into apposition. This is proved to be its real source, by the circumstance that the ring becomes much more evident after the absorption of the blood has commenced than it is at first; while in those cases where the effusion of blood has been very considerable, no ring is perceptible during life, and it is found, after death, that scarcely any attempt at reparation has been made, and that the fibrinous exudation is very scanty, or altogether absent. This exudation is generally absorbed in course of time, but some- times a process of ossification is set up in it; the fibrinous ring becomes converted into an osseous ridge, and that part of the cranium oyer which the blood had been poured out is roughened by the formation of new bone upon its surface. The meaning of the appearances thus produced was long misunderstood, and they were thought to be owing to a process of destruction, not to one of cure. The roughened sur- face of the skull was looked on as the result of ulceration by which its outer table had at one part been destroyed, and the bony ridge around it was supposed to be the edge of that part of the outer table to which the disease had not yet extended. The real nature of these changes was extremely well exemplified in a very remarkable case that came under my notice, in which the blood was effused between the skull and dura mater, as well as between it and the pericranium.' This drawing shows the processes of cure in progress. First, how- ever, you may notice the perfect smoothness of the inner surface of the bone, in order to display which the edge of the clot is raised. Its outer as well as its inner investment had been detached from this por- tion of the skull by the effusion of blood beneath them, and the bone continues unroughened, because an attempt at reparation was impos- sible here. At the edge of the clot, the dura mater and the bone come again into contact, and nature has here begun the cure. New bone has been deposited, and an osseous ridge has been formed pre- cisely similar to that which in so many instances surrounds the exter- nal effusion. Nor is this all; but bony plates are beginning to be deposited between the layers of the dura mater, exemplifying the manner in which, when blood has been poured out beneath the peri- cranium, that membrane sometimes becomes ossified, and accounting for the crackling sensation that in these cases is felt on pressing the tumor. iji t. The characteristics of these tumors are so well marked, that they are not likely to be confounded with swellings of the scalp produced by any other cause. A hernia of the brain, indeed, may present some i A description of this case will be found at p. 397 of vol. xxviii. of the Medico- Chirurgical Transactions 0/5 EFFUSION OF BLOOD EXTERNAL TO THE SKULL. resemblance to them, since it forms a soft, painless tumor, unattended by discoloration of the integuments, and the edges of the aperture in the bone through which the brain protrudes may easily be taken for the ring surrounding an effusion of blood beneath the pericranium. Independently, however, of the pulsating character of the swelling formed by hernia of the brain, its situation at one of the fontanelles, probably the posterior, or in the course of one of the sutures, will generally distinguish it sufficiently from these sanguineous tumors, which are almost always seated on the parietal bone, and near to its protuberance. While the nature of this affection was ill understood, many practi- tioners regarded it as of very serious import, and thought that its cure could be effected only by making a free incision into the tumor, and emptying it of the effused blood, or else by applying caustic to its surface, with the view of exciting suppuration within it. There is, however, no real necessity for these severe measures, which appear, in not a few instances, to have caused the death of the child; for the blood will, in the course of a few weeks, be absorbed, and the tumor diminish and disappear of its own accord. I have even seen a tumor of larger size than my fist, which was seated on the right parietal bone, but extended considerably beyond the mesial line, disappear com- pletely, of its own accord, in the course of four months. The great difficulty, indeed, that you will encounter will consist in persuading the parents to _ let the swelling alone, and to wait till time effects its removal. While, however, the affection generally requires no treat- ment, and is not attended by any danger, it is yet right to bear in mind the possibility of internal as well as external effusion having taken place. In this case, as happened in an instance that came under my notice, the sudden increase of the internal effusion may be fol- lowed by apoplectic symptoms, and death; or, as in the other instance which I have just mentioned of the very large effusion, the injury inflicted on the brain may be so considerable that the child may sur- vive only to present every sign of hopeless idiocy. Perhaps I may be pardoned if I digress for a moment to notice the occasional pouring out of blood beneath the occipito-frontalis or temporal muscle in children as the result of a blow on the head. Unlike a bruise, this effusion does not always take place at the precise spot where the injury was inflicted, but the greater size of the vessels that traverse the skull at the side seems to be the reason why a shock, such as a fall on the occiput, is sometimes succeeded by the formation of a tumor of this kind at the side of the head, and not at the part which received the blow. It has twice come under my notice in these circumstances. The tumor thus formed is soft, painless, and fluctuat- ing, and its size at first increases very rapidly, but the integuments covering it are neither hot nor discolored. It is not surrounded by so well-defined a ring as circumscribes the swelling formed by the effusion of blood beneath the pericranium; the ridge is imperfect, its edge is much less sharp, and it is often to be felt nowhere except near to the insertion of the temporal muscle. In this as in the other case, nature herself is usually fully equal to HEMORRHAGE INTO THE ARACHNOID. 63 the removal of the blood, and the consequent dispersion of the swell- ing. Cerebral hemorrhage, though at no other time so frequent as im- mediately after birth, may occur at any period of subsequent childhood, under the influence of causes that favor congestion of the brain, or even independently of any cause that we can discover. The hemor- rhage still takes place almost invariably into the arachnoid cavity, and blood is sometimes poured out there in very large quantity; but the accident is neither so invariably nor so speedily fatal as in the new- born infant. If death should follow very soon after the occurrence of the effusion, the blood is found unchanged, forming a more or less extensive layer upon the convex surface of the brain, and extending downwards and backwards towards the base of the organ, but seldom situated at its anterior part unless the hemorrhage have been unusually profuse. If life be prolonged, the clot speedily separates into serum and crassa- mentum, and a series of changes commence in the latter, the effect of which is to deprive it of its coloring matter, and to convert it, in course of time, into a delicate false membrane, which lies in close apposition with the parietal arachnoid. This transformation may sometimes be observed while in course of progress, and a central clot may then be seen gradually losing itself in a membrane that grows more and more delicate towards its periphery. If, as occasionally happens, successive effusions of blood take place at somewhat distant intervals, this mem- brane may become thick and firm, and may even present a pearly lustre; which circumstance has led some observers into the error of attributing the appearance to alteration and thickening of the dura mater. The amount of the original effusion has much to do with the rapidity of the changes in the clot. If the effusion were but incon- siderable, the serum of the blood soon becomes absorbed, and no other trace of the occurrence remains than the false membrane lining a por- tion of the arachnoid. If the hemorrhage were at all abundant, the reddish serum will, even after the lapse of a considerable time, be very evident on opening the sac of the arachnoid, and some of it will pro- bably be found entangled in the substance of the clot. By degrees the serum loses its color, but its quantity may still continue for a long time undiminished, or the efforts of nature may even entirely fail to accomplish its absorption. The fluid in such cases is either simply contained within the arachnoid cavity, or, having remained inclosed within the clot during the changes which it underwent, appears at length to be situated within a delicate cyst or shut sac. If the hemorrhage, in the first instance, were very considerable, or if it were to recur two or three times, the yielding cranium of the child will enlarge, the head will alter in form, and the case will assume many of the characters of chronic hydrocephalus.1 All writers, even those who, like MM. Eilliet and Bartbez, have 1 Not having had the opportunity of observing the whole series of changes said to take place in blood effused into the sac of the arachnoid, I have chiefly followed the account given by MM. Rilliet and Barthez, in their Traite des Maladies des Enfans, Zq ed., Paris, 1853, vol. ii. pp. 247 to 255. 61 HEMORRHAGE INTO THE ARACHNOID. thrown the most light on the anatomy and pathology of cerebral hemorrhage in the child, concur in representing its symptoms as extremely obscure. Paralysis, which, in the grown person, is one of the most frequent results of the escape of blood from the cerebral vessels, is so rare in the child that it was observed by M. Legendre1 only in one out of nine cases, and by MM. Rilliet and Barthez2 in one out of seventeen cases. This peculiarity is doubtless in great mea- sure accounted for by the circumstance of the blood being almost always poured out into the cavity of the arachnoid, so that the pres- sure which it exerts on the brain is generally diffused over the surface of the organ, and is nowhere very considerable. The absence of paralytic symptoms, however, is not the sole cause of the obscurity of these cases, but the indications of cerebral dis- turbance by which they are attended vary greatly in kind as well as in degree. The sudden occurrence of violent convulsions, and their frequent return, alternating with spasmodic contraction of the fingers and toes in the intervals, appear to be the most frequent indications of the effusion of blood upon the surface of the brain. I need not say, however, that such symptoms taken alone would by no means justify you in inferring that effusion of blood had taken place. Many cir- cumstances having reference to the previous history of the child, as well as to its present condition, must be taken into account in form- ing a diagnosis. Hemorrhage into the arachnoid cavity is most fre- quent in early childhood—symptoms such as have been enumerated would therefore acquire additional diagnostic importance in proportion to the tender age of the child in whom they occurred. The probability of their betokening this accident would be still further strengthened if the child who experienced them had previously suffered from frequent attacks of cerebral congestion, or had been recently exposed to the sun without proper covering for the head; or had been placed in other circumstances calculated to favor determination of bloed to the head. The popular notion that associates the idea of rude health and general plethora with the occurrence of apoplexy in the adult, is in many instances altogether fallacious. In the case of the child it has still less foundation, since the effusion of blood upon the brain occurs much more frequently in weakly children than in such as are robust. There seems to be reason, indeed, for supposing that the hemorrhage is sometimes of a purely passive character, and dependent on an altered state of the blood. I will relate to you a case or two as illus- trations of this cachectic form of cerebral hemorrhage. Some years ago, I saw a little boy, five weeks old, the child of healthy parents, and who had been perfectly well for the first fort- night after his birth; he then, without any evident cause, grew drowsy, and vomited often, and his skin became quite jaundiced. His abdomen at this time was large and hard, and he cried when pressure was made on the right hypochondrium; these symptoms still continued 1 Recherches Anatomo-Pathologiques sur quelques Maladies de l'Enfance, 8vo. Paris, 1846, p. 130. 2 Lib. cit., p. 257. ILLUSTRATIVE CASES. 65 when he was brought to me. A leech now applied on the right side drew a good deal of blood, and the hemorrhage was stopped with difficulty ; the bowels, previously constipated, were acted on by small doses of calomel and castor oil, and in three days the child lost the yellow tinge of his skin, became cheerful, and seemed much better. He was now, however, on the 18th of July, suddenly seized with hur- ried respiration and great depression, soon followed by violent con- vulsions, during which he screamed aloud. At the same time it was observed that his left hand had begun to swell, and to put on a livid hue, and on the 20th, the right hand also became cedematous. His whole surface grew quite sallow, and, on the day before he died, the oedema of the left hand had much increased; the livor had become considerably deeper, and there were small spots of extravasated blood over each knuckle. The right elbow was slightly livid; the right hand much swollen, but of its natural color; and a small black spot had appeared under the chin, corresponding to the knot of the cap- string. The fits recurred very frequently, the child in the intervals lying quite still; the pupils were contracted, and the condition seemed to be one of extreme exhaustion rather than of coma. On the 20th, the power of deglutition was lost, and after several returns of less violent convulsions, the child died at 9 A. M. on July 21st, about sixty hours after the occurrence of the first fit. The sinuses of the brain were full of fluid blood; a black coagu- lum, three or four lines thick, covered the whole posterior part of both hemispheres, extending from the posterior third of the parietal bones, occupying the whole concha of the occipital bone, and reaching along the base of the skull to the foramen magnum. A little blood was likewise effused about the anterior part of the base of the brain, though the quantity was very small in comparison with what was found at its posterior part. The substance of the brain was very pale, and all the organs of the body were anaemic, except the liver, which was gorged with fluid blood, while the heart was quite empty. The ductus arteriosus was closed, the foramen ovale admitted a probe with ease, the ductus venosus admitted one with difficulty. Another instance has since then come under my notice, in which passive hemorrhage took place into the arachnoid in a child exhausted by long-continued illness, the effects of which were aggravated by poverty and want. From the age of two to that of five months the child had been under my care in consequence of frequent attacks of hsematemesis and purging of blood, and though his health afterwards improved, yet he never became strong, and his evacuations were almost always white, and deficient in bile. After he was weaned, the^ coarse food which his indigent parents gave him did not nourish him; he lost flesh and strength, and when almost three years old was puny and emaciated. Three days before his death an attack of diarrhoea came on, which induced great exhaustion; and while suffering from this affection, he suddenly grew comatose, cold, and almost pulseless, and his breathing became so slow that he inspired only four or five times in a minute. In this state he lay for twenty-four hours, and then died quietly. Nearly six ounces of dark coagulated blood were found in 5 QQ HEMORRHAGE INTO THE SUBSTANCE OF THE BRAIN. the sac of the arachnoid, over the right hemisphere of the brain; a little blood was likewise effused beneath the arachnoid, and there was a very small clot in the lower and front part of the right middle lobe of the brain, but no ruptured vessels could be perceived. Great anas- mia of every organ, and a state of extreme attenuation of the walls of the heart, were the only other remarkable appearances. Hemorrhage into the substance of the brain, though extremely rare in infancy and childhood, does sometimes occur, and then gives rise to appearances similar to those with which we are familiar in the adult. Death, however, usually takes place too speedily in these cases for any of those changes to occur in the apoplectic effusion which are often observed in the adult, and which betoken the advance that nature has made in her efforts to repair the injury of the brain. I have only twice met with distinct extravasation of blood into the substance of the brain in children. In the first case, that of a little girl eleven months old, the occurrence was evidently due to the impe- diment to the circulation through the brain produced by an attack of inflammation of the sinuses of the dura mater. In addition to other appearances, which I shall describe in a future lecture,1 there was great venous congestion of the membranes covering the middle lobe of the left hemisphere of the brain, and the cerebral veins were distended with coagula, and their coats were thickened. At the anterior part of the lower surface of the left middle lobe of the brain there were four apoplectic effusions, in all of which the blood still retained its natural color, and each effusion was situated close to an obliterated and dis- tended vein. The largest clot extended for an inch into the substance of the brain, the others were of smaller dimensions. Head symptoms, as might be expected, had existed in this little child for a long time before her death. The occurrence of the effusion was probably syn- chronous with a sudden attack of extreme faintness that came on forty- eight hours before she died, and from which she never completely rallied. The other instance of hemorrhage into the substance of the brain occurred in a girl eleven years old, the child of healthy parents, and whose own health had been quite good until she was six years of age. At that time the extraction of a molar tooth was followed by necrosis of a large portion of the lower jaw, and by the formation of abscesses in the face and head, from which bone escaped. An abscess, attended with similar exfoliation of bone, formed likewise on the right foot, and it was three years before the child had recovered completely. Though much disfigured by the disease, her health ever after con- tinued good until April 12, 1846. She was then suddenly and cause- lessly attacked by vomiting and pain in the head, for which no other treatment was adopted during ten days than the occasional adminis- tration of an aperient. During this time, however, a condition of stupor gradually stole over the child, for which, on April 21st, a blister was applied to the back of her neck with great relief. On April 23d she had two attacks of convulsions, with an interval of four hours 1 See Lecture VIII. ILLUSTRATIVE CASES. 67 between each. She struggled much during their continuance, espe- cially with the right side; when the convulsions subsided, partial palsy of the left side remained ; the child complained much of her head, and sank from time to time into a state of stupor, from which, however, she could always be roused. Yery free purgation on the 24th of April, and the application of another blister to the back of the neck, were followed by some amendment. On the evening of the 25th another fit occurred, with symptoms similar to those that had been observed on the previous occasions; but it was not followed by any increase in the palsy of the left side, nor was the degree of stupor so considerable as on the former occasion. Mercurials, which had been employed from the commencement of the attack, had now produced a decided influ- ence on the mouth, and the abundant action of the bowels was again succeeded by much improvement in the child's condition. The pulse, which had varied from 60. to 70, now continued about 70, and was natural in character, and the child improved daily, though taking no other medicines than occasional aperients. The headache returned occasionally, though each time it was less severe than the time before; but on the evening of May 15th, this amendment was suddenly inter- rupted by an attack of violent pain in the abdomen, which was soon followed by convulsions and coma, and the child died convulsed in sixteen hours; on the 36th day from the first attack of pain in the head. On making an examination of the head, permission for which was obtained with difficulty, blood was found to be effused into the sub- arachnoid tissue over a great part of the right hemisphere of the brain. The quantity of blood, however, was nowhere very consider- able, but merely occupied the sulci between the convolutions. The brain presented no remarkable appearance, except that on a level with, and just exterior to the right lateral ventricle, there was a large clot of blood, rather larger than a hen's egg, but of more irregular shape, around which the brain was softened. This effusion was per- fectly black throughout, the coloring particles of the blood being equally diffused through it, and no appearance betokened that hemor- rhage had previously taken place in this situation. The anterior cerebral artery ran for a considerable distance just outside the clot, but it could not be ascertained that it had given way at any point. Cerebral hemorrhage is one of the few affections of early life con- cerning the treatment of which but little can be said; for where the symptoms of a disease are so obscure, it would be idle laying down elaborate rules for its cure. The general principles, according to which you would manage a case of congestion of the brain, would still guide you if hemorrhage had taken place. It cannot, however, be necessary for me to repeat to-day the observations on that point to which I yes- terday directed your attention. Before concluding, I must for a moment refer to a form of cerebral hemorrhage, which, though of no great importance, yet forms an exception to what has been stated as to the rarity of the accident in early life. In children who have been affected with tubercular disease of the brain, it is by no means unusual to observe very small effusions 68 INFLAMMATORY AFFECTIONS OF THE BRAIN. of blood in the midst of softened cerebral matter that surrounds the deposit. This capillary apoplexy, produced by some of the minute vessels of the brain giving way, is, however, seldom extensive, and probably has but little share even in accelerating the fatal event. When next we meet, we shall pass from this subject, which, it must be owned, has more of a pathological than of a practical interest, and shall enter on the study of the inflammatory affections of the brain in childhood. LECTURE VI. Inflammatory Affections of the Brain—frequent in childhood, but overlooked by early writers—first noticed about a century ago—described under the name of acute hydrocephalus, by Dr. Whytt. Acute Hydrocephalus—progress of knowledge with reference to it.—The name re- stricted in these lectures to scrofulous inflammation of the brain, which is much more frequent than its simple inflammation in childhood. Morbid appearance in acute hydrocephalus—due either to inflammation or to tuber- cular deposit—alterations more apparent in the membranes at the base of the brain than in those of its convexity.—Reasons for considering granulations of the membranes as tubercular.—Increase of fluid in the ventricles almost invariable. —Central softening of the brain not a post-mortem alteration—frequently con- nected with changes in the lining of the ventricles. Symptoms of the three stages of the disease. Few of the diseases of childhood are more serious than those in- flammatory affections of the brain on the examination of which we are now about to enter. They occasion 9.8 per cent, of all deaths under five years of age in this metropolis, while they are so especially the diseases of early life, that 81.1 per cent, of all cases of fatal inflamma- tion of the brain occur in children under five years of age, 90.2 per cent, before the age of 10, and 92.4 per cent, before the age of 15.1 But though the frequency of these affections in the young is a matter of such popular notoriety that most of you were familiar with the fact long before you were engaged in your present profession, yet if you turn to the writings of any of the old physicians, you will find in them no mention of inflammation of the brain in childhood. At first this may surprise you, but a few moments' consideration will explain the seeming oversight. Convulsions, which form a promi- nent symptom in most cases of inflammation of the brain, occur, as I need not remind you, in the course of many other affections of the nervous system. An accident so alarming as a fit of convulsions is sure to attract attention, but much careful examination is often needed to distinguish those minor differences betweeu the symptoms which 1 Deduced from 5th and 8th Reports of Registrar-General for 1842-5. INFLAMMATORY AFFECTIONS OF THE BRAIN. 69 precede or accompany it, that alone would indicate the cause to which it is due. It cannot, then, be surprising, that in the absence of this minute care, many diseases, though differing in most important par- ticulars, should have long been classed together under the head of convulsions, and that inflammation of the brain should not have been recognized as a distinct affection. The importance of some of those less obvious structural changes which we know to be most significant of the nature of previous diseases, was not then understood, so that an alteration in the consistence of the brain, or a diminution in the transparency of its membranes, often passed unnoticed: and anatomi- cal research was not exact enough to make up for the deficiencies in clinical observation. But just as the physician's attention was fixed on the convulsive seizures which in so many cases affected his patients, so the eye of the anatomist was often arrested by the discovery of a large quantity of fluid in the interior of the brain. Sometimes this fluid had been secreted in such quantity as not only to distend the ventricles of the brain, but to occasion a manifest enlargement of the skull. In such cases, the disease was essentially chronic in its course, and was called, from its most striking characters, dropsy of the brain, or chronic hydrocephalus. Speculation, however, was set afloat by the occasional notice of cases in which, though fluid was found in large quantity within the brain, yet the previous disease had been of short duration, its symp- toms had been acute, and the fever, drowsiness, and cerebral disturb- ance which attended it, had run a very rapid course to their fatal termination. Dr. Whytt was the first1 who, in the year 1768, clearly pointed out the connection between these symptoms and the accumu- lation of fluid in the ventricles. His attention, like that of previous observers, was mainly fixed on this point, to the exclusion of other morbid appearances, and he was thus left to regard the disease as an acute dropsy of the brain. Little can even now be added to his de- scription of the malady, but further observation has shown that the presence of an increased quantity of fluid in the brain, on which he laid so much stress, is not of invariable occurrence: that there is no certain relation between the amount of the fluid and the intensity of the symptoms, or the rapidity of their course; and that it is almost always associated with other very important lesions, some of which are the evident results of inflammation. Many years were occupied in the investigations which led to this conclusion; so that long before Whytt's theory had been ascertained to be erroneous, people had grown familiar with the name which he proposed for the disease, and in this country it is still called hydrocephalus, or acute hydrocephalus. A most important step towards a knowledge of the true pathology of this disease, was the discovery that the fluid poured out into the' ventricles is not a mere dropsical effusion, but that it is the result ot previous inflammatory action. A difficulty, however, appeared when it was ascertained that in those cases in which the signs of inflamma- 1 In his Observations on the Dropsy in the Brain, 8vo. Edin. 1768. 70 ACUTE HYDROCEPHALUS. tion of the brain were most evident during life, and its effects most marked after death, both the symptoms and the morbid appearances differed in some respects from those usually observed in Whytt s disease. The almost invariable existence of a very obvious tendency to scrofula in well-marked instances of Whytt's disease, and its fre- quent absence in other cases of inflammation of the brain, did much towards solving this difficulty. It was next discovered that in nearly every instance in which Whytt's disease terminates fatally, tubercle is present in greater or less abundance in various organs of the body; and to the acuteness of French anatomists we owe the last step, m this investigation, by which it has been shown that in the majority of cases the membranes of the brain themselves are the seat of tubercular deposit. . We are thus led to the conclusion that inflammation of the brain occurs in early life under two different conditions. It now and then comes on in previously healthy children, but occurs much oftener in connection with the tuberculous cachexia, or as the result of tuber- cular deposit in the brain or its membranes. The term encephalitis may be properly used to denote the cases of simple inflammation of the brain, while we may with advantage restrict that of acute hydroce- phalus to cases of cerebral inflammation in scrofulous subjects. Owing to the extreme rarity of the former affection, it will, I think, be our better plan first to study minutely all the characters of acute hydroce- phalus, and then to examine the points of difference between simple and scrofulous inflammation of the brain. We will commence this investigation with an inquiry into the nature of the appearances found after death in cases where acute hydrocephalus has had a fatal termination. These may be divided into two classes, according as they are the result of inflammation or of the deposit of tubercle; and changes due to both of these causes are often found in the membranes of the brain as well as in its substance. The appearances which present themselves on the skull being opened are seldom very striking, for the dura mater is usually healthy, and the changes in the arachnoid are not in general of a kind at once to attract attention. Sometimes, indeed, the eye is struck by an exces- sive vascularity of the membranes, but this appearance often depends on the over-filling of the large vessels, as the result of position. Atten- tive examination will enable us to distinguish between this, and that increase of vascularity which is produeed by a uniform injection of the minuter vessels; and moderate pressure, while it causes the disap- pearance of the apparent vascularity in the former case, will produce no effect on the true congestion in the latter. The secretion that naturally moistens the sac of the arachnoid is altered, increased, or suppressed; but the last of these changes is the most frequent, while the first is seldom observed in cases of hydroce- phalus. The preternatural dryness of the membrane is usually con- nected with some diminution of its natural transparency; it looks dull and lustreless, and feels sticky—a state to which the French have applied the term "poisseux^ The dulness of the arachnoid is some- times more considerable, and it then presents an opaline appearance, MORBID APPEARANCES. 71 which is very evident at those parts where the membrane passes from one convolution to another. This opalescence is not often general, but is usually most marked about the upper part of the hemispheres, and in the neighborhood of the longitudinal fissure. When any considerable degree of vascularity of the membranes is evident, this is, of course, chiefly due to the injection of the minute vessels of the pia mater. Such intense injection of the pia mater is, however, far less frequent than the effusion of fluid between it and the arachnoid, and it is still less common to find the two appearances in the same subject. The effused fluid is for the most part colorless and transparent, and if present in any considerable quantity, the surface of the convolutions then appears as if covered by a layer of transpa- rent jelly, though on puncturing the membrane a drop of clear serum will exude. The effusion of lymph or pus into the pia mater covering any considerable extent of the convexity of the brain is very seldom met with, but deposits of a yellow puriforra lymph are not unfre- quently seen occupying the depressions between the convolutions, or following the course of the vessels along the sides, or at the upper surface of the hemispheres. But though the alterations presented by the membranes at the con- vexity of the brain are often comparatively trivial, the membranes at the base of the organ almost always show unequivocal traces of inflam- matory action. The predominance of the affection of the membranes at the base of the brain has indeed been regarded by some writers as pathognomonic of scrofulous inflammation of the organ j1 and though this rule is not without exception, still it holds good in the vast majority of cases In thirty-seven out of forty-two fatal cases of acute hydroce- phalus in which I carefully recorded the condition of the membranes, those at the base of the brain were found to be the seat of disease more or less extensive, and always more considerable than that which existed at the vertex In one of the cases in which the membranes at the base were healthy, there was a good deal of serous effusion beneath the arachnoid at the convexity ; and in another instance there was some fluid in the sac of the arachnoid, and the pia mater covering the upper surface of the brain was greatly injected; but in the three remaining cases the membranes at the upper, as well as those at the lower part of the brain, were perfectly healthy. The least considerable of the morbid changes in the membranes at the base of the brain consists in a milky or opaline condition ot the arachnoid and pia mater, but chiefly of the former, sometimes extend- ing over the whole lower surface of the cerebrum, but seldom being eo ually apparent in that part of the membrane which invests the cere- bellum. But, besides this opacity, we usually observe much more distinct evidence of inflammatory action in the effusion of yellow lymph beneath the arachnoid. This is generally found about the olfactory nerves, which are often completely imbedded in it, while a i On which subject the valuable essay of M. Rilliet, De VIxiflaxQTnatiOTi franoto des Meninges chez les Enfants, in the Archives de Medecine for Dec, Jan. and Feb. 1846-/, may be consulted with advantage. 72 GRANULATIONS OF THE MEMBRANES. similar effusion extending across the longitudinal fissure unites the two hemispheres of the brain together. A deposit of the same kind like- wise reaches up the fissure of Sylvius in many cases, and connects the anterior and middle lobes of the brain with each other; or if poured out in less abundance, it may be seen running up in narrow yellow lines by the side of the vessels as they pass from the base of the brain towards its convexity. It is in the neighborhood of the pons Yarolii, however, and about the optic nerves, that the most remarkable altera- tions are met with. The opacity of the arachnoid is here particularly evident, while the subjacent pia mater is opaque, much thickened, and often infiltrated with a peculiar semi-transparent gelatinous matter, sometimes of a dirty yellowish-green color. This matter is occasion- ally so abundant as perfectly to conceal the third and fourth nerves, and at the same time to invest the optic nerves with a coating two or three lines in thickness; though, on being dissected off, the substance of the nerves beneath appears quite healthy. When this morbid con- dition exists in any very considerable degree it extends beyond the pons, and involves the membranes covering the medulla oblongata, especially at its anterior surface. It is only within the past thirty years that attention has been drawn to the importance of another element, besides mere inflammation, in the production of acute hydrocephalus. The peculiar granular appear- ances which various parts of the membranes of the brain almost in- variably present in this disease, though noticed many years before, began then to engage the special attention of several French physicians.1 The conclusion to which we are led by their careful investigation of the subject, is, that this appearance is not due to inflammation, as was once supposed, but that it is occasioned by the presence of tubercular deposits. These deposits often assume the form of minute, flattened, spherical bodies of the size of a small pin's head, or smaller, and either of a yellowish color, and rather friable under pressure, or grayish, semitransparent, and resistant, almost exactly resembling the gray granulations which are sometimes seen in the lungs or pleurae of phthisical subjects. They are likewise sometimes met with in what would seem to be an earlier stage, when they appear like small opaque spots of a dead white color, much smaller than a pin's head, and com- municating no perceptible roughness to the membrane. This appear- ance is often observed in the arachnoid covering the cerebellum, and those parts of the base of the brain where the arachnoid is stretched across from one part of the organ to another. The flattened yellow- ish bodies are most frequently seen at the convexity of the brain, and on either side of the hemispheres. They generally follow the course of the vessels that ramify in the pia mater, and accordingly occupy the sulci between the convolutions much oftener than their summit. The firm gray bodies are mostly seen about the pons or imbedded in the pia mater in the neighborhood of the optic nerves, or projecting from 1 M. Papavoine appears to have been the first who, in the Journal Hebdomadaire for 1830, vol. vi. p. 113, clearly established the tubercular nature of these granulations of the membranes of the brain. TUBERCULAR NATURE OF THE GRANULATIONS. 73 the surface of the membranes that cover the medulla oblongata. They are also often deposited in the arachnoid lining the occipital bone, and are then sometimes collected in considerable numbers around the foramen magnum. These bodies, sometimes of a gray, at other times of a yellow color, are likewise met with, though less frequently, in the substance of the velum interpositum, or imbedded in the choroid plexuses, and in both of these situations they are sometimes very abundant. These bodies, however, do not always retain the appearance of dis- tinct granules, but sometimes, on separating two folds of the arachnoid which had seemed to be glued together by an effusion of yellow lymph or concrete pus, we find that the matter which forms these adhesions is not homogeneous, but that it consists of an aggregation of minute granular bodies connected together by the lymph or pus in which they are imbedded. This appearance is often met with at the con- vexity of the brain, and close to the longitudinal fissure, and rather more towards its posterior than its anterior part; a strip of this yellow matter, half an .inch long by two or three lines broad, connecting to- gether the two hemispheres of the brain or the two surfaces of the arachnoid. Sometimes two or three deposits of this kind are observed at the convex surface of the brain, but they are generally more ex- tensive at the base of the organ, where they occupy the longitudinal fissure and the fissure of Sylvius, and frequently connect opposite surfaces of the brain so closely together as to render their separation impossible without injury to its substance. But, you may ask me for the proof of these granular bodies being, as I have represented them to be, real tubercular deposits. It would occupy nearly the whole of this lecture to detail all the arguments that have been adduced on both sides of the question, for it is a question which has been much dis- puted; since some persons were long disposed to regard them merely as the products of inflammation, while the majority of French writers are so convinced of their tubercular nature, and regard their presence as so essentially characteristic of this form of cerebral disease, that, discarding the term of Acute Hydrocephalus, they have, almost with- out exception, agreed to designate it Tubercular Meningitis. The reasons which appear to be conclusive in favor of the tubercular nature of these bodies,1 are— 1st. That they are always associated with tubercle elsewhere. 2d. That their abundance is not in proportion to the amount of inflammatory mischief. 3d. That they are sometimes met with in cases where no head symptoms were observed during life, and unconnected with any sign of inflammation discovered after death; and 4th. That their chemical composition and their microscopic struc- ture are identical with those of tubercle in other organs of the body. ' With reference to these points, see Becquerel, Recherches Cliniques sur la Me- ningite des Enfans, 8vo. Paris, 1838, p. 20 ; and Lebert, Physiologie Pathologique, &c. 8vo. Paris, 1845, vol. i. pp. 440-449. _ 2 It is perhaps scarcely necessary to give a caution against confounding with these tubercular granulations those small corpuscles, the Pacchionian bodies, as they are 74 SOFTENING OF THE BRAIN Notwithstanding the important nature of the changes presented by the membranes of the brain in cases of acute hydrocephalus, it was long before they attracted as much attention as the alterations^ in the substance of the brain itself, and especially as that distension of its cavi- ties with fluid from which the malady has derived its name. The sur- face of the brain, indeed, generally presents but few traces of disease, though sometimes the convolutions are greatly flattened, and the sulci between them almost obliterated by the pressure of the fluid from within. The cerebral substance is often healthy as low down as the centre of Vieussens, or presents no change more important than the presence of an unusual number of bloody points, the divided cerebral vessels. But, though unaltered to the eye, a diminution of consist- ence is often perceptible as the ventricles are approached. Sometimes the whole brain seems softer than natural, while at other times, though not actually softened, it is infiltrated with fluid, as though it had soaked up the serum from the ventricles. The presence of a larger quantity of fluid than natural in the lateral ventricles is of almost constant occurrence. In 41 out of 43 cases in which death had taken place under the symptoms of acute hydro- cephalus, I found an appreciable quantity of fluid in the ventricles; and in 35 of these cases the quantity was considerable, amounting to several ounces. The fluid is in general a perfectly transparent serum, resembling passive effusions poured out from other serous membranes; and such it doubtless is in many cases in which it is found distending the lateral ventricles. But, in a large proportion of instances of hydrocephalus, the increased secretion in the ventricles is associated with a very notable change in the surrounding cerebral substance. This change consists in a loss of the natural firmness of the central parts of the brain ; varying in degree from a slight diminution of con- sistence to a state of perfect difnuence, in which the cerebral substance forms a pulpy mass that is easily washed away by a stream of water; or the softening may be even more considerable, and the cerebral matter may become semifluid, and closely resemble thick cream. The parts thus affected are perfectly pale and bloodless, and the adjacent substance of the brain is usually rather anaemic. The fornix, septum lucidum, corpus callosum, and posterior horn of the lateral ventricles, are the parts most frequently affected; the optic thalami, corpora striata, and lower parts of the middle and posterior lobes of the brain, rank next in this respect, while the anterior lobes are but seldom termed, which are met with either singly or in groups upon the upper surface of the hemispheres near the falx cerebri. They are minute round excrescences either semi- transparent or of a white color, made up of dense fibrous tissue like that of lowly organized cellular tissue. The arachnoid around them is not unfrequently somewhat thickened ; but they are in no other respect to be regarded as pathological conditions, than that there appears to be some connection between their development and the previous frequent occurrence of cerebral congestion. In the course of time they some- times perforate the dura mater, and form little depressions in the bone in which they become imbedded. They not seldom undergo conversion into the carbonate and phosphate of lime, and yield also slight traces of silex ; and are in all respects dif- ferent from the bodies referred to in the text. See Luschka, in Mailer's Archiv., 1852, p. 101; a review of a thesis by M. Faivre, in Arch. Gtn. de Ate'd., Avril, 1854; and Rokitansky, Pathol. Anat., Wien, 1856, vol. ii. p. 407. NOT DUE TO IMBIBITION OF FLUID. 75 softened. In a few instances the cerebellum is involved in the soften- ing, and now and then the whole brain is found to have lost much of its natural firmness—a change, however, which is usually much more marked on one side than the other. Closely allied to this softening is the state to which I have already referred, wherein the whole brain appears perfectly infiltrated with serum, as though it had been long soaked in it, and had imbibed it like a sponge. A mechanical explanation has been frequently suggested to account both for this appearance and for the central softening of the brain, which you will observe is most marked in those very parts to which the fluid in the ventricles would naturally gravitate after death. Many facts, however, are opposed to this view of the cause of softening of the brain. If it were a change induced by the imbibition of fluid after death, we should expect to find it as constant as is hypostatic conges- tion of the lungs; but instead of this being the case, fluid is found in many instances in the ventricles without the consistence of the brain being in the least diminished. In a recent work on Acute Hydroce- phalus, which embodies the results of a very large number of dissec- tions, it is stated that central softening of the brain existed only in 47 out of 71 instances, in which the ventricles contained a quantity of serum varying from 3 to 11 ounces.1 In my records of the examina- tion of the brain in hydrocephalus, I have preserved an accurate ac- count of the condition of the cerebral substance in 41 cases, and find that in 14 instances there was not the least central softening, although the ventricles contained fluid in every case but one, and the quantity amounted on seven occasions to several ounces. M. Louis, too, men- tions in his work on Phthisis,2 that in 75 out of 101 tubercular sub- jects, each ventricle contained a quantity of fluid varying from half an ounce to two or three ounces, but yet in only 6 of these 101 cases were the central parts of the brain at all softened. And, not to dwell on any other arguments which might be adduced, it may be added that M. Eokitansky has subjected the supposed hygroscopic property of the brain to the test of experiment, and found that no change what- ever was produced in slices of cerebral matter by soaking them for hours in serum. But if we reject the theory of this change in the brain being a mere post-mortem occurrence, the question still remains, to what is it due? M. Eokitansky regards it as a condition of acute oedema of the brain, often, though not invariably, associated with inflammation, since its products, pus and exudation corpuscles, are usually found in the broken down or infiltrated nervous matter. One very strong proof of the close connection that subsists between softening of the brain and an inflammatory process going on in the organ, is furnished by the changes which in many of these cases may be observed in the lining membrane of the ventricles. In 24 cases of acute hydrocephalus, in which central softening of the brain co-existed with 1 Beobachtungen und Bemerkungen iiber den rasch verlaufenden Wasserkopf. Von K. Herrich. 8vo. Regensburg, 1847, p. 161, § 126. 2 Recherches sur la Phthisic 2de ed. 8vo. Paris, 1843, p. 160, § 161. 76 SOFTENING OF THE BRAIN the presence of fluid in the ventricles, accurate notes were taken of the condition of their lining, and in three instances only was it found to be healthy. In one of these three cases the central softening was very inconsiderable, and in the other two cases the softening of the central parts was associated with very marked softening of other parts of the brain, which were altered in color as well as in consistence. The lining of the ventricles in the remaining 21 cases was notablf altered, although the degree of its change was very variable. The first alteration that takes place in it is the loss of its transparency, which is often, though not always, associated with a turgid state of its vessels. It next acquires an unnatural toughness, so that it can be raised by the point of the scalpel: and sometimes it is not merely opaque and tough, but greatly thickened, forming a dense firm mem- brane ; and once or twice I have noticed its inner surface present a slightly granular appearance. These changes in the membrane do not bear any certain relation to the quantity of fluid or to the degree of central softening, though it is rare to find an extreme degree of change in the lining of the ventricles without a considerable quantity of fluid in their cavity, and great softening of the brain around them.1 1 The subjoined note contains an analysis of my dissections of 43 cases of acute hydrocephalus, as far as respects the presence of fluid in the ventricles, the state of their lining membrane, and the condition of the cerebral substance; particulars the mutual relation of which to each other have not yet been fully investigated. In 13 of these 43 cases there is no express mention of the condition of the lining of the ventricles. In 2 the state of the cerebral substance is only imperfectly described. In 41 the condition of the cerebral substance was carefully noted, and in 14 of these cases the brain was not softened at its centre. In 1 of these 14 cases the ventricles contained no fluid. 1 " " " very little. 3 " " " not above 1 oz. 2 " " " 1J oz. 1 " " " 3oz. 1 " " " 4 oz. 1 " " " 6 oz. 1 " " a considerable quantity. In 6 of these 14 cases the state of the lining of the ventricles is likewise expressly described. In 1, in which there was no fluid in the ventricles, and in 1 in which there was very little fluid, their lining was not altered. In 1, in which there was no fluid, the choroid plexuses were beset with tubercular granulations. In 1, in which there were six drachms, and in 1, in which there was an ounce of fluid, the lining of the ventricles was tougher than natural. In 1, in which there were 4 oz. of fluid, their lining was slightly opaque. In 12 of these 14 cases the consistence of the cerebral substance was everywhere natural. In 1 the brain was generally firmer than usual. In 1 the anterior parts of both posterior cerebral lobes, and the whole of the cere- bellum, were softened—changes which were most evident on the left side. In 27 cases the central parts of the brain were softened. In 9 of these 27 cases the softening was but slight at the centre. In 1 of these 9 cases there were not above two drachms of fluid in the ventricles, the lining of which was considerably thickened. In 1 of these 9 cases the substance of the brain elsewhere was healthy: six ounces of fluid in the ventricles, their lining healthy. In 2 of these 9 cases the substance of the brain elsewhere was healthy : four ounces THE RESULT OF INFLAMMATION. 77 It happens sometimes that we find large patches of tubercular matter deposited beneath the membranes on the convex surface of the brain, of fluid in the ventricles, their lining granular; and lymph was in one of the cases adherent to the choroid plexuses. In 1 of these 9 cases the substance of the brain elsewhere was healthy ; much fluid in the ventricles, their vessels large, choroid plexuses turgid. In 1 of these 9 cases the substance of the brain elsewhere was healthy; much fluid in the ventricles, their lining opaque, and vessels turgid. In 1 there was much yellow softening of the anterior and lower half of the middle lobes, greater in degree and extent on the left side; not above half an ounce of fluid in the ventricles. In 1 the substance of the brain generally was very vascular, the lining of the ven- tricles tough; there was some softening of each posterior horn; considerable of the left; which moreover contained a good deal of fluid, great effusion of lymph and hya- line matter at base of the brain. And, lastly, in 1, the anterior horn of the left, and the posterior of the right ventri- cle, were softened; the ventricles contained four ounces of clear fluid; their lining was granular, much thickened, and its vascularity increased. In 18 instances the central softening was considerable. In 4 of these 18 cases the cerebral substance elsewhere was softened also. _ In 1 of these 4 cases both posterior lobes were softened, especially the right, and the brain there had an uniform yellowish-white color. In 1 of these 4 cases the brain was very vascular down to the centre of Vieussens ; the lower and posterior third of left posterior lobe was of a yellowish-white color, and quite fluid. Six ounces of fluid in the ventricles. Cerebellum soft. _ In 1 of these cases there was great congestion of the brain, and general softening increased towards the centre. Much turbid reddish fluid in the ventricles. In the last of these 4 cases the cerebral substance was natural down to the centre of Vieussens, but below it was greatly softened, especially on the left side, where the gray and white matters were scarcely distinguishable from each other. In 8 other cases the lining of the ventricles was altered, but there was no softening except at the centre. .....,. . In 1 there was but two drachms of fluid in each ventricle, but its lining was opaque, thickened, and slightly granular: and in 1, where there were 3 ounces of fluid, the membrane was tough, and the venous trunks in the ventricles were enlarged. _ In 2 it had lost its polish, and was slightly thickened. Six ounces of fluid in the ventricles in one instance, and only two in the other. In 1 it was thickened and dull. - Much fluid in the ventricles. In 2 it was opaque and thickened. Much fluid in the ventricles. In 1 there were only three ounces of fluid in the ventricles, but their lining partook of the general softening; the central parts of the brain being almost diffluent. In 6 instances the lining of the ventricles was altered, and the cerebral substance elsewhere softened, viz :— __. , In 1 the whole brain was softened ; the thalami optici were of a gelatinous consist- ence for a quarter of an inch deep : there was much fluid in the ventricles, and their '^In iThere^waT'increased vascularity and general softening of the cerebrum and cerebellum ; much fluid in the ventricles, and their lining very thick andfirm. In 1 softening began about half an inch below the surface of the brain, and in- creased towards the centre; much fluid in the ventricles, and their lining remarkably t In 1 there was great softening of both posterior lobes, especially of the right; two ounces of fluid in the ventricles, and their lining but slightly opaque. . In 1 there was great vascularity, especially of the gray matter of the convolutions extreme softening of the anterior and middle lobes, proceeding from the longitudinal fissure outwards, most marked on the right side ; but the posterior lobe was not at all affected. There was capillary apoplexy of the left corpus striatum. The ventricles contained four ounces of turbid rose-colored serum ; their lining membrane was very vascular, thick, and firm in some parts-thick, soft, and actually disintegrated in 0t And lastly, in 1 there were two ounces of fluid in the ventricles, the vessels of which were turgid, while the softening involved the optic thalami and corpora striata, as well as the septum lucidum and fornix. 78 ACDTE HYDROCEPHALUS; and extending to the depth of about a line into its tissue, in children who have died of acute hydrocephalus. Now and then, also, masses of tubercle, of a spheroidal shape, and of various sizes, are found im- bedded in the cerebral substance. This latter appearance, however, is not frequent; it existed only in four out of the forty-three cases on which I have founded my remarks on the morbid anatomy of acute hydrocephalus; and even in these cases peculiar symptoms existed which during the lifetime of the patient led to the suspicion of the disease being something else than an ordinary attack of water on the brain. The complications of hydrocephalus consist almost entirely in the deposit of tubercle in many organs of the body, and in the various results to which that tubercular deposit may have given rise. The lungs and the bronchial glands are the parts most frequently and most seriously invaded by the tubercular deposit; the spleen, liver, mesen- teric glands, and intestines, rank next in frequency as the seat of tubercle. The complication of hydrocephalus with tuberculous ulce- ration of the intestines is one which, though not very frequent, must not be lost sight of, since its existence may give rise to diarrhoea, and thus lead to an error of diagnosis on your part, if you look for consti- pation of the bowels as an invariable symptom of water on the brain. But let us now pass to the examination of the symptoms of acute hydrocephalus. We cannot, however, do more to-day than familiarize ourselves with the main features of the disease, and must leave all attempts at filling up the outline to our next meeting. The first or premonitory stage of the affection is attended by many indications of cerebral congestion, coupled with general febrile dis- turbance, and presenting exacerbations and remissions at irregular periods. The child becomes gloomy, pettish, and slow in its move- ments, and is little pleased by its usual amusements. Or, at other times, its spirits are very variable; it will sometimes cease suddenly in the midst of its play, and run to hide its head in its mother's lap, putting its hand to its head, and complaining of headache, or saying merely that it is tired and sleepy, and wants to go to bed. Some- times, too, it turns giddy, as you will know, not so much from its complaint of dizziness, as from its suddenly standing still, gazing around for a moment as if lost, and then either beginning to cry at the strange sensation, or seeming to awake from a reverie, and at once returning to its play. The infant in its nurse's arms betrays the same sensation by a sudden look of alarm, a momentary cry, and a hasty clinging to its nurse. If the child can walk, it may be observed to drag one leg, halting in its gait, though but slightly, and seldom as much at one time as at another, so that both the parents and the medical attendant may be disposed to attribute it to an ungainly habit which the child has contracted. The appetite is usually bad, though sometimes very variable ; and the child, when apparently busy at play, may all at once throw down its toys, and beg for food; then refuse what is offered, or taking a hasty bite, may seem to nau- seate the half-tasted morsel, may open its mouth, stretch out its tongue, and heave as if about to vomit. The thirst is seldom con- SYMPTOMS OF ITS THREE STAGES. 79 siderable, and sometimes there is an actual aversion to drink as well as to food, apparently from its exciting or increasing the sickness. The stomach, however, seldom rejects everything; but the same food as occasions sickness at one time is retained at another. Sometimes the child vomits only after taking food ; at other times, even when the stomach is empty, it brings up some greenish phlegm without much effort and with no relief. These attacks of vomiting seldom occur oftener than two or three times a day; but they may return for several days together, the child's head probably growing heavier, and its headache more severe. The bowels during this time are dis- ordered, generally constipated from the very first, though their con- dition in this respect sometimes varies at the commencement of the disease. The evacuations are usually scanty, sometimes pale, often of different colors, almost always deficient in bile, frequently mud- colored, and very offensive. The tongue is not dry, generally rather red at the tip and edges, coated with white fur in the centre, which becomes yellowish towards the root. Occasionally I have seen it very moist, and uniformly coated with a thin white fur. The skin is harsh, but there is no great heat of surface; the nares are dry, the eyes lus- treless, the pulse accelerated, but seldom exceeding 120 in children of four years old and upwards; not full nor strong, but often unequal in the force and duration of its beats. The child is drowsy, and will sometimes want to be put to bed two or three times in the day; but it is restless, sleeps ill, grinds its teeth in sleep, lies with its eyes par- tially open, awakes with the slightest noise, or even starts up in alarm without any apparent cause. At night, too, the existence of intole- rance of light is often first noticed in consequence of the child's com- plaints about the presence of the candle in the room. I need scarcely say that you must not expect to find all these symp- toms in every case, neither, indeed, when present, are they persistent, but the child's condition varies greatly in the course of a few minutes; cheerfulness alternating with depression, and sound sleep being now and then enjoyed in the midst of the unrefreshing dozes of the night. It will not be by a hurried visit of a few minutes that you will learn these things; you must not grudge your time, if you hope ever to attain to excellence in the management of children's diseases. This precursory stage is of very variable duration, but on the average does not exceed four or five days. If the disease be not recognized, or if the treatment adopted be unsuccessful, it will pass into the second stage, in which the nature of the affection is very apparent, though unhappily the prospect of its cure is almost lost. The child no longer has intervals of cheerfulness, nor attempts to sit up, but wishes to be left quiet in bed, and the face assumes a permanent expression of anxiety and suffering. The eyes are often kept closed, and the eye- brows are knit, the child endeavoring to shut out the light from its morbidly sensitive retina. The skin continues dry, the face is some- times flushed, and the head often hot; and though these two symp- toms vary much in their duration, coming and going without any evident cause, yet there is a permanently increased pulsation of the carotids and if the skull be not ossified the bram may be felt and 80 ACUTE HYDROCEPHALUS; seen forcibly beating through the anterior fontanelle. The child is now very averse to being disturbed, and often lies in a drowsy condi- tion, unless spoken to, when, if old enough to answer, it usually complains of its head, or of weariness or sleepiness. Its replies are generally rational, but very short; and if it need anything, it asks in as few words as possible, in a quick, pettish manner, and shows much irritability if not at once attended to. At other times it lies with its face turned from the light, either quite quiet, or moaning in a low tone of voice, and now and then uttering a short, sharp, lamentable cry, which M. Coindet, of Geneva, regarded as characteristic of the disease, and hence termed it cri hydrencephalique; but making no other complaint than the low moan and the occasional plaintive cry. To this, how- ever, there are exceptions, and children sometimes scream with the intensity of the pain, or cry out, "My head! my head!" most piteously. As the night comes on there is almost a distinct exacerbation of the symptoms, and the quiet of the day is frequently succeeded by a noisy and excited state, in which vociferous cries about the heard alternate with delirium. This, however, is not by any means a constant occur- rence ; an increase of restlessness being often the only difference from the state of stupor in which the child lay during the day. At the commencement of this stage the pulse is quickened, sometimes very much so, and is in many cases unequal in the force and quickness of the beats. Irregularity of its rhythm, or distinct intermission in its beat, is the next change, and is usually perceived at the same time with a great diminution in its frequency, which often falls in a few hours from 120 to 90 or 80. At the same that these changes take place in the general characters of the pulse, its power becomes mani- festly diminished, while the slightest exertion, such as attends any alteration in the child's position in the bed, will often suffice to increase its frequency twenty beats or more in the minute. The child some- times keeps its eyes so firmly closed that we can scarcely see the state of its pupils. Usually they are not much affected, but sometimes one is more dilated and acts more sluggishly than the other, or, in other cases, strabismus exists, though perhaps in a very slight degree, or confined to one eye. It is seldom that vomiting continues beyond the commencement of this stage, but its cessation is not followed by any desire either for food or drink. The bowels usually become even more constipated than they were before, and the evacuations continue quite as unnatural, while all flatus disappears from the intestines, and the abdomen thus acquires that shrunken form on which much stress has been laid by some writers as characteristic of hydrocephalus. The transition from this to the third stage of the disease is sometimes effected very gradually by the deepening of the state of drowsiness, till it amounts to a stupor, from which it is impossible to rouse the child. At other times, however, this stupor comes on very suddenly, succeeding immediately to an attack of convulsions. These convul- sions usually affect one side much more than the other, and after the fit has passed off' one side is generally found partially or completely paralyzed, while the child makes constant automatic movements with the other, carrying the hand to the head, and alternately flexing and SYMPTOMS OF ITS THREE STAGES. 81 extending the leg. The side which is, the most affected during the fit is generally, though not invariably, the most palsied afterwards. When the third stage is fully established, the child lies upon its back in a state of complete insensibility, with one leg stretched out, the other drawn up towards the abdomen. The tremulous hands are either employed in picking the lips or nose till the blood comes, or one hand is kept on the genitals while the other is rubbing the face or head. The head is at one moment hot, and the face flushed, and then the heat disap- pears and the flush fades, though usually there is a permanent increase in temperature about the occiput. Sometimes the skin is dry, and then, though the extremities are cold, a profuse sweat breaks out on some part of the body or on the head. The pulse often loses its irregu- larity, but at the same time it grows smaller and more rapid, till at length it can be counted only at the heart. The eyelids now close only very partially, and in most cases there is some degree of strabismus. Light is no longer unpleasant, for the dilated pupils are either alto- gether motionless, or they act very sluggishly, frequently oscillating under the stimulus of a bright light, alternately contracting and dilating, till at length they subside into their former dilated condition. The child now often makes automatic movements with its mouth, as though chewing, or as though endeavoring to swallow something. It generally happens that, although sensibility is quite extinguished, the child will still swallow anything that is put in its mouth, and the power of deglutition is in most cases one of the very last to be abolished. An attack of convulsions now sometimes puts an end to the painful scene; but often the child lives on for days, though wasted to a skele- ton, and its features so changed by suffering that those persons who had seen it but a short time before would now scarcely recognize it. The head often becomes somewhat retracted, and the child bores with the occiput in the pillow; the eyelids are wide open, and the eyes turned upwards so as to conceal three-fourths of the iris beneath the upper lid, while the countenance is still further disfigured by a horrible squint, or by a constant rolling of the eyes. The pupils are now fixed and glassy, the white of the eyes is extremely bloodshot, and their surface is besmeared with a copious secretion from the Meibomian glands, which collects in their corners. One leg and arm are stiff and motionless, the other in constant spasmodic movement, while the hands are often clenched and the wrists bent upon the forearm. At the same time there is frequently so much subsultus as to render it impossible to count the pulse, and the muscles of the face^ire thrown from time to time into a state of spasmodic twitching. Cold clammy sweats break out abundantly about the head, the breathing is labored, deglu- tition becomes difficult, and the child almost chokes with the effort to swallow, or lets the fluids run out at the corners of its mouth. It is uncertain how long this condition may endure; the recurrence of con- vulsions usually hastens the end, but sometimes many days will pass, during which death is hourly expected, and earnestly prayed for, to put an end to the patient's sufferings. 6 82 DIAGNOSIS OF HYDROCEPHALUS. LECTURE VII. Acute Hydrocephalus, continued.—Diversities in its course and in its modes of attack — insidious approach in phthisical subjects —resemblance of its symptoms to those of remittent fever—of simple gastric disorder—serious import of continued sickness-in case of gastric disorder. Prognosis.—Disease almost always fatal—appearances of improvement often delusive —cautions against being misled by them. Duration of the disease—real nature of cases of water-stroke. Treatment.—Prophylaxis.—Treatment of disease—rules for depletion, for use of purga- tives, mercurials, application of cold.—Diet of patients—circumstances in which opiates may be useful—when blisters are to be applied—alleged efficacy of tartar- emetic ointment as a counter-irritant. Conclusion. It can scarcely be necessary to observe that acute hydrocephalus does not always run precisely that course which I described to you at our last meeting. Almost every case, indeed, presents some slight peculiarity, either in the comparative severity of the different symp- toms, in the date of their occurrence, or in the order in which they succeed each other. Convulsions, for instance, though hardly ever absent, occur earlier in one case than in another—affect in one the whole body, in another are limited to one side—are succeeded in one instance by paralysis, in another by a stiff and contracted state of the limbs. Again, coma sometimes comes on gradually, at other times takes place suddenly; in one instance it continues long, in another is speedily followed by death. The pupils sometimes become early in- sensible to light; at other times they continue to act, though slowly, almost to the time of death; and in like manner strabismus may exist in various forms, or there may be constant rotation of the eyeball, or neither of these symptoms may be present; and yet we cannot couple these diversities in the signs of the disease with any certain differences in the morbid appearances. But, how much soever one case of hydro- cephalus may differ from another in these respects, such differences are of comparatively but little moment, since, whether these symptoms occur early or late—whether they are slight or severe—short in their duration, or of long continuance—the appearance of any one of them stamps the character of the disease too plainly for it to be mistaken, and indicates not the incipient but the fully developed evil. The deviations from the ordinary mode of its attack are far more important, since they may lead you to mistake the nature of the disease during the only time when treatment is likely to be of much avail. The healthy and robust are comparatively seldom attacked by hy- drocephalus, and in many instances the indications of declining health precede for weeks or months the real premonitory symptoms of the ITS SYMPTOMS OBSCURE IN PHTHISICAL SUBJECTS. 83 disease. You may, however, be so much taken up with watching the former as to overlook the latter, or to misinterpret their meaning. Your solicitude is excited by the gradual decay of a child's strength, and the wasting of his flesh. You observe that he becomes subject to irregular febrile attacks—that he coughs a little—that he loses his appetite—that his bowels are almost always disordered, and generally constipated—and that he makes frequent vague complaints of pains in his limbs, or of weariness or headache. These symptoms, which depend upon that general deposit of tubercle in the different organs of the body which almost every dissection of fatal cases of hydrocephalus reveals, make you apprehensive lest phthisis be about to come on, and yqu often auscultate the chest in the expectation of discovering some signs of disease in the lungs. At length the child seems worse—he coughs more, and is more feverish—grows heavier and more dull, but does not complain more about his head—or, at most, says that the cough makes his head ache. The parents think the child must have caught cold, and you do not see the indication of any new disorder; for, though listless and moody, he still moves about the house, and sometimes plays, though in a spiritless manner. Simple treatment seems to do a little good, and you not unnaturally hope that the aggra- vation of the symptoms will prove only temporary; but, after an un- usually restless night, a fit of convulsions comes on, or the listlessness deepens in the course of a few hours, and without any evident cause, into profound coma, and a very few days terminate the patient's life.' A little girl, nearly eight years old, was brought to the Children's Hospital one December. She was very pale, very languid, and so emaciated that she looked as if far advanced in consumption. Her mother stated that from birth the child's health had been delicate! but that she had had no disease until the previous July, when hoop- ing-cough came on, which in a few days was complicated by the occurrence of measles, attended with diarrhoea. She recovered from these ailments, though they left her very thin and very weak, and the hooping-cough did not completely cease until late in the autumn. From the time of the hooping-cough ceasing, the child's health im- proved, but her appetite was never very good, and she seemed by de- grees to become more and more unable to eat the coarse food of poverty. She next was sick sometimes after taking food, and then complained occasionally of headache; and after these fresh symptoms had con- tinued for a few days, her mother brought her to the hospital. She attended as an out-patient for nearly a fortnight, during which time no new symptom appeared; but the child grew daily weaker, and ac- cordingly, was received into the house on December 16tb. The cir- cumstance that the auscultatory signs of phthisis which were present, consisted merely in slight impairment of resonance on the left side posteriorly, with coarse breathing and loud expiratory sounds, led to the hope that the mischief in the lungs was not very considerable. She was ordered beef-tea, with a little wine, and h mixture containing the nitromuriatic and hydrocyanic acids. For a few hours, the comforts of the hospital made a change in her for the better; but, on the night of the 17th, she slept badly, com- 81 DIAGNOSIS OF HYDROCEPHALUS plained of headathe on the following morning, and was sick after her breakfast. A single dose of calomel freely relieved her bowels, blisters behind the ears removed the headache, and the sickness was quite stopped by the prussic acid given in an effervescing mixture. This improvement, however, lasted only for twenty four hours. On Decem- ber 20th, after a restless night, she became very drowsy, refused her beef-tea, asked for nothing, complained of nothing, but, if much pressed, said that her head ached. A blister was put on the shaven scalp; the wine, which flushed her, was discontinued, while an attempt was made to nourish h'er with beef-tea enemata. The drowsiness, in spite of the blister, deepened on the next day into coma; and thus she lay, in a state of unconsciousness, with occasional convulsive twitchings of the muscles of the face for the last two days of her life, till she died quietly on the morning of December 25th. On examining the body after death, there was found advanced tuberculous disease of the bronchial glands at the left side of the trachea, but the lungs were quite free from tubercle. The ventricles of the brain contained some fluid; the arachnoid at the base was less transparent than natural; while a thin layer of toughish yellow lymph extended over the pons Varolii, being rather more considerable at the right than the left side. The two hemispheres of the brain were united by old adhesions along the longitudinal fissure, and the ante- rior and middle lobes were connected along .the fissure of Sylvius; but there was scarcely any effusion of hyaline matter, or any granu- lar appearance between the pons and the optic commissure, where usually it is so marked. There were but few symptoms of the coming disease; for the same reason, I imagine, as that which will account for the comparatively slight appearances after death: namely, that it takes but little to ex- tinguish life, when long-standing ailments have so enfeebled all the vital powers. In cases such as this, you will, it is true, most likely be able to do little or nothing, even if you recognize the approach of hydrocephalus from the earliest indication of its coming. But you will save your patient's friends some sorrow, and yourself some reproach, if you dis- cover the danger at a distance. Now, whenever any child, especially if it be of a consumptive family, has been failing in health for some weeks or months, without evident cause, I advise you to look with much suspicion on the supervention of unusual drowsiness or listless- ness, or on any aggravation of the cough, for which you cannot find adequate reason in the information afforded by auscultation. A fre- quent, short, dry cough is not infrequent at the commencement of hydrocephalus; but in cases where cough has existed for some time, you are very likely to refer its aggravation to mischief in the chest, and to lose sight of its possible connection with affection of the brain. Inquire, therefore, in every doubtful case, whether there has been any vomiting—for sometimes it is but slight, and occurs only after food has been taken, and then only occasionally, so that it may seem to the parents to be a symptom of little importance. Ascertain the condition of the bowels; watch the pulse most carefully; it may not be irregular FROM REMITTENT FEVER. 85 nor intermittent, but you will probably find a little inequality in the force and duration of its beats: if so, you may be sure that the head is suffering, and if the head suffer in such a patient, it is in ninety-nine cases out of a hundred from the approach of hydrocephalus. Do not content yourselves with seeing your patient once a day; visit him at least morning and evening—stay some time with him, watch him closely, and see how far he is capable of being amused: but if you be still strangers to that freemasonry which assures a little child that you love it, you will very likely fail of arriving at the truth. But it may happen that a child, though not robust, had yet been tolerably weil till a week or two before you visited it, and that it was then attacked by febrile symptoms, with a little headache, and perhaps with vomiting and constipation. You learn that these two symptoms were but of short duration, but that the fever has continued ever since, and that the child has been very taciturn, rather drowsy, and averse to being disturbed, though giving rational answers when spoken to. You regard the case as one of remittent fever, and treat it without either improvement or deterioration, till the appearance of convul- sions or of coma corrects your diagnosis, though unfortunately too late. It must be confessed that it is sometimes a matter of great difficulty to distinguish between these two affections. It may help you, indeed, to bear in mind that remittent fever is very rare before five years of age, and is hardly ever met with in children under three; while at least half of all cases of hydrocephalus occur in children who have not completed their fifth year. But still this is not the kind of evi- dence on which you can place much reliance in a doubtful case. There are differences in the symptoms, however, which will generally enable you to discriminate between them, if you have acquired the habit of minute and careful observation. The vomiting, on which I have laid so much stress as a symptom of approaching hydrocephalus, is often absent even at the onset of remittent fever; it soon ceases, and is not followed by that abiding nausea which is frequent in hydrocephalus. In remittent fever the bowels are often relaxed from the very outset, or speedily become so, and the evacuations present no resemblance to the scanty, dark, or mud-colored motions which are voided in hydrocephalus; but are usually watery, fecal, and of a lightish color. Tenderness of the abdomen is nearly constant in remittent fever, and is greater in the iliac regions than elsewhere, and wind can always be felt in the intestines. The tongue is not moist as in hydrocephalus, and is seldom much loaded, but has in general only a thin coating of yellow fur at the centre and towards the root, while it is very red at the tip and edges, and becomes dry at an early stage of the disease. In hydrocephalus there is frequently a great distaste for drink as well as for food, while although the appe- tite is lost in cases of remittent fever, yet the patients have great desire for drink, especially for cold drink, to quench the urgent thirst. The heat of the skin in remittent fever is extremely pungent, and much greater than in hydrocephalus, in which, although there is great dry- ness of the surface, yet the temperature is seldom much increased. The pulse in remittent fever is much quicker than in hydrocephalus; 86 PROGNOSIS IN HYDROCEPHALUS. it continues quick throughout, and never becomes unequal or irregu- lar, while its frequency is in direct proportion to the elevation of the temperature of the surface. In remittent fever the child makes few complaints about its head, but delirium is of early occurrence, espe- cially at night; in hydrocephalus, on the contrary, true delirium hardly ever occurs till an advanced period of the disease, and is sometimes absent altogether. In remittent fever, as its name implies, there are distinct remissions and exacerbations of the symptoms, the patient getting better towards morning, and worse again as night ap- proaches; while, though there are many fluctuations in the course of hydrocephalus, yet we observe no definite periods at which the symp- toms invariably remit or are increased in severity. With due caution you will scarcely take a case of incipient hydro- cephalus for one of simple gastric disorder, though there are many points of resemblance between the two. Vomiting and constipation occur in both, and there is usuall}' some degree of headache in the latter affection, though seldom severe or lasting. Mere gastric disorder is not attended with much febrile disturbance; the face, though heavy, is not distressed nor anxious, while the tongue is usually much more coated than at the onset of an attack of hydrocephalus. The relief that follows the use of remedies in the less dangerous affection is com- plete as well as speedy; the sickness will cease after the operation of an emetic, the bowels will act copiously after the administration of a brisk purgative, and in a day or two your patient will be quite well. The persistence of vomiting, however, in any case which you had thought to be one merely of gastric disorder, must be looked upon by you with great suspicion, and this even though the bowels have acted freely from medicine, and though there be no obvious indication of mischief in the head. I once saw a case in which the continuance of intractable vomiting for more than six weeks after the cessation of a short but severe attack of diarrhoea, was the only symptom of illness in a boy five years of age. At length he became a little drowsy, and once or twice, when closely questioned, said that his head ached. Not quite two days after the first complaint of headache, the child had a violent fit of convulsions, and in the course of the succeeding week he died, having suffered during that time from all the symptoms of acute hydrocephalus, and his body presenting after death its charac- teristic lesions. An inquiry of little less importance than that concerning the means of distinguishing between one disease and another, respects the prog- nosis that we are to form, the inferences that we may draw, from the course of the malady, either to encourage hope or to excite anxiety. Unfortunately the prognosis in hydrocephalus is so unfavorable that we can scarcely speak of the circumstances which regulate it; for under almost every variety of condition, of symptoms, and of treat- ment, the patients die. The cases are but very few in which I have seen any other than a fatal issue follow on even the premonitory symptoms of water on the brain. Once I saw recovery take place after the second stage of hydrocephalus had commenced, and once I watched with surprise the gradual subsidence of the disease, though PROGNOSIS IN HYDROCEPHALUS. 87 convulsions had already taken place, and had been followed by coma. In that instance the child, three and a half years old, was a member of a phthisical family, and her younger brother had died a year before of hydrocephalus. The disease in her case ran its ordinary course, unchecked by the customary treatment. Convulsions took place, coma succeeded them, deglutition was very difficult, the pupils were dilated and almost motionless, the pulse was very feeble and very frequent, and everything portended the speedy death which one looks for as the usual termination of such symptoms. Food was still given, as the power of swallowing was not entirely lost, and ammonia and ether were administered, which after a time were exchanged for quinine. For days unconsciousness continued, and the first return of voluntary effort was shown by the child raising her hand to steady the cup that was put to her lips. She next recovered the power of vision, but still could not move her legs, nor utter any articulate sound. The power of speech was not regained for some weeks, nor that of walk- in »■ for many months; the gait long continued tottering and uncer- tain, and the child's manner half idiotic. Three years have now elapsed since then, and recovery is as perfect as probably it ever will be; but the child, though not now deficient in intelligence, has never regained flesh, nor recovered the look of health, nor the manners of a child, but walks about unsteadily, with a weird cast of countenance, and a vacant smile, and each time that I see her, I feel surprised that the disease, evidently still latent, has not yet returned. I am aware that other practitioners have arrived at results far more favorable than those to which my own experience has led me; but while I would gladly, if it were possible, modify my statements, I feel sure that a careful perusal of the cases of alleged recovery recorded by different writers must satisfy every one that the disease in almost every instance was not hydrocephalus at all; and that often it was some ailment bearing to it but a very slight resemblance. It is re- markable, indeed, as M. Eilliet1 well observes in a recent very valuable paper on this subject, that almost all the instances in which recovery from hydrocephalus is stated to have taken place, occurred before the real nature of the disease was understood, while, since its tubercular nature has been recognized, not a single authenticated case of the kind has been published by any French physician. M Guersant, of Paris, who probably had seen more than any man now living of children's diseases, gives the following statement as the result of his experience:— . . "Tubercular meningitis," says he, "may sometimes terminate by recovery in the first stage, though the nature of such cases is always more or less doubtful; in the second stage I have not seen one child recover out of a hundred, and even those who seem to have recovered have either sunk afterwards under a return of the same disease, in its acute form, or have died of phthisis. As to patients in whom the disease has reached the third stage, I have never seen them improve even for a moment."2 1 Archives Gen. de Medecine, Dec. 1853. 2 Diet. Med., t. xix. p. 403; quoted by MM. Rilliet and Barthez, op. cit., 1st edition, t. iii. p. 531. 88 DELUSIVE APPEARANCES OF IMPROVEMENT. The minuteness with which M. Rilliet records the history of his patient's recovery, leaves little room for doubt that the case was one of tubercular hydrocephalus in the third stage; and the bare possi- bility of error is removed by the circumstance that the child died five years afterwards under a recurrence of the former symptoms; and that on a post-mortem examination the old mischief at the base of the brain was clearly distinguishable from the effects of the recent disease under which the child had sunk. This case, however, and the few others which are scattered through the annals of medicine, can be regarded only as the exceptions which prove the rule that hydroce- phalus, following the law of tubercular disease in general, is almost incurable, while it proves mortal all the more frequently owing to the importance of the organ which is its seat. Since, then, the fatality of the disease is almost invariable, it may seem to you superfluous for me to say anything more with reference to the prognosis; but I am desirous of guarding you against being deceived by certain delusive appearances of improvement which are by no means unusual even in cases where the real nature of the disease has for some two or three days been clearly manifest. A few years ago, a little girl, three years old, was brought to me in a state of pro- found coma, and presenting the symptoms of the third stage of acute hydrocephalus, of which she died forty-eight hours afterwards, without having had any return of consciousness. I learned from her mother, that, fourteen days previously, the child had been attacked by vomit- ing, attended by fever and great drowsiness; but that these symptoms abated in three days, and that the child improved and was reo-ainino- her cheerfulness until the morning of the day before she was brought to me, when her mother found her comatose, and in just the condition in which she was when I saw her. A more acute observer than this child's mother would probably have seen something to make her dis trust the apparent improvement; but it is evident that the change was great from fever and drowsiness, and frequent vomiting, to a cessation of the sickness, a diminution of the fever, and a return of cheerful- ness; and yet during all this time disease was going on, and producing the very extensive softening of the central and posterior parts of the brain which was discovered after death. The cases in which you are likely to fall into error are for the most part such as have come on insidiously, unattended by very violent symptoms, and about which you perhaps hesitated some little time before you became convinced that so grave a malady as hydrocephalus could wear so mild a form. Treatment for some days produces no effect, the disease remaining stationary; but at length your hopes are raised by finding that the vomiting has ceased, and that the constipated condition of the bowels has been overcome. The heat of head has disappeared, the pulse presents much less irregularity than before, or may even have lost it altogether; the child's restlessness has subsided, and its manner is almost natural. Perhaps the child seems rather drowsy, or it may be sleeping at the time of your visit; but the account you hear of'it seems satisfactory: its repose is quiet, and the mother rejoices: her little one has had no sound sleep for many days, and will, she thinks DURATION OF ACUTE HYDROCEPHALUS. 89 —and you may think so too—be much better when it wakes. It does not wake up, but it swallows well when some drink is given in a spoon, and the mother is still content. Presently slight twitchings of the face and hands are seen, bu*t the child does not wake—you cannot rouse it: the sleep has passed into coma, and the coma will end in death. Always suspect the sleep which follows continued restlessness in a case of hydrocephalus. In other cases, although the disease did not come on so insidiously, and although it has reached a stage at which all its characters are well marked, you may yet be led for a few hours to entertain, and perhaps to express, ill-founded hopes, in consequence of the symptoms having somewhat abated, of the child having had some hours of quiet sleep, or having ceased to vomit, or no longer complaining of its head, or being visited by a short gleam of cheerfulness. You must not forget, however, that it is characteristic of hydrocephalus to present irregular remissions, that they last but for a few hours, and that at your next visit you may find every bad symptom returned, and, possibly, some fresh one superadded. Usually, too, you may be guarded from error by observing the suddenness of the change, and that the condition which has now come on is the very opposite of that which before existed, preternatural excitement having been suc- ceeded by an equally unnatural apathy, or great talkativeness having taken the place of obstinate silence, or the pulse, which before was above 130, having sunk all at once to 90 in the minute. At other times, though there is a general abatement in all the previous symp- toms, yet some new one may have appeared; not more formidable, perhaps, than the occurrence of a slight degree of strabismus which had not existed before, but. still enough to indicate that the mischief is still going on, and that you must not dare to hope. A still more remarkable temporary improvement is sometimes observed, that " lightening before death," which seems, contrary to all expectation, to warrant a hope of recovery even when dissolution is impending. The only instance of it which has come under my notice occurred in a girl, aged seven years, who died on the fifteenth day of an attack of acute hydrocephalus. She had been in a state of stupor for six days, and profoundly comatose for two days, when she became conscious, swallowed some drink, spoke sensibly, and said she knew her father. She became worse again, however, in the course of an hour and a half, though she did not sink into the same deep coma as before, and in another hour she died. A few points still remain on which I must touch before passing to the consideration of the treatment of hydrocephalus. One of these is the question of its duration. The exact determination of this is not always easy, owing to the insidious manner in which the disease comes on; but, on the whole, there is less discrepancy than might have been expected between the statements of different writers. Of 117 cases observed or collected by Dr. Hennis Green, 80 terminated within 14 days, and 31 more within 20 days. Of 28 cases recorded by Golis,1 18 terminated within 14 days, and only 2 exceeded 20 1 Praktische Abhandlungen, etc. 8vo. Wien, 1820. Vol. i. 90 THE THREE STAGES OF HYDROCEPHALUS. days. MM. Killiet and Barthez1 state the average duration of 28 cases that came under their observation to have been 22 days; and the average duration of 42 fatal cases of which I have a complete re- cord, was about 20 days. Of these 42 cases, that which ran the most rapid course terminated fatally in five days; death took place in 11 more before the fourteenth day; in 18 others during the third week, and in 6 during the fourth week. In the remaining 6 cases indications of cerebral disturbance had existed for four, six, or eight weeks; but death took place in every instance in less than 21 days after the ap- pearance of well-marked symptoms of hydrocephalus, and in one on the eighth day from their becoming clearly manifest. We are, then, warranted in stating that the disease usually runs its course in from two to three weeks. The late celebrated Dr. Golis, of Vienna, proposed the name of water- stroke for some cases in which the head symptoms were of such short duration as not to exceed twenty-four or forty-eight hours. Such a rapid course, however, is not observed in true tubercular hydrocepha- lus; but the name of water-stroke has been applied to a great variety of cases which have presented little in common except the presence of head symptoms, and their rapidly fatal termination.2 The appellation has been sometimes bestowed on cases of intense cerebral congestion; at other times on cases of simple meningitis. In a few instances the name may have been given to cases of true hydrocephalus in which the rapid course of the disease has been apparent, rather than real, owing to its having succeeded to chicken-pox, or having come on in the course of that febrile disturbance which vaccination sometimes excites, or which attends upon dentition. In such circumstances it often happens that the manifestations of cerebral disease are mistakenly attributed entirely to the previous cause of irritation in the system, so that, when the signs of serious mischief force themselves upon the notice, the hydrocephalus has wellnigh run its course. In describing this disease I divided it into three stages, but did so simply for convenience. Many physicians, however, have attached much greater importance to this division, regarding the first as the stage of turgescence; the second, as that of inflammation; the third, that of effusion. Again, the first has been characterized as the stage of increased sensibility; the second, of diminished sensibility ; the third, of palsy. Lastly, Dr. Whytt proposed a division that has been much followed, based on the variations of the pulse, which is usually quick and regular in the first stage, slow and irregular in the second, and quick in the third. There are too many exceptions, however, to the order of these changes, for it to be right to make them the founda- tion of any division of the disease into different stages; and the same remark may be made with reference to any arrangement founded on the variations in the sensibility of the patient. I have said that the phenomena of the pulse are not constant; I need scarcely add, that the slow, irregular pulse is no proof of the 1 Op. cit., vol. iii. p. 497. 2 In proof of this statement, see Golis, lib. cit., Cases 1 to 9. PROPHYLACTIC TREATMENT OF HYDROCEPHALUS. 91 occurrence of effusion ; neither is the dilated pupil a proof of it; it is a proof of great mischief having been inflicted on the brain ; so are the strabismus and the rolling of the eyes which frequently accompany it; but you cannot connect these symptoms with injuries of a special kind, or involving particular parts of the brain. Although a disease of childhood, acute hydrocephalus is by no means most frequent in early infancy. In only 5 of 43 fatal cases in which the diagnosis was confirmed by a post-mortem examination, were my patients under a year old; 9 were under 3 years of age; 23 between 3 and 6; 5 between 6 and 9; and 1 between 10 and 11 years old.1 ' From all that I have told you about hydrocephalus, you have, I doubt not, already deduced the practical inference, that the only treat- ment likely to avail much is the prophylactic; and that, if you would hope ever to save a patient, you must treat the mere threatenings of his disease, and not remain inactive until you see the malady fully developed before you. The prophylactic treatment of hydrocephalus must be in the main the prophylactic treatment of consumption, since not only is tubercle in- variably present in the various organs of children who have died of hydrocephalus, but the disease itself often supervenes on more or less definite phthisical symptoms, as is shown by the fact that the previous health of the children was indifferent in more than two-thirds of the cases that came under my notice. The influence of hereditary pre- disposition to phthisis, in favoring the development of hydrocephalus, on which almost all writers have insisted, is illustrated by the circum- stance, that in twenty out of twenty seven instances, in which the health of the relatives was made the subject of special inquiry, it was ascertained that either the father, mother, aunt, or uncle, had died of phthisis. In any case where several children of the same family have already died of hydrocephalus, or have shown a marked tendency to the dis- ease the mother should for the future abstain from suckling her infants, and they should be brought up by a healthy wet-nurse. In such circumstances, too, it is desirable that a child should always live in the country; should be warmly clad, and should wear flannel next its skin. Its diet should be simple, and any change in it should be made with the greatest caution, while milk should for a long time form one of its chief aliments; and it would be desirable not to wean it until after it had cut four molar teeth, as well as all the incisors. As it grows up, over exertion, either of mind or body, must be most carefully avoided; and on this account, though free exercise in the air is highly beneficial, gymnastic exercises are by no means to be recom- mended. The child must be watched carefully during the whole period of dentition, and every precaution must be taken to shield it 1 This statement as to the time of life at which hydrocephalus is most frequent is fully borne out by the Fifth and Eighth Reports of the Registrar-General, from which it appears that while only 7 per cent, of the total deaths under one year old in this metropolis resulted from cephalitis and hydrocephalus, these diseases caused 12.5 per cent, of the deaths between 1 and 3 ; 12.5 per cent, of those between 3 and 5; 11.1 per cent, of those between 5 and 10 ; and 5.9 per cent, of those between 10 and 15. 92 PROPHYLACTIC TREATMENT OF HYDROCEPHALUS. from the contagion of measles, hooping-cough, or scarlatina; since these diseases, which tend to excite the tuberculous cachexy, would be likely greatly to aggravate the disposition to hydrocephalus, or even to bring on an attack of the disease. The condition of the bowels must be most carefully watched; constipation must not be allowed to exist even for a day, and the least indication of gastric disorder must be regarded as a serious matter. It is not desirable that calomel should be used as a domestic remedy; but if the simplest aperients (such as castor oil, or the infusion of senna, or of rhubarb1) do not act, the child should be immediately placed under proper medical care. If at any time there should be heat of head, and the child appear squeamish, you must be* at hand with your remedies, and those well chosen. Any bulky remedy would probably be rejected; but the stomach is almost sure to bear a grain or two of calomel with sugar, and you may follow this up with small quantities of the sulphate of magnesia2 every hour, until the bowels act freely. A small dose of mercury and chalk, or of calomel, may be continued every night for two or three times; and if any feverishness remain, or the bowels be disposed to be constipated, the sulphate of magnesia may still be given twice or thrice a day. Leeches should not be applied to the head without very obvious necessity, nor then in large numbers, for stru- mous children do not bear the loss of blood well; and your endeavor should, therefore, always be, not simply to cure,' but to cure at the smallest possible expense to the constitution. After attacks of this kind, children sometimes recover their health very slowly, and much good may then be effected by a judicious use of tonics. The infusion of calumba,3 with small doses of rhubarb, is a very suitable medicine, and one which children generally take tolerably well. Or you may give the ferrocitrate of quinine in orange-flower water, and sweetened with the syrup of orange-peel,4 while you secure the healthy action of the bowels by a grain or two of hyd. c. creta\ combined with five or six of rhubarb, administered every night, or every other night. If threatenings of head affection have frequently occurred, an issue should be inserted in the back of the neck; for the keeping up a con- stant discharge from the neighborhood of the head is certainly very serviceable in many instances as a means of warding off hydrocepha- lus. A most remarkable instance of this is recorded by Dr. Cheyne, who mentions that all the children in a numerous family were carried off by water on the brain, with the exception of one, in whose case the precaution was adopted of putting a seton in the back of his neck. 1 (No- 5.) 2 (No. 6.) B-—Potassse sulphat. gr. xij. R.—Magnes. sulphat. 3ij. Inf. rhei 3vss. Syr. aurantii 3ij. Trse.aurant.3ss. Aqua? carui 3vj.—M. 3iJomnihora Aquae carui 3ij.—M. gss p. r. n. donee alvus respondeat. For a child three years old. For a child three years old. 3 (No. 7.) I£.—Inf. calumbae §ij, gij. Inf. rhei givss. Trae. aurantii ,^iss.—M. 3iij bis die. For a child, three years old. 4 See Formula No. 4, page 56. TREATMENT OF THE ATTACK—DEPLETION. 93 But the opportunity may not be afforded you of adopting this pro- phylactic treatment; and when you first see your patient, the exist- ence of headache, vomiting, constipation, and a quickened pulse, with perhaps a very slight inequality in its beat, may leave you but little doubt as to the formidable nature of the disease with which you have to contend. In doing this, there are three remedies on which practi- tioners commonly rely, namely, depletion, purging, and the adminis- tration of mercury. With reference to depletion, you must not forget that the disease in which you are about to employ it, although of inflammatory nature, is inflammation in a scrofulous subject, and is in many cases grafted on previous organic disease; such as those tubercular deposits in the membranes of the brain which I have already described to you. You cannot, therefore, hope to cut short the affection by a large bleeding, but your object must be to take blood enough to relieve the congested brain, and no more than is necessary for that purpose. Avoid pre- cipitancy in what you do, and do not let your apprehensions betray you into that over-activity which is sometimes more fatal to a patient than his disease. If you feel any doubt as to the necessity of deple- tion, visit your patient again before determining on it, but do not delay that visit long. Order a dose of calomel, to be followed by some sulphate of magnesia, if, as is most probable, the bowels be con- fined, and return again in three or four hours. You may then find that the bowels have acted, and the sickness has ceased; that the head is cooler, and aches less; and that depletion is, for the present at any rate, unnecessary. Or the child's state may be the same, and you may still feel uncertain as to the right course. In that case, at once obtain the assistance of some other practitioner. This is the season when advice may be really useful, for it is only at the outset of the disease that its cure is possible; when convulsions have occurred, or coma is coming on, your treatment matters comparatively little, for the season of hope and the opportunity for action have then fled. Though you may have determined on the propriety of depletion, it will seldom be found, even at the outset of the disease, that the character of the pulse is such as to warrant venesection. Local bleed- ing will generally answer every purpose, and, indeed, the application of leeches may, as I have already mentioned to you,1 be so managed in the case of infants or young children, as to answer every purpose of general depletion. One caution may not be out of place with refer- ence to the part of the head on which leeches should be put, in child- ren ; since, though the reasons for it are obvious, it nevertheless' is often forgotten. They should be applied to the vertex, because, if put on the temples, they hang down over the eyes and terrify the child; if behind the ears, they are very likely to be rubbed off as it rolls its head from side to side. I will not say that this depletion is never to be repeated, but I believe that in by far the greater number of cases you will do no good whatever by its repetition, and the ex- ceptional cases will generally be those in which, very marked relief 1 See Lecture IV., page 51. 94 PURGATIVES—CALOMEL IN HYDROCEPHALUS. having followed the first bleeding, the same symptoms of congestion of the brain appear to be returning twenty-four or thirty-six hours afterwards. If you do not see the child until the second stage of the disease is far advanced—till general convulsions have occurred, or twitchings of the limbs, or of the muscles of the face, an appearance of extreme alarm, or a state of alternate contraction and dilatation of the pupils, show them to be impending—you must be exceedingly careful in abstracting blood. In such circumstances, I have seen con- vulsions, to all appearance induced, and the fatal course of the disease accelerated, by a rather free, though by no means immoderate, loss of blood. The value of purgatives in the treatment of hydrocephalus can scarcely be overrated; but they must be given so as not merely to obtain free action of the bowels, but to maintain it for some days. After having once overcome the constipation, you will secure this end best by giving small doses of a purgative every four or six hours. The administration of a strong cathartic every morning will not an- swer this end nearly so well; for, independently of the chance of its being rejected by the stomach, you will find that the dose which suf- ficed the first time will not be large enough the second, and that there will be a constantly increasing difficulty in obtaining an evacuation. The nausea and vomiting which at first stood in the way of your ad- ministering any medicine, are often so much relieved by depletion, that the stomach will almost immediately afterwards bear a dose of calomel and jalap, or calomel and scammony, which may be repeated every three hours, until it acts, while you at the same time-endeavor to quicken its operation by the administration of a purgative enema. There is no use, however, in persevering with these medicines if they excite sickness, and it is then better to give a single large dose of calomel in some loaf sugar, and to follow it up by a solution of sul- phate of magnesia, which should be repeated at short intervals. When a free evacuation has been obtained, the same salt, in combination with the nitrate of potash, will often keep up a free action of the bowels, as well as stimulate the kidneys to increased activity* These remedies may be either mixed with the child's drink, or be dissolved in water flavored with syrup of lemon or of orange-peel.1 Mercurial preparations, and especially calomel, have long had a high reputation in all the cerebral diseases of early life. Unhappily my own experience does not bear out the common practice, and I put no faith in calomel, nor in the production of salivation, as a means of curing hydrocephalus. I have seen children die whose mouths had been made sore by mercury, without any influence appearing to have been thereby exerted on the disease; and I recollect two who, at the time of their death, were in a state of most profuse salivation. What- ever good I have seen in these cases from calomel has been when it was given in combination with purgatives, or when it produced a purgative effect. Let me, however, again remind you that you may have hydro- 1 See Formula No. 1, page 53. LOCAL APPLICATION OF COLD — DIET— NARCOTICS. 95 cephalus combined with tubercular ulceration of the intestines, and that in such a case diarrhoea may exist from the outset, or may come on after a mild dose of some aperient. Now and then, too, without such a cause, constipation is absent, while diarrhoea comes on occa- sionally in the advanced disease. You must not, therefore, draw in- ferences as to the state of the patient too exclusively from the condition of the bowels. I insisted much on the local employment of cold when speaking about the management of cases of cerebral congestion. It is likewise a very valuable agent in the treatment of hydrocephalus; but its application requires to be judiciously regulated. You will generally find it of service after depletion, for you have abstracted blood on account of the febrile disturbance, and heat of head, and other indications of con- gestion of the brain, all of which cold will be a powerful auxiliary in subduing. So long as the signs of active congestion of the brain are present, cold will be of service; but it should not be employed inde- pendently of those symptoms which betoken the existence of that condition; nor can you hope to see any benefit result from cold applications to the head in the advanced stages of the disease. I need scarcely say that the application of cold with a shock, or the pouring cold water from a height upon the head, though a very valuable means of arousing the child from the state of coma into which it sinks in some cases of intense cerebral congestion, is wholly inapplicable in the coma of hydrocephalus. The functions of the brain are here not merely interrupted by the excess of blood in the organ, but they are abolished by the disorganization of its tissue, or the compression of its substance by the effusion of fluid. In the management of children attacked by hydrocephalus you must not forget that for the most part they are of feeble constitution, and that they will not bear too rigorous a diet. Just at first, indeed, while the febrile symptoms run high, and the bowels are unrelieved, or the sickness is urgent, the less the patient takes the better. After- wards, however, it is desirable that he should be supplied with as much light and unstimulating nutriment as he will take; such, for instance, as arrowroot, or veal or beef-tea, either of which will often remain on the stomach when most other articles of food or drink would be rejected. In the treatment of many diseases you see physicians destroy the sense of pain by narcotics, and the question naturally suggests itself to you whether you may not sometimes venture, in the management of hydrocephalus, to mitigate by their means your patient's sufferings. The inquiry is one not very easy to reply to satisfactorily. I think, however, that there are two conditions under which you would be justified in trying the experiment of giving them. Sometimes the disease sets in with great excitement, and a condition closely resem- bling mania in the adult, symptoms which may have been ushered in by convulsions. In such a case, although the heat of head and the flush of the face may have disappeared after free depletion and the copious action of purgative medicine, and though the pulse is feeble as well as frequent, yet the excitement may be scarcely if at all di- 96 USE OF BLISTERS—TARTAR-EMETIC OINTMENT. minished. Here an opiate will sometimes give the relief which nothing else will procure; your patient will fall asleep, and wake tranquillized in the course of two or three hours. In other cases, which did not set in thus violently, restlessness, talkativeness, and a kind of half delirious consciousness of pain in the head, become very distressing as the disease advances, being always aggravated at night, so that your patient's condition seems one of constant suffering. But he is not able to bear any more active treatment, and, indeed, you have already emptied your quiver of such weapons. In these circum- stances I have sometimes given a full dose of morphia, and have continued it every night for several nights together with manifest relief. Another inquiry that you may put is, when are you to employ blisters? Certainly not at the beginning of the disease, when they would increase the general irritation, and do more harm than good. At a later period they may be of service, when the excitement is about to yield to that stupor which usually precedes the state of com- plete coma. They should then be applied to the nape of the neck or to the vertex; and I am disposed to think the latter the better place, since, when applied to the nape of the neck, they often become dis- placed by that boring movement of the head which the child in many instances keeps up unconsciously. It is well, too, to remember that the skin in hydrocephalus is very inapt to vesicate, so that a blister will require to be kept on for ten or twelve hours; contrary to what ought to be your usual practice with children. Cases enough are on record proving the utility of blisters thus applied, to render it your duty not to neglect this means. 1 have made a few trials of a very energetic counter-irritant which has recently been strongly recommended by a German physician,1 but my experience does not induce me to recommend its adoption. Dr. Hahn employs an ointment composed of one part of tartar emetic and two parts of lard; of which a portion, the size of a hazelnut, is to be rubbed on the shaven scalp over a surface some two and a half inches in circumference, every two hours, till an abundant pustular eruption is produced. The sores which follow this inunction are remarkably intractable, requiring sometimes many months for their cure; but Dr. Hahn asserts, and gives some cases in proof of the assertion, that even in an advanced stage of hydrocephalus, and after the supervention of coma, recovery has often taken place under the use of his remedy. Many of the cases that he relates, however, are clearly not instances of hydrocephalus at all, while the theory which he propounds of the existence of a sort of antagonism between tuber- cular meningitis and certain pustular eruptions of the skin, and on which he founds the assumption of a sort of specific virtue in the tartar-emetic ointment, is a mere hypothesis, of the correctness of which, as a general law, we have no sort of evidence. In the cases in iwhich I tried it, it produced most formidable ulcerations of the scalp: it did what a very energetic counter-irritant might be expected 1 De la Meningite Tuberculeuse, etc., par H. Hahn. 8vo. Paris, 1835. SIMPLE INFLAMMATION OF THE BRAIN. 97 to do, but nothing more, and it was difficult to convince bystanders that a large black-looking wound did not increase the suffering of patients whose disease it certainly failed to arrest. Need I say that you must not think of treating a case of hydro- cephalus throughout just in the same way as you did at its commence- ment? There is, if the disease do not run a very rapid course, a stage of weakness and exhaustion, often associated with a half-coma- tose condition, though sometimes attended with a considerable degree of suffering, which frequently precedes the signs of approaching death. The bowels are now sometimes relaxed, though oftener they continue constipated, because the nervous energy which kept up the peristaltic movements of the intestines is worn out. The powers of organic as well as those of animal life are palsied. This is the time for the ad- ministration of quinine, for the employment of nutritious broths and jellies, and even of wine. You may perhaps be disposed to ask me what I think of this remedy or the other, which has at different times been boasted of, as having done good when other means had failed. Now you must not infer from my silence that I do not believe that other medicines besides those which I have spoken of have been of service; but to attempt to canvass the respective merits of each would, I fear, be a tedious task, and one from which you would derive but little profit. Besides, let me remind you of what Sydenham says: "* * * In eo prsecipue stat Medicina Practica, ut genuinas Indicatiopes expiscari valeamus, non ut remedia excogitemus quibus illis satisfieri possit; quod qui minus observabant, Empericos armis instruxere, quibus Medicorum opera imitari queant." LECTURE Y III. Simple Inflammation of the Brain—its differences from hydrocephalus—occasional extreme rapidity of its course—cases in illustration—morbid appearances—fre- quent connection with meningitis of the cord—extreme rarity as an idiopathic affection—treatment. Inflammation of the Brain succeeding to Disease of the Ear—digression concern- ing otitis—its symptoms—distinctions between it and inflammation of the brain —treatment—chronic otorrhoea, with disease of the temporal bone—case. Phlebitis of the Sinuses of the Dura Mater—circumstances in which it occurs— it sometimes succeeds to large collections of pus in distant organs—case in illus- tration. We have been engaged at our last two meetings with the study of one form of inflammation of the brain in the young subject. We found hydrocephalus to be an affection almost exclusively confined to children whose previous health had been indifferent, who had shown some indications of phthisis, or in whose family phthisical 7 98 SIMPLE INFLAMMATION OF THE BRAIN. disease existed. We observed its development to be gradual, its progress often tardy and attended with irregular remissions, but its issue almost always fatal. The alterations of structure discovered after death were seen to be slight at the convexity of the brain but very obvious at its base, where, in addition to the effects ot inflam- mation, the membranes often present a peculiar granular appearance. The fluid contained in the ventricles of the brain is almost always transparent, and tubercle is discovered in some, often in many, of the viscera. . , But we sometimes meet with cases in which inflammation of the brain has given rise to changes that contrast remarkably with those which true hydrocephalus produces. We find the cerebral mem- branes intensely injected, the effusion of lymph or pus abundant, espe- cially about the convex surface of the brain, where it sometimes forms a layer concealing the convulsions from view. Moreover, the fluid that occupies the cavity of the arachnoid, as well as that within the ventricles, is turbid and mixed with lymph, while the membranes present no trace of that granular appearance so remarkable in true hydrocephalus, and the various organs of the body are free from tubercle. If we inquire as to the symptoms by which this disease was attended during the lifetime of the patient, we shall most likely find that they present fresh reasons for distinguishing between it and hydrocephalus. We shall learn that the attack came on in a previously healthy child, that it was either ushered in by convulsions, or that they soon oc- curred, that they returned often, and probably that they continued with but little intermission until death took place. We shall be told, moreover, that the disease set in with violent vomiting and intense febrile excitement; and that having commenced thus severely, it advanced rapidly, and without remission, to its fatal termination, which may have arrived in the course of a few hours, and is seldom delayed beyond the first week. Some cases of this simple encephalitis are recorded by Golis, under the name of Water-stroke: I will select one of them, as affording a good specimen of the most acute form of the disease.1 " A little girl, 14 months old, who was healthy and strong and fat, was suddenly seized at 5 o'clock in the morning, after a restless night, with violent fever and frightful general convulsions. Medical assistance was at once obtained, and in less than thirty minutes from the commencement of the attack, four leeches were applied behind the ears, which drew three ounces of blood: calomel and other reme- dies were administered internally, and mustard poultices were applied to the soles of the feet. These remedies soon alleviated the symp- toms, but the relief lasted for but a very short time; the fever returned as intensely as before, convulsions came on again, attended with opisthotonos, and the child became comatose. Hemiplegia suc- ceeded ; the pupils became extremely contracted; complete loss of vision, and spasmodic twitching of the muscles of the face, soon fol- 1 Praktische Abhandlungen, etc., vol. i. Case 2. SIMPLE INFLAMMATION OF THE BRAIN. 99 lowed, and thirteen hours after the first convulsive seizure, in spite of most appropriate and energetic treatment, the little child died. "The vessels of the scalp were loaded with blood, and the skull was so intensely congested as to appear of a deep blue color. The sinuses were full of coagulated blood mixed with lymph, and all the vessels of the brain and its membranes were enlarged and turgid with blood. " A large quantity of coagulated lymph covered the convolutions of the brain and the corpus callosum like a false membrane, and fur- nished a delicate lining to the lateral ventricles, whose walls were softened and in part broken down. The ventricles contained about three ounces of turbid serum, and there was a considerable quantity of lymph at the base of the brain." As I have never seen an instance of this most rapid form of me- ningitis, I will draw for another illustration of it upon that valuable storehouse of facts, Dr. Abercrombie's work on Diseases of the Brain.1 "A child, aged 2 years, 21st May, 1826, was suddenly seized in the morning wTth severe and long continued convulsion. It left her in a dull and torpid state, in which she did not seem to recognize the persons about her. She had lain in this state for several hours, when the convulsions returned, and during the following night it recurred a third time, and was very severe and of long continuance. I saw her on the morning of the 23d, and while I was sitting by her she was again attacked with severe and long continued convulsion, which affected every part of the body, the face and the eyes in par- ticular being frightfully distorted. The countenance was pale, and expressive of exhaustion ; the pulse frequent. Her bowels had been freely opened by medicine previously prescribed by Dr. Beilby, and the motions were dark and unhealthy. Farther purging was em- ployed, with topical bleeding, cold applications to the head, and blis- tering After this attack she continued free from convulsion till the afternoon of the 23d; in the interval she had remained in a partially comatose state, with frequent starting; pulse frequent but feeble; pupils rather dilated; she took some food. In the afternoon of the 23d the convulsion returned with greater severity; and on the 24th there was a constant succession of paroxysms during the whole day, with sinking of the vital powers; and she died early in the evening " On removing the dura mater, the surface of the brain appeared in many places covered by a deposition of adventitious membrane betwixt the arachnoid and pia mater. It was chiefly found above the openings between the convolutions, and in some places appeared to dip a little way between them. The arachnoid membrane when detached appeared to be healthy, but the pia mater was throughout in the highest state of vascularity, especially between the convolu- tions; and when the brain was cut vertically, the spaces between the convolutions were most strikingly marked by a bright line of vivid redness, produced by the inflamed membrane. There was no effusiou in the ventricles, and no other morbid appearance." ' Case 10, p. 52. 100 SIMPLE INFLAMMATION OF THE BRAIN. It would not answer any useful purpose to multiply the recital of cases, since though there are great varieties in the duration of the disease, yet its general features are the same in almost every instance, and will, I think, readily be recognized by you as betokening an affection very different from ordinary hydrocephalus. The morbid appearances are sometimes found to vary both in their degree and in theif extent, without any corresponding difference being observed in the symptoms. With the exception of its course being more rapid, Golis's case differed but little from that recorded by Dr. Abercrombie. I believe that in the majority of instances the lining of the ventricles is affected; and it is certainly more common for the membranes at the base of the brain to be involved in the disease, than for it to be entirely limited to those at the convexity. It may also be doubted whether the membranes of the spinabcord are not also affected in the greater number of cases; but unfortunately the histories of but few post-mortem examinations contain complete details with reference to their condition. I have had the opportunity of examining five fatal cases of acute meningitis in infants or children, and in three of these there was not only abundant deposit of lymph on the surface of the convolutions, but it was effused copiously at the base of the brain; the ventricles contained turbid serum intermixed with flakes of lymph, and the membranes of the spinal cord were in- flamed, and coated in many parts with lymph and pus. In all of these three cases the children were under a year old, and the disease came on without any assignable cause, as it did also in the case of another little boy, aged 13 months. In that instance, however, no lymph was effused anywhere; the ventricles contained only a small quantity of transparent fluid, and the most remarkable appearance consisted in an intense injection of the pia mater of the convexity and of the surface of the convolutions for about two lines in depth, the cerebral substance in that situation being softened, so that portions of it were removed when the pia mater was stripped off. In another instance, where all the symptoms of encephalitis succeeded to an injury of the neck and head, the membranes at the convexity of the brain, and also the choroid plexuses and the velum interpositum, were intensely red; there was much effusion in the sub-arachnoid tissue; not much in the lateral ventricles, though their lining was considerably thickened. The substance of the brain was injected and much softer than natural, especially toward the centre of the organ and at its left side. In both of these cases the membranes at the base of the brain were perfectly healthy, but the spinal cord was not examined. I have seen two other cases in which I believe that inflammation existed of the membranes both of the brain and spinal cord, but in which I had no opportunity of making an examination after death. These seven cases constitute the whole of my experience in this for- midable disease. Acute inflammation of the brain or its membranes is fortunately of very rare occurrence in childhood, except as the result of fracture of the skull, or of injury to the head or neck. Exposure to the heat of INFLAMMATION BEGINNING WITHOUT THE SKULL. 101 the sun has been known to induce it; sometimes it comes on in chil- dren who are apparently recovering from scarlatina; and at other times it occurs without our being able to trace it to any definite cause. In the treatment of this affection, our remedies must be, in the main, the same as we should employ to combat the acute inflammation of any other vital organ. Bleeding, purgatives, mercurials, and the ap- plication of cold, are the grand means on which we must rely; and these must be used with an unsparing hand if we would have any chance of saving our patient. Our prospect of success, however, depends almost entirely upon our seeing the patient at the very out- set. The case which I quoted from Golis showed you what extensive mischief may occur in thirteen hours, and instances are on record in which a greater amount of injury has been discovered after a still shorter train of symptoms. Even in those cases which do not run this extremely rapid course, and in which the mischief found after death is not so considerable, there is little less need for speedy as well as active interference, for if life be prolonged for a day or two without the disease being overcome, the patient often sinks into an exhausted condition, in which active treatment can be no longer ventured on. Formidable though these cases are, yet, if seen early, and treated actively, they may be regarded more hopefully than those in which the brain and its membranes become inflamed in consequence of the extension to them of disease beginning without the skull. You will oc- casionally see instances of this occurrence in children who have suffered from scrofulous disease of the cervical vertebrae, when a life of suffer- ing is terminated by a most painful death; or inflammation of the brain, proving very quickly fatal, may come on in a child who has long had discharges from the ear, with occasional attacks of earache. Vague threatening of mischief in the head may perhaps have existed for some time, just sufficient to excite your apprehension, but not so serious nor so definite as to call for decided interference; and yet, when death takes place, you will find it almost impossible to reconcile the existence of lesions so extensive and of such long standing as a post-mortem examination discovers, with the long-continued absence of definite cerebral symptoms. In Dr Abercrombie's work on Diseases of the Brain,1 an account is o-iven of a boy, aged 14 years, who had been affected for two months with headache and discharge of matter from the right ear. A week before his death the pain increased, and was accompanied by great debility, giddiness, and some vomiting. He continued in this slate, without stupor or any other remarkable symptom, until the day ot his death, when he was suddenly seized with convulsions, and died An abscess was found in the middle lobe of the right hemisphere ot the brain, and another in the cerebellum, and there was extensive caries of the pars petrosa, with effusion of three ounces of fluid in the ventricles. . . , I have quoted this case in order to impress upon your minds that every, even the slightest, indication of cerebral disturbance is to be 1 Page 37 ; quoted from Mr. Parkinson, in London Med. Repository, March, 1817. 102 INFLAMMATION OF THE INTERNAL EAR. looked on with the greatest anxiety in children who have suffered from chronic otorrhoea. Your solicitude must be redoubled if the discharge from the meatus had ever been attended with the formation of abscesses at the back of the ear, or burrowing between the carti- lage and the bone, since they would render it extremely probable that caries of the bone had existed, and that the membranes of the brain had been reached by the advance of the disease. Inflammation of the brain occasionally supervenes on disease of the internal ear, even though there have been no actual exposure of the dura mater by destruction of the bone, and though attacks of otitis have not been of frequent occurrence. Attacks of otitis, indeed, are of importance, not merely on account of the occasional superventiou upon them of inflammation of the brain, but also on account of the severe suffering by which they are always attended. In many in- stances, too, needless alarm may be excited by the symptoms of in- flammation of the ear being supposed to betoken that the brain itself is the seat of the mischief; and hence it is very desirable to become familiar with the diagnostic marks that distinguish the less from the more dangerous affection. The name of Otitis has been applied to inflammation of very differ- ent parts of the organ of hearing, and in common parlance no adequate distinction has been drawn between the affection of the external audi- tory canal and that of the more deeply-seated parts of the ear, pos- terior to the membrana tympani. The earache of infants and young children is sometimes due to inflammation of one, sometimes of all, of these structures. It is more frequent in all its forms in early life than in adult age, and it is the more deserving of mention since the amount of suffering by which it is attended is by no means a certain criterion by which to judge of its importance. When limited to the external auditory canal, the inflammation, though apt to recur from slight causes, and though very painful, seldom leads either to perma- nent discharge from the ear, or to permanent impairment of hearing. Inflammation of the mucous membrane lining the cavity of the tym- panum, when occurring as an acute idiopathic affection, is usually associated with affection of the external auditory canal, and then often greatly aggravates the child's sufferings. It does, however, often run a comparatively chronic course attended with uneasiness rather than with severe pain, but which betokens the progress of mischief within the ear such as is likely to lead to abiding dulness of hearing. The deafness that follows measles and scarlatina is due to inflammation, which terminates in secretion of pus within the cavity of the tympa- num whence it escapes through the membrana tympani; a mischief either repaired as the inflammation declines by the closure of the opening, or rendered altogether incurable by the detachment of the bones of the ear. In strumous subjects, too, the evil which thus originated may become chronic, may involve the petrous portion of the temporal bone, and may thence eventually extend to the brain. The same result may also follow on long standing purulent discharge from the ear dependent on chronic inflammation of the external meatus; INFLAMMATION OF THE INTERNAL EAR. 103 and it is this circumstance which gives to otorrhoea in childhood its most grave significance. The full detail of the symptoms and management of these various affections comes rather within the province of the aural surgeon,1 than within mine. I must not, however, pass them entirely without men- tion. Attacks of earache are most frequent before the completion of the first dentition, and are by no means rare in young children who are perfectly unable to point out the seat of their sufferings. The attack sometimes comes on quite suddenly, but usually the child is fretful and languid for a period varying from a few hours to one or two days before acute pain is experienced. In this premonitory stage, however, it will often cry, if tossed or moved briskly, noise seems unpleasant to it, and it does not care to be played with; while chil- dren who are still at the breast show a disinclination to suck, though they will take food from a spoon. The infant seeks to rest its head on its mother's shoulder, or, if lying in its cot, moves its head uneasily from side to side, and then buries its face in the pillow. If you watch closely, you will see that it is always the same side of the head which it seeks to bury in the pillow, or to rest on its nurse's arm, and that no other position seems to give any ease except this one, which, after much restlessness, the child will take up, and to which, if disturbed, it will always return. The gentle support to the ear seems to soothe the little patient; it cries itself to sleep, but after a short doze, some fresh twinge of pain arouses it, or some accidental movement disturbs it, and it awakes crying aloud, and refusing to be pacified, and may continue so for hours together. Sometimes the external ear is red, and the hand is often applied to the affected side of the head; but neither of these symptoms is constant. The intensity of the pain sel- dom lasts for more than a few hours, when, in many instances, a copi- ous discharge of offensive pus takes place from the ear, and the child is well. In some instances, indeed, the subsidence of the disease on one side is followed by a similar attack on the opposite side, and the same acute suffering is once more gone through, and terminates in the same manner. Sometimes, too, this complete cure does not take place, but the earache abates, or altogether ceases for a day or two, and then returns; no discharge, or but a very scanty discharge, taking place, while, for weeks together, the child has but few intervals of perfect ease. In infants, earache seldom follows this chronic course, though I have occasionally seen it do so in older children; and the disease is in these cases seated within the cavity of the tympanum. In children who are too young to express their sufferings by words, the violence of their cries/coupled with the absence of all indications of disease in the chest or abdomen, naturally lead to the suspicion of something being wrong in the head. There are three circumstances, however, which may satisfy you that the case is not one of ordinary hydrocephalus; the child does not vomit, the bowels are not consti- 1 Two papers by Mr. Toynbee may be consulted with advantage ; the one a pamphlet on Otorrhoea and Otitis, the other, in vol. xxxiv. of Med.-Chir. Transactions, on " Those affections of the ear which produce disease in the brain." 104 TREATMENT OF OTITIS. pated, and there is but little febrile disturbance. The loud and pas- sionate cry, the dread of movement, and the evident relief afforded by resting one side of the head, are evidences of the ear being affected; while in many instances the movement of the hand to the head, and the redness of the external ear, with the swelling of the meatus, con- cur to make the diagnosis easy. Sometimes, when in doubt, you will be able to satisfy yourselves that the cause of suffering is in the ear by pressing the cartilages of the organ slightly inwards, which will produce very evident pain on the affected side, while, if practised on the other side, it will not occasion any suffering. The treatment of this painful affection is very simple. In many instances the suffering is greatly relieved by warm fomentations, or by applying to the ear a poultice of hot bran or chamomile flowers. A little oil, to which some laudanum has been added, may be dropped into the ear, and repeated from time to time; while if the pain be extremely severe, or have continued for several hours, it may be wise to apply a few leeches to the mastoid process. If the earache return frequently, a small blister should be applied behind the ear, or slight vesication may be produced by means of the acetum cantharidis. The possible supervention of inflammation of the brain must of course be borne in mind, and any indication of its approach must be immediately combated; but fortunately this occurs less frequently as a complication of otitis than as a sequela of long-continued purulent discharge from the ear, which has probably been attended with con- stant though not very severe pain in the head. A little boy, four years old, was for some time under my care, who had suffered for eighteen months from purulent discharge of a very offensive character from both ears. After this discharge had continued for six months, an abscess formed behind the left ear, which, on being opened, gave issue to lij ot very fetid pus. A month afterwards a large portion of the mastoid process of the left temporal bone was exfoliated, and for several weeks after this occurrence the left side of the face was fre- quently thrown into a state of twitching movement, which showed that some of the branches of the portio dura had been involved in the disease. This symptom disappeared after the lapse of nine months, but the discharge continued as fetid as ever, though much more pro- fuse from the right than from the left ear; and long after the abscess had ceased to discharge, a fistulous opening still continued leading down to the diseased bone, and the little boy was in almost constant suffering from headache. Sometimes the pain was very severe, and quite prevented his sleeping, and then it abated for several days or weeks without any evident cause. On giving up my appointment at the Children's Infirmary, I lost sight of the child ; there can, however, be little doubt but that sooner or later an acute attack of inflammation of the membranes of the brain will come on, and prove quickly fatal. In those cases where offensive puriform discharge from the ear has been of long continuance, and the matter is sometimes tinged or streaked with blood, astringent injections must be used only with the greatest care, while their employment is not at all advisable if exfolia- tion of bone have taken place, since in such a case not only is the INFLAMMATION OF SINUSES OF DURA MATER. 105 internal ear disorganized, but the dura mater has very probably become exposed. Attention to cleanliness, by frequently syringing out the ear with warm water, or with a solution of gr. j or gr. ij of the acetate of lead in an ounce of water, constitutes all the topical treatment on which it would be safe to venture, while the most sedu- lous attention must be paid to the general health of the patient. It still remains for me to no.tipe one singular form of cerebral dis- ease, which, though not confined to children, is seen much oftener among them than among adults; namely, phlebitis of the sinuses of the dura mater. In grown persons it usually succeeds to some injury of the head, but in the child it has generally been observed as a conse- quence of long-continued purulent otorrhoea, combined with disease of the temporal bone, or it has been connected with disease of the frontal sinuses, or has followed an abscess of the scalp. In one or two instances, also, it has seemed to be excited by the presence of large collections of pus in distant parts of the body. M. Tonnele, who has written a very valuable paper on inflammation of the sinuses of the dura mater in children,1 records one instance in which it coincided with a pleuritic effusion ; and a somewhat similar case has come under my own notice, which I will relate, partly on account of its rarity, partly because it illustrates exceedingly well the morbid appearances observed in cases of this description. A healthy little girl was attacked by scarlatina when eight months old. The attack was not severe, but, after it had passed away, she did not regain her previous health, but continued restless and feverish; she was sometimes sick, and her eyelids were often slightly swollen. A fortnight after the rash appeared, she had one or two violent con- vulsive seizures, but they ceased after her gums were lanced, and did not appear to be in any way connected with her subsequent illness. She continued out of health until she was ten and a half months old, when her mother noticed, in addition to the puffiness of the eyelids, a swelling of the legs and abdomen, for which she came under my care when eleven months old. The legs were then very oedematous, and fluctuation was distinctly felt through the parietes of the abdomen, the urine being scanty and high-colored. In the course of about three weeks her condition had improved considerably, the urine having increased much, the anasarca having greatly diminished, and the abdo- men being one inch and a half less in circumference. A fit of con- vulsions now came on without any apparent cause, but no other symptoms of cerebral mischief followed it, and the convulsions did not return. After the lapse of another week a discharge of sero- purulent fluid took place from the umbilicus, and continued for several days in quantities of from a quarter to half a pint daily. This dis- charge was attended with an improvement rather than a deterioration in the child's health; but after it had continued for eleven days, fever and dyspnoea suddenly came on, with dulness on percussion over the right side of the chest, and absence of respiratory murmur in that situation. The discharge ceased for a week during the urgency of the Journal Hebdomadaire, vol. v. p. 337. 1825. 106 INFLAMMATION OF SINUSES OF DURA MATER. thoracic symptoms, but then reappeared, though scantily. The child now grew thinner and weaker, and sank into a state of hectic. No new symptoms came on till she was suddenly seized with extreme faintness, amounting to almost perfect syncope. She rallied, how- ever, under the use of stimulants, but forty-eight hours afterwards the faintness returned, and terminated in death, without any convulsion having preceded it, just five months and a half after the attack of scarlatina, and two months after she came under my care. On an examination of the body after death, pleurisy of the right side was discovered, with about 3yj of pus in the right pleura, and peritonitis, with Oiij of pus in the abdomen; the passage being still traceable through which the fluid had escaped at the umbilicus. The dura mater adhered firmly to the skull, along the posterior half of the longitudinal sinus, at the torcular Herophili, and along the left lateral sinus; but elsewhere it was easily detached from the cranium. The sinuses on the right side were healthy, but the blood within them was almost entirely coagulated. The posterior half of the longi- tudinal sinus, the torcular, the left lateral and left occipital sinuses, were blocked up with fibrinous coagulum, precisely such as one sees in inflamed veins, and the clot extended into the internal jugular vein. The coats of the longitudinal and of the inner half of the lateral sinus were much thickened, and their lining membrane had lost its polish, was uneven, and presented a dirty appearance. There was some congestion of the arachnoid, a considerable quan- tity of fluid in the ventricles, and sections of the brain presented more bloody points .than natural, especially on the left side. The base of the brain was perfectly healthy on the right side, but there was great venous congestion beneath the middle lobe of the hemisphere; the cerebral veins in that situation were distended with coagulum, and their coats were thickened. Towards the anterior part of the left middle lobe were four apoplectic effusions, in all of which the blood retained its natural color. Each of these effusions was connected with an obstructed and distended vein. The largest clot extended an inch into the substance of the brain ; the others were of smaller extent. I cannot speak to you of any symptom as pathognomonic of this oc- currence; it usually comes on, as in this instance, in much debilitated children, and though it generally follows some injury or disease in the neighborhood of the brain, you will bear in mind the possibility of its occurrence whenever large collections of pus exist in any part, and will draw a very unfavorable prognosis in the event of head'symp- toms coming on in such circumstances. CHRONIC HYDROCEPHALUS. 107 LECTURE IX. Chronic Hydrocephalus—various conditions under which fluid collects in the skull —divided into the external and the internal—symptoms of both nearly identical —changes in form and size of the head—and their mode of production—course of the disease—termination almost always fatal. Inteunal Hydrocephalus—important questions involved in its pathology—frequent connection with malformation of brain—but also follows inflammation of lining of ventricles—description of post-mortem appearances—case illustrative of its connection with inflammation—process of cure usually mere arrest of disease. External Hydrocephalus—circumstances in which it exists—its relation to hemor- rhage into the arachnoid. Treatment of both forms of the disease. Importance, but difficulty, of distinguishing curable and incurable cases—Golis's plan—Com- pression—Puncture—Cases suited for each mode of treatment. We have now completed our examination of the acute inflammatory affections of the brain, and with them we may consider that we have dismissed the most important class of diseases of that organ. Before we pass, however, to those in the production of which inflammation bears no part, we must study one malady which forms a kind of con- necting link between the two. Chronic hydrocephalus, or dropsy of the brain, is a morbid condition met with in children at various ages, and coming on in a great variety of circumstances. Sometimes it is congenital, and is then often, though by no means invariably, associated with malformation of the brain. In subsequent childhood, an excess of blood in the brain, or its defi- ciency, or the existence of some impediment to the circulation through the organ, are conditions all of which have been found to give rise to the effusion of fluid into the cavities of the brain, or upon its sur- face. Instances of chronic hydrocephalus are on record, which have succeeded to hemorrhage into the sac of the arachnoid; others, that have been connected with wasting of the brain, in consequence of the supply of blood being inadequate to its due nutrition, or in which obliteration of the sinuses by disease, or the pressure of a morbid growth upon some of the vessels of the brain, has interfered with the due performance of the cerebral circulation. In many cases, however, I believe, as do MM. Eokitansky and Vrolik,1 that the disease is not a mere passive dropsy, nor simply a consequence of arrested cerebral development, but that it is the result of a slow kind of inflammation of the arachnoid, especially of that lining the ventricles, which may have existed during foetal life, or may not have attacked the child until after its birth. 1 Rokitansky, Pathologische Anatomie, vol. ii. p. 754 : Vrolik, Handboek der Ziek- tedundige Ontleedkunde, Amsterdam, 1840, 8vo., p. 514-5.57. 108 SYMPTOMS OF CHRONIC HYDROCEPHALUS. According to the situation in which the fluid collects, a division has been made of chronic hydrocephalus into the external and the internal; the former term being applied to cases in which the fluid collects in the sack of the arachnoid; the latter, to those in which it accumulates in the ventricles of the brain. The two conditions sometimes coexist, but generally they are independent of each other; the internal hydro- cephalus being the more frequent and the more important. To it, therefore, we will first direct our attention, premising, however, that the symptoms of the two varieties are so nearly identical that internal hydrocephalus has often been supposed to exist in cases where an examination after death has ascertained that the fluid was in reality situated external to the brain. The early symptoms of the disease vary. When it is congenital, indi- cations of cerebral disturbance are generally apparent from the infant's birth. These are sometimes serious; such, for instance, as convulsions, recurring almost daily; at other times, they are comparatively slight, and consist in nothing more than strabismus, or a strange rolling of the eyes unattended by any very definite sign of affection of the brain. The size of the head generally attracts attention, before long, and causes importance to be attached to symptoms which otherwise might have given rise to but little anxiety. In some instances, however, the increased size of the head is not very obvious until the child is a few weeks old, although well-marked symptoms of mischief in the brain existed from its birth. Enlargement of the head, indeed, is by no means invariably the first indication of chronic hydrocephalus. In 12 out of 45 cases, fits, returning frequently, had existed for some weeks before the head was observed to increase in size; in 6, the enlargement of the head succeeded to an attack resembling acute hydrocephalus; and in 4 other instances, it had been preceded by some well-marked indication of cerebral disturbance. In the remain- ing 23 cases, no distinct cerebral symptom preceded the enlargement of the head; but in almost every instance the child's health had been noticed to be failing for some time, although the cause of its illness was not apparent. In whatever way the disease begins, impairment of the process of nutrition is sure to be one among its earliest symptoms. The child may suck well, and, indeed, may seem eager for food, but it loses both flesh and strength; and often, although the head has not yet attained any disproportionate size, the child is unable to support it, either losing the power it had once possessed, or never attaining that which, with its increasing age, it ought to acquire. The bowels are usually, though not invariably, constipated. Sometimes diarrhoea comes on for a day or two; but, under either condition, the evacuations are almost always of an unhealthy character. Thus far, indeed, there is but little to distinguish the case from any other in which a young in- fant is imperfectly nourished; but, even though no well-marked cere- bral symptom be present, occasional attacks of heat of head will be observed, attended with pulsation or tension of the anterior fontanelle, while crying and restlessness often alternate with a drowsy condition, though the child almost always sleeps ill at night. In many instances, CHANGES IN THE FORM OF THE SKULL. 109 too, the open condition of the fontanelles and sutures excites attention long before any enlargement of the head becomes perceptible., By and by, however, the increased size of the head grows very manifest, and the child's physiognomy soon assumes the distinguish- ing features of chronic hydrocephalus. As the disease advances, the unossified sutures become wider, the fontanelles increase in size, their angles extend far into the sutures in which they terminate, while the fluid, pressing equally in all directions, tends to impart a globular shape to the receptacle in which it is contained. Some of the casts upon the table afford striking illustrations of this change in the form of the cranium, which would be still more remarkable were it not for the very unequal resistance of different parts of its parietes. The bones at the vertex of the skull are much less firmly fixed than the others, and ossification is nowhere so tardy as at the anterior fon- tanelle, and along the inner edges of the parietal bones. Hence it results that the great increase in the size of the head is effected by enlargement of the anterior fontanelle, and by widening of the sagit- tal suture. The os frontis consequently becomes pushed forwards, the parietal bones are driven backwards and outwards, and the occi- pital bone downwards and backwards. The displacement of the bones is very obvious in this hydrocephalic skull, but it is still more striking in the two engravings which I here show you.1 You notice the great prominence of the forehead, and the alteration in the position of the parietal bones, which are driven backwards as well as outwards, so that the natural relations of their protuberances are altogether changed; while in this remarkable case of a man named Cardinal, who, though hydrocephalic from his infancy, lived to the age of twenty- nine years, the occipital bone lies almost completely in a horizontal position. You will observe, too, another remarkable alteration pro- duced by the yielding of the orbitar plates of the frontal bone, which are driven by the accumulating fluid from a horizontal into an oblique direction. Sometimes, indeed, they become nearly perpendicular, when, by contracting the orbits, they give to the eyeballs that un- natural prominence, and that peculiar downward direction, which constitute one of the most remarkable features in cases of chronic hydrocephalus. Few objects are more pitiable than a little child who is the subject of far-advanced chronic hydrocephalus. While the skin hangs in wrinkles on its attenuated limbs, the enlarged head appears full, almost to bursting, owing to the stretching of the scalp; and the scanty growth of hair does not at all conceal the distended veins that run over its whole surface. The size of the skull, too, appears greater than it really is, since the face not only does not partake of the en- largement, but retains its infantile dimensions much longer than natu- ral. The eyes are so displaced by the altered direction of the orbitar plates that the white sclerotica projects below the upper lid, and the iris is more than half hidden beneath the lower. Often, too, there is 1 Baillie's Morbid Anatomy, fasc. x. plate iii. fig. 1, and the drawing of Cardinal's skull, in Bright's Reports, vol. ii. part 2, plate xxxv. 110 PATHOLOGY OF CHRONIC INTERNAL HYDROCEPHALUS. a considerable degrSe of convergent strabismus, or a constant rolling movement of the eyeball, which the child is unable to control; or the pupil is dilated, and quite insensible to light. The symptoms of cerebral disturbance that attend the advance of the disease differ much in severity. Sometimes there is little besides a state of uneasiness and restlessness, aggravated at intervals when the head grows hot and the fontanelle becomes tense. In other cases convulsions occur very frequently being induced by extremely slight causes, or coming on without any. In several instances I have ob- served spasmodic attacks of difficult breathing, attended with a crow- ing sound in inspiration, and those symptoms which constitute spasmodic croup, seizures of which sometimes come on even before there is much enlargement of the head. But, whether the cerebral symptoms are. slight or severe, almost every case of chronic hydro- cephalus has pauses in its course, during which the child seems to enjoy a comparative immunity from suffering, and gains flesh, while its head ceases for a time to enlarge. Nothing, however, can be more variable than the frequency of these pauses, or their duration. Though almost every case of chronic hydrocephalus is fatal, yet death takes place in very different ways. Children who are the sub- jects of the disease are almost always very weakly: hence, they often give way under the first serious illness that attacks them, and are carried off by maladies totally unconnected with their head affection; while many others sink into that state of atrophy by which the dis- ease of the brain is often accompanied, and die exhausted. Others are carried off'suddenly by convulsions, or fall victims to some severe paroxysm of spasmodic croup: and there are other instances in which the disease seems lighted up again after a pause, by the irritation of teething, or by some trivial accident, and death is preceded by the indications of acute cerebral mischief. The pathology of chronic internal hydrocephalus involves questions not merely of scientific interest, but of great practical moment; for if we come to the conclusion at which some observers of high autho- rity have arrived, that it is almost invariably the effect of arrest of the development of the brain, all therapeutical proceedings must be worse than useless. The early date of the occurrence of its symptoms, in the great majority of cases, lends support, indeed, to the opinion that the causes to which it is due must generally have existed before birth; for I find, on examination of the history of 54 cases, 18 of which came under my own observation, that some indications of it were observed in 50 of this number, before the child was six months old; that in 14 of these its symptoms existed from birth; and that in 21 more, they appeared before the completion of the third month. The knife of the anatomist, too, has discovered evidences of congenital malformation of the brain, in some instances in which no sign of hydrocephalus was apparent until several weeks after the child's birth: a fact which still further deepens the dark colors in which this malady has been portrayed. Still, large as is the proportion of cases in which symptoms of chronic hydrocephalus have existed from birth, I am disposed to INTERNAL HYDROCEPHALUS —MORBID APPEARANCES. Ill believe the exceptions to this not to be so extremely rare as some imagine, and am further of opinion, that, even in cases of congenital hydrocephalus, inflammation of the lining of the lateral ventricles, such as produces it after birth, may, in some instances at least, have excited it during foetal life. In seven post-mortem examinations of children affected with chronic internal hydrocephalus, who died at the respective ages of 16 months, 3 years, 8 months, 19 months, 2 years, 3£ and 3| years, I found the corpus callosum perfect in every instance. In all, also, the fornix was present; thrice it and the septum lucidum were thickened and tough; twice they were found torn and softened, acute hydrocephalus having supervened on the chronic disease. Once the septum lucidum was absent, and once both it and a large portion of the fornix also were wanting. In one case the state of the membranes lining the ventricles was not noted ; in the other six it was thickened, four times very remarkably; and twice it was roughened and granular, a condi- tion which is also occasionally to be seen in fatal cases of acute hydro- cephalus. With the exception of one instance, in which the accumulation of a large quantity of fluid in the ventricles coexisted with a cancerous tumor of the brain, the above cases constitute the whole of my expe- rience of the post-mortem appearances of chronic internal hydroce- phalus ; and they certainly tend to support the opinion that its con- nection with inflammation of the lining of the ventricles is of less rare occurrence than some observers have supposed. The granular condi- tion of the arachnoid lining the ventricles varies from a very slight degree, in which it is perceptible only in certain lights, and scarcely conveys a sense of roughness to the finger, to an unevenness as marked as that of shagreen, or even to a condition in which the granulations, still retaining their transparency, become distinct, slightly prominent, flattened bodies, a third of an inch or more in diameter, as I once observed them to be; or even acquire, as Professor Eokitansky says,1 distinct pedicles, and hang down into the cavity of the ventricles. These granulations are, as far as I know, usually associated with traces of inflammation of the arachnoid at other parts, while they are met with in cases where the ventricles contain no excess of fluid, and in adults as well as in children,2 and are far from being necessarily con- nected with the evidences of tubercular disease either in the brain or in other parts of the body. My friend, Dr. Ormerod, has kindly com- municated to me the particulars of six cases in which he observed this granular state of the lining membrane of the ventricles in the adult; and in every instance it was associated with other indications of old inflammation of the arachnoid. More recently, too, my friend and colleague, Dr. Kirkes, from his large opportunities of observation at St. Bartholomew's Hospital, has furnished me with an account of 24 cases, in 20 of which the subjects were adults, the lining of whose ventricles presented this granular condition in a more or less marked 1 Pathologische Anatomie, vol. ii. p. 748. 2 The condition was, I believe, first noticed by Dr. Bright in his Medical Reports, vol. ii. part 2, p. 693. 112 INTERNAL HYDROCEPHALUS—MORBID APPEARANCES. degree. In every instance it was associated with other morbid appear- ances in the brain; and in 16 of the number the most important of these appearances were such as indicated the arachnoid in other parts to have been the seat of inflammation.1 In some cases—as, for instance, in this drawing by Professor Vrolik2 of the brain of a young man who died of chronic hydroce- phalus at the age of 20—a false membrane is found in the interior of one or other ventricle, and may even occlude the foramen of Monro; an accident which, by interrupting the communication between the two sides of the brain, may serve to account for the unequal disten- sion of the two ventricles, and the great want of symmetry occasionally observed in hydrocephalic skulls. The marks of inflammation of the membranes at the base of the brain are, moreover, in many instances, very evident; and there is often an extremely abundant effusion of that hyaline matter in the meshes of the pia mater, to which I called your attention when speaking of acute hydrocephalus. Lastly, I may remark, that the observation, in a large number of instances, that the cerebral substance has been simply unfolded by the accumulation of the fluid in the ventricles, so that even when of extreme tenuity the gray and white matter could still be distinguished, proves not merely that the brain was not melted down by the action of the fluid, but also that its accumulation could not, in these instances, be due to the arrest of cerebral development. Besides the evideiace which post-mortem examinations often furnish of the connection of chronic internal hydrocephalus with previous inflammatory action, the history of the patient's illness sometimes affords distinct proof of its occurrence. A striking instance of this has been published by M. Eilliet, of Geneva,3 in the case of a little girl 10? years old, in whom the symptoms of acute cerebral inflam- mation were succeeded by those of chronic disease in the brain which terminated fatally at the end of four months. Ten ounces of transpa- rent but highly albuminous fluid were contained in the lateral ventri- cles, the lining membrane of which was nearly half a line thick, having a gelatinous appearance, as if softened, but being in reality so tough that it could be torn away from the cerebral substance in long strips. Though in the following history the connection between the acute and the chronic evil is far less striking than in M. Eilliet's case, yet I think few will refuse to admit the injury to the head and the subse- quent cerebral symptoms as the first steps in the chain of morbid processes which led to the distension of the ventricles of the brain with fluid, and to the development of all the symptoms of chronic hydrocephalus. 1 Of the 34 cases on which the above statements are founded, 8 occurred in children under 10 years old; the remainder in persons of 18 and upwards. In 11 instances, 6 of which occurred in children, the granular condition of the lining of the ventricles was associated with tubercular disease of the brain or its membranes ; and in two others tubercle was deposited in other organs ; but in the remaining 21 cases neither of these complications existed. 2 Traite sur la Hydrocephalie Interne, 4to. plate iii. Amsterdam, 1839. 3 Archives Gen. de Medecine, Dec. 1847. INTERNAL HYDROCEPHALUS—MORBID APPEARANCES. 113 A little girl, the child of healthy parents, was healthy when born, and continued so until she was five months old, when she fell out of the arms of the person who was nursing her, and on the same day was taken in a fit, and lay stupid and senseless for some hours. She was leeched and blistered for these and other head symptoms which the parents were unable to describe very accurately, and to all appear- ance recovered. When a year old, however, head symptoms returned, and for several weeks convulsions were of extremely frequent occur- rence; but at length ceased. About that time, the child being then fif- teen months old, her mother first noticed that her head was beginning to enlarge, since which time she had had no return of fits, but the head continued to increase in size down to the time when I first saw her, she being then just three years old. Her countenance presented all the peculiarities of chronic hydro- cephalus in a very marked degree: her head was large, measuring 20 inches in circumference, and 13J from one meatus auditorius to the other; her forehead was prominent, and her eyes were directed down- wards, while her body was very ill nourished. Her bowels were regular, her bodily functions generally natural, and she was very voracious. She was by no means stupid, but on the contrary showed much shrewdness, though she was noisy and almost constantly chattering. I had not seen her above once or twice, when she was attacked by measles, on the second day of which convulsions came on, and she sank into a comatose state interrupted only by convulsive twitchings of the limbs, and died in this condition on the fourth day of her illness. The head was examined 48 hours after death. The bones of the head were quite firm and hard; the posterior fontanelle was closed, but the anterior was open ; its diameter in either direction being about 3J inches. There was no fluid in the sac of the arachnoid, nor morbid condi- tion of the membranes either at the vertex or base of the brain. A very small quantity of fluid was in the subarachnoid tissue and a pint of perfectly transparent serum in the lateral ventricles. The convolutions of the brain were quite flattened : its cortical sub- stance was of natural thickness, the white substance very thin, and expanded around the ventricles, which were dilated to four times their natural size. The white substance of the wall of the ventricles was quite firm, and separable into a thin tough layer, leaving the substance of the brain quite natural beneath. The septum lucidum was tough and membranous, and much thickened. The edges of the fornix were firmly adherent to the upper surface of the optic thalamus, and in- cluded between them a portion of the choroid plexus. The membrane lining the ventricles was universally thickened; where it covered the corpora striata, the optic thalami, the commis- sures, and the floor of the fourth ventricle, it was not only peculiarly tough, but granular, and presented an appearance just like shagreen. The size of the head in this case had been increasing but slowly, and probably, had the child not been cut off by the intercurrent attack 8 114 EXTERNAL HYDROCEPHALUS. of measles, the effusion of fluid would at length have come to a stand still, and the hydrocephalus would have been cured; at least, as much as hydrocephalus usually is. Strictly speaking, however, there is in general no cure of the affection, but merely an arrest of its progress; no more fluid is poured out, but that already effused is unabsorbed; the sutures and fontanelles become ossified, and the enormous size of the head attracts less attention, not because there is any diminution in its dimensions, but because the disproportion between the cranium and the face becomes less striking, owing to the development of the latter as the child grows older. In some instances, indeed, Professor Otto1 is of opinion that a real cure is effected by an increased activity of the "nutrition of the brain producing hypertrophy of the organ; the fluid being absorbed, and nerve matter deposited in its stead. This, however, is in all probability a purely exceptional occurrence; and the majority of hydrocephalic patients who survive the advance of the disease still have their lateral ventricles distended with fluid. This was all that occurred in the well-known case of Thomas Cardi- nal, whose bust I here show you. Having been hydrocephalic from infancy, he yet lived to the age of 29, in the possession of a tolerable amount of bodily and mental activity. On examination of his body after death, between seven and eight pints of fluid were found in his cranium. In the greater number of instances symptoms exist during life which show clearly enough that the arrest of the disease differs widely from its cure, or that the malady of the brain which it pro- duces, or with which it was associated, is irreparable; for the intellec- tual powers are generally feeble, and the temper very irritable, while the child is often unable to walk, and its sight is very imperfect. The presence of a large quantity of fluid in the sac of the arach- noid, constituting what is called external hydrocephalus, may arise from several causes. 1st. The commissures of the distended brain may yield, and a portion of the whole of the fluid which it contains may escape into the cavity of the cranium. This seems to have taken place in the case of Cardinal, whose skull contained seven or eight pints of fluid, while "the brain lay at its base, with its hemispheres opened outwards like the leaves of a book."2 2d. An atrophied condition of the brain may exist, and fluid may be poured out to fill up the vacuum thus produced in the skull; and such cases are generally of a very hopeless kind, the defect of cerebral development being almost always the result of congenital malforma- tion or of intra-uterine disease. 3d. A large quantity of fluid is sometimes found in the sac of the arachnoid, as the result of hemorrhage into its cavity, and of the changes subsequently undergone by the effused blood. MM. Eilliet and Barthez, who have most ably investigated the subject of hemor- rhage into the arachnoid, believe that chronic hydrocephalus frequently has this origin. I have seen a few cases which I suspect were of this 1 Rokitansky's Pathologische Anatomie, 1st ed. vol. ii. p. 749-769. 2 Bright's Reports, vol. i. part 1, p. 433. TREATMENT OF CHRONIC HYDROCEPHALUS. 115 nature, but have never had the opportunity of confirming ray suspi- cion by a post-mortem examination. In cases of this last kind, more may be expected both from nature's own reparative powers, and from the resources of art, than in any other form of chronic hydrocephalus. Unfortunately, their symptoms, as I have stated at the beginning of this lecture, so closely resemble those of the other less hopeful varieties of the disease, that their diag- nosis is attended by much difficulty and uncertainty, and must be founded, in great measure, on the previous history of the patient. " It is never congenital, but generally begins about the tenth month ; that is to say, about the time when the teeth begin to appear. The head, indeed, enlarges gradually, but does not acquire so large a size as in internal hydrocephalus: while, lastly, it is always preceded by repeated convulsions, or by some other form of active cerebral dis- turbance, which marks the date of the occurrence of hemorrhage.'" The observation has often been made, that the reputed means of cure of any disease are generally numerous in a directly inverse proportion to its curability; and to this rule chronic hydrocephalus certainly forms no exception: "Its remedies have been derived," as Golis says, "from all the kingdoms of nature, and include almost every kind of surgical contrivance and pharmaceutical compound." It would be an almost endless task to attempt estimating the comparative value of them all; and I think it more useful to direct your attention to a few points of real importance. First of all, I would have you bear in mind that there are some cases in which you can do no permanent good, but in which treatment must fail, not because it is improper, but because the malady does not admit of cure. Such cases are those in which the accumulation of fluid within the brain is associated with extensive congenital disease, or malformation of the organ. If aware of its existence, our treatment would, of course, be simply palliative, and our efforts would be limited to securing euthanasia, since we could not hope to avert death. We should suspect the affection to be incurable, if, though the head were large, and its ossification very imperfect, the forehead were low and shelving; if a considerable degree of paralysis were present, if con- vulsions occurred daily and causelessly, and especially if these or other indications of serious cerebral disorder had existed almost from birth. Unfortunately, these hopeless cases are by no means invariably characterized by peculiar symptoms, and the amount of functional disturbance often affords but a very incorrect index to the extent of organic lesion: your prognosis, therefore, must always be most guarded, and even when you see every reason to expect success, you must yet be prepared for failure. On the other hand, you must not regard a case as hopeless, and abstain from remedial measures, merely on account of the head having been larger than natural at birth, or its ossification having been less advanced than usual, since we have evidence of perfect recovery from 1 Legendre, Recherches Anatomo-pathologiques, p. 135. See also Rilliet et Barthez, op. cit., 2d ed., vol. ii. p. 259. 116 GOLIS'S PLAN —COMPRESSION OF THE HEAD. chronic hydrocephalus in cases where many circumstances had ap- peared to indicate that the disease was congenital. The state of the cerebral functions must influence your prognosis as much as the size of the head, or even more. In either form of chronic hydrocephalus, the success of treatment must depend, to a great degree, upon its being adopted early, but in no stage of the disease can good be expected from violent remedies; rough measures would be likely to destroy the patient rather than the malady. I do not know of any plan, on the whole, more likely to be of service, than that which Professor Golis, of Vienna, recommended as the result of many years' experience. He advises that the head of the child be shorn, or its hair cut close, and that one or two drachms of the mild mercurial ointment be rubbed daily into its scalp. At the same time, the head is to be kept constantly covered with a flannel cap, to prevent the risk of the perspiration being checked by the cold air, and gr. \, or gr. ss of calomel, should be given twice a day, unless diarrhoea come on, when the inunction alone must be employed. This plan should be persevered in for thirty or forty days, when, if the patient appear improving, the remedies may be very gradually dimi- nished, but the cap should be still worn even after the inunction has been discontinued. Should no great improvement appear after a lapse of six or eight weeks, some mild diuretic may be conjoined with the other remedies, and a couple of issues may be inserted in the occiput. For this measure, however, I have always substituted the frequent application of blisters to the back of the neck. The woollen cap, recommended by Golis, often seems agreeable to the child, but sometimes I have had to discontinue it, in consequence of the heat of head which it produced. In most cases, too, you will be compelled to resort to occasional leeching, in order to subdue the attacks of heat of head and restlessness, which are exacerbated from time to time, and often attended with other symptoms that threaten the supervention of acute disease. The observation that in some cases where the spontaneous cure of chronic hydrocephalus takes place, the ossification of the head, pre- viously so imperfect, makes rapid advances, and the bones become early united, led Mr. Barnard,1 of Bath, to imitate nature's processes, and to bandage the head so as to prevent its yielding to the accumu- lating fluid. He has related several cases of the successful adoption of this practice, though, like many other persons, he rides his hobby rather too hard, and advocates his mechanical method to the exclusion of all other treatment. It is, however, a valuable adjunct to other treatment in some cases. Unless you apply it well it will be of little service, and the plasters by which the compression is exerted will come off. You cannot do better than follow M. Trousseau's rules for their application.2 He uses strips of diachylon plaster about one-third of an inch broad; and applies them: 1st, from each mastoid process to the outer part of the orbit of the opposite side; 2d, from the hair 1 Cases of Chronic Hydrocephalus, &c, by J. H. Barnard, 8vo., London, 1S39. 2 Journal de Medecine, April, 1843. PUNCTURE OF HEAD IN CHRONIC HYDROCEPHALUS. 117 at the back of the neck along the longitudinal suture to the root of the nose; 3d, across the whole head, in such a manner that the differ- ent strips shall cross each other at the vertex ; 4th, a strip is cut long enough to go thrice round the head. Its first turn passes over the eyebrows, above the ears, and a little below the occipital protuber- ance, so that the ends of all the other strips shall project about one- fourth of an inch below the circular strip. These ends are next to be doubled up on the circular strip, and its remaining two turns are then to be passed over them just in the same direction as the first turn. By this means you secure a firm, and equal, and very powerful pressure on the head. You must watch the results of this proceeding very carefully, and loosen the plasters if symptoms of compression appear, since it once happened to M. Trousseau, from neglect of this precaution, that the fluid acted on the base of the skull, detaching the ethmoid bone from its connections, and thus occasioned the infant's death. You will naturally inquire whether pressure is applicable to every case; and, if not, when it should be employed ? I regret that I can- not answer these inquiries so satisfactorily as I could wish. It is my belief, however, that cases of external hydrocephalus, which have suc- ceeded to previous hemorrhage into the arachnoid, will be found better adapted than any others to treatment by mechanical means; while I am quite sure, from actual experience, that when there is any appear- ance of active cerebral disease, pressure will not do good. Puncture of the cranium, and the evacuation of the fluid, is an- other proceeding which has been occasionally resorted to from a very early period in the history of medicine, and which is even at the pre- sent day strongly advocated by some writers; not merely as a pallia- tive measure, or as an adjunct to other remedies, but as a means of effecting the radical cure of the disease. Opinion, however, is much divided as to the propriety of this practice, the statistics of which certainly do not yield any very encouraging results. Fifty-six cases, the particulars of which I published some years ago,1 as I found them recorded in various publications, yielded a proportion of fifteen alleged recoveries; but on subjecting these cases to a rigid analysis, it appeared that in only four of this number were the particulars recorded with sufficient accuracy, or had the interval since the per- formance of the operation been long enough, to warrant our admitting them as permanent cures. The very unfavorable conclusions which I then expressed with reference to this operation were afterwards criti- cized by M. Durand-Fardel,2 a gentleman whose opinion on any ques- tion connected with cerebral disease is entitled to very great weight. He observed that, while it is admitted that in a few cases puncture of the cranium has been followed by complete and permanent cure, its failure on other occasions was often manifestly due to the existence of utterly incurable malformation of the brain; while in many instances, though the operation failed to effect a cure, yet the very frequency 1 In the Medical Gazette, April, 1842. 2 In the Bulletin Generale de Therapeutique, vol xxiii. p 190. 118 CASES SUITED FOR PUNCTURE. with which it was repeated proved that in itself it is not usually at- tended with any considerable danger. Since, then, it may do good— since, if it should fail, its failure is often due to causes which no remedy could remove—since, even if it should do no good, yet in the majority of instances it will do nO harm, while if left to itself the course of the disease is almost invariably to a fatal result, he advo- cates its performance in cases of chronic hydrocephalus. Though I cannot but fear that this gentleman rather underrates the amount of immediate risk attendant on the operation, yet I think that his autho- rity ought at least to have so much weight with you as to prevent your looking upon its performance as altogether unjustifiable, and the rather since there is good reason for believing that the accumula- tion of fluid in the ventricles is frequently the result of previous inflammation of their lining membrane, and that puncture of the cranium may therefore contribute to the cure of dropsy of the brain, just as tapping the abdomen does to the cure of ascites.1 I should regard any case as favorable for the operation, which, on the whole, there was good ground for believing to be one of external hydrocephalus, or in which the enlargement of the head had not been attended by indications of active cerebral disease. Though less promising, I should not reject the operation simply because enlarge- ment of the head had been congenital; while I should always be more ready to operate if nutrition were well performed than if the child were emaciated. I would not, however, have you operate simply because the head is large; for it does not appear that diminu- tion in its size has resulted from the puncture, but only arrest of its enlargement; and if the disease be at a standstill, and the cerebral functions tolerably well performed, you would risk much with the chance of gaining but very little. The proper situation for the punc- ture is the coronal suture, about an inch or an inch and a half from the anterior fontanelle. A fine trocar and canula are the best instru- ments ; and care must be taken not merely to withdraw only a very few ounces of fluid at a time, but to keep up pressure both during the escape of the fluid as well as afterwards. 1 See, moreover, some remarks on this operation, and cases of its successful per- formance, in the Oesterr. Med. Jahrbucher, vol. xxii. p. 27, by Dr Schopf-Merei, late of Manchester, and previously the distinguished director of the Children's Hospital at Pesth. HYPERTROPHY OF THE BRAIN. 119 LECTURE X. Hypertrophy of the Brain—usually associated with general disorder of nutrition— symptoms and course—seldom directly fatal—nature of change in brain—altera- tions in form of skull, and difference from chronic hydrocephalus.—Treatment.— Partial hypertrophy. Atrophy of the Brain—case illustrative of its defective development.—Wasting of the brain in protracted illness.—Temporary retrocession of mental powers in children after long illness.—Case of partial atrophy. The anxiety of parents is sometimes needlessly excited in conse- quence of an infant's head being larger than common, and even though the child's health be good the relations are apprehensive lest it should be affected with water in the brain. Now you must not be too ready to take up this cry, which is one often raised by nurses and ignorant persons, or to suppose that every large head is therefore unnatural; for one child may have a bigger head than another, just as it may have a bigger hand or foot. But it may be that the child's head is not only larger than natural, but that well-marked symptoms of cerebral disturbance are present, and you may feel yourselves com- pelled to adopt the opinion that the case is one of incipient chronic hydrocephalus. The subsequent history of the patient may in many respects confirm your original diagnosis, so that great will be your surprise, on examining the body after death, at not finding a drop of serum in the ventricles, although, when you opened the skull, the cerebral convolutions had appeared flattened, as if the brain were greatly distended with fluid. Individual cases of this kind had been mentioned by medical writers at different times, but Laennec1 was the first who drew atten- tion to hypertrophy of the brain as a condition resembling chronic hydrocephalus in many of its symptoms, and liable to be mistaken for it. It has since then been frequently noticed, and I am not sure that an undue importance has not sometimes been attached to it, as though it were of much more common occurrence than you will really find it to be in practice. I have placed upon the table a cast taken from the head of a child who was affected with hypertrophy of the brain, and whose very re- markable case is related by Dr. Watson.2 He came under the care of the late Dr. Sweatman when two years old, and his head, which had been gradually increasing from the age of six months, was then so large as by its weight to prevent the child from continuing long in the upright posture. The boy was active and lively, though thin. He 1 Journal de Medecine, Chirurgie, et Pharmacie, 1806, t. xi. p. 669. 2 Lectures, 4th ed., vol. i. p. 425. 120 HYPERTROPHY OF THE BRAIN — SYMPTOMS. had never any fit or convulsion, but occasionally seemed uneasy, and would then relieve himself by laying his head upon a chair. He had never squinted, nor was he subject to drowsiness or starting during his sleep, and his pupils contracted naturally. His appetite was good, and all the animal functions were well performed. The case was sup- posed to be one of chronic hydrocephalus; but no urgent symptoms being present, active remedies were not employed. About six months afterwards the child died of inflammation of the chest, and Dr. Sweat- man examined the head. It measured 12 inches from ear to ear over the vertex, 13 inches from the superciliary ridges to the occipital, and 21 inches in circumference. The anterior fontanelle, which was quite flat, measured 2J inches by 1J across its opposite angles; the poste- rior fontanelle was completely closed, as was the frontal suture. The skull generally was increased in thickness; the morbid appearances in the membranes of the brain were quite trivial; the ventricles were empty, not dilated; the convolutions were perfectly distinct, and re- tained their proper rounded shape. The medullary matter, however, presented a very unusual vascularity. It is not merely on account of the great size which the head attained that I have quoted this history, but because it affords an instance of the overgrowth of the brain unconnected with any general disorder of the processes of nutrition. Such an occurrence is very rare, for hy- pertrophy of the brain is usually only one manifestation of a deep- seated disorder of the nutritive process, and is met with, in connection with rickets or scrofula, in the narrow lanes of a crowded city, or in the unhealthy valleys of mountainous districts, where goitre and cre- tinism are endemic. The majority of cases of hypertrophy of the brain that have come under my notice in London have occurred in infants about six or eight months old. Their history had usually been that, without any definite illness, the children had lost their appetite, and grown by de- grees dull and apathetic, though restless and uneasy. Notwithstanding the general apathy, this restlessness is often very considerable, though it does not show itself in cries so much as in a state of general unea- siness, and in frequent startings from sleep. Short gleams of cheer- fulness occur when the children are awake, but these are usually very transient. The head seems too heavy to be borne, and even when its size is not much greater than natural it hangs backward, or to one side, as if the muscles were too weak to support it. If placed in its cot, a child who is thus affected bores with its occiput in the pillow, while its head is almost constantly in a state of profuse perspiration. Convulsions sometimes occur without any evident cause, but threat- ening^ of their attack are much more frequent than their actual occur- rence, the child awaking suddenly with a start and a peculiar cry, like that of spasmodic croup, the surface turning livid, and the respiration becoming difficult for a few moments, and the symptoms then sub- siding of their own accord. Such attacks may issue in general con- vulsions, which may terminate fatally; but infants thus affected do not by any means invariably die of the cerebral disorder, but being weakly, they are often cut off by the first malady which attacks them. SYMPTOMS OF HYPERTROPHY OF THE BRAIN. 121 If life be prolonged, it becomes more and more evident that the pro- cess of nutrition is imperfectly performed: the child loses flesh and looks out of health, and enlargement of the wrists and ankles shows the connection between this disease and rickets—a connection which becomes more evident in the second and third years of the child's life. When the child survives infancy, or when, as occasionally happens, the symptoms of hypertrophy of the brain do not come on until den- tition has been in a great measure accomplished, convulsions are of very rare occurrence. Complaints of headache, however, are frequent and severe; and, though drowsy in the daytime, the child generally rests ill at night, and often awakes crying and alarmed. Besides these symptoms too, the child has occasional attacks of feverishness, with great increase of the headache, and giddiness, which last for a few hours or a day, and then subside of their own accord, while it grows by degrees more and more dull and listless, and its mental powers become obviously impaired. It happens, in some cases, that, as the child grows older, these symp- t ms become less and less severe; the health improves, the rickety deformity of the limbs gradually disappears, and the infant who had excited so much solicitude becomes at length a healthy child. There is a termination in complete idiocy, which I have never seen in this country, but some years ago I observed some instances of it in the Hospital for Cretins, which then existed near Interlachen; and I be- lieve that the association of cretinism and idiocy with hypertrophy of the brain is by no means of unusual occurrence. Death is not often the direct result of the affection of the brain, but generally takes place owing to the supervention of some other disease. The affections, however, which prove most fatal are those which favor cerebral con- gestion—such as hooping cough, or the eruptive^ fevers, especially scarlatina. You must not infer that hypertrophy of the brain has existed in every instance in which the organ may appear to be large, and its convolutions somewhat flattened, although the ventricles are free from fluid. The weight and apparent size of the brain are much influenced by the quantity of blood contained within it, and it may appear too large for the skull simply because the vessels are overfull.1 In true hypertrophy, on the contrary, the brain is generally pale and anaemic, unless death should chance to have taken place as the result of an attack of cerebral congestion. Neither, indeed, is the process one of mere increased growth, but the nutrition of the organ is modified in character, as well as increased in activity. The gray matter of the brain is but little involved in it, and, with the exception of its color being somewhat paler than natural, it shows scarcely any alteration. The white matter, on the contrary, is both paler and firmer than in a state of health; and Professor Eokitansky2 states, as the result of many microscopical examinations, that its augmented bulk is not produced either by the development of new nervous fibrils, or by the 1 See Mauthner's elaborate tables of the weight of the brain in various circum- stances, lib cit , sect. v. 2 Lib. cit-, vol. ii. p. 771. 122 TREATMENT OF HYPERTROPHY OF THE BRAIN. enlargement of those already existing, but by an increase in the inter- mediate granular matter. These changes, too, do not affect indiffer- ently all parts of the brain, but are confined to the hemispheres, and do not implicate either the base of the organ or the cerebellum. Chronic hydrocephalus is the only affection with which hypertrophy of the brain is liable to be confounded: the diagnosis between the two affections is often by no means easy, though it is of much importance with reference both to our prognosis and our treatment, for we should have more hope of the recovery of a child whose brain is merely hypertrophied, than of one whose brain is distended with fluid, while the means by which we should endeavor to effect a cure would differ widely in the two cases. The history of the patient would afford some help towards determining this question ; for the symptoms of chronic hydrocephalus generally come on earlier, and soon grow much more serious, than those of hypertrophy of the brain, and the cerebral disturb- ance is throughout much more marked in cases of the former than in those of the latter kind. The form and size of the head, too, present peculiarities by which you may often be enabled to distinguish between the two conditions. Both diseases are attended by enlargement of the head, and in both the ossification of the skull is very tardy, but the head does not attain so large a size in hypertrophy of the brain as in chronic hydrocephalus, neither are the fontanelles and sutures so widely open. The skull likewise presents some peculiarities in form, which are so remarkable as to have attracted the attention of several observers, though I must own that I do not thoroughly understand how they are produced. The head not merely shows no tendency to assume the rounded form characteristic of chronic hydrocephalus, but its enlargement is first apparent at the occiput, and the bulging of the hind head continues throughout especially striking. The forehead may, in the course of time, become prominent and overhanging, but the eye remains deep sunk in its socket, for no change takes place in the direction of the orbitar plates, such as is produced by the pressure of fluid within the brain, and which gives to the eye that unnatural prominence, and that peculiar downward direction, which are so striking in cases of chronic hydrocephalus. In hydrocephalus the anterior fontanelle is tense and prominent, owing to the pressure of the fluid within ; but when the brain is hypertrophied, there is no prominence, but an actual depression in this situation. I have more than once observed this condition in a very remarkable degree, the depression not being limited to the anterior fontanelle, but being ob- servable at all the sutures; and you may notice something of the kind in this cast. When hypertrophy of the brain occurs in the adult, the symptoms that arise are, in great measure, due to the compression which the organ undergoes from its bony case being too small to contain it. These symptoms are, of course, obscure ; while, even if the nature of the affection could be recognized, its cure must be hopeless. In the infant, however, and the child whose head is incompletely ossified, the immediate consequences of the evil are far less serious, while some benefit may be expected from the judicious employment of remedies. TREATMENT OF HYPERTROPHY OF THE BRAIN. 123 since over-development of the brain in childhood is almost always associated with general disorder of the processes of growth and nutri- tion. We are not, indeed, acquainted with any means by which we can directly check the morbid increase of the brain, but all our efforts should be turned towards improving the general health, while we in- terfere directly with the cerebral symptoms only in so far as their urgency may render it absolutely necessary. The child, therefore, must not be dosed with calomel merely because its head is affected, though the deficient secretion of bile may often render the employ- ment of small doses of mercurials necessary. Similar restrictions would apply to depletion, for we have seen that the hypertrophied brain is characterized by a want of blood rather than by its super- abundance ; but, nevertheless, occasional attacks of cerebral conges- tion may render local depletion necessary, and the exacerbations of headache, with vertigo and fever, will, if severe, be often benefited by its employment. I have now and then tried counter irritation by means of the tartar-emetic ointment rubbed into the back of the neck, with much relief to the head symptoms, in the case of children who were suffering from the indications of hypertrophy of the brain, but I should fear to have recourse to this measure in infants. In them, indeed, one of our first efforts must be to relieve the brain from the constant irritation to which it is exposed when the child is in the recumbent posture, and the head rests on the yielding and imperfectly ossified occiput. For this purpose, we cannot do better than follow the suggestion of a German physician, Dr. Elsasser,1 and have a small horsehair cushion prepared for the child's head to rest on, a piece. being cut out of it large enough to receive the occiput. In cases both of hypertrophy of the brain and of chronic hydrocephalus, I have seen the adoption of this simple contrivance followed by almost immediate cessation of the rotatory movement of the head, and by quiet sleep in its cot, to which perhaps for weeks before the child had been a stranger. It is not desirable that a child who suffers from this affection should sleep entirely without covering to the head. The profuse perspiration of the head is more effectually checked by a thin linen cap, which may be changed once or twice in the night, while at the same time the child is saved from the danger of catching cold. While these hygienic proceedings, which have especial reference to the head, are attended to, the child should be daily sponged with salt and water, or with sea water, if it be possible to remove it to some place on the coast, such as Brighton; or it would probably be bene- fitted by immersion in a tan-bath, in which it should remain for several minutes.2 1 Der weiche Hinterkopf. 8vo. p. 205. Stuttgart, 1843. 2 The tan-bath, which I have employed with very marked benefit in the case of weakly and rickety children among the poor, is prepared, as directed by Dr. Elsasser, by boiling three handfuls of bruised oak bark tied up in a linen bag, in three quarts of water for half an hour, and adding the decoction to the water of the child's bath. These baths should be applied tepid, and their use should be continued every day for several weeks. 124 ATROPHY OF THE BRAIN. The remedies under the continued use of which I have seen the most good result, are the extract of bark, from which you may pass to the preparations of iron—such as Yinum Ferri, or the ferrocitrate of quinine.1 I have not made much trial of the iodide of potassium, since in all the cases that I have seen some more decided tonic appeared necessary. I have, however, given the syrup of the iodide of iron sometimes with advantage; and in cases where the tendency to rickets was well marked, I have observed a most decided improve- ment follow the use of the cod-liver oil in doses of a drachm twice a day for a child of three years old. I may just mention that, not- withstanding its nauseous taste, this medicine is usually readily taken by children, some of whom even become fond of it. With reference to diet, it will probably be desirable, if the child be not weaned, to obtain for it a healthy wet-nurse; while, after wean- ing, a diet of milk, with an egg once or twice daily, will often agree better than any other food. In cases of this kind, and, indeed, in all where the digestive powers are feeble, a preponderance of farinaceous food is not desirable, while the child may with safety be allowed a little veal broth or beef-tea daily, or even a little meat if it have cut some of its molar teeth. Cases of partial hypertrophy of the brain are on record, in which one hemisphere alone was affected, or in which some one or more of the central parts of the brain greatly exceeded the natural size, whilst the rest of the organ deviated in no respect from its normal condition. An instance of the kind you see represented in this drawing of Dr. Mauthner's,* in which the right optic thalamus was as large as a hen's egg in a girl of three years old. In cases of this sort sometimes no symptoms are present, and the anomaly is only accidentally disco- vered after death; whilst in others, although there are indications of cerebral disturbance, yet they are not such as to enable us to deter- mine the nature of the evil of which they are the expression. There is a condition of the brain the direct opposite of that which we have been examining, in which the organ falls below the natural size, or in which atrophy of the brain exists. I do not refer here to those cases where the brain is imperfectly formed, the head exceed- ingly small, and the child idiotic from birth ; but this state of micro- cephalus appears sometimes to come on afterwards, owing probably, as has been suggested, to premature closure of the fontanelles and sutures. Such a case I saw several years ago, when a woman brought to me her boy, who was three years old, the elder of two children of perfectly healthy parents, none of whose relatives had ever shown any sign of consumption, idiocy, or mental derangement. When born, this boy was perfectly well formed, neither did he present any pecu- liarity till he was six months old, when his mother began to observe that he did not look any one in the face, and that he seemed to take but little notice of anything. When eight months old, he began to have fits, which had since returned about once a week, being preceded by extreme restlessness for a day or two.. The fits lasted for a quarter 1 See Formulae, Nos. 3 and 4, at page 56. * Lib. cit., plate i. and p. 189. ATROPHY OF THE BRAIN. 125 of an hour; they were attended by convulsive movements of both sides, and followed by drowsiness, which continued for some days. The child ate and drank, though not heartily, and he seemed anxious for food. He did not distinguish between what was nice and what was nasty, swallowing all things with the same readiness, though de- glutition appeared to be difficultly performed. He had cut all his teeth, he seemed tolerably well nourished, and his body and limbs were well formed. He was, however, quite unable to stand ; he passed his urine and feces under him without appearing to take the slightest notice of it, and he seemed destitute of every glimmering of understanding. His mother said that his head was smaller than that of her infant which was only six months old. It measured seventeen inches in cir- cumference around the parietal protuberances, and eleven inches across the head from the centre of the meatus of one ear to the same point on the opposite side. The forehead was extremely narrow, and the head shelved upwards quite in a sugar-loaf shape. All the sutures and fontanelles were firmly ossified, but I have unfortunately omitted to record at what age they became so. I never saw this boy again, but two or three similar cases have since come under my notice. I have nothing more to say about them, for their cure is manifestly quite hopeless, and, therefore, though they may interest us as patho- logists, they scarcely concern us as practical physicians. Of much higher practical importance are those instances in which the brain of children wastes during long-continued illness. The scalp, in such cases, will usually be found bloodless, the fontanelles collapsed, and the process of ossification will be seen to have been unusually tardy, Fluid will be found within the sac of the arachnoid, and effused into the subjacent pia mater. The brain will be far from filling up the cavity of the skull, so that a knife may be passed in many places between it and the cranial walls. The sulci between the convolutions appear unusually deep, and fluid will be found both at the base of the brain and in the ventricles, as well as in the pia mater. The cere- bral substance is pale, and its texture firmer than usual. The important point about such cases is, that cerebral symptoms and frequently recurring convulsions may be observed in a child whose brain is nevertheless not diseased, but too feeble and too wasted to perform its functions. If, then, you find indications of cerebral disturbance come on in infants who have been exhausted and emaciated by previous illness, you must not interpose too hastly with remedies directed against a supposed disease of the brain, but bethink you whether these symptoms may not be merely the signs of the brain having become unequal to its duties from its having been imperfectly nourished : and do not, without consideration, abandon the tonic plan of treatment which you had been previously pursuing. It is only in infants that accidents of this grave nature are likely to ensue, from the imperfect nutrition of the brain consequent on protracted illness: but symptoms arise in older children, in similar circumstances, well calculated to excite the apprehension of parents. In children who have but lately learned to talk, I have sometimes known loss of speech follow a long illness, the child being too weak to 126 PARTIAL ATROPHY OF THE BRAIN. talk, just for the same reason as it is too weak to walk. Occasionally, however, the child apparently regains its previous health, and yet makes no efforts to articulate, even for two or three months. In cases of this kind I have seen parents thrown into great anxiety from the fear lest the child's continued silence should be the result of the in- tellect having become impaired during its illness. I imagine that in many of these cases the child has forgotten during its illness much of its newly-acquired knowledge, and that it is some time before it again feels equal to the mental effort of shaping its ideas into words. Usually, however, when it begins to make the effort, it recovers its speech rapidly; and you may therefore console the parents with this prospect. Even a manifest retrocession of the intellectual endowments should not be regarded with too much anxiety, when it has followed some long-continued disease, for it may be the result of mere weakness; the vacant look, the unmeaning laugh, and the silly manner, gradually disappearing as the child gains strength. The brain seems to regain its lower powers, and to perform its humbler functions, before it re- sumes its nobler office as the organ of the mind. Partial atrophy, like partial hypertrophy of the brain, may occur we know not why, and may be discovered, after death, where the existence of cerebral disease had never been suspected; or we may find the explanation of a number of anomalous symptoms, which had existed during life, in a wasted condition of some portion of the organ. This state may be the result of original confirmation, or it may come on as the result of disease, in which latter case the substance of the wasted portion of the brain is usually found to be much firmer than natural. We are greatly in the dark as to the nature of the process by which this change is effected; but it is thought in some cases to be the remote consequence of hemorrhage into the cerebral substance, and in others, to be induced by a slow kind of inflammation. One case of this kind has come under my own notice, which, for its rarity, I will relate to you. The patient was a little girl, aged three years and ten months, the child of phthisical parents, but whose health, though delicate, had never been interrupted by any serious illness until she had an attack of remittent fever in the early part of the spring of 1845; she re- covered from it without any bad symptom, and seemed doing pretty well for about a month, when she became sleepy and heavy, and feverish, for which symptoms she was brought to me on May 19th. After being under a mild antiphlogistic treatment for a week, she got better, and was beginning to walk about again, when she awoke one morning with her face drawn to one side—a condition, however, which did not continue. When she attempted to walk, it was noticed that she halted very much on her left leg, and that it sometimes gave way under her, so that she fell down on that side, and then turned round upon her back. She had, besides, but little power with her left hand and arm, so that she could not grasp anything firmly, nor hold it steadily. The child's bowels were at that time constipated : I purged her freely, and sent her into the country, whence she returned PARTIAL ATROPHY OF THE BRAIN. 127 in the beginning of August, much improved in every respect, though still limping a little with the left leg, and using her right arm in pre- ference to the left. At the end of September I saw her again, she having then a bad impetiginous eruption on the scalp, which was treated with warm poultices and water dressing ; when, on October 6th, she began to limp with her right leg, just as she had previously done with her left; though in otner respects she continued pretty well. On October 17th, the affection of the right leg was a good deal less marked; but the child now became unwilling to walk, often turning giddy, and always catching hold of something by which to steady herself. When attempting to walk, she often fell down into a sitting posture; and then would sit on the floor, laughing loudly. Fits of uncontrollable laughter often came on without any cause, and the face began to assume an idiotic expression. There was occasionally slight inward strabismus of both eyes, but the pulse was soft and undis- turbed ; the bowels were regular, and the evacuations natural, and the child rested well at night, though her head was often rather hot. A week afterwards there was no new symptom, except that the child kept her neck quite stiff, as though she feared to move it. Her head grew hotter, and she began to have a frequent teasing cough, while her power of walking varied almost every day; she now, too, grew more restless at night. On the morning of the 27th, frequent convulsive twitches of the muscles of the face and extremities came on, and the left eye became permanently turned inwards. She had no sleep in the night; general convulsions came on at 8 A. M. on the 28th, and she died convulsed two hours afterwards. I found some deposit of tubercle in the bronchial glands, but none in the brain, where I had expected to discover it. The left hemi- sphere of the cerebellum, however, was, as you see both in this draw- ing and in the preparation itself, fully a third smaller than the right; it was of extremely firm consistence, quite leathery, and on making a section of it, its surface presented a rose tint. The halves of the pons and medulla oblongata were of equal size, as were the two hemi- spheres of the cerebrum. It was evident, too, that this condition was not congenital, since the two halves of the skull were of equal size, and the elevations and depressions in the interior of its base were precisely similar on both sides. There was a little fluid at the base of the brain, but none in the ventricles; a state of general conges- tion of the brain and its membranes being the only other remarkable appearances. The spinal cord could not be examined. There was no trace of* any old effusion of blood in the substance of the cerebellum, though the symptoms that occurred in May, and the subsequent gradual improvement of the patient, are not easily expli- cable on any other supposition than that hemorrhage had at that time taken place into the substance of the brain. The history of the case presents another difficulty, in the circumstance that the disease was seated on the same side as that to which the symptoms had been chiefly referred. Another problem which I cannot pretend to solve is, why 128 HYDROCEPHALOID DISEASE. the paralysis should in the first instance have affected the left side, while on the occurrence of the relapse in October, the right leg was palsied. I must therefore content myself with the bare relation of this history. LECTURE XI. Hydrocephaloid Disease—often succeeds to sympathetic disturbance of brain in course of various affections—supervening on diarrhoea, pneumonia, and cerebral congestion—diagnosis in each of these circumstances.—Prophylaxis, and treat- ment. Tubercle of the Brain—its frequency in childhood—its anatomical characters. Symptoms—occasionally absent—generally very obscure—symptoms of premoni- tory stage, their great diversity—symptoms of acute stage also various—diversi- ties in these respects cannot be altogether explained by the morbid appearances. —Occasional recovery where symptoms of cerebral tubercle have long existed — Treatment. <,_ Hydatids and Cancer of the brain. Closely connected with the state of atrophy of the brain, which we examined in the last lecture, is that condition which is induced if the organ be somewhat suddenly deprived of its usual supply of blood. Even in the adult a profuse loss of blood is followed, as you well know, by extremely severe headache, and by various other cere- bral symptoms. In the child, whose brain needs for the due perform- ance of its functions a proportion ably larger quantity of blood, the symptoms that follow its excessive loss are of a corresponding gravity. Often, indeed, they present a striking similarity to those which betoken inflammation of the brain; a fact implied in the name of the hydroce- phaloid disease, by which Dr. Marshall Hall, who was among the first to call the notice of the profession to this affection, has proposed that it should be designated. "This affection," says he, in his admirable essay on the subject,1 " may be divided into two stages: the first, that of irritability; the second, that of torpor. In the former there appears to be a feeble attempt at reaction; in the latter, the powers appear to be more pros- trate. These two stages resemble in many of their symptoms the first and second stages of hydrocephalus respectively. "In the first stage the infant becomes irritable, restless, and fever- ish ; the face flushed, the surface hot, and the pulse frequent; there is an undue sensitiveness of the nerves of feeling, and the little patient starts on being touched, or from any sudden noise; there are sighing ' Republished in his work On the Diseases and Derangements of the Nervous Sys- tem, 8vo., chap. v. sect, iii., London, 1841. It can scarcely be necessary to refer to Dr. Gooch's paper " On Symptoms in Children erroneously attributed to Congestion of the Brain," for another most graphic account of this disorder. SYMPTOMS OF HYDROCEPHALOID DISEASE. 129 and moaning during sleep, and screaming; the bowels are flatulent and loose, and the evacuations are mucous and disordered. "If, through an erroneous notion as to the nature of this affection, nourishment and cordials be not given, or if the diarrhoea continue, either spontaneously, or from the administration of medicine, the ex- haustion which ensues is apt to lead to a very different train of symp- toms. The countenance becomes pale, and the cheeks cool or cold; the eyelids are half closed; the eyes are unfixed, and unattracted by any object placed before them, the pupils unmoved on the approach of light; the breathing, from being quick, becomes irregular, and effected by sighs ; the voice becomes husky ; and there is sometimes a husky, teasing cough; and eventually, if the strength of the little patient continue to decline, there is a crepitus or rattling in the breathing. The evacuations are generally green; the feet are apt to be cold." In early infancy symptoms of this kind sometimes succeed to pre- mature weaning, especially if that be followed by an unsuitable diet; but afterwards they are generally induced by some definite attack of illness, either exhausting in itself, or for the cure of which active measures had been necessary. It is important, too, to bear in mind that they are not equally apt to come on in the course of all diseases, but that those in the early stages of which considerable cerebral irritation has existed, are much more likely to assume the characters of this spurious hydrocephalus when the bodily powers are exhausted. There is no disorder in which the two conditions of considerable sympathetic disturbance of the brain, coupled with rapid exhaustion of the vital powers, are so completely fulfilled, as in infantile diar- rhoea, and in no other affection do we meet with such frequent or such well-marked instances of the supervention of the hydrocephaloid disease. It is not long since a previously healthy boy, aged 18 months, was brought to me suffering from vomiting and diarrhoea, which had ex- isted for three days previously. After treatment had been continued for two days the purging ceased, but the child seemed to have a distaste for all nourishment, and refused both milk and arrowroot, and the mother made but few attempts to overcome this repugnance: so that for twenty-four hours the child took hardly anything except water and barley-water, and those in small quantities. On the afternoon of the sixth day the child became faint, and seemed so feeble during the night that the mother became much alarmed, and came again to me on the morning of the seventh day. The child's face was then sunken and very anxious; it lay, as if dozing, with half-closed eyes; breath- ing hurriedly; suddenly waking up from time to time in a state of alarm and restlessness, and then in a few moments subsiding into its former condition. The skin was dry but cool; the extremities were almost cold ; the lips were dry and parched, and some sordes had col- lected about the teeth; the tongue was dry, red, and glazed, and coated in the centre and towards the root with yellowish fur. The pulse was extremely feeble. There was very great thirst. The bowels had not acted for twelve hours. 9 130 SYMPTOMS OF HYDROCEPHALOID DISEASE. I ordered the child a tablespoonful of equal parts of milk and barley-water every half hour, with the addition of fifteen drops of brandy every hour, and directed that some strong veal broth should be prepared and given every two hours. At the same time a draught containing ten grains of aromatic confection, half a drachm of the compound tincture of bark, and six drops of sal-volatile, was given every three hours, and a grain of Dover's powder was directed to be taken at bedtime. Within six hours after the commencement of this treatment the child began to improve ; it slept tolerably well in the night, and the next day was lying tranquilly in bed, looking about and smiling cheer- fully ; the extremities were warmer, and the skin had lost its harsh- ness; the tongue was no longer dry, and the pulse had increased in power. The stimulants were gradually withdrawn; no further bad symptom came on, and the child was soon convalescent. It is of great importance rightly to interpret the meaning of the symptoms which attend the first stage of this affection, and to discrimi- nate between the cerebral disturbance of approaching exhaustion, and that which implies the existence of real mischief in the brain. A little girl was seized with diarrhoea on August 8th, which at first was severe, but soon yielded to treatment, and she was again conva- lescent; when, on the 15th, vomiting and purging returned with great violence, and were attended with much febrile disturbance. On the following day she was still worse in all respects, but was not brought to me again until the 17th. She then looked exceedingly ill; her face was sallow, but with a flush on each cheek, and her eyes were deeply sunk. She lay in a half-dozing state, with her eyelids half closed, and the eyeballs turned upwards, so that nothing but the scle- rotica was visible; but from this condition she awoke frequently and suddenly in a state of great alarm, and looking if she were about to have a fit of convulsions. Her skin was hot and very dry ; her pulse very frequent, but not strong; and there was some subsultus of the tendons of the wrist. The abdomen was rather tympanitic; the tongue red, coated with white mucus; the thirst was great, the vom- iting very frequent, and the bowels acted two or three times in the course of an hour, the evacuations having the appearances of dirty water. The child was immediately placed in a tepid bath; an enema con- taining five drops of laudanum was next administered, and the abdo- men was covered with a large bran poultice. The extreme irritability was almost immediately relieved by the warm bath, and still further soothed by the enema. The bowels ceased to act so frequently, and the stomach began to bear small quantities of barley-water and other drinks, which were given cold. In a few hours the imminent danger had passed away, and the child recovered in the course of a few days. If, in a case of this kind, you fall into the error of regarding the cerebral symptoms as the signs of active disease, and withhold the Dover's powder, or the opiate enema that might have checked the diarrhoea and soothed the irritability, while you apply cold lotions to the head and give the child nothing more nutritious than barley-water DIAGNOSIS OF SPURIOUS HYDROCEPHALUS. 131 in small quantities, because the irritability of the stomach which re- sults from weakness seems to you to be the indication of disease in the brain, the restlessness will before long alternate with coma, and the child will die either comatose or in convulsions. But it is not only in the course of diarrhoea that errors of this sort may be committed. The early stages of pneumonia are often attended with so much sympathetic disturbance of the brain, as to throw the other symptoms into the background. The child vomits, it refers all its suffering to its head, and possibly has an attack of convulsions almost at the outset. You not unnaturally assume the case to be one of cerebral congestion, and treat it accordingly with free local deple- tion. On the next day the indications of disordered respiration are more apparent; you think your former diagnosis was incorrect, and probably apply more leeches to the chest to combat the pneumonia you had overlooked. The urgency of the symptoms may be relieved by these means, or, if that be not the case, still the reaction will dimi- nish with the diminished power, and the child for a short time seems to suffer less. But soon the restlessness of exhaustion comes on, and then follow the soporose condition and the apparent coma: you con- demn yourself for having overlooked the cerebral mischief, of which you fancy you now have most convincing proof: you renew your antiphlogistic measures, to arrest, if it be not too late, this imaginary hydrocephalus, and your patient dies. Something of the same kind too may happen in cases where the brain has really been congested, and where the depletion, which you practised somewhat too freely, was in reality indicated, though to a smaller amount. The restlessness and heat of head may have been diminished by your treatment, and the bowels may have been relieved by the purgatives you administered. In a few hours, however, rest- lessness returns, though not to so great a degree as before, the child moans sadly when awake, and this suffering state alternates with a drowsy condition, while the stomach, irritable before, now rejects everything almost as soon as swallowed, though the child still seems eager for drink. The previous arrest of very similar symptoms, though but for a few hours, by active treatment, seems to you to indicate the propriety of continuing the same plan, but nevertheless, the drowsiness deepens into coma, and the child dies of hydrocephalus, as you suppose—in reality of the nimia diligentia medici. "Forewarned, forearmed," says the old proverb. When head symp- toms come on in the infant, do not judge of their import simply from the present condition of the child, but ascertain its previous history. Learn whether any other members of the family have had hydroce- phalus or been consumptive. Inquire whether this infant has thriven at the breast, or whether it has for some time been drooping; if already weaned, ascertain on what it is now fed, whether signs of declining health soon followed on the change of diet, while it throve so long as it was suckled. Ask what signs of disorder of the bowels there have been, and observe at what times the vomiting comes on ; whether only after sucking or taking food, or whether efforts to vomit occur when the stomach is quite empty. 132 TREATMENT OF THE AFFECTION. In a case where the symptoms of cerebral disturbance, and those of disordered respiration, come on almost at the same time in a previously healthy child, and so alternate with each other as to render your diag- nosis difficult, you will do well to remember that pneumonia often sets in with much sympathetic disorder of the nervous system, and that the disease is much more likely to be seated in the lungs than in the brain. In most cases auscultation will enable you to decide the ques- tion, and if you once accustom yourselves to listen to a child's chest as invariably as you would look at its tongue or count its pulse, you will but seldom have to reproach yourselves for the uncertain diag- nosis and the vacillating treatment into which, in cases of this descrip- tion, you will otherwise be too often betrayed. In a child suffering from diarrhoea, you will be prepared to meet with sympathetic disturbance of the brain, and will not allow the occurrence of its symptoms to deter you from adopting the treatment which the diarrhoea requires. If doubt cross your mind as to their signification, and you fear lest mischief be really going on in the brain, it will usually suffice to watch the symptoms closely, in order to detect a want of correspondence between them, which would not exist if true cerebral disease were present. Attention to this point will guard you from error during the stage of excitement, as well as in that of exhaustion and stupor, which simulates the last stage of hydro- cephalus. In no circumstances are mistakes more easily committed, and never are their results more mischievous, than when real congestion of the brain has been somewhat over-treated, and the consequent symptoms of exhaustion are supposed to be those of advancing disease. In such a case, however, it will usually be observed that great faintness had been induced by the first depletion, and that the quiet which suc- ceeded it was that of exhaustion as much as of mitigated suffering. If so, the returning restlessness will probably be the index of the feeble power of the brain, no longer adequate to the performance of its wonted functions, rather than the evidence of active disease of the organ. Nor will the history be the only safeguard from error, but the fontanelle sunk below the level of the cranial bones, instead of being tense and pulsating, the cool surface, and the pulse presenting no other characters than those of frequency and feebleness, will all point to the real nature of the case. You do not need to be told that to deplete in such circumstances would be to destroy your patient— that food is needed, not physic. The sunken powers of life are to be rallied, and as their strength returns, the functions of the brain will again go on harmoniously. Although the diagnosis of this affection is sometimes attended with difficulty, the rules for its prevention and its cure are happily very simple. Bearing in mind the possible supervention of the hydroce- phaloid disease, you would never keep an infant from the breast, nor put a young child on a spare diet for several days, without most abso- lute necessity; you would pay especial attention to its food, if the disease from which it suffers be, like diarrhoea, such as interferes directly with its nutrition. Again, you would not trust depletion of TUBERCLE OF THE BRAIN. 133 a young child, especially if suffering from head affection, to a nurse, but would yourselves exercise the supervision of it. And, lastly, in the treatment of every disease, you would at once suspend the anti- phlogistic measures that you had previously been adopting, and resort to the use of stimulants and tonics so soon as any of the symptoms that we have been examining make their appearance. The state of general restlessness and irritability that attends the early stages of exhaustion is often greatly soothed by the tepid bath, continued for not more than five minutes, for fear of still further depressing the infant's powers. While you secure a free access of air too, you must be extremely cautious to maintain the room at a suffi- cient temperature; for the power of generating heat is diminished in a very remarkable degree in young animals who from any cause are insufficiently nourished. The irritability of the stomach is best over- come by giving nourishment in extremely small doses—as a dessert- spoonful of asses' milk for an infant, or of veal-tea for an older child, given by little and little every half hour. If the symptoms have suc- ceeded to weaning, a healthy wet-nurse should, if possible, be at once obtained; but as the effort to suck seems sometimes to exhaust the child, and, probably, thereby to favor vomiting, it is sometimes better at first to give the nurse's milk by a teaspoon. If the exhaustion be very great, and a state analogous to coma be impending, a hot mus- tard bath is sometimes serviceable in rousing the child; while, at the same time, a few drops of sal-volatile, or of brandy, may be given every few hours. It is desirable, however, to suspend the use of the more powerful direct stimulants so soon as it can safely be done, though a nutritious diet will be necessary for some time. Tonic medicines, likewise, are often of much service, few of which are pre- ferable to the extract of bark, which, dissolved in caraway water, mixed with a few drops of the tincture, and well sweetened, will be taken very readily by most children. The addition of a little milk to the medicine when taken still further covers any unpleasant taste.1 Those cases in which the brain becomes the seat of various morbid growths still remain for us to consider, before we pass to the study of affections of the spinal cord. In the child, as in the adult, the brain may become the seat of hydatid cysts, or of cancerous tumors, or of tubercular deposits; but I should not detain you long with their study, if it were not that the last of these three morbid conditions, though exceedingly rare in the adult, is by no means unusual in the child. Thus, while M. Louis met with only a single case in which the brain contained tubercle, out of 117 examinations of adults who had died of phthisis, MM. Rilliet and Barthez discovered tubercle in the brain of 37 out of 312 children, between the ages of 1 and 15, in some organ or other of whose body this morbid deposit existed. You will remember that I am not now speaking of cases where tubercle is present merely in the membranes of the brain, producing that granular appearance to which I called your attention when treating of acute hydrocephalus; but my remarks 1 See Formula No. 3, at p. 56. 134 TUBERCLE OF THE BRAIN—MORBID APPEARANCES. refer to separate deposits of tubercular matter in the substance of the brain. These deposits are for the most part distinctly circumscribed, of a rounded form, and varying in dimensions from the size of a millet-seed to that of a split pea, or of a bean, or even larger. The largest mass that I ever met with in the brain of a child was almost as big as a sugared almond, but they have been seen three or four times as large. Sometimes there is but a single deposit in the brain, but in the majority of cases there are three or four small deposits, of the size of a millet-seed or rather larger, as well as a single mass of greater magnitude. Sometimes, though not often, the deposits of tubercle are limited to one hemisphere of the brain ; but it generally happens that there is a marked preponderance of the affection on one side. The situation of these deposits varies greatly, and they have been found in all parts of the brain, both on its surface and in its interior. The smaller deposits are, I think, most frequently observed on the convexity of the brain, and they are then found closely ad- herent to the pia mater, to which they remain attached if that mem- brane be stripped off. They seem, however, to have some connection with the cerebral substance besides mere juxtaposition, since a thin investment of it clings to them, and the place where they were situ- ated may be seen after their removal to be quite uneven. Even when situated at the base of the brain, or in the cerebellum, they often retain this relation to the pia mater; and those larger masses, which generally appear more deeply seated, will often be found, if the con- volutions be unfolded, to have been in reality not far removed from the surface. Now and then a distinct, firm, fibrous capsule may be found investing the deposit; but this is oftener absent, or at any rate so delicate as not to be clearly perceptible. I have never seen these deposits presenting throughout the characters of the gray semi-trans- parent tubercle frequently noticed in the lungs, but once I found the exterior of a small deposit in this stage, while its central part had undergone the transformation into the ordinary friable yellow tuber- culous matter—a condition which Eokitansky has also occasionally met with. Softening sometimes goes on in cerebral tubercles; the process beginning in the centre, and gradually extending towards the periphery—a condition which I have observed in 4 out of 19 cases. The brain around the softened deposits is almost always of a rose tint, and more or less softened, though this alteration seldom extends for a distance of more than two or three lines; and once I observed the cerebral substance perfectly unchanged around a small tubercle, in which the process of softening was already considerably advanced. As a general rule, the brain around deposits of crude tubercle still retains its natural characters; but to this I have seen one exception. If death usually occurs before the process of softening has taken place in the tubercular deposits, still rarer is it for life to be so pro- longed as to give opportunity for the occurrence of that cretaceous transformation by which the disease in other organs is sometimes arrested. MM. Rilliet and Barthez have observed it only twice out of 37 cases of cerebral tubercle; and but one instance of it has come under my notice, in a boy 3J years old, in whom but one deposit TUBERCLE OF THE BRAIN — MORBID APPEARANCES. 135 existed, of the size of a large pea, situated in the left hemisphere of the cerebellum. The change was in this instance incomplete, when death took place from acute hydrocephalus, succeeding to the sudden cessation of otorrhoea. Had the child lived, however, it is probable that the disease would have been altogether cured, for no tubercles were present in any other organ of the body, with the exception of the bronchial glands; and in them the same curative process was going on. Cerebral tubercle does not invariably affect the rouuded form, but it occasionally extends as a patch, half an inch or more in length, by two or three lines in breadth, immediately beneath the pia mater, and not reaching above one or two lines deep into the cerebral substance, which is usually slightly softened beneath it. Now and then too the deposit takes place not in distinct and isolated masses, but in the form of infiltration into the tissue of the brain, which, in this situation, is of a rose-red color, and extremely soft. This condition has come twice under my notice, and was associated on both occasions with abundant tubercular deposits in almost all the viscera. These tubercular deposits in the cerebral substance are very often, but by no means invariably, associated with that granular state of the membranes which I described to you as occurring in many cases of hydrocephalus. Thickening of the membranes, and effusion of hyaline matter into the pia mater at the base of the brain—the evidences, in short, of meningitis—are often present, as well as abundant effusion of fluid into the ventricles, and softening of the central parts of the brain. Sometimes, however, the signs of inflammation of the mem- branes exist without any effusion into the ventricles; and in a few instances the ventricles contain an abundance of fluid, but no soften- ing of the central parts of the brain exists, nor any sign of inflamma- tion of the membranes. I know of no instance in which tubercle was limited to the brain in childhood; but if present there, it always exists in other viscera, and is but one of the results of that general cachexia which may show itself in any of the various forms of scrofulous or phthisical disease. I am unacquainted with any special cause that renders the brain more liable to this disease in childhood than in adult age, or even in youth. It certainly is not owing simply to the intensity of the tu- berculous cachexia, and the consequently greater abundance of the morbid deposit, for 1 have met with many instances of far more ex- tensive tubercular degeneration than existed in those cases where the brain had become its seat. Cases are not yet recorded in numbers sufficient for us to determine accurately the time of the greatest liability to this affection, or whether difference of sex exerts any real influence in predisposing to it. Of my own 19 cases, 10 were male and 9 female; 5 were under 2 years of age; 3 between 2 and 3; 5 between 3 and 4; 1 between 4 and 5; 2 between 5 and 6; and of the remaining 3, one was 6|; one, 8; and one 10 years of age.1 1 The cases recorded by Dr. H. Green, in vol. xxv. of the Medico-Chirurgical Trans- actions, by MM. Rilliet and Barthez, in vol. iii. of the first edition of their work ; and 136 SYMPTOMS OF TUBERCLE OF THE BRAIN. We come now to the examination of a very difficult question— namely, that of the symptoms of this affection. The difficulty arises from many sources; for sometimes the disease gives rise to no symp- toms at all, and its existence is not discovered till after death; and even when symptoms are present, neither their character nor their intensity bears any invariable relation to the extent of the local mis- chief or its seat; while, lastly, the symptoms that usually betoken tubercle of the brain sometimes exist where no such morbid growth occupies the organ. Cases in which no symptom whatever marks during life the presence of the morbid deposit in the brain, are very unusual, and have never come under my own observation. Much less rare, though still con- stituting exceptions to the general rule, are the instances of complete absence of all premonitory indications of cerebral disorder; symptoms of disease of the brain manifesting themselves suddenly and with violence, and carrying off in the course of a few days, or perhaps even a few hours, the child in whom tubercle has for months been develop- ing itself. No reason can be assigned for the complete latency of the affection in some instances, or for the sudden supervention of cerebral symptoms in others, after the deposit has existed for a long time without giving rise to any indications of its presence. It is true that the brain in the immediate neighborhood of the tubercular deposit does not, to the best of my knowledge, present any sign of softening in those cases which have been characterized by absence of all pre- monitory signs of cerebral disturbance, and that the tubercle itself always appears in the crude state. This fact at once suggests a plau- sible explanation of these cases, founded on the assumption that the symptoms, when observed, do not depend simply on the presence of tubercle, but rather on the changes in the surrounding brain. Such an hypothesis, however, is contradicted by the fact that cerebral symp toms sometimes occur in cases where no perceptible disorganization of the brain has taken place either around the tubercle or elsewhere. In most instances some kind of premonitory symptoms manifest themselves before the commencement of the child's fatal illness; but these are very variable in their character, and often very difficult of interpretation. Dr. Hennis Green, in his very valuable paper, " On Tubercle of the Brain, in Children," mentions pain in the head as having been present in 17 out of 20 cases; but this symptom attends upon so many other affections, that, taken by itself, its diagnostic value is but small. In young children who are unable to describe their sensations, we cannot be certain of the existence of headache; but must be content to infer it from causeless fretfulness, drowsiness, or listlessness. One or other of these indications of disorder of the sen- sorium was present, however, as the most marked premonitory symp- by Professor Hirsch, of Konigsberg, in a dissertation De Tuberculosi Cerebri, 8vo., 1847, added to my own, made up a total of 67, which may be thus arranged:— Male. Female. From 6 months to 5 years .... 23 14 From 5 years to 10 years .... 9 13 From 10 years to 15 years .... 3 5 35 32 SYMPTOMS OF TUBERCLE OF THE BRAIN. 137 torn, in 10 out of 14 cases in which forewarnings of mischief preceded the child's fatal illness.1 1 In the following note I have endeavored to bring together the more important points in the history of the 19 cases of cerebral tubercle on which my remarks are founded. There were no premonitory symptoms of head affection in 5 cases. No. Sex. M. Age. Previous history. Fatal illness. Duration. 1 yrs. m. 4 0 Convalescent for 3 weeks from Tubercular meningitis. 19 days measles. 2 M. 1 5 Cough for 2 months. Fits, coma, died in fits. 6 " 3 F. 2 6 Tabes mesenterica, 4 months. Fits, coma, died comatose. 5 " 4 F. 10 0 Constipation, debility, 2 mos. Typhoid symptoms, no fits. 9 " 5 M. 1 0 Phthisis, 5 months. Drowsiness, fits, coma, fre-quent fits. 7 " More or less marked signs of cerebral disturbance existed in the remaining 14 cases ; namely:— No. Sex. Age. Premonitory symptoms. Duration. Fatal illness. Duration. 1 M. yrs 2 m. 0 Fretfulness. 8 days Fit, coma. 99 hrs. 2 F. 3 3 Great drowsiness succeed-ing cynanche parotidea. 6 w'ks Fits for some hours, re-turned in 5 days, then fre-quent, drowsy in inter-vals, coma. 24 days 3 F. 0 6 Dull, drowsy, suppressed eruption on scalp. 1 mo. Deepening stupor, fit, coma. 6 " 4 8 0 Drowsy, listless, feverish. 14 days Stupor, coma, ptosis of the lwk. right eyelid, dilatation of right pupil, no fit. 5 M. 1 9 Otorrhoea 6 weeks, pain in head, crying at night 14 " Vomit'g followed by coma, fits, death comatose. 83 hrs. 6 M. 3 6 Otorrhoea 9 months, pain in head on its sudden cessa-tion, and excited manner. 7 " Several fits, furious deli-rium, coma. 3 days 7 F. 6 6 Headache, sickness, consti-pation. 2 mos. Supervention of acute hy-drocephalus, fits. 16 " 8 M. 3 6 Habitual rotatory motion of head, pain in forehead, feverish. 2 " Symptoms of acute hydro-cephalus, fit 5 hours be-fore death. 13 " 9 F. 3 0 Fit, left side affected, re-turn in 4 days, twitching of left side. 13 days Symptoms of acute hy-drocephalus, pneumonia supervened and caused death. 35 " 10 M. 1 11 Epileptic fits from 7th mo., drowsiness from 15th mo. 16 mos. Slight fit, followed by coma. 24 hrs. 11 M. 2 0 Head hung to left side since measles. 4 " Two fits, stupor, automatic movement of right side, 5 days death comatose. 12 F. 3 3 Sudden twitching of right hand, arm, and leg, torti-collis paralysis of right 9 " Head heavy 10 days, deep-ened into coma, death comatose from effusion of 10 " portio dura, last 2 symp- blood at base of brain. toms disappeared, others improved, no headache. 13 F. 5 4 Fit, followed by paralysis of right side, 5 months before, and impairment of intellect, febrile attack 3 months, almost constant convulsions 6 weeks. 5 " Increase of convulsions, deepening of coma, death comatose. 6wks. 14 F. 5 0 Headache after measles 4 months, ptosis of right eyelid 1 month. 4 " Increase of headache, con-vulsions 5 days before death, comatose. 14 days 138 SYMPTOMS OF TUBERCLE OF THE BRAIN. When headache is present it is yet but seldom that any connection can be traced between the seat of the tubercle and the situation of the pain which is, for the most part, referred to the forehead. It is often very severe, so that during its continuance the child is entirely taken up with its suffering, and shrieks with the severity of the pain; but it does not continue with this intensity for more than a few hours, and on the next day the child will be found to be no worse than usual. Vomiting in many instances attends these exacerbations of pain; and, when this is the case, the absence of any gastric disorder suffi- cient to account for it will lead you to suspect the presence of tubercle in the brain. In some cases, however, the headache, though severe, does not present this remarkable intensity, while there is so much permanent impairment of the general health, that an occasional attack of sickness does not surprise you. On the other hand you will meet with delicate children in whom attacks of violent headache sometimes accompanied by vomiting, come on from very slight causes, or appa- rently without any cause at all, and return at irregular intervals for years together, till they gradually subside as the health becomes more robust, and cease altogether at the age of puberty, or sooner. In a doubtful case, the existence of irregularity of the pulse would to some extent govern your decision; though its occurrence in cases of cere- bral tubercle is not constant: while I have known children in whom every attack of gastric or intestinal disorder was accompanied by this symptom in a very marked degree. In infants, and in children under two years of age, we of course lose the evidence which is afforded by the patient's complaints of headache, and can only infer it to be present from the occasional loss of cheerfulness, and the attacks of fretfulness and crying. Sometimes, too, the suffering of the brain shows itself in other ways besides headache. The temper becomes wayward and passionate, or a general dulness steals over all the faculties, and the child grows quite indifferent to what is going on around it. One little boy, aged two years, whom I watched for some weeks before his death, never made any complaint of headache. He was fretful, and cried if moved, but was perfectly quiet if allowed to remain in his chair, where he would sit half dozing for hours together. Affections of the motor system are often among the early indica- tions of this disease, but neither are they so definite as to present anything pathognomonic of cerebral tubercle. A boy who died at three and a half years old, and in the left hemisphere of whose cerebellum there was a tubercle as large as a pea, had been subject from his earliest infancy to an almost constant and involuntary rota- tory movement of the head when in the recumbent posture. And in another boy, who was two years old at death, the head had hung for four months towards the left shoulder before any other symptom of mischief in the brain appeared: convulsions then suddenly came on, and the child died in 72 hours. Sometimes paralysis of a limb comes on gradually; or, though actual paralysis does not exist, yet the power over one side becomes greatly weakened, and the child drags one leg, or is observed invariably to use'one arm in preference to the other. Convulsive movements, however, are the most frequent of the affec- SYMPTOMS OF TUBERCLE OF THE BRAIN. 139 tions of the motor system, and paralysis of a limb, or impaired power over it, usually succeeds to their occurrence, and but seldom takes place independently of them. Kegular epileptic seizures, attended with equal affection of both sides during the fit, and followed by no impairment of power over any part, are decidedly unusual, and have only once come under my notice; but the convulsive movements generally assume one of two characters. Either they are occasional in their occurrence, attended with insensibility, though the movements are confined to one side of the body or to one limb, the same being affected on each occasion; and these attacks are usually of compara- tively short duration, varying from a few minutes to a few hours;— or the intellect is unimpaired, but movements like those of chorea affect one limb or one set of muscles constantly. Of this 1 saw a striking instance in a little girl who died from hemorrhage beneath the arachnoid at the base of the brain when 3J years old, and in whom numerous tubercles were present in the left optic thalamus, and one in the right hemisphere of the cerebellum. Nine months before her death she was seized, when apparently in perfect health, with twitching, tremulous movements of the right hand, which in 14 days extended to the arm, and in a month to the leg, so as to prevent her walking. In 2 months the head was drawn to the left shoulder, and in 4 the mouth to the left side. In 3£ months the head was held straight, and in 5 months the mouth was no longer drawn awry. The tremulous movements diminished, the child began to walk about, and continued to improve till 20 days before her death. She then grew dull, and the tremor returned. In 10 days she became comatose, and continued so, with occasional convulsions, in which for the first time both sides were affected, till she died. This case illustrates another fact perhaps worth notice; namely, that convulsions affecting one side only are sometimes seen, although tubercle is present in both hemispheres; or in other instances both sides are affected by the convulsions, and yet the deposit is found only in one hemisphere of the brain. Lastly, it may be added, that when convulsions, whether general or partial, attended with insensi- bility, have once occurred, they are seldom absent for many days together, though to this there are occasional exceptions, in which a pa'use of many months ensues after the first convulsive seizure; the general health, indeed, being impaired, but no sign clearly indicating the special mischief that exists in the brain. The transition from the premonitory to the acute stage sometimes fakes place gradually, the convulsions becoming more and more frequent, the other cerebral symptoms more serious, and the intervals of freedom from suffering shorter; or the change takes place suddenly, and without such previous increase in the severity of the child's sufferings as to make you anticipate its approaching death; and yet we cannot always discover such differences between the morbid ap- pearances in the two cases as suffice to explain the dissimilar course of the disease. In the 19 cases of which I have preserved a record, the duration of the acute stage varied from 24 hours to 42 days; being under a week in 9 instances; between one and two weeks in 4; be- 140 SYMPTOMS OF TUBERCLE OF THE BRAIN. tween two and three in 2; once extending to 24; once to 35 days; and in one instance convulsions were of perpetual recurrence for six weeks, when at last the child died. In four instances the acute stage was attended by the ordinary symptoms of acute hydrocephalus; once death took place from apoplexy dependent on effusion of blood at the base of the brain; once the child gradually sank into a typhoid condition, and died without any convulsion; and once coma stole on gradually, death again being unpreceded by convulsive movements. In the remaining 10 cases, convulsions took place, though obeying no definite rule as to the frequency of their occurrence, or the inten- sity of the coma by which they are succeeded. Wide as the differences are between the effects mentioned as pro- duced by cerebral tubercle in one case, from those which are observed in another, and impossible as it is completely to account for them, they are yet, perhaps, not so altogether inexplicable as at first sight they may appear. The size or position of the deposit, or the rapidity of its growth, may in one case produce pressure on the brain, occa- sion the effusion of fluid, and thus cause the patient's death; or the accidental congestion of the brain following the arrest of some dis- charge, or the healing of some eruption, or attending on some inter- current febrile disorder, may render it sensible of the presence of the morbid deposit which it had endured quietly for weeks or months, and all the indications of serious cerebral irritation may at once become apparent. In another case softening may take place in the tubercular mass, and, extending to the adjacent tissue, inflammation of the brain may be lighted up ; or the deposit not being limited to the brain itself, but affecting its envelops also, tubercular meningitis may supervene, as it often does, and destroy the patient. These considerations may serve to explain cases where the tuber- cular deposit has been found external to the substance of the brain, merely pressing on it, but in no way altering its tissue. Such a case I once saw in the person of a little girl, 10 years old, who for five months had suffered from strumous disease of the knee-joint, but had never manifested any head symptom during her six weeks' stay in the Middlesex Hospital. She was taken home at the end of this time, but had not left the hospital many hours when convulsions of the right side came on, which were succeeded by coma: and this deepened, till in the course of forty-eight hours it became absolute. Convulsions occasionally returned, always affecting the right side, which from the first continued paralyzed in the intervals between their occurrence. She lay thus for eight days without any sign of amendment, and then died. There was a large quantity of clear serum in the lateral ven- tricles, and much escaped from the spinal canal. There was no disease ' of the brain, nor any important morbid appearance in the spinal cord; but there was disease about the odontoid process and its articulation with the atlas, with a collection of tubercular matter around it, form- ing a tumor which, situated in the mesial line, encroached somewhat on the occipital foramen, though pressing but very slightly on the cord. In the quiet of the hospital this disease had produced no syrnp* DIAGNOSIS AND TREATMENT. 141 torn; the excitement of her return home kindled the spark and de- stroyed the patient. Bearing these things in mind too we can account for the sudden death of a child, in whom a solitary tubercle in the brain had already passed into the cretaceous state, but where habitual otorrhoea had ceased suddenly; and we can understand the reason for the intermit- tent character which the symptoms of cerebral tubercle so frequently assume.1 I do not wish for one moment to exaggerate the difficulties that attend the diagnosis of this affection; but, at the same time, if we assume that we have to do with an incurable disease, we are less likely to use efficient means of treatment than if we felt that there is still some room for hope. While, therefore, I would have you bear in mind that the symptoms which we have been passing in review, especially if associated with indications of tubercle in other organs, render the presence of tubercle in the brain in the highest degree probable, they yet do not afford absolutely certain evidence of it; and further, that the occasional observation of cerebral tubercle which has undergone the cretaceous change, shows that recovery from the disease is not absolutely impossible. Headache aggravated at intervals, and asso- ciated with occasional convulsive movements of one limb, and even with attacks of an epileptic character, may occur in children who yet after a time recover, and show, by the robust health they subsequently attain to, that some cause of a less abiding nature than tubercular deposit must have given rise to the disturbance of the brain ; or, on the other hand, though serious cerebral disease may exist, and such as gives rise at length to a fatal result, yet it may appear after death that it was such as would have been mitigated, if not cured, by appro- priate treatment. You must not, then, be merely passive spectators of these symp- toms; and, if you watch cases of this kind with attention, you will generally find that they afford you some clue to the treatment that you should follow. Either there is manifest gastric and intestinal disorder, or there are indications of a state of general debility, or there are signs of inflammatory disease in the brain. In the first case, the re- gulation of the bowels, and the careful management of the diet, are obviously indicated ; in the second, iron may be given with advantage, and the shower-bath may be cautiously tried, and, if it do not alarm the child, it may often be continued with much benefit. In those cases where there seems to be some slow mischief in the brain, I have once or twice seen recovery take place, contrary to all my anticipations, from the employment of Small doses of mercury night and morning, persevered with for many weeks. In such cases, too, counter-irritation by means ^ of the tartar-emetic ointment rubbed into the back of the neck is .ofteu ' followed by the happiest effects. A little girl, 14 months old, was some time since under my care for the frequent recurrence of convulsive ■ See, with reference to the various effects of cerebral tubercle, and the different ways in which it may prove fatal, the excellent chapter on tubercle of the brain in Dietl's work, already referred to, pp. 346—356. 142 DISEASES OF THE SPINAL CORD. attack of a very anomalous character. So long as a discharge was kept up from her neck by the tartar emetic ointment, the fits did not occur; but if the discharge ceased for two or three days, they were sure to return. These are the principles by which your conduct must be governed; but you will find that each case will present some special peculiarity, and will need to be studied and treated for itself. Tumors of other kinds may exist in the brain in childhood, though they appear to be more frequent in the middle-aged or the old.1 I once saw a case in which hydatids had formed in the substance of the brain in a girl of seven years old; and once, also, I saw cancer affect- ing the brain and its membranes in a boy two and a half years old. But, though such occurrences are interesting from their rarity, I do not know any circumstance, except the absence of the signs of tuber- cular disease in the patient, by which you could determine during life that certain cerebral symptoms arose from hydatids or cancer of the brain, and not from tubercle in that organ. LECTURE XII. Diseases of the Spinal Coed—their study rendered more difficult by the tender age of children. Irritation and Congestion of the Cord. Inflammation of the Membranes of the Cord—sometimes epidemic—not common as a sporadic affection. Illustrative cases.—Inflammation of the Substance of the Cord—extremely rare in its acute form—in its chronic form gives rise to symptoms similar to those which occur when bones of the spine are diseased. Cases. Trismus—extremely rare in this country—symptoms—post-mortem appearances— Causes of the disease—influence of vitiated air—treatment almost hopeless. At the commencement of these Lectures, I called your attention to the predominence of the spinal over the cerebral part of the nervous system, as constituting one of the grand characteristics of early life. Since then, our daily course of inquiry has brought before us numerous confirmations of this truth, and has shown us how slight a disturbance of the functions of the brain may suffice to destroy the harmony of those which belong to the spinal cord. To-day we pass from the consideration of those cases in which the brain, is the original seat of disorder, and the spinal 'cord suffers only secondarily, to the study of others, where that organ is primarily affected. I need not remind you, how much obscurity hangs over the 1 Of the 34 cases of non-tuberculous tumors in the brain, which form the basis of Friedereich's elaborate " Beitrage zur Lehre von den Geschwiilsten innerhalb der Schadelhohle" (8vo., Wiirzburg, 1853), none occurred in children under 10 years old ; and only four in young persons between the ages of 10 and 20. IRRITATION AND CONGESTION OF THE SPINAL CORD. 143 ailments of the spinal cord at all periods of life ; but in the young subject this is not ai little increased by the difficulty that attends the observation of some of those symptoms which would be obvious enough in the adult. Thus, for instance, while impairment or loss of the locomotive power in the grown person could hardly escape our notice for a moment, it might fail to attract much attention in a young child, who often totters in his gait, or even becomes unable to walk, if from any cause his health should fail. Or, again, the impaired sensation, or the vague pains in the limbs, which the adult would be sure to tell us of, would be but ill described by a child, even though it had long been able to talk, while terror might cause it to cry if any attempt was made to examine its back, |nd might thus prevent our ascertaining the presence or absence of tenderness of the spine. These are difficulties, however, which patience and tact will overcome; for not only the diseases of the spinal cord, but the symptoms by which they manifest themselves, are much the same at all ages, the chief difference being that in the one case they strike the eye even of the careless, while in the other, careful observation is necessary for their detection. Irritation of the cord, however produced, gives rise in the child, as well as in the adult, to impairment of the motor power. A little boy, between two and three years old, remarkably strong and healthy, was observed, without any obvious cause, to fail in his general health, and at the same time to totter in his gait, to become indisposed to move, and, at last, almost entirely to cease walking; and this impairment of his power of walking was quite out of all proportion to the signs of ill health by which it was attended. After watching him for a time, it was discovered that the child had become addicted to the practice of masturbation. This was put a stop to, and he soon regained his health, and with it his power of walking. In this instance the cause of the irritation of the cord, and of the con- sequent impairment of its functions, was obvious enough, but cases now and then occur in which symptoms of disorder of the spinal cord manifest themselves without our being able to discover on what they depend. Such cases, too, are all the more important from the circum- stance that the symptoms which attend them simulate serious disease, and are likely to lead us into the unguarded expression of a very un- favorable prognosis as to their issue. On the 30th of December, a few years ago, I saw a delicate boy, between four and five years old, who had been drooping in health, though without any definite symptom, for a week or two; but had complained of a stiff neck for the first time on the previous Christmas day. This ailment, however, had disappeared, and recurred more than once between then and the 28th; since which last date it had been constant, though not always the same in degree, being less marked in the morning, more so towards night. The child looked out of health, and seemed verv languid; he moved very cautiously, as if afraid of the slightest jar; his shoulders being raised, his head thrown rather back, and kept most carefully motionless; while he complained bitterly of any attempt to bend his neck, and said that 144 MENINGITIS OF THE SPINAL CORD. pressure on the upper part of the cervical spine occasioned him much pain. The boy's appearance and manner were precisely those of a patient suffering from disease of the cervical vertebrae; and a most experienced surgeon, who saw the case with me, expressed himself as very apprehensive that the case was a bad one, though whether the disease was in the spinal cord or in the vertebrae he considered to be uncertain. 1 certainly took a most unfavorable view of the affection; and was much surprised to learn subsequently that, after the applica- tion of four leeches to the back of the neck, the child went to sleep, slept during the night, and awoke the next morning with the most complete power over the muscles of the neck, showing no pain in moving his head, complaining of no tenderness of the spine, nor did any such symptoms manifest#themselves at any subsequent period. I do not pretend to explain the case; I relate it, because it was new to me, and may be so to you also. Probably there was some unusual congestion of the vessels of the cord, which the local depletion at once removed, and thus cured the patient. That such a condition existed in the following instance is still more likely, for here there was a local injury amply sufficient to produce it. In May, 1845, a little girl, four years old, was brought to me by her mother, who said that ten days before, the child had had a fall on her back, while left in the charge of a servant; that on the following morning she was unable to stand or move, unless supported; and that she had ever since continued in the same condition. Her appearance was rather anxious; her face was slightly flushed; skin warm and dry; tongue slightly furred; pulse frequent, and with power. If placed on her feet, she clung hold of her mother, sank down into a stooping, half-squatting posture, and immediately began to cry. She could walk if firmly supported, but hurriedly and unsteadily, stepping on her toes, her legs moving in a semicircle with her toes turned in- wards, and one foot being put down just in front of the other. On examining the spine, the integuments from the tenth to the twelfth dorsal vertebra presented a little puffmess, and there was very great tenderness of the spine in that situation ; and even when not touched, the child complained of pain in her back. There was no appetite, but great thirst; the bowels were constipated; the appearance of the urine was natural, and neither feces nor urine were voided uncon- sciously. She was cupped on the loins to 3iv, and on the following day was much relieved, moving her legs more readily, and suffering much less from pain in the back On the 17th she was able to stand, and could walk a little without suffering. Attention was paid to keep the bowels open, and in a few days she was quite well. Besides cases of this kind, however, in which there is some uncer- tainty as to the cause of the functional disorder of the spinal cord, others are sometimes met with of a more formidable, though of a less obscure kind. Such are the cases, fortunately by no means common, in which the spinal cord or its membranes are the seat of inflam- mation. Inflammation of the membranes of the spinal cord prevailed epidemi- MENINGITIS OF THE SPINAL CORD. 145 cally in many parts of France from 1842 to 1844. The victims of the disease, which proved very fatal, were almost entirely youths a little past the period of puberty. An epidemic of a similar kind was lately prevalent in many of the hospitals and workhouses of Ireland ; but in that country boys under twelve years of age were almost the only persons who suffered from it. The arachnoid of the spinal cord was found in every instance to be the part chiefly affected, though in most cases the membranes of the brain seem to have been slightly involved in the disease. Notwithstanding the great extent of the inflammation of the membranes of the cord, and the effusion of lymph beneath them. the nervous substance appears to have been comparatively seldom attacked by it, and never with much severity. The disease generally came on very suddenly, and its course was often extremely rapid, some patients dying in twenty-four hours, while few survived the fourth day. Severe pain in the abdomen, attended with vomiting and purging, and a condition of general collapse, marked the outset of the affection. A state of reaction soon succeeded, the surface in the course of a few hours becoming hot, the pulse full, and its frequency varying from 120 to 140, while the face assumed a tetanic expression, and the head was retracted and firmly fixed. General convulsions, or coma, succeeded to this condition, and failure of deglutition, with a slow and labored pulse, followed as the immediate precursors of death. I must refer you to Dr. Mayne's account of this epidemic, which is contained in the Dublin Quarterly Journal for August, 1846, for I have not seen the disease in any other than a sporadic form, and even then but seldom. Perhaps, therefore, I shall convey to you a more truthful impression of the general characters of inflammatory affections of the spinal cord and its membranes, by relating to you a few of those instances that have come under my own notice, rather than by attempt- ing to draw a general portraiture of them from too small a number of examples. A boy, aged eleven years, of a phthisical family, who seven months previously had had severe and long-continued attacks-of headache, was greatly distressed by hearing of the sudden death of a relation. On the following day he had slight nausea, with pain in the head; but in a day or two he suffered more from pain in his limbs, especially in the calves of the legs, and also shooting from the situation of the coccyx to the middle of the back. He complained, moreover, of a constant pain at the epigastrium, which, as well as that about the lower part of the back, was always much aggravated when the bowels acted; they being, however, usually constipated. These symptoms were associated with great weakness of the legs, which he dragged when walking, and he reached the Children's Infirmary, from which his home was about a mile distant, with much difficulty. On the following day I visited him, and ascertained, on examining the spine, that there was conside- rable tenderness on pressure from about the middle of the dorsal ver- tebras to the apex of the sacrum, but greatest about the lumbar region. There was no intolerance of light, but very distressing sense of giddi- ness, complete loss of appetite, constant sensation of sickness, and a nasty taste in the mouth. The intellect during the whole illness was 10 116 MENINGITIS OF THE SPINAL CORD. only once affected, and then but for a few hours; and the child was remarkably acute, and described his different sensations with great exactness. The pain in the loins was relieved by cupping; but on the next day the headache was increased in severity, and there was some subsultus of the tendons of the forearms, and a good deal of twitching of the hands. This symptom disappeared after the boy had been depleted copiously by leeches to the head, and after his gums had begun to be affected by "mercury, which was freely administered to him; but his pulse, which during the whole of his illness never exceeded 75, sank to 60 in the minute, and its beat became irregular. As the mouth became decidedly sore, first the shooting pains in the back and limbs ceased; then the pulse became regular, and rose in frequency; then the epigastric pain disappeared, and was succeeded for a time by a sense of weight there. By degrees the tenderness of the spine dimi- nished, and finally ceased, and the headache grew less; but his legs long continued weak, so that he could not tread firmly, and the slightest noise, or any kind of over-exertion, brought on an immediate increase of his sufferings. A seton was put in the back of his neck, and the influence of mercury on the system was cautiously maintained for four months before the boy appeared sufficiently well to justify the discon- tinuance of remedies. But the disease may run a more acute course, and to a less favor- able termination. A little boy, one year old, who had cut four incisor teeth, and whose health had been habitually good, was brought to me by his mother, after three weeks' illness. She told me that he had been suddenly seized with great fever and heat of skin, accompanied, after a lapse of four days, by violent screams. At the outset of his illness, he had been cupped at the back of his neck, and leeches had been applied to the head, without amendment, and, for a week before I saw him, all treat- ment had been discontinued. The child then lay in his mother's lap, frequently crying with a low distressed whimper; his face was usually pale, but occasionally flushed; his head was thrown back, so that the occiput and back of the neck were nearly in contact with each other. The sterno-mastoid muscles were rather rigid, though there was no trismus. The hands were clenched, the thumbs drawn into the palm, and occasional attacks came on, in which he uttered a scream, and then bent his body back into an arch. The child sucked eagerly, but fre- quently dropped the nipple as if in pain; the pupils acted naturally; the pulse was frequent, small, and hard. In the course of the suc- ceeding day, frequent convulsive twitchings and startings of the limbs took place, affecting the left arm more than any other part. His face grew habitually pale and more sunken, and the spine became habitu- ally, though slightly, curved forwards, notwithstanding which, occa- sional attacks of opisthotonos still occurred. The pupils still acted well, but a new symptom appeared, in the labored breathing, which sometimes became so difficult that the child seemed almost choking, while phlegm collected in his throat, which he appeared unable to get rid of. This dyspnoea would almost imply that the inflammation MENINGITIS OF THE SPINAL CORD. 147 had been gradually travelling upwards till it began to involve the origins cff the cerebral nerves—a supposition still further confirmed by finding, two days afterwards, that the eyeballs were in state of con- stant convulsive rotation. After this, which was the fifth day from that on which I first saw the child, he was not again brought to me; but, though this case is incomplete, yet it helps to fill up the portrait- ure of the disease. To complete it, however, I must relate one instance more, in which the results of examination after death, confirmed the diagnosis. Some years ago, I saw a little boy, five months old, of whom his mother gave me the following history : A month before, he had been attacked by shivering (an unusual occurrence in a young child), and, in the night following this seizure, had many fits, during which he screamed much, and became very stiff. After they had continued for three days, returning at intervals of an hour or half an hour, a little diminution in their severity followed the use of some medicine pre- scribed for him by a surgeon ; but, even when I saw him, ten or twelve often occurred in the twenty-four hours, though a day would now and then pass without any. The fits were described as presenting the characters of opisthotonos, though in a less marked degree than when they first came on. The retraction of the head, by which they were attended at first, subsided as they passed off; but in the course of two or three days, the tendency to keep the head thrown back became constant, and for a fortnight the head had never been brought out of that position. The mother thought, too, that the child had been blind for that period. The child appeared well grown and well nourished, and the face was not expressive of particular suffering, but the head was drawn back so that the occiput rested between the shoulders, while the back was bent forwards in a state of perfect emprosthotonos; the legs were drawn up towards the abdomen, the palms of the hands turned back- wards and outwards, the fingers clenched, and the thumbs drawn into the palm. On turning the child round on its face, the body formed a complete arch, resting on the chin and knees. The whole spine was very tender, and this tenderness was greatest about its upper part. The pupils were dilated and immovable; suction was difficultly per- formed, though there was no trismus, but the child vomited everything it took almost immediately. The pulse was at this time too rapid and too feeble to be counted, and the child died in a fit of convulsions, twenty-four hours afterwards. On examining the body, blood was found effused, though not in any considerable quantity, within the spinal canal, but external to the dura mater, from the third cervical to the third dorsal vertebra. A thick layer of white lymph was present, both under the arachnoid and in its cavity, along the whole posterior surface of the lumbar and dorsal portions of the cord, and likewise existed in the cervical portion, though in a less degree. Anteriorly, blood and lymph occupied the whole cervical portion of the sac of the arachnoid, and were effused beneath the membrane; but in the remainder of the front of the cord, there were merely patches of lymph beneath the arachnoid. The 148 ACUTE INFLAMMATION OF SUBSTANCE OF CORD. substance of the cord was apparently healthy. On lifting up the cere- bellum, a considerable quantity of serum, with flakes of lymph, escaped from the base of the skull, and the whole under surface of the cere- bellum had a uniform coating of white lymph at least a line and a half in thickness, which extended over the medulla oblongata, and was continuous with the deposit of lymph along the spinal cord. The lateral ventricles of the brain were much distended with fluid, in which large irregular masses of yellow lymph were floating. The corpora striata and the fornix were much softened, but the rest of the brain and the membranes at its convexity were quite healthy. It can scarcely be necessary that I should comment on these cases, either to point out to you the many respects in which inflammation of the spinal cord differs from that of the brain, or to insist on the absolute necessity of active antiphlogistic treatment being adopted at the very outset of the disease. I apprehend that in the case that recovered, as well as in the other two which terminated fatally, the membranes were chiefly, if not exclusively, affected. I have not met with any instance of acute inflammation and subsequent softening of the substance of the spinal cord, although there are many such on record. It has been supposed that paralytic symptoms usually attend this affection, while stiffness and spasm of the muscles characterize spinal meningitis; but though this is probably true in many instances, yet it does not by any means hold good in all. Three cases are related by MM. Rilliet and Bar- thez, where the disease ran its course with symptoms of tetanus and trismus, which continued up to the time of the patient's death. In one of these cases the child died in thirty-six hours ; in the second, in ninety-six hours; but in the third, a temporary remission having occurred, the patient survived for thirteen days. I select from Dr. Mauthner's valuable treatise on the disease of the Brain and Spinal Cord in Children, a very characteristic case of acute inflammatory softening of the spinal marrow.1 A girl, aged eleven years, whose occupation as a sempstress com- pelled her to remain for many hours daily in a sitting posture, with her head bent forwards, while she was at the same time much exposed to currents of cold air, was seized, after she had followed this employ- ment for three weeks, with dragging and tearing pains in the back of her neck. As these pains grew more severe, voluntary power over the arms became impaired, and the paralysis increasing rapidly in spite of the application of leeches to the back of the neck, she was admitted into the Hospital for Children at Yienna, under Dr. Mauth- ner's care, on Dec. 26th. Both arms were at that time completely palsied, flaccid, cool, and almost insensible; the lower extremities still obeyed the will, but the girl was unable to stand firmly. The mind was perfectly clear, the appetite good, deglutition easy, and pulse natural; and in these respects her condition continued un- changed to the very last, except that the pulse became very frequent on the day of the child's death. On the 28th, the legs were palsied, 1 Lib. cit., p. 421, Case 117. CHRONIC INFLAMMATION OF SUBSTANCE OF CORD. 149 and the urine was passed involuntarily. On the 29th, voluntary power over the hands and feet was likewise completely lost, and sen- sation in them was imperfect. On the 30th, sensation was perfectly lost in all extremities. The child had desire to pass feces, the bowels not having acted for three days, but she had not power to do so. On the 31st, the sphincter ani was likewise paralyzed, and opened to the size of a shilling. On January 4th the hardened feces began to fall out of the gaping anus; the respiration was feeble, articulation diffi- culs. On the 6th, the child was in much distress, and for many days < had scarcely slept at all; the whole left side of the body was com- pletely paralyzed, and only the right side of the chest moved in res- piration. Her exhaustion was so extreme that her voice was scarcely audible, but the muscles of the face still retained the power of motion and sensation perfectly, and the intellect was quite clear, though the child died the same night. The spinal cord presented the only morbid appearance; the mem- branes being perfectly healthy. The medulla oblongata was as soft as butter, of a yellow color, not retaining a trace of its natural organi- zation ; and the same condition existed in the whole of the spinal cord as low as the cauda equina, where it once more resumed its natural appearance and characters. The chronic form of inflammation of the cord will much oftener come under your notice as one of the consequences of caries of the vertebrae. You will remember, too, that this serious result, and the paralysis to which it gives rise, are not produced simply by the distortion of the spine and the mechanical compression of the cord, but rather by ex- tension to it of inflammatory action. You have, then, in these cases a double danger to combat; both that which arises from the disease in the spinal column itself, and that which depends on the probable extension to the cord of the disease which began in the bones. The symptoms of the two affections present likewise so many points of resemblance in their early stages that you can never feel sure that the cord is uninvolved. Of this we have ample proof in those rare cases in which chronic softening of the cord occurs independent of any affection of the bones of the spine. You will find a case that illus- trates this fact very well in M. Louis's valuable paper, On the Condi- tion of the Spinal Marrow in Cases of Caries of the Vertebrse;1 and I will relate to you another still more remarkable instance of it, which came under my notice. On March 31, 1846, a little girl aged three years and a quarter, the strumous child of unhealthy parents, in whose family phthisis was hereditary, was brought to me by her mother. Nine months pre- viously, her father having taken her in his arms and tossed her, she suddenly cried out that she was hurt, and for several days afterwards refused to walk, and seemed unable to stand, sinking down on her hams if set on her feet. She made no definite complaint, however; no injury was anywhere observable, and in about three weeks she 1 Memoires, ou Recherches Anatomico-Pathologiques, 8vo., Memoire viii. Observ. i. p. 411. Paris, 1826. 150 CHRONIC INFLAMMATION OF SUBSTANCE OF CORD. seemed to have recovered her health, and continued well until the middle of March, when her frequent complaints of pain in the neck attracted her mother's attention. The appearance of the little girl, when first placed under my care, was very remarkable; for though the face wore no expresion of suffering, yet the neck was so much bent as to give an unusual prominence to the seventh cervical verte- bra, and the head was constantly directed downwards. No part of the spine seemed particularly tender; but any attempt to raise the head was forcibly resisted, and seemed to occasion considerable pain. The child walked, though with a tottering gait, and if left alone for a few minutes sank down upon her knees to play. Her constant complaint was of being tired and drowsy, notwithstanding which she slept ill; her appetite was bad, and her bowels were constipated. I regarded the case as one of incipient disease of the cervical vertebras, and was anxious to make an issue in the back of the neck, but the parents refused to consent to this proceeding. Medical treatment, therefore was confined to the administration of the cod-liver oil, and afterwards of the syrup of the iodide of iron; but though no fresh symp- toms appeared, the child gradually lost strength. On the 12th of May, she was able to walk a distance of nearly half a mile; but on the 14th, though not worse in other respects, she was unable to raise her hands, and was forced to be fed by another person. In the even- ing she complained of her eyes aching, but nevertheless slept tolerably well till 1 A.M. She then awoke crying and fretful; but on being taken up passed an evacuation, and on lying down again, after a few efforts to vomit, which soon subsided, spoke a few words to her mother, in whose arms she was lying. After breathing in a sighing manner for a few moments she seemed to fall asleep, and in this sleep died so quietly, that her mother was ignorant of it until awakened by her daughter's corpse beginning to grow cold. On examining the body after death the brain was found to be quite healthy, with the exception of some venous congestion of the arach- noid. The muscles of the back and the bones of the spinal column were perfectly healthy; but on laying open the vertebral canal, the spinal cord, from a level with the third down to the seventh cervical vertebra, bulged considerably, so as completely to occupy the canal, though above and below this its size was natural. In this situation the two layers of the arachnoid of the cord were firmly connected together by numerous filamentous adhesions, and the membrane itself was opaque and thickened. The cord in the situation of this bulging had a shining gelatinous appearance, not unlike turbid and badly made jelly, with a yellowish lymph-like matter infiltrated into it. This softening involved the posterior columns of the cord much more than the anterior; the bulging, too, seemed due to the posterior columns, though the anterior pre- sented some degree of softening. Three apoplectic effusions were discovered in the spinal cord. The first was situated just below the calamus scriptorius, and was about the size of a lentil; the nervous matter all around being perfectly healthy. The second, which was larger, was just at the commence- INFANTILE TRISMUS — ITS SYMPTOMS. 151 ment of the swelling of the cord, and partially extended into the sound parts. It just showed through the surface of the cord as big as half a pea, but on longitudinally dividing the cord, was seen to be of the bigness of a kidney bean; and the third effusion, just above the termination of the swelling of the cord, was about as large as a big pea. Besides these there were several small ecchymosed spots in the softened parts of the cord, but all the effusions of blood were strictly limited to the posterior columns of the cord. This case presents many points of interest. The scrofulous dia- thesis in the family; the probable injury to the spine, followed, for a short time, by impairment of the motor power; the subsequent occur- rence of pain in the bended neck, and the fixed position of the head, all seemed to warrant the opinion that the vertebras were diseased; but all resulted from inflammatory softening of the spinal cord, while the bones were perfectly healthy. The softening of the posterior columns of the cord, and the extravasation of blood into their sub- stance, while the anterior columns were in a state of comparative integrity, are occurrences very remarkable when coupled with the impaired motor power.1 Cases such as this are warnings to us to avoid hasty generalizations on physiological subjects; they show us how hard some of the Sphinx's riddles are to read. There still remains one affection which we must notice in connec- tion with the diseases of the spinal cord, although it is one whose pathology is by no means thoroughly understood. The trismus or tetanus of new-born children is a malady which, though frequent in the West Indian Islands, is seldom seen in this country. Four in- stances of it have come under my own notice, three of which occurred in the Dublin Lying-in Hospital, while for the opportunity of observ- ing the fourth, I am indebted to the courtesy of Mr. Stone, of Christ's Hospital. The disease may come on within twelve hours after birth, or, on the other hand, may not occur for several days; but it very rarely makes its appearance after the lapse of a week. I once saw it attack a child fifteen hours after its birth, but in the other cases it came on upon the fifth day in one instance, and the sixth in the other two. Though it runs a rapid course, yet its onset is gradual; one of the first things that attracts the mother's notice being, in general, that the child does not take the breast when put to it, but utters a whimpering cry, and if the mouth be then examined, it will be found more or less firmly fixed. Sometimes general convulsions come on suddenly, and usher in the other symptoms, but they more frequently follow than precede the trismus. When fully developed, these fits, which come on in paroxysms, are ushered in by a screech, or are attended by some impairment of the respiration, and during their continuance the whole surface becomes livid. The hands are strongly clenched, the feet forcibly flexed on the ankles, and the toes bent, and remain so during the fit, and the trunk is curved backwards in a condition of ' It is impossible in so young a subject to ascertain accurately the state of sensation, but there was no obvious indication of its impairment in this case. 152 TRISMUS — ITS PATHOLOGY DOUBTFUL. opisthotonos; the mouth is generally drawn slightly open, and the lower jaw firmly fixed. When the fit subsides, the muscles do not be- come generally relaxed, but the child still lies with its hands clenched, and its thumbs drawn into the palm, the legs being generally crossed, and the great toe separated widely from the others, while the head is thrown back, and the opisthotonos continues, though in a diminished degree. The condition of the mouth is peculiar and characteristic. The jaws at first are slightly open, and the corners of the mouth drawn downwards and backwards, but as the disease advances the jaws be- come quite closed, the corners of the mouth even more drawn down, and the lips firmly compressed against the gums. The power of suck- ing is early lost, but for some time the child continues able to swal- low ; at length, however, it accomplishes this with great difficulty, a convulsion sometimes following the attempt, while even that fluid which had apparently been swallowed is, for the most part, speedily regurgitated. The child dies either during some paroxysm of convul- sions, or, seeming much exhausted, it sinks into a comatose condition, and so expires. There are few affections that run so fearfully rapid a course as this; its fatal termination almost always taking place within thirty-six, often within twenty-four hours from the appearance of the first symptoms. The most frequent post-mortem appearance in these cases, and that which I found in the bodies of all the four children whom I observed, consists of effusion of blood, either fluid or coagulated, into the cel- lular tissue surrounding the theca of the cord. Conjoined with this there is generally a congested state of the vessels of the spinal arach- noid, and sometimes an effusion of blood or serum into its cavity. The signs of congestion about the head are less constant, though much oftener present than absent, and sometimes existing in an extreme degree, while in one instance I found not merely a highly congested state of the cerebral vessels, but also an effusion of blood in consider- able quantity between the skull and dura mater, and also a slighter effusion into the arachnoid cavity. In spite, however, of the striking nature of these morbid appear- ances, I formerly hesitated in referring the symptoms of trismus with certainty to this apoplectic condition of the cord. My hesitation arose from the circumstance that on examining, some years ago, the bodies of infants who died soon after birth in the Dublin Lying-in Hospital, I very frequently found great fulness of the vessels of the cord, and a gelatinous matter, which was frequently deeply tinged with blood, effused around its theca. It therefore became a question whether appearances such as are met with in cases of trismus might not in reality be due to the position in which the bodies had been allowed to remain, resting on the back, and thus be rather the result of simple gravitation than the consequences of the disease. These doubts, how- ever, have been set at rest by the very excellent observations of Dr. Weber, of Kiel,1 who placed the bodies of infants in various positions 1 Beitriige zur pathologischen Anatomie der Neugebornen, 8vo. part i. pp. 7, 63, and 73. Kiel, 1851. CAUSES OF TRISMUS. 153 before examining them, and thus was able to discriminate between morbid and pseudo-morbid appearances, and who, moreover, although he on every occasion placed children who had died of trismus upon their face immediately after death, yet always found intense injection of the minute vessels of the cord and its membranes, extravasation of blood external to the theca, and other appearances similar to those which I have just described to you. There are few diseases respecting the cause of which opinions so various have prevailed as with regard to trismus. Bearing in mind the frequency of external injury as a cause of locked-jaw in the adult, some writers have sought to find in every case the history of a blow or other injury to which it might possibly be attributed; while others have conceived that it depended on awkward management of the navel-string, or on injury of some kind or other inflicted on it. This last opinion has appeared to derive support from some cases in which the umbilical vein has presented the signs of phlebitis; but further observation has shown these appearances to be anything but constant, and though carefully sought for, they were not found in any of the cases which came under my notice. Moreover, a German physician, Dr. Mildner, of Prague,1 who has recorded the results of 46 cases of fatal inflammation of the umbilical vessels in children born in the Lying-in Hospital in that city, states that convulsions occurred in only 5 of the number, and that in no instance had these convulsions the least resemblance to those which characterize trismus. Congestion of the liver, impairment of its functions, and icterus, were among the symptoms which attended it, as well as, in many of the cases, peri- tonitis, inflammation of the abdominal integuments, purulent infection of the blood, and the formation of abscesses in the joints, which oc- curred 33 times, while in 4 cases hemorrhage took place from the umbilicus. We may, then, fairly conclude that the connection be- tween this disease and trismus is merely an accidental coincidence. The remarkable frequency of the disease in hot climates, where the heat of the day is succeeded by intense cold at night, favors the opinion that interruption of the function of the skin, by sudden alter- nations of temperature, is a powerful cause of the disease. In an epidemic of this disease in the Lying-in Hospital at Stockholm, in 1834,2 there seemed also to be a most marked connection between the periods of its greatest prevalence and the fluctuations of temperature. Nothing, however, can be more satisfactorily proved, than the ten- dency of a vitiated state of atmosphere to produce it. Where such a condition exists, there trismus abounds, be the peculiarities of climate or temperature what they may. It is very frequent among the chil- dren of the negroes in the slave States of America; it is depopulating the island of St. Kilda, and 64 per cent, of the infants born in West- mannoe, a small islet off the coast of Iceland, die of it between the fifth and twelfth day from birth.3 Dirt, and defective ventilation, are i Prager Vierteljahrschrift, v. 2, 1848 ; and Schmidt's Jahrb. No. 7, p. 64, 1848. 2 Cederschjold, in Busch's Zeitschrift fur Geburtsk., x. 345. 3 See a very interesting notice, in the British and Foreign Medico-Chirurgical Re- view for April, 1850, of a work by Dr. Schleisner on the Sanitary Condition of Iceland. 154 CONVULSIONS. probably almost the only points in common between the dweller in the southern States of the Union and the inhabitants of Northern Europe and the Arctic regions. But, if any further proof were needed that to this cause, and not to some fancied displacement of the cranial bones,' this disease is really to be attributed, we are furnished with it in the records of the Dublin Lying-in Hospital, which point out both the evil and its remedy. Sixty years ago, every sixth child born in that institution died within a fortnight after birth, and trismus was the cause of the death of \% of these children. Dr. Joseph Clarke adopted means to secure the efficient ventilation of the hospital, and the mortality of the children fell at once to 1 in 19^; and during Dr. Collins's mastership, from 1826 to 1833, was only 1 in 58$, and but little more than the ninth part of that mortality depended on trismus.2 But though we may hope by wise hygienic measures to avert this disease, yet, when once it has become developed, our prospects of cure are so slender that I may almost say the task is hopeless. I have not seen leeches employed, but, bearing in mind the post-mortem appear- ances, should certainly be disposed to apply them freely at the outset of the disease. I have seen the hot bath used with temporary relief; but though I have witnessed the employment of calomel and of anti- spasmodics, as assafoetida, and the administration of an enema of gr. iij of tobacco infused for half an hour in Iviij of water, yet I have never known any of these means followed by even a temporary pause in the symptoms; and the endeavor to excite the action of the skin is the only measure that in the cases which I witnessed seemed to be of the slightest service. LECTURE XIII. Convulsions, independent of organic cerebral disease—their two forms. The acute form, how distinguishable from those dependent on disease of the brain—practical importance of the distinction—rules for their treatment. The chronic form— relation to them of Spasm of the Glottis—import of this spasm—one of several signs of disorder of nervous system. Relation of these convulsions to processes of development in teething—but exciting causes various. Symptoms—descrip- tion of carpo-pedal contractions—ways in which death is produced. Treatment— rules for diet and for the regulation of the bowels—caution with respect to lancing the gums—occasional necessity for free depletion—case in illustration. Sugges- tions as to general management, and prevention of an attack. Use of chloroform. Remarks on some anomalous forms of convulsion, and on the Eclampsia Nutans. In the third of these Lectures, when passing in review the different signs of disorder of the nervous system, I made some remarks on the 1 A theory propounded by Dr. Sims, of Alabama, in the American Journal of the Medical Sciences for 1846, and further expanded in the same journal for July and October, 1848. 2 Collins's Treatise on Midwifery, p. 513. ACUTE FORM OF CONVULSIONS. 155 subject of convulsions. I tried to show you how their import varies in different circumstances; how at one time they betoken real disease of the nervous centres, at another only betray their irritation from some cause which, if death occur, may yet leave behind no trace such as the skill of the anatomist can discover. Cases of the former kind have hitherto exclusively engaged our attention, but we must not quit the study of disorders of the nervous system without some consideration of the latter. In the adults, fits sometimes occur independent of obvious cerebral disease; the patient falls to the ground struggling and insensible; but after a time the convulsion ceases, consciousness returns, and the patient recovers. Our anxiety in such cases is much less for the present than for the future: death in the fit is a rare accident, but what we dread is the recurrence of the fits, the weakening of the intellect, the slow impair- ment of the health which epilepsy brings with it. In the child our apprehension is twofold; for the frailer machinery is more readily brought to a stand-still, and the risk of death in the fit is far greater than in the adult; while, should the child survive, the convulsions of infancy may issue in the epilepsy of riper years; and, in fact, seem to do so in a very large number of instances. The convulsions of infancy and early childhood generally assume one of two characters. Either they are sudden in their onset, violent in their character, frequent in their return, or they come on gradually and, after various forebodings, present less violence, occur at longer intervals, but are not therefore by any means devoid of peril. Cases of the first kind run some risk of being overtreated, from their sup- posed dependence on active cerebral mischief; cases of the second kind often excite less apprehension than they really warrant, until their symptoms have become manifest in their full intensity. Some of the most marked examples of the sudden access of violent convulsions which have come under my notice have been in children in whom they succeeded to the sudden drying up of an eruption on the scalp. Even in such cases, however, where we might most readily suspect some direct influence on the brain, the character of the fits is widely different from that which we observe in instances of real cere- bral disease. The illness preceding them is neither very marked nor of long duration, while, when the fits come on, instead of only one side of the body, or one set of muscles being affected, sometimes one side is convulsed, sometimes the other, or both are involved equally. Even after the fits have frequently returned, paralysis does not suc- ceed to them, and often neither sleep nor coma, while frequently consciousness returns, even before the convulsive movements have completely ceased, and the pupils, though dilated during the fit, act again almost or quite as well as ever as soon as it has passed off. Vomiting does not precede nor accompany the attack; nor an obsti- nately constipated state of the bowels; and the abdomen is often much distended with flatus, the endeavor to get rid of which produces trou- blesome hiccough, while the inspiration is often accompanied by a peculiar crowing sound. There is at no time the burning heat of the head which is observed in active inflammatory disease of the brain; 156 ACUTE FORM OF CONVULSIONS. there are not the piercing cry, nor the constant wail, nor the tearless eyes, nor the shrunken abdomen, nor the automatic movements of one side and the contraction of the limbs on the other, which attend upon tubercular hydrocephalus. These characteristics are such as ought to prevent the by no means unusual error of regarding the attack as symptomatic of active disease of the brain; and under that impression depleting the child freely, dosing it with mercury in large quantities, and at short intervals; a course of proceeding by which all chances of recovery are frustrated, and hopes, small at first, are altogether destroyed. The state of the child before the occurrence of the fits, and the amount of apparent congestion of the brain, must in cases of this kind determine the question of depletion. Moderate depletion once is often well borne, but the persistence of the fits must not be thought neces- sarily to indicate the propriety of its repetition. If the attack suc- ceeded to the rapid disappearances of some eruption on the scalp, an attempt may be made to reproduce it by rubbing in every three hours an ointment composed of one drachm of powdered ipecacuanha to an ounce of lard; which generally produces an abundant papular erup- tion in the course of from twelve to twenty-four hours. If a purgative be indicated, a single dose of calomel has the advantage of acting surely and speedily, but mercury, given in any other manner or with any other object, is out of place. The flatus by which the intestines are distended is got rid of better by an assafcetida enema than by any other means; while the application to the abdomen of a cloth dipped in a stimulating liniment (such, for instance, as a drachm of oil of turpentine, five drachms of the simple camphor liniment, and six drachms of olive oil), and that covered by a light linseed meal poul- tice, both serves as a counter-irritant, prevents the reproduction of the flatus, and relieves that spasm of the abdominal muscles which in many of these cases adds very painfully to the infant's sufferings. These measures having been adopted, you may now, according to the general condition of the patient, prescribe either some carminative medicine with small doses of ether, or of the fetid spirits of ammonia, or a single dose of Dover's powder, if restlessness and excitability have outlasted the other symptoms; or a simple saline, as the citrate of potash with small doses of the tincture of henbane ; or the hydrocyanic acid with a little chloric ether at short intervals—a sedative which, whenever there is a doubt as to the expediency of employing direct narcotics, has always seemed to me of especial value. Within certain limits, this treatment must of course be modified according to the exact nature of the case, but enough has already been said to mark out the general principles upon which your treatment should be conducted ; while even if the attack had seemed at first to present some obscurity as to its cause, a few hours will suffice for its removal; will develop the signs of cerebral inflammation, if that were impending, or will bring to light the character of the fever which is making this stormy onset. So long as, notwithstanding the frequency of the return of the fits, recovery is complete after each, so long as the power of deglutition subsists, and the natural hue of the lips and face SPASM OF THE GLOTTIS. 157 announces the oxygenation of the blood to be well performed, you may give on the whole a favorable prognosis, though always guarding it by admission of the possibility of the child dying in a fit from that spasm of the glottis, and consequent arrest of breathing, which is the great source of danger in infantile convulsions. This Spasm of the Glottis is, indeed, one of the most remarkable features in many convulsive affections of infancy and childhood; though more especially of that variety to which I have referred as coming on gradually, and pursuing a somewhat chronic course. So prominent a feature, indeed, is it of this latter class of convul- sions, that attention has been very generally directed to this one symptom, almost to the exclusion of the other signs of disorder of the nervous system by which it is accompanied, and the various terms, spasmodic croup, child-crowing, spasm of the glottis, and laryngismus stridulus, show how great has been the disposition to regard it as a distinct and independent disease. Hence has resulted the inconveni- ence, that attention being directed exclusively to the affection of the respiratory function, local causes have been too much sought for to account for the local symptom; defective, if not erroneous explana- tions of its occurrence have been proposed, and sufficient regard has not been paid in its treatment to the great diversity of conditions under which it may supervene. The sobbing breathing, or the sense of choking, so characteristic of the hysterical patient, are but instances of spasm of the respiratory muscles, similar to those which we observe in the infant, and equally due to the great excitability of the nervous system. In the hysteri- cal girl, fits are frequently superadded to the affection of the respira- tory muscles; and in the child, spasm of the muscles of the extremities, giving rise to the drawing of the thumb into the palm, and to the separation of the great toe from the other toes, or to the forcible ex- tension of the foot upon the ankle, is seldom absent; while general convulsions often supervene under slight causes, or even without any apparent reason. In both cases the affections are usually attendant upon important processes of development, since while in the former instance they generally come on about the period of puberty, they oftenest occur in the latter during the time of teething; and this with so great frequency, that in thirty-one out of thirty-seven cases of which I have preserved a record, the symptoms manifested themselves between the age of six months and two years, or just at that time when the process of dentition is going on with the greatest activity. The direct irritation of the trifacial nerve in teething has no doubt a great share in the production of the symptom at that time, but I apprehend that we should be in error if we confined our attention entirely to the local cause, and attributed this, more than any other form of convulsive affection which occurs at this time, simply to the mechanical irritation of the teeth pressing on or cutting through the gum. The period of teething, like that of puberty, constitutes one of the great epochs of life; it is a time when great changes are going on ill tfie whole organism—when the animal machine, being in a state of increased activity, its parts are more than usually apt to get 158 CAUSES AND SYMPTOMS OF out of order. New diseases appear, or such as were before of rare occurrence become frequent; catarrhal affections and disorders of the intestinal mucous membrane are extremely prevalent, and the brain grows more than ever liable to congestion of its vessels. In these circumstances, the various spasmodic affections, of which spasm of the glottis is the most striking and the most important, often occur as the secondary rather than as the primary result of dentition. The child has cut some of its teeth without any symptom of disorder of the nervous system making its appearance, but at length it suffers an attack of diarrhoea, or the bowels are allowed to become constipated, or signs of cerebral congestion show themselves. A crowing sound now becomes audible with the inspiration, and with it some or all of the whole train of convulsive symptoms which I shall presently describe make their appearance. It may be that the gums are not swollen, nor any tooth near the surface just at the moment when the signs of disturbance of the nervous system occurred, but their connection with the process of dentition is not the less undeniable. In many instances, too, though these symptoms may subside as the health improves, yet so great is the nervous excitability of the patient, that they return when he cuts another tooth, and this even without a recurrence of that general disorder which attended them on the former occasion. The various sources of irritation, however, that give rise to these affections are not limited to the period of teething; and hence they may be met with before the commencement of that process as well as after its termination. By no one has this fact been more clearly stated, or the mode of action of the various exciting causes more successfully explained, than by the late Dr. Marshall Hall. " Spasm of the Glottis," says this distinguished physiologist,1 " is an excitation of the true spinal or excito-motory system. It originates in I. 1. The trifacial, in teething. 2. The pneumogastric, in over- or improperly-fed infants. 3. The spinal nerves, in constipation, intestinal disorder, or catharsis. These act through the medium of II. The spinal marrow, and III. 1. The inferior or recurrent laryngeal, the constrictor of the larynx. 2. The intercostals and diaphragmatic, the motors of respira- tion." In illustration of these observations as to the various causes on which these symptoms depend, I may mention that I have seen them in a child ten weeks old as a consequence of improper feeding: in another, aged nineteen months, they followed the sudden suppression of long continued diarrhoea; while in a third, aged two years, they came on during an attack of purging with severe pain in the abdomen. In another child, aged two years and a half, they seemed to depend on a state of cerebral congestion which succeeded to habitual consti- 1 Lib. cit., p. 171. SPASM OF THE GLOTTIS. 159 pation; in a fifth, aged nine months, they supervened in the course of chronic hydrocephalus; and, not needlessly to swell the list, in a sixth child, who died when two months old, convulsions occurred for a period of six weeks, and eventually occasioned its death, without its having been possible to discover, either from the symptoms or from the appearances found on examination of the body, any cause to which they could be attributed. But this principle admits of a wider application. Not only are the convulsions which occur during dentition symptomatic of something more than the undue pressure of a tooth against the gum, but in by far the greater number of instances, we have to look deeper than the local cause to which at last the signs of disturbance of the nervous system were due, and find that it is only on the removal of some influence which acted injuriously on the whole constitution that the liability to convulsions ceases. Thus, for instance, in the child brought up by hand, the commencement of teething is ushered in by convul- sions, a wet-nurse is procured, the convulsions cease; or medical care has failed to relieve the infant resident in London, it is removed to the country and the fits previously so frequent disappear. In spite, however, of the illustration of this fact which the action of remedies affords, it is yet too often lost sight of. The defective nutrition which shows itself in the bowed limbs, and distorted form of the rickety patient, is attended in early life by special proneness to convulsious. A German physician1 thought that he had discovered, in the tardy ossification of the skull, in such children, an adequate explanation of their liability to disturbance of the functions of the imperfectly protected brain, and putting a part for the whole, wrote by a very pardonable, but not the less mistaken synecdoche, an essay on " The soft Occiput." Again, one of the commonest manifestations of the tuberculous diathesis is glandular enlargement; and the late Dr. Hugh Ley2 propounded a theory which explained the symptoms of spasm of the glottis by an assumed pressure of the enlarged cervical glands on the recurrent laryngeal nerve. Still more recently, we find a practi- tioner of considerable experience struck by the connection of spasm of the glottis3 with enlargement of the liver, and framing a mechanical explanation of the trouble of respiration by the impediment to the descent of the diaphragm which is occasioned by the great size of the oro-an. Of the frequent coexistence of the enlarged and fatty liver with spasm of the glottis there can be no doubt; but it does not there- fore follow, that we are to accept the mechanical explanation of the fact which Mr. Hood suggests. More than two years ago, my friend and former collegue, Dr. Eolleston, now Lee's Eeader in Anatomy, at Oxford, wrote a paper which I wish that his modesty had not with- held from publication, in which he shows that this same fatty liver is present in many instances of the hydrocephaloid disease of early infancy; the extreme anaemia, the feeble powers, the rapid sinking ' Der weiche Hinterkopf, etc., von Dr. C. L. Elsasser. 8vo. Stuttgart, 1843. 2 On Laryngismus Stridulus. 8vo. London, 1836. 3 On Scarlet Fever and Crowing Inspiration. 8vo. London, 1857. 160 CAUSES AND SYMPTOMS OF under slight ailments, the supervention of signs of disorder of the nervous system (among which spasm of the glottis is by no means necessarily present), being found associated with this grave defect in nature's great alembic, and consequently with imperfect depuration and depraved character of the blood. But modern physiology1 gives a still graver import to this, as to other morbid conditions of the liver in connection with those disorders of the nervous system in early life which are associated with anaemia or with deranged nutri- tion. The liver would seem to be not merely a purifier, but an actual generator, of the blood; its disease, therefore, interferes immediately with sanguification, and prevents the best devised tonic remedies from exercising that influence which otherwise they would not fail to pro- duce. It follows, then, with reference to all the disorders of the nervous system in early life, that while the mode in which they manifest them- selves varies from slight and unimportant causes, and while local accidents may account for their assuming this or the other special form, we must in all instances endeavor to look beyond them to the constitutional ailment, sometimes of one kind, sometimes of another, to which, as their ultimate occasion, they are due. Bearing in mind now what I have just said with reference to the import of Spasm of the Glottis—how it is but one of many signs of the general disorder of the nervous system—we may proceed to exa- mine the conditions under which it usually manifests itself; the symp- toms by which it is generally attended.. It is a disorder that almost always comes on by degrees; and its early symptoms are seldom such as to excite the alarm of non-professional persons. It does not often occur in perfectly healthy children; but an infant who is attacked by it has usually been observed to be drooping for some time pre- viously, to have lost its appetite, to have become fretful by day and restless by night, and to present many of those ill-defined ailments which are popularly ascribed to teething. At length, after these symptoms have continued for a few days or weeks, a slight crowing sound is occasionally heard with the child's respiration. The sound is something between the hoop of hooping-cough and the stridor of true croup; it must be heard to be known, but when once heard will easily be recognized. Usually it is first noticed on the child awaking out of sleep, but sometimes it is perceived during a fit of crying, or comes on while the infant is sucking. Now and then the first crow is very loud, and, by its resemblance to the sound of croup, at once alarms the family : but this is not generally the case; and its loudness usually increases in proportion as its return becomes more frequent. The spasm may have been excited by some temporary cause, and the sound which is its token may in that case not be heard again; but 1 Funke, Lehrbuch der Physiologie, vol. i. 2d ed., 8vo., Leipzig, 1858, says, in § 35, on the metamorphosis of the blood in the liver : " It is the more correct view to regard the liver as an organ the special function of which is the formation of new blood cells, and to consider the change of the materials which during, and probably in consequence of, that new formation are excreted from the blood into bile, only as its secondary duty." See p. 147. SPASM OF THE GLOTTIS. 161 generally it returns after the lapse of a few hours, or of a day or two. It will soon be found, as its return becomes more frequent, that cer- tain conditions favor its occurrence; that the child wakes suddenly from sleep with an attack of it, that excitement induces it, or deglu- tition, or the effort of sucking; so that the child will suddenly drop the nipple, make a croupy sound with its breathing, and then return to the breast again. Throughout the whole course of the affection its attacks will be found to be more frequent by night than by day; and to occur mostly either soon after the child has lain down to sleep, or towards midnight, when the first sound sleep is drawing to a close. At first the child seems, during the intervals of the attack, in as good health as before—except, perhaps, that it is rather more pettish and wilful; but it is not long before graver symptoms than the occa- sional occurrence of an unusual sound with inspiration excite atten- tion, and give rise to alarm. Fits of difficult breathing occasionally come on, in which the child throws its head back, while its face and lips become livid, or an ashy paleness surrounds the mouth, slight convulsive movements pass over the muscles of the face; the chest is motionless, and suffocation seems impending. But in a few seconds the spasm yields, expiration is effected, and a long, loud, crowing in- spiration succeeds, or the child begins to cry. Breathing now goes on naturally; the crowing is not repeated, or the crying ceases; a look of apprehension dwells for a moment on the infant's features, but then passes away; it turns once more to its playthings, or begins sucking again as if nothing were the matter. A few hours, or even a few days, may pass before this alarming occurrence is again observed; but it does recur, and another symptom of the disturbance of the nervous system is soon superadded, if it have not, as is often the case, existed from the very beginning. This consists in a peculiar contrac- tion of the hands and feet; a state which may likewise not infre- quently be noticed, during infancy, unattended by any spasmodic affection of the respiratory organs; though it is often overlooked, since, unlike the peculiar noise in breathing, it does not force itself on the attention even of the most unobservant. It differs much in degree: sometimes the thumb is drawn into the palm by the action of its adductor muscles, while the fingers are unaffected; at other times the fingers are closed more or less firmly, and the thumb is shut into the palm; or, coupled with this, the hand itself is forcibly flexed on the wrist. In the slightest degree of affection of the foot, the great toe is drawn a little away from the other toes; in severer de- grees of the affection this abduction of the great toe is very consid- erable, and the whole foot is forcibly bent upon the ankle, and its sole directed a little inwards. Affection of the hands generally precedes the affection of the feet, and may even exist without it; but I have never seen spasmodic contraction of the feet when the hands were unaffected. At first this state is temporary, but it does not come on and cease simultaneously with the attacks of crowing inspiration, though generally much aggravated during its paroxysms. Sometimes a child in whom the crowing inspiration has been heard, will awake in the morning with the hands and feet firmly flexed, although he may 11 162 SPASM OF THE GLOTTIS. not have had any attack of difficult breathing during the night. At other times, though but seldom, this state will subside during sleep; while very often it is impossible to assign any reason for its cessation or return. The hands may often be unflexed by bending the fingers, but they will resume their former position on the withdrawal of the force; and such attempts are painful to the child. When the contrac- tion is but slight, children still use their hands; but when consider- able, they cannot employ them, and they sometimes cry, as if the contraction of the muscles were attended with pain. Coupled with these carpopedal contractions, the back of the hand and the instep are sometimes swollen, tense, and livid; and occasionally there is slight puffiness about the face. This condition is sometimes more general, and on two successive years the same child was brought to me, in whom these attacks of crowing inspiration were accompanied by a state of tense anasarca of the whole body.1 When the disease has reached this degree of intensity, a slight crowing sound often attends each inspiration, and the paroxysms of difficult breathing are much more severe; they last longer, and some- times terminate in general convulsions. The breathing now does not return at once to its natural frequency, but continues hurried for a few minutes after the occurrence of each fit of dyspnoea; and it is sometimes attended with a little wheezing, from the accumulation of mucus in the trachea and larger bronchi during the paroxysm. When this wheezing is permanent, I do not apprehend that it constitutes any essential part of the disease, but regard it either as due to an acciden- tal complication with catarrh, which is so frequent during the period of dentition, or as the result of the affection being associated with tubercle in the lungs or bronchial glands. The slightest cause is now sufficient to bring on an attack of difficult breathing; it may be pro- duced by a current of air, by a sudden change of temperature, by slight pressure on the larynx, by the act of deglutition, or by momentary excitement. The state of sleep seems particularly favorable to its occurrence, and the short fitful dozes are interrupted by the return of impending suffocation. The general condition of the child varies much during the existence of these symptoms, but is always widely removed from a state of health. The bowels are almost invariably disordered, constipation being more frequent than diarrhoea. The mouth is sometimes hot, and the gums are swollen ; the child is evidently suffering from the process of teeth- ing ; and this is the state with which spasm of the glottis is perhaps most frequently associated. Sometimes there is evident congestion of the brain, and the face is flushed, the head hot, and the pulse frequent; but these flushes of the face are usually temporary, and the skin is generally pallid. When the affection has continued for some weeks, the countenance often assumes a haggard, miserable aspect; and though it may come on in children apparently in good health, I have never 1 This case presented a remarkable similarity to one described by Dr. M. Hall, at p. 185 of his work on the Diseases and Derangements of the Nervous System. 8vo. Loud.1841. TREATMENT OF SPASM OF THE GLOTTIS. 163 known the health continue good, after the disease, even in a mild form, has lasted for any time. Death sometimes takes place during one of the paroxysms of dysp- noea, the child being suffocated by the long continuance of the spasm; or at other times the often-repeated difficulty of breathing induces a state of permanent cerebral congestion ; general convulsions occur, and the child dies convulsed or comatose, serous effusion having taken place into the ventricles of the brain. Should the child escape both these dangers, and should no tubercular disease of the lungs or bron- chial glands exist, recovery is almost sure eventually to take place; though the convalescence is often very protracted, and the attack is apt to return under the influence of the same causes as originally excited it. The treatment of spasm of the glottis must be regulated by the na- ture of the exciting cause; and this, as you have already seen, varies much in different cases. In infants before the period of dentition, it is usually induced by over-feeding, or by food of an improper kind. Our inquiries, therefore, must at once be directed to ascertain how the infant is fed; and supposing it to be still suckled, it will be wise to interdict any other food than the mother's milk—or, at most, to allow only a little barley-water. Spasm of the glottis, however, occurs much oftener in infants who are brought by hand, or in those who have been weaned, than in children still at the breast. In such cases, much pains are sometimes necessary in order to ascertain precisely the kind of food that best suits the infant. Two parts of milk, and one of bar- ley-water, sweetened with a little loaf-sugar; or equal parts of milk and of a solution of isinglass, made of the thickness of barley-water, generally agree very well; but much caution must be used in the in- troduction of farinaceous articles into the child's diet. Asses' milk, which forms the nearest approach to its natural food, must sometimes be given till the child has decidedly improved; while, if it be puny, and do not appear to thrive, and the crowing inspiration continue undiminished, it may become absolutely necessary to restore it to the breast. The state of the bowels requires no less attention than the regulation of the diet. The tendency to constipation must be combated, not by drastic purgatives, but by mild aperients. Castor oil often answers the purpose very well, but sometimes each dose of it nauseates a child for several hours, and then it is not desirable to employ it if a daily aperient should be needed. Both senna and manna are apt to gripe; and if they be found on trial to produce this effect, their use must not be persevered in. Few medicines act more mildly or more certainly in children than aloes; and the bitter of the compound decoction may be much concealed by extract of liquorice. The bulk of a medicine, however, often opposes a great difficulty to its employment in infancy; and if that be the case, the powder may be substituted for the decoc- tion. If slightly moistened, mixed with a little coarse sugar, and placed on the tongue, it will often be swallowed very readily. The habitual use of mercurials to overcome the constipation is not de- sirable; their employment is better limited to those cases in which 164 TREATMENT OF SPASM OF THE GLOTTIS. the bowels are not only sluggish, but the evacuations unnatural in character. The action of the bowels may be encouraged by rubbing the abdo- men twice a day with a liniment composed of equal parts of soap liniment and tincture of aloes; or the bowels may sometimes be in- duced to act regularly in young infants by the daily employment of a small soap suppository. Enemata, consisting either of warm water or gruel, may also be given for the same purpose. Sedulous attention to the diet and the state of the bowels will sometimes effect a cure; but in many instances tonics may be em- ployed with advantage, and probably none with such decided benefit as the preparations of iron. Eemoval to the pure air, however, or to the sea-coast, is often a tonic of greater power in these cases than all the contents of the laboratory, and one which you will find in some instances to be absolutely indispensable to the child's cure. All these cares are not less needed in children in whom the process of dentition has already commenced. In them, however, the irritation of teething is often the exciting cause of the affection, and lancing the gums is frequently needed in addition to the other treatment. The relief thus afforded is sometimes very striking; and the frequent repetition of the operation may be necessary to diminish the swelling and tension, and to ease the pain of the congested gum. It is not, however, a proceeding to be adopted, irrespective of all other con- siderations, simply because the child had begun to cut his teeth when the attack of spasm of the glottis came on. Dentition does not go on continuously from the time when the first tooth is cut until the com- pletion of the whole set, but there are regular pauses in the process, during which its advance is suspended for several weeks together. Thus, for instance, after the appearance of the incisors, there is a pause for several weeks or months before the first molar teeth appear, and then there is another cessation in the process before the child begins to cut its canine teeth. The spasm of the-glottis, therefore, may come on during one of these pauses, and be excited by some cause quite unconnected with dentition. Lancing the gums, too, is not well borne in every case, even when it may have appeared to be indicated; and I have more than once been compelled to discontinue it, on account of the pain and alarm which it excited, bringing on a violent spasmodic seizure, whenever I attempted to practise it. In some instances the spasm of the glottis is associated with mani- fest uneasiness in the head. It has been suggested that in some of these cases the brain is kept in a state of constant irritation, owing to the deficiently ossified skull being too thin to defend it from injury, while at the same time it affords no adequate counter-pressure to check the over-distension of the cerebral vessels. I have seen one case that seemed to lend decided support to this opinion, and many others have come under my notice, in which the recommendation that a horse-hair cushion should be made for the head to rest on, having a hole in its centre, so as to relieve the occiput from all pressure, has been acted on with manifest advantage. The supervention of attacks of spasm of the glottis, in a case of well-marked chronic hydrocephalus, would OCCASIONAL NECESSITY FOR DEPLETION. 165 call for little change in the treatment, though it must evidently add much to the danger of the patient. Symptoms of cerebral congestion are sometimes associated with this condition. They are seldom such as to call for active interference; but the tepid bath and neutral salines, with small doses of hyoscyamus,1 are often of much service in quieting the general excitement of the circulation, while the occasional application of a leech to the head may be beneficial, especially if general convulsions are beginning to supervene on the attacks of dyspnoea. It is possible that you may meet with a case in which active deple- tion is indicated, and you must not allow the consciousness, that, as a general rule, it is inappropriate, to prevent you from having recourse to it in such exceptional instances as the following. In this case, indeed, it was found necessary to carry depletion beyond that point which is in general expedient in so young a child. Some years since I saw a little boy, 2J years old, who had already suffered from several attacks of spasm of the glottis. A return of the affection had taken place about seven weeks before, though not attended by any very alarming symptoms until after the lapse of a month, when a general convulsive seizure occurred. From this he recovered, and he had for some days appeared to be convalescent from the spasmodic attacks, when his bowels became disordered, and a good deal purged, and after they had been so for two or three days his mother noticed one afternoon that his thumbs were forcibly drawn into the palm of his hands. With the exception of this contraction of his thumbs, however, he seemed as well as usual, and had a toler- ably good night: but immediately on awaking at six o'clock on the following morning he had a paroxysm of stridulous breathing, in which he crowed so loudly as to be heard over the whole house. His face at the same time became greatly flushed, and his hands and feet contracted, as they were when I visited him three hours afterwards. His face was then much flushed, his head hot, his pupils rather dilated, his pulse full and bounding; his thumbs were drawn across the palm; the fingers were not closed, but the hands were forcibly flexed on the wrist; °the great toe was drawn far apart from the other toes, which were flexed, and the whole foot was stiffly bent on the ankle. The child was then breathing quietly, and seemed drowsy; but he screamed out the moment he was touched, as if the least disturbance of his limbs gave him pain. Eight leeches were applied to his temples, and drew much blood, but without producing any amelioration of his condition. A croupy sound continued to attend his respiration, and he had a fit of urgent dyspnoea, with loud stridulous breathing, between my first visit at 9 in the morning and my second at 5 in the evening. I now bled him from the arm to 3yj, which subdued the fulness of the pulse, blanched his lips, and diminished the flush of his face, though it did not cause actual fainting. I ordered cold to be applied to the head, and saw him ao-ain at 71 P. M., when I found that he had been lying quiet 1 See Formula No. 2, page 54. 166 GENERAL MANAGEMENT OF ever since I left him, and had had some tranquil sleep, without any crowing sound attending the breathing. His pulse was less full, the flush of his face was diminished, the heat of the head was gone, and the contractions of the hands and feet were both less, and less firm. A powder with gr. j of calomel and gr. viij of rhubarb, which had been given in the morning, and had produced one evacuation, was now repeated. The child had some sleep in the night, and no access of dyspnoea returned, nor did the croupy sound again accompany the inspiration. In the course of the day the spasmodic contractions of the hands and feet greatly diminished, and the child became cheerful. In five days from this formidable attack he was quite well, and continued so for a year, when a slight return of spasm of the glottis took place, in the course of a severe impetiginous eruption on the scalp. Before concluding this lecture I will suggest a few cautions, appli- cable alike to all cases of spasm of the glottis. Sudden excitement, and especially a fit of crying, are likely to bring on the attack, and since there is a possibility of any one of these attacks proving fatal, the greatest care must be taken in the management of the child to avoid all unnecessary occasions of annoyance or distress. Although the benefit that accrues from fresh air, or from a change of air, is often very great, yet it is very important that the child should not be exposed to the cold or wind, for I have seen such expo- sure followed by a severe attack of dyspnoea, or by the occurrence of general convulsions. The hazard of such an occurrence is greater in proportion to the severity and long continuance of the affection; and, in such cases, the excitability of the spinal cord, and the irritability of the surface, seem sometimes to become as great as they may be observed to be in frogs when narcotized, whom you may then throw into convulsions by merely shaking the table on which they are placed. It is possible that this condition in the infant may be due to a cause not unlike that which produces it in the lower animal. In the latter, it is manifestly due to the influence on the nervous system of blood impregnated with opium; in the former, a similar influence may be exerted by blood the proper depuration of which has been prevented by the frequent recurrence of spasm of the glottis. There is also another reason for caution in exposing the child to cold or wind, namely, that the occurrence of catarrh is almost sure to be followed by an aggravation of the spasmodic affection. On more than one occasion I have seen the supervention of catarrh convert a very mild into a very serious attack; and once the exacerbation of the symptoms thus produced was the cause of the infant's death. The parents should in every instance be made fully aware of the uncertainty that attends this affection—of the possibility of death taking place very suddenly and unexpectedly. In the paroxysm itself but little can be done. Cold water may be dashed on the face, and the fauces may be irritated, or the finger passed down into the pharynx, so as to bring on if possible the effort to vomit, while at the same time the legs and lower part of the body may be placed in a hot bath. CASES OF SPASM OF THE GLOTTIS. 167 The remarkable observations of MM. Braun and Chiari1 on the employment of chloroform in puerperal convulsions, and a short paper by Dr. Simpson, of Edinburgh,2 on its utility in the convulsions of children, drew my attention to it, and I have tried it extensively, and in many instances with advantage. In cases where depletion is inad- missible, where the convulsions are not obviously due to organic disease of the brain, while they are both severe in their character and are returning with frequency, the inhalation of chloroform sometimes altogether arrests them. It is also of service in attacks of a more chronic kind, in which, though convulsions are less violent, yet the irritability of the nervous system is extreme, and every change of posture, and every attempt at deglutition, are followed either by threatenings of a fit, or by actual convulsions. Its efficient use, how- ever, is not easy to secure, since it requires the constant presence in the house of some one competent to administer it; while if intrusted to the parents or to a nurse, the fears of the former, and the want of intelligence of the latter, generally render its employment merely nominal. Even when most skilfully administered, too, the efficacy of the remedy soon ceases, if, from the return of the convulsions, the necessity should arise for its being given at very short intervals. In these circumstances the narcotism soon becomes very partial, and the fits recur altogether unmitigated by it—a result which I have also observed in puerperal convulsions. I have never seen mischief follow from its use; but its power of doing good seems usually to be more evanescent than that of other sedatives. There are still a few points connected with the derangements of the nervous system in early life, which require a brief notice before I close this lecture. And first, with reference to cases, happily rare, of violent, causeless, and fatal convulsions in early life, independent of disease of the brain. Such attacks are very unusual after the com- pletion of dentition; sometimes they occur without any apparent exciting cause, but more frequently they follow on some slight error in diet, or on slight exposure to the heat of the sun, or on the drying up of some cutaneous eruption, or of some long existing strumous sore. They are characterized by the violence of the convulsive move- ments, by the depth of the coma which succeeds to them, and by the very rapid failure of the child's powers. I think, too, it may be said, that convulsions attended by such circumstances warrant more serious apprehension in children of three or four years old, than in infants of a year or eighteen months. For this the reason doubtless is, that at an age when the nervous system is less susceptible than in infancy, an attack of this kind implies a graver disturbance, and one less likely to pass away. Death in these seizures seems to take place, not from asphyxia, as in spasm of the glottis, but from exhaustion of the nervous powers, just as one sees it do in cases of puerperal convul- sions ; the skin becoming colder, the pulse more feeble after each attack, and complete collapse being induced within twenty-four, some- times within twelve hours from the first seizure. 1 Klinik der Geburtshiilfe, etc. part ii. p. 249, 8vo. Erlangen, 1853. 2 Obstetric Works, vol. ii. p. 470, from Ed. Monthly Journal, Jan. 1852. 168 PECULIAR FORMS OF CONVULSIONS. Far less hopeless are cases, with which we also meet occasionally, of the exceedingly frequent recurrence of convulsions; five, ten, or rtrore taking place every day, for days or weeks together. Such attacks are seldom or never met with after the completion of denti- tion. The danger to life seems to lessen with the frequency of their recurrence, but there is hazard lest they should end by becoming habitual; while, further, there seems to be a very decided relation between the liability-to convulsions in early infancy, and the develop- ment of epilepsy in subsequent childhood. One word, in conclusion, with reference to that peculiar form of convulsion, to which, from the movements that characterize it, the name of Eclampsia Nutans,1 or the Salaam convulsion, has been given, and in which some observers have thought they recognized the signs of a special disease. Infants and children affected by it, bow the head and bend the body slightly forward, a movement which is repeated with great rapidity, sometimes twenty, fifty, or even a hundred times, and then ceases, but returns once or oftener in the twenty-four hours. During the attack the child seems bewildered, but complete consciousness returns as soon as the movements end; and in one case which was under my care, the infant seemed relieved, and quite bright and happy the moment that the movements ceased. In connection with these attacks, there is a general failure of health, and enfeebling of the mental powers, but they do not tend to destroy life, nor are they connected with any special form of cerebral disease, nor have they any invariable issue. Their tendency, however, unquestionably is to pass into confirmed epilepsy; and the bowing of the head seldom lasts for more than a few weeks without some other convulsive movement becoming associ- ated with it. Often it is a slight convulsive movement of one or other arm, but the attacks of general convulsions occasionally intervene, and at last they take the place almost or altogether of the previous bowings of the head, and the case becomes one of ordinary epilepsy, with, in genera], very considerable impairment of the intellect. Just the same course, however, is observed to be followed by other partial convulsions, though such convulsions seldom attract attention by their singularity to the same extent as the Eclampsia Nutans. A year or two ago, however, I saw an infant, seven months old, in whom attacks of an oscillatory movement of the head from side to side came on just in the same manner, and associated with the same impairment of the general health, as usually attends the Salaam convulsion. The rarity of the latter affection, too, consists not in the nature of the movement, but in its frequent repetition, and I have often observed the first sign of incipient epilepsy in the child to be a sudden bowing downwards of the head, instantaneously recovered from, and just attracting notice by the bruising of the forehead, which has struck against a table or 1 Four cases of this affection were described by Mr. Newnham in the British Record of Obstetric Medicine, March 15,1849 ; two are related by Dr. Faber, in J. f. Kinderkr., vol. xiv. p. 260; two by Dr. Ebert, Annalen der Charite" zu Berlin, 1850 ; one by Dr. Willshire at a meeting of the Westminster Medical Society, March, 1851; and proba- bly others may be found in the medical journals. CAUSES OF EPILEPSY. 169 chair. Next this bowing ceases to be confined to the neck, and the child falls forwards on the ground, though still the attack is so momentary, that it rises again immediately; and it sometimes is not until after an attack of general convulsion has awakened the anxiety of relatives, that any meaning begins to be attached to what was long supposed to be merely the effect of a child's heedlessness, or of its not having thoroughly learnt to walk. Such cases are but a few illustra- tions of the fact already so often insisted on, that in the study as in the treatment of the diseases of early life, nothing is too trivial to notice—that the slightest occurrences often have the gravest import. LECTURE XIY. Epilepsy—its causes—illustrative tables—its general character and influence on the mind. Circumstances which must regulate our prognosis. Treatment—futility of specifics—general management. Chorea—not exclusively a disease of childhood—causes which influence its occur- rence—its relation to rheumatism. Symptoms, prognosis, and treatment. Partial chorea. We yesterday studied the convulsions of early childhood in their gravest aspect, as immediately threatening life; but a painful interest attaches to them independent of the anxiety which they excite lest they should prove immediately fatal. There is the dread of their per- sistence, or of the child being left with his nervous system so shaken that fits may recur at some later period: that convulsions in infancy of childhood may issue in epilepsy in youth or manhood. Nor, in- deed, does this seem to be a groundless fear, for of 68 cases which form the basis of M. Herpin's1 elaborate work on epilepsy, 17 or 25 per cent, date from the first five years of existence; and of 36 cases that came under my own observation in young persons under the age of 14; years, 22 dated back to the first 4 years of life, 10 occurred be- tween the ages of 4 and 10, and 4 between 10 and 12. TABLE, Showing Age of Patients at Commencement of Attacks of Epilepsy. Age at commencement. Males. Females. Total. Under 6 months 3 3 Between 6 and 12 months 4 2 6 " 1 " 2 years 3 2 5 « 2 " 3 " 2 3 5 " 3 " 4 " 2 1 3 » 4 " 5 " 1 1 " 5 " 10 " 6 3 9 " 10 " 12 " 2 2 4 19 17 36 1 Du Pronostic, etc., de l'Epilepsie, 8vo. Paris, 1852, p. 336. 170 CAUSES OF EPILEPSY. So many other questions, however, have been raised with reference to epilepsy, and our data for replying to them are at present so meagre, that I have thrown together into another table some of the more important facts connected with this disease. The number of observa- tions from which it is drawn up are far too few for it to be of any great value, but still it may suggest some points for your considera- tion, and you may find its form useful for recording the future results of your own experience. TABLE. Male. Fe-male. Age when attacked. Age first when seen. Alleged cause. State of mind. yrs. mos. yrs. mos. 0 1 1 week 10 10 None. Idiotic. 0 1 0 3 4 0 Inflammation of brain. do. 0 1 0 4 8 3 Dentition. Failure of memory, irri-table temper. 0 1 0 7 6 0 None. Not affected. 1 0 0 7 3 4 Dentition. Violent temper; dull. 0 1 0 8J 3 8 do. Backward. 1 0 0 9' 9 0 do. Dull. 1 0 0 9 3 2 do. Idiotic. 1 0 0 10 0 11 do. do. 1 0 1 0 2 3 do. do. 0 1 1 0 6 0 None. Insane. 1 0 1 2 7 11 Dentition. Not affected. 0 1 1 3 1 11 None. do. 1 0 1 6 4 0 do. do. 0 1 2 0 4 1 do. do. 0 1 2 2 2 6 Scarlet fever. Idiotic. 1 0 2 2 7 0 Dentition. Not affected. 0 1 2 3 3 6 None. Idiotic. 1 0 2 4 3 2 do. Not affected. 1 0 3 0 4 3 Hereditary. do. 1 0 3 0 8 1 Fall. Insane; idiotic. 0 1 3 4 6 0 None. Not affected. 0 1 4 0 5 5 Violent anger. Duller than formerly. 1 0 5 0 13 0 Fright, elder brother epileptic. Not affected. 1 0 6 0 11 4 Fright, had one fit at 17 months. do. 1 0 6 5 8 5 None. do. 1 0 7 0 8 0 None, had one fit at 8 months. do. 0 1 7 10 10 10 None. Occasional insanity. 1 0 8 0 9 0 do. Not affected. 0 1 9 0 9 9 do. Becoming dull. 1 0 9 3 9 5 Hereditary. Not affected. 0 1 9 4 10 0 None. Impaired memory. 0 1 10 0 10 0 Fright. Not affected. 1 0 10 4 11 0 Fall. do. 1 0 11 H 11 9 None. do. 0 1 11 7 11 8 Gastric disorder. do. 19 17 The influence of hereditary predisposition in favoring the occur- rence of epilepsy is too well known to require any further substan- 1 Ceased at 2 years; returned at 8 years and 9 months. STATE OF MIND IN EPILEPSY. 171 tiation.1 It was noticed in 4 of the above 36 cases, or in 11 per cent.; a very high proportion, which probably would have been somewhat modified by a larger number of observations. In 11 out of the 36 cases, some cause was assigned for the occurrence of the fits; namely, fright in three instances, injury to the head in one, in another a severe fall, and in another a violent paroxysm of anger, inflammation of the brain in one, scarlet fever in one, gastric disorder in one case, in which the fits ceased at the end of a month after the employment of remedies to correct the disturbance of the digestive functions ; while in nine cases, or in a fourth of the whole number, the fits which had con- tinued ever sinpe began during dentition, and were attributed, rightly or wrongly, to the constitutional disturbance which attended that pro- cess. Though it is quite possible that the alleged cause of the fits was not always the real one, yet the mere fact of the disorder super- vening in nine instances at the time when the process of teething was going on with activity, deserves to be borne in mind, as a fresh illus- tration of the peculiar excitability of the nervous system at that im- portant period of development. I have endeavored to define the state of the mind in these cases, but in a mere table this admits of only a very imperfect representation; for in many instances, when it is said to have been unaffected, the child was dull, or its memory was feeble, or it was generally backward. In four boys and four girls the weakness of the mind amounted to idiocy, which in the case of one girl was associated with occasional attacks of maniacal excitement; and in two other girls, the epileptic attacks coexisted with peculiarities of manner and disposition such as appeared to me to justify their being regarded as instances of moral insanity. Though these cases are unselected, it is yet possible that they present a darker prospect, with respect to affections of the mind in connection with epilepsy in early life, than reality will warrant; but even though it be so, there is yet enough in them to justify us in regarding this disorder with the greatest anxiety and apprehension. There is, indeed, one peculiarity in the mind of children which should never be lost sight of, when we endeavor to estimate the influ- ence of disturbing causes upon it; namely, that it is undeveloped, and that having but partially and imperfectly acquired its powers, it is consequently more easily obscured than in subsequent life. In 6 of the 10 cases in which the mind was most seriously affected, the epi- leptic attacks dated back to the first year of life; in 2 others, the children were between 2 and 3 years of age; in 1 the attack followed a fall at 3 years of age; while only in one was the patient between 7 and 8 years old at the commencement of the epileptic seizures. It seems, indeed, as if the inference which these facts suggests held good to even a greater degree than one might at first imagine; and as if we might state as a general rule that, in proportion as epilepsy comes on early, will the chances of its being associated with serious disorder of the mind be increased. M. Cazauvieilh,2 in his elaborate essay on 1 Herpin, op. cit., p. 328, estimates the frequency of epilepsy as from four to five times greater in the family of epileptics, than in the population at large. 2 Archives Gen. de Medecine, Janvier, 1826, p. 43. 172 PROGNOSIS IN EPILEPSY. the connection between epilepsy and insanity, gives as the result of a comparison between 26 female epileptics in whom the disease preceded menstruation, and 26 in whom its occurrence succeeded it, the state- ment that in 19 of the former, and in only 10 of the latter, it was associated with insanity. This fact is always to be borne in mind, when consulted about a case of epilepsy in early life, since it obviously must exercise a great influence upon our prognosis. To the best of my knowledge, the general characters of epilepsy in childhood agree closely with those which it presents in after life. I have observed the petit mal, as it is termed, continue in children for a period of several months, and finally issue in regular epileptic seizures, and at the present time am watching a boy of 8J- years old, in whom the frequent occurrence of causeless though almost momen- tary vertigo seems to portend the approach of epilepsy. In the child, I have sometimes noticed the loss of consciousness during the seizure to be imperfect, and this in spite of very marked convulsive move- ments; fits, with complete insensibility, occurring occasionally in the same patient, and being of longer duration, though not attended with a greater amount of convulsion, than those in which the loss of con- sciousness was incomplete. In one instance, attacks of apparently causeless alarm, accompanied by much excitement and incoherent talking, passed in the course of a few months into regular epileptic seizures; in another instance, a girl who came under' my care at the age of 10 years and 10 months, had had an attack of general convul- sions when 8 years old, for which no cause could be assigned. Since that time she had been liable to occasional attacks of strange excite- ment of manner; and these had for six months been attended with a sort of cataleptic condition, in which she stood motionless for a minute or two, wildly staring at vacancy, and uttering a few incoherent words, which apparently had reference to some object she saw, though she could never be induced to describe her imaginings. Eleven months after the commencement of these attacks their peculiar character dis- appeared, and she began to have regular epileptic seizures, while, in the intervals, her actions and manner, though often rational enough, were frequently those of an insane person. In a boy aged 9, in whom for a year epileptic fits had occurred causelessly, and with a rapidly increasing frequency, until at length three or four came on weekly, and sometimes more than one in a day, a sort of maniacal excitement seized him occasionally, in which he struck other children though they had given him no provocation, and though he appeared at the time to be aware that he was doing wrong. The above mentioned peculiarities seem to depend almost entirely on the greater feebleness of the intellectual and moral powers in early life, and their consequent liability to be disordered more easily than in the adult. They are, as might be expected, most observable in cases in which epilepsy has not come on till about five or six years of age, or somewhat later; the convulsions, which date from early infancy, lead to a more complete obscuring of the mind, and the cases in which they have occurred often present themselves to us as instances of idiocy PROGNOSIS IN EPILEPSY. 173 complicated with epilepsy, rather than as cases of epilepsy producing disorder of the mind by their frequent return. The question is often put to us, in practice, as to the probability of fits terminating in epilepsy; or, on the other hand, as to the ground for hope, in any case, that epileptic attacks, which have already fre- quently recurred, will eventually cease. With reference to neither of these inquiries, however, are we in possession of data such as to enable us to gtve an answer with much certainty. I do not think that those fits of which spasm of the glottis is a prominent symptom often pass into confirmed epilepsy; long continued struggling is not a character- istic of them, but more often drowsiness or stupor immediately suc- ceeding to the fits, and heaviness and dulness continuing for_ some hours'after them. As to the prospect of epileptic seizures ceasing at puberty, I fear that the hope is a very groundless one. It is scarcely to be expected that a new period of development should be attended by anything else than a fresh excitement, and an increased disturbance of the nervous system; so that there is more reason for anticipating a deterioration in the patient's condition, than for expecting an improve- ment from the changes of puberty. It is true that, if epilepsy comes on while dentition is in active progress, we may hope for, though we cannot with certainty calculate on, amendment when teething is accom- plished; and though 1 have no statistics bearing on the subject, yet my impression is that I have oftener known epilepsy cease spontane- ously between the fourth and sixth years than at any other period. In the same way, if epilepsy occur during the changes that usher in puberty, we may look forward with some degree of cheerfulness to the time when all of those changes shall have been completed. In each of these cases, however, it is not the period of excitement, but the season of repose, on which our hopes are founded; while, to leave the case untreated, in the vague expectation of what, at a certain cri- tical epoch of life, the healing power of nature may be able to effect, would be to trifle alike with our own reputation and with our patient's prospects of recovery. The first point in every case is obviously to make out, if possible, the cause on which the fits depend, or to ascer- tain, by the most minute observation and inquiry, the peculiarities of health with which their occurrence is associated. The diet, the bodily exercise, the mental pursuits, all need the most rigid investigation; the condition of the bowels, the state of the evacuations, require to be most carefully examined; and the fact of the first dentition having been accomplished is no adequate reason for omitting to watch the process of teething most sedulously. I have seen one or two instances in which convulsive attacks of an epileptic character attended the cutting of the permanent molar teeth; and illustrations of this fact (to which Dr. Ashburner1 was the first to call attention) are to be found in all our medical journals. In proportion as the fits admit of being traced with probability to causes of a remediable character, may our prognosis be favorable. The severity of the fits is a matter of less importance, with reference to prognosis, than the frequency of ' In his work " On Dentition and its Coincident Disorders," 12mo., London. 174 TREATMENT OF EPILEPSY. their occurrence; and the oftener they recur, even in a mild form, or the more frequent their forebodings, such as dizziness, or momentary stupor, the less is the prospect of their cessation. In forming our prognosis, also, regard must be had to the state of the child's mind in the°intervals between the fits; and the less the intellect seems to be dulled, or the moral faculties perverted, the more encouraging may be our opinion. In judging of this last point, it is well to bear in mind that a child who has been liable to any such affection is almost sure to be backward in learning; very likely to be wayward in temper, for his friends will have been afraid to overtax him with work ; and they will probably, from fear of crossing him, have indulged many of his caprices. We must judge of his intellect less by the child's amount of actual knowledge than by his power of answering simple questions concerning things familiar to him; and must draw our con- clusion as to the state of his moral faculties from his general childlike character, his fondness for the same pursuits, his showing the same dispositions, manifesting similar attachments, having similar good and bad qualities to those which we observe in other children of his own age, or a few years younger. With reference to the treatment of epilepsy, I know of no specific for it; and the much-vaunted oxide of zinc has proved as powerless in my hands as in those of most who have tried it on the strength of the high encomiums bestowed on it by M. Herpin. Indeed, I do not think that it will be in the search for specifics that we shall light upon the appropriate treatment of a disorder which depends upon causes so almost numberless as epilepsy. If there be any obvious, or even probable exciting cause, our first attempts must of course be directed to its removal; and, according to its nature, depletion may or may not be indicated; or the administration of alterative or purgative medicines may be desirable. Unfortunately, in a large number of instances no definite cause is discoverable, and we are thrown entirely upon general principles for the regulation of our conduct. As violent and sudden excitement of any kind will often bring on an epileptic seizure, so the influence of the opposite condition in warding off its attacks is very remarkable; and on several occasions I have received patients into the Children's Hospital, who were reported to have epi- leptic seizures several times in a week, and who nevertheless remained a fortnight or more in the institution without any attack coming on. The quiet, however, which suits the epileptic, is not the quiet of list- less, apathetic idleness, but the judicial alternation of tranquil occu- pation and amusement. The mind must not be left to slumber, from the apprehension of work bringing on a fit, but the work must as far as possible be such as to interest the child. It is an observation often made, that adult epileptics who follow dangerous trades, as that of a bricklayer, for instance, scarcely ever have attacks when occupied in their pursuit; and children are rarely seized when at play, but often- est either when in bed at night, or before getting up in the morning, or when sitting quiet in the evening, tired and unoccupied. The good results, too, which I hear have followed the introduction of gymnastic exercises among the epileptic patients at the Bicetre, in Paris, point GENERAL MANAGEMENT OF EPILEPTICS. 175 in the same direction. In the occupations of epileptics, therefore, such pursuits as not merely employ the mental faculties, but also give work to the hands, such as gardening, carpentering, or the tending of animals, are especially to be recommended; and if by these the mind can be kept awake, the grand object of teaching is answered, and backwardness in reading, writing, or those kinds of knowledge which other children at the same age have acquired, is of very little moment. Many epileptics have an indistinct articulation, and almost all have a slouching gait, and an awkward manner. The former can often be corrected to a considerable degree by teaching the child simple chants, which are almost always easily acquired, and practised with pleasure. The latter may be rectified by drilling, not carried into tedious minutiae, but limited to simple movements, and the irksomeness of drill is almost completely done away with by music; while I believe ,that the accustoming a child to the strict control and regulation of all its voluntary movements is of very great importance indeed as a curative agent. Many of these measures could be much better carried out in class than by a child alone, and whatever may seem at first to be the objections to the association of epileptics, I have no doubt but that they would be more than compensated for by the advantage. Epileptic children cannot be educated with such as are healthy— partly for the sake of the latter, but at least equally so for their own; since the different regulations to which they must be subjected, the difference in their education, their amusements, and often in their diet, would be to them a source of ceaseless distress. If educated alone, however, not only do they lose all the advantages of association with other children, though both intellectually and morally this is of great moment, but also they become, far too obviously for their own benefit, the centre around which everything in the household turns, while rules become doubly irksome when apparently made for themselves alone, and not part of a general system to which others besides have to submit. These advantages, however, are not at present to be ob- tained, and we are compelled to put up with the more imperfect carrying out of our directions, either at the patient's home, or, still better, under the superintendence of some competent person who devotes the whole of his time to the care of the child. The diet should be mild, nutritious, but unstimulating, and, as a general rule, should include meat comparatively seldom, and in small quantities. I have certainly seen epileptic fits increased both in fre- quency and severity by an abundant meat diet, and diminished in both respects when a diet chiefly of milk and vegetables was adopted.1 1 My attention was first drawn to the importance of abstinence from a meat diet in epileptics by Dr. Maxwell, the resident physician to the Asylum for Idiots. This caution, too, gains still greater weight from the testimony of Dr. Jackson, of Boston, in America, who, in his Letters to a Young Physician, 12mo., Boston, U. S., 1855, p. 67, insists very strongly on its importance. As already stated, I have little faith in the influence of mere drugs ; but I have a yearly increasing confidence in the influence of diet, judicious management, and mental and moral as well as physical hygiene in epilepsy occurring in early life, independent of hereditary predisposition, and uncon- nected with approaching puberty. 176 CHARACTERISTICS OF CHOREA. When the approach of a fit has been usually preceded by stupor, or headache, or drowsiness, I think that I have sometimes warded off' its occurrence by putting a few leeches on the head: but epilepsy is not to be cured by systematic bleeding, nor by systematic purging, nor, I may repeat, by any of the various medicines which at different times have been employed for its cure, and the very number of which is perhaps the best proof that could be adduced of the ineffi- cacy of all. Almost every lecture has furnished some fresh illustration of that connection between the development of an organ, or a set of organs, and their liability to disorder which characterizes the diseases of early life. The growing brain is readily overfilled with blood, readily emptied of it; cerebral congestion, cerebral hemorrhage are frequent, and so is the opposite state of anaemia, producing as we have seen the signs of spurious hydrocephalus. The balance is so easily disturbed, between the different parts of the nervous system, that convulsions occur with a frequency proportionate to the tender years of the pa- tient, assuming all sorts of strange forms; now threatening life in one way, now in another, destroying the child suddenly by spasmodic closure of its glottis, or exhausting it by their violence and their ceaseless return ; or lastly, working a change so subtle, that the knife of the anatomist cannot detect it, and yet so serious, as to induce their perpetual recurrence, and to convert the once bright and hopeful child into the dull and all but hopeless epileptic. But we have not yet completed our survey of this class of affections, for there are various forms of impairment of the motor power which are still unnoticed, ailments which indeed rarely threaten life or per- manently disturb the mental faculties, but which are yet tedious in their progress, often distressing in their character, and difficult of cure. I shall reserve for another lecture those cases in which there is mere loss of power over a limb, or over some of its muscles, and will now notice those in which that power is imperfectly exercised, in which the will no longer exerts its full control, but the muscles of some parts are left in a state of involuntary activity, though still per- forming imperfectly their proper duties. The characters just enumerated are those which mark a disorder with which you are doubtless all familiar, the Chorea Sancti Yili, or St. Vitus's dance. It is, however, by no means one of the most frequent affections of childhood; for it was met with only in 192 out of more than 51,000 patients under 12 years of age, who were brought to the Children's Hospital. Chorea, indeed, is, as the subjoined table1 shows, less a disease of childhood than of that period of development which intervenes between the second dentition and the completion of the changes that attend on puberty. 1 Deduced from the cases reported by Dr. Hughes, in Guy's Hospital Reports, Second Series, vol. iv., 1846 ; by M. Rufz, in Archives de Me'decine, February, 1834; and from the statistics of M. Wicke, as reported by Romberg, Nervenkrankheiten, vol. ii. part 2, p. 177. 4 6 10 22 11 33 64 142 206 87 220 307 CHOREA, ITS CAUSES, INFLUENCE OF AGE AND SEX. 177 Age. Male. Female. Total. At or under 4 years..... More than 4, but not exceeding 6 years . " 6, " " 10 " " 10, " " 15 " Total.....177 379 556 It must also be added, that the liability to chorea does not cease entirely with the completion of the changes that accompany puberty ; but that it has been computed that a fourth of all cases of it occur during adult life. I believe, indeed, though I cannot prove, that this estimate of the frequency of chorea in the adult is exaggerated, while, when it does occur in the grown person, it is probably due either to . the influence of some grave internal inflammation, such as. pericar- ditis or endocarditis, or to that peculiar state of the constitution which gives rise to rheumatism, or to both these causes combined.1 The reason of the greater rarity of chorea in early childhood than subsequently, is, I apprehend, to be found, in the circumstance that with the progress of growth and the increase of strength the nervous system becomes less impressionable, and the causes which in the infant would have produced a fit, or would have given rise to that more chronic form of convulsive disorder, of which spasm of the glottis is a common accompaniment, no longer produce such grave results. They do not endanger life, they do not even abolish consciousness, but they shake the control of the will over the voluntary movements, and produce chorea. As the boy grows older, his liability to all con- vulsive diseases diminishes; and as the girl grows older, hers lessens too, but not to the same extent. In her, disorders of a milder kind show themselves with a frequency from which the boy's hardier frame altogether defends him; and chorea occurs only as one form of dis- turbance of the nervous system, having reference to an earlier stage of development than that at which hysteria commonly appears, when, in connection with the first performance and first consciousness of 1 Much discrepancy of opinion prevails still with reference to the nature of the re- lation subsisting between chorea and rheumatism. M. See, in his valuable essay on Chorea, in vol. xv. of the Mtmoires de VAcadimie de Medecine, alleges the relation to be so intimate, that of* 109 cases of rheumatism admitted into the Hopital des Enfans, 61 were complicated with chorea. No subsequent observer, however, bears, out these statements to anything like their full extent, while the experience of many persons of deserved authority is altogether opposed to their correctness, at least in so far as children are concerned. Thus MM. Rilliet and Barthez, at p. 585 of vol. ii. of the second edition of their work on Diseases of Children, observe, that while rheuma- tism is very common at Geneva, chorea is exceedingly rare. M. Rilliet states that during the past ten years he has seen but two cases of chorea in his private practice, though many children affected with rheumatism have been under his care, and neither of the two chorea patients had, or ever had, rheumatism. M. Lombard, too, during twenty years' extensive practice in that city, had seen the complication of rheumatism with chorea only once. It has never come under my own observation ; and of sixteen cases of chorea in children under eleven years of age, of which I have a record, there was not one in which it co-existed with rheumatism and but one where, six months previously, fever with pain in the limbs was said to have existed. While, therefore, the two affections have been observed together too often for this to have been the result of a mere coincidence, the exceptions are far too numerous to warrant any hypothesis which regards rheumatism, in either an acute or chronic form, as the ordinary cause of chorea. 12 178 SYMPTOMS OF CHOREA. new functions and a new destiny, the mind and the emotions partici- pate in disorders previously limited to the motor powers. TABLE, Showing the Age and Sex of 192 Patients brought to the Children's Hospital suffering from Chorea. Age. Between 3 and 6 months . 6 " 12 a 12 " 18 « 18 months and 2 years 2 and 3 years 3 " 4 a 4 " 5 a 5 " 6 a 6 " 7 « 7 " 8 » 8 " 9 u 9 " 10 u 10 " 12 > go o O rH At all ages above Ij years. From diseases of the nervous system Do. of the respiratory system Do. of the digestive system 30.5 26.9 17.5 18.5 39.5 12.8 17.6 33.0 5.5 24.3 32.8 14.1 15.1 29.5 6.5 10.6 30.7 8.8 10.4 38.0 7.7 PECULIARITIES IN EARLY LIFE. 221 that we often saw it but indistinctly—sometimes, perhaps, altogether failed to perceive it. The same means, however, as have enabled us to bring medical knowledge, with reference to the diseases of the chest in the adult, almost to the state of one of the exact sciences, still stand us in stead here; and care and patience will enable us to discover the condition of the lungs with nearly as much certainty in an infant as in a grown person. Nor is the greater facility of their diagnosis the only circumstance that lightens their study, but a feeling of hopefulness attends their investigation which we often missed in the subjects that have lately engaged our attention. They, indeed, furnished us with interesting pathological studies: we stood around the sick bed, and watched nature's struggles with disease that was irremediable, and we traced its effects afterwards as we examined the dead body; but the diagnosis of the affection was in many instances but the sentence of the patient's death; and we often felt that, as practical physicians, there was but little for us to do. We shall, it is true, meet with some such affections in our study of diseases of the chest, but happily they are few in com- parison with those which, in addition to much that would interest the mere pathologist, present still more that will give ample scope for all the skill of the practical physician. At first sight, it may seem to you that there can be little in the organs of respiration and circulation in early life different from their condition in riper years. And it is true that the part they play is as important at the first hour of existence as in the most advanced old age, and that their structure and functions undergo no such changes as we have noticed taking place in the brain during infancy and child- hood; but nevertheless they present some important peculiarities in the young, with which you must be acquainted before you can hope to treat their diseases with success. The condition of infancy is one of unceasing development; all the organs of vegetative life have, so to speak, double work to do—not merely to supply the daily waste, and to remove effete and useless matter, but to build up that wondrous edifice, the human body. It is probably in great measure on this account that the blood in infancy and childhood runs its course more rapidly, and that the lungs vivify it more frequently than in adult age. We shall probably not be far wrong if we estimate the average frequency of the pulse in the grown person, when making no exertion, at 75, and of the respirations at 12 in the minute.1 In infants not above a week old, the average fre- quency of the respiration is 39, and of the pulse 102 ; but the former may rise to 84, and the latter to 140, as the result of some transient excitement or disturbance, and wholly independent of disease. Until the sixth year the average frequency of the pulse continues at 102; and though that of the respiration diminishes, yet it does not fall below 30. The variations between their maximum and minimum 1 This result is afforded by the numerous and careful observations of Professor Vierordt: see his article Respiration, in Wagner's Handworterbuch der Physiologie, Part 12, 8vo., Brunswick, 1845, p. 874. 222 FEEBLENESS OF THE INSPIRATORY POWER. frequency are now, however, circumscribed within limits which grow narrower as the child approaches manhood.1 Although the rapid pulse and quick breathing of early life are pro- bably in great measure due to the activity of the vital processes, yet the wide variations in their frequency induced by very slight accidents lead to the suspicion that this is not their only cause, but that both phenomena are to a certain extent indications of the infant's weakness. This suspicion is still further strengthened by our knowledge of the fact, that the quantity of carbonic acid exhaled at each expiration diminishes in proportion as the expirations are more frequent ;2 so that it is plain that the rapidity of the respiratory movements is not of itself a measure of the activity of the respiratory process. But still stronger proof of this fact may be adduced. Animal heat is generated almost entirely by respiration. If, therefore, the activity of the vital processes were in proportion to the rapidity of the breathing, the new- born infant should be warmer than the child, and the child than the youth. But this is not so, for M. Roger has found, as the result of many most elaborate investigations, that the temperature of the child at six years of age exceeds that of the infant of a week old by more than half a degree of Fahrenheit, although the respiration is nearly a fourth less frequent.3 There seems^ then, good reason for believing that the rapid breathing of the child is to some extent the result of its more delicate frame, rendering it unable, at a single effort, to inspire as deeply as the more robust adult, so that it is compelled, by the frequent repetition of its efforts, to make up for their comparative feebleness. Quite in keeping with this is the small power of resisting cold, or of maintaining an independent temperature, which is a distinguishing peculiarity of early life. If the young of any warm-blooded animal be exposed to a low temperature, its respiration at first increases in frequency, but if not soon restored to a warmer atmosphere, the nervous energy that should set the respiratory apparatus in motion becomes still more depressed ; air enters the lungs imperfectly, the inspirations grow less frequent, and the warmth of the body sinks rapidly down to that of the sur- rounding medium. Nor is this all; but it often happens, if a young infant has been thus exposed to the cold, and especially if this has been done before the respiration had become properly established, that no subsequent removal to a warmer atmosphere will suffice to raise the temperature, or to set in proper activity the respiratory process. But not merely is the respiratory apparatus more delicate in the child than in the adult, for so are all the organs in early life, but it is feebler, as compared with the work it has to do, with the difficulties 1 The chief authority for the statements in the text is the valuable essay of M. Roger, De la Temperature chez les Enfants, 8vo., Paris, 1844. The more recent researches of M. Seux, Sur les Maladies des Enfants Nouveau-Nes, 8vo., Paris, 1855, do but confirm in the main the results already arrived at with reference to the wide variations in the frequency of the pulse in new-born infants. 2 See Vierordt's experiments on this subject, loc. cit., p. 887. 3 The recent researches of Dr. V. Barensprung, published in Muller's Archiv, 1851, p. 125, do not confirm the above statement, but they are too few in number to invali- date it, and therefore it is still retained in the text. See § 5 of v. Barensprung's essay. FEEBLENESS OF THE INSPIRATORY POWER. 223 it has to overcome; and this constitutes a most important peculiarity in the physiology of respiration in early life, and greatly modifies its pathology. The interesting researches of Mr. Hutchinson1 have shown us that in the case of the adult " the resistance to the ordinary breathing force, independently of the elastic power of the lungs, is equal to lifting more than 100 lbs. at every ordinary inspiration." The elasticity of the walls of the chest, which present this resistance, is in proportion to the size of the thorax, nearly as great in the infant as in the adult; but how much smaller is the muscular power by which this resistance is to be overcome! You see proof of it in the ordinary mode of respi- ration of a young infant, which presents something almost of difficulty. The breathing is quick and short, then, after a few seconds, there suc- ceeds a pause, and then the hurried respiratory movements begin again, while the slightest disturbance, or the most trivial excitement, will at any time raise the frequency of the inspirations by ten or twelve in the minute. This respiration, too, is almost entirely abdo- minal ; the chest moves but little, its walls are but little expanded, and the ear detects in the respiratory murmur little or nothing of that clear, loud sound which is so characteristic of a subsequent period of childhood, and with which you are all familiar by the name of puerile respiration. This peculiarity of the breathing in eardy infancy, to which M. Trousseau was, I believe, the first to call attention, is another token of the feebleness of the inspiratory power. As the child grows older, and its strength increases, and its muscular system becomes more developed, the chest expands with each inspiration, and the faint respiratory murmur is succeeded by the loud puerile breathing, which is heard as the air enters into the smaller air-cells. The resistance of the walls of the chest, however, is not the only obstacle to be overcome at each inspiratory effort, but the lungs them- selves are furnished with an elastic fibrous investment, processes of which dip down into their substance, and form the parietes of the different lobules. If you blow air forcibly into the lungs after their removal from the body, the resiliency of their tissue will expel a large proportion of the air the moment your effort at inflatation is suspended. This elasticity of the lungs, then, which has been estimated as offering in the adult male an obstacle to each inspiration equal'to 150 lbs., and in the female equal to 120 lbs. avoirdupois, is constantly tending to empty them of air, and constantly resisting the introduction of more.2 The want of breath, however, puts the respiratory muscles into play; the man takes a deep inspiration, and by this effort he unconsciously overcomes the resistance of the chest and the elasticity of the lungs. The new-born infant feels the same want, and makes the same effort, 1 On the Respiratory Functions, in vol. xxix. of the Medico-Chirurgical Transactions. 2 The investigations of Professor Donders and of Mr. Hutchinson into the amount of this elasticity of the lungs, though carried on independently, conduct to very similar results, the former estimating it as equal to §ix 5X avoirdupois per square inch as a maximum, the latter estimating it on the average at tbss per square inch. See the researches of Prof. Donders, in the Nederlandsche Lancet, Dec, 1849 ; and Schmidt's Jahrb., Dec, 1850 ; and article Thorax, by Mr. Hutchinson, in Cyclopaedia of Anatomy and Physiology, vol. xiv. p. 1058. 224 IMPERFECT EXPANSION OF THE LUNGS. but its muscular power is small, and its inspirations are often so feeble as to draw the air in some parts only into the larger bronchi, while many of the smaller air-tubes remain undilated, and much of the lung continues in its foetal state. The blood being thus but imperfectly aerated, all the processes of nutrition go on imperfectly; the vital powers languish, the inspiratory efforts become more and more feeble, the temperature sinks, and the infant dies. But not only may this state persist as the result of imperfect respiration at birth, but cold, or the want of sufficient food, or any other cause that impairs the already feeble muscular power favors its supervention. As the power of the inspiratory muscles is impaired, the air no longer penetrates into the lungs so far as it once did, while the residual air is gradually driven out of the pulmonary cells by the elasticity of the lung, and portions once permeable to air become, in the course of time altogether useless. Or an increase of the ordinary resistance to the entrance of the air will have the same effect; and if the pouring out of mucus into the bronchial tubes should much obstruct them, large portions of lung will by degrees become emptied and collapsed, the dyspnoea will grow urgent, and the child will die from symptoms such as, in the adult, result only from most serious structural disease. The possibility of a large portion of the respiratory apparatus re- maining useless from birth, or becoming so afterwards, without any serious disease of these organs, is a most important element in the pathology of infancy and early childhood. It warns us to be on our guard, during the course of various maladies, against a danger which, in more advanced life, we have not to apprehend; while, at the same time, it teaches us that the dyspnoea, the hurried breathing, and many other symptoms which, in the adult, would call for most active treat- ment, may result, in infancy, from simple weakness, and require stimu- lating rather than depletory measures. Before we proceed to study the diseases of the respiratory organs in infancy and childhood, we must make ourselves thoroughly acquainted with this state of imperfect expansion of the lungs. It presents itself to us in two different circumstances:— 1st. As a congenital condition—a more or less considerable portion of the lung never having become penetrated by air, but having re- mained in its foetal state. 2d. As an acquired condition: portions of the lung which once were freely traversed by air ceasing to admit it; and this not from alteration of structure, but from a simple collapse of the pulmonary tissue. It is now nearly thirty years since Dr. Edward Jo'rg gave the first clear description of the former of these two conditions, to which he applied the rather cramp name of ateleklasis, from at^s, imperfect, and ixtaois, expansion.1 We will first study this, since it is the simpler form of the affection, and we shall thereby obtain a clue to the understanding of the second form. 1 In his dissertation De pulmonum vitio organico, &c. Lips., 1832 ; and afterwards more fully in his work Die Fotuslunge im gebornen Kinde, 8vo. Grimma, 1835. EFFECTS OF INFLATION ON COLLAPSED LUNG. 225 If you examine the body of a new-born infant, or of one that has survived its birth but a few days, you will sometimes find patches of the lung of a dark red color, and depressed below the surrounding tissue, thus giving to the surface of the organ an uneven appearance. These darker portions, which exactly resemble foetal lung, are solid to the touch, do not crepitate at all under the finger, and sink im- mediately if thrown into water, while no minute air-bubbles are inter- mingled with the small quantity of reddish serum which pressure causes to exude from their divided substance. They are not friable nor easily torn, their cut surface is perfectly smooth, closely resem- bling a piece of muscle, and, if examined under a lens, the pale col- lapsed air-tubes are seen intersecting their substance, and scarcely distinguishable from the small vessels, which are almost devoid of blood. If air be blown into a lung some lobules of which have this appear- ance, it will permeate the collapsed air-tubes; the pulmonary vesicles will by degrees become distended, and the solid lobules will rise to a level with the rest of the lung, will acquire the same color and con- sistence, and, like other parts of the organ, will float in water. A single inflation, however, is by no means sufficient to render this change permanent, but the moment the tube is withdrawn the air will escape, and the recently distended lobules will again collapse, and sink below the rest of the lung; their color, too, will become dark, though less so than before. Even if, after you have distended the lung to the utmost, you pass a ligature round the bronchi, and allow the lung to dry, a difference will still in general be very perceptible between the size of the air-vesicles which had been inflated by your efforts, and of those which had been distended during life by the natural process of respiration. The force required thus to distend the collapsed portions of the lung is very variable: sometimes it requires all the force you can possibly exert, and continued for some minutes. If the child had survived for several weeks, the air will penetrate only very imper- fectly into the collapsed lobules, while in some parts the resistance will be greater than it can overcome, and the most forcible inflation will be followed by no effect. The situations in which this condition is most frequently met with, are the languette and lower edge of the upper lobes, the middle lobe of the right lung, and the posterior part and lower edge of the lower lobes; and inflation restores these parts to a natural condition much less easily than it does any patches of the same kind in other situations. Whether the impermeability of some collapsed lobules is owing to adhesions having taken place between the opposite surfaces of the minuter bronchi, as has been suggested, I cannot pretend to say, but the supposition is plausible, and microsco- pical researches, according to which the bronchi of a portion of col- lapsed lung lose their lining of tessellated epithelium, lend it a still further degree of probability.1 1 See a paper on this subject by Prof. Kostlin, in Schmidt's Jahrbucher, 1850. No. 1, p. 28. ** 15 226 CASES ILLUSTRATIVE OF SYMPTOMS It is usual to find, in connection with this state of the parenchyma of the lungs, that the pulmonary vessels contain less blood than usual, that the foramen ovale is unusually open, and the ductus arteriosus but very imperfectly closed. If the child have survived its birth but a short time, the brain is frequently found congested; but, otherwise, there is often nothing observable more than anaemia of all the organs, together with a general state of atrophy. Sometimes bronchitis attacks a lung thus affected, and, besides the presence of mucus in the air- passages, there is then very often a state of congestion of the lungs, which renders the contrast between the collapsed and the healthy lobules less striking. The causes of this condition are not clearly made out. Dr. Jorg has attributed great importance to precipitate labor as a frequent cause of its occurrence, and has suggested a somewhat fanciful theory to explain its mode of production. He conceives that one grand use of the uterine contractions is gradually to enfeeble the circulation through the placenta, and thus to induce in the foetus that besoin de respirer which shall excite the complete establishment of respiration immedi- ately on its birth. If, however, by the very rapid course of labor, the child should be born while the foetal circulation is still going on with unimpaired vigor, the want of air will not be experienced by the child, and its attempts to breathe will be feeble and imperfect. It is probably better, instead of indulging in speculations of this sort, to content ourselves with the simple statement that when, from any cause whatever, the establishment of respiration at all has been attended with difficulty, there is a very great probability that its establishment will never be complete, but that some lobules only will receive the air, while it will not penetrate into other parts of the lung. The pro- bability of this occurring, too, will be still greater if the children be weakly or ill-nourished when born, or if they be exposed soon after birth to cold or other unfavorable hygienic influences, such as are calculated to interfere with the due performance of respiration. Cases in which this condition of the lungs exists usually present the history of the child having been apparently stillborn; and, though resuscitated after a time, yet still continuing unable to utter a strong and loud cry like that of other children. Even after breathing has gone on for some time, such children usually appear feeble; and though they may have attained the full term of foetal life, yet they can scarcely suck, although they often make the effort. An infant thus affected sleeps even more than new-born infants usually do; its voice is very feeble, and rather a whimper than a cry ; and the chest is seen to be very little, if at all, dilated by the respiratory movements. The tem- perature falls, the skin becomes pale, and the lips grow livid, and often slight twitching is observed in the course of a few hours about the muscles of the face. The difficulty in sucking increases, the voice grows weaker and more whimpering, or even altogether inaudible, while respiration is attended with a slight rale, or an occasional cough: and the convulsive movements return more frequently, and are no longer confined to the face, but affect also the muscles of the extremi- ties. Any sudden movement suffices to bring on these convulsive OF IMPERFECT EXPANSION OF LUNGS. 227 seizures: but even while perfectly still the child's condition is not uniform, but it will suddenly become convulsed; and during this seizure the respiration will be extremely difficult, and death will seem momentarily impending. In a few minutes, however, all this disturb- ance ceases, and the extreme weakness of the child, its inability to suck, its feeble voice, and its frequent and imperfect inspirations, are the only abiding indications of the serious disorder from which it suffers. But the other symptoms return again and again, till at length, after the lapse of a few days, or a few weeks, the infant dies. But I will relate a case which may serve to impress these charac- teristics on your memory. A little boy, three weeks old, was brought to me at the Children's Infirmary, on March 13, 1846. He was puny, emaciated, with a cold surface and bloodless conjunctivae. His face, which was wizened like that of an old man, was occasionally distorted by slight convulsive twitches; and these fits, as the mother termed them, were, according to her account, sometimes much more severe. The abdomen was tympanitic, and it alone was seen to move during respiration, there being hardly any lateral expansion of the chest. The ear applied to the chest heard but little air entering; and the cry was a stifled whimper, in which none of the inspiratory sound, the reprise of French writers, was distinguishable. The child sucked with difficulty, and had wasted ever since its birth, though no diarrhoea existed, but the bowels, on the contrary, showed a tendency to consti- pation. The chest was rubbed twice a day with a stimulating liniment, and a mixture was given containing some ammonia and the compound tincture of bark. Under this treatment the child appeared to improve; it began to breathe less rapidly and in a less labored manner, and its cry became louder. The parents, however, were miserably destitute, the mother in an ill state of health, so that her milk afforded but a very imperfect sustenance for the child. From the beginning of April he grew less well, and began to have occasional attacks of general convulsions, in one of which he died on April 26, 1846. On examining the body, large portions of both lungs presented the appearances which I have described as characteristic of their im- perfect expansion; but inflation restored them to a crepitant state. Some patches, however, though they admitted air and assumed the same color as the rest of the lung, yet could not by any effort be dilated so completely as to rise to a level with the surrounding tissue. The foramen ovale was open, the margin of the valve for fully half its circumference not being adherent, although the valve was sufficiently large for its closure. The ductus arteriosus also was quite permeable, although of considerably less calibre than during foetal life. This case affords a very good specimen of one way in which the affection leads on to a fatal termination; but sometimes, and probably in those instances in which the affected portion of lung is not so con- siderable, a less formidable train of symptoms usher in the fatal event. Convulsive twitchings, such as I have before mentioned, do not occur, nor are periodic exacerbations of the symptoms observed; but the child is merely feeble, and its breath is short, and it has an occasional 228 IMPERFECT EXPANSION OF LUNG. cough. It sucks, though with difficulty, but it loses flesh, the bowels become disordered, and medicine is unable to restrain the diarrhoea. The unchecked diarrhoea increases the emaciation and exhaustion of the child, which dies at length worn out and wasted to a skeleton. Sometimes, too, we meet with cases in which the child eventually recovers, and it is then very interesting to watch the gradual diminu- tion in the frequency and violence of the paroxysms of dyspnoea, while the respiration grows by degrees more equable, and the cry louder, the power of sucking increases, and the child at length attains to perfect health. A little boy, four months old, was placed under my care by his mother, who informed me that the child had presented in some un- natural position during labor, so that manual interference was required to effect her delivery; and when born the infant appeared dead, and was recovered only after very great difficulty, and after the occurrence of convulsions; the convulsions had since returned almost every day, sometimes, indeed, they occurred several times in the same day, and always came on with greater frequency by day than by night. The attempt to suck often induced them, as did also any rapid movement about the room, or any sudden change of posture. During the fits the child did not struggle much, but he always turned extremely livid about the face and mouth. No fit ever lasted longer than five minutes, and during the intervals between them the child seemed pretty well, except that he often suffered from a suffocating cough. He appeared tolerably well grown, and well nourished, and the temperature of the surface was nearly natural. The respiration, how- ever, was very hurried, and was almost entirely abdominal, the chest being hardly at all expanded. The cry, moreover, was feeble, and without reprise. There was a considerable want of resonance of both sides of the chest posteriorly, and deficient entrance of air into the back of both lungs. Both the dulness and the scanty admission of air were more obvious in the left than in the right infra-scapular region, and some mucous rale was heard in the former situation. The child was placed in a hot bath, and an emetic was given it every night; the chest, both in front and back, was rubbed twice a day with a stimulating liniment, and the face was ordered to be sprinkled with cold water whenever any threatenings of the fits came on. At the end of five days the child was better, and the cry louder, though without any distinct reprise. Small doses of the ferrocitrate of quinine were now combined with the other remedies, while the emetics were discontinued, as on some occasions they had appeared to excite the convulsions. First the cry grew louder, then the appear- ance improved and the manner became more cheerful, then the cough was less troublesome and the breathing less habitually wheezing, and at the same time the chest began to expand more, and the marked dulness of its lower parts gradually diminished. At the end of five weeks, the child was discharged with increased flesh and invigorated strength, and with no ailment more serious than a slight degree of wheezing respiration. ITS DIAGNOSIS AND TREATMENT. 229 The history of this patient may serve to show us that even very serious symptoms should not lead us to despair of recovery, while it illustrates the importance of forming an accurate diagnosis between this affection and congenital phthisis (the only malady with which it is likely to be confounded), lest we either cherish unfounded expecta- tions, or discourage hopes that might reasonably be entertained. A little care will usually suffice to enable us to distinguish between these two affections, notwithstanding some general points of resem- blance between them. The symptoms of the imperfect inflation of the lungs date from the infant's birth: but it scarcely ever happens that tuberculous disorganization of the lung is so extensive in the new-born child as to interfere with the establishment of the respira- tory function. But not only do not the symptoms of phthisis appear so early, but they likewise seldom advance so rapidly as those of atelektasis. Phthisis, too, is not from the beginning attended with the same debility, nor with difficulty in sucking, while it is associated with a febrile action which is quite wanting in atelektasis. The head symptoms which in so large a number of cases attend the imperfect inflation of the lungs, are absent in phthisis; while, lastly, auscultation would furnish some clue to the real nature of the case: in the one instance there would, in general, be simply a deficiency of air; in the other, respiration, accompanied with rades, and often with bronchial breathing. The treatment required by this affection need not detain us long. The importance of maintaining an equable temperature around every child in whom respiration is not duly performed, cannot be too much insisted on; and the power of generating heat being, as you know, much diminished, this temperature ought not to be below 70°, and in bad cases may be even 10° higher. Besides attending to preserve this warmth around the child, benefit often accrues from the employ- ment of the hot bath once or twice every day, at a temperature of 100° Fahrenheit, to which mustard may be added to render it more stimulating to the surface. The child should not be allowed to remain longer than five minutes in the bath, and should be enveloped in hot flannels immediately afterwards, to prevent its taking cold. The back and chest should be rubbed twice or oftener every day with a stimulating liniment, as camphor or soap liniment, which may be di- luted with a little oil, if it be too irritating to the skin. If the child be very feeble, stimulants may be given, of which there are none better than the compound spirit of ammonia or ether, or the spiritus ammonias succinatus, the unpleasant pungency of which remedies is concealed by milk better than by any other menstruum. The daily employment of a gentle emetic of ipecacuanha has in some instances appeared to be of service, not merely by relieving the air-tubes of any mucus that may have accumulated there, but by inducing several deep inspirations, and thus aiding the complete establishment of respiration. As the child improves, the more directly stimulating medicines may be withdrawn, and tonics substituted for them, among which few are better than the extract of cinchona.1 It has the great advantage of 1 See Formula No. 3, p. 56. 230 COLLAPSE OF LUNG AFTER BIRTH: not disordering the bowels; a point of no small importance in any case in which diarrhoea is likely to occur. In.some cases there is a sluggishness of the bowels, and a deficiency in the secretion of bile; very minute doses of the hydr. c. creta will often remedy the latter, and the use of a soap suppository will frequently render the internal employment of any purgative needless. The child should be put to the breast unless it be very feeble, but in that case should not be allowed to exhaust its strength in fruitless attempts to suck. It will be better to draw the breast, and give the child its mother's milk by means of a spoon or from a bottle, which latter plan has this advan- tage, that while it costs the child but little effort to get its food, we avoid the risk of its forgetting how to suck, an inconvenience which attends the use of the spoon if continued for any length of time. Arti- ficial feeding is not at all desirable in such cases, though sometimes, if the child be very weak, it may be necessary at first to give a few drops of brandy in its milk every three or four hours. This plan of treatment must be patiently persevered in, nor must the supervention of symptoms of an apparently acute character induce too wide a devia- tion from it. The head symptoms in particular must be combated cautiously, lest by too great a solicitude to overcome them we destroy the patient rather than the disease. LECTURE XVIII. Collapse of Lung that has once been expanded—described as lobular pneumonia by various writers—its characters—symptoms and difference from true pneumonia. —Observations of Bailly and Legendre.—Is not to be regarded as a post-mortem occurrence.—Illustrative cases.—Instances of its occurrence in the adult.—Simi- lar causes tend to produce it at all periods of life—hence very frequent in old age. Induration of the Cellular Tissue—its characters—remarkable reduction of tempera- ture that attends it—appearances after death—condition of deficient expansion, or of collapse of the lung, noticed by many observers, though misunderstood by most, is probable cause of the induration or oedema of the surface. The condition of the lungs which we were occupied in examining at the last lecture is of importance, even if regarded merely as a con- genital state, the result of nature having failed in the attempt to estab- lish respiration, and to fit the child thoroughly for the new mode of existence to which it is destined after birth. But it3 claims on our attention are still greater when we bear in mind the possibility of its occurrence in consequence of a variety of causes operating after birth, so that lungs once permeable to air may cease to admit it, and death may at length occur from apncea without any serious structural change having taken place in the organs of respiration. Appearances supposed to be the result of pneumonia had long MISTAKEN FOR LOBULAR PNEUMONIA. 231 attracted the notice of writers on diseases of children, by the wide differences which they presented from those which inflammation of the lungs gives rise to in the adult.1 It had been observed that in- fants and children under five years of age often died after presenting some of the symptoms of inflammation of the lungs, such as cough and difficult breathing, together with more or less extensive dulness of the chest on percussion, and some or other of the auscultatory signs of solidification of the lung. In such cases these peculiar morbid appearances were especially well marked. But while they seemed to prove that these changes in the lung were the consequences of pneu- monia, it happened not infrequently that the fever and the pneumonic symptoms underwent a great abatement before any sign of approach- ing death appeared, or that children who had seemed to die worn out from various causes, and during whose lifetime no indication of inflam- mation of the lungs had existed, presented the supposed anatomical evidences of pneumonia in a most remarkable degree. The frequency of occurrences of this kind led to the assumption that pneumonia was an extremely frequent concomitant of almost all the diseases of infancy and early childhood; that this pneumonia was very often latent (that is to say, that it did not manifest its existence by those symptoms which usually attend it); aud lastly, that, owing to causes which-were differently stated by different observers, it gave rise to alterations in the lung very dissimilar from those which it occasioned in the adult. One of the most remarkable peculiarities of this supposed infantile pneumonia led to its receiving the appellation of lobular pneumonia, as expressive of the fact that it did not attack a large tract of lung, or the whole of a lobe, at one time, but that it affected isolated lobules, which might be seen of a dark color, solid, often depressed below the surrounding parts, and sinking in water if detached from the healthy tissue in the midst of which they were situated. Sometimes the affec- tion was strictly limited to a single lobule, the boundaries of which could be exactly traced; and though it often happened that a cluster of lobules was thus hard, and dark, and solid, still there was no gradual shading-off from the darker to the lighter parts; so that it was evident that, in whatever way the disease extended, at any rate it did not advance by mere continuity of tissue. Sometimes almost the whole of one lobe was thus affected, a few lobules only still re- taining a healthy aspect, and crepitating under the finger; and it often happened that the bronchi leading to it were full of mucus or pus, while at other times there was marked congestion of the lung; and in the midst of this congested tissue were two or three solid, hepatized patches. All these circumstances, as it may be conceived, variously modified the morbid appearances. In the last case the lobular pneu- monia was thought to be becoming generalized; or, in other words, the inflammation originally limited to certain lobules was supposed to have begun to extend to the adjacent tissues, constituting a kind of 1 In the British and Foreign Medico-Chirurgical Review for October, 1853, is a very clear and interesting sketch, by Dr. Willshire, of the progress of knowledge with reference to pneumonia, and conditions of the lung resembling it in early life. 232 COLLAPSE OF THE LUNG—MISTAKEN DIAGNOSIS. transition state between lobular and lobar pneumonia. The lower edge of the different lobes, the whole of the middle lobe of the right lung, and often a very considerable portion or the whole of one or other lower lobe, were also sometimes found in a state to which, among other names, that of carnification was applied, on account of its close resemblance to a piece of muscular tissue. A portion of carnified lung showed the closest possible similarity to a lung that had been compressed by effusion into the pleura. It was dark, tough, solid, contained no air, presented a smooth surface when cut, yielded a small quantity of bloody serum when pressed, and, indeed, seemed almost like a piece of flesh; in all which respects it resembled a portion of lung hepatized by lobular pneumonia, and differed from the lung of the adult when that has been rendered solid by inflammation. The course of the disease in many of these cases during the life- time of the patient, and the results of medical treatment, tended to enhance the difficulties which the above-described anatomical pecu- liarities placed in the way of referring lobular pneumonia to the same category of affections with the pneumonia of the adult. Venesection, leeches, and mercurials, the ordinary antiphlogistic apparatus in the pneumonia of the adult, often appeared to hasten the child's death; blisters rarely effected any good, and the blistered surface often showed a remarkable indisposition to heal. On the other hand, emetics and rubefacients were frequently of service ; a stimulant plan of treatment was almost always necessary at an early period, and sometimes seemed to be required nearly from the outset of the affection. The rapidity of the changes that took place in the physical condition of the lnug was another peculiarity which rendered the nature of the affection still more obscure; for where air was heard entering freely on one day, none would be perceptible on the morrow, but percussion of that part of the chest would yield a sound of complete dulness. On the other hand, it happened sometimes, though much less often, that dul- ness was succeeded just as quickly by resonance on percussion, and that breathing became distinctly audible where on the previous day no sound of air was to be heard. Nothing can show more forcibly the influence of a name, than the fact that this condition of the lungs should have been described by all writers as lobular pneumonia, and that its symptoms should have been attributed to inflammation, while yet it was evident from the concurrent testimony of every one that neither in its progress nor in its results was it similar to inflammation of the lungs in the adult, much less identical with it. Having, however, once been called pneu- monia, every person continued to call it so, though often with a full recognition of its peculiarities. Even the close resemblance which the lung presented to foetal lung, or to those undilated portions which are characteristic of atelektasis, was noticed and discussed by myself, and by many far better observers, apparently without a suspicion that both states were identical. But while the peculiarities of lobular pneumonia were thus gene- rally commented on, it seems strange that no one should have had recourse to the experiment of inflation in order to obtain a solution RESEARCHES OF BAILLY AND LEGENDRE. 233 of some of the difficulties that existed with reference to its nature. This oversight seems the more extraordinary, when we call to mind that this very means had cleared up so many doubts concerning ap- pearances in the lungs of new-born infants, which had once been supposed to be the result of pneumonia in the foetus, or of some arrest of development. At length the experiment was tried by MM. Bailly and Legendre,1 and though, as in the old tale of Columbus and the egg, the thing seems so obvious that there is some risk of our under- rating the merit of those who were the first to do it, it must not be forgotten that, by that simple means, they have thrown more light on the affections of the lungs in infancy and childhood, than all the writers of the previous ten years together. MM. Bailly and Legendre state, as the result of their observations, that the appearances to which the name of lobular pneumonia has commonly been given are in reality produced by an occlusion of the pul- monary vesicles. This occlusion, say they—and the correctness of their opinion is now universally admitted—is due to the inspiratory power having been inadequate to overcome that elasticity of the lung which I described to you in my last lecture as constantly tending to empty the pulmonary vesicles of air, and constantly impeding its entrance. Coupled with this, however, there is another cause, the full influence of which had not been recognized till dwelt on by Dr. Gard- ner, of Edinburgh,2 namely, the presence of the secretions in the bronchi, and the obstacle which they present, sometimes at one point and sometimes at another, to the admission of air. The child inspires, and the secretion, which it could neither expectorate nor expel by coughing, closes the entrance to some small bronchial tube. With the Succeeding expiration, a little of the air retained behind this ob- stacle escapes, and on the next occasion a little more, till at length, no single inspiratory effort having been strong enough to surmount the obstruction, while with each expiration the quantity of air behind it is lessened, the vesicle collapses, and its situation is betrayed by the small, dark, depressed spot which may be seen on the surface of the luno-, and felt solid or non-crepitant beneath the finger. In bronchitis, where this secretion is abundant, perhaps excessive, the obstacle to the entrance of air which thence arises becomes in the case of young children a very serious source of danger, and the pos- sible occurrence of collapse of the lung must make you very guarded in the expression of your prognosis, even when the symptoms do not appear to be formidable. In such cases, too, the congestion of the pulmonary tissue, and the consequent pressure of the gorged vessels on the air-cells, both favor their collapse and impede their expansion. But besides these cases, in which the collapse of the lung becomes < Nouvelles Recherches sur quelques Maladies du Poumon; in the Arch. Gen. de ^ol^Jllt^^^orny of Bronchitis, &c.; reprinted from the Monthly J°? TO^e^enTe'to'this point, there are some conclusive experiments of MMRil- liet and Barthez, recorded in vol. i. p. 427, note, of the second edition of their work on Children's Diseases. 234 CASES OF COLLAPSE OF THE LUNG. a grave, perhaps even a fatal complication of disease already existing, there are others in which this condition occurs independently of any affection of the air-passages, and destroys life suddenly and unex- pectedly. If from any cause the inspiratory powers be very feeble, the obstacle in the air tubes need be but very slight in order to pro- duce collapse—need certainly be nothing more than may be presented by the gradual accumulation in the bronchi of their natural secre- tions ; while in some instances, such as the one which I will now relate to you, the collapse of the lung may be considerable, though the bronchi may contain no appreciable amount of secretion. A little girl was attacked, when a month old, by very severe diar- rhoea, which lasted for three weeks, and then left her greatly ex- hausted and much emaciated. No return of the purging occurred, and the child lived, though in a state of great weakness, till she was five months old. For the last five weeks of her life she was under my care, and sometimes she seemed, for a day or two, as if she were gaining strength and might recover; but these signs of improvement were never of long duration. Three days before she died, her breath grew suddenly hurried ; the dyspnoea was not attended with any cough, but, from the time of its coming on, the child's exhaustion increased, and her respiration grew more rapid until her death. No organ showed any sign of disease, but all presented a most remarkable degree of anaemia. Two-thirds of the upper, and almost the whole of the lower lobe of the right lung, were dark, solid, and non-crepitant; and a few lobules of the left lung presented the same appearance. Inflation restored them to exactly the same state as the rest of the lung. The bronchi were preternaturally pale, and con- tained no secretions. It is not possible to say why the child's inspi- ratory power grew too feeble to fill the lungs at one moment rather than at another, but few will doubt that it had become so just at the time when the dyspnoea occurred. A portion of the lung having become collapsed, the elastic ribs tended to render abortive any faint effort to draw in more breath, and thus the vital flame went out for want of air to feed it. Sometimes the occurrence of this condition is long preceded by indications of the imperfect performance of the respiratory functions, but yet they go on sufficiently to keep the machinery of life in mo- tion, till some trivial, perhaps some inappreciable cause—a draught of cold air, a little over-exertion, the horizontal posture too long con- tinued, the customary food delayed an hour beyond the usual time- sinks them so low, that they soon cease forever. Some time ago I saw a little girl ten months old, who had lost her mother soon after her birth, and had been indebted to a stranger for what should have been a mother's cares. She never throve; her chest presented that peculiar malformation commonly called pigeon- breast, and the diaphragm drew her yielding ribs inwards, and thus produced a circular constriction around the base of the thorax.1 But 1 A very interesting explanation of the mechanism by which this deformity of the chest is produced is given by MM. Rilliet and Barthez, op. cit., vol. i. p. 45. CASES OF COLLAPSE OF THE LUNG. 235 though she was a backward child, and though her respiration was always almost as abdominal as that of a new-born infant, there was no definite evidence of disease till she was nine months old. She then lost flesh rapidly, and began to cough without having had any previous catarrh. Her case seemed to be one of bronchial phthisis. Four days before she died her breath suddenly became much op- pressed, and her cough far more severe than it had been before. The dyspnoea rapidly increased, but her cough soon became less fre- quent. A few hours before her death her lips were quite livid ; she was breathing from eighty to eighty-six times in the minute, the abdominal muscles acting most violently, but the chest being scarcely at all expanded. Auscultation detected nothing more than some rather large mucous rale in the lung. After death no tubercle was found in any organ, but large portions of both lungs presented the undilated condition, which disappeared entirely on inflation. The bronchi were pale, and contained very little mucus, but the right side of the heart was greatly distended with co- agulated blood, which its thin, pale, and flaccid substance had evidently been unequal to propel with the requisite vigor. The imperfect respiration had here for some time manifested itself; the vital powers had long been feeble; nutrition had been ill per- formed, and the heart itself had shared in the general feebleness, till at length the secretion of a comparatively small amount of mucus presented an obstacle to the free entrance of air, which, though slight in itself, was greater than the child could overcome; and the whole machinery of life was thus suddenly brought to a stand-still. In both of these cases the feebleness of the inspiratory power was the chief cause of the collapse of the lung. The result is the same, however, if the obstacle be increased, as if the power be diminished; and hence, as I have already mentioned, the supervention of this state of lung becomes one of the most perilous, while it is one of the most frequent, complications of infantile bronchitis. A little girl, previously quite healthy, was seized when ten months old with symptoms of acute bronchitis, suffocative cough returning in paroxysms, and some- times followed by the rejection of a muco-purulent fluid. The symp- toms throughout did not seem to allow of depletion; but ammonia, with decoction of senega and tincture of squills, and other expectorants of a stimulating kind, were given with temporary amendment. The child did not, however, appear to have undergone any marked change, either for better or worse, except that she had certainly lost both flesh and strength, when coldness, faintness, and exceedingly labored re- spiration, suddenly came on, and continued till her death, which took place in the course of twenty-four hours. A few recent adhesions were found on each side of the chest, be- tween the costal and pulmonary pleura. The trachea contained a large quantity of mucopurulent matter, and the same secretion abounded in the bronchial tubes, many of which were filled by it, while nowhere did air-bubbles appear intermixed with it. There was some congestion of both lungs, especially posteriorly; the upper and posterior part of the upper lobe of the right lung, the whole of the 236 COLLAPSE PRODUCED BY SAME CAUSES AT ALL AGES. middle lobe, and the posterior part and lower edge of the lower lobe were dark, solid, non-crepitant, and depressed below the adjacent tissue. The same state existed in the whole inferior third of the upper lobe, and the lower edge of the lower lobe of the left lung. On inflat- ing the lung, most of these parts were restored to a perfectly natural condition, but some patches still remained less dilated than the others, and some of the darker, almost violet colored portions of the lower lobes appeared but little affected by it. But, you may naturally inquire whether any occurrence of a similar kind is ever met with in the adult, since there is certainly no such peculiarity in the structure of the lung in childhood as should render it then exclusively liable to a morbid process from which, in all other ages,,it is exempt. My own experience would not enable me to answer this question; but my friend Dr. Baly has communicated to me the particulars of three cases in which he found large portions of the lung in the adult presenting the characters that we have been studying in the child, aijfl, like it, resuming a natural appearance on the insufflation of air into the bronchi. The patients in all of these cases died of fever, attended with dysenteric symptoms; and for some days before their death were in a state of great exhaustion, such as appeared to indicate the free employment of stimulants. In two in- stances, distinct dyspnoea occurred some days previous to death ; but though the chest lost its resonance in the situation of the affected parts of the lung, and the breathing there was deficient, yet the minute crepitation of pneumonia was not detected in either case, but merely some mucous rale. In addition to extensive disease in the intestines, this collapsed condition of portions of the lung was found, uncon- nected with any disease of those organs in one of the cases, combined with the effusion of tenacious mucus in the bronchi leading towards the collapsed portions in a second, and associated with true pneumonia and a state of red or gray hepatization of other parts in a third.1 But these are by no means isolated cases; for it would seem as if in some diseases which are attended by much depression of the vital power, this collapse of the lungs were by no means unusual. To adduce but one illustration of the fact, it may be mentioned that M. Louis2 found in nineteen out of forty-six post-mortem examinations of patients who had died of typhoid fever, a condition of the lungs 1 The minute accuracy of Dr. Baly's description induces me to subjoin the follow- ing particulars of one of the examinations, as he allows me to extract them from his case book: " No effusion ; lungs healthy, except in lower and posterior fourth of right inferior lobe, which is of a dark, purple color, is depressed somewhat below the level of other parts, does not crepitate, feels solid, but flexible and tough, almost leathery, and sinks quickly in water ; the part having these characters is distinctly defined by boundaries of lobules. The whole lung being inflated, the part just described receives air with greater difficulty than the other parts, but at length becomes distended lobule by lobule, and assumes the same pale red color as the rest of the lungs. The change takes place, as has been stated, lobule by lobule, separate lobules appearing suddenly of the paler color, not merely at the margins of the dark mass, but also in its centre. On cutting through the lungs and tracing the bronchi, it is found that the ramifica- tions of those tubes which go to the dark, contracted, and condensed parts, are filled up with tough mucus, from which those going to other parts are free." 2 Recherches sur la Gastro-enterite, 8vo., Paris, 1829; tome i. pp. 361-364. COLLAPSE OF THE LUNG IN THE AGED. 237 which he calls " carnification," and which it is evident (although he did not try the effect of inflation) was identical with the state so fre- quent in the child. He describes the parts thus affected as of a deep purple red, having lost the natural suppleness of the lung, being solid and sinking in water; they were, moreover, tougher than healthy lung; if divided, the section became covered with a reddish fluid, perfectly destitute of air, while the tissue neither resembled that of healthy lung, nor presented the peculiar granular appearance charac- teristic of lung in the second stage of pneumonia. More recently, too, Dr. Gairdner, of Edinburgh, in his very important essays on the pathological anatomy of bronchitis, already referred to, has mentioned this condition of the lungs as having been of frequent occurrence during the epidemic fever of 1847. . It is true, however, that in these cases the condition of the fung was merely superadded to other lesions in themselves adequate to occasion the patient's death; and hence, though interesting to the mere pathologist, it yet loses much of its value in the eyes ot the practical physician. But it will not seem to you that too much stress has been laid on this state, if it should appear that whenever the power of the inspiratory muscles is much diminished there is a ten- dency to its supervention, so that it alone may be the cause of death; and this, which I have put hypothetically, really does occur in old age. The term second childhood is not a mere figure of speech, expressive solely of the decay of the mental powers, by which the evening of life is obscured and made like the twilight of the mind in early in- fancy but it is in many points the statement of a physical truth. Thus as old age creeps on, and the nutrition is no longer adequate to supply the waste, the respiration loses the character which it presented in the adult, and the extremes of life in this respect present a close resemblance to each other. The muscles of the chest grow too feeble to dilate it fully; the diaphragm becomes, as it was in early mtancy, the principal inspiratory muscle, and the vertical diameter of the thorax is that in which its chief enlargement takes place. The ear applied to the chest no longer detects the puerile breathing of youth, nor the clear vesicular murmur of manhood; but the respiration is coarser, sometimes almost bronchial. There is not occasion, as in infancy, for more rapid breathing to maintain the high activity of the vital processes, but the worn-out machinery needs to be put in motion more frequently than in the adult, in order to obtain oxygen enough to support existence; and, accordingly, MM. Hourman and Dechambre found the average frequency of the respiration in 255 old women at the Salpetriere to be 21.79 in the minute, while in some whose frame seemed most decayed it was far more rapid. Just as in infancy, too, so in old age, these respiratory movements are most irregular bome- times the parietea of the thorax continue for a long time motion lew and then there succeed a series of rapid movements, while at other ' The above facts with respect to the respiration in the aged are derived from the interesting papers of MM. Hourman and .Dechambre, m the Arch, de Med. foi 183o and 1836. See especially the number for Nov. 1835. 238 INDURATION OF THE CELLULAR TISSUE. times the intervals between the inspirations are irregular, but the inspiratory movements are of the same intensity and duration. Here, then, without pursuing the comparison further, we have ample proof of the many points of resemblance between the physiological condi- tion of the respiratory function in early life and in old age. The respiratory organs, too, in their pathological state, present, as might be expected, the same resemblance; and, accordingly, MM. Hourman and Dechambre1 notice a state in which the pulmonary parenchyma is of a very deep, sometimes almost of a blue color, or nearly black, non-crepitant, and presenting a smooth surface on a section of it being made. The lung thus altered is often remarkably tough, almost like Indian rubber; while under pressure, a viscous fluid, generally of a reddish color, and containing no air-bubbles, exudes from it. The idea of inflating the lung had not occurred to these observers; but they remark, that, if portions of lung presenting these characters be dried, the air-cells have a tendency to reappear without having under- gone any other change than a well-marked contraction. I have dwelt long on this pathological condition, though I think not longer than its importance demands; because we shall find that in some form or other it presents itself, modifying the symptoms, determining the prognosis, and influencing the treatment of almost all the affections of the lung in early infancy. We shall pass to the study of some of these diseases at the next lecture; but, before doing so, may notice an affection about whose nature much controversy has arisen, but to which, thanks to the re- searches of MM. Bailly and Legendre, we may now assign a place as one of the results of the imperfect expansion or subsequent collapse of the lungs, and of the consequently incomplete performance of the respiratory function. Though very rare in this country, induration of the cellular tissue is extremely common in the foundling hospitals of the Continent, where so many causes contribute to depress the new- born infant's feeble powers. The children in whom it occurs are usually weakly, not seldom permature, and its first symptoms gene- rally appear between the first and fifth day after birth, though occa- sionally they do not come on till later. In many instances a livid redness of the whole surface is obvious from birth; but the appear- ance of a circumscribed hard spot on one or other extremity, or on some prominent part of the face, as the end of the chin, or the cheek bone, is the first sign of the commencement of this affection. Other spots of a similar kind are soon discovered on different parts of the surface; and the body generally, and the hardened spots in particular, are found to present a temperature much below the natural warmth of the body. It appears, indeed, from M. Roger's researches,2 that a general reduction of the temperature precedes the induration, or, at least, exists in a very marked degree, while the induration is still ex- tremely slight. Sometimes too the premonitory loss of temperature,3 > Op. cit., Mars, 1836, p. 272. * Op. cit., pp. 124-151. 3 Hervieux, Sur PAlgidite progressive des Nouveaux-Nes, in Arch. Gen. de Med., Nov. 1855. CAUSES OF INDURATION. 239 may be perceived in weakly children without being succeeded by the appearance of spots of induration. This, however, is exceptional, and in the majority of instances the sinking of the temperature and the extension of the induration advance together, and the warmth of the surface may eventually fall from 100° to 90°, 80°, or even lower. If the induration become very extensive, it affects the integuments of the chest and the abdomen, as well as the extremities, and the body feels cold and stiff, as though it were frozen. This condition is, as might be expected, attended with great impair- ment of the general health, and with a very remarkable degree of emaciation.1 Children suffering from it are extremely weak, often too weak to suck; their pulse is very small, their respiration abdo- minal, and their cry is faint and whimpering, wholly unlike that of a healthy infant. In some of the worst cases, too, a bloody fluid is discharged in considerable quantity from the nose and mouth. If the indurated parts be punctured, a small quantity of reddish serum escapes from them, though generally without much diminution of their previous hardness. . . If the induration be at all general, death almost invariably takes place ; and so great is the fatality of the affection, that, including even sb>ht'cases, five-sixths of those children who are attacked by it in the hospitals of Paris, die. In very slight cases, however, if the infant be at once placed in favorable circumstances, recovery need not be 6The hardness of the surface still persists after death, and the ab- sence of any peculiarity in the effused serum, or of any sign of active disease, left writers generally in much perplexity as to its cause. 1 he venous system is usually found gorged with fluid blood, and this con- gestion is often apparent in the cerebral vessels, as well as in those ot the abdominal viscera, particularly the liver. Both the thorax and abdomen also frequently contain a quantity of serum, often tinged with blood—effusions which are evidently of a passive nature, since they are unattended by any trace of inflammation either of the pleura or peritoneum. None of the viscera present any morbid appearances of half so much importance as those which are met with in the lungs, a very great part of which displays those changes to which your attention has already been directed as characteristic of their deficient expansion.2 This condition of the lungs had been noticed and most • In a paper by M. Elsasser, of Stuttgard, reprinted in the Archives de Mdecinetor May 1853 ;Pfrom7the Archiv f. physiolog. Heilkunde are some very inter*ng fac with reference to the loss of weight in the course of this affection ™e f^ ^unS of weight in 53 fatal cases, was f of a pound ; the extremes each way being six ounces ^ The° obsTrvations of J. A. Troccon, in his dissertation " Sur la maladie connue sous le nom d^eXdssement du tissu ceilulaire," 4to Paris, 1814 are especia ly remark- able since he not only described with accuracy the physical conJ?ta™ °* *„ Jp not' but evn tried the experiment of inflating them in order to P^* ^^7 nsviffli as had been erroneously supposed, in a state of gangrene. He says— J ai msi me ensuite de PaS dans les poumons par la trachee, aussitot la couleur noire qui etait * Lur basrsiuhaiigee enune couleur rouge claire, laquelle s'est etendue de proche en nrochelmesurequ! je continuais ces insufflations." After removing a ligature which Kad app ed a?ound the veins, and allowing the escape of the blood with which the 240 TREATMENT OF INDURATION OF CELLULAR TISSUE. carefully described many years ago, as one of the most striking attendants on induration of the cellular tissue. It was thought by some of those who described it to be the result of pneumonia ; while other observers, justly insisting on the absence of the other effects of inflammation of the pulmonary tissue, yet drew the attention of pathologists too much away from the chest, where the clue to the solu- tion of the question as to the cause of the affection was to be found, had they but known how to use it. We, however, are aware that those appearances once thought to be the result of pneumonia are in reality due to the unexpanded condition of the lung; and we can understand how it may happen, if children be exposed to cold imme- diately after birth, and then transferred to the ill-ventilated wards of a foundling hospital, and there fed with food far other than that which nature destined for them, that respiration may be but very imperfectly established ; that their temperature may consequently fall, and the blood flowing in part through the unclosed foetal passages may stag- nate in its course, may give rise to passive effusions into the great cavities of the body, and to an anasarcous swelling of the surface. There are, it is true, some peculiarities in this form of oedema, but not such as to invalidate the above explanation of the cause to which it is due. The treatment of this affection implies the removal of every cause likely to induce it. Hence warmth stands foremost both as a curative and as a preventive measure. The warm bath may be resorted to as a means of raising the child's surface to a proper temperature, pro- vided its extreme weakness do not contraindicate that measure. Gentle friction with warm oil is a means which has been tried for this purpose with advantage. The child should be nourished with breast milk, even if it be too feeble to suck, and stimulants, of which white wine whey is a very good one, will, in many instances, be needed. Defective respiration being the ultimate source of all the symptoms, the main principles of all your treatment must be the same as have already been laid down for your guidance in cases of atelektasis of the lung; and these it can hardly be necessary to recapitulate. I should have said more about this affection, its nature and treat- ment, if it were one with which you were likely to meet often ; but, in consideration of its extreme rarity in this country, I may, perhaps, be excused for passing it over with this cursory notice. heart and lungs were gorged, he resumed the inflation of the lungs, and " les organes de la respiration ont 6te presque de suite dans un etat absolument naturel, et aussi beaux que ceux que l'on voit pendus devant nos boucheries."—pp. 37, 38. It seems strange that neither M. Troccon nor subsequent observers perceived the full bearing of these experiments till similar ones were instituted by MM. Bailly and Legendre. INFLAMMATION OF RESPIRATORY MUCOUS MEMBRANE. 241 LECTURE XIX. Inflammatory Affections of the Respiratory Mucous Membrane—comparative rarity of catarrh during the first weeks of life—Coryza—simple and pseudo-membranous, or malignant—Catarrh, causes adding to its importance in early life—its treat- ment—danger of bronchitis or pneumonia. Post-mortem appearances of Bronchitis—redness of the membrane—nature of the contents of the bronchi—dilatation of their cavity.—Extension of the inflammation to the lining of the pulmonary vesicles, producing vesicular bronchitis. State of the lungs in bronchitis—frequency of congestion—carnification of some lobules —possible extension of inflammation to the pulmonary tissue, producing lobular pneumonia—suppuration of these patches, producing vomicae. Although two lectures have already been devoted to the pathology of the respiratory organs, yet, until to-day, we have not been able to commence the study of their special diseases. - , • « They may be divided into the three grand classes of the inflamma- tory the nervous, and those which result from morbid deposits. We will'examine these in the order in which I have enumerated them. At every age inflammatory affections of the respiratory mucous mem- brane exceed all others in frequency; and even when the pulmonary substance becomes eventually involved, it is often by the extension to it of mischief which began in the mucous membrane. But in infancy and childhood, this is pre-eminently the case, for the delicate and highly vascular lining of the respiratory organs resists but feebly the influence of noxious impressions from without, while it sympa- thizes most acutely with many morbid processes within. This extreme susceptibility of the mucous membrane of the respi- ratory oro-ans in childhood renders its disorders of very frequent occurrence while we are compelled to study closely the signification of symptoms that may betoken disturbance from such various causes. Something of this sympathy with the affections of other parts exists even in the adult, as we may see exemplified in the cough that attends upon affections of the liver; but in the child, the sympathetic disorder of the respiratory mucous membrane is vastly more frequent; and nurses, taught by experience, will speak to you about a tooth cough, a stomach cough, a worm cough; while you wi 1 soon find tor your- selves that the intestinal mucous membrane is seldom affected without that of the respiratory apparatus suffering too. . . It is a curious fact, however, to which Professor Jorg, ot 1-eipsic, was the first person to call attention, that this extreme susceptibility of the lining of the respiratory apparatus does not exist to the same degree during the first month or two of life as it does afterwards. ' Handbuch der Kinderkrankheiten, Svo., Leipsig, 1836, p. 531. 16 242 CORYZA. The exposure of an infant two or three weeks old to a low tempera- ture, or to a vitiated air, will be followed by disturbance of the func- tion of the liver, and the occurrence of jaundice; or, perhaps, by such depression of the muscular power as to render the child incapable of taking a full inspiration, so that its lungs collapse, and it dies from disorder of the respiratory organs, but without the cough or bron- chitic symptoms, which would not fail, if it were a little older, to announce the irritation of the mucous membrane of the air tubes. Why this is so I do not know, but I suppose it to be the result of the generally feeble vitality which renders the lining of the bronchi less susceptible; just as that of the intestine also seems to be at the same period ; since, while constipation is frequent, diarrhoea is comparatively rare during the first two months of life. The mucous membrane of the nares, however, has not, by any means, this insensibility, and coryza is an affection most frequent, and most important, during the first two months of life, when the other forms of catarrh are comparatively rare. This affection, in its most frequent form, is a source of discomfort rather than of danger. Its most prominent symptom has given rise to its vulgar name of "the snuffles;" for, the mucous membrane of the nares being swollen, the child is no longer able to breathe through its nose as it was wont to do, but is compelled to breathe likewise through its mouth, and its difficult inspirations are attended by a peculiar snuffling noise, which, during sleep, sometimes amounts to a complete snore. As in common catarrh, the secretion from the membrane is at first suppressed, afterwards it flows in an increased quantity, and then, at length, it is altered in character, and becomes thicker and puriform; and then it sometimes dries and forms crusts about the nostrils, which interfere greatly with free respiration, and cause the child much annoyance. At the outset, there is often a degree of heat of skin and febrile disturbance, but these symptoms soon subside, and, with the exception of the snuffling respiration, the child seems quite well. If the attack be more severe, however, it may occasion a good deal of suffering, for, if respiration through the nose be very much impeded or altogether prevented, the child is rendered unable to suck, and so soon as it has seized the nipple and begun to draw the milk, it is compelled to leave it, in a state of threatening suffocation. Its distress, too, is further increased by the circumstance that, its mouth being constantly kept open in order to breathe, the tongue and throat become extremely dry, and deglutition, even when the child is fed with a spoon, is often attended with difficulty. Any such severity of the disease, however, is very unusual, though such cases do sometimes occur, and even prove fatal; the difficulty of breathing and sucking, together, wearing out the patient. When this event occurs, something more seems to exist than a simple inflammation of the Schneiderian membrane, since it either secretes a very tenacious mucus in extreme abundance, or becomes coated with false membrane, which sometimes extends even to the tonsils and palate. Cases of this kind are usually associated with extreme depression of the vjfal powers, and have received, on this account, the name of coryza maligna. In the Found- TREATMENT OF CORYZA. 243 ling Hospitals of the Continent, this malignant coryza is not very uncommon. I have never but once, however, seen anything approach- ing to it in severity, except where it has occurred as a complication of scarlatina or diphtheria. In that instance, which itself, perhaps, might not improperly be regarded as one of diphtheria, a little boy, six months old, was brought to me on the 25th October, 1842. His health had been good until the 20th, when he became hoarse; on the 22d, this hoarseness had much increased, and he became unable to suck, since which time he had continued to grow worse. When I saw him his skin was warm, face rather flushed, eyes watering, and a thick, ropy mucus obstructed his nostrils. He cried with a suppressed, but squeaking voice, and breathed with a peculiar wheezing noise, though air entered the chest unattended by any rale. The child was unable to suck, and even when he drank from a cup the fluid often returned through his nose. The inside of the mouth was very red, and the tonsils and soft palate were especially so. The mouth was full of an extremely tenacious mucus, which it was necessary, from time to time, to take out with the hand. A saturated solution of alum was injected up the nostrils, with great relief to the child, the secretion from the nares growing more decidedly puriform, but less adhesive; and the child became able to suck a little. On the 28th, however, the child's powers seemed much depressed; it sucked eagerly, for the secretion from the nose had become almost watery, but it swallowed with much difficulty. A layer of false mem- brane of a yellowish-white color had now appeared on the soft palate and back of the hard palate and on the tonsils. A lotion of three grains of the nitrate of silver to an ounce of water was applied to the back of the throat, and a mixture of the extract of bark with ammonia was given every six hours. On the 1st of No- vember the child was better, could both swallow and suck well, and the false membrane had entirely disappeared from the mouth ; but the palate was still red, and presented some broad superficial patches of ulceration. The subsequent recovery was tardy, but the immediate danger was over, and no relapse occurred. The simple coryza calls, as I have already observed, for but little treatment, and, indeed, treatment appears to exert but little influence over it. It is desirable, however, if there be much difficulty in breath- ing, that the child be taken from the breast, though it may still be fed with its mother's milk by means of a spoon, since the fruitless efforts to suck aggravate its sufferings, and should therefore be prevented. If heat of skin and other indications of fever attend its onset, some mild diaphoretic medicine, with a few drops of ipecacuanha wine, may be given:' attention must be paid to the state of the bowels, and in the°course of ten days or a fortnight the infant will be found again breathing quietly, and the disease will have subsided. As the secre- 1 (No. 8.) I£.—Liq. am. acet. 5j- Vin. ipecac, tt^xvj. Pot. nitratis gr. viij. * Mist, amygdalae 5vij.— M. 5j 4tis horis. For a child six months old. 244 CHRONIC CORYZA. tion becomes thicker, care must be taken to prevent its accumulating and drying at the opening of the nostrils, by which it would cause serious discomfort to the child. In the malignant variety of the disease local as well as general treatment becomes necessary. The tendency to the formation of false membrane in the nares must be combated by injections of alum or nitrate of silver while the condition of the fauces must be watched as narrowly as that of the nares, and similar applications must be made to them on the appearance of any unusual redness there, since such increase of vascularity is only the first stage of that process which would issue in the exudation of false membrane. At the same time, a general tonic plan of treatment will be called for, and care will be needed to insure the child's taking a proper quantity of nutriment, since its powers of sucking and deglu- tition will in all probability both be impaired. Cases are sometimes met with, in which coryza, though not of a severe kind, is troublesome by its continuance for weeks together. This chronic coryza is, I believe, almost always connected with a syphilitic taint. I have on several occasions met with it when there were not above one or two spots of copper-colored eruption to mark its character; and a few instances of it have come under my notice in which no positive evidence of venereal taint, either past or present, could be obtained, but which nevertheless got well under the use of small doses of the hydrarg. c. creta. With the increasing age of the infant there is a growing liability to catarrh, and during the period of dentition the susceptibility of the mucous membrane of the respiratory organs appears to have attained its maximum. Slight variations of temperature now induce catarrhal seizures ; or even, independently of any such exciting cause, the mere approach of a tooth towards the surface of the gum often gives rise to its symptoms which subside when the source of irritation ceases. Such attacks often alternate with attacks of diarrhoea, or the two co-exist; the symptoms of disturbance of the intestinal mucous membrane pre- dominating at one time, those of disturbance of the respiratory mem- brane at another. The preponderance of one or the other affection seems much to depend on atmospheric causes; and children who, dur- ing the months of June, July, August, and September, would suffer from diarrhoea, will in precisely similar circumstances in the earlier months of spring, or the later months of autumn, suffer from catarrh. From the extreme susceptibility of these two great mucous surfaces arises a large proportion of the ailments, and many even of the serious diseases of infancy. Morbid as well as reparative processes go on most rapidly in early life; the flux of to-day may to-morrow be attended by dysenteric symptoms; the catarrh of to-day may to-morrow have put on the grave features of acute bronchitis. Now these two circumstances taken together—the extreme suscep- tibility of the respiratory mucous membrane, and the rapidity with which its trivial disorder sometimes becomes a grave disease—give to the catarrhal affections of infancy an importance such as in more ad- vanced life they do not possess. This importance, too, is still further increased by the tendency of the lung to become collapsed when the entrance of air into its minuter cells is impeded even by a compara- CATARRH—ITS TREATMENT. 245 tively trivial cause; while in other cases, or even in connection with the collapsed condition of the lung, the inflammatory process may invade the pulmonary cells and the general tissue of the lung, and that which had seemed a slight cold may grow to a dangerous bron- chitis, or a still more dangerous pneumonia. Of catarrh itself and its general characters little need be said. Allow- ing for the difference between the ages of the patients, its symptoms are the same as in the adult. Sneezing, and running at the eyes and nose, and cough, a hot skin and quickened pulse, attend it. In some children the febrile disturbance with which even a common attack of cold sets in is very severe for the first twenty-four hours or more, and then the more threatening symptoms subside, and the true nature of the affection becomes apparent. At other times when catarrh is ex- tremely prevalent—epidemic, in short—this severe onset is usual; and the affection closely resembles, or is probably identical with, influenza. Often, too, you will find the commencement of an epidemic of hooping- cough preluded by an unusual prevalence of catarrh, the cough by degrees assuming in more and more numerous cases the paroxysmal character and peculiar sound of pertussis. It is unnecessary to allude to the catarrhal symptoms which precede measles ; but bearing in mind that what seems to be a mere cold may turn out to be the first stage of a very serious malady, you are furnished with an additional reason for not slighting it. Lastly, you must not forget that the frequent return of attacks of catarrh is sometimes an indication of that irritable state of the bronchial membrane which the abundant deposit of tuber- cle in the lungs occasions; and this, again, yields another argument for not neglecting an apparently trivial ailment. While it is your duty, however, on so many grounds, to watch closely every child, although its indisposition may not seem to be more than a simple catarrh, yet in the way of actual medical treatment very little is required. The child must be kept in one temperature; and, if the nursery be an airy room, it is desirable that it be confined to that apartment. If already weaned, it may be well to withdraw some of the more solid articles of diet; if not, care must be taken that the child does not, in consequence of its thirst, suck too much; and a little barley-water should therefore be given it from time to time. A warm bath at night will do much to allay the heat of skin; and, if the febrile disturbance be considerable, a couple of grains of James's powder, with half a grain of calomel, may be given to a child a year old, at bedtime. During the day, a mixture, containing a few drops of ipecacuanha and antimonial wine, with a little of the compound tincture of camphor, if the cough irritate by its frequent return, may be given with advantage ; and as the fever subsides, the spirit of nitrous ether may be substituted for the antimonial wine ' 1 (No. 9.) (No. 10.) R..—Vin. ipecacuanha rt^x. ^.—Vin. ipecac. tt\x. Vin. ant. pot.-tart, rt^xxx. Oxym. scillse n^xl. Tinct. camph. co. r^xx. Spir. aeth. nitr. n^xx. Mist, amygdalae gvij.—M. Tinct. camph. co. ir\,xx. 3ij 4tis horis. Aquae anisi gviss.—M. 5ij 4tis horis. For children of one year old. 246 MORBID APPEARANCES OF THE BRONCHI. The danger, however, in these cases, is of a more grave disorder of the air passages coming on; and this brings us to a subject which we cannot pass over hurriedly—namely, the bronchitis and pneumonia of infancy and childhood. The study of these affections in childhood is beset by some difficul- ties which we do not meet with in the adult. The points of difference between bronchitis and pneumonia are sufficiently well marked in the adult for all purposes of practical utility, although many inquiries may be started with reference to the intimate nature of the morbid processes, which we may be unable to answer satisfactorily. Besides, whether the capillaries, or the pulmonary cells, or their parietes, be the structures first attacked, it is clear that they are all involved in pneumonia from a very early stage of the disease; and hence we find it attended from the outset with peculiar symptoms, such as do not occur in bronchitis. Pneumonia, similar to that of the adult, is some- times observed even in early childhood; but it often happens that, though the pulmonary substance becomes eventually a partaker in the disease, yet it is not so at first; but the inflammation, beginning in the larger air-tubes, has passed along them to the smaller bronchi, and then at length involving the tissue of the lung, the case comes to be one neither of pure bronchitis nor of pure pneumonia, but a mix- ture of the two, which has not inaptly been termed bronchio-pneumonia. Another source of difficulty in the study of these affections, as well as an occasion of the great peril that attends them, is the tendency which we have already observed in the lung during early life to become col- lapsed, and no longer to admit that air without which the changes in the blood cannot take place, and the absence of which naturally ag- gravates the mischief that the inflammatory disease itself tends so immediately to produce. I must beg you, therefore, to pardon me if I enter rather more minutely than is my custom into the description of the morbid appear- ances produced by inflammation of the lungs and air-tubes in infancy and childhood. An increased degree of redness of the mucous membrane of the bronchi is almost constantly observed in the case of children who have died of inflammation of the lungs or air-tubes. There are three sources of error, however, against which it is essential to guard when examining the bronchi with reference to this point. The first is the occasional disappearance of redness after death, even where the presence of an abundant muco-purulent secretion in the tubes bears evidence to the activity of the inflammatory process; the second is the apparent redness of the smaller tubes in cases where the lungs are congested or in- flamed, and which may be due, not to the increased vascularity of the bronchi themselves, but to their transparency, allowing that of the subjacent tissue to be seen through them. The third is the occasional staining of the mucous membrane, owing to the transudation of the blood through the coats of the vessels after death. With care, how- ever, none of these circumstances will lead you astray. The redness of the bronchi varies much both in degree and extent, and in some cases which have approached to the character of pneumo- MORBID APPEARANCES O-^ THE BRONCHI. 247 nia rather than of bronchitis, is sometimes limited to the inflamed lobes. In cases, however, in which much bronchitis has existed, very marked redness generally begins about an inch above the bifurcation of the trachea, and pervades all the bronchi, being deeper in the se- condary than in the primary tubes, and retaining nearly as great an intensity even in the tertiary branches. It may stop here, or it may extend even into the ultimate ramuscules, or into the pulmonary cells themselves. In the majority of cases no other change besides this intense redness is perceptible in the mucous membrane, but sometimes it appears both thickened and softened; and on one occasion in which a fatal attack of acute bronchitis supervened on a long continuance of the chronic stage of the disease, the bronchial mucous membrane was intensely red, and so thickened as to have an almost villous appearance, and closely to resemble red velvet. Ulceration of the mucous membrane of the trachea and larger bronchi, which is occasionally met with in the bronchitis of adults, I never observed but once. In that case, a little boy, twenty months old, who had suffered from a not very severe attack of bronchitis, in the course of which, however, he had occasional difficulty in deglutition, with return of fluids by the nose, died rather suddenly. The only remarkable appearance besides a general redness of the bronchial tubes consisted in the presence of several small ex- cavated ulcerations or erosions in the upper part of the larynx, just above the chordae vocales. Associated with the changes in the mucous membrane of the bronchi there is an alteration in the character of their secretion._ At first, no doubt, this secretion is suppressed, just as we see that furnished by the Schneiderian membrane to be in a common cold; but after- wards it is poured out abundantly, and next ceases to present its natural characters of a glairy mucus; becoming opaque, thick, puri- form, or actually purulent, while in a few less common instances the secretion assumes the form and consistence of false membrane, consti- tuting a true croup of the bronchi. Any traces of blood are but very seldom observed in the secretion, and the quantity of air-bubbles in- termingled with it is usually in inverse proportion to the thickness of the secretion and its abundance. But not only are the contents of the air-tubes altered in character, and, for the most part, increased in quantity, but the tubes themselves often undergo a marked alteration in their calibre, and become greatly dilated. This dilatation is usually observable from the secondary bronchi to the minutest air-tubes; the branches often being as large as the parent trunk, or even larger: but that fusiform dilatation which is met with in the adult has never come under my notice. On one occasion, however, in addition to a general cylindrical enlargement of the tubes, many of them presented a marked dilatation about half an inch from their termination; the tube expanding into a cavity big enouo-h to hold half a nut. The interior of these cavities was not per- fectly smooth and regular, but its thickened lining was in many parts thrown into folds or wrinkles. The case in which this appearance was observed was the one already mentioned, where the mucous mem- 248 MORBID APPEARANCES OF THE BRONCHI. brane of the bronchi presented so extraordinary a degree of thick- ening. Dilatation of the bronchi was once supposed to be the purely me- chanical effect of the accumulation of the secretions within them. There is, however, no constant relation between the quantity of the liquids within the bronchi and the degree of their dilatation, and we must look to two other circumstances as being the primary causes of the occurrence. The first of these is the weakening of the muscular fibres of the bronchi by the inflammatory action; the other, the loss of the ciliary epithelium which lines the air-tubes when in a state of health, and contributes by the incessant vibration of its cilia to keep them free for the access of air. Whenever bronchitis has reached such an intensity as to give rise to the abundant pouring out of thick fluid into the air-tubes, so that the air can no longer permeate them with facility, while this difficulty is still further increased by the loss of the ciliary epithelium, and by the weakening of the contractile power of the bronchi, which would have helped to keep them free, it often happens that the feeble inspi- ratory power of the child becomes wholly inadequate to fill the lungs; large portions of them collapse, and bronchitis thus becomes the indi- rect cause of carnification of the lung. In some cases, the inflammation of the respiratory mucous mem- brane extends further than usual along the smaller bronchi, until it involves their extremities and the pulmonary vesicles themselves, when it produces an appearance almost peculiar to childhood, and which has been described under the names of vesicular pneum,onia or vesicular bronchitis. A lung, or a portion of a lung, thus affected, no longer contains any air—it is dark in color, and feels tough, though solid; its surface is beset by a number of small, circular, yellow, slightly prominent spots, of the size of a millet-seed, or smaller, -which, on a hasty glance, present a very great resemblance to crude tubercles. A very little attention, however, suffices to distinguish between them ; for not only do these yellow spots differ from tubercle in their favorite seat being along the lower margins of the different lobes, but on puncturing any of them with the point of a scalpel, a drop of pus will exude, and the yellow spot will disappear. Some- times, too, a minute bronchus may be traced running to its termina- tion in one of these little sacs. It has been suggested that this ap- pearance may be due to the secretions formed in the air-tubes being forced by the column of air which enters in inspiration into the smaller bronchi and pulmonary vesicles, the cavities of which thus become mechanically distended. The opinion that the secretions which occupy these parts are produced at the spot where they are discovered, by inflammation of the ultimate ramuscules of the bronchi, is, however, generally entertained, and is supported by very conclusive evidence. Bronchitis often exists unattended with this peculiar appearance; and on the other hand, vesicular bronchitis is met with independent of general inflammation of the air-tubes, while, though usually partial, and often limited to the lower border of one or other lobe, it is some- times very extensive, and occupies nearly the whole of the lower lobe TRUE LOBULAR PNEUMONIA. 249 on either side, constituting the most important of the morbid appear- ances discovered on examining the chest. It may, and unquestionably often does, happen that children die of bronchitis alone, and without any notable affection of the pulmonary tissue. But it is much more frequent for the pulmonary substance to bear a part in the morbid process; and this share may either be limited to mere congestion, or may rise in degree until it produces all those consequences which we find attendant on inflammation of the tissue of the lung in the adult. Some degree of congestion of the lung is almost constant if bronchitis be at all severe, for the circulation through the organ is disturbed, the blood flows less freely than natural, and its changes take place more slowly. It stagnates first in those depending parts whence position renders its return most difficult; and the portions of the lung thus affected become by degrees more and more extensive. Dark, solid, non-crepitant patches may be often seen in the midst of a lung thus congested; and until the results of inflation showed that a wrong inter- pretation had been given to the appearance, these patches were regarded as the centres whence the inflammation was extending to the surround- ing tissue. You do not need to be reminded that they are lobules which have collapsed, and become impervious to air; and portions of lung in which this occurrence has taken place seem to have but little disposition to become the seat of active inflammation, and to pass into a state of red or gray hepatization. At the same time, however, it must be borne in mind that this indisposition to active inflamma- tion does not by any means amount to actual immunity from it, and that carnified lung may sometimes become softened, or even infiltrated with pus. It does, however, happen now and then that the lung is found in a condition which may justly be called lobular pneumonia, as the result of the extension to the surrounding tissue of inflammation beginning in the air-tubes. Patches of lung will then be interspersed through the surrounding pulmonary tissue, of a vivid red color, of various sizes, from that of a pea to that of an almond, irregular in shape, and not circumscribed exactly by the margins of lobules, as is the case with portions of carnified lung. This process going on in a number of different situations, the affected parts may at length coalesce, and a pneumonia, at first lobular, may thus eventually become generalized. Or, though this should not occur, the inflammation may yet go on in the isolated portions of lung to the infiltration of pus into its sub- stance, or the actual destruction of its tissue, when a portion of the lung will appear riddled with small distinct abscesses, seldom larger than a pea, irregular in form, and communicating more or less evi- dently with a minute air-tube. They may be distinguished from the vomicae produced by softened tubercle, partly by the absence of tuber- cular deposits in other parts of the body, and by their being almost always limited to a single lobe of one lung. Their own characters, however, are sufficiently well marked, for they are altogether destitute of those 'solid walls which the tubercular deposit forms around a phthi- sical cavity; though the yellow lymph which often lines them may be 250 LOBAR PNEUMONIA; mistaken by the inattentive observer for tubercle. MM. Killiet and Barthez mention having found the pulmonary substance healthy, except in the immediate periphery of these abscesses; but no instance of this kind has come under my own observation, the pneumonia having in each instance become generalized. ^ The appearances we have hitherto been considering are due almost exclusively to inflammation of the air-tubes; and many of them are peculiar to infancy and childhood. We might next proceed to study the symptoms that betoken their existence; but, on the one hand, they seldom exist quite alone, and, on the other hand, their symptoms pre- sent so many points of resemblance to those of pneumonia strictly so called, that it may be better to complete our survey of the morbid appearances that result from inflammation affecting either the air-tubes or the parenchyma of the lung, before we pass to the study of the symptoms that attend the one or the other during life. The completion of this subject, however, must be postponed to the next lecture. LECTURE XX. Inflammatory Affections of the Tissue of the Lung. — Lobar Pneumonia—More common in early life than has been supposed—Its general characters the same as in the adult—Some morbid appearances deserving especial notice ; viz. sub- pleural ecchymoses, pneumonic abscess, and emphysema of the uninflamed por- tions of the lung. Frequency and causes of inflammation of the respiratory organs—Influence of age— of previous attacks—of various diseases. Bronchitis—its Symptoms and Treatment—A more eerious disease than in the adult, and why—Symptoms of capillary bronchitis—Illustrative case—Results of auscul- tation. Treatment of bronchitis—Rules for depletion and the use of antimony—The dyspnoea not always dependent on severity of the inflammation—Treatment of this nervous dyspnoea—Treatment of bronchitis in its chronic stage. Influenza—Its peculiarities in early life. We were occupied during the last lecture with the examination of some of the results of inflammation of the respiratory organs in early life, and considered more especially those changes which inflammation produces in the air-tubes. You were told on that occasion that the disease does not always remain limited to the bronchia or pulmonary vesicles, but that it sometimes involves the substance of the lung, and thus gives rise to the appearance of a number of small circumscribed patches interspersed throughout its tissue, either red, hard, and solid, or gray from the infiltration of pus; while, if the mischief advance one step further, it may lead to the destruction of the parenchyma of the organ at these points, and thus produce numerous minute abscesses NOT UNUSUAL IN CHILDHOOD. 251 —a condition which has thrice come under my observation. Cases of this kind, constituting true lobular pneumonia, though somewhat less rare than in the adult, are yet of very infrequent occurrence. It is almost needless to remind you that the contrary opinion resulted from persons not having learned till very lately to distinguish between that solidity of the lung which is produced by inflammation, and that which results from the mere collapse of its air-cells. The exaggerated estimate of the frequency of lobular pneumonia, and the peculiar character of the field presented at the Hospital for Children at Paris, in which the most diligent and most successful students of children's disease labored, led to an underrating of the fre- quency and importance of lobar pneumonia such as is met with in the adult; and hence you will find but little said concerning it in many most valuable works of our continental neighbors. Lobar pneumonia, however, is often met with in early life both as an idiopathic and a secondary affection, giving rise to the same morbid appearances as in the adult, and requiring a very similar treatment. Not only are the physical characters of the lung in lobar pneumonia the same in childhood as in adult age, but the three stages of engorge- ment, of red and of gray hepatization, are observed with much the same frequency at the one period of life as at the other. I find that after rejecting all cases in which pneumonia occurred as a complica- tion of phthisis, or of acute pleurisy, and in which the results might be modified by the disease to which the inflammation of the lung suc- ceeded, I have a record of 64 cases in which the condition of the in- flamed lung was carefully noticed. In 10 of these cases the 1st and 2d stages of pneumonia co-existed. " 4 " " 1st and 3d " " " 16 " " 2d and 3d " " "11 " " all 3 stages " " " 9 " " lung was in the 1st stage only. " 8 " " lung was in the 2d " " 6 " " lung was in the 3d " 64 This result tallies very closely with that obtained by M. Grisolle,1 on an examination of 40 cases of pneumonia in the adult. In 4 cases the 1st and 2d stages of pneumonia co-existed. 3 1st and 3d 16 2d and 3d 2 " all 3 stages 7 " lung was in the 2d stage only. 8 " lung was in the 3d 40 It will be seen, on a comparison of these tables, that the third stage of pneumonia occurs not much less often in children than in adults, 1 Traite de la Pneumonie, 8vo. Paris, 1841, p. 18. 252 PULMONARY ABSCESS. having been met with in the former in the proportion of 57.8, in the latter in the proportion of 72 per cent.; and the main difference be- tween the two consists in the greater frequency with which all three stages of pneumonia co-exist in the young subject. This peculiarity of pneumonia in childhood is probably due to the^endency which the disease then displays to involve a large extent of pulmonary tissue; and to the same cause we must attribute the frequency of double pneumonia in early life, which, in the cases that came under my notice, preponderated greatly over those wherein only one lung suffered. The well known law, according to which pneumonia of the right lung is more common than pneumonia of the left, holds good in childhood; nor is the frequency of concomitant pleurisy much, if at all, less in the child than in the adult. The contrary opinion arose from the error to which reference has so often been made, of regard- ing cases of collapsed lung, either with or without bronchitis, as in- stances of red hepatization of the pulmonary substance. Instead of inflammation of the lungs being less active in the child than in the adult, there are some facts which would seem to lead to a directly opposite conclusion. Such are the frequency with which, in fatal pneumonia in children, ecchymoses are found beneath the pleura covering the inflamed lung, the more common occurrence of pulmonary abscess in early than in adult life, and the very extensive emphysema which is often observed in those parts of the lung to which the inflam- mation has not extended. The sub-pleural ecchymoses appear to result from the rupture of some of the minute capillaries of the lungs in consequence of the great dis- turbance of the circulation through them. They are usually small, like petechias, but occasionally they attain a large size, and once or twice they have presented themselves to me extending a little way into the tissue of the lung, constituting little spots of pulmonary apo- plexy, about the size of a millet-seed, or even a little larger. They are most numerous on the posterior surface of the lungs, and especially in parts where the lung has become hepatized, though by no means confined to those situations. The termination of pneumonia in abscess of. the lung is so rare an occurrence in the adult, that Laennec did not meet with it above five or six times in the course of several hundred examinations of persons who had died of inflammation of the lungs. In the child, however, the case is otherwise, for abscess of the lung has come under my observation in three out of the sixty-four examinations of cases of lobar pneumonia, on which my present remarks are founded. In one of these cases, that of a boy, aged twenty months, who died on the fourteenth day after the commencement of an illness which resembled remittent fever in many of its symptoms, but was associated from the outset with the indications of pneumonia, the following appearances were observed: The upper and middle lobes of the right lung were connected to each other, and to the walls of the chest, by adhesions which were chiefly recent. Nearly the whole of the upper lobe was solid, and sank in water. It was of a mottled reddish-gray color, in EMPHYSEMA. 253 which gray predominated; it broke with a granular fracture, and was readily reduced to a dirty putrilage. Near the apex was a portion the size of a walnut, which was already soft and in a state of quag- mire. The upper two-thirds of the middle lobe were in the same condition as the, upper lobe; the lower third was emphysematous. In the centre of the middle lobe was a cavity the size of a bean, irre- gular in form, intersected by the remains of some vessels, lined by a thin layer of yellow lymph, and surrounded by lung in the third stage of pneumonia; but neither in that lobe nor in any part of the pulmo- nary tissue was there the least trace of tubercle, and the only indica- tion of phthisical disease consisted in one bronchial gland having become converted into tubercle which had undergone the cretaceous transformation. The lower lobe of the right lung was in the first stage of pneumonia; the left upper lobe was quite healthy; the left lower lobe was in a state of mingled red and gray hepatization. The other two cases occurred in children who had suffered for some weeks from hooping-cough, and in both the lungs contained numerous semi-trans- parent, gray, tubercular granulations. One of the children was a boy, five years old; the other a little girl, aged two years. In the case of the former, the abscess, as large as a walnut, was situated at the lower border of the upper lobe, extending a little into the lower lobe. In the latter it was of the size of an unshelled almond, and occupied a similar position with reference to the right upper and middle lobes. The characters of the abscess were the same in both instances, being situated almost immediately beneath the pleura; from which a wall of lung not above two lines in thickness separated it. Its cavity was partly filled with a yellowish, puriform, very tenacious fluid, like very tenacious pus, and which did not bear any resemblance to softened tubercle. It was not lined by any membrane: there was no appear- ance of tubercular deposit in the hepatized lung in its immediate vicinity, which was generally in the second stage of pneumonia, nor was it situated near to, nor in communication with, any large bron- chial tube. The lung in childhood shows a much greater tendency to pass into a state of gangrene, than in adult age. It may be doubted, however, whether this gangrene is the result of the intensity of the inflamma- tion so much as of some peculiar change in the blood which favors the occurrence of mortification. The occasional prevalence of gan- grene of the lung and of other parts, as an endemic affection, in the Hopital des Enfans at Paris, favors the latter supposition, with which the only instance of it that has come under my own observation in the child is quite in accordance. The emphysematous condition of the uninflamed portions of the lung in cases of fatal pneumonia in early life, seems to be connected with the rapidity of the advance of the disease. It is usually most obvious at the anterior part of the upper lobes of the lungs, and at the margin of the other lobes, and always bears a marked relation to the short- ness of the patient's illness, and the extent of lung which has been rendered unavailable for purposes of respiration. The cases, however, 254 CAUSES OF PNEUMONIA. which terminate most rapidly are not those in which the direct results of inflammation are the most extensive, but rather those in which collapse of a considerable portion of lung has taken place; and the emphysema, which is met with also in many cases of vesicular bronchitis, is consequent less on the inflammation than on the collapse by which it is accompanied. Its occurrence in those circumstances affords therefore an illustration of that modification of the inspiratory theory of emphysema so clearly propounded and so ably supported by Dr. W. Grairdner, of Edinburgh ;* and which regards the over-dis- tension of the air-vesicles of one part of the lung as a necessary com- pensation for their collapse, and the consequent diminished bulk of another part, while the enlargement and the capacity of the thorax during inspiration remain the same, or at any rate are but slightly modified.2 The causes which give rise to inflammation of the lungs and air- tubes are, to a great extent, the same at all periods of life; so that we need not devote much attention to the special study of those which tend to produce it in childhood. It should be borne in mind, however, that the fluctuations in temperature, or the biting wind, or the cold weather, which may be encountered with impunity by the robust adult, may prove most deadly when they act on the feeble frame and delicate organs of the child. Hence it is, in great measure, that inflammation of the respiratory organs is so much more frequent, and so much more fatal, in childhood than in adult age, and in in- fancy than in childhood. The fact is well shown by the Eeports of the Registrar-General for the years 1842 and 1845, from which it appears that 67.1 per cent, of the total mortality from inflammation of the lungs and bronchi, in the metropolis, took place in persons under fifteen years of age; 63.2 per cent, under five; 57.1 under three; and 28.7 per cent, under one year. But the tendency to these affections, as is shown in the following table, is not greatest in the first month of life, diminishing in proportion as the child advances in age and increases in strength; but the time when they are most prevalent coincides exactly with the time when the susceptibility of all the mucous membranes is at its highest point, namely, the period of dentition. 1 On the Pathological Anatomy of Bronchitis, etc. 8vo. Edinburgh, 1850 ; and Edinburgh Monthly Journal, vol. xiv. 2 In the second and third editions of these lectures I stated that the amount of emphysema bore a " marked relation to the shortness of the patient's illness, and the extent of lung which had been invaded by the inflammation." A careful re-exam- ination of the accounts of my post-mortems of cases of pneumonia and bronchitis, con- vinces me that the statement as now modified is more correct in point of fact, while at the same time it harmonizes perfectly with Dr. Gairdner's theory of emphysema. That theory, however, is, I am convinced, applicable only to one class of cases, while of another equally numerous, Dr. Jenner's expiratory theory (see his paper in vol. xl. of the Medico-Chirurgical Transactions) offers the true solution. To this reference will be made when the subject of hooping-cough comes for consideration. CAUSES OF PNEUMONIA. 255 TABLE, Showing out of 231 cases of children dying from various diseases, in whom I carefully examined the thoracic, viscera, the number of instances in which the lungs, bronchi, and pleura presented no signs of recent inflammation, and also those in which signs of it were discovered. The first line represents the former, the second the latter class of cases. eq CO ■ r-j « o . o . ^> £ ™ o o o o ~A r-l — to ^3 Sj3 "-• !>> IN m- m ^ "* oj X5 jj OS „; t" '75 GO f/; 01 « I-H ^ rt „; 0> £ fcs 9 bH S a E« 0 5 S 3 S 3 S 3 S 3 S3 S3 ss S 5| fn P o O OI O cs O c u a En " Pn** £"> SK £* fe^ En i1 *-> fi* fi^ Pn En 5 13 17 13 5 14 16 5 8 2 6 4 3 2 1 116 3 10 14 17 21 14 9 7 7 5 3 2 1 2 115 This table illustrates the fact mentioned in the last lecture, that when the child is first born, the mucous membrane of the respiratory organs is endowed with but little of that susceptibility which it after- wards acquires, and that accordingly those diseases whose point of departure is from that membrane are far less frequent during the first six months of life than they become during the succeeding eighteen months; while, from the completion of the second year up to the time of puberty, they go on diminishing in frequency and fatality. And there are important practical inferences which may be deduced from the facts we have just mentioned. They teach us not only that a catarrh is a much more serious thing in infancy than in adult age, but also that it is more serious at one period of infancy than at an- other, and they warn us to guard a child, during the time that the process of teething is going on, with double care against all causes that are likely to excite inflammation of its respiratory organs. There are some diseases which, after having occurred once, confer on persons an immunity from subsequent attacks. This, however, is far from being the case with bronchitis or pneumonia in early life, but the susceptibility of the respiratory organs appears to increase in exact proportion to the frequency with which they have already suffered,1 and a child who has once been attacked by inflammation of the lungs or air tubes is more likely to have a second attack brought on by a slight change of temperature than another who had never suffered from it would be to experience a seizure from a much graver cause. With advancing age this susceptibility seems to wear out— the child outgrows it; but we should act most unwisely if we were to sanction exposure to the cold with the view of hardening a child against its influence. The importance of inflammatory diseases of the respiratory organs depends not merely on the frequency of their occurrence as idiopathic 1 In a tract on Pneumonia in Children, published some years ago in the British and Foreign Medical Review, I mentioned that of 78 children who came under my care for inflammation of the lungs, 31 were stated to have had previous attacks of the disease ; 21 once; 4 twice: 2 four times ; and 4 were said to have had it several times, though the exact number of seizures was not mentioned. Of these 31, 10 were under two years of age, 10 between two and three, and the remaining 11 between three and six. 256 SYMPTOMS OF BRONCHITIS. affections, but also on their tendency to supervene in the course of other maladies. This tendency, though very evident at all ages, is especially remarkable in early life, as is apparent from the fact that, in 33 only of the 115 cases enumerated in the former table was the inflammation an idiopathic affection. When we come to the subject of measles, hooping-cough, croup, diarrhoea, and remittent fever, it will be necessary to study these secondary attacks of bronchitis and pneumonia with attention, since they constitute frequent and serious complications of those diseases, against which it behooves us to be most anxiously on the watch. We will now pass to the study of the symptoms of bronchitis, and will commence with the examination of the most simple form of in- flammation of the air-tubes—namely, that which develops itself out of ordinary catarrh. In such a case the child has for some days seemed to suffer from nothing more serious than a common cold; but, by degrees, instead of the cold and cough subsiding, the heat of skin becomes more considerable, the cough tighter, more frequent, and more painful, the child sometimes crying after each cough: the pulse becomes more rapid, the respiration wheezing, hurried, and often somewhat irregular. These graver symptoms often steal on very gradually, and among the poor it by no means seldom happens that the disease has already attained an advanced stage, and the condition has become one of very considerable peril, before the parents, never very observant of those ailments that are not attended with acute suffering, take the alarm. The flush of the face and the heat of the skin become increased, the respiration grows more labored, and the cough more troublesome towards evening; and the first hours of the night are usually very restless, but the child then falls asleep, and often dozes tranquilly for some hours; it then generally awakes with its respiration very oppressed, for the secretions have been accumulat- ing in the smaller bronchi, and have now begun to impede the en- trance of the air. An attack of cough probably comes on, which very likely ends in vomiting and the rejection of some mucus, and then by degrees the breathing becomes more easy, and the child may for a short time seem comparatively cheerful. The temperature of the surface, though increased, is variable; and, if the disease continue for several days, perspiration will be observed occasionally to break out on the body, while the pulse, though quickened, is not very much accelerated, and the tongue continues moist throughout. The ear detects nothing in the chest besides a mixture of rhonchus, sibilus, and largish crepitation; the dry sounds preponderating at the upper, the moist at the lower part of the chest, and being vastly more abund ant behind than in front. Now in the adult a condition such as this would excite but little apprehension, but in the child it must be borne in mind that nothing more is needed than a copious secretion of mucus in the bronchi, or a feeble condition of the vital powers, to prevent the air from freely entering the pulmonary vesicles, and thus to induce the collapse of a large portion of the lung. Thus it is, at least as I apprehend, that we must explain many of the instances in which urgent dyspnoea, and all the symptoms of serious pulmonary SYMPTOMS OF CAPILLARY BRONCHITIS. 257 disease, have developed themselves in the course of a few hours out of what had seemed to be nothing more than a rather severe cold, or a bronchitis of moderate intensity. This too accounts for the occa- sional sudden supervention of dulness on percussion, and of bronchial respiration in the child; so that you may discover them in the morn- ing in a situation where over night the percussion was good, and no sound was heard of graver import than large crepitation; changes which, unlike those dependent on solidification of the lung from in- flammation, you may find, as has been remarked by Dr. Gairdner, of Edinburgh, unaccompanied by any exacerbation of the febrile symp- toms. This rapid change in the ausculatory phenomena has been noticed by Dr. Stokes as occasionally happening in the pneumonia of the adult.1 That distinguished physician offered no explanation of the occurrence; but we can now understand what is its true import, and what the reasons are for its being met with so much oftener in the child than in the adult. But, notwithstanding this danger, which is great in proportion to the youth of a child, yet most cases of idiopathic bronchitis that come on gradually, developing themselves out of previous catarrhal symp- toms, have a favorable termination; and, as a general rule, it may be stated that an attack which is long in arriving at its acme is seldom very dangerous in its character. Pure idiopathic bronchitis, occurring in an otherwise healthy child, in most cases subsides in the course of a few days, leaving the patient with an increased susceptibility to the influence of those causes which brought on the first attack, and per- haps with a degree of debility, the recovery from which may be pro- tracted for many weeks. There is, however, a form of acute bronchitis which is often, though not always, idiopathic, that runs its course with much rapidity, and generally tends to a fatal termination. In this, the suffocative catarrh of some writers—the capillary bronchitis of others—the smaller air- tubes throughout the whole or a considerable portion of the lungs are attacked either in connection with the larger bronchi, or independently of them; and the inflammation, which is very intense, usually termi- nates in the abundant secretion of pus, or in the formation of false membrane that nearly obliterates their cavity, or, involving the pul- monary vesicles themselves, it gives rise through a considerable ex- tent of the lungs to those appearances which have been described under the names of vesicular pneumonia and vesicular bronchitis. Its attack is sometimes sudden, though in the great majority of cases it is preceded for a few days by the ordinary symptoms of ca- tarrh, or it supervenes on that condition of bronchial irritation which accompanies or follows one or other of the eruptive fevers. In these lat- . ter circumstances there is either a progressive though rapid increase in the severity of the bronchitic symptoms, or there is a sudden outbreak of fever and dyspnoea, and the cough becomes all at once frequent, short, and hacking. The disease soon attains a very considerable intensity; the face becomes anxious and oppressed, the eyes heavy, 1 On the Diseases of the Chest. Svo. Dublin, 1837, pp. 311 and 327. 17 258 SYMPTOMS OF CAPILLARY BRONCHITIS: the manner distressed; the respiration very hurried, generally irregu- lar, and interrupted by the cough, which frequently seems to occasion pain. The restlessness is often extreme, and the position which the child assumes very variable ; but, in whatever attitude it may have placed itself, it does not like to be disturbed, and endeavors at once to return to its former posture. If spoken to, the child's answers are hurried, and its manners impatient, as though it were too much taken up with its suffering, or with the business of respiration, to be able to reply to questions. Sometimes it will say that it feels stuffed, or will complain of distress about the sternum, or of pain at the epigastrium; while pressure at the abdomen, by interfering with the free descent of the diaphragm, always produces much discomfort. There is no appe- tite ; and, though at first the thirst is very considerable, yet the child soon ceases to take much drink, for it wants breath to swallow fluids in any quantity, and therefore does little more than moisten its lips. At the same time the tongue is moist, and either differs but little from its condition in health, or it has a thin coating of yellowish fur; the bowels are usually constipated, and not only are nausea or vomiting seldom present, but emetic remedies often fail of their ordinary effect when given in the course of this affection. As the disease advances the cough becomes less hacking, though it continues very frequent: it sometimes puts on a paroxysmal character, and returns in fits some- what like those of a hooping-cough, except that each fit of coughing is shorter, does not terminate with a whoop, and is seldom attended with expectoration. Even if the cough be accompanied by expecto- ration, it is seldom that anything is spit up more than a little mucus tinged with blood, or now and then a little pure blood, while in a few instances small shreds of false membrane are intermingled with the mucus. For a time the respiration grows more and more hurried, and paroxysms of dyspnoea continue to occur at irregular intervals almost to the last. In these paroxysms the child's distress and rest- lessness are extreme, and it sometimes throws itself wildly about the bed. The breathing does not, however, go on increasing in rapidity until the patient's death; but, after the disease has reached its acme, the respiration often grows less frequent, though more irregular and more variable. The face loses its flush, and, instead, acquires a livid hue ; the cough becomes smothered, and occurs less often ; the pulse grows in frequency and fails in power ; and though there is often a diminution of the restlessness, yet, if able to talk, the child will gene- rally say that it is no better. As death approaches, though the respi- ration grows more labored and more abdominal, yet the child's suffer- ing generally diminishes, or a state of somnolence gradually steals over it, in which it lies till roused by an attack of cough or by a paroxysm of dyspnoea, and then, after a struggle for breath, it sub- sides into its former drowsiness. The struggles for breath grow feebler with each returning paroxysm, the drowsiness becomes more profound, and the patient dies. Tt may be worth while to fill up what is wanting in this brief sketch of the disease by the history of a case that displayed many of its most characteristic features. ILLUSTRATIVE CASE. 259 A little boy, aged 7|- years, after suffering for a few days from general feverishness, with a constipated state of the bowels, was at- tacked on the 6th of April with incessant short cough and hurried breathing, for which symptoms he was ordered to be bled to six ounces, although only two ounces of blood were obtained. Twelve leeches were applied to his chest, and powders containing two grains of calomel and a quarter of a grain of antimony were given him ev^ry four hours. The leech-bites bled profusely, and afforded some relief to the dyspnoea; but, notwithstanding this, the child passed a very restless night. The next morning, he was found lying on his back, with his knees drawn up towards the abdomen, his face anxious, his eyes heavy, his skin dry; breathing at the rate of 78 inspirations in the minute, his respiration being often interrupted by a short, hacking cough. His pulse was 138, and sharp. He complained of no pain, except when the abdomen was pressed on, but seemed then to suffer considerable uneasiness about the epigastrium. Percussion of the front of the chest occasioned so much pain that it could not be prac- tised satisfactorily, and behind it did not elicit any difference between the two sides. Throughout the whole of both lungs, sub-crepitant rale was heard. It was smallest in the inferior dorsal region, but was nowhere so small as true pneumonic crepitus. The boy was cupped to five ounces between the shoulders, and tartar emetic was ordered in quarter of a grain doses every ten minutes until free vomiting should be produced, after which the powders were to be resumed. He took two grains of the tartar emetic without the slightest effect being produced; and on the 8th his respiration had risen to 98, and his pulse to 144. On the 9th, his respiration had sunk to 72, but the pulse had risen to 156. The cough was usually short and hacking; but attacks of it, which resembled paroxysms of hooping-cough, now came on at intervals. The tartar emetic was now given in doses of half a grain every two hours, but with no effect beyond that of pro- ducing a feeling of nausea, and occasioning very slight vomiting twice. For an hour or two early on the morning of the 10th, he seemed somewhat better; but this improvement soon passed away, and he began to complain of great pain in the chest; whereas his answer previously to all inquiries had been, "I am so stuffed!" His cough was more severe; and the mucus which he now and then ex- pectorated with it was sometimes tinged with blood. He passed another night of distressing restlessness, but, on the morning of the 11th, grew quieter, and, when not disturbed, lay on his right side dozing. If spoken to, he gave intelligent answers, and said, "I am no better," though, if left alone, he made no complaint. He continued drowsy all through the day. Towards evening, he had a few minutes of cheerfulness, and spoke of his own accord to his father. His mother lay down by his side; he slept, and seemed to breathe gently. She slept too; and, when she awoke at 4 P. M. on the 12th, her boy was dead ; life had fled so quietly that, though her arm was round him, she had not been disturbed. I need not detail to you the appearances found on dissection of the body, since they were such as have been mentioned as characteristic 260 TREATMENT OF BRONCHITIS. of capillary bronchitis; though the air-tubes, notwithstanding their intense injection, contained neither pus nor false membrane, and very little mucus. The case illustrates the remarks already made on the symptoms of the disease, and illustrates, too, the remarkable results which percussion and auscultation yield in this affection, since sub- crepitant rale continued to be heard to the last, unmixed with bron- chial breathing or pneumonic crepitus, while, so long as percussion could be practised, it failed to elicit a dull sound anywhere. Though the indications afforded by auscultation and percussion are often sufficiently characteristic of this disease, yet there are some cir- cumstances which may occasionally render their information doubt- ful. The child is sometimes so extremely alarmed, and the sensibility of its surface so much increased, that we have much difficulty in per- cussing the chest; but we shall usually be able to distinguish this from the painfulness of the walls of the thorax which attends pleurisy, by finding that it is not limited to one-half of the chest, but that it is felt equally on either side, and as much in front as behind. If we can succeed in percussing the chest, however, it will be found to yield a natural, sometimes even an increased degree of resonance, while little, if any, difference can be discovered between the sound afforded by the upper, and that given out by the lower part of the chest; or, should such be perceived, it is generally due to pneumonia having super- vened. The ear detects a scanty transmission of air, attended at first with rhonchus and sibilus, but soon with a universal sub-crepitant rale, heard most distinctly on the child making a deep inspiration. By the term sub-crepitant rale, it can hardly be necessary for me to say that a sound is meant smaller in character than large mucous rale, but larger than the true small crepitation of pneumonia. As the dis- ease advances, the only change that takes place consists in this sub- crepitant rale being replaced by a large mucous rale, the result not of any improvement in the child's condition, but of the air scarcely pene- trating beyond the larger bronchi; for you will still hear the smaller sound during the deep inspiration that follows the attack of cough. This form of bronchitis is one not only very dangerous, but like- wise very rapid in its course to a fatal issue. One little girl in whom it came on while convalescent from an attack of measles fourteen days before, died within forty-eight hours; and the boy whose case has been just related died in less than four days from the appearance of any serious symptom. Those, however, were instances of a rather unusual rapidity in its course; and from five to eight days, which is the estimate of its duration formed by M. Fauvel, who has written a very valuable essay on the disease,1 is probably not far from the true average. But we may now pass to the treatment of bronchitis, in which you will find those general rules applicable that have already been laid down when we were speaking of catarrh; while, in exact proportion 1 Recherches sur la Bronchite Capillaire, etc. 4to. Paris, 1840; republished in a more extended form in Vol. II. of the " Memoires de la Societe Medicale d'Observa- tion," 8vo. Paris, 1^44. TREATMENT OF BRONCHITIS. 261 to the severity of the symptoms, will be the care with which you must watch against the supervention either of pneumonia or of that collapse of the lung which is so grave an occurrence in early child- hood. In the ordinary forms of bronchitis, general depletion is neither required nor well borne, and even the local abstraction of blood must not be heedlessly resorted to. Leeches may be applied at the com- mencement of the attack, if the child be strong, and the febrile dis- turbance considerable, and they may be employed subsequently, if, while the child's powers are still undiminished, the cough should become shorter and more hacking, and the crepitation either very general and abundant, or smaller in the lower than in the upper lobes. They must not be employed with the view of at once cutting short the attack, nor must we be led by the relief afforded by their first application to repeat them in the hope of subduing the disease by depletory measures. I usually apply about four leeches to a robust child of two years old, and it is very rarely that I repeat their appli- cation. The situation in which they are applied is not altogether unimportant. I prefer applying them beneath the scapulas; partly because there may be some advantage in drawing blood from the neighborhood of that part of the lungs which is most likely to become congested, but still more because the child is not alarmed, as it would be if they were put on the front of the chest, where they are within its sight; and because in this situation it is unable to irritate the bites by picking them, as it is very apt to do when they are beginning to heal. There is in these cases the less excuse for over-depletion, since we are possessed in the tartar emetic of a most powerful means of sub- duing the disease. In a healthy child suffering from bronchitis of moderate severity, I sometimes give it in the form of James's powder, combined with a small quantity of calomel and ipecacuanha, every four hours for the first twenty-four or thirty-six hours. This combination usually acts on the bowels slightly, as well as on the skin; and if the child be now relieved, the calomel may be suspended, and small doses of antimonial and ipecacuanha wine may be given instead, in a mixture. A severe attack of the disease calls for the use of antimony in larger doses, so as to obtain its emetic effect at first, and afterwards, by the repetition of the remedy every hour or two hours, to keep the child for one or two days under its influence. Even in cases where the disease is not so severe as to require the energetic employment of antimony, there is generally an exacerbation of fever and dyspnoea towards evening, and this is often much relieved by an emetic of antimony and ipecacuanha, which may also in many cases be repeated with advantage in the morning, when the child having been asleep for some hours, during which the mucus has been collecting in the bronchi, it breathes with difficulty on awaking, until, the air-tubes having been freely emptied by an effort at vomiting, the air is once more enabled freely to permeate the lungs. Even in those cases which at first re- quired the constant use of large doses of antimony, it is a matter of importance to dispense with them as soon as we can with safety, and 262 NERVOUS DYSPNCEA. to substitute the use of emetics at intervals, while we employ some milder expectorant medicine between the doses of the emetic. It can scarcely be necessary to remind you that there are few medicines which exert so depressing an influence on the muscular powers as the tartar emetic. If, therefore, in a child whose air-tubes are already nearly filled with the abundant secretion, you carry the depressing effect of antimony too far, the air will no longer be inspired with force sufficient to make it reach the smaller bronchi, and collapse of the lung will consequently take place. It follows, then, that we must not venture to carry the depressing effects of antimony so far in the child as we may safely do in the adult, but when the medicine has either ceased to vomit, or is merely regurgitated without effort, we must either suspend it altogether or greatly diminish its dose, or give it at distant intervals, so as to obtain its emetic action, while we allow time between the doses sufficient to permit the child perfectly to re- cover its powers. The effect of vomiting, on the other hand, is useful in two ways, for it not only empties the air-tubes of the mucus that obstructs them, but it also occasions several deep inspirations to be made, by which the air is drawn into the remotest parts of the lungs, and their tendency to collapse is thus prevented. Your attention has on more than one occasion been called to the remarkable tendency of the nervous system in early life to sympathize in the affections of other parts. This tendency is often very evident in inflammation of the respiratory organs ; and, accordingly, you must not always take the degree of dyspnoea, in a case of infantile bron- chitis, as a measure of the affection of the lungs, since it may be only an evidence of the sympathy of the nervous system. If you treat this symptom actively, without having first inquired into its import, you may destroy your patient. When first taken ill, indeed, the child's respiration was hurried and laborious; you applied leeches to the chest, and gave tartar emetic freely; and the breathing, which grew less hurried and less oppressed, justified the wisdom of your treat- ment. But if the respiration again rise in frequency, and you, in order to reduce it, redouble the activity of your treatment, you may be disappointed in the effect you hoped to attain ; the respiration may grow more and more frequent, and the child before long die in con- vulsions. If, in such a case, you had examined the patient with due care, you would probably have discovered that the dyspnoea was not associated with increase of the heat of the skin; you would have learned that it had varied much within a few hours, sometimes subsid- ing and then returning without adequate cause; you would not have detected any deterioration in the results of auscultation, while you would probably have perceived in the half closed eyes, or the thumbs drawn into the palms, signs of the disturbance of the nervous system. This nervous dyspncea sometimes occurs early in the disease, at a time when active treatment is evidently indicated; and while that plan'is continued, we shall best meet this symptom by applying a mustard poultice to the chest, and by placing the child as high as the pelvis in a hot bath. The evening attacks of dyspnoea are often more effectually controlled by this than by any other means. When these TREATMENT OF NERVOUS DYSPNCEA. 263 symptoms come on at a more advanced period of the disease, or in a child previously debilitated, they indicate that active treatment must no longer be persevered in. The antimony must be discontinued, or its dose greatly reduced, and the vinum ipecacuanhas, with small doses of nitrous ether and of the compound tincture of camphor should now be given,1 or even small doses of Dover's powder. The general restlessness will be much relieved by immersing the whole body in a warm bath, which should not be employed at so high a temperature as when used for its counter-irritant action. At the same time, atten- tion must be paid to support the child's strength by veal broth, arrow- root, or other nutritious diet. After the acute symptoms of bronchitis have been subdued, the subsequent convalescence of the patient is often protracted by the continuance of cough and wheezing respiration—symptoms which on a very slight cause are apt again to put on the more serious charac- ters of the acute disease. In this chronic stage, a general tonic plan of treatment must be adopted, while at the same time much benefit will often be obtained by the employment of a stimulating liniment to the chest.2 The extract of bark is an extremely useful tonic, espe- cially in cases where there exists any tendency to diarrhoea; while the wheezing is often relieved by the administration of ipecacuanha every night. If the secretion in the bronchi be very abundant, the decoction of senega, with ammonia and tincture of squills, is often superior to any other medicine.3 If the bronchitis have supervened during dentition, you must not be surprised at slight relapses occur- ring just as each tooth approaches the gum. At other times, however, bronchitic symptoms continue for a long period, the expectoration being copious and puriform, while the child loses flesh, and the rela- tions become, not unnaturally, apprehensive lest it should be phthi- sical. Their fears may be well founded, but at the same time that you would recommend change of climate to some warmer country in the winter, or to the sea coast during the summer, you would, as I shall hereafter point out to you when speaking of phthisis, be warranted in taking a much more favorable view of such cases in a child than in the adult. The general principles on which you must treat the more grave attacks of capillary bronchitis have been laid down in what has been already said. A greater degree of activity in your treatment is needed; 1 See Formula No. 10, p. 245. fc 2 (No. 11.) ,-j R.—Lin. camph. co. §j. Tinct. lyttae 5>j- Tinct. opii ^ij.—M. Ft. Linimentum. The pungency of liniments often compels us to employ them to the posterior part of tbe cbest only, or to rub the front of the chest with a much weakerTmiment than that which is used for the back. 3 (No. 12.) , R.—Decoct, senegse ^ij 3v. Ammon. sesquicarb. gr. viij. Tinct. scillse n\,xvj. Syr. Tolutan. 5iij-—M. 5i'j 4tis horis e lacte. For a child from two to three years old. * 264 INFLUENZA, you may even deplete generally, and follow up this depletion by local bleeding: but the caution already given against the repeated abstrac- tion of blood holds good here. With reference to antimony too, it is while the emetic action of the remedy continues that you may hope for benefit from its employment; while you must be careful not to persevere in its use when the livid face and faltering pulse show that the aeration of the blood is nowhere duly carried on. A blister to the chest, and the stimulant expectorants—as ammonia and senega, may now be given, while the attempt may be made, by emetics of squills and ipecacuanha, to unload the bronchi at intervals of four or six hours. These are the cases, however, in which, if you do not get the better of the disease at first, your subsequent remedies will pro- bably be too tardy to overtake it. Before concluding this lecture, it may be as well to say a few words on the subject of influenza, or epidemic catarrh, as we observe it among . infants and children. Catarrhal epidemics, indeed, not infrequently occur among the young at a time when there is no general prevalence of the same class of ailments in the adult population, and they do so especially just before the commencement of an epidemic of measles or hooping-cough, and for a short period after its outbreak. Such catarrhs, however, are not in general very severe, and are important chiefly as forewarnings of the more serious disorder by which they are often succeeded. This affection assumes, on the other hand, a more serious character when influenza is generally prevalent; and children are attacked, not especially, but in common with persons of all ages. It is then often very severe, and in many instances presents notable peculiarities, with a description of which I prefer occupying your time to repeating over again the description of how ordinary catarrh assumes by degrees the graver features of bronchitis, and the bronchitis, in its turn, becomes associated with pneumonia. Of course, in every epidemic of influenza there are many instances of this occurrence, and, in every case, we need watch most carefully for its indications. But the anomalous forms of influenza are of no less moment. Of these, one of the most remarkable is characterized by the intensity of the febrile disturbance as contrasted with the comparative unimportance of the chest symp- toms, so that the ailment sometimes runs its course more like a severe attack of ephemera than like an affection in which the organs of respi- ration are implicated. In such circumstances I have even known convulsions occur in very susceptible children, and be followed by a state of intense overpowering drowsiness, which, though unaccom- panied by other signs of cerebral disturbance, continued for twenty- four hours, and then gradually subsided, being succeeded either by a slight feverish condition or by the ordinary catarrhal symptoms, and those not always of great severity. The convulsive seizures are, in- deed, exceptional, and of decidedly rare occurrence; but the burning skin, the extremely frequent pulse, and the irresistible drowsiness, are by no means unusual; a child going to bed a little ailing, sleeping heavily during the night, seeming unable to get up in the morning, OR EPIDEMIC CATARRH. 265 and continuing apparently overpowered by the disorder for the en- suing twenty-four hours, but then recovering with great rapidity. It is not, however, by any means constant for the disorder of the nervous system to be thus limited to the sensorium ; for in very many instances, the respiration is greatly disturbed; and with the burning skin and heavy head there are associated acceleration of breathing, and evidently imperfect aeration of the blood such as we may often observe in hooping-cough. This disorder of breathing too will often be found to be utterly out of proportion to the gravity of the auscul- tatory signs, which generally consist in a large diffused rhonchus, equally audible over the whole of the chest. The danger, indeed, frequently consists less in the occurrence of pneumonia or in the advance of bronchitis than in the supervention of a state of collapse, such as in epidemics of influenza, not infre- quently carries off' the aged. In the influenza of 1856, many instances of this kind came under my notice, by no means exclusively among infants, but at least as often among children between two and three years of age, in whom the attack set in with considerable nervous dyspnoea and heat of skin (symptoms which on some occasions had undoubtedly been treated with over activity before the patient came under my notice), but in the course of two or three days the fever suddenly disappeared, and was succeeded by a state of extreme depres- sion, with a cool, moist skin, a very feeble pulse, and labored respira- tion. In this condition the children, though quite conscious when roused, lay generally dozing, while, though the somewhat livid hue of the lips and surface seemed to imply the existence of some serious mischief in the lungs, there was often nothing to be heard but a large moist r&de. When this state was well marked, the symptoms of ex- haustion usually went on increasing, in spite of the free employment of stimulants, and terminated fatally on several occasions in the course of forty-eight hours; and within a week from the commencement of the illness. One more point deserves notice, and that is the frequent tediousness of the convalescence from influenza; an irregularly remittent febrile condition, with complete loss of appetite, and much impairment of strength often remaining behind. These symptoms, however, disap- peared, and sometimes rapidly, under the beneficial influence of change of air and preparations of quinine. The cautions to be borne in mind in the treatment of influenza are sufficiently apparent from the remarks which have just been made. The danger in these cases is oftenest that of doing too much, of mis- interpreting the nervous element, which plays so important a part in the production of the symptoms, and of regarding the dyspnoea, the hurried breathing, and the rapid pulse, as the necessary evidence of active inflammation of the lungs or air-tubes, calling for vigorous treatment to subdue it. As a general rule, both depletory measures and the employment of large doses of antimonials are out of place, and the indications are best answered by maintaining a uniform warm temperature in the room, by giving gentle diaphoretics, with small doses of ipecacuanha, and of some opiate, such as the compound tine- 266 PNEUMONIA. ture of camphor, or Dover's powder, if the cough is very troublesome or the nervous dyspnoea considerable. Counter-irration by large mus- tard poultices to the chest will often relieve any great access of difficult breathing; and the evidence of auscultation should be very decided to justify a recourse to stronger measures, while it must be borne in mind that the necessity for ammonia, ether, and wine, is by no means unlikely to occur, and that the first appearance of those signs of ex- haustion which I have just described must be taken as an indication for their immediate employment. LECTURE XXI. Pneumonia, its Symptoms and Treatment.—Symptoms of pneumonia frequently pre- sent a mixed character when it supervenes on bronchitis.—Idiopathic pneumonia —approach of first stage generally gradual—characteristic peculiarities in mode of sucking and of respiration—attack sometimes sudden. Symptoms of second stage—results of auscultation—reasons for rarity of true pulmonic crepitus. Symptoms of third stage—convulsions often precede death—their import—occa- sional imperfect recovery—auscultatory phenomena of this stage. Nature of modifications in symptoms produced by association with bronchitis. Diag- nosis from bronchitis—pleurisy—hydrocephalus—remittent fever—intestinal dis- order during dentition. Treatment.—Depletion, general and local; rules for each.—Tartar emetic—limitations as to its use. Mercury—its importance—danger of salivation very slight. Diet ■—antiphlogistic in the early stages—caution as to sucking—stimulants often needed in advanced stage. Blisters in general not desirable. It was stated in the last lecture, that the supervention of inflamma- tion of the substance of the lungs constitutes one of the chief dangers of infantile bronchitis. Pneumonia, however, is not to be regarded as being invariably a secondary affection; for, in some cases, while the disease of the air-tubes is but trivial, the pulmonary substance is the seat of serious inflammation; and in other instances the air-tubes are altogether unaffected, or at least are involved only in common with the other constituents of the lung. In either case, there are peculiari- ties enough, both in the symptoms observed and in the treatment required, to render the separate study of pneumonia indispensable. When pneumonia supervenes, as it by no means seldom does, on previous catarrhal symptoms, the disease often comes on insidiously, and develops itself so gradually out of the preceding trivial ailments that it is not possible to determine the exact date of its' attack. At other times, indeed, there is a sudden and well-marked increase of the fever and dyspnoea, and an aggravation of all the symptoms, sufficient clearly to point out the date of the supervention of the pneumonia. But, even though this should be the case, yet, if there were much bronchitis previously, the affection of the air-tubes will often mask SYMPTOMS OF FIRST STAGE OF PNEUMONIA. 267 that of the lung to some degree; and the case not presenting the symptoms either of pure bronchitis or of unmixed pneumonia will assume some of the characters of each, and merit, both by the phe- nomena attending it during life, as well as by the appearances found after death, the name of bronchio-pneumonia. Cases of this mixed character occur most frequently during the period of teething, when the mucous membranes are especially susceptible. We will return to notice some of these peculiarities hereafter, but will first examine the symptoms that attend a case of idiopathic pneumonia, where the pul- monary substance has been affected from the outset, and has not merely become involved by the extension to it of mischief commencing in the bronchi. In almost all of these unmixed cases, a condition of general fever- ishness, exacerbated towards evening, with fretfulness and pain in the head, precede the more marked symptoms. The child is either rest- less at night, or, if it sleep, its repose is unsound; it talks in its sleep, or wakes in a state of alarm. Sometimes from the very commence- ment, at other times soon after the appearance of these febrile symp- toms, cough comes on; at first, short and hacking, frequently not causing the child any uneasiness, and so slight as scarcely to excite the notice, and not at all to awaken the anxiety of the parents. Loss of appetite and increase of thirst are early observable; the bowels are usually constipated, and vomiting is not unfrequent, especially in infants at the breast. The tongue and lips are at the same time of a florid red; the tongue is less moist than usual, and is generally coated in the middle with a thickish white fur. In these symptoms, indeed, there is but little to mark the real nature of the case, or to point to the organ whose disease has kindled the fever in the system; for the slight cough, if not overlooked, may yet be attributed to irritation of the bronchi, sympathetic with derangement of the stomach or intes- tines. The respiration, too, is not always much hurried at this early period; while, in the young child, both its frequency, and that of the pulse, are much modified by position; and the results of auscultation are not uniform, and may sometimes afford no information at all. Even now, however, there are some signs which to the attentive observer will convey much information, and information all the more valuable from our being furnished with it chiefly in those young infants in whom the diagnosis of the disease is attended with most difficulty. The seat of the mischief is shown to be in the respiratory organs, by the child no longer breathing through the nares, while the tongue is applied to the roof of the mouth, as in health; but, by its breathing through the open mouth also, whence the tongue early ac- quires an unusual degree of dryness. This same inability to respire comfortably through the nares causes the child to suck by starts; it seizes the breast eagerly, sucks for a few moments with greediness, then suddenly drops the nipple, and in many instances begins to cry. As the disease advances, these peculiarities in the mode of sucking and of respiration often become more striking; but it is at its onset that they are most valuable, since then we have fewer indications to lead us right. 268 SYMPTOMS OF SECOND STAGE OF PNEUMONIA. It is not, however, thus gradually that pneumonia always comes on ; for sometimes a child who had gone to bed well, or merely a little poorly, wakes in the night in a state of alarm, refusing to be pacified, with a flushed face and burning skin, and hurried breathing and short cough. This sudden supervention of pneumonia is not so often met with among infants at the breast as among children from two to four years old. Often, though not always, this severe onset of the disease has appeared to depend on the pneumonia being associated with exten- sive inflammation of the pleura; but sometimes the symptoms which at first seemed so threatening, soon subside, and the affection, in its subsequent stages presents no peculiarity, and is not by any means remarkable for its severity. This first stage of pneumonia passes, for the most part, by degrees into the second, in which the nature of the affection is generally ob- vious to all. The momentary cheerfulness which before existed has now passed away; infants now no longer wish to be removed from the cradle, or from the recumbent posture in their nurse's arms, and older children have quite lost all interest in their play; they become drowsy, ask to be put to bed, and cry if taken up. The hurry of the respiration is now abundantly evident; the alee nasi are dilated with each inspiration, the abdominal muscles are brought into play to assist in its performance, and any change of posture renders the breathing more labored and more hurried. The cough has become much more frequent; it is still hard, sometimes is evidently painful, so that the child cries with each cough; at other times it is an almost constant short hack. The bright flush of the face, and the florid tint of the lips, have gone, but the heat of skin continues; for the per- sistence of an almost unvarying high temperature throughout its course, is, as M. Eoger has shown, one of the characteristics of the pneumonia of the child as well as of that of the adult. It is a pun- gent heat, which becomes more sensible the longer the hand is kept in contact with the surface; and so great is the elevation of tempera- ture, that M. Boger found it average almost 104° Fahr. in ninety-seven experiments, while in some cases it greatly exceeded this degree. Though so intense, however, this heat is unequal at different parts— the extremities being cool, or even cold, while the body is hot; but there is no moisture on any part of the skin. The face now assumes a puffed, heavy, but anxious appearance, and when the child is very young, or the pneumonia very extensive, the lips put on a livid hue, which is also very evident around the mouth, while the face generally is pale. The thirst usually continues very urgent, but children at the breast still vomit the milk. This is apparently owing to their thirst being so urgent as to lead them to suck too greedily, and thus overload their stomach, since while they generally vomit almost im- mediately after leaving the breast, they do not reject small quantities of fluid given them from a cup or spoon. The disease of the lungs now betrays itself most strikingly in children at the breast, for as often as they attempt to suck, the respiration becomes at once greatly hurried; they drop the nipple, panting, from their mouth, or, having RESULTS OF AUSCULTATION. 269 seized it, have not breath sufficient to make the vacuum necessary to bring the flow of milk. The results of auscultation, though variable, are now sufficiently obvious. Crepitation is now heard, often in both lungs, and generally in their lower and posterior parts—seldom, however, the minute crepitus such as we hear in the pneumonia of the adult, but that 'sound known as the sub-crepitant rale. The comparative rarity of true pneumonic crepitus in inflammation of the lungs in infancy is a point not to be lost sight of: often, however, if you keep your ear to an infant's chest, and wait till it takes an unusually deep inspira- tion, you will hear the true crepitus of pneumonia just for a moment when the air enters the pulmonary vesicles ; and then again you will lose it when the child breathes as it was doing before, and you will hear only the sub-crepitant rale. If the inflammation have attacked only one lung you will perhaps be struck by the loud puerile breath- ing in the healthy organ, which is thus compelled to perform a double function. If both be involved, you may almost overlook the disease, since you have not the aid afforded by contrast; unless, as sometimes happens, the mischief on the one side is so far advanced as to cause bronchial breathing, while on the other side crepitation alone is audi- ble. This bronchial breathing is sometimes heard associated with the sub-crepitant rale, or with large crepitation, while at other times the ear detects nothing but the whiff of air through the larger air-tubes; and often this alone is audible on an ordinary inspiration, while on a deep breath being taken, the subcrepitant rale will be at once percep- tible. In the child, we lose all the information which, in the adult, is afforded by the different modifications of the voice sound; for the shrill or querulous tone of a suffering child, and the words often uttered in very different keys, afford, even when the child is old enough to talk well, results far too uncertain to be trustworthy. Percussion sometimes yields a very manifest dulness on the affected side; and this dulness is usually most evident in the infra-scapular region. At other times, however, no such marked results are afforded, but the lower parts of the chest give a somewhat duller sound than the upper, and the impression communicated to the finger is that of greater solidity below than above the scapula. This last sign is often very valuable, since it may be perceived at a time when the ear can- not clearly detect actual dulness on percussion. Death may take place in this, the second stage of pneumonia, if a very extensive portion of lung have been involved in the disease, or if it be associated with much inflammation of the pleura, or if the pneumonia have been grafted on severe bronchitis. The pneumonia which supervenes on measles, or which comes on in a child debilitated by previous illness, sometimes terminates unexpectedly in this stage, and on an examination of the body after death, the lung is found scarcely to have passed beyond the first stage of pneumonia, except in a few portions of but limited extent; though still larger tracts will probably be found in the state of carnification, and to the sudden supervention of this condition the fatal event is probably in great measure due. It is important, too, to bear in mind that in weakly 270 SYMPTOMS OF THIRD STAGE OF PNEUMONIA. children a pneumonia of even very small extent will often prove fatal; hence the great importance of watching most sedulously against all those intercurrent affections of the lungs which come on in the course of diarrhoea, measles, remittent fever, &c. But the pneumonia may be free from any of the above-named com- plications, and then, if unchecked by treatment, it will pass into the third stage. The respiration now becomes more labored, and though its frequency is sometimes diminished, it will be found to have become irregular, several short and hurried inspirations being followed by one or two deeper, and at longer intervals, and these again by hurried breathing. The cough sometimes ceases altogether, or if not, it is less frequent, and looser, since it is now produced by the child's efforts to clear the larger air-tubes from the accumulating secretions. The voice is often lost, the patient speaking only in a hoarse whisper; while children who were just learning to talk will frequently maintain complete silence, as if conscious that they have no breath to waste in words. The face looks sunken, the extremities are cold, and though the trunk retains its high temperature almost to the last, yet the skin often loses somewhat of its previous dryness, and clammy sweats break out, especially about the head. The pulse is extremely frequent and small, and the beats so run into each other that it is almost impos- sible to count them. The child is sometimes very restless at intervals, tossing about from side to side as much as its reduced powers will permit; but it usually lies in a state of half consciousness, though sensible when spoken to, and fretful if disturbed. If raised hastily from the recumbent posture, or if put to the breast, the great increase of dyspnoea which is immediately produced shows how seriously the respiratory organs are affected. In many cases, too, the livid hue of the face and of the nails is a further proof of the great impediment which exists to the decarbonization of the blood; and once I saw pur- purous spots appear on the arms and hands thirty-six ho.urs before the death of a previously healthy child of a year old, in whom an attack of idiopathic pneumonia terminated fatally on the seventeenth day. This condition seldom lasts above two or three days; for either life becomes gradually extinct, without the supervention of any new symptom, or convulsions occur, which are followed by fatal coma, or the child recovers from it for a few hours, only to suffer a second attack of convulsions, and a return of coma, in which it dies. It can scarcely be necessary to remind you of what was said, some time since, with reference to the import of convulsions, and to their being, in many cases, merely a token of disturbance of the functions of the brain, such as delirium is in the adult. The former symptoms in the child, and the latter in the adult, betoken, in a case of pneumonia, that the brain is suffering from the circulation through it of imperfectly aerated blood. The third stage, however, does not always advance thus uninter- ruptedly to a fatal issue, but a kind of imperfect recovery sometimes takes place. A diminution is obvious in the more alarming symp- toms; the patient begins to express some desire for food, as well as for drink, and even has occasional gleams of cheerfulness. The cough, RESULTS OF AUSCULTATION. 271 which in many instances had almost or altogether ceased, returns, but is short and hacking, although there is sometimes a good deal of mucus in the larger air-tubes. The dyspnoea is no longer urgent, though the breath is habitually short. The skin is hot, dry, and harsh, and evening exacerbations of fever often occur; the tongue is red, dry, and sometimes chapped, or presents small aphthous ulcers at its edges; diarrhoea is not infrequent; the child wastes daily, and dies in the course of a week or two, worn out and exceedingly emaciated. The auscultatory signs of this third stage of pneumonia are, in the main, those of the second stage, except that the bronchial breathing usually becomes both more "distinct and more extensive, occupying situations where either the sub-crepitant rale, or even large crepita- tion, had previously been heard. As it extends, too, it becomes audi- ble in front as well as behind; and both it, and dulness on percussion, may be perceived in the infra-mammary as well as in the infra-scapu- lar region, to which at first they are almost always limited. This bronchial breathing is generally much more extensive on one side than on the other ; and sometimes it is heard throughout the whole posterior p&rt of one side of the chest; but it is exceedingly unusual to find bronchial breathing confined to the upper part of one lung, except in cases where there existed previous tubercular disease of the organ; and then the pulmonary tissue may become solidified under the influence of an amount of disease which otherwise would be inade- quate to produce this result. The symptoms that attend the third stage of the disease usually are the result of the lung having passed into the state of suppuration. I say usually, for sometimes recovery eventually takes place even from a condition apparently desperate; and in such cases the degree to which disorganization of the lung had actually advanced must always remain uncertain. The results of auscultation do not help us, any more than in the adult, to determine with certainty the amount of injury that the lung has sustained; while we are deprived almost entirely of that informa- tion which in the grown person is afforded us by the changes in the appearance of the sputa. In some cases of rapidly fatal pneumonia, I have seen a frothy secretion collect about the mouth; but this was evidently not furnished by the air-tubes, but was merely the saliva which the child was unable either to spit out or to swallow. The cough of pneumonia being generally short and not paroxysmal, we have not so much chance of seeing the sputa as in the case of acute bronchitis ; and children even of five or six years old seldom spit out the matters that they expectorate, but almost always swallow them. When resolution of a hepatized lung takes place, the changes in the physical signs of the disease are much the same as are perceived in the adult. I have not, however, in any instance detected a return of true pneumonic crepitation ; but sub-crepitant rale in most cases be- came audible, and in a few instances large crepitation. In either case, mucous rale was eventually heard; and it often continued for many days after the lung had in other respects recovered its natural con- 272 BRONCHIO-PNEUMONIA. dition; apparently much as, in the pneumonia of the adult, pro- longed expiration often persists for a long time after all the other signs of disease have disappeared. At the commencement of this lecture, reference was made to cases in which the symptoms of pneumonia are modified by those of the bronchitis with which it is associated. In such cases, there is from the very outset a marked degree of dyspnoea and distress; and the face presents from the first a livid hue. The cough is less short than in simple pneumonia; but it comes on in paroxysms, which greatly distress the patient. The respiration is more hurried and more irregu- lar; and this irregularity comes on at an earlier stage of the disease. Large crepitation and sub-crepitant rade are generally heard very ex- tensively in both lungs; but true pneumonic crepitation is unusual. A preponderating affection of the lower lobes is seldom perceptible; and, since these cases usually tend to a rapid termination, death some- times takes place before either dulness on percussion, or bronchial breathing, has become distinctly audible. Such are the characters generally presented by pneumonia in early life; and these are usually so well marked as to render it? impossible either to overlook the disease, or to mistake its symptoms for those of some other malady. This, however, is not invariably the case even when the inflammation of the lungs occurs as an idiopathic affection; while in those instances in which it comes on in the course of other diseases, it very often remains latent; and much acuteness of percep- tion, as well as much patient observation, are necessary for its detec- tion. We will pass over, for the present, the consideration of second- ary pneumonia, since to understand all the varieties that it presents would require a previous acquaintance with those diseases in the course of which the inflammation of the lungs supervenes. When we come to the study of hooping-cough, croup, measles, remittent fever, &c, I will endeavor to point out the period at which, in each of these maladies, pneumonia is most to be apprehended, and the symptoms that indicate its attack ; but to-day we will confine our notice to those cases in which the inflammation of the respiratory organs occurs as an idiopathic affection. The points of difference between pneumonia and bronchitis have already been dwelt on so fully as to render it unnecessary to recapitulate them. In many cases they are too obvious to admit of your falling into error, but in others they are so shaded off that it is difficult to determine whether the characters of one or of the other predominate; and we are forced to conclude that the two exist together, the one obscuring the otherwise well-marked features of the other. In the child, as in the adult, some degree of pleurisy exists in a large proportion of cases of pneumonia, though sometimes so slight as to be scarcely noticed; whilst in other cases, though a little friction sound may be heard for a short time, yet it is evident that the danger to life is occasioned by the mischief in the lung, and not by the affec- tion of the pleura. Sometimes, however, inflammation of the pleura is the chief, if not the sole, cause of the patient's danger, and hence it DIAGNOSIS OF PNEUMONIA. 273 is desirable to know, even at the outset, whether the lung or its investing membrane is the part chiefly affected. An attack of pleurisy is much oftener marked by complaint of severe pain in the chest, than is an attack of pneumonia; or if the child be unable to express its feelings, the seizure is not infrequently announced by violent and continued screaming. Sympathetic disturbance of the brain is more frequent and more severe at the onset of an attack of pleurisy than of pneumonia, and the attendant restlessness is greater. Auscultation, too, fails to discover the crepitant or sub-crepitant rale which characterizes pneumonia, but air enters the lung on the affected side much less freely than on the other, and a friction sound may perhaps be distinguished; though this is by no means invariable, and even when present it may easily be mistaken for rhonchus. It may be laid down as a rule, subject to but few exceptions, that whenever a child is suddenly seized with symptoms which, while they indicate some affection of the lungs, are yet unattended with the auscultatory signs of pneumonia, the disease from which it is suffering is pleurisy; and this probability is rendered almost a certainty, if, while the child bears percussion on one side of the chest, it cries and struggles on the slightest attempt at percussion on the opposite side. The error of taking a case of pneumonia for one of pleurisy, how- ever, or the opposite, is of comparatively little moment; but there are other diseases for which pneumonia may be taken, in which the error of diagnosis will lead to serious, and perhaps fatal, mistakes in treatment. These mistakes, too, may be made at almost any stage of the dis- ease. At the commencement pneumonia may be taken for incipient hydrocephalus. The vomiting, the pain in the head, the restless nights, with talking in the sleep, which attend the onset of almost all the acute affections of childhood, the fever, and the constipated state of the bowels common to both diseases, lead to this error. The cough in some cases of pneumonia is so slight as scarcely to be noticed, while even if present it may be taken for that sympathetic cough which is sometimes present in the early stages of hydrocephalus; and the child, if questioned, may complain of his head, and of nothing else. But still there are circumstances which would lead the attentive observer, independently of auscultation, to detect the real nature of the case. The vomiting that ushers in an attack of pneumonia, though some- times violent, seldom continues long, and is unattended with that permanent nausea and irritability of the stomach which are so marked in the first stage of hydrocephalus. The evacuations in pneumonia are natural; the tongue is of a much more vivid red than in hydro- cephalus ; the pulse is much more frequent, the heat of the skin far greater, and more remarkable on the trunk than about the head, and the thirst is generally urgent. If these indications, however, be over- looked at the commencement of the attack, and if auscultation, by which the error might still be set right, be neglected, it is probable that each subsequent occurrence will be misinterpreted, and that the real nature of the disease will not be understood until it is revealed by the post-mortem examination. More or less sympathetic affection 18 274 DIAGNOSIS OF PNEUMONIA. of the head is seldom wanting in pneumonia to confirm the precon- ceived, erroneous notion; while, as the child grows worse, the diffi- culties in the way of making a careful auscultation increase. Convul- sions sometimes occur even several days before the patient's death, and the head symptoms may appear, especially to a prejudiced ob- server, to be much more striking than any which indicate affection of the lungs. It sometimes happens that the sympathetic disturbance of the stomach and bowels is so considerable as to obscure the chest symptoms, and the case is taken for one of enteritis; or perhaps, if the heat of skin and sensorial disturbance be considerable, for one of remittent fever; and this latter error is especially likely to be committed if the upper lobes of the lung are the seat of the inflammation. The vomiting at the outset of the disease, the pain referred to the abdomen, with the evident increase of discomfort on pressure, the red tongue, with its disposition to dryness, and the diarrhoea that exists in these rather exceptional cases of pneumonia, are the circumstances which tend to lead into error; and this error may be confirmed on the practitioner finding that at least temporary relief follows the application of leeches and poultices to the abdomen. With reference to the complaint of pain in the belly, which seems often to have a large share in inducing this error, it must be remembered that the statements of children with reference to the seat of pain are very vague, and that they frequently speak of the belly when they mean the chest; while the impediment to the descent of the diaphragm occasioned by pressure on the abdo- men, especially if this pressure be either sudden or considerable, will almost always excite expressions of uneasiness when the organs of respiration are in any way affected. It is in careful auscultation that your chief safeguard against these mistakes will consist; but you will find besides, that by accustoming yourselves to look not at one or two prominent symptoms only, but at the relation which each bears to the other, many of the chief difficulties in the way of forming a correct diagnosis will disappear. It may perhaps seem to you that much of this is very dry and rather needless detail; but unfortunately my own case-books would enable me to illustrate each of these errors of diagnosis against which it is my endeavor to guard you. One more caution I would offer you, and that is, not to overlook the pneumonia which sometimes comes on in children while teething. Unless you be on the watch for it, its early symptoms will probably fail to excite your apprehension, since they will be regarded as the result of that sympathetic irrita- tion of the air-tubes which so often accompanies dentition, and the time for action will thus be allowed to pass unemployed. The dis- ease comes on most frequently in weakly children, is unattended by much constitutional reaction, and often runs a somewhat chronic course; while its nature is further obscured by the tendency to diar- rhoea which exists during dentition, and which is now excited by the thoracic affection. The purging often becomes the most striking symp- tom, and all means are employed to suppress it, and to check the vomiting which generally attends it. These efforts, however, are un- TREATMENT OF PNEUMONIA. 275 availing; the child wastes daily, and its skin hangs in wrinkles about its attenuated limbs, while the abdomen becomes tumid from the col- lection of flatus in the large intestines, and tender on pressure, and the tongue grows red, dry, and chapped, or covered with aphthous ulcers. The cough now perhaps attracts notice; but both it and the bronchial breathing in the lungs are probably looked on as indica- tions of phthisis, and the doctor consoles himself with the belief that he has failed to cure the disease because it was irremediable. At last the child is worn out, and dies, and great is the surprise to find no tubercle in any part of the body, no disease in the intestines, but pneumonia, with purulent infiltration in both lungs—a disease which ought to have been detected, and which probably might have been cured. We come now, in conclusion, to the consideration of the treatment of pneumonia in children. The main principles that guide us are the same as in inflammation of the lungs in the adult, and our chief re- liance is placed on the same remedies in both cases—namely, deple- tion, calomel, and tartar emetic. You will find that many of the continental writers on the diseases of children are greatly opposed to the abstraction of blood in cases of infantile pneumonia, and that some even assert that it invariably debilitates the system, and accelerates the patient's death. This opin- ion, however, has been formed by the observation of those secondary pneumonias which are of such frequent occurrence among the inmates of the Children's Hospital at Paris ; and therapeutical conclusions de- duced from cases of so peculiar a kind as are there presented, cannot be framed into rules for the general guidance of our conduct. But much misapprehension has also arisen from confounding the condition of collapse of the lung with that of its solidification from true inflam- matory action ; and the mistaken pathology has led to mistaken treat- ment. In the management of cases of idiopathic pneumonia occur- ring in previously healthy children, whatever be their age, depletion is as important a remedy as in the adult; nor will the most energetic employment of any other antiphlogistic measures enable us safely to dispense with its use. In a healthy child of four years old a vein may be opened in the arm, and 3fv of blood may be allowed to flow, provided that faintness be not earlier produced, without there being any reason for us to apprehend that the plan we are adopting is too energetic. It often happens that the child faints before this quantity of blood has been drawn, while in other cases not above one or two ounces of blood can be obtained. Still, whenever the patient is seen at the commencement of the attack, general depletion is desirable, even though it should be necessary to follow it up by local bleeding; for the immediate effect which it produces is greater than that which follows local depletion, and the quantity of blood abstracted by it is definite; while, if both the nurse and the medical attendant under- stand how to manage children, it may be so conducted as to cause them but little excitement or alarm. If but very little blood can be drawn from the arm, or if, as is not seldom the case with infants under 276 USE OF TARTAR EMETIC. two years of age, it be not possible to find a vein, depletion must be accomplished by means of leeches, which, for reasons already stated, it is desirable to apply beneath the scapulas. How great soever may have been the relief which followed the first bleeding, it is not always permanent; and hence the child should be seen again in from six to eight hours; and if the symptoms appear to be returning with anything of their former severity, depletion must be repeated; though then local bloodletting is to be preferred to venesection, even in cases in which bleeding from the arm had been resorted to in the first instance. It must never be forgotten that in the child, as well as in the adult, no subsequent care can make up for the in- efficient treatment of the early stage of pneumonia : if the first twenty- four hours be allowed to pass while you are employing inadequate remedies, the lung, which at first was merely congested, will have be- come solid, and recovery, if it takes place eventually, will be tardy, and perhaps imperfect. On the other hand, cases that set in with the greatest severity sometimes appear to be at once cut short by free de- pletion ; the violent symptoms being arrested, and recovery going on uninterruptedly, almost without the employment of any other remedy. In the treatment of the pneumonia of the adult we are accustomed to follow up the advantages gained by depletion by the administration of tartar emetic; and, under proper restrictions, the remedy is no less valuable in early life. Given in doses of one-eighth of a grain every ten minutes till vomiting is produced in the case of a child of two years old, and continued every hour or two hours afterwards for a period of twenty-four or thirty-six hours, it subdues the fever and abates the dyspnoea in a most remarkable manner ; often rendering a repetition of depletion unnecessary, and sometimes speedily removing all signs of the disease. It is not safe, however, in the great majority of cases, to place our dependence entirely on the administration of antimony. In cases of secondary pneumonia, especially if the affec- tion of the parenchyma of the lungs were preceded by well-marked bronchitic symptoms, antimony may sometimes be given at once with- out having recourse to the abstraction of blood previously; but, in pure idiopathic pneumonia, depletion either general or local ought almost always to precede its use. When antimony does good, it generally gives an earnest of that good within a few hours from its first administration; and the production of some sensible effect, such as vomiting or very decided nausea, has appeared to me to be a condi- tion of its utility : unlike what we observe in the adult, in whom the good results which it produces are sometimes independent of any ap- preciable influence on the general condition of the patient. When complete tolerance of the medicine has been established, our subse- quent conduct must be determined by the results of auscultation. Should that inform us that the physical condition of the lung has greatly improved, as well as the general state of the patient, the use of the remedy may be persevered in at somewhat longer intervals. If the signs of inflammation be advancing, and have become percepti- ble in portions of lung previously free from disease, mercury must be employed, which may be combined with small doses of antimony, EMPLOYMENT OF MERCURIALS—DIET. 277 while large doses of that remedy may still be given to combat any sudden increase of fever or dyspnoea that may chance to supervene. If, notwithstanding a manifest diminution of the fever and reduction of the dyspnoea, bronchial breathing should have become distinctly audible, mercurials must at once be substituted for the antimony ; and the existence in any case of extensive or well-marked bronchial respi- ration should be regarded as of itself contraindicating the antimonial plan of treatment. It is not my intention to say, that after the super- vention of bronchial respiration antimony ought never to be given, but only that it should not be employed except in small doses, and in combination with other remedies. In cases where the symptoms do not set in with such violence as to indicate the necessity for very large doses of antimony, or in which the disease has passed that stage where antimony so given is likely to be beneficial, mercurials may be used with great advantage. In cases of the former kind, from two thirds of a grain to a grain of calomel combined with two or three grains of James's powder, may be given every six hours to a child two years old. If the case be of a graver kind, and bronchial breathing have become perceptible, notwithstand- ing depletion and the administration of tartar emetic, the calomel must be given more frequently—as every four or three hours, combined with small doses of Dover's powder and tartar emetic, if the child be not so depressed as to render the use of the latter medicine inex- pedient. Sometimes the combination of antimony with the mercurial is at first well borne, but afterwards it becomes desirable to discon- tinue it on account of the sickness that it produces, or on account of the debility of the patient. The diarrhoea which the calomel excites may usually be checked by increasing the dose of the Dover's powder. There are some troublesome cases, however, in which the stomach or bowels are so irritable that scarcely any medicine can be borne; and in them, as well as in cases of neglected pneumonia in which the proper time for active treatment has been allowed to pass by, and the child has become exhausted, while a large extent of lung is im- pervious to air, much benefit sometimes follows the persevering use of mercurial inunction, or the employment of that convenient substitute for inunction, the mercurial belt, on which the ointment should be renewed every twelve hours. In infants and children under five years of age, the gums hardly ever become affected by mercury, even though most energetically employed; and it has never yet occurred to me to meet with an instance of profuse salivation, or of dangerous ulceration of the gums. Such accidents, however, do now and then occur, and have been known to terminate in fatal gangrene of the cheek, or in necrosis of the jaw. On this account, therefore, you must watch the condition of the gums in infants and children to whom you are administering mercury, just as you would do in the case of the adult, and diminish or discontinue the remedy on the first indica- tion of their being affected. The diet of children in the early stages of pneumonia should be most sparing; and infants not weaned should have some less nutri- tious food than the mother's milk, which their thirst will otherwise 278 STIMULANTS —BLISTERS. lead them to take more abundantly even than when they are well. If the pneumonia be severe, it is better to give even the mother's milk with a spoon, rather than to allow the infant to suck, since the very act of sucking is injurious, and taxes to the utmost the respira- tory function, the organs of which it is desirable to keep in as unex- cited a state as possible. But though the treatment of inflammation of the lungs requires a most strict antiphlogistic regimen in the early stages of the disease, yet in many cases there arrives a period in which a spare diet is no longer suitable—in which your main efforts must be directed to support the constitutional powers, rather than to subdue the local inflammation. If you forget this, it may happen to you to overcome the mischief in the chest, but to lose your patient with head symp- toms, brought on by carrying too far, or by continuing too long, the very treatment which, within proper limits, was most salutary. No point in the management of the disease is more difficult than the seizing the exact moment when the employment of stimulants becomes necessary; and no general rule can be laid down for regulating their use. If, however, the patient were beginning to be much purged, if the respiration were growing more labored and irregular, though diminished in frequency, and if the pulse were becoming more fre- quent, and above all, smaller and smaller, it is high time to resort to their use. Wine is as indispensable in such cases in the pneumonia of the child as in that of the adult; and it may be necessary to give it even to infants at the breast. Ammonia may also be advantage- ously administered in this stage of the disease, either in a mixture with the decoction of senega,1 or dissolved in milk, which conceals its disagreeable pungency better than any other vehicle. If diarrhoea do not exist, strong beef-tea or veal-broth is the best form in which nutriment can be given; but if the bowels be relaxed, arrowroot, or the decoction blanche2 of the French hospitals, should be substituted for it. In conclusion, it may be well to offer a caution with reference to the employment of blisters—a measure to which we often have recourse with advantage during the resolution of pneumonia in the adult, but which, as a general rule, is not advisable in young children whose lungs have been solidified by the disease. Stimulating liniments3 may be employed with advantage; they produce very evident good, and are unattended by the risk that always accompanies making a breach of the surface in a young child exhausted by previous illness. The risk of such sores taking on an unhealthy character appears to be greater after inflammation of the lungs than after almost any other disease; and it may be added, that the risk is still greater in those cases of secondary pneumonia that supervene on measles. 1 See Formula No. 12, p. 263. 2 See Note, p. 56. 3 See Formula No. 11, p. 263. (EDEMA OF THE LUNGS. 279 LECTURE XXII. CEdema of the Lungs—occasionally comes on in the course of scarlatinal dropsy— severity of the symptoms, and their sudden accession.—Difference between cha- racters of oedematous and hepatized lung—treatment—importance of venesection —occasional exceptions to its use.—Chronic oedema, or carnification. Gangrene of the Lung.—Case illustrative of the disease—is not the result of mere intensity of inflammation—unattended by any pathognomonic symptom. Pleurisy—its rarity in childhood as an acute uncomplicated idiopathic affection—its symptoms and morbid appearances similar to those observed in the adult—it occasionally simulates other diseases, as affections of the head, and of the abdo- men—Evidences of auscultation less conclusive than in the adult, and why. Treatment—importance of early adoption of active measures—principles of treatment same as in the adult. Chronic pleurisy—rarely idiopathic—occurs oftener in connection with dropsy after scarlatina—its symptoms frequently obscure. Before we proceed to the examination of some other forms of in- flammatory disease of the respiratory organs, it may be convenient to notice two conditions of the pulmonary tissue, which, though not the direct results of inflammation, yet are closely connected with it. One of these conditions is acute oedema of the lung; the other is gangrene of its substance. It is unnecessary to occupy your time with any detailed account of that anasarcous state of the lungs which is sometimes met with in con- nection with general dropsy of long standing, or with some old disease of the heart and great vessels. In such cases, which are very rare in childhood, the oedema of the lungs is a secondary affection, and has very little share in producing the patient's death. But it occasionally happens that children are attacked by intense dyspnoea, and other symptoms of disorder of the respiratory organs, which terminate rapidly in death; while it is discovered, on an examination of the body, that the thoracic viscera generally are free from disease, but that the tissue of the lungs is loaded with serous fluid. Laennec' refers to such an accident as probably accounting for the occasional sudden supervention of extreme dyspnoea in children recovering from measles; but a recent French writer, M. Legendre,2 is, to the best of my know- ledge, the first person who has clearly proved the connection between the symptoms observed during life, and the state of extreme oedema of the pulmonary tissue after death. 1 On the Diseases of the Chest, translated by Dr. Forbes, 4th edition, p. 164, Lon- don, 1834. i Recherches sur quelques Maladies de l'Enfance, 8vo. pp. 324-352, Paris, 1S46. 280 CHARACTERS OF (EDEMATOUS LUNG. This cedema of the lungs, though it sometimes destroys life very speedily, is seldom, if ever, a purely idiopathic affection, but occurs generally as one of the complications of that acute anasarca which not unfrequently succeeds to scarlatina; and even then it is not of very common occurrence. M. Legendre records only four cases, all of which were observed in children who were suffering from anasarca after scarlatina; but several instances of it have come under my notice since the publication of his observations, in all of which it supervened during scarlatinal dropsy. In some of these cases it came on while the children were laboring under a great degree of anasarca; while in others the dropsy had greatly abated before the thoracic symptoms appeared. Indications of slight mischief in the chest, such as frequent dry cough, some degree of dyspnoea, with rhonchus and sibilus, or scanty crepitation, preceded the more serious symptoms for two or three days. The patient, in short, had seemed to be suffering from a bronchitis of moderate intensity, when suddenly extreme difficulty of respiration supervened, attended with very hurried breathing, orthop- noea, and most tumultuous and violent action of the heart, though with a feeble pulse. The cough continued, being still short, and quite unaccompanied by expectoration. Auscultation in such circumstances does not seem to give account of mischief sufficiently serious to ex- plain the alarming nature of the symptoms. It may be thought that air enters the lungs less freely than it should do; but the crepitation heard is scanty, bronchial respiration is not perceptible, neither is the resonance of the chest on percussion diminished unless fluid has at the same time been effused into the pleura. Nevertheless, if relief be not soon afforded, the child's sufferings in a few hours amount to perfect agony; the difficulty of respiration and the tumultuous action of the heart continuing; the lips and face becoming perfectly livid, but the intellect remaining clear, and the child complaining of great distress referred to the heart or epigastrium; till at length death takes place suddenly, which it sometimes does within twenty-four hours from the appearance of these alarming symptoms. At other times the approach of the disease is more gradual, the dyspnoea being augmented in pa- roxysms, but, on tbe whole, increasing with the increase of the general anasarca, and proving fatal in the course of five or six days. On examining after death the bodies of children who have died of this acute oedema of the lungs, some transparent serum is usually found in the chest; and a few deposits of lymph on the surface of the lung sometimes betoken the existence of slight inflammation of the pleura. The lungs themselves are of a deep red color, firm, and des- titute of air through a great extent of their substance, not breaking down so easily as lung in a state of true hepatization would do, but giving exit, when cut into, to a most abundant quantity of reddish serum, mixed with very few air-bubbles. If the lung be punctured, the fluid will by degrees drain out, and the organ will recover much of its natural flaccidity; while, if air be blown into the bronchi, the pulmonary tissue will completely resume its light color, and will crepi- tate as in a state of health. These experiments show that the fluid TREATMENT OF G3DEMA OF THE LUNGS. 281 is not accurately incorporated with the substance of the lung; and M. Legendre explains the sudden occurrence of alarming dyspnoea in some instances by the assumption that it is due to compression of the air-vesicles by the rapid pouring out of fluid into the cellular tissue by which they are surrounded. The supposition, however, that the fluid is in these cases entirely external to the pulmonary vesicles does not appear to be well founded, for watery fluids1 will pass by endos- mosis from one part of the lung to another, and will even transude through the pleura. The general effect, however, is the same, whether the chief accumulation of fluid be within the air-cellsj or external to them ; for in either case the free entrance of air is impeded ; while the severity of the symptoms depends on the rapidity with which the oedema has taken place almost as much as upon its degree. In cases where it comes on towards the close of some chronic affection, there is often no dyspnoea nor any aggravation of the patient's sufferings to mark its occurrence; while, when it takes place suddenly, not only are the symptoms most urgent, but the right auricle and ventricle are found, after death, enormously distended with coagulated blood—a token of the difficulty with which the heart had discharged the func- tions to the performance of which it at length became wholly un- equal. In every case of anasarca, after scarlatina, the possibility of the supervention of this condition must be borne in mind ; and every endeavor must be made, by the employment of diaphoretics and antimonials, and by the use of the hot air bath, to maintain the action of the skin, and to relieve thereby the congested kidneys. If, in spite of care, or, as far oftener happens, from want of it, these symptoms should occur, your course of treatment must be governed by the child's general condition. If its employment be not absolutely contraindi- cated, free venesection will be found to bring the same remarkable and immediate relief which it affords to those most urgent symptoms which follow the escape of air into the pleura; and the relief is proba- bly in both cases brought about in the same manner. After deple- tion, large doses of tartar emetic should be given, since there is no other remedy that so speedily or effectually reduces the urgent dysp- noea. In the subsequent management of the case, just such remedies are required as would be best calculated to relieve the general dropsy; and, as that decreases, the oedema of the lungs will likewise diminish and disappear. Very often, however, especially among the poor, the oedema of the lung comes on after long neglect of the patient's symptoms, or after some course of treatment altogether inefficient has been adopted; and the cold extremities, the livid surface, and the feeble pulse forbid all depletory measures, and render the use of any depressing remedy, such as antimony, altogether inappropriate. In such circumstances, a directly opposite plan must be adopted; a large mustard poultice 1 See the remarks and experiments of M. Barthez, in a note at p. 188 of vol. ii. of his and M. Rilliet's work on Diseases of Children. 282 CHRONIC (EDEMA — GANGRENE OF THE LUNG. must be applied to the chest; stimulants must be given abundantly, such as the nitrous or sulphuric ether, wine or brandy; and some- times it is necessary to continue these measures for several days; while some mild diuretic, such as the tartrate or citrate of potass, or the benzoic acid, are the only medicines which we can venture to employ. On one or two occasions, 1 have found reaction speedily follow the use of the stimulants, and have even been able in six or eight hours not only to discontinue them, but have even ventured to take blood from the arm; and the relief which followed justified the wisdom of the course. These, however, are exceptional cases; and care is often needed, on the other hand, lest the child should sink from the too early withdrawal of the stimulants. It would be wrong, perhaps, to leave this subject without some notice of the views of M. Baron1 with reference to certain alterations in the lungs, and in other parenchymatous viscera, which he believes to be due to chronic oedema of their tissue. He describes a state of carnification in which the substance of the organ becomes dark, firm, and compact, as if from compression; but, instead of these changes being attended by any diminution of its bulk, its size is actually increased. This alteration, though observable both in the liver and spleen, is naturally most striking when it exists in the lung, and was found by M. Baron, in all instances, either coexisting with dropsical effusions, or present in cases where such effusions had previously existed. He believes it to be due to long-standing oedema, to depend on changes in the tissue which the infiltration of fluid brings about • in the course of time. The tendency of this condition, when the lung is the part affected by it, is to compress the air-cells, and to interfere with the entrance of air; but, nevertheless, in many cases there were no symptoms announcing its existence during life; and air was found in the pulmonary vesicles after death, a fact which goes far to sub- stantiate the correctness of Dr. Gairdner's opinion, that positive ob- struction of the bronchial tubes is necessary to prevent the entrance of air into the lung; that the mere elasticity of its tissue, or conges- tion of its vessels, is not adequate to occasion this result. I will not, however, dwell further on these opinions, which involve questions of morbid anatomy more than of practical medicine, and the rather since I have no observations of my own bearing on the subject. My experience of gangrene of the lung in childhood is extremely limited, for only one case of it has come under my notice. The particulars of it, however, may be worth relating, since they illustrate very well the symptoms which the disease usually presents, and the circumstances in which it generally occurs. A little girl, three years old, the child of healthy parents, who had previously had good health, with the exception of a severe attack of inflammation of the lungs when two years old, began to droop in health, to cough, and to have shortness of breath, on the 11th of 1 In the Gazette Medicale for 1851 ; and republished in the Journal f'.'.r Kinder- krankheiten, vol. xviii., March, 1652. GANGRENE OF THE LUNG. 283 February, 1848. No treatment was adopted until the child was brought to me on the 15th. Her breathing was then more oppressed, her general condition more cast down, and her strength more reduced than is usual in so short a time from the commencement of an attack of pneumonia, which had not set in with very severe symptoms. Four leeches were applied beneath the right scapula, and half-grain doses of calomel and Dover's powder were given every three hours. Slight relief succeeded to the bleeding, but this was of but short duration ; and the child did not seem to be either better or seriously worse until the 19th, when she appeared to be losing strength. The mercury was now discontinued, and ammonia and nourishing diet were freely given. On the 20th, the gums both of the upper and lower jaw began to swell; by the next day they were ulcerated ; the breath became very fetid, and a discolored, stinking fluid, ran from the mouth. The thoracic symptoms continued much the same, not at all increasing in intensity, and the cough growing looser than before; but the child became paler and more exsanguine, and con- tinued to lose power. The ulceration of the gums extended to the fold of the lower lip, and three of the incisor teeth fell out before the disease was finally checked, on Feb. 26th, by the application of the pure nitric acid. The child did not appear to suffer pain, but was very restless, and continually harassed by efforts to vomit, during which she rejected nothing but an offensive mucus. She was ex- tremely indisposed to take either wine or any nourishment for four days before her death, which took place, apparently from exhaustion, on the 1st of March, nineteen days after the commencement of her illness. On an examination of the body after death, the left lung was found perfectly healthy, with the exception of some emphysema of its upper, and considerable congestion of its lower lobe. The right lung, which consisted of only two lobes, was universally solid and non-crepitant, with the exception of about a fourth of the upper and inner edge of the upper lobe, which was emphysematous. The two lobes were connected together by a layer of yellow lymph. The exterior of the lung generally was of a dark grayish-red color, with irregular patches.of yellow deposit beneath the pleura, some of which were nearly half an inch in length and a quarter in breadth; besides which many small purulent deposits were contained within the pulmonary vesicles, as in vesicular bronchitis. The upper part of the upper lobe, and a small portion near the diaphragmatic surface of the lower lobe, felt soft and boggy to the touch. On cutting into the upper lobe, a cavity was opened as large as a hen's egg, very irregular in form, intersected in various directions by the tubes and vessels that crossed it; from which, as well as from the walls of the cavity, portions of lung hung in shreds. The cavity contained a small quantity of dirty, grayish-yellow putrilage, which exhaled a most fetid odor. The substance of the lung in the immediate neighborhood was in a state of far advanced purulent infiltration, and other parts of the lobe were in an earlier stage of the same condition ; besides which, 284 GANGRENE OF THE LUNG. small collections of puriform fluid, not bigger than a split pea, were found in various parts of its substance. The state of the lower lobe on the whole resembled that of the upper, but the cavity in it was not larger than a marble, and contained a small quantity of yellow pus, of a less fetid character than that in the upper lobe. The bron- chial glands were swollen, soft, of a homogeneous aspect, and a gray color; but neither in them, nor in either lung, nor in any organ of the body, was there the least trace of tubercular deposit. Although there was, in this instance, a larger amount of inflamma- tory disorganization of the lung than is usually met with in connection with gangrene of its substance, yet the symptoms noticed during the patient's lifetime were precisely such as are generally observed in cases of this description. The child was attacked by symptoms of pneumonia, which, however, were far from being severe; but, never- theless, by the fifth day from their commencement, the greater part of the right lung had become impervious to air, and percussion over the right side of the chest, on the 15th of February, yielded an almost entirely dull sound. Even then the child's strength seemed much reduced, and, in the course of a few days more, she sank into a state of great weakness. Throughout the whole course of the disease, there was tbe same absence of striking indications of the extent to which the respiratory organs had suffered, and this even after a large portion of the lung was completely disorganized. Tbe most remarkable phe- nomena were those which betokened the general loss of power in the system, while the appearance of gangrenous ulceration about the gums tended to prove the correctness of the opinion which refers the dis- ease to some peculiar alteration of the circulating fluid rather than to the violence of the inflammatory action. Another circumstance which tends to support this opinion is, that gangrene of the lung much more frequently supervenes on the pneumonia that comes on in the course of the exanthematous fevers than on idiopathic inflammation of the lungs. The disease, too, occurs far more rarely in children who are well fed, and who live in pure air, than in those who are surrounded by unfavorable hygienic conditions. Hence it results that this, as well as other forms of gangrene, are met with in the Children's Hos- pital, at Paris, with far greater frequency than elsewhere, and that they sometimes show a tendency to become epidemic in that institu- tion. There is no symptom that can be mentioned as of constant occur- rence in gangrene of the lung in children, and as pathognomonic of the disease. That peculiar fetor of the breath on which so much reliance is placed in cases of gangrene of the lung in the adult, some- times loses its value in the child, as it did in the case just related, by the co-existence with it of gangrene of the mouth. It happens, too, not unfrequently, that the characteristic odor of the breath is altogether absent in cases of gangrene of the lung—a circumstance for which it is not easy to account, though of the fact there can be no doubt, since it rests on the authority of MM. Rilliet and Barthez. Should you meet with any case in which you apprehend that this condition of the lung is present, you would adopt a tonic and stimu- .ACUTE PLEURISY. 285 lant plan of treatment, as affording the only chance, and that a very slender one, of saving the patient's life. Dr. Stokes's suggestion, too,1 for the administration of chlorine, in the form of the chloride of lime or soda, should not be forgotten, since, if the remedy did nothing else, it might diminish that fetor of the breath, which is a source of very great suffering to the patient. Pleurisy, or inflammation of the investing membrane of the lungs, is a disease which received, until comparatively lately, much less attention than its importance deserves. Some writers on the diseases of children, indeed, have left it altogether unnoticed, on account of its supposed extreme rarity in early life; though this opinion is cer- tainly erroneous, so far as regards that secondary pleurisy which comes on in the course of pneumonia, and which is almost, if not quite, as frequent in childhood as in adult age. It is true that acute idiopathic pleurisy, unconnected with pneumonia, or in which the inflammation of the lung bears but a very small proportion to that of the pleura, is an uncommon affection during the first years of childhood, and that, as a cause of death, its rarity is extreme. According to the Reports of the Registrar-General, of 202 fatal cases of pleurisy that occurred in London in the years 1842 and 1845, only 14, or 6.4 per cent., took place in children under five years old; while you will not have for- gotten that 63.2 per cent, of all fatal cases of pneumonia are alleged, on the same authority, to have befallen children aged less than five years. It may be doubted whether this statement, which rests only to a comparatively small extent on the results of post-mortem exami- nation, does not under-estimate the frequency of idiopathic pleurisy in early life. But, be this as it may, the rarity of the disease unques- tionably diminishes after the first years of infancy are passed; while its importance as an occasional complication or sequela of other affec- tions, and more particularly of scarlet fever, and the frequent obscurity of its symptoms, are the reasons for devoting to it more than a passing notice. In fatal cases of pleurisy in childhood, the appearances found after death are precisely the same as are met with in the adult. Adhesions between the costal and pulmonary pleura, and between the different lobes of one or other lung, associated sometimes with very intense redness of parts of the membrane, are hardly ever wanting, and in con- nection with them a small quantity of transparent serum, often of a reddish tint, is sometimes effused into the cavity of the chest. In other cases the effused matters are entirely solid, and both the surface of the lung and the interior of the thorax are coated with a distinct investment of lymph; or, in addition to the deposit of lymph on the lung, fluid is poured out into the chest—no longer transparent serum, but either a sero-purulent fluid in which flakes of lymph are floating, or, more rarely, healthy pus. The most frequent complication of pleurisy is with inflammation of the lungs; besides which, it occasion- ally happens, when the left pleura has been the seat of inflammation, that the disease extends from it to the pericardium, which on four 1 Op. cit., p. 359. 286 DIAGNOSIS OF PLEURISY such occasions I have found lined with lymph, partially adherent to the heart, and containing a sero-purulent fluid.1 The main symptoms that attend the disease, as well as the physical signs of its existence, are the same at all ages. There are, however, some circumstances peculiar to early life, which, unless you are on your guard, may serve to obscure the real nature of the affection. The history of a case of acute pleurisy in childhood is generally something to this effect: A child previously in perfect health is suddenly attacked by pain referred to the chest or to the upper part of the abdomen, so severe as to occasion it to cry aloud; perhaps attended at first by vomiting of a greenish fluid, accompanied with fever, a rapid pulse, and hurried respiration, interrupted by frequent short cough, which evidently occasions pain, and which the child labors, though in vain, to suppress. After a few hours the severity of the pain subsides; but the fever, hurried respiration, and cough, continue, and the child, though usually it looks heavy and seems drowsy, yet becomes ex- tremely restless at intervals—cries and struggles, as if in pain, and violently resists any attempt to alter its position, since every move- ment brings on an exacerbation of its sufferings. The posture which it selects varies much; sometimes its breath seems disturbed in any other than an upright position; at other times it lies on its back, or on one side; but, whatever be the posture, any alteration of it appears to cause much distress, and is sure to be resisted by the patient. The probabilities are, that, if you auscultate the chest of a child in whom these symptoms exist, you will hear good breathing through the whole of one lung. On the other side, the air will be most likely found t» enter less freely, though unaccompanied by any moist sound, perhaps unattended by any morbid sound at all; or, possibly, a rough sound like a rhonchus may be audible on this side, and for this you may very likely at first take it, though with more attention it will be discovered to be a friction sound. A day or two later you will pro- 1 In 54 cases in which the above-mentioned consequences of recent inflammation of the pleura were observed after death in non-phthisical subjects, they existed in the following combinations :— Redness of the pleura existed alone ...... 1 " with recent adhesions and deposit of lymph . 18 Serous effusion existed alone ........ 12 with adhesions, or deposits of lymph . . 7 Sero-purulent effusion ......... 9 Effusion of pus .......... 7 54 In 29 of the above 54 cases, the affection of the pleura, though sometimes consider- able, appeared to be secondary, and subsidiary to that of the lung itself. In the re- maining 25, the pleura was the chief seat of the mischief, the lung being either simply compressed by the quantity of the effused fluid, or its inflammation being secondary in extent and importance to that of which the pleura bore evidence. In 6 of the above 25 cases, the affection of the pleura was idiopathic; 13 times it succeeded to scarlet fever; once to acute rheumatism with pericarditis; once to typhus fever ; and twice it succeeded to peritonitis. In one instance it followed inflam- mation of the sinuses of the dura mater ; and once fatal hydrothorax supervened in a case of general dropsy, which, as far as could be ascertained, had not been preceded by any of the exanthematous fevers. FROM CEREBRAL AND ABDOMINAL INFLAMMATION. 287 bably detect a sound like that of bronchial breathing, as you pass your ear from above downwards along the posterior part of the chest, while the friction sound will have disappeared; and still lower there will be an utter absence of all sound. In many instances, however, no friction sound is to be heard at the commencement of the attack, though it may become audible on its decline, but a bronchial character of the respiration will be perceived as one of the earliest auscultatory signs of the disease. The walls of this side of the chest, if their ten- derness do not prevent your trying percussion, will yield a much less resonant sound than usual; while, at the same time, a distinct sense of solidity will be communicated to the finger, and the vocal fremitus will either be indistinct, or altogether absent. I need hardly pursue the detail of other symptoms which are the necessary result of pleurisy, whatever be the age of the person in whom it occurs. The diminished mobility of the affected side, the displacement of the heart, the bulging of the intercostal spaces, and the enlargement of the chest on the diseased side, are phenomena that take place under the influence of the same causes at every age, though their occurrence is less frequent in childhood than in adult age, since the effusion of fluid is usually more scanty. The course of the dis- ease, whether towards recovery or to a fatal issue, presents nothing remarkable in childhood; but it is chiefly at the commencement that you are likely to mistake its nature. The symptoms by which an attack of acute pleurisy is ushered in, point sometimes rather to the head than to the chest. The child is seized with vomiting, attended by fever and intense headache: it either cries aloud, or is delirious at night, or screams muoh in its sleep, and, when morning comes, complains much of its head, but denies having any pain whatever in its chest, while the short cough and the hurried breathing may be thought to be merely the result of the cerebral disturbance. Sometimes, too, the cough is altogether absent, and the acceleration of the breathing so slight as not to sug- gest the idea that serious mischief is going on in the chest. Under the impression that the child is suffering from cerebral disease, aus- cultation is omitted, or at least practised hastily and superficially, and consequently serves but to confirm the erroneous diagnosis. It often happens, indeed, that in these cases no friction sound is perceptible, and that you have no other indication to guide you aright besides the feebleness of the respiratory murmur on the affected side. The child, too, fearful of taking a deep inspiration, fills neither lung completely, so that the information usually gained by comparison of the breathing in one lung with that in the other is in great measure lost. Still, the presence of feeble respiratory murmur, at the lower part of one lung, when coupled with the sudden access of acute febrile symptoms in a previously healthy child, points almost invariably to the existence of acute pleurisy; while a careful consideration of the patient's history and general condition will, even irrespective of the results of auscul- tation, go far towards preventing you from falling into error. The onset of the illness has been far too acute, attended with far too much febrile disturbance, for a case of tubercular hydrocephalus, while many 288 DIAPHRAGMATIC PLEURISY. of the signs of cerebral mischief which might be expected in a case of simple encephalitis have not presented themselves. The heat of head is not greater than that of the rest of the surface; the cries with which the disease set in have not ended in coma. It happens but seldom that convulsions mark the commencement of the disease; but, if they had occurred at the onset, they have not since returned: neither twitching of the muscles, nor strabismus, nor retraction of the head, is present; and though the child may cry (as children when ill and fretful often do) at the curtain being undrawn and the candle brought near it, yet there is no real intolerance of light, while, in spite of its fretfulness, the intelligence is not otherwise perverted. Error indeed is easy, but to avoid it requires in this, as in most instances, not so much great acuteness as great care and great patience. The pain with which pleurisy sets in is sometimes referred not to the chest, but to the abdomen ; and its commencement may be attended with vomiting and purging. This mode of onset of the disease is espe- cially likely to be observed in cases of diaphragmatic pleurisy, and more particularly if the inflammation be seated on the right side; and in this latter case, bilious vomiting is often one of the most marked of the early symptoms. Pressure on the abdomen, too, not only in these, but frequently also in other cases, occasions a considerable in- crease of suffering; and you may thus be led to overlook the existence of the pleurisy, and to allow your attention to be entirely directed to the abdominal symptoms. In any such doubtful case, it is well to bear in mind, that children, long after they can talk, describe the nature and seat of their sufferings very inaccurately; and if, as often happen^ in these cases, they refer the pain to the right hypochondrium, you should not forget that pain in that situation is at all ages much oftener connected with inflammation of the pleura than of the perito- neum ; and, lastly, that the increase of discomfort produced by pres- sure on the abdomen may be due to the additional impediment thereby offered to the already laboring respiration. The careful auscultation, which I need not say should never be neglected, will generally save you from error, but in a case of diaphragmatic pleurisy you are rather left to infer the nature of the disease from the non-correspondence of its symptoms with those of any other ailment, than enabled to decide upon its character from any positive sign of mischief in the chest with which your ear makes you acquainted. The heat of skin, the fre- quency of the pulse, and the hurry of the breathing, are such as to exclude the suspicion of almost all affections of the abdomen; while not only do not the general characters of the attack tally with those of acute peritonitis, but there is no such tenderness upon even slight pressure, no such tension of the abdominal walls, no such dread of the slightest movement, as characterize that disease. Your great safe- guard will be found, in such a case, in the right interpretation of the general symptoms, and in the recognition of the fact, that, when at- tended with acute febrile symptoms, the mere imperfect entrance of air into the lung is itself a valuable indication of inflammation of the pleura. The danger, in cases of pleurisy in early life, is, however, not simply that of overlooking the existence of mischief in the chest, but TREATMENT OF PLEURISY. 289 also of referring that mischief to a wrong cause. The fever, and cough and dyspnoea, may be so marked as to render the former mistake im- possible; but auscultation, unless you rightly interpret the information it affords, may not guarantee you against the latter. It is not by any means a matter of indifference whether you take a case of pleurisy for one of pneumonia, or whether, in a case of bronchitis, which may for some time have been under your care, you recognize the inflammation of the pleura which may have supervened, or see in the increased urgency of the chest symptoms merely an exacerbation of the pre- vious ailment. The error, indeed, is one not likely to be committed in a case of idiopathic pleurisy that you may have watched from the commencement, but it is one into which you may very probably fall in those instances where pleurisy succeeds to the exanthemata, espe- cially to scarlet fever, and less often to measles. Cough and hurried breathing, and rhonchus, with some crepitant rale, may have already existed for some time, and in these circumstances, a friction sound, even if it should become audible, is very likely to be unnoticed. But, besides this, the unequal breathing so characteristic of early life, as the result of which air may seem one hour to enter one lung imper- fectly, while a few hours subsequently the deficient respiration may appear to be on the opposite side, naturally leads you to undervalue the importance of mere deficient respiration. But, if the bronchial character of the breathing forces itself on your attention, the proba- bility is, that, without any further consideration, you may put that down as an unequivocal proof of the advance of pneumonia, and altogether overlook the pleurisy of which in this instance it is an indication. It is the more important to bear in mind the possibility of error, since some of the means of distinguishing between pleurisy and pneu- monia on which we rely much in the adult are less available in the child. It is so difficult to induce children to speak several words consecutively in the same tone, and their voice is often so feeble, as to deprive us in great measure of the information which its different resonance on the two sides would otherwise afford. For the same reason, too, the difference of vocal vibration, as perceived on apply- ing the hands to either side of the chest, is often by no means so manifest in children as in grown persons. The experiment, however, is one which should never be omitted, since the information which it yields, provided it do not fail altogether, is as valuable in the one case as in the other. Two more hints may perhaps be of service in help- ing to keep you from error: first, that the limitation of the physical signs of affection of the chest to one side, of itself raises a presump- tion that that affection is inflammation of the pleura, not of the lung; and second, that the bronchial breathing which is perceived at an early period of^an attack of acute pleurisy is attended by diminished resonance on percussion rather than by that absolute dulness which is perceived when the substance of the lung itself has passed into a state of hepatization. But we may pass now to the consideration of the treatment of acute pleurisy in childhood; a subject which need not detain us long, since 19 290 TREATMENT OF PLEURISY. the age of the patient in no respect alters the principles that must guide our conduct. If seen sufficiently early, and treated with due activity, cases of acute pleurisy in infancy and childhood nearly al- ways have a favorable termination, and in almost every instance that has come under my own observation in which the issue of the disease was unfortunate, either all treatment had been neglected until the children were past hope, or the nature of the complaint had been mis- taken, or the treatment followed had not been sufficiently active. This last error it is of great moment to avoid, for acute inflammation of the pleura in childhood runs its course with greater rapidity to a fatal issue than in the adult. Of nine fatal cases of acute pleurisy in childhood, of which I have preserved a record, one ended in death on the third day, three on the sixth day, one on the ninth, two within a fortnight; while one of the remaining two terminated in thirty days, and the life of the child in the ninth case was prolonged for several months, death eventually taking place from the development of phthisical disease in the lungs. In almost every case, provided the symptoms be at all urgent, and the child's previous health have been good, general depletion should be resorted to, and you need not be afraid of carrying this first bleed- ing to syncope, since children generally faint after the abstraction of a comparatively small quantity of blood from the arm. It will be almost always necessary to follow this up by local bleeding, but it is desirable to wait for three or four hours in order that you may be enabled to estimate the effect produced by the previous venesection. A second bleeding from the arm is seldom needed, and may almost always be avoided if local depletion be not too timorously practised. After depletion our chief reliance is to be placed on calomel, which should be freely given in combination with opium or Dover's powder. Antimony, which often renders us such good service in pneumonia, is here of little use; and though it may somewhat diminish the fre- quency of the breathing, it exerts little or no influence upon the local mischief; a fact which renders the establishing a correct diag- nosis between inflammation of the lungs and of the pleura of so much importance. A pleurisy treated thus actively is sometimes overcome in the course of twenty-four or forty-eight hours, so that nothiug re- mains of symptoms which had appeared so formidable. Often, how- ever, after the acute symptoms have subsided, the affected side remains dull, and the respiration scanty, for several weeks together; and now is the time when the use of blisters, associated with the exhibition of small doses of calomel, will be of most essential service, and will generally effect the complete absorption of the fluid, and the restora- tion of the patient to perfect health. This, however, is not always the case; but sometimes, in spite of re- medies perseveringly employed, one side of the chest continues full of fluid; and the question then comes before us, whether it will not be expedient to let out that fluid by mechanical means. My own expe- rience of the operation is too limited to enable me to answer mauy of the important questions which may be proposed with reference to it. I may, however, state that the impression left on my mind by each CHRONIC PLEURISY. 291 year's additional experience is more and more in favor of its compara- tively early performance. I have directed it to be done in six cases, in all of which the fluid was purulent. All the patients did well with the exception of a boy, in whom gangrene of the mouth came on, of which, and not of any direct result of the operation, he died. I am disposed to think that acute idiopathic pleurisy has in the child a greater tendency than in the adult to terminate by the effusion of pus, and should on that account advocate the performance of paracentesis, whenever, with the subsidence of the symptoms of active inflammation, there was not a corresponding abatement in the dyspnoea, and a mani- fest progress in the absorption of the fluid. Several instances, indeed, occur to my mind, in which I fear that the life of the child may in former years have been sacrificed owing to delay, and an unfounded hesitation on my part to puncture the chest. I have little or nothing to say with reference to the details of the operation. The fluid having in each case been purulent, no attempt was made to close the wound, but a linseed poultice was applied over it; and discharge went on for many days, and in one instance for seve- ral weeks, though gradually diminishing as the lung itself by degrees expanded. The very yielding character of the walls of the chest in early life renders the liability to the production of very serious de- formity by the shrinking of the diseased side, and the bulging of that which is healthy, far greater than in the adult. Time, too, will do far less in the child than in the grown person towards mitigating this evil, or rather, if not prevented at the outset, the progress of growth tends each year to increase it. In order to counteract this disposition, I have employed Tavernier's belt, with a crutch under the arm of the affected side, and have had every reason to be satisfied with the re- sult; since, to judge from two cases in which I applied it as soon as very decided contraction of the chest began to be apparent, it seems most completely to arrest its progress, and to give opportunity for nature to restore, in great measure, the symmetry of the two sides of the trunk. Pleurisy does not always present itself as an idiopathic affection. It supervenes, as we have already noticed, in the course of pneumonia, increasing the suffering of the patient, and, if severe, adding much to his danger. It comes on sometimes during acute rheumatism, either with or without pericarditis, and on two occasions I have observed pleurisy, with effusion into one side of the chest, succeed to an attack of peritonitis. But besides these cases in which the affection of the pleura retains an acute character, the disease is likewise met with in a chronic form, and manifesting its existence by comparatively few symptoms. Attacks of clironic pleurisy are sometimes idiopathic; and it is not always possible to trace them back to their commencement in an acute seizure. The cough and dyspnoea in such cases are trouble- some rather than distressing, and nothing but examination of the chest would lead to a suspicion of the serious nature of the affection. Cases of this description usually do well under the employment of local counter-irritation and the administration of mercury and diuretics, though the absorption of the fluid is in general effected very gradually. 292 CROUP. Chronic pleurisy, however, is a very rare occurrence as a purely idio- pathic affection in early life; but it is one of the most important, and far from being one of the least common complications of the dropsy which often succeeds to scarlatina. In these circumstances, too, it often needs much attention to detect it, since it may for a long time give rise to but few symptoms that might betray its existence. Some cough and some dyspnoea almost invariably attend the anasarca that succeeds scarlatina, and often there is no complaint of pain, nor in- crease of the cough, nor exaggeration of the dyspnoea, to betoken the onset of this new and formidable disease. At length, perhaps, the anasarca disappears, and now, when we notice the emaciated condition of the child, we observe for the first time that one-half of the chest is much larger than the other, that it remains immovable during respi- ration, and we discover that it is full of fluid. Or, our attention may be suddenly called to the mischief that has been going on, by the child becoming unable to breathe except in one posture, and even then with extreme difficulty; the fluid has been poured out so abundantly as at length almost to prevent respiration, and when we find out the evil it is almost too late to effect its cure. It is by the adoption of a vigorous antiphlogistic treatment in the dropsy that follows scarlatina that you will be most likely to prevent the supervention of this serious malady; it is only by the most atten- tive daily auscultation that you will in many cases get notice of its approach. LECTURE XXIII. Croup.—Reasons for not studying it earlier in the course—discrepancy of opinion with reference to it—two distinct though allied diseases included under the name. Laryngeal Croup ; or Cynanche Laryngea.—Causes of the diseases—its frequency in childhood, in the male subject, in northern climates, in rural districts. Post-mortem appearances—variations in the extent of false membrane in the air- passages—changes associated with it—affection of the fauces and soft palate. Symptoms—occasional sudden onset—catarrhal stage, general course of a fatal case- occasional delusive appearances of amendment.—Evidences of auscultation- changes in tracheal sound. Duration. Prognosis. Treatment—importance of abstraction of blood—directions for its performance, and for the administration of tartar emetic—when and how mercurials are to be em- ployed. In strict propriety the very important disease which we are about to investigate to-day, ought to have engaged our attention immediately after we had completed our study of infantile bronchitis. Two reasons, however, independent of mere convenience, have led me to postpone till now the consideration of the subject of croup. One of these reasons is, that its gravity is often greatly increased by the association with it of inflammation of the lungs—a complication the importance of which it was essential that you should thoroughly understand ; the other is, CROUP. 293 that croup, though an inflammatory disease, is not without a very evident spasmodic element in every case; so that it may very appro- priately form a sort of transition between the inflammatory and the spasmodic diseases of the respiratory organs. It can scarcely be necessary to tell any of you that croup is the English name for the disease designated by scientific writers cynanche trachealis, or cynanche laryngea. It consists in inflammation, generally of a highly acute character, of the larynx or trachea, or of both, which terminates in the majority of cases in the exudation of false mem- brane more or less abundantly upon the affected surface. The formidable nature of the symptoms by which it is attended, and the rapidity with which it tends to a fatal issue, have led many of the ablest physicians to devote much time and attention to the study of croup. It might, therefore, be anticipated that our know- ledge of a disease which betrays itself by very manifest and highly characteristic symptoms, and which gives rise, when fatal, to changes easily appreciable after death, should, by this time, be very definite and settled. With reference to many of the more important points in the history of the malady, writers are now, indeed, pretty well agreed; but croup, like many other diseases that depend to a great degree on atmospheric and telluric causes, is modified in many of its symptoms by peculiarities of air, water, and situation. The affection assumes one character among the poor of a crowded city, and another among the children of the laborer in some rural district.1 1 I have preserved a record of twenty-three cases of croup that came under my notice at the Royal Infirmary for children, between May, 1839, and April, 1849. Of these twenty-three cases, eleven were idiopathic, twelve secondary ; five of the former and two of the latter recovered. In two of the idiopathic cases that recovered, a scanty formation of false membrane was observed upon the velum and tonsils, but no such appearance existed in the other idiopathic cases. Three of the six fatal idiopathic cases were examined after death ; in two the false membrane was confined to the larynx ; and there was but little injection of the trachea or bronchi; in the third case there was great redness both of the trachea and bronchi, and a large quantity of puru- lent secretion in both, and ulceration of the mucous membrane of the larynx, but no false membrane. Of the twelve secondary cases, one supervened in the course of pneumonia; in the other eleven, croup appeared as the sequela or concomitant of measles, and ten of the twelve terminated fatally. In the cases which recovered, and in three of those which terminated fatally, there was no false membrane on the velum or fauces, but in the other seven, false membrane was present in those situations as well as in the larynx, and twice this false membrane extended into the oesophagus. Six of the fatal cases were examined after death; in one there was no false membrane anywhere, but intense redness of the larynx, trachea and bronchi, with an uneven granular appearance of the larynx, and ulceration about the epiglottis. In the other five cases the larynx contained more or less false membrane, and its surface was ulcerated ; and in four of the cases the palate and tonsils were inflamed and coated with false membrane. In all these five cases pneumonia existed in both lungs, and four times it was found to have reached in some parts the stage of purulent infil- tration. These results, which differ in so many respects from the conclusions of many most excellent observers in this country, approach much more nearly to those obtained in the Hopital des Enfans Malades at Paris. The district in which my observations were made is low, with defective sewerage, open drains running close to many of the houses; and most of the patients were the children of poor parents, who occupied only one room, and who consequently were placed in most unfavorable hygienic con- ditions. I may further add, that with the change of my field for observation since the open- ing of the Children's Hospital, a more sthenic form of the disease has come under my 294 TWO DISTINCT DISEASES INCLUDED UNDER If, therefore, you find that my account of the disease varies in any respect from the description given by some other writers, or from the results of your own observation hereafter, do not too hastily assume either that your teacher has been mistaken, or that your own observa- tion has been incorrect. The difference may be nothing more than a fresh exemplification of the old story of the shield, silver on the one side and golden on the other, about which the knights in the fable quarrelled. There are, indeed, two diseases which have often been included under the common name of croup, though the points of difference between them are at least as numerous and as important as are those in which they resemble each other. Of these two diseases, the one is almost always idiopathic, the other is often secondary; the one attacks persons in perfect health, is sthenic in its character, acute in its course, and usually proves amenable to antiphlogistic treatment; the other attacks by preference those who are out of health, or who are sur- rounded by unfavorable hygienic conditions, and is remarkable for the asthenic character of the symptoms which attend it. The one selects its victims almost exclusively from among children, is incapable of being diffused by contagion, is governed in its prevalence by the influence of season, temperature, and climate, but rarely becomes, in the usual acceptation of the term, an epidemic; while the other attacks adults as well as children, is propagated by contagion, and though it occasionally occurs in a sporadic form, is susceptible of wide-spread epidemic prevalence. The one is developed out of catarrh, and the amount of disease of the respiratory organs is the exact measure of the danger which attends it; while the other affects the organs of respiration secondarily, and its peril is often altogether out of propor- tion to the degree in which they are involved, and death itself may take place, although they are altogether unaffected. In this latter ail- ment, too, a long train of sequelae not unfrequently remains after the local symptoms have been dissipated—the evidence of its affinity to the class of blood diseases rather than to that of simple inflammations. Cynanche trachealis, cynanche laryngea, are the appellations of the former; Home,1 and Cheyne,2 and Albers,3 its historians; angina ma- ligna, the garotillo, morbus strangulatorius, diphthe"rite, the synonyms of the latter; Severinus,4 Bard,5 Starr,6 Eumsey,7 and Bretonneau,8 some of the writers who have most carefully described it. notice ; and in some of the fatal cases which have occurred in that institution under my care, a complete false membrane not only lined the trachea, but extended even into the tertiary bronchi. 1 An Inquiry into the Nature, Cause, and Cure of the Croup. 8vo., Edinburgh, 1765. 2 On the Pathology of the Larynx and Bronchia. 8vo., Edinburgh, 1809. 3 De Tracheitide Infantum. 4to., Lipsise, 1816. 1 De paedanchone maligna, &c, in De recondita, abscessuum natura, p. 513. 4to. Ludg. Bat., 1724. 5 An Inquiry into the Nature, &c, of the Angina Suffocativa, in Transactions of American Philosophical Society. 4to., vol. i., 2d ed., Philadelphia, 1789, p. 388. 6 An Account of the Morbus Strangulatorius, in Philosophical Transactions, vol. xlvi., 4to., London, 1752, p. 435. 7 Transactions of a Society for the Improvement of Medical and Surgical Knowledge, vol. ii. ° . 8 De la Diphtherite. 8vo., Paris, 1826. THE COMMON NAME OF CROUP. 295 Different, however, as the two diseases are, there are yet between them points of similarity no less striking, " Facies non una, nee diversa tamen," and the diagnostic difficulties, which are thus almost inevitable, are still further enhanced by the occasional simultaneous prevalence of both affections. It will be my endeavor to describe, first, that disease which is most frequent in this country, and then to give the best account in my power of that other malady, which, though a less constant, is yet a more formidable visitant, and one less within the power of medicine to control. Croup, or cynanche laryngea, in the form which it usually assumes in this country, is essentially a disease of early life; for it appears, from the Fifth Eeport of the Eegistrar-General, that while 1,022 out of 98,391 deaths in the metropolis and twenty-four town districts took place from croup, 1,013, or 99.9 per cent, of those deaths occurred before the age of fifteen; and 879, or 87.9 per cent., before the age of five years. Of thirty-nine cases of croup occurring among the in- patients of the Children's Hospital, thirty-two took place in children under five years of age, and only seven in children between the ages of five and ten. Twenty-four of the patients were males, fifteen females. It has been attempted to explain this great frequency of croup in early life by the imperfect development of the organ of the voice before puberty. This, however, can scarcely be admitted as a valid explanation, since it does not at all account for the extreme rarity of the disease after five years of age. The preponderance of male over female children, among those who are attacked by croup, is another fact which, though confirmed by the experience of all observ- ers, has never received any adequate explanation.1 Croup appears to be influenced by peculiarities of climate and locality much more than most diseases of the respiratory organs. Though not entirely confined to northern climates, it prevails but seldom in the southern parts of Europe, and is even less frequent in the southern than in the northern counties of England. In Kent, Surrey, and Sussex, the deaths from croup are to the deaths from all causes in the proportion of .9 per cent.; while in the four northern counties, Dur- ham, Northumberland, Cumberland, and Westmoreland, which con- tain an equal population, the deaths from this cause are in the propor- tion of 1.6 per cent. It is endemic in particular localities; and residence near the sea, proximity to the mouths of large rivers, a moist soil, and a damp atmosphere, have been enumerated as greatly 1 From the Fifth Report of the Registrar-General, it appears that, while the deaths of males under 15 from all causes, are to the deaths of females from all causes as 11 to 10, the deaths from croup are as 15 to 10. Of 249 cases that came under Golis' observations at Vienna, 144 occurred in males, 105 in females ; at Geneva, under Jurine's observations, 54 males and 37 females died of croup, between the years 1791 and 1808 ; and the relation of the sexes at Berlin among the deaths from croup between 1838 and 1849 was, as nearly as possible, as 5 to 4, the actual numbers being 545 male to 459 female children. See Honerkopff iiber die Anwendung des Schwefelsauren Kup- feroryd's gegen Croup. 8vo., Leipzig, 1852. 296 CAUSES OF CROUP—MORBID APPEARANCES. predisposing to the disease. The influence of these local peculiarities has probably, in some instances, been overrated; but still it cannot be denied, for a most striking illustration of it is afforded by the com- parative rarity of croup in towns, and its frequency in rural districts. In the county of Surrey, exclusive of the metropolitan districts, the mortality from all causes, under five years of 'age, is little more than a third of the mortality in Liverpool, and little more than half the mortality in London. But the total mortality, under five years of age, from croup, in the county of Surrey, is to that in Liverpool nearly as 3 to 2, and to that in London as 2 to 1; so that out of 100 children dying under five years of age, from all causes, more than four times as many will have died from croup in Surrey as in Liverpool, and exactly four times as many as in London. Variations in the condition of the atmosphere, and peculiarities of situation, not only influence the frequency of the occurrence of croup, but they likewise greatly modify its character, and determine, to a considerable extent, the nature of the lesions which it produces. The chief morbid appearances, however, are always discovered in the larynx, trachea, and air-tubes. They consist of redness of the mucous mem- brane, which is often thickened, sometimes abraded or ulcerated, and very generally covered with a more or less abundant exudation of false membrane. This exudation, however, though so generally met with as to have suggested to medical writers the terms angina polyposa, angina membranacea, as appropriate designations of croup, is neither invariable in its occurrence, nor of a uniform extent in all cases. It is found in the larynx oftener than in the trachea, and in both more frequently than in the bronchi. Nevertheless, in many instances, the secretion of false membrane is so extensive as not only to line the larynx and trachea, but even to reach into the minuter air-tubes, form- ing a complete cast of many of their ramifications. There appears to be some connection between the circumstances in which children become attacked by croup, and the extent of false membrane in the air-passages, which a post-mortem examination reveals. In rural dis- tricts, where the disease wears throughout a sthenic character, false membrane is deposited in greater abundance, and over a greater extent of surface, than is usually observed in the case of the poor in this metropolis; while, on the other hand, we find, in London, a condition of unhealthy ulceration about the larynx, ulceration and the deposit of false membrane about the tonsils and palate in many instances— appearances which are seldom met with in children placed in circum- stances more favorable to health.1 In cases of croup that have come under my ov/n observation, the formation of false membrane in the larynx has seemed almost invari- ably to precede its deposit in the trachea; and not infrequently it has been found constituting a tough, continuous membrane in the former situation, but growing less tenacious in the upper part of the trachea, 1 It is open to question how far one is justified in classing such cases with true croup; whether they do not approach more nearly to diphtheria, or whether, at least, they do not form a sort of connecting link between the two diseases. MORBID APPEARANCES IN CROUP. 297 and passing gradually into a thick, puriform mucus, interspersed with shreds of lymph. I have usually observed the false membrane lining the whole of the larynx, and reaching down to the lower edge of the thyroid cartilage, while the trachea contained nothing else than a puriform matter, or glairy mucus, sometimes of a reddish color. In some instances, the false membrane has been confined to the upper part of the larynx, lining the lower surface of the epiglottis, blocking up the opening of the sacculus laryngis, and covering the chordae vocales, but not extending any further. When first secreted, the false membrane is firmly adherent to the mucous lining of the air-passages; but, after a time, a secretion of a puriform character is generally poured out, which detaches the membrane from its connections; and it is after this occurrence has taken place that tubular pieces of false membrane have sometimes been expectorated. This detachment of the false membrane from the subjacent surface takes place more fre- quently and more completely from the interior of the trachea than from that of the larynx. On removing the false membrane from the trachea, the lining of the tube is seldom found to present any change other than an increase of its vascularity, which, though sometimes very considerable, does not bear any certain relation to the amount of false membrane present. The greater difficulty in removing the false membrane from the larynx depends upon the more extensive alterations which the lining of that part of the air-tubes is usually found to have undergone. It is generally red and swollen, especially about the edges of the rima glottidis and the arytenoid cartilages, and the opening of the sacculus laryngis. Small aphthous ulcerations are also frequent in the two former situations; and, occasionally, the ulceration being more extensive, the whole of the larynx, on detaching the false membrane that lined it, presents a worm-eaten appearance. It seldom happens that the bronchi are perfectly free from disease; but, even though the trachea contain no false membrane, and present but few signs of inflammation, they are almost always much con- gested, and contain a muco-purulent or purulent secretion; though false membrane is seldom found in them, except when it is continuous with a similar adventitious structure in the trachea. Pneumonia, in all its stages, is far from being unusual, and is a complication especially to be feared in those cases where croup occurs as a secondary affection in the course of measles. The cavity of the mouth and the fauces do not present any invari- able alteration in cases of croup. Congestion about the fauces and soft palate is of frequent occurrence, sometimes coupled with a scanty deposit of fa'lse membrane in those situations, or the tonsils are found in a state of ulceration. In that form of croup which succeeds to measles, there is moreover in many instances a condition of unhealthy inflammation, and aphthous ulceration of the mouth and gums, a slight speck of ash-colored false membrane covering each little ulcer. In many of these cases, I apprehend that the laryngeal affection does not come on in consequence of extension to the air-passages of disease beginning in the mouth, but that the disease is the same in both situ- ations ; though the accident of the locality renders that a serious 298 SYMPTOMS OF FIRST AND SECOND STAGE IN CROUP. disorder when seated in the larynx, which is but a trivial ailment when affecting the mouth. Cases of this last kind have been called cases of ulcerated laryngitis. They have always come under my notice associated with the exudation of a false membrane; and be-' tween them and croup I can discover no essential difference. Whatever be the circumstances in which croup comes on, the symp- toms resulting from disease obstructing the channel of the larynx and trachea by false membrane, or inducing a spasmodic closure of their aperture, must always be to a great extent the same. Its mode of onset, however, is very variable. Sometimes, especially in those forms of croup that prevail among healthy children living in the country, the disease is announced by few, if any, premonitory symp- toms ; but the affection of the larynx is apparent from the very outset, and attains in the course of a few hours to a high degree of intensity. Some years since I saw a little boy, about seven years old, living at some distance from London. He had overheated himself at play dur- ing the afternoon of a hot day in August, but went to bed apparently well at eight o'clock, and soon fell asleep. At ten, he began to breathe with the peculiar noise characteristic of croup, and presented all the symptoms of the disease before midnight. In his treatise on croup, Professor Golis, of Vienna,1 relates the case of a little boy four years old, previously in perfect health, who having gone out of an overheated room into the open air, during an extremely cold winter's day, was seized while walking with all the symptoms of most violent croup, which proved fatal in fourteen hours. This sudden onset and rapid course of the disease, however, are of rare occurrence, and croup generally comes on gradually, attended in its first stage by but fewsymptoms that could distinguish it from ordinary catarrh. Slight fever, drowsiness, suffusion of the eyes, and defluxion from the nares, attend it. The respiration is not perceptibly disturbed, and the cough, though frequent, presents no peculiar character. There is, besides, occasional complaint of slight sore-throat, or of uneasy sensation about the larynx, but so slight as scarcely to attract atten- tion, and not sufficient to cause any alarm. The duration of this stage is very variable: nor is there any regularity in the mode of its transition into the second stage. In the majority of cases, indeed, the transition takes place" gradually; but thirty-six hours seldom pass without the supervention of some symp- tom which, to the well-schooled observer, would betray the nature of the coming danger. Most symptoms may continue unchanged, per- haps scarcely aggravated, but a slight modification takes place in the character of the cough, which now becomes attended with a peculiar ringing sound, difficult to describe, but when once heard not easily forgotten. This peculiarity in the cough very often precedes any change in the respiration, and may sometimes be so slight as scarcely to attract the parent's notice at the time, and to be remembered only when the full development of the.disease leads to inquiries as to how 1 De rite cognoscenda et sananda Angina Membranacea, 8vo., Tiennse. Observ. iv. p. 141. SYMPTOMS OF THE SECOND STAGE. 299 the attack came on. Soon after this modification of the cough has become perceptible, or even simultaneously with it, the respiration undergoes a change no less remarkable. The act of inspiration be- comes prolonged, and attended with a stridor as difficult to describe, but as characteristic of the disease, as the tone of the cough. It often happens that these two pathognomonic symptoms first come on, or at least first excite attention, in the night, and that a child who at bed- time was supposed to ail nothing, or at most to have a slight cold, awakes suddenly with ringing cough and stridulous breathing, fre- quently in a state of alarm and with marked dyspnoea. Through the whole course of the disease, indeed, an obvious tendency exists to nocturnal exacerbations, and to remissions as the morning approaches. In whatever manner these symptoms may have come on, they will not continue for many hours without being attended by increase of fever, by acceleration, and soon by difficulty of respiration. The skin becomes hot and dry, the face flushed, the breathing hurried, the cough frequent, the pulse full and quick, the child dull, fretful, and passionate. For a few minutes, indeed, it may appear cheerful, may turn to its playthings, and breathe more naturally, though the peculiar respiratory sound never ceases altogether. Soon, however, the dysp- noea returns with increased intensity; the whole chest heaves with the inspiratory effort, which is more prolonged and attended with great stridor. During it, perspiration breaks out at every pore, and the veins of the neck and face become greatly distended. Short and forci- ble expiration follows, and after this state of dyspnoea has lasted for some minutes, an interval of comparative ease succeeds. The child now often falls asleep exhausted; but during sleep, the sound attend- ing respiration is heard in an exaggerated degree. Though the drow- siness is great, sleep is uneasy, and frequently interrupted by violent startings, in spite of which the child may still sleep on. After some minutes he awakes in a state of terror, to pass through another pa- roxysm similar to the preceding one, though more severe. The cough does not increase in severity in proportion as the disease advances; it is unattended by expectoration, or at most a little mucus is spit up, but without any relief. Although the paroxysms of dyspnoea are not dependent on the cough, they are sometimes provoked by it, and the two or three inspirations next following an effort of coughing are often attended with increased stridor. From the first appearance of the more marked symptoms, the voice is hoarse, cracked, and whispering, or in young children is either totally suppressed, or, if their voice be not actually extinct, at least their disinclination to speak is so great, that they will reply to questions only by signs, and cannot be induced by any persuasion to utter a word. There is almost always much eagerness for drink, and deglutition is generally well performed. The fauces are often red, though their redness bears no direct proportion to the intensity of the croupal symptoms; and there is frequently considerable tenderness of the larynx. The tongue is red at the tip and edges, but coated in the centre and at the back with thick white fur; the bowels are rather constipated, and the appetite for food is entirely lost. 300 SYMPTOMS OF THE THIRD STAGE—AUSCULTATION. As the disease advances, the paroxysms become less marked, or rather, the intermissions grow less distinct, and the child is constantly engaged with the effort to respire. The cough now sometimes ceases altogether, and the breathing frequently becomes sibilant rather than stridulous. The child throws its head back as far as possible, in order to increase the capacity of the trachea, the chest is heaved violently at each effort to inspire, and the larynx is depressed forcibly towards the sternum, while the abdominal muscles co-operate ener- getically in expiration. The face is heavy and anxious, the eyes are dull, the lips livid, the skin dry, and the extremities cold; or clammy sweats bedew the surface. The respiration is hurried, unequal and irregular, and the pulse is very frequent and very feeble. Though no remissions now occur, there are frequent exacerbations, in which the child throws itself about, and puts its hand to its throat, as though to tear away some obstacle to the admission of air, while helpless, hopeless agony, is depicted on its countenance. In the midst of these sufferings the patient dies, or coma or convulsions come on, and close the scene. It is not always, however, that the last stage of croup is attended by such distressing symptoms. The treatment employed may seem to have mitigated the severity of the disease; the restlessness may give place to ease, the burning skin may grow moist, tbe respiration may become tranquil, the cough loose with but little clangor; expec- toration may be easy, and a wheezing, attended with a very slight croupy sound, may be the only indication of the dangerous disease under which the patient is suffering. This apparent amendment may continue for a few hours, and then be succeeded, without any assign- able cause, by the return of all the former symptoms, and soon be followed by death; or, the mitigation of the disease may be accom- panied with great drowsiness, which, however, does not excite alarm, since it is very naturally attributed to the exhaustion produced partly by the disease, partly by the remedies. During sleep, the respiration is deep and tranquil, like that of a person in a sound slumber; it is, indeed, attended by a kind of wheeze, but presents little of the croupy stridor; and when awake the child is quite sensible, and even cheerful. After a time, however, it becomes difficult thoroughly to rouse him; his pulse grows more rapid, the moisture on his skin changes almost imperceptibly to a cold clammy sweat, and convulsive twitchings of the angles of the mouth occasionally disturb the repose of his features. Silently, but surely, the exudation has been making pro- gress, and when the alarm is taken, it is too late; the stupor deepens, and the child dies comatose, or rouses only to spend its last hours in the vain struggle for breath, and embittered by all the painful cir- cumstances which ordinarily attend the suffocative stage of croup. Auscultation yields us information in cases of croup with reference to two important points; namely, the amount of obstruction to the entrance of air into the lungs, and the extent of disease of the air- tubes or substance of the lungs which accompanies it. At first, air is heard entering the chest freely, and unattended by any morbid sound other than that stridor which is produced in the larynx. If DURATION OF CROUP. 301 the lungs should continue unaffected, no other morbid sound will be heard; but, as the disease advances, the same negative results will be obtained from auscultation as are yielded by it in cases of emphysema —a feeble respiratory murmur belying the loud resonance on per- cussion. Often, however, respiration is attended from the commence- ment with the sonorous rhonchus of the first stage of bronchitis, though masked to some extent by the croupy noise in the trachea. Even in cases where the disease is originally confined to the larynx or trachea, inflammation almost always extends to the bronchi; often, also, to the substance of the lungs, so that mucous* or subcrepitant rale generally becomes perceptible during its course, often attended by impaired resonance on percussion over the lower part of the chest. Air, however, may enter so imperfectly as not to fill the smaller bronchi; and these sounds may be quite unperceived, unless the aus- cultator listen at the moment when the child makes an unusually deep inspiration, such as often follows a fit of coughing. Tbe pneumonia, too, in alb cases that I have observed, was double, and the resonance consequently nearly equally diminished on both sides of the chest. Hence the importance of comparing the sound elicited by percussion of the upper with that given out by the lower part of the chest—a point to which you will remember that your attention has already been called on several occasions. The changes in the tracheal sound which attend the progress of the disease may be traced with great distinctness by applying a stetho- scope to the larynx. Some writers have thought that they recognized in its variations the indications of the formation of false membrane, and that they also afford a means whereby to judge of its extent. I believe that usually when false membrane has been extensively formed in the larynx, the tracheal sound becomes less stridulous and more sibilant; but I noticed on one occasion those changes in the tracheal sound which are supposed to indicate the presence of a very extensive deposit of false membrane, although no false membrane was either expectorated during the patient's lifetime, or discovered in the inflamed larynx and trachea after her death. We must conclude, therefore, that the changes in the tracheal sound do not afford absolutely certain evidence of the existence of false membrane, and that still less can they be regarded as safe criterions of its extent. It is difficult to state with precision the duration of a disease such as croup, since its premonitory symptoms vary greatly, and its fatal termination is often in great measure due to the concomitant or con- secutive bronchitis, or pneumonia. When the laryngeal affection goes on to destroy life, it is seldom that more than forty-eight, or at the most seventy-two, hours elapse from the full development of the croupal symptoms to the fatal event; and, allowing the ordinary dura- tion of the premonitory stage to be about thirty-six hours, the disease will be found to run its course in from four to six days. Twice I knew death take place within thirty-six hours from the occurrence of the first croupal symptoms; and, on a third occasion, within thirty- seven hours ; but these are instances of unusually rapid termination of the disease. Treatment sometimes partially subdues it; but it 302 PROGNOSIS — DANGER OF RELAPSES IN CROUP. returns, and the relapse, in the course of a few hours, proves fatal. Now and then the acute symptoms subside, and the disease assumes a chronic character; but this has only twice come under my notice in i idiopathic croup, though it is more common in that form of the dis- ease which we shall have hereafter to notice as constituting a serious complication of measles. The prognosis of croup must always be guarded, and is generally unfavorable, since the disease is unquestionably one of the most dangerous to which childhood is liable. Much depends upon the patient being seen at an early stage of the disease; and the prospect of recovery is generally very small if no treatment should have been adopted until after the full development of the symptoms. The pre- sence of bronchitis, and still more of pneumonia, adds greatly to the dangers of the affection, and would induce us to form a very unfavor- able opinion of the chances of recovery. A second attack of croup is generally less serious than the first; and cases in which catarrhal symptoms have preceded the seizure for several days are more amena- ble to treatment than those in which the premonitory stage has been short, or altogether absent. Diminution of the dyspnoea in the inter- vals of the cough—a louder and looser cough, attended with expecto- ration or vomiting of muco-purulent matter, intermingled with shreds of false membrane—a less suppressed voice, less anxiety, and less restlessness—all indicate that the disease is abating. Much caution, however, must be exercised in drawing a favorable conclusion from a diminution of the severity of the symptoms, until such improvement has continued for twenty-four hours at least. In all but the most acute cases of croup, the remittent character of the disease is very apparent; and it is well to bear in mind that the fatal termination usually takes place with extreme rapidity, when an exacerbation of the symptoms follows soon after a manifest remission of their intensity.1 It can scarcely be necessary to remind you that the extinction of the voice, suppression of the cough, the change from stridulous to sibilant breathing, and increased difficulty of respiration, all show death to be surely and speedily approaching. The danger of being lulled into security by the apparent improve- ment of a child who has been attacked by croup, is so serious that, before proceeding to consider the treatment of the disease, I will relate to you a case by way of caution. On the 25th of June, a little girl, four years old, became hoarse, and lost her appetite, though she did not appear otherwise ill. On the 27th, she seemed less well, and in the night was very restless, and had difficulty of breathing. On the 28th, respiration was more difficult; and, though she had but little cough, she seemed sometimes in danger of choking. In the night, a croupy sound accompanied her breathing; and violent attacks of dyspnoea were of frequent occurrence. On the 29th she was taken to a surgeon, who gave her some medi- cine, after each dose of which she was sick, and this sickness was fol- 1 "Mox post symptomatum remissionem recidivantes, brevi ac certa morte de- muntur."—Golis, lib. cit., p. 164. TREATMENT OF CROUP. 303 lowed by much relief, and by an almost complete cessation of the croupy sound. This improvement was thought to have continued during the 30th; the child slept quietly during the night, and was considered so much better by her parents that she was brought by them to the Children's Hospital at 9 A. M., on July 1st. As she lay in the lap in a sitting posture, her countenance was pale and livid, her respiration was sibilant, her surface cool, her pulse very frequent and feeble, but there did not appear to be about her any of the distress usual in the advanced stages of croup. At 9 A. M. she was admitted ; at 6 P. M. she died; though no*great distress nor violent struggle for breath preceded her death. The extensive deposit of false membrane in the trachea and bronchi showed that, in spite of her apparent amendment for a season, disease must all the time have been advanc- ing, unsuspected by her friends, overlooked even by her medical attendant. In no disease is the prompt employment of appropriate treatment more important than in croup, since in none does the use of remedies sooner become unavailing. Even in cases where the attack is merely apprehended, but where catarrh exists, attended with a slight ringing cough, such as often indicates the commencement of croup, the patfeut should be watched most sedulously, and visited not merely by day- time, but also late in the evening; and attention should be particularly directed to the character of the respiration during sleep as well as in the waking state. The child should at once be placed in a warm bath, be confined to bed, be placed on a spare diet, and should take an emetic of ipecacuanha and antimony, to be followed by some mild saline medicine, containing slightly nauseating doses of antimonial wine.1 At the same time the air which the child breathes should be both warm and moist, the temperature of the room being steadily kept up at 65°, while the moisture of the air is easily maintained, by a kettle boing on the fire, with a long roll of paper, or, still better, a tin tube attached to its spout, which serves to direct the steam into the apartment. These simple precautions, useful in diminishing the irri- tability of the air-tubes when croup is merely threatened, are, I need scarcely say, of still greater moment when the disease is fully developed.2 By these measures, which should be observed with especial care if the premonitory symptoms of croup appear in a child who has previously suffered from the disease, or in whose family a liability to it exists, you may often succeed in warding off the attack. 1 (No. 13.) R.—Potassse bicarbonatis gr. xl. Acidi citrici gr. xx. Vin. ant. pot.-tart. 3iss- Vin. ipecac. tt\xx. Syr. limonum 5iiss. Aqua giiss. 3iij 3tia vel 4ta quaque hora. For a child two years old. 2 At the Children's Hospital, so much importance is attached to the maintenance of a warm and moist atmosphere around the croup patient, that we are accustomed to inclose the bed with woollen curtains, and to introduce within them the rose of an apparatus constructed like that sometimes employed as a vapor bath, by which means uniformity of temperature and moisture can be maintained for days together. 304 TREATMENT OF CROUP—DEPLETION—EMETICS. A far more energetic plan must be resorted to if the disease set in with violence, or if, the indications of its approach having been either overlooked or unchecked, the symptoms should have attained their full development before the patient came under your notice. The abstraction of blood, and the administration of tartar emetic, are the two measures on which your main reliance must be placed; and you must bleed largely, and give tartar emetic freely, remembering that if relief do not come soon it will not come at all—that there is not dan- ger only, but death in delay. I have never met with an exception to the rule which prescribes the free abstraction of blood in every case of severe idiopathic croup, when seen at an early period, and before the purple lips and livid countenance, and failing pulse, announce the •long-continuance of a serious obstacle to the free admission of air into the lungs. Even in very young children local depletion forms in these cases but a poor substitute for general bleeding, for it is not merely the abstraction of a certain quantity of blood that is needed, but its removal in such a manner as most speedily to produce an effect on the system. Bleeding from the jugular vein is preferable in these circumstances to venesection in the arm, since the latter often fails in children under three years old; and the blood never flows so freely as when taken from the jugular vein. It is not easy to state in figures the exact quantity to be abstracted, since the child's previous health, the intensity of the symptoms, and the effect produced by the flow of the blood, must all be taken into account in determining when to stop. Dr. Cheyne says : " The removal of three ounces of blood from a child between one and two years of age, or of six ounces from a child from eight till ten, generally appears to make a sufficient impression on the disease;" and this is a sufficiently near approach to a correct estimate of what is usually needed. The effect of free venesection is often very striking, and as the blood flows, the respiration may be seen to become notably easier. But though the relief thus afforded is very great, it proves but temporary; and unless followed by other remedies, the symptoms will often regain their former 'intensity in the course of four or six hours. I have not seen any instance in which the repeti- tion of general bleeding appeared indicated, but many of you will probably meet with such cases in the country. Local depletion I have occasionally employed with advantage a few hours after the general bleeding; but if you follow up the first loss of blood by the free em- ployment of tartar emetic, you will often be spared the necessity for further depletion. It has been recommended that leeches should be applied to the top of the sternum rather than to the windpipe, since difficulty may be experienced in arresting their bleeding if applied in the latter situation, as children are very intolerant of pressure in that neighborhood. The caution is worth bearing in mind; but if you superintend the application of the leeches yourselves, which in such a case you certainly ought to do, the advantage of drawing the blood as nearly as possible from the affected part will more than make up for the risk of some slight difficulty in stopping the flow. To accomplish any real good by means of the tartar emetic it must be given in doses of an eighth, a quarter, or half a grain every ten TREATMENT OF CROUP. 305 minutes until vomiting is produced; and the same doses should after- wards be continued every half hour, until decided and permanent relief has been afforded. The dose that at first caused vomiting, may, after it has been repeated a few times, cease to excite it, in which case we must increase it, and not rest satisfied with tolerance of the medi- cine having been established, since its utility appears to be closely connected with its emetic power. Nauseating doses of antimony have not seemed to me to check the disease so surely, while they cause a greater depression of the system, and thus mask the approach of the fatal event. A striking illustration of the superiority of emetic over nauseating doses of medicine, is given by M. Valleix,1 who states that in thirty-one out of fifty-three cases of true croup, ipecacuanha and antimony were employed in full doses as emetics, and of these thirty- one cases fifteen recovered; while of the twenty-two cases in which their use was but sparingly resorted to, only one recovered. If after antimony has been thus administered for four or six hours, no satisfactory measure of improvement should have appeared, local depletion may be resorted to; or possibly a repetition of general bleeding may in some cases be ventured on. If the croupal symp- toms, on the other hand, should have begun to abate, the antimony may be given at longer intervals; but you cannot be too much on your guard against being misled by temporary improvement, and abandoning the medicine too soon. Its use likewise is not to be relinquished by gradually diminishing the dose and substituting a quantity sufficient only to induce nausea for that which caused vomit- ing, but a full dose should be given every hour or two hours, instead of every half hour, and if amendment continue, the interval may be prolonged to three, four, or six hours. It is now, after the severity of the disease has been subdued by antimony, that the time has come for the administration of calomel. From the very commencement of the attack, mercurial inunction may be had recourse to every two or three hours; or a flannel bandage on which two drachms of mercurial oint- ment have been spread, may be swathed around the abdomen of the patient; but the action of mercurials is far too slow to overtake, at its outset, a disease which tends so rapidly to a fatal issue. At this period, however, calomel seems to have a twofold utility; it counter- acts the tendency to the formation of false membrane in the air- passages, and prevents or subdues that inflammation of the lungs which is so frequent and so fatal a complication of the disease. I usually employ it in doses of half a grain or a grain in children from two to five years old every hour or two hours, in combination with minute doses of ipecacuanha, but interrupting its use at intervals in order to give an antimonial emetic. The appearance of any exacer- bation of the croupal symptoms, however, would lead me at once to discontinue the calomel, and to return to the emetic employment of antimony. There is, however, one point which it is important to remember in the management of the severer cases of croup, lest you fall into the 1 Bulletin General de Therapeutique, Oct. 1843, p. 246. 20 306 TREATMENT OF CROUP. error of over-treating your patient; an error not less hazardous than the opposite one of too great inertness. The disease, as you know, has a marked tendency to exacerbations and remissions, even inde- pendently of any physical change in the condition of the respiratory organs. You must not, therefore, allow the return of more difficult breathing, after a period of comparative tranquillity, to lead you at once to the inference that the child is worse, and that necessity exists for renewed and increased activity of treatment. It is very possible that the increased dyspnoea may be merely spasmodic; that immers- ing the child in a hot bath will give immediate and most signal relief; and that if you auscultate the chest afterwards, you will find the air entering the lungs in as large a quantity as before, and unattended by any increase of morbid sounds. The administration of calomel is not necessary in every case of croup, for when seen early and treated with due activity, its symptoms are sometimes completely removed in the course of a few hours. But though we may sometimes be warranted in suspending all active treat- ment for a season, yet we must watch our patient with most untiring care for some days after the decline of the acute croupal symptoms, and at each visit our attention must be directed to the condition of the lungs, in order that we may at once put a stop at its very com- mencement to that inflammation of the smaller bronchi and of the pulmonary substance which so often disappoints the fairest prospects of recovery. Its treatment does not differ from that of ordinary bron- chitis or pneumonia, except that depletion is not generally indicated, and that it not infrequently becomes necessary to support the patient's strength, even from a very early period. Your own good sense will suggest to you the care and watching which are required during convalescence from croup; the necessity of withdrawing your remedies cautiously, and of awaiting the com- plete disappearance of all hoarseness, and the cessation of all cough, before you allow the child to breathe the external air. In cases where the peculiar croupal sound continues with slight cough, long after every other sign of mischief about the larynx has subsided, you will often find it of service to paint the neighborhood of the windpipe every day with the tincture of iodine; a mild, but in the circumstances a very efficacious, form of counter-irritation. It still remains for us to inquire into the treatment of cases in which we have not the good fortune to encounter the disease at its outset, but in which we have to combat it when it has already reached the second stage. This subject, however, must be reserved for our next lecture. CROUP — TREATMENT OF ITS SECOND STAGE. 307 LECTURE XXIY. Croup continued.—Treatment of the more advanced stages of the disease.—Tracheo- tomy—the difference between the results obtained by it in England and in France, and its probable cause—objections to its performance—reasons for not regarding them as conclusive.—Inquiry into the object of the operation—indications for its performance—its dangers—and how they are to be obviated. In the last lecture we were occupied with the consideration of the management of those cases of croup in which the patient is seen early, and in which his condition warrants the employment of powerful anti- phlogistic measures. He may, however, be seen too late for such means to be allowable, or they may have been tried in vain. If anti- mony cease to vomit, or if it be rejected immediately and without effort, the fluid thrown up being unmixed with phlegm or false mem- brane, while the temperature sinks, the lips grow more livid, the pulse becomes more frequent and feeble, and the paroxysms of dyspnoea are undiminished in severity ; or if the respiration, though less laborious, be attended with a sibilant instead of a stridulous sound, it is evident that by continuing the medicine we may destroy the patient, but shall fail to cure the disease. A totally different plan of treatment must at once be adopted, though with but slender hope of success. An attempt should be made to arouse the child from the state of collapse into which it is sinking, by placing it for a few minutes in a hot mustard bath, and emetics of the sulphate of copper should at once be administered. The sulphate of copper has been considered by some writers to be possessed of a specific influence over croup. I cannot, however, take this view of its action. It has seemed to me to be nothing more than an emetic of great power, and therefore espe- cially applicable in cases where considerable depression exists, where the stomach has consequently lost much of its irritability, and where tartar emetic would probably not act at all, or if it did, would be injurious from its depressing action. Alum has been recommended in similar circumstances, and I dare say would answer equally well, though perhaps there is some advantage in the smaller bulk of the sulphate of copper.1 I am accustomed to give it dissolved in water in quarter or half-grain doses every quarter of an hour till free vomit- ing has been produced, but have never trusted to it alone, in the same way as in an earlier stage of the disease I am used to rely on tartar emetic. I employ it with a twofold purpose: first, to obtain the 1 Alum has been used and strenuously recommended in these circumstances by Dr. Meigs, of Philadelphia; and the experience of his son, Dr. J. Meigs, as recorded in his work on Diseases of Children, seems fully to bear out his father's recommenda- tion. He gives a teaspoonful in honey or syrup, every 10 or 15 minutes, till free vomiting is produced. 308 TREATMENT OF CROUP—COUNTER-IRRITATION. stimulant action of an emetic; second, to prevent, if possible, the accumulation of false membrane in the larynx. Hence, if the child seem again sinking into a state of collapse, or if coma appear coming on, or if the dyspnoea become much aggravated, the sulphate of copper may again be employed to induce vomiting. If, however, in these cases, or in others in which, though some degree of improvement has followed the previous treatment, yet the child has been much reduced by it, emetics should not act, I would not advise you to attempt to compel vomiting by irritating the fauces, or by other similar proceed- ings. On one occasion I saw these endeavors succeeded, not by the vomiting, which they were intended to excite, but by general convul- sion, followed by a comatose condition, in which death took place an hour and a half afterwards. Examination of the body discovered some congestion of the brain, but showed at the same time that the affection of the air-passages had not reached such a degree as to have precluded the possibility of recovery, and that the patient's death had been caused not by the disease, but rather by the ill-judged employ- ment of the remedy. In this stage of croup the decoction of senega is a medicine of great value, and may be given in combination with the carbonate of am- monia and tincture of squills, every two hours.1 The pungency of the ammonia is best concealed by sweetening the medicine with treacle or with coarse sugar, and mixing it with about a third of milk; and in this form children will seldom refuse it. ' No other remedy or combi- nation of remedies has appeared to me to be so useful as a stimulant expectorant in the advanced stages of croup or bronchitis. The patient's strength must be supported by beef-tea, and a generally nu- tritious diet; and even wine may be indicated; though small, indeed, are the hopes that remain when the vital powers have sunk so low as to require its employment. While by these means you try to keep your patient alive, there is still one remedy that you may use, and use actively, though I fear it must be admitted with no great prospect of success. You employ mercury, or you increase the dose in which you have previously prescribed it. A grain of calomel may be given every hour to a child from two to three years old, unless the exist- ence of profuse diarrhoea should contraindicate its use; while, at the same time, a drachm of strong mercurial ointment may be rubbed into the thighs every two hours. If diarrhoea be present, the calomel must be given more sparingly, or must even be altogether omitted. Much difference of opinion prevails among writers of high repute as to the proper time for employing counter-irritation in cases of croup, and still more as to the part to which this counter-irritation should be applied. I believe that when the disease has been checked by antiphlogistic measures, and the symptoms have lost something of their severity, much good is done by the application of blisters to the upper part of the sternum. But, on the other hand, if croup have reached an advanced stage, unchecked by previous remedies, blisters to the sternum have seemed to me nearly, if not altogether useless; 1 See Formula No. 12, p. 263. TRACHEOTOMY. 309 while, from the application of a large blister to the throat, covering the larynx and reaching down nearly to the sternum, I have often observed the paroxysms of dyspnoea to be much alleviated, the respi- ration to be rendered far more easy, and expectoration for the first time to accompany the cough. In any case, if very manifest relief were not observed within six hours after the abstraction of blood and the administration of antimony, while further depletion did not ap- pear justifiable, I should apply a blister to the throat.1 It was to be expected that the probable utility of bronchotomy in cases of croup should suggest itself to the earliest observers of the disease. For many years, however, after it was first advocated on theoretical grounds by Dr. Home, the value of the operation was not put to the test; and even for a long time after it had been tried, but one instance was recorded of any other than an unsuccessful result.2 In the year 1825, M. Bretonneau, of Tours, saved the life of a little girl when in the last stage of croup, by performing tracheotomy; and the operation has since then been performed in France nearly five hundred times, and rather more than a fourth of the patients who underwent it recovered.3 The results of the operation in this country are, however, far less favorable than those which have been obtained in France; and many attempts, though none to the best of my judgment altogether satisfac- tory, have been made to account for this difference. Much is proba- bly due to the difference between the characters which the disease presents in the two countries; for in France the croupal symptoms are induced in the majority of instances by the extension to the larynx of false membrane originally deposited on the fauces and soft palate ; while the bronchitis and pneumonia, which in this ccfuiltry often accompany or even usher in the laryngeal affection," are tftere secondary in point of time, and subordinate in importance. More may, however, be attributed to the earlier stage of the disease in which the operation is resorted to abroad than in England; so that, while in this country a successful tracheotomy represents a child snatched from inevitable death, in not a few of the instances of its performance in France other means might have been tried, and would probably have controlled the disease.4 Still, if these facts detract something from the apparent value of the operation, they at least show that in itself it is 1 This opinion being opposed to that of men such as Dr. Stokes and Mr. Porter, I feel it necessary to appeal in support of it to the authority of Golis, lib. cit., p. 118, and Albers, De Tracheitide Infantum, p. 127 ; and not to rest it solely on the results of my own experience. 2 In this case the operation was performed in the year 1782, by Mr. Andre, of London, on a little girl five years old. The particulars are related in a dissertation, published at Leyden in 1786, by Mr. T. White, whence they are extracted by Dr. Farre, and appended as a note to a paper of his on Croup, at page 338 of vol. iii. of the Medico-Chirurgical Transactions. 3 The most recent statement with which I am acquainted of the results of tracheo- tomy in France, is that of MM. H. Roger and S6e, which yields 126 recoveries to 446 operations, or 27 per cent, during the last 7 years.— Gaz. 27eWo/n., Nov. 12,1858, p. 789. 1 In illustration of this fact, two cases may be noticed, recorded in the Journal de la Society Me'dicale d'Indre et Loire, extracted and commented on in the Bull. Gen. de The'rapeutique, Octobre, 1842. 310 TRACHEOTOMY IN CROUP. not attended by serious danger; and recent statistics prove that, in as far at least as the diphtheritic form of croup is concerned,1 there is no sort of connection between an increased frequency in the performance of tracheotomy and a higher mortality from the disease. Further, it must be conceded that even the somewhat premature performance of tracheotomy may not be altogether without some compensating ad- vantage, by the relief which it affords to that spasmodic action of the muscles of the glottis, which endangers the patient's life independently of the extent of false membrane in the air-tubes. But, whatever might be the result of the very early performance of tracheotomy, such a proceeding would be practicable only in a hospital; and we must base our conclusions, with reference to the operation, on a due consideration of the circumstances in which alone we are likely to have the opportunity of performing it. " There is," as Dr. Stokes2 has truly observed, "always that kind of feeling connected with a surgical operation in acute diseases which prevents its being proposed, assented to, or performed, unless under nearly desperate circumstances, and when all other means have failed. In the case before us, the opera- tion is performed at a time when the situation of the patient is the worst possible for success; when the nervous system has been pro- foundly injured, and the lungs, even though no primary complication may have existed, have become extensively congested." Among my patients at the Children's Dispensary, I never had recourse to the operation—partly for the reasons stated by Dr. Stokes, partly because it would have been impossible in the houses of the poor to command that constant attention and minute care which are absolutely essential to the success of tracheotomy, even when everything in the patient's condition concurs to warrant its performance. Since the opening of the Hospital for Sick Children, I have been concerned in the per- formance of the operation upon seven patients who were under my care either in that institution, or in private. In none of them were those precautions wanting which, after tracheotomy has been prac- tised, conduce to its successful issue; but all the children died; and he who lived longest survived only forty hours. It would, however, be unfair to deduce from these facts too unfavorable an inference, since six of the seven patients were under five years of age; while it is among older children that the highest averages of success are ob- tained; and in all of these the operation was had recourse to as offer- ing the only chance of preserving life.3 But, in spite of the unfavorable issue of the few cases in which I have either directed or sanctioned the performance of tracheotomy in 1 Roger and See, loc. cit. 2 On Diseases of the Chest, 8vo. p. 220. Dublin, 1837. 3 The recent thesis of M. Millard, De la Trache'otomie dans lecasde Croup, Ato., Paris, 1858, illustrates extremely well the almost invariable fatality of tracheotomy when performed on young children. Of 124 cases in which the operation was performed at tbe Hopital des Enfans between January, 1857, and July, 1858, 29, or 24 per cent., had a favorable issue. But of 20 children under two years old who were operated on, none survived ; and of 36 between two and three, only 5—the remaining 24 recoveries having been obtained in children between the ages of three and nine. ARGUMENTS AGAINST THE OPERATION. 311 croup, I am so far from being opposed to the operation, that my chief anxiety is to make out the indications which may justify me in having more timely recourse to it in future. The discrepancies of opinion which have prevailed with reference to it are, I think, partly due to an over-estimate on the part both of its advocates and opponents, of the ends which it is proposed to attain by it. In itself, tracheotomy in croup is not a curative proceeding, nor can its performance warrant the discontinuance of those measures previously resorted to, whose object was to overcome the disease of the larynx and trachea. It professes to remove in some cases the danger of immediate death from suffocation, and thus to give time for nature and art to do their best in overcoming the inflammation of the air passages, or in obviat- ing its results. That it should prove inefficacious to accomplish this in cases where false membrane has extended to the extreme bronchi, is no argument against its performance in the present state of our knowledge, though it furnishes a cogent reason for the endeavor to perfect our diagnosis, so that our failures may be lessened by our less often attempting the impossible. The questions that call for determination in any endeavors to estimate the value of tracheotomy are, first, whether the danger of croup arises from causes which in certain instances tracheotomy, and that alone, can remove; and secondly, whether the dangers attendant or consequent on the operation are themselves of such a kind as to outweigh its advantages. If these inquiries should be answered in favor of the operation, we may then endeavor to determine by what means its danger can be most effectually lessened, and those cases be best discriminated in which the benefits of the proceeding are likely to be most signal. It has been objected by no less an authority than Dr. Cheyne, that inasmuch as three-eighths of the aperture of the larynx have been found free in fatal cases of croup, there must have existed during life room enough for the entrance of air; or that, in other words, the suffocative symptoms of croup do not depend on a cause which tra- cheotomy can remove. The operation, however, is not performed merely on the mechanical principle of removing from the windpipe a quantity of matter which prevents the entrance of air into the lungs; but it is done rather to obviate the dangers of that spasm of the glottis which the inflammation occasions, and which will not cease until either the inflammation is subdued, or the spasm relaxes with the approach of death. Even the narrow opening made into the trachea—often much narrower than the aperture of the larynx, though diminished by swelling or encroached on by false membrane —suffices, for a time at least, to admit all the air which the patient needs, and the dyspnoea is relieved. The inflamed larynx is now at rest, while the air entering continuously, and without effort, duly oxygenates the blood; and the child is thus placed in a condition in which all remedial agents would seem much more likely to tell upon it, than when it was in a state of impending suffocation. Tracheotomy, then, in cases of croup, answers a twofold end, and 312 TRACHEOTOMY IN CROUP. one not by other means attainable.1 It removes in some instances a positive mechanical obstacle to the entrance of air into the lungs, while in all it puts a stop to that spasm of the glottis which interferes with respiration as much as the actual deposit of false membrane, though not as constantly or with equal peril. Now it may be asked what evils are there attendant on the opera- tion that counterpoise these indisputable benefits ? To this inquiry it does not seem to me that the opponents of tracheotomy give any sufficient answer. It is admitted on all hands that in itself the opera- tion is not attended by serious hazard; while the uncertainty as to its issue depends, not on any defect in the proceeding, but on an imperfect knowledge of what cases are within the power of art to succor, and what are beyond the help, not of tracheotomy only, but of all other measures likewise. The shock of the operation is seldom serious except in cases where it has been delayed to the very last moment; serious hemorrhage is a very rare accident, and is generally due to the unskilfulness of the operator, while the dysphagia which occasionally follows is a troublesome rather than a dangerous occur- rence, and one, too, which is not encountered until the canula has been worn some days. The gravest charge against the operation is that it is apt to induce serious bronchitis, or at any rate to aggravate any previously existing inflammation of the lungs or air-tubes. I am not altogether certain that there is not some grouud for this accusa- tion, but on the other hand it must be borne in mind that these very diseases are the ordinary, almost invariable complications of croup, however treated; and further that they are not ordinary sequelae of tracheotomy when resorted to in other circumstances, as in cases of acute laryngitis, or of oedema of the glottis. But if we come to the conclusion that in cases of croup which have not yielded to ordinary medical treatment, and in which there seems reason to anticipate a speedy death unless the inability to fill the lungs with air can be soon relieved, the operation of tracheotomy does not superadd some peculiar danger of its own more certain and more desperate than those by which the patient is already surrounded, it then becomes our duty to resort to it; and this not at the last moment, but so soon as ever we feel that our remedies are too tardy to over- 1 I purposely pass with this slight notice, the proposition of M. Bouchut (originally suggested indeed by the famous Desault) for the so-called " tubage de la glotte," or in- troduction of a tube within the canal of the larynx, in order to keep a passage perma- nently free for the entrance of air, and thus to do away with the necessity for the performance of tracheotomy in croup. M. Trousseau's report on the subject to the Academy of Medicine at Paris, most temperately but at the same time most conclu- sively exposes the fallacies of M. Bouchut, and shows the small practical value of the suggestion, as well as its almost complete inapplicability to the treatment of croup. Of seven cases in which this proceeding was resorted to five terminated fatally, and in the only two patients who recovered tracheotomy was performed. The proceeding is very difficult to accomplish, while in some instances the presence of the tube with- in the glottis could not be tolerated by the patients, and its removal was necessary ; and though M. Trousseau admits its possible utility in cases of oedema of the glottis, and of simple laryngitis, I should doubt whether even in these instances the presence of a foreign body within the opening of the larynx would not be likely to produce a most mischievous irritation of the diseased organ, and such as would far exceed that which would be excited by a tube in the trachea. WHEN THE OPERATION IS INDICATED. 313 take the disease. In such circumstances, to gain time is to gain every- thing, and it is just this which tracheotomy places within our reach. It is not possible to fix absolutely what rate of mortality may be fairly expected to follow an operation performed in circumstances such as those which call for tracheotomy; for that, unlike most surgical pro- ceedings, does not remove the disease for which it is had recourse to, it does but give the constitution another chance of battling with it; and many of the deaths after tracheotomy are, strictly speaking, far from being instances of failure of the operation. The operation may have done all that it could do, but false membrane may have extended far beyond the opening in the trachea, or the bronchitis may have reached the capillary air-tubes, or the pneumonia may have involved the pul- monary substance too extensively for recovery to be possible. We may hence deduce a limitation to the performance of tracheotomy which I cannot state better than in the words of the great advocate of tracheotomy, M. Trousseau,1 who "forbids the performance of the ope- ration in any case where the danger to the child appears to depend on disease of the general system rather than on the affection of the larynx or trachea." But in cases where no such contraindication exists, it is yet evident that the issue of the operation must be in a great measure controlled by the age of the patient, by the fact of the disease being idiopathic or secondary, by the extent of the disease of the respiratory organs generally, and that this influence must be of a kind which no surgical dexterity or medical skill can do much to control or to modify. Some circumstances may, however, be borne in mind as influencing the result of tracheotomy, while at the same time they are not beyond the control of the medical attendant. The first of these concerns the size of the tracheal tube, a point the importance of which was first insisted on by M. Trousseau. He ex- plains the occasional speedy and apparently causeless disappearance of the amendment that at first succeeds the operation of tracheotomy by the inadequate size of the canula which is frequently employed, and which does not provide for the permanent admission of a sufficient quantity of air. The air admitted through even a small canula is enough to afford temporary relief, but not enough for the continued discharge of the functions of the organism ; and the return of hurried breathing, and the reappearance of the livid hue of the surface, be- token the imperfect depuration of the blood. " Take," says he in illustration of this fact, "a quill, and, closing your nostrils, endeavor to breathe entirely through it; at first you breathe easily enough, but soon your respiration becomes laborious; and at length you are fain to throw away the quill, and with open mouth once more to fill your lungs completely. Now precisely this is what happens, when an open- ing of inadequate size is made into the trachea; air enters readily, and without the interruption which the spasm of the glottis occasioned; but it does not enter in sufficient quantity, and hence the return of the symptoms, and the patient's death." Acting on this principle, M. 1 Archives Gen. de Medecine, March, 1855, p. 257. 314 TRACHEOTOMY IN CROUP. Trousseau makes a larger opening into the trachea, and introduces a larger canula than had previously been customary: and this practice I believe to be now gaining ground among persons who have omitted to acknowledge their obligation to M. Trousseau for the suggestion. The second of these precautions has reference to the necessity of sur- rounding the child after the operation with a warm, moist atmosphere, such as alone it ought to be allowed to respire; though, unfortunately, this is very much neglected not in hospitals only, but also in private practice. The importance of attention to this point, and also to sur- rounding the neck with several folds of muslin, so as to cover the orifice of the tube, as well as to keep the canula free, cannot be over- stated ; and yet these little things are overlooked or intrusted to un- skilful hands, because they seem too trivial for such large issues to be dependent on them. The third caution which I would urge is, that medical treatment must not be suspended, nor necessarily modified, after tracheotomy has been performed. The operation, indeed, seems so heroic a mea- sure, and when it yields relief, the relief is so speedy and so striking as to occasion some risk of its being forgotten that the disease has not been removed by it, that its danger has only been postponed, and that the indications for treatment continue the same after tracheotomy as they were before. A word or two with reference to the after-management of cases- of tracheotomy will comprise all that I have to say on this subject. My own patients have never lived long enough after the operation for me to become practically familiar with the difficulties which arise some few days after its performance. These, however, apart from such as are the consequences of the supervention or increase of the disease of the respiratory organs, are twofold, and arise from the con- dition of the wound, and from the occasional supervention of difficulty of swallowing. One of the reasons for seeking to remove the canula as early as possible is supplied by the irritation of the edges of the wound which its long-continued presence is apt to produce. I saw the death of a child take place from this cause on the 11th day after the otherwise successful performance of tracheotomy by my colleague, Mr. Athol Johnson; and it was ascertained after death that in addition to the destruction of several rings of the trachea, an abscess had formed in tbe anterior mediastinum which communicated with the external wound by sinuses that burrowed between the trachea and oesopha- gus. In fat children the unhealthy state of the edges of the wound is partly produced by the canula remaining deeply sunk in the flesh; an evil which would perhaps be lessened by the use of a long canula with a very broad shield; or else by the employment of one "a lor- gnette," as it has been termed by its inventor, M. Paul Guersant; that is to say, capable of being lengthened by pulling it out, like a telescope or an opera-glass. Besides this, the covering the wound with lint thickly spread with spermaceti ointment, and placing over that a piece of oiled silk so as to defend it as far as may be from irritation, and from the external air; as well as the touching its edges daily with DIPHTHERIA, OR ANGINA MALIGNA. 315 the nitrate of silver, are the most important means of maintaining its healthy condition. The difficulty of deglutition is an inconvenience which usually comes on about the fifth or sixth day after the operation : that is to say at the time when the larynx, though now free from the false membrane which before occluded it, has not completely recovered from the effects of the disease, but a state of partial paralysis of its muscles remains, which allows food, and especially liquids, to enter the air-tubes. If the patient is sufficiently intelligent to admit of M. Archambault's suggestion1 being adopted, and will place the finger on the opening of the tube, and endeavor to breathe quietly through the larynx when swallowing, it is very likely that the want of harmony between respi- ration and deglutition will be overcome in many instances, though according to M. Trousseau's experience, by no means in all. In the majority of cases, however, we are compelled, by the tender age of our patients, to confine ourselves to feeding them as far as possible on solid, or at least on pultaceous food; rejecting all drink as far as possible, and giving it when absolutely necessary in small quantities, and either immediately before or a considerable time after food.2 In some instances M. Guersant has found the use of the stomach-pump necessary to convey food safely into the stomach; though happily such are exceptional cases; while generally the larynx recovers itself in three or four days, and deglutition is no longer attended with diffi- culty or danger. LECTURE XXY. Diphtheria, or Angina Maligna.—Not a new disease.—Its anatomical characters— mode of extension of the disease.—Its relation to true croup. Symptoms of diphtheria—in its milder form, insidious supervention of croupal symp- toms—in its severer forms, peculiar depression which attends it—evidence of its affinity to the class of blood diseases.—Its sequelae.—Relation between it and scarlatina considered—evidence on both sides of the question stated—that in favor of their non-identity considered to preponderate. Treatment—local applications—constitutional measures—necessity for tonics and stimulants. Modified form of the disease—usually a complication of measles—its symptoms and treatment. Laryngitis Stridula, or croup with predominance of spasmodic symptoms—not a dis- tinct disease, but results from constitutional peculiarity.—Illustrative case. Instances of spasmodic cough and affection of larynx, from irritation in lungs—intes- tines—brain.—Note on thymic asthma. Reference was made in the last lecture to a second form of disease, resembling croup in some respects, though differing in others, alike, 1 L'Union Medicale, Juillet, 1854. 2 Archives Gen. de Medecine, Mars, 1855. 316 DIPHTHERIA, OR ANGINA MALIGNA. but not the same, and calling, therefore, for a separate notice. This other disease, Angina Maligna, Diphtheritis, or, more correctly, Diph- theria, is no new malady,1 but one which, though always prevalent, forces itself occasionally upon general notice by the formidable symp- toms that sometimes attend it, by the rapidity with which it then runs its course, and by its selection of several victims from one town, one village, or one family. At such seasons it wears a character which seems so different from that which it assumes in its milder forms as to render it almost impossible to believe that the slight sore throat which caused only a trivial inconvenience, and hardly required any medical treatment, is one with the malignant disease, whose local symptoms are often cast into the shade by the grave constitutional disorder that attends them. In each case, however, its essential anatomical characteristic is the same, and consists of redness, and swelling involving the tonsils and soft palate, and accompanied within a few hours by the exudation on their surface of a dense, white, false membrane, appearing in little points or spots which speedily coalesce, and form a uniform invest- ment to the part where swelling and redness were first apparent. The white color of the original deposit is speedily lost as fresh exuda- tion is produced; and the membrane becomes gray or blackish as the air acts upon it, or as blood from the congested mucous surface beneath stains it. Speedily, too, it splits up into shreds, which, hang- ing down at the back of the fauces, produce that appearance of a sloughing tissue which imposed upon the early observers, and obtained for the disease the name of Angina Gangraenosa. If detached from its connections, a number of minute bloody points on the subjacent tissue attest the firmness with which the false mem- brane adhered to it; but, beyond increase of their vascularity, the parts do not in general display any marked alteration. I doubt, how- ever, whether that rigid classification which would refer to a separate category all those instances in which there exists distinct erosion or ulceration of the mucous membrane beneath the exudation is either practically useful or pathologically tenable; for while the surface of the tonsils is not invariably free from ulceration, I believe that in a very large proportion of the instances in which the exudation extends into the air-passages the mucous lining of the larynx is distinctly eroded, and small specks of ulceration are discernible about the edges of the glottis. Coupled with this condition of the fauces there is usually a swell- ing of the submaxillary glands, and of the adjacent cellular tissue; as well as to some extent also of the parotids. This swelling, however, though very rapid in its formation, and equally so in its disappearance, is seldom so considerable as that which often attends upon scarlatina; 1 Starr's unpretending account of the disease at Liskeard, a century ago, details all the most characteristic features of diphtheria : the false membrane on the fauces, its extension to the air-passages, its appearance on blistered surfaces and upon the skin behind the ears, leave scarcely a symptom wanting to prove the identity of the two affections. Those who wish to pursue the question will find all necessary information in Fuch's Historische [Intersuchungen iiber Angina Maligna, 8vo. Wurzburg, 1828. ITS CHARACTERISTIC SYMPTOMS. 317 it has but little tendency to terminate in abscess, and still less to assume the brawny hardness, and the extremely indolent character which often add so much both to the suffering and the danger of that disease. Although the soft palate and tonsils are the parts on which the deposit is first observable; it often does not remain limited to those situations, but its tendency is to extend by mere continuity of tissue to the mouth, the pharynx and oesophagus; to the larynx and trachea, and also occasionally upwards into the nares. Affection of the mucous membrane of the mouth, and the deposit of exudation on the tongue or on the inside of the cheeks or on the surface of the gums, is an exceptional occurrence. I have met with it only on two occasions, and I believe that at all times it is far more frequently absent than present. In two instances, though the mouth was free from false membrane, the oesophagus was lined by it for two-thirds of its length; the subjacent mucous surface showing but very slight increase of vascularity ; and the exudation being but very loosely connected with it. The disposition of the false membrane to affect the nares seems to vary much in different epidemics. It has never come under my notice in this country, though a discharge from the nostrils similar to the scarlatinal coryza is far from being unusual. M. Bretonneau,1 however, gives a caution which must not be forgotten, to the effect that in some few instances the disease begins at the nares, and extends thence in a manner so insidious as to escape the notice of all who are not forewarned, and on the look-out for the occurrence. The relation between the amount of deposit on the fauces and the extension of false membrane to the air-passages is by no means con- stant. A very slight deposit on the soft palate and tonsils soon dis- appearing, may yet be succeeded by a very abundant exudation in the larynx and trachea, while, on the other hand, most extensive forma- tions of false membrane at the back of the throat may yet never involve the air-passages. The appearances produced by the extension of the diphtheritic deposit to the air-passages are precisely the same as those observed in cynanche trachealis, in which, without any pre- vious affection of the fauces, the inflammation has attacked the larynx and trachea. It has indeed been suggested by M. Isambert,2 in a recent very valuable paper, that the condition of the subjacent mucous membrane furnishes a ground of distinction between the affections; and that while in diphtheria the surface beneath the exudation is often ulcerated, no such erosion of the mucous membrane is met with in genuine croup. My own observation does not, however, altogether bear out this difference; for ulceration of the mucous membrane has come under my notice in primary croup, though less frequently than in cases of the diphtheritic kind; and its presence or absence seems to me mainly dependent on the rate of progress of the disease towards a fatal termination. When false membrane is deposited very exten- sively, and when death takes place in consequence most speedily, the mucous surfaces have appeared least altered; when the course of the 1 Archives Gen. de Medecine, Jan. and Sept. 1855. 2 Ibid., March and April, 1857. 318 DIPHTHERIA, OR ANGINA MALIGNA. disease is slower and the false membrane limited almost or altogether to the larynx, ulceration has seemed to me most frequent, and has in some of these cases amounted to an almost complete erosion of the lining of the larynx. In conformity with this I may add that it is in the croup that succeeds to measles, which is usually the least rapid in its course, that we commonly find the alteration of the mucous membrane the most considerable. I have come indeed to the conclusion, which I long hesitated to adopt, that what differences soever exist between croup and diphthe- ria, they must be sought elsewhere than in the pathological changes observable in the respiratory organs. The mere extent of false mem- brane in the air-passages certainly affords no ground for a distinction between the two affections, though I think it is more common to find the false membrane reaching to the tertiary bronchi in diphtheria than in primary croup. A distinction between the two diseases founded on the greater frequency of bronchitis and pneumonia in primary croup becomes to my mind with every year's added experi- ence less and less tenable ; and when once it has invaded the air-pass- ages, diphtheria seems to produce precisely the same changes, to the same extent, and with at least the same rapidity, as primary croup. But even though this be so, the sameness of the anatomical changes produced by two diseases does not suffice to establish their identity. The practitioner of midwifery knows that simple puerperal metritis and puerperal fever are diseases which differ widely in their symp- toms, their course, their danger, and the degree to which they are amenable to remedies, though in both, when they terminate fatally, precisely the same alterations in the womb are discovered. In the same way, if we extend our inquiry beyond the mere changes wrought in the respiratory organs, the differences between croup and diphtheria at once become apparent; and the affinities of the latter disease are seen to be to the class of blood diseases, rather than to that of purely local inflammations, to which croup belongs. Diphtheria presents itself in two forms: either as a primary or as a secondary disease. In the former case it is often sporadic, and is then generally mild in character; but occasionally it is epidemic, and then conforms to the general laws of epidemic disease, and manifests on its first attack a degree of severity which passes off as its prevalence de- clines. When it occurs as a secondary affection, it is as a sequela to one or other of those diseases (especially measles and scarlatina), which are distinguished by the alterations that they bring about in the cir- culating fluid. With scarlet fever too its relations seem to be peculiarly intimate, for while there is no evidence that the one furnishes any positive protection from the other, both not infrequently prevail toge- ther; and it does occasionally happen that even in the same house- hold some individuals will be attacked by diphtheria, and others by well-marked scarlet fever. Until within the past two or three years, diphtheria had not been observed in London or its vicinity, within the memory of the present generation, except either as a sequela of measles, or else in that sporadic form which derives all its importance from the extension of SYMPTOMS OF DIPHTHERIA. 319 false membrane to the larynx and trachea, and the consequent pro- duction of croupal symptoms. Becently, however, the disease has assumed a more formidable type, and its symptoms have resembled those which it often displays in France, though to the best of my knowledge that disposition to the formation of exudation on abraded surfaces, and at the outlet of all mucous canals, which is by no means unusual there, has occurred in this country very rarely or not at all. In its less severe forms the disease is ushered in by mild febrile symptoms accompanied with slight sore throat;—the most remarkable feature of the case being generally that the depression of the patient is out of proportion to the severity of the local ailment. Examina- tion of the throat shows a slight degree of swelling, and redness, not usually very vivid, and at first confined to one tonsil. In the course of a few hours white specks are observed on the tonsil, chiefly on its inner surface, and before long the other tonsil becomes similarly af- fected, Avhile, in some instances, though by no means constantly, a slight deposit appears on the velum and uvula. One or two applica- tions of caustics or astringents to the part are usually sufficient to clear away the deposit, or it may disappear spontaneously, and not be re- produced, and in two or three days the patient is pretty well again, though strength is in general regained less quickly than might have been expected from the comparative mildness of the attack. In cases so slight it is no easy matter to recognize the features of a highly dangerous disease; for there is no coryza, no swelling of the sub-maxillary glands, no increased secretion of saliva, no offensive odor of the breath, nor any disorder of the respiratory functions. Still, out of forerunners as trivial as these, croupal symptoms may be developed, and as the deposit on the fauces, when slight, is often not persistent, no trace of it may be perceptible when the signs of the affection of the larynx first attract attention. Whether croup comes on as a primary or as a secondary disease its signs are always much the same, and I need not therefore occupy your time in repeating the description of them; but it must not be forgotten that its advances are often most insidious when it succeeds to diphtheritic deposit on the fauces. The cough, in these circumstances, may present but little of the loud clangor of ordinary croup, and the respiration may have little of the characteristic stridor; but grave apprehensions may be all at once excited (and this especially in infants and young children) by the breathing suddenly becoming sibilant and interrupted by par- oxysms of urgent dyspnoea, the evidence of the already complete formation of false membrane, and the herald of death, which may not delay four-and-twenty hours from the first sign of serious danger. But, much though it imports us to be on the look-out for this train of symptoms, they are not the expression of the special severity of the disease, but rather of the accidental extension of its consequences to the air-passages. It is true that to this accident much of the dan- ger of diphtheria is due, and true too that in the worst forms of the disease it is more frequent than in its slighter manifestations; but while we must be always on the look-out for croupal symptoms, they do not constitute the disease; they are by no means the only source 320 SYMPTOMS OF DIPHTHERIA. of its dangers; nor is it in their occurrence that the most character- istic features of diphtheria are to be sought. Even in the more serious cases, the course of the disease, in its early stages, is slow and often insidious. For a day or two there is perhaps much febrile disturbance and a heat of skin which raises the suspicion that scarlatina is about to appear, of which the painful swelling of the sub-maxillary glands seems to be a still further indi- cation. No rash, however, makes its appearance; the heat of skin often subsides completely, so that the surface becomes even cooler than natural; while the absence of the red and prominent papillae which beset the tongue in scarlatina, belies the evidence of the sore throat. The fauces are red and swollen, sometimes very much so, but the redness is not vivid, and there is not in general that difficulty in opening the mouth which is experienced in scarlet fever, when the sore throat is at all severe. The false membrane appears almost simultaneously on both tonsils; and soon after on the soft palate and uvula, and the latter is generally much swollen, and contributes a good deaf to obstruct the channel of the fauces. Accompanying this state of the throat, there is often a discharge from the nares, resembling the coryza of scarlet fever, and as has already been mentioned false membrane is occasionally deposited there, whence it may travel to the posterior nares, and so to the throat and air-passages. When the deposit is considerable the appearance of the tongue is peculiar. It is usually red at the tip, but thickly coated with white fur, which on the dorsum and towards the root of the tongue is almost membrani- form. It is not usual for the inside of the mouth to be affected, but now and then the gums are red, soft, and spongy, and covered here and there, as well as the inside of the cheek, with patches of false membrane, beneath which the tissue appears red and shining. When the mouth is thus affected the secretion of saliva is considerably in- creased; but I have never seen that profuse dribbling of it which takes place in stomatitis, nor have I observed that complication of stomatitis with diphtheria of which M. Bretonneau speaks, and which led him to regard the two diseases as closely related to each other. It is after the false membrane has been formed somewhat abundantly for two or three days that it undergoes those changes which impart to the breath its peculiarly offensive odor, and give to the fauces that appearance of being the seat of a sloughing ulceration, whence arose the old names of angina maligna, angina gangraenosa. Even when the affection of the throat is most considerable, deglutition can still almost always be performed, not easily, indeed, but yet, in general, without that extreme difficulty which one often observes in the sore throat of scarlet fever, and of common quinsy, while I do not remem- ber ever seeing liquids return by the nose. The voice is hoarse and indistinct, independently of actual affection of the larynx; and a short, spasmodic, slightly ringing cough is not infrequently heard, due to the irritation of the larynx by the mischief in its vicinity. But, though these symptoms do not necessarily imply that the air-passages are actually involved in the disease, they should keep us most anxiously on the watch, since very few tokens indicate SYMPTOMS OF DIPHTHERIA. 321 this event; and they are often of a kind to escape the notice of the unobservant. The general symptoms which attend this local affection are invari- ably those of extreme depression, and of depression showing itself in that form which one sees in some of the worst cases of puerperal fever, or following some grave internal injury, as rupture of the uterus, rather than that which comes on in the course of ordinary diseases. The intellect is generally clear; the muscular powers are not incon- siderable; while, at the same time, the extremities are cold ; the pulse is either extremely frequent, or else very feeble and irregular in its beat. For two or three days together, this condition may continue, the pulse growing feebler, the signs of failing power more manifest, and this in spite of stimulants being administered lavishly, and taken readily, until at length either the signs of the last stage of croup sud- denly appear, showing that the local mischief has been extending silently and unperceived, or else an attack of syncope follows on some sudden and violent action of the bowels, or causeless convulsions come on, and in the subsequent coma the patient dies. This depression, too, is by no means constantly proportionate to the extent of the false membrane; nor is the danger of it passed even when the local mis- chief, as far at least as the eye can reach, has altogether disappeared; for I have known frequently recurring syncope take place even when no traces of false membrane remained on the fauces; and fatal con- vulsions come on when the local mischief was so slight that nothing but the previous death of a member of the family from well-marked diphtheria had called attention to the throat, and had led me to watch with painful solicitude a local ailment which owed all its importance to being an evidence of grave constitutional disease. The simultaneous or successive affection of different and distant parts is one of the great evidences on which we are wont to rely, in proof that a disease belongs to that great class of blood diseases whose importance and whose distinctive characters modern pathology has done so much to elucidate. The more closely we study diphtheria, the stronger will its claims appear to be referred to this category. The false membrane, whose most usual seat is on the fauces, whence it extends into the air-passages, is not limited to those situations, but occasionally invades other parts, and forms behind the ears, upon the vulva, or on abraded surfaces; while in the albuminuria, which some- times accompanies it, another point of resemblance has been alleged to exist1 between diphtheria and other maladies which result from purulent infection. In some epidemics of diphtheria, the formation of false membrane on different parts has been a frequent occurrence. Thus Bard,2 describing the disease as it prevailed nearly a century ago in America, speaks of the formation of ulcers behind the ears, covered in some places with sloughs resembling those on the tonsils; and Starr, in his description of the epidemic at Liskeard,3 notices " a rotten membranous body, or slough, generated on the skin of a pa- 1 Bouchut and Empis, Gaz. Hebdom., Nov. 12,1858. 2 Loc. cit., p. 392. 3 Loc. cit., p. 440. 21 322 DURATION OF DIPHTHERIA. tient, on the neck and arm, where blisters had been applied ;" and says that the part presented " a white surface which had the aspect of an oversoaked membrane." But besides the formation of false mem- brane on abraded surfaces, the mucous membrane of the vulva seems often to be the seat of a similar deposit; and in some rare cases the prepuce is affected in the same manner, or small superficial ulcers break out on different parts of the body, and become speedily covered with false membrane. The identity of the disease in these circum- stances with ordinary diphtheria is established beyond doubt by facts such as those observed by M. Trousseau1 in a village in the neighbor- hood of Orleans, where diphtheria prevailed, presenting in some per- sons its ordinary features; manifesting itself in others by deposits of false membrane on the vulva, on the mamma, on blistered surfaces, or on ulcers, and proving fatal in some cases without the throat being at all involved in the disease. It is not easy to fix the duration of a malady whose course is not infrequently so anomalous, and which, as we shall see hereafter, not seldom leaves sequelae in its train such as are themselves only fresh manifestations of the working of the original morbid poison. Per- haps, however, fourteen days might be fixed as the maximum dura- tion of those cases which terminate fatally by the extension of false membrane to the air-passages; and from the sixth to the tenth day might be taken as to the period within which the greater number of cases have a fatal termination from any cause. The most rapidly fatal cases are those in which death depends on affection of the larynx, and in them death sometimes takes place in from twenty-four to thirty- six hours from the apparent commencement of the attack; the local symptoms throwing the signs of constitutional disorder completely into.the shade; sometimes rendering it almost impossible to determine whether a case should be classed with diphtheria or with simple cynache trachealis. Eeference has already been made to the occasional death of patients in whom the local affection had throughout been so inconsiderable as to produce but few symptoms, or had even altogether disappeared before the fatal issue took place. But other cases are sometimes observed where long-continued illness remains, or where even death takes place not from the disease itself nor from any of its immediate effects, but from its remote sequelae, from a sort of accidental conse- quences. These remote results of diphtheria have been noticed both by Bretonneau and Trousseau ; and some of them have probably come under the observation of most persons who have had even a very limited experience of the disease. Thus, for instance, I saw a child between three and four years old, whose infant brother had died of diphtheria, and who herself had had very slight deposit of false mem- brane on her fauces, attacked by causeless convulsions when apparently convalescent, and when more than a week had elapsed since the throat presented any unnatural condition; and these convulsions terminated in fatal coma within less than twenty-four hours. A lady whose child 1 De la Diphtherite cutanee, in Arch, de Med., Juillet, 1830, p. 383. SEQUELS OF DIPHTHERIA. 323 ao-ed three years had died of diphtheria extending to the air-passages, and who herself had suffered from very slight sore throat with a trace of false membrane on the tonsils, was attacked by sudden faintness, almost amounting to syncope, with extreme feebleness of pulse and a sense of impending dissolution which for more than twenty-four hours were scarcely kept in check by the almost incessant administration of stimulants. Cases of a similar kind might no doubt be multiplied; but besides these earlier sequelae there are more remote consequences which, though perhaps not very frequent, are yet both important in themselves, and also as furnishing additional distinctions between this disease and any simply inflammatory affection. Both MM. Bretonneau and Trousseau have referred to this peculiar condition, but it is to M. Faure1 that we are indebted for the most complete account of it, derived partly from his own observation, partly from facts detailed by others. He describes it as" a state characterized by a gradual increasing loss of power, showing itself especially in all those functions connected with muscular movement. In some instances, several sets of organs are affected, in others, only one; while again in others the whole system is involved in the gene- ral debility. But, whatever are the variations in this respect, there is no definite relation between the severity of the primary symptoms of diphtheria and that of the sequelae. The primary symptoms, though very formidable, do yet by no means of necessity prove fatal, while on the other hand the comparative mildness of the attack^will not justify an absolutely favorable prognosis, since death sometimes follows where everything had seemed to warrant the most confident expectation of recovery." Several cases are related by M. Faure, in illustration of the differ- ent phases of this condition, and he then proceeds to sum up the general results as follows : " Some time after an attack of diphtheria from which the patient has so completely recovered that no trace of false membrane is left behind, the skin grows causelessly more and more colorless, so that at length it assumes an almost livid pallor. Severe pains begin at the same time to be felt in the joints, the pa- tient loses power over his limbs, and soon sinks into a state of indes- cribable weakness. At the same time, the disorders that appear in different functions show that the various organs which should minister to them are involved so far as they are dependent upon muscular power. In this respect, however, the phenomena are not constant, for sometimes it is one set of organs and sometimes another which suffers most from this weakness. "Very generally, in consequence of the want of muscular power, or, more strictly speaking, in consequence of its complete abolition, the patient becomes unable to sit upright, or does so with great diffi- culty, while the legs cannot bear the weight of the body; the arms become nerveless, and cease to obey the will, and all the movements grow uncertain, tottering, hesitating, and apparently purposeless. Very remarkable disorders show themselves also within the throat; 1 Union Medicale de Paris, Fevrier, 1857 ; and J. Kinderkr. fur Jan., 1858. 324 RELATION OF DIPHTHERIA for the velum is completely paralyzed, and hangs down like a flaccid, lifeless curtain, which interferes with speech and deglutition. All the muscles of the jaw, those too of the neck and chest, are partially paralyzed, in consequence of which mastication is rendered difficult, and the food can neither be easily moved about in the mouth nor readily swallowed. From the same cause, too, it is not infrequently regurgitated, and the laborious deglutition often induces spasms of the respiratory apparatus. Vision is impaired, one or other pupil often remains widely dilated even in the strongest light, and squinting is not unusual. The sensibility of the skin is much diminished; in the limbs it is sometimes completely lost, though morbid sensations, such, for instance, as formication, are sometimes experienced. GMema of various parts often occurs, while, less commonly, parts here and there lose their vitality, and become gangrenous. No general reaction occurs; fever is rare. The skin usually has a certain degree of moist- ure. The features grow duller and more and more expressionless, though a foolish smile sometimes crosses them, or now and then a ray of intelligence appears. Some patients have frequent fainting fits. As the condition goes on from bad to worse, the weakness becomes extreme, and death at length either follows some fainting fit, or takes place when exhaustion has reached its uttermost; life as it were quietly, almost imperceptibly, passing away. This fatal termination is of course by no means of invariable occur- rence, nor are the symptoms constantly so severe as those here de- picted, but I have preferred to give M. Faure's account of them in full detail, both by reason of their own importance and also because they furnish some materials towards the solution of the much debated question as to the exact relation subsisting between diphtheria and scar- latina. By some persons the two diseases, in spite of certain points of resemblance, are regarded as essentially different; and notwith- standing some difficulties, which compel a degree of hesitation in the expression of an opinion, my own view is to that effect. By others, diphtheria is looked on only as an anomalous form of scarlet fever, in which the throat affection is unaccompanied by the rash that ordi- narily characterizes it. It must be admitted that many circumstances favor this latter opinion ; for not only are diphtheria and scarlatina frequently preva- lent simultaneously in the same town or neighborhood, but even in the same family; one or two members of which may be attacked by the peculiar sore throat with membranous deposit on the fauces while a third may present all the symptoms of ordinary scarlet fever. Thus, for instance, on August 31, 1858, a child was admitted into the Children's Hospital in a moribund condition from diphtheria, and died on the same day. On the 28th September, his brother was also received, having been attacked by the same symptoms on the 26th, and he died on the 8th of October, without the least trace of rash having ever been apparent. On October 6th, his sister was admitted with simple scarlatina, which ran a very mild course, and from which she recovered without any trace of albumen having appeared in her urine. A similar occurrence happened more recently. TO SCARLATINA. 325 On December 6th, 1828, a girl aged 9| years was received under the care of Dr. Jenner, into the Children's Hospital, and died on the 8th. On December 8th, her sister sickened, her throat was red, and a very slight deposit of false membrane appeared on it, and on the 11th, the rash of scarlet fever appeared. The disease ran a mild course with but little sore throat and nothing remarkable in the character of the eruption. There was, however, a somewhat greater depression than the general symptoms would have led one to antici- pate. In both of these instances, the children were alleged, and apparently on good authority, to have had scarlatina before. On the occasion of their being in the hospital, there was nothing to distinguish their disease from ordinary scarlet fever, and assuming them to have had it before, their cases must be looked on as an instance of a second attack, and therefore as enhancing the evidence of the strong affinity between it and diphtheria. The multiplication of well authenticated facts of this kind, of the same contagion producing indifferently scar- latina in one subject, diphtheria in another, may suffice to determine the question. At present, however, such evidence is not afforded either conclusive enough in its character, or based on facts so numer- ous as to be decisive; and any one who bears in mind how long a time passed before scarlatina and measles were discriminated from each other, or how close are the resemblances between variola, vaccinia, and varicella, will be very careful not to infer identity too hastily because analogies are very close. But further, it may be alleged in support of the opinion that scarla- tina and diphtheria are but different manifestations of one disease; that, in some instances, when several members of tbe same family have been attacked by diphtheria, a rash very similar to that of scarlatina has been observed in some of the number. This rash may indeed have continued only for a few hours, and may have been very partial, but yet its characters have been thought to be sufficiently marked to leave no doubt as to its import. Moreover, it may be added that oedema of the surface, and an albuminous condition of the urine, though by no means general attendants on diphtheria, yet occur sufficiently often to draw still closer the analogies between the two diseases. It cannot be disputed that these facts carry great weight, and it seems no easy matter to negative the presumptions which they raise. Still, there are some considerations that may be adduced on the oppo- site side, and which must make us at least suspend our judgment. 1st. In all epidemics of scarlatina, the anomalous cases form but a small minority, and the absence of rash is the exception to a general rule. In epidemics of diphtheria, however, the existence of a rash, even though partial and evanescent, is but rarely noticed, and in some epidemics is not at all observed. 2d. In cases of malignant scarlet fever terminating fatally, and with- out the appearance of any rash, death usually occurs very early, and is preceded by very marked cerebral disturbance, by violent delirium, or by profound insensibility; while on the other hand, the fatal issue in diphtheria is generally far less speedy in its approach, and the dis- 326 DIPHTHERIA NOT IDENTICAL WITH SCARLATINA. ease, even in it worst forms, is usually remarkable for the perfect clearness of the intellect almost to the very last. 3d. The characters of the tongue in diphtheria differ entirely from those which it presents in scarlatina, and even the rash, on the occa- sional appearance of which so much stress has been laid, is in many respects dissimilar from the scarlatinoid eruption. It is for the most part an uniform blush of erythematous redness, unattended by the peculiar punctated appearance which marks the scarlatinoid rash. It appears suddenly in patches, is vivid from the very first, not deepen- ing gradually in intensity like the rash of scarlet fever, while its sud- den and speedy disappearance is not followed by any change in the other symptoms, nor by any increase in their severity. 4th. The oedema of the surface, which is occasionally present, comes on during the acute stage of diphtheria, not during its decline; it is inconsiderable in degree, is unaccompanied by serous effusion into the cavities of the chest or abdomen, and is by no means of necessity associated with albuminuria. The presence of albumen in the urine is not accompanied with diminution in the quantity of the secretion, nor with any other change in its character such as would be obvious on a cursory examination, for it still continues pale in color, and acid in its reaction. The albumen seems also often to disappear at a very early period of the disease; its disappearance takes place suddenly, and though its presence is usually observed in cases where the disease is severe, yet there does not seem to be any necessary connection be- tween the urine becoming non-albuminous and the disease assuming a milder type. 5th. The whole train of the sequelae of the two affections is entirely different, and while, on the other hand, the convalescence from diph- theria presents none of the formidable dropsical symptoms which so often succeed to scarlet fever, the peculiar loss of nervous power and the temporary muscular paralysis which sometimes follow diphtheria have no analogy to any of the sequelae of scarlet fever. 6th. Scarlet fever does not protect from diphtheria, nor, on the other hand, does diphtheria defend from scarlet fever. To both of these facts universal experience bears testimony, and it would scarcely be justifiable to assume that every instance, or even the majority of in- stances, of the succession of diphtheria to scarlet fever, or the opposite, are illustrations of a secondary attack of scarlet fever. An example which puts this in a very strong light was recently communicated to me. In a school in the neighborhood of London, diphtheria broke out; many of the lads were affected by it, and one or two died. Seve- ral of those who were convalescent from the disease were sent to the sea-coast for the more speedy recovery of their strength, and while there, some were attacked by scarlet fever, and this also, in one or two cases, proved fatal. The above facts appear to me of greater weight as disproving the identity of scarlet fever and diphtheria, than were those which were adduced on the opposite side of the question. Further information, and more accurate information, may suggest a different interpretation, and may lead to an opposite conclusion; but at the same time I am TREATMENT OF DIPHTHERIA. 327 bound to express my opinion as to the side towards which the balance of evidence at present inclines. Two main points are involved in the treatment of this disease; the one the control of the local mischief, the other the support of the con- stitutional powers. All the various measures which have been em- ployed are directed to one or other of these objects; and there is at the present day a degree of unanimity as to the means to be resorted to such as is of rare occurrence in questions of therapeutics. Deple- tion, antiphlogistics of all kinds, blisters, and all counter-irritants by which the surface may be abraded, though used at one time on the continent, under what are believed to have been mistaken views as to the nature of this affection, are now by common consent altogether discontinued; and the only points debated among practitioners regard the comparative merit of this or that local application, or of this or that tonic medicine. I do not believe that there is any remedy, either local or general, which exercises a specific influence over diphtheria, such, for instance, as the chlorate of potass seems to possess in controlling stomatitis, or as quinine displays in cutting short an attack of ague. There is, how- ever, usually a very marked connection between the early arrest of the deposit, however effected, and the speedy recovery of the patient, although it sometimes happens that the constitutional symptoms of the disease have a fatal issue after all trace of false membrane has dis- appeared from the fauces. In illustration of the connection between the arrest of the deposit and the cutting short of the disease, M. Trous- seau relates the story of the epidemic prevalence of diphtheria in a village where all the cases treated by the medical men, who confined themselves to the employment of constitutional remedies, proved fatal, while the only cures were wrought by an old woman who despised the doctors and their remedies, and applied indiscriminately to every- body's throat a rough and rather violent escharotic. Local remedies then take a very foremost place in the treatment of diphtheria; and I am accustomed, whenever I see even a streak of false membrane on either tonsil, to apply twice in the twenty-four hours, until the deposit completely disappears, a solution of a drachm of nitrate of silver to an ounce of distilled water, by means of a large, soft, camel-hair pencil. In those cases in which there is much swell- ing about the tonsils, or in which the tumefaction of the glands of the neck renders the opening of the mouth difficult, a probang armed with a small piece of sponge soaked in the solution must be applied as freely as possible to the back of the throat; but when it is practica- ble, I prefer the gentler mode of employing the remedy. In some instances this agent fails to arrest the advances of the deposit, and we must then exchange it for a more powerful application, such as the strong hydrochloric acid diluted with from four to ten parts of honey. The chief objection to the use of the solid nitrate of silver, when a powerful caustic is required, is that if the extent of false membrane be- at all considerable, the solid nitrate of silver can seldom be brought into contact with more than a very small part of the affected surface,. while the action of the fluid caustic will be far more diffused. One 328 TREATMENT OF DIPHTHERIA. or, at the most, two applications of the stronger caustics in the twenty- four hours suffice, and one of the reasons why their use is preferable to the more frequent application of weaker solutions is, that the act of applying them distresses the child, and is apt to be very violently resisted; so that it is desirable that these contests which tend of necessity to weaken as well as to annoy it should occur as seldom as possible. On this account, too, I have hardly ever employed the in- sufflation of powdered alum or of calomel, and have tried only once or twice painting the tonsils and soft palate, as some have advised, with the tincture of sesquichloride of iron. In those instances, however, it did not seem to exercise any specific influence over the deposit, but acted as any other moderately powerful astringent might be expected to do. While it is desirable not to irritate the child by over-frequent cauterization of the fauces, something may yet be done to keep the mouth free from the secretions which are apt to accumulate in it, and to remove the ropy mucus which impedes deglutition by syringing the mouth every three or four hours with a lotion of the chloride of soda, in the proportion of half an ounce of the solution to six ounces of water. The discharge from the nostrils which both distresses by its irritating qualities, impedes easy respiration, and is also sometimes a preliminary to the subsequent deposit of false-membrane, may also be controlled by the injection of a solution of nitrate of silver of the strength of three to five grains to an ounce of distilled water every four or six hours. The swelling of the sub-maxillary glands may also be diminished, and deglutition somewhat facilitated, as in cases of scarlatina, by the sedulous application of a linseed poultice, or of the spongiopiline fomentations to the neck. While the above local measures are to be employed, the constitu- tional treatment must be pursued no less diligently. The constitu- tional treatment indeed consists almost exclusively in the administration of food and stimulants, and the employment of tonic remedies. The feverish condition which is often observed at the outset of diphtheria must not mislead us into withholding nourishment, or into resorting to an antiphlogistic plan of treatment. If indeed the tongue is coated, and the bowels are constipated, and there is much heat of skin at the onset of the attack, an ipecacuanha emetic may be given, followed by a mild aperient; but even though wine may in such circumstances be withheld for a short time, beef-tea must be given from the first, and stimulants must not be long delayed. The softness, and feebleness of the pulse indeed almost always give, in spite of the heat of surface, plain intimation of the course which we should pursue, and very often a shorter time than twenty-four hours suffices to dissipate entirely tbe febrile symptoms with which the disease sets in, and to show it in its real characters. There is not, I believe, any one tonic which has in these cases a marked superiority over others, but I am accustomed generally to give quinine with the tincture of bark and hydrochloric acid at short intervals. The chlorate of potash which exercises so marked an in- fluence over stomatitis, and displays it even to some extent in cases of gangrene of the mouth, has not seemed to have any power to con- DIPHTHERIA COMPLICATING MEASLES. 329 trol the diphtheritic deposit. Neither, indeed, have I found the ses- quichloride of iron vindicate in my hands its claims to that specific virtue for which some practitioners have given it credit. On one or two occasions, indeed, patients whose condition had deteriorated under the use of iron improved rapidly when bark and mineral acids were substituted for it. I do not consider, however, that my experience has been sufficient to warrant my expressing a decided opinion with reference to it; and indeed, if we judge the question on theoretical grounds, it would not be possible to find a remedy more appropriate than iron in cases of diphtheria. In the great majority of instances it must be confessed that the employment of medicine has seemed of importance altogether sub- ordinate to the administration of food and stimulants; and children of four years old have taken six ounces of port wine and one or two ounces of brandy for several days together, not only with manifest advantage, but apparently as the only means by which life could be maintained. When deglutition has been very difficult, or when, with- out any absolute difficulty in swallowing, the patient has refused nour- ishment (a symptom I may add of very ill omen, and which usually preluded, the death of the patient), I have had recourse to beef-tea enemata with temporary advantage; though in no instance did patients ultimately recover in whom the indisposition to take food was other than a very transitory symptom. Now and then a single dose of ipecacuanha in the earlier stages of the disease has relieved the difficulty of deglutition when that was troublesome, but I have not observed any internal remedy check the advance of croupal symptoms coming on in the course of diphtheria, for which tonic and stimulant measures had been necessary; and the energetic employment of local cauterization, and possibly the perform- ance of tracheotomy, furnish in such circumstances the only, and that a most desperate, hope of saving the patient's life. There are indeed cases of a different class, to which reference was made in the last lec- ture, where the affection of the larynx develops itself out of ordinary catarrhal symptoms, and where the disease differs from true cynanche trachealis only in the circumstance of a limited deposit of false mem- brane appearing on the soft palate. In such cases, which form a sort of connecting link between true croup and genuine diphtheria, deple- tion, antimonials, and the whole class of antiphlogistics may be re- sorted to; for life is in them endangered by the primary disease in the larynx, not by the mere extension to it of mischief beginning in the throat. There is another form of disease, allied to diphtheria by many of its characters, allied to cynanche laryngea by others, which presents itself to us as a most dangerous complication of some other affection, almost always of measles, and with which I was perfectly familiar at a time when my acquaintance with genuine idiopathic diphtheria was very slight and imperfect. This variety of croup seldom begins until the eruption of measles is on the decline, or till the process of desquamation has commenced. Its occurrence is most frequent from the third to the sixth day from 330 DIPHTHERIA COMPLICATING MEASLES. the appearance of the eruption, but it oftener occurs at a later than at an earlier period. It is sometimes attended with well-marked symptoms from the very first, but it often happens that the character of the disease is masked, and its course insidious, and that the degree of suffering during life affords no correct index to the amount of mis- chief which may be revealed by a dissection after death. Of itself it is highly dangerous, and its hazard is increased by the frequent co- existence with it of inflammation of the lungs, which serves moreover to throw the symptoms of croup into the shade. When the laryngeal affection comes on three or four days after the appearance of measles, its presence is usually betokened by much more obvious symptoms than when it occurs after the lapse of a longer period from the febrile attack. Sometimes, however, it develops itself unnoticed, simultane- ously with the measles, and causes a fatal issue when the medical attendant is least prepared to expect it. The child in such cases is evidently more seriously ill than can be accounted for by the mere existence of measles; but he makes no definite complaint, neither are there any obvious indications of the special suffering of any particular organ. There are considerable drowsiness, disinclination to swallow, and reluctance to speak; but the cough may be very slight, and the respiration free from distinct croupy stridor, while the child speaks in so low a tone that it is almost impossible to appreciate any alteration of the voice. In such circumstances, the most careful observation is needed to avoid error. The loss of voice should of itself direct atten- tion to the state of the larynx; the cry should be listened to atten- tively; pressure should be made on the larynx, to ascertain whether much tenderness exists, and examination of the fauces should never be neglected. But little less obscure, and of much more frequent occurrence, are those instances in which the laryngeal affection attends the process of desquamation. Recovery up to a certain point had probably gone on well, when, sometimes with, sometimes without, an increase of the cough and morbillous catarrh, the febrile symptoms become exacer- bated, and the child droops, again, apparently without any adequate cause. Sometimes a loud, sonorous cough, succeeded or accompanied by alteration of the respiratory sounds, betrays the nature of the disease; but at other times there are no symptoms besides unusual drowsiness, reluctance to speak, or alteration in the tone of the voice, with disinclination to swallow, or difficulty in the act of deglutition. In many instances, deglutition is scarcely at all impeded; and I re- member only one case in which the difficulty of swallowing was so great that fluids returned by the nose. But, even though these symp- toms be but slight, it will usually be observed, on examining the mouth, that the gums have a spongy appearance, or are actually ulcerated; that the tongue is preternaturally red and raw, and that small aphthous ulcers have formed upon its edges and on the lining membrane of the mouth. The soft palate will usually be seen to be red and swollen; and specks of false membrane will be observed on the velum or tonsils. In such a case, if it terminate fatally, the dura- tion of life is very variable; though the disease, for the most part, TREATMENT OF DIPHTHERIA. 331 runs a somewhat chronic course. The child's strength declines daily; and emaciation makes rapid progress; yet no acute symptoms appear. There is great restlessness; and no posture seems easy to the child; or else it sits constantly upright in bed, distress and dyspnoea follow- ing any attempt to place it in the recumbent position. The alteration of the voice is succeeded by complete aphonia; the frequent hacking cough, which had previously caused much annoyance, ceases alto- gether ; and, although evidently thirsty, the child often refuses drink, or swallows with difficulty. Diarrhoea or pneumonia usually super- venes, and hastens death; though, in some instances, exacerbation of the croupal symptoms, coupled with the increasing weakness of the child, are the only causes of the fatal termination. On examining after death the bodies of children who have died of this affection, not only is the mucous membrane of the mouth found inflamed and ulcerated, but the soft palate, fauces, epiglottis, and the upper part of the pharynx, are seen to be more or less intensely con- gested, and coated more or less extensively with false membrane. The epiglottis is often ulcerated on both its surfaces, and partially coated with false membrane; and the mucous membrane of the larynx is generally eroded by numerous small ulcerations, as well as covered with a similar deposit. I have in no instance observed false mem- brane extending below the larynx; and, although the trachea is usually congested, sometimes intensely so, yet this is .by no means of invariable occurrence. Bronchitis and pneumonia, especially the latter, are frequent complications of this affection. In whatever circumstances this form of croup may occur, it is generally attended with so great a depression of the vital powers as to contraindicate the employment of active antiphlogistic treatment. I have occasionally applied leeches to the throat if there was much tenderness about the larynx, or if the croupy symptoms had early acquired considerable intensity; but the two means on which I place my chief reliance are the careful and repeated cauterization of the fauces, and the employment of emetics. If the deposit of false mem- brane be extensive, the strong Irydrochloric acid, diluted with a four- fold quantity of honey, is the best application to the fauces; but in most instances, a solution qf a scruple of nitrate of silver in an ounce of distilled water, answers every purpose. A probang has been con- trived by Dr. Horace Green, of New York,1 the sponge attached to which is sufficiently small to enter the glottis of the child, and by means of it he has applied a solution of 9ij of argent, nitrat. dis- solved in an ounce of water, not merely to the back of the throat and the neighborhood of the glottis, as many French physicians have done before him, but he also carries the sponge into the interior of the larynx itself. This proceeding, too, repeated every two to every six hours, according to the urgency of the case, has been followed in 1 Observations on the Pathology of Croup, &c, 12mo. New York, 1849. The adop- tion of somewhat similar proceedings by MM. Bretonneau, Trousseau, and Gerouard, does not seem to me sufficient to justify the very grave charges of plagiarism brought against Dr. Green by one of his countrymen, in the American Journal of Medical Science, Jan. 1849. 332 TREATMENT OF DIPHTHERIA. some apparently desperate cases by the patient's recovery. I have employed it on a few occasions, but the distress which it occasions has not seemed to me counterbalanced by any decided influence on the croupal symptoms; while I cannot divest myself of the fear that the somewhat rough manipulation involved in attempting to pass the sponge within the rima of the glottis may not be even positively mis- chievous. At the same time that I adopt these local measures I employ the tartar emetic in the same manner as in cases of simple cynanche trachealis, except that it is not always desirable to give it in such frequently repeated doses as in the other more active malady. If relief be not speedily obtained, a mustard poultice should be applied to the throat; but the employment of a blister is hardly ever desirable, since, in such circumstances, a vesicated surface rarely heals favorably. The slower course which these cases often run affords more time for the action of calomel than we generally have in pure cynanche tra- chealis ; and unless the presence of diarrhoea contraindicate its em- ployment, the remedy is one not to be omitted. It should be given in doses of one grain every hour to a child of three or four years old, combined with a quarter of a grain of ipecacuanha; but if the symp- toms be at all urgent, the emetic should be repeated every four or six hours, to detach any false membranes that may have been de- posited on the fauces; and cauterization should be practised again, to prevent their renewal. As improvement advances, these remedies may be repeated at longer intervals, while expectoration may be pro- moted by the employment of the decoction of senega, with squills and ammonia, as has been already recommended. Care must be taken throughout not to depress the child too much by over-active treat- ment; nourishment must be given from an early period, and even before it is safe to discontinue the cauterization of the throat and the occasional employment of emetics, the extract of bark in combination with its tincture, or some other form of direct tonic, may be needed. When consequent on measles, the cauterization of the throat is especially necessary; and the ulcerated condition of the mouth is often much benefited by the frequent application to it of a solution of a scruple of borax in an ounce of water. The tendency to diar- rhoea sometimes prevents .the employment of calomel; while, owing to the weakened state of the system, we cannot always venture on the use of antimony. In such a case, we may still have recourse to mer- curial inunction; and while the local cauterization is most sedulously attended to, emetics of ipecacuanha may be given two or three times a day, or the sulphate of copper may be substituted for it if it cause purging or fail to vomit. We find, however, in many instances a most urgent necessity for supporting the child's strength, even from the very first. The occurrence of pneumonia is the accident most to be dreaded in the progress of the case, and may require a modification of the treatment, though, in its management, the asthenic character of the affection must always be borne in mind. Recovery is generally very slow, even in cases that terminate favorably; and it often hap- LARYNGITIS STRIDULA. 333 pens that after all alarming symptoms have been removed, the voice is long in regaining its proper character. The peculiar sound that characterizes the cough of croup, the stridor of the respiration, and the urgent dyspnoea which attend the progress of the disease, result, as I scarcely need remind you, almost entirely from the spasmodic action of the muscles of the larynx, and not from the mechanical obstacle which the presence of false membrane offers to the free admission or exit of air. We have seen that these symp- toms are, on the whole, less marked in cases where croup appears as a secondary affection, and the larynx becomes involved by the ex- tension to it of disease beginning in the throat, than in those where the air-passages themselves are primarily affected. Still, they vary much, both in the period of their occurrence and the degree of their severity, even in those cases that most resemble each other; and they bear no certain relation to the intensity of the inflammation any more than to the amount of the deposit of false membrane. The diversi- ties in this respect depend on constitutional peculiarity rather than on any essential difference in the nature of the disease. This view, indeed, is not taken by all writers, but some observers of deservedly high repute—such, for instance, as M. Guersant1—have conceived that there are differences sufficient to warrant our placing in a separate category those cases of croup which are marked by the predominance of spasmodic symptoms. They have proposed to desig- nate this form of tbe disease by the name of laryngitis stridula, to distinguish it from ordinary croup, the laryngitis pseudomembranacea. It was doubtless the observation of some cases of this kind that led Dr. Millar,2 more than ninety years ago, to describe, under the name of the acute asthma, a disease resembling croup in many respects, but presenting a mixture of spasmodic and inflammatory symptoms: the former predominating at the commencement of the disease, the latter towards its close. Dr. Millar appears, indeed, in some measure, to have confounded two very different affections—the true spasmodic croup, or laryngismus stridulus, with the inflammatory croup, or cynanche trachealis, under the idea that they constituted the two stages of one disease. But, nevertheless, cases are sometimes observed that bear a very close resemblance to Millar's description; though no advantage seems to me likely to arise from constituting a new species of croup out of a modification in its symptoms produced by the idio- syncrasy of the patient. In some children there is a greater tendency to spasmodic affections than in others; in such the laryngeal nerves will take the alarm at the very outset of the disease, and the paroxysms of dyspnoea will consequently commence at an early stage, and will soon attain great intensityvbut may become masked by the permanent distress of breath- ing to which the disease in its progress gives rise. In other instances, the symptoms of inflammatory disease, and those of spasmodic dis- 1 In the article Croup, in vol. ix. of the 2d edition of the Dictionnaire de Medecine, &c. Paris, 1835. 2 Observations on the Asthma and on the Hooping-cough, 8vo. London, 1769. 334 LARYNGITIS STRIDULA —CASE. turbance, may be so commingled, or may so alternate with each other, as to render it hard to tell from which the child suffers most. This was the case with a little boy ten months old, who some years since came under my care, suffering from what seemed at first to be ordi- naryinflammatory croup. The symptoms though not very urgent, were plainly marked, and the active employment of antimony soon dissipated them. During the whole course of the disease, however, the child who seemed highly nervous and excitable, suffered from fits of dyspnoea far more severe than could have been anticipated from the general mildness of the attack, or than would have been supposed to exist by any one who had seen the child only in the intervals of the paroxysm. The cough and respiration had for forty-eight hours entirely lost all croupy character, and nothing but catarrh seemed left behind, when the child was suddenly seized with extreme diffi- culty of breathing, attended with slight croupy noise, and lay stiff in his nurse's arms with his thumbs drawn into the palms of his hands, and his great toe separated from the others. Four-and-twenty hours had elapsed from the supervention of these new symptoms before I was able to visit the child. He was then extremely restless; his face was flushed, his thumbs were drawn into the palms of his hands, and his feet were forcibly extended; his breathing was labored, and attended with a hoarse croupy sound, which became still more distinct whenever the child coughed. The bowels had not acted for a couple of days, but an hour after my visit some purgative medicine, of which large doses had been given during the previous six or eight hours, began to act, and produced three very copious evacuations, with per- fect relief to all his symptoms. The carpopedal contractions disap- peared, the respiration became easy, and the face ceased to be flushed or anxious. The child slept well through the night, was cheerful on the following day, and slight hoarseness attending his occasional cough was the only remaining symptom. In a day or two that also disap- peared, and the child perfectly recovered. The influence of that spasmodic element which enters so largely into the production of the symptoms of cynanche trachealis is seen in many cases in the long persistence of a croupy sound with the cough, and in its subsequent recurrence when a patient who has once had croup catches cold. In these cases the nerves have doubtless not thoroughly recovered from the effects of the previous inflammation. Before closing this lecture, one or two additional illustrations may be adduced of spasmodic affection of the larynx in connection with dis- ease seated elsewhere;1 though the remarks made at an early period of the course, on spasm of the glottis as a frequent attendant on the convulsive affections of infancy, must have made you thoroughly familiar with its occurrence.2 1 See Lecture xiii., p. 157. 2 There is a form of spasmodic affection of the larynx, which, under the name of Thymic Asthma, has attracted considerable attention among continental writers, though my own experience concerning it is confined to a single case which I observed many years ago. The spasm of the glottis which is the most prominent symptom in SPASMODIC AFFECTIONS OF THE LARYNX. 335 MM. Rilliet and Barthez have described a spasmodic cough that returns in paroxysms, is loud, attended with an imperfect hoop, and this affection is supposed to be due to the pressure of the hypertrophied thymus on the larynx, and the consequent irritation of its nerves. The essay of Haugsted—Thymi in homine, etc.: descriptio anatomica, pathologica et physiologica, 8vo. Hafnise, 1832—may be consulted with advantage by any one desirous of becoming thoroughly acquainted with the subject. I will merely relate the case to which I have referred, and do so rather on account of its rarity than of any important practical inferences which I am prepared to deduce from it. The subject of the observation was a little boy, who was brought to me at the age of six months, suffering from symptoms which his mother said had existed, though in a less aggravated degree, almost from the time of his birth ; but which had not much alarmed her until they were followed by an attack of general convulsions a day or two before I saw the child. These symptoms consisted in the occasional occurrence of great difficulty in breathing, attended with considerable livor of the surface, con- tinuing for a very short time, and returning every two or three weeks without any assignable cause. From the sixth month the child seemed very liable to catch cold, and had frequent cough and wheezing ; but a little rhonchus was all that was ever perceptible in the lungs ; and febrile symptoms were at no time apparent. The attacks of difficult breathing often occurred at night, the child waking from sleep with them, or they were sometimes produced by deglutition, which process always seemed to be attended with slight difficulty whenever the child attempted, as it grew older, to swallow semi-solid substances. It was remarkable that no distinct crowing sound ever attended the inspiration ; but that the child having turned extremely livid dur- ing the paroxysm of dyspnoea, gradually recovered its breath, and the livor and anx- iety of the countenance disappeared by degrees. Profuse perspiration about the head generally followed these seizures ; and sometimes the child would pass into a state of general convulsions, in which, however, it did not struggle much, but continued to breathe hurriedly for some time after they had passed off. From about the ninth month, slight cough was almost constantly present, though still unattended by any febrile disturbance : the head was sometimes very hot, and the difficulty of degluti- tion, the dyspnoea, and the convulsions, increased both in severity and in the frequency of their recurrence. The child now cut the two lower incisors, but without any change taking place in his general condition. Two or three weeks before his death, which happened when just a twelvemonth old, he had an attack of coryza, with abundant puriform discharge, which, by its hardening, blocked up the nostrils, and caused a good deal of distress in breathing, though unattended by any really grave symptom. He was recovering from this, when, one morning early, a paroxysm of dyspnoea came on, which was followed by a slight fit that left him pale and exhausted. About two hours afterwards, his breathing not having become as quiet and natural as before the first paroxysm, another attack came on, in which he died. On examining the body after death, the lividity of all the depending parts was very remarkable. The pericranium stripped off very easily from the bones of the skull, which were exceedingly vascular. There was considerable vascularity of the dura mater, the sinuses of which, and the cerebral veins generally, were gorged with fluid blood. There was no injection of the pia mater ; sections of the brain presented a rather greater number of bloody points than natural, but its substance was firm, and the lateral ventricles contained but little fluid. The first object seen on opening the chest was the thymus gland, which occupied the whole of the anterior mediastinum, and nearly concealed the heart. Its structure was apparently natural; its length was 3} inches, and it weighed 328£ grains. The heart was extremely large, as large as the heart of a child three years old. Its auricles and the veins, both the cavae and the pulmonary veins, were full of fluid blood. The organ was not well contracted; its structure was perfectly healthy, and the foetal openings were closed. There was a good deal of thick mucus in the trachea and bronchi, but they were perfectly healthy ; and the rest of the body presented no remarkable appearance, ex- cept that a considerable extent of both lungs was in a state of carnification. Now, notwithstanding some points of difference between this case and those in which spasm of the glottis has been induced by a different cause, yet we recognize in it the grand symptoms of that affection, and those the same as make up the spasmodic ele- ment in cases of inflammatory croup. The enlargement of the thymus appears to 336 HOOPING-COUGH. may be easily taken for hooping-cough by the inattentive observer. It is, however, a symptom of bronchial phthisis, due to the extension to the larynx of irritation seated in a distant part of the respiratory organs. Intestinal irritation is a frequent cause of nervous cough in child- hood. It is sometimes a loud, solitary, ringing cough—the tussis ovilla, tussis ferina of medical writers: at other times it is a short dry cough, attended with no particular inconvenience, but teazing from its frequency. Both of these forms appear to result in many instances from the presence of worms, and speedily cease under the judicious employment of purgative medicines. Lastly, I may once more remind you of the cough which is occa- sionally heard in the early stage of inflammatory affections of the brain. It is a very short, hoarse cough, which sometimes continues for a few minutes almost incessantly, then ceases for a time, and then, after a pause, returns again. The disturbance of the brain is sym- pathized with by the larynx, and the depletion which relieves the for- mer organ removes the irritation of the latter. LECTURE XXTI. Hooping-Cough.—Course of the disease in its simplest form—subject to great varia- tions in its mode of onset and degree of severity.—Signification of the hoop.— Course of the disease when declining.—Its danger depends on its complications.— Complication with bronchitis—at its outset, or when it has continued for some time—Complication with disorder of the nervous system—sometimes exists from the first, and causes death even before characters of disease are fully developed —but may come on at any period—various forms assumed by disorder of nervous system—great danger when paroxysms of cough terminate in convulsions—cau- tion as to nervous character of dyspnoea in many cases, and as to danger of over- treating it.—True hydrocephalus rare as a complication. We pass to-day to the study of one of the most common disorders of childhood. Few persons attain to adult age without having ex- perienced an attack of hooping-cough, and still fewer of those who escape it when children suffer from it in after-life. Hooping-cough, then, claims our notice as being essentially a disease of early life; but as it is one which almost every old woman professes have induced permanent irritation about the windpipe, which betrayed itself by the frequent cough and the constant wheezing. To the same cause, too, must be referred the difficult deglutition, while the convulsions were probably much favored by the enlarged gland pressing upon the superior cava and right auricle, and thus impeding the return of blood from the head : nor must we forget, among the probable causes of the child's sudden death, the remarkable degree of cardiac hypertrophy. The fatal event, however, might possibly not have occurred but for the attack of coryza, and the consequent impairment of the respiratory function, which naturally tended to in- crease the congestion of the brain. SYMPTOMS OF HOOPING-COUGH. 337 to cure, we might fairly expect not to be detained long with its study. We find, however, that in this metropolis it ranks fourth among the causes of death under five years of age; inflammation of the lungs, convulsions, and hydrocephalus, being the only more fatal ailments. A cursory inquiry will not suffice to make us thoroughly acquainted with all points of importance in the history of a disease that has so many victims. The affection in its simplest form consists of a cough of spasmodic character, that usually succeeds to catarrhal symptoms, and having recurred at intervals for a few weeks, ceases without having occasioned any serious disturbance of the general health, or having required any active medical treatment. In its graver forms it is one of the most fearful diseases that we ever have to encounter, often keeping the life of the patient for days or weeks st,ogether in almost constant jeopardy, liable to be exaggerated by the most trivial cause, or ren- dered fatal by the slightest error in treatment; while the highest effort of our art is limited to mitigating the severity and warding off the urgent danger of symptoms which we are unable wholly to subdue, and which we must trust to time and nature thoroughly to cure. Such great differences in the course of the disease in different cases have given rise to many ingenious theories as to its nature and seat, framed with the view of explaining that which cannot but strike all observers as so enigmatical in its character. None of these specula- tions, however, have led to any useful practical result, and we shall be better employed than in their study, if we confine ourselves to the simple observation of the phenomena of the disease. In doing this, we will begin with those cases in which it is most simple and perilous, and will then examine in succession the different modes in which its course becomes complicated and dangerous. An attack of hooping-cough usually begins with catarrh, and pre- sents at first little or nothing to distinguish it from a common cold7 except that sometimes the cough is attended almost from the outset with a peculiar ringing sound. By degrees the catarrhal symptoms abate, and the slight disturbance of the child's health altogether ceases, but nevertheless the cough continues; it grows louder and lasts lon- ger than before, and assumes something of a suffocative character, in all of which respects a tendency to exacerbation towards night be- comes early apparent. As the cough grows severer, its peculiarities become more and more manifest; during each paroxysm the child turns red in the face, and its whole frame is shaken with the violence of the cough. Each fit of coughing is now made up of a number of short, hurried expirations, so forcible, and succeeding each other with such rapidity, that the lungs are emptied, to a great degree, of air, and the child is brought by their continuance into a condition of im- pending suffocation. At length the child draws breath with a long, loud, sonorous inspiration—the hoop from which the disease derives its name—and the attack sometimes terminates. More often, how- ever, the hoop is followed by but a momentary pause, and the hurried expiratory efforts begin again, and are again arrested by the loud in- spiration—perhaps only to recommence; until, after the abundant 22 338 COURSE OF THE DISEASE IN ITS SIMPLEST FORM. expectoration of glairy mucus, or retching, or actual vomiting, free inspiration takes place, and quiet breathing by degrees returns. If you listen to the chest during a fit of hooping-cough, you will hear no sound whatever in the lungs; but when the hoop occurs, you will once more perceive air entering, though not penetrating into the mi- nuter bronchi. It is not till the fit is over, and respiration once more goes on quietly, that the air reaches the pulmonary cells again ; but then you will hear vesicular murmur as clear as if nothing ailed the child, or at most interrupted only by a little rhonchus, or by slight mucous rale. If the cough be severe, quiet breathing does not return, nor the vesicular murmur become audible, till some time after the paroxysm is over; and occasionally, short and laborious respiration ushers in each fit of coughing. The child them seems to have a pre- sentiment of the coming seizure; its face grows anxious, it looks up at its mother, and clings more closely to her; or, if old enough to run about, you may observe it, even before its breathing has be- come manifestly affected, throw down its playthings, and hasten to seize hold of a chair, or of some article of furniture, for support during the approaching fit of coughing. If the case be uncomplicated, even though the attack be severe, the child's health continues good, and little or nothing ails it during the intervals of the cough. Its appetite is not impaired, but after throwing up the contents of the stomach in a fit of coughing, it asks for food almost immediately. It sleeps soundly, except when roused by the cough; the bowels act regularly, or are perhaps a little consti- pated, and slight complaint of headache or languor, with loss of the usual cheerfulness, are often all the permanent ill effects to be dis- cerned between the seizures. After the hoop has been heard, the disease goes on for about a week to increase in severity, the cough becoming more frequent, its paroxysms severer and more suffocating, and attended with more frequent hoop. After remaining stationary for ten days or a fort- night, it begins to decline; and one of the first indications of this is usually afforded by a diminution in the severity of the nocturnal exacerbations. We next find, either that the fits of coughing are less frequent, or, though they should occur as often as before, yet they are less severe, and sometimes cease without the occurrence of a hoop. When on the decline, however, exposure to the cold, neglect of the state of the bowels, or mental excitement, will suffice in many cases to bring back the hoop, and to increase the previously dimin- ished severity of the attack. For the most part, the cough loses its spasmodic character for many days before it ceases altogether; and you may even find a child, otherwise in good health, who, some six weeks after an attack of hooping-cough, still has occasional returns of cough, which a slight cause would once more convert into an ail- ment with all the characters of fully developed pertussis. - Such is the ordinary course of the disease in those cases in which it is unattended by any complication, and does not give rise to any formidable symptom, but issues in the complete recovery of the patient. But even in favorable cases its course is often variously DURATION OF CATARRHAL STAGE OF HOOPING-COUGH. 339 modified, while these modifications derive additional importance from frequently betokening or accompanying some of those serious com- plications to which the danger of the disease is almost exclusively due. The average duration of the catarrhal stage of hooping-cough as deduced from a comparison of fifty-five cases, in which the date of the occurrence of the first distinct hoop was ascertained, was 12.7 days. In nineteen of these cases the first hoop was heard within seven days from the commencement of the catarrhal symptoms, and in nineteen more cases during the succeeding seven days; but the extreme limits of the duration of the premonitory stage are very wide apart, since on one occasion it lasted only two days, and on another thirty-five days. But there are many other respects in which the mode of onset of hooping-cough varies, as is clearly shown by the following facts:— In fifty-five cases the average duration of the catarrhal stage was 12.7 days; the extremes being 2 and 35 days. In eighteen cases the catarrhal stage lasted on the average only 8.3 days, when the cough assumed a distinctly paroxysmal character; but no hoop occurred till the fifteenth day. In four cases, after the catarrhal stage had lasted on the average 11.5 days, the cough became paroxysmal, but no hoop occurred during the whole course of the affection. In one case the cough had a distinctly paroxysmal character from the first, but no hoop occurred during the whole course of the affection. In six cases the cough was paroxysmal from the outset, and continued so on the average 9.3 days, at the end of which time distinct hoop accompanied it. In three cases a distinct hoop attended the cough from the very commencement. Some of these may be merely accidental differences, but I believe that most of them are by no means unimportant, and that they depend on causes with which a little observation will make you acquainted. My excuse, indeed, for bringing before you such dry detail with reference to hooping-cough, is, that there is scarcely any other disease of early life concerning which we are so much in want of definite facts. Its general features are so obvious, that persons have not observed with equal care those less striking characters which yet are of much moment, as affording sure grounds for prognosis, and trustworthy indications for the guidance of treatment. Unusual protraction of the catarrhal stage of hooping-cough is, I believe, usually met with either at the commencement of an epidemic of the disease, or towards its close. Epidemic hooping-cough very frequently succeeds to epidemic catarrh; the former disease becom- ing gradually developed out of the latter, and the persistence of cough in several cases long after the decline of all other indications of catarrh is often one of the fist signs of the commencement of an epidemic of hooping-cough. The characters of hooping-cough, like those of other epidemic diseases, often become less marked towards the decline of its prevalence, and we then meet with cases in which catarrhal symp- toms continne long, while the paroxysms of cough are slight, and the hoop occurs very seldom and not severely. It may be laid down as 340 CAUSE OF THE HOOP a general rule, that those cases in which the catarrhal stage is of long continuance seldom become severe during their subsequent progress, and the same holds good with reference to the majority of those cases in which the hoop does not come on until after the cough has for some time assumed a paroxysmal character. There are, however, some instances, which we shall hereafter have to notice, where the long duration of the paroxysmal and suffocative character of the cough, unattended by any hoop, is a sign of the peculiar intensity of the disease, rather than of its mildness: on the other hand, the preter- natural shortness of the catarrhal stage, or its total absence, is not of itself any proof that the disease will be more than usually severe. It is usually observed in very young children, who, as I have already told you, are but little liable to catarrhal affections, and who are not so often attacked by hooping-cough as those who are older. Some- times, however, when other children in the same family are suffering from it, they contract the disease apparently by contagion, and in that case it frequently happens that no purely catarrhal symptoms precede it, but that the cough from the first presents a paroxysmal character, and soon becomes attended with a distinct hoop. Instead of coming on with catarrh of moderate intensity, hooping- cough sometimes sets in with great fever, dyspnoea, and many symp- toms of severe bronchitis; though the results of auscultation do not indicate such serious disease as, judging from the amount of constitu- tional disturbance, we should expect to discover. In such cases, it is only on the subsidence of the acute symptoms, which usually give way speedily under treatment, that the real nature of the disease be- comes apparent. We then observe, however, that while the child in all other respects improves, the cough continues unabated, that it soon grows more severe, returning in paroxysms, and being attended before long by the characteristic hoop. Besides these cases, there are others, though much less common, in which, though the catarrhal symptoms are not unusually severe, the child yet has paroxysms of dyspnoea, which generally come on at night, and may excite much apprehension on the part of the parents. The attacks do not appear to be induced by any previous fit of coughing, and after lasting from half an hour to an hour they pass off of their own accord, leaving the child free for many hours together, and probably not returning until the follow- ing night. While the child continues subject to them, auscultation discovers no sign of serious mischief in the lungs; but in proportion as the paroxysms of the cough increase in distinctness, and the hoop becomes established, the fits of dyspnoea diminish, and in the course of a few days entirely disappear. Some days usually elapse after the general characters of the disease have become well marked, before it reaches its acme, and during this time its nocturnal paroxysms generally increase in a greater ratio, both as to frequency and severity, than those which occur by day. Such, at least, was the course of the disease in thirty-eight out of forty-seven cases in which this point was especially noticed. The nocturnal exacerbation is sometimes so marked, that the fits of cough- ing are not only severer, but are actually more numerous by night- WHICH ATTENDS THE FITS OF COUGHING. 341 time than by day. In very mild cases of hooping-cough there is but little difference between the frequency and severity of the paroxysms at night-time and by day; and in other instances, while the child rests quietly through the greater part of the night, there is yet a marked aggravation of the cough on first lying down at night, and on first waking in the morning. When the exacerbations occur at these two periods, the evening exacerbation is often induced by the child being removed to a bedroom less warm than the apartment in which it spends the day, while the morning attack results from the accumula- tion of mucus in the bronchi during the hours of sleep. Neither of these causes, however, is the sole occasion of the increased severity of the disease at night, nor is the occurrence peculiar to hooping-cough, but is observed also in asthma, and in many other affections of the respiratory organs in adults. The severity of the nocturnal paroxysms is often a very good criterion of the general severity of the disease; and any exacerbation of the disease is usually attended with special exacerbation of the nocturnal paroxysms, and not merely by more frequent coughing and hooping, but likewise by a marked increase of dyspnoea. On the other hand, a diminution of the nocturnal exacerbations is one of the most frequent indications that the disease has begun to lose something of its previous severity, and the cough often ceases entirely at night for some time before it disappears completely during the daytime. • Cough, preceded by catarrhal symptoms, aggravated in paroxj^sms, assuming a suffocative character, and attended with a peculiar sono- rous inspiration called a hoop, were said to be the characteristics of this disease. The last two of these phenomena are the special results of the nervous element which goes to make up the very compound character of hooping-cough. Hence, in those cases which are very mild, there is so little spasm of the glottis, that air enters freely when the child draws breath after a fit of coughing; and the hoop is occa- sional and faint; while it is still more seldom that the cough displays that suffocative character which, when severe, constitutes one of its most formidable peculiarities. None of the phenomena of this disease call for such close observa- tion as the hoop from which it derives its name. Its occurrence indi- cates on the one hand the existence of spasm of the glottis; and hence, in those cases which are very slight, it takes place but seldom, while it hardly ever comes on until the disease has lasted a certain time, and acquired a certain degree of intensity. It shows, however, on the other hand, that air does enter when the child endeavors to inspire; and, therefore, in cases of severe hooping-cough, a loud, long-drawn, sonorous hoop, instead of adding to our apprehension, tends rather to quiet it, for it assures us that the spasm does not amount to actual closure of the glottis, and that, for this time at least, the child will not choke in the fit of coughing. I have already mentioned to you that the nocturnal dyspnoea which excites anxiety in some cases while hooping-cough is coming on, may disappear altogether when the dis- ease has assumed its regular type, and the hoop has become loud and distinct. Just in the same way, the violent suffocative character of 342 VARIATIONS IN THE DISTINCTNESS OF THE HOOP. the paroxysm often abates, the fits of coughing become fewer, and the dyspnoea grows less urgent after the hoop has become developed. But, if the disease should increase in severity, cough comes on more frequently, and the paroxysms are of longer continuance, so that the face grows quite livid before they pass away. The pauses in the fit are now no longer marked by the sonorous hoop; but, after a mo- mentary cessation, the cough recommences; and though, when at length the attack passes off, a hoop is heard, it is more stridulous than it used to be, though not so loud. Each paroxysm of cough is now preceded and followed by marked dyspnoea, and the child has scarcely recovered from one attack before another comes on. The hoop now sometimes disappears altogether, or is very occasional, very short, and suppressed; and then the cough itself loses its former character; the child dreads its approach much, and tries to suppress it, but in vain; the whole frame labors with the convulsive efforts, but no sound is produced; the larynx is now completely closed; violent but fruitless expiratory efforts are made, as in some of the worst cases of spasmodic croup, till general convulsions come on; or at length the spasmodic constriction yields, and the attempt at expiration is successful. The spasm over, the child once more draws breath; but it seems quite exhausted by the violence of the struggle; while sometimes, before it has recovered from this seizure, another, and then another succeed, till one at length proves fatal.' When the disease has approached to this degree of intensity, we should rejoice to hear the loud, long hoop again, which would be a sure token of some diminution in the suffocative character of the cough. We should next find that, as the hoop regained its former character, those more numerous but less distinct efforts which the child had made before would be merged in the single prolonged in- spiration. The dyspnoea would next diminish, and then the severity of each paroxysm would grow less; and then they would not recur so often, and the hoop would be less loud, and the night attacks less fre- quent. If amendment were to continue, the attacks would become more brief, and they would sometimes pass off without any hoop, while the mucous expectoration would become more copious; next, the hoop would altogether cease; but the cough would continue to recur in paroxysms, and to present something of its old suffocative character; and then this too would cease, though cough might still continue for a time longer. The variations in the course of hooping-cough which I have now described depend for the most part either on the greater or less intensity of the disease, or on some idiosyncrasy of the patient, or on some peculiarity in the epidemic constitution of the year. There are, however, other, and some of them much more important changes in its symptoms and its course, which result from hooping-cough becom- ing complicated with another disease. Of these complications, by far the most frequent and most perilous are those which it presents with bronchitis and pneumonia on the one hand, and with convulsions, con- gestion of the brain, or hydrocephalus on the other. Their import- ance, too, is greatly increased by there being no period of the disease COMPLICATIONS OF HOOPING-COUGH. 343 to which we can look as bringing with it any immunity from either; but, from the commencement of the cough to its complete disappear- ance, we are at any moment exposed to the risk of disease, either of the lungs or of the brain, converting a trivial into a most formidable affection.1 The circumstances in which hooping-cough becomes associated with other affections of the respiratory organs are very various. Sometimes, as I have already mentioned, rather severe bronchitic symptoms, fre- quent short cough, and considerable dyspnoea, precede the full deve- lopment of the disease. This occurrence is oftenest met with at the commencement of epidemics of hooping-cough, or in children the mucous membrane of whose air-tubes may be supposed to have ac- quired a peculiar susceptibility from many previous bronchitic seizures. On the whole, however, these are not the cases which need excite our greatest solicitude, for the constitutional symptoms, which are gene- rally out of all proportion to the amount of the local mischief, usually subside in the course of a few days, just as we often observe to be the case with epidemic influenza in the adult; and as the characteristic cough and hoop come on, all cause for anxiety disappears. Those cases are in general much more serious in which the symp- toms of bronchitis or pneumonia come on after the cough has assumed the characters of hooping-cough. This complication sometimes occurs very early in the course of the disease, and then the bronchitis and hooping-cough appear to be developed almost simultaneously. For a day or two, perhaps, a hoop has been heard accompanying the cough at intervals, and nothing has appeared to indicate that the attack will be unusually severe, when all the symptoms suddenly become very much aggravated; the skin grows hot; the respiration and pulse be- come very much hurried, and this increase in their frequency is per- manent, though much greater at one time than at another. The cough at the same time becomes more frequent and more severe, and the hoop is more violent; but the cough is almost entirely unattended with expectoration, or if a little mucus be spit up it is almost always streaked with blood. Though very violent, the fits of coughing are 1 Of 35 children who died of hooping-cough under my care, 17 perished in conse- quence of the supervention of bronchitis or pneumonia ; 18 from congestion of the brain, from convulsions coming on in a fit of coughing, or from hydrocephalus. Reckoning the commencement of the disease from the first distinct hoop, or first appearance of a well-marked paroxysmal character of the cough, it appears that of 31 cases in which this point was noted— Dying through Dying through lungs. the brain. Total. Dying within 0 1 1 7 days. 2 4 6 14 days. 2 3 5 21 days. 0 2 2 28 days. 1 1 2 5 weeks. 2 0 2 6 weeks. 3 3 6 7 weeks. 1 1 2 8 weeks. 4 1 5 from 8 weeks — — — to 3 months. 15 16 31 344 COMPLICATIONS OF HOOPING-COUGH: not very long, and they seldom or never end with vomiting. The ear detects mucous rale through nearly the whole of both lungs; on a deep inspiration, still smaller sounds are heard, for inflammation has attacked the minuter air-tubes; and the case is one of hooping-cough complicated with capillary bronchitis. Supposing the disease to continue, the cough will often in a day or two lose its characteristic hoop, an occurrence which you will likewise observe in the course of many other intercurrent febrile or inflam- matory affections that may supervene during an attack of hooping- cough. The cough, too, may become less frequent, or may lose its paroxysmal character, though it will still appear to cause much suffer- ing. The respiration will increase in frequency, the child constantly laboring for breath, and being distressed by the slightest movement, since that adds to its dyspnoea. In one little child two years old, the inspirations two days before her death were 130 in the minute, and then on the following day they sank to 80; but her feet were now cold, her face was livid, and her pulse very feeble. It was she of whose lungs I showed the drawing some days since, illustrative of vesicular bronchitis; and her case might be taken as a type of those in which acute bronchitis comes on at an early stage of hooping-cough. Death takes place more speedily in cases of this kind than under any other form of affection of the lungs which comes on in the course of hooping-cough. I have seen a child die on the sixth day from the first appearance of any indication that the disease was other than a very mild attack of hooping-cough. It will not surprise you that the fatal event should take place so speedily, if you bear in mind that after death we discover either intense injection, even of the smaller bronchi, with copious effusion of pus into their cavities, or very ex- tensive vesicular bronchitis, or both conditions together. But it is not only at the outset of an attack of hooping-cough that we encounter the danger of its becoming complicated with other disease of the lungs. Exposure to cold, or damp, may at almost any period induce an exacerbation of the cough, or a distinct attack of bronchitis. If, however, the disease have already lasted for some ten clays or a fortnight, without having presented any grave features, such intercurrent bronchitic seizures are usually very tractable. As a general rule, those cases have appeared to me to be far more serious in which bronchitic symptoms become developed of their own accord out of severe hooping-cough. In such cases there has usually been a gradual increase in the child's sufferings; the cough growing more frequent, and, though not more violent, yet evidently occasion- ing the child greater suffering; while the hoop is unchanged in its cha- racter. At the same time the child seems overwhelmed by the disease; its face is anxious and puffed, the eyes are much suffused, the skin usually dry and hot; dyspnoea is no longer confined to the periods just before and just after a fit of coughing, but the respiration is habitually wheezing, hurried, and rather irregular. The ear at the same time, detects mucus or subcrepitant rale through the whole of both lungs. Such cases are seldom very rapid in their course. The symptoms, after exciting our solicitude for a week, ten days, or a fort- BRONCHITIS — PNEUMONIA—CEREBRAL CONGESTION. 345 night, may gradually abate in severity, and the disease may run the remainder of its course slowly, but safely. If the case should have an unfavorable issue, this sometimes takes place speedily, owing to the supervention of cerebral symptoms; and the child then dies during a paroxysm of coughing. Or the minute bronchi may become involved in the inflammatory mischief; the case may assume the characters of pneumonia, and bronchial breathing and dulness on percussion may reveal during the patient's lifetime the nature of the mischief which will be disclosed on an examination after death. In a still more numerous class of cases, the disease retains its chronic character to the last, and presents little or no variation from day to day. The violence of the cough, and the frequency of its re- turn, sometimes continue unabated, though often they undergoa marked diminution. The respiration grows more hurried than before, the fever becomes exacerbated, and the emaciation extreme; while the child's strength is still more enfeebled by the supervention of a troublesome diarrhoea, which no remedies are adequate to restrain. Death at length takes place, sometimes from pure exhaustion; and the transition from sleep to death is so gentle as to be almost imper- ceptible. At other times an increase of the symptoms of bronchitis or pneumonia becomes apparent for two or three days previously; or in other cases the child dies exhausted in a fit of coughing, or convul- sions take place a few hours before death, and the patient dies con- vulsed or comatose. The complication of hooping-cough with serious disorder of the nervous system is almost as frequent as its association with grave mischief in the lungs and air-tubes, and even more dangerous and perplexing. Hazard from this source attends alike the onset of the disease, its acme, and decline; and the mode in which the danger presents itself is no less variable than are the seasons of its occurrence. The nervous system sometimes suffers so severely from the very first, that death takes place almost before the disease has had time to assume its usual char- acters. At other times hooping-cough comes on naturally; its two elements, the bronchitic and the nervous (if I may be allowed the expression), increase daily in intensity, till all at once the symptoms of the former recede, and are almost lost in those of the latter, which in a day or two bring on the fatal termination of the case. Or lastly, no symptoms referable to the nervous system call for our solicitude until after the hooping-cough has continued many weeks; but then the long continuance of the disease seems to excite mischief in the brain, and death overtakes the patient when we had already begun to hope that nothing more than time was needed to perfect his cure. Danger from this cause sometimes assumes the form of simple con- gestion of the brain ; drowsiness is followed by convulsions, and these are succeeded by fatal coma. In other instances the spinal system of nerves becomes excited to more tumultuous reaction; and carpopedal contractions, and attacks of spasm of the glottis, are superadded to frequently recurring general convulsions; while in some cases the long continuance of hooping-cough gives rise to the development of acute hydrocephalus. The time will not be lost which we may 346 COMPLICATIONS OF HOOPING-COUGH. spend in the examination of each of these various modes in which hooping-cough becomes complicated with disorder of the nervous system. In very young children, and in those in whom the process of den- tition is still going on at the time of their becoming affected with hooping-cough, the symptoms of disturbance of the nervous system are sometimes formidable even from the outset. In such cases the preliminary catarrh is usually of short duration, and the cough, though not very frequent, yet assumes a paroxysmal character almost from the first. Each fit of coughing is extremely violent and suffocative; it lasts for several minutes, is not attended by any distinct hoop, nor followed by vomiting, but ceases apparently from the child being too exhausted to make any further effort. In the intervals of the cough the face is flushed, the eyes are suffused, and the child is very drowsy, and averse to being disturbed—a condition which is manifestly in- creased by each paroxsym of coughing. When the cough comes on, the flush of the face deepens to a livid hue, the pupils become dilated, con- vulsions seem impending and at length come on, aud though but of short continuance, yet they often leave the child in a state of profound stupor. This condition seldom lasts long: sometimes the effort at coughing brings on a fatal convulsive seizure, at other times the cough does not return, but convulsions recur independently of it, and in twenty- four or thirty-six hours from their first occurrence the child dies. No cases of hooping-cough run so surely or so speedily as these to a fatal termination, which even the most judicious treatment will often fail to prevent. I have seen death take place in less than a week from the commencement of the cough, and have known several in- stances of its occurrence long before the lapse of a fortnight. The circumstance of the cough having run its course naturally up to a certain point, affords, however, no guarantee against the super- vention of a danger similar to that which we have just been contem- plating. It is, indeed, but seldom that any case which for the first ten days or fortnight has been mild in character, afterwards presents these alarming symptoms of cerebral disturbance; for in most in- stances the cough will have been severe from the commencement, the paroxysms frequent and of long continuance, the hoop loud, each attack terminating with vomiting, and the return of each being much dreaded by the child. In all this, however, there is nothing to direct special attention to the head, and the approach of the new danger is not always very obvious. Sometimes the first indication that the head suffers is afforded by tbe increased irritability of the stomach, which becomes almost unable to retain food or drink. And here let me urge upon you the importance of duly estimating the signification of this symptom. Vomiting, independent of the fits of coughing, if it persists for above twenty-four hours, and be not referable to the remedies you are employing, nor connected with obvious gastric dis- order, should always excite your solicitude, and direct your attention most anxiously to the head. At other times, either in connection with this irritability of the stomach, or even independently of it, the child is observed to become DANGER WHEN CONVULSIONS ARE FREQUENT. 347 daily more heavy and drowsy, and averse to movement; complaining of headache if able to talk, and appearing overwhelmed by the disease to a greater degree than can be accounted for either by the severity of the paroxysms or the frequency of their recurrence. This condi- tion is generally succeeded by aggravation of the dyspnoea both before and after each fit of coughing, the respiration sometimes not regaining its proper frequency d uring the interval between their return, though auscultation fails to detect any adequate cause for this hurried breathing. In some instances the hoop still continues as loud as be- fore; but if that be the case, the cough grows harder, and hardly any mucus is expectorated; while streaks of blood are seen in the matters rejected by vomiting. It happens more frequently, however, that these symptoms are associated with a more or less complete suppres- sion of the hoop; the cough losing something of its distinctly parox- ysmal character, but becoming more suffocative; the child, on each occasion of its return, vainly striving to suppress it. A convulsive seizure now, in some cases, supervenes on an effort to cough, and in this the child expires; or the fatal convulsion may come on to all ap- pearance causelessly; or, more frequently, the first convulsion does not occasion death, but it leaves the child in a comatose condition, which is interrupted by the frequent return of convulsions, one of which at length proves fatal. It happens sometimes that children who are laboring under severe hooping-cough are suddenly seized, during a paroxysm of coughing, with a fit of convulsions; and they may die in this fit, even though they had not previously seemed to suffer from any serious disorder of the nervous system. Death in such cases takes place as the result of spasmodic closure of the larynx, and consequent congestion of the brain; you watch for a few moments the fruitless expiratory efforts of the child, and then all is over, just as in many fatal cases of spasmodic croup. The relation between hooping cough and spasmodic croup, indeed, is sometimes very apparent; and you may observe, after some unusually violent fit of coughing, the thumbs drawn into the palms, the hand flexed upon the wrist, or the great toe drawn apart from the others. At first, probably, the symptoms will be slight, and will soon pass away; but their import is most serious. You will expect soon to see other and graver indications of the disturbance of the nervous system—if, indeed, they be not already present. It is especially in cases of this sort that you will observe a degree of dyspnoea which you cannot explain; and that the child will seem to make the most violent efforts to suppress the cough—efforts which are really invol- untary, and are the result of the spasmodic closure of the glottis, which is sure, if complete and long continued, to be followed by an attack of convulsions. If treatment fail, the carpopedal contractions will become permanent, the eyes will close but partially, the breathing will grow extremely unequal and irregular, as well as hurried, the hoop will no longer be heard, and the cough itself will yield only a kind of smothered sound. The surface will grow quite livid, in con- sequence of the extremely imperfect performance of the respiratory function; the child will sink into a state of stupor, in which it will 348 COMPLICATIONS OF HOOPING-COUGH: lie with dilated pupils and constant twitching of the muscles of its face, till a great effort to cough comes on, and passes almost at once into a convulsive paroxysm. The fits at length occur independent of any attempt at coughing, and once I saw a considerable degree of stiffness of the whole spinal column precede for twelve hours the death of a little boy, who fell a victim to hooping-cough thus sadly complicated with disorder of the nervous system. It would be only by the recital of cases that I could bring before your notice each minute variation of the characters of these formi- dable complications of hooping-cough; and for such details there remains no time to-day. There are two points, however, bearing on this subject, which I am most anxious to impress on your memory. One is, that the supervention of dyspnoea, or the sudden aggravation of difficulty of breathing which had existed previously, is often one of the earliest indications of serious affection of the nervous system. The other point, on which I shall have to dwell at our next lecture, is, that if, mistaking the import of this nervous dyspnoea, you direct your treatment to some imagined mischief in the chest, and make free use of antimony and other depressing medicines, you will aggravate, instead of relieving, the difficulty of breathing; and, the irritability of the nervous system increasing in proportion as the respiration be- comes impaired, you will hasten the occurrence of convulsions, and of that formidable train of symptoms which we have just been con- templating. I mentioned that true tubercular hydrocephalus is now and then met with as a complication of hooping-cough. Fortunately it is not of frequent occurrence, though the danger of its supervention should never be forgotten in the case of weakly children who have long suffered from severe hooping-cough. Two instances of it have come under my observation; but in one of these cases the cerebral disease was associated with such a large amount of mischief in the chest as would of itself have sufficed to destroy the child. The other case was of much importance, as showing the insidious manner in which fatal disease may steal on, presenting little to excite serious apprehension till long after the possibility of doing good has passed away. The patient, a boy five years old, of a phthisical family on his mother's side, was attacked by hooping-cough, from which he suffered severely. The disease was attended with great dyspnoea, with general oedema and great lividity of the surface. No auscultatory signs of serious mischief in the lungs existed at any time; but the oppression of breathing was so considerable, and the child seemed so completely overwhelmed by the disorder, that I feared he would not recover. After he had suffered from the cough for about five weeks, and three weeks before his death, matters seemed to take a more favorable turn; his cough diminished greatly both in frequency and severity, and his strength returned under a tonic plan of treatment. He still, however, continued low-spirited, and very much disposed to sleep; and this condition of depression progressively increased, until, about a week before his death, he sank into a state of complete stupor; but no convulsions occurred either as precursors of the stupor or during ACUTE HYDROCEPHALUS. 349 its continuance. He lay on his back, either sleeping, or in a state of stupor, from which, however, he could be partially aroused, when his pupils, before contracted, would become suddenly dilated to the full, and he would stare wildly about for a few moments : the pupils would then oscillate for a short time between dilatation and contraction, but soon revert to their former contracted condition. The bowels were not constipated at any time, neither did vomiting occur, and the pulse continued frequent till within a day or two of his death. Strabismus came on a day or two before he died, and two days before his death deglutition became difficult, and he began to make slight automatic movements with his hands and arms. Paroxysms of cough continued to recur to the very last: they were suffocative in character, but un- attended by hoop. At the end of the eighth week from the com- mencement of his cough, the child, who was extremely emaciated, died quietly. After death, the membranes of the brain were found much con- gested; there was a large quantity of fluid in the ventricles; the central parts of the brain were diffluent, and its lower parts were likewise considerably softened. The membranes at the base of the brain presented an opalescent appearance, and were bestudded with numerous minute granules, while about the optic nerves they were greatly thickened and infiltrated with that hyaline matter to which I have often called your attention. There was much congestion of the bronchi and pulmonary sub- stance. The lungs contained a good deal of tubercle, mostly in the state of gray granulations, and a small cavity occupied the lower part of the left upper lobe. Many points of importance connected with the history of hooping- cough remain for our examination before we can proceed to consider its treatment; but all of these must be reserved till our next meeting. .LECTURE XXVII. Hooping-Cough continued.—Complications with diarrhoea and intestinal disorder— with great irritability of the stomach—with measles and varicella.—Duration of the disease.—Relapses.—Influence of age, sex, season, &c, in its production.— Post-mortem appearances. Treatments—No real specific for hooping-cough.—Treatment of first and second stages —utility of hydrocyanic acid—of counter-irritation—of attention to temperature —danger of overtreating the bronchitis of hooping-cough.—Treatment of third stage of disease. It is a peculiarity of the affection which we are now studying, that much of the suffering, and almost all the danger that attend it, are the result, not of the disorder itself, but of some complication that super- 350 COMPLICATIONS OF HOOPING-COUGH—DIARRHCEA, ETC. venes during its course. We have already examined the two most frequent and most formidable sources of danger to patients laboring under hooping-cough, but others remain, against which it behooves us to be no less sedulously on our guard. Some days ago I mentioned to you that a state of extreme irrita- bility of the lining of the air-tubes is one of the characteristics of early childhood. To this are due the attacks of catarrh which children often experience while teething, and the cough which, wholly inde- pendent of exposure to cold, comes on as the result of sympathy with irritation in some distant viscus. This high degree of susceptibility, however, is not confined to the bronchi, but is possessed in the young subject by the whole tract of mucous membranes; diarrhaea often accompanies catarrh, or alternates with it, and in the course of inflam- mation of the lungs the patient's life is sometimes jeopardized, or his death hastened, by the supervention of an intractable looseness of the bowels. Diarrhoea, though comparatively seldom fatal, is frequently a very troublesome complication of hooping-cough, and, if it continue, it greatly reduces the strength of a child, and interferes with the em- ployment of some of those means to which otherwise we might have recourse. It sometimes sets in with the preliminary catarrh, and abates as that subsides, but in other cases it harasses the patient at intervals during the whole course of the affection. It is, however, when it supervenes in the course of an attack of hooping-cough which has already attained considerable severity, that it should excite our chief solicitude. It does not, indeed, in the majority of instances, betoken the supervention of disease in the intestines, but it is one of the forms of constitutional disturbance that attend upon a congested state of the brain, or it indicates the advance of serious mischief in the lungs. I have, indeed, seen diarrhoea become the most prominent symptom in a case of severe hooping-cough, the bowels being for days so irritable, that their action was excited by the slightest article of food or drink, while the abdomen was exquisitely tender; and yet, when death at length took place, unusual redness and prominence of the Peyerian glands were the only morbid appearances in the intes- tines, while the signs of intense bronchitis and inflammation which in some parts had advanced to suppuration, were discovered in the lungs. • An irritable state of the stomach, with occasional vomiting, are symp- toms almost constantly observed at some period or other in the course of hooping-cough. In cases of a mild character, they usually occur only when the cough has reached its acme, and vomiting succeeds to none but the severest fits of coughing, while it is one of the earliest symptoms to cease as the severity of the disease declines. Sometimes, however, very distressing nausea, harasses the patient, and efforts to vomit not only follow the paroxysms of coughing, but are excited by food or by the blandest fluid. I have already warned you of the serious import of this symptom in many instances, and have called your attention to it as being frequently one of the earliest indications of DURATION OF HOOPING-COUGH. 351 cerebral mischief. In some few instances I have observed it come on very early in the disease, and subside by degrees as the cough assumed a distinctly paroxysmal character; just as is the case some- times with that nervous dyspnoea of which I spoke in my last lecture. Sometimes it continues to be a troublesome though almost a solitary symptom of disturbance of the nervous system, the cough not being severe, nor the child's health at all seriously impaired; and in two instances that I met with it appeared to be the result of a state of extreme irritability about the fauces, so that the cough, which hardly ever occurred at other times, was immediately excited by any attempt at deglutition, and the effort to cough terminated almost directly in vomiting. Nausea and vomiting are sometimes associated with gene- ral intestinal disorder, and diarrhoea; at other times there is equal evidence of disorder of the digestive organs in a constipated state of the bowels, a red tongue, with perhaps numerous small aphthous ulcers about the mouth, or in the large quantity of frothy mucus rejected by the stomach at each effort to vomit. Before leaving the subject of the complications of hooping-cough, I must notice the relation that appears to exist between it and two of the eruptive fevers, namely, measles and chicken-pox. It has been thought, indeed, by some writers, that there is no connection between these diseases other than that of their accidental association; but my own experience would lead me to incliue to an opposite opinion, which is likewise entertained by several high authorities. I am not, indeed, able at this moment to adduce a number of observations bearing on this point sufficient to establish the fact beyond doubt; but my belief is, that the occurrence of any one of these diseases during the epidemic prevalence of another, increases the liability of the child to become affected by that which is epidemic, and that an exacerbation of the fever of hooping cough, and the appearance of more serious illness than the local symptoms account for, is very likely to be due to the approach either of measles or of varicella. Like other intercurrent febrile and inflammatory affections, both measles and chicken-pox often produce some temporary abatement of the paroxysms of hooping-cough, and sometimes cure the disease alto- gether. In this, however, there is nothing constant, for hooping-cough often appears not to be in the least modified in its character by the supervention of the other malady: while in some cases the complica- tion adds to the mischief in the chest, and increases the patient's suf- fering and danger. Although there are many important points of analogy between hooping-cough and some of the exanthemata, yet in nothing is the difference between these affections more apparent than in the uncer- tain duration of the former, in the exacerbations which take place during its course, either causelessly or from very slight occasions, and in the actual relapses that sometimes occur after apparent cure. It is a matter of considerable difficulty, in the case of a disease so protracted in its course as hooping-cough, to make even an approximation to a correct estimate of its duration. In twenty-five cases, however, I had 352 CERTAIN CAUSES WHICH PRODUCE HOOPING-COUGH. the opportunity of watching the patients from the time when the cough first assumed a paroxysmal character, or the hoop first became audible, until the final cessation of all cough. From this small number of observations I should be disposed to estimate the average duration of hooping-cough at ten weeks; of which period nearly two weeks1 would be occupied by the preliminary catarrh, for four weeks the cough would present the characteristic hoop, and the cough would continue for about the same period to occur occasionally, gradually losing its pa- roxysmal character; though exposure to cold, or any trivial cause, would suffice to bring back the hoop, and to restore to the paroxysms of the cough all their former intensity. So long as any cough con- tinues, even though very occasional in its occurrence, and though the hoop have entirely ceased for many weeks, the patient cannot be re- garded as well; while the neglect of proper hygienic precautions may protract the duration of the cough for between three and four months —an occurrence by no means unusual among the poor. I have on several occasions treated children for hooping-cough during the spring, in whom the hoop has disappeared, and the cough almost ceased, in the warm months of summer; but on the approach of autumn has returned with nearly it former intensity. In other cases, hooping- cough contracted in the early part of autumn has returned during the prevalence of cold March winds; or a casual catarrhal seizure has been followed by a recurrence of all the signs of the disease in a severe form. These relapses of hooping-cough frequently set in with considerable severity, the paroxysms of cough being very frequent, and the hoop loud and often repeated ; but, if treated judiciously, they are much more amenable to remedies than is the first attack of the disease. A true recurrence of hooping-cough, after the disease has been per- fectly cured, is at least as unusual as the occurrence of measles or smallpox twice in the same subject. Only one instance of hooping- cough affecting the same patient more than once has come under my notice. In that case, the patient was a girl aged seven years, who, when three years old, had very severe hooping-cough, which lasted for several weeks, the paroxysms of cough being frequent, and the hoop loud and often repeated. In March, 1845, hooping-cough being then epidemic, she experienced a return of the disease in a very severe form, and continued to suffer from it until the end of June. But little more remains to complete the history of the disease, ex- cept that we notice briefly the circumstances in which it comes on. It is essentially an affection of childhood, few children escaping from it; while more than half of the cases of it occur before the completion of the third year. After the age of five years, its frequency rapidly diminishes; and, after ten, it becomes so extremely rare that, out of 1,367 cases in which I noticed the patient's age, I find but eleven in 1 The estimate of the duration of the catarrhal stage is deduced from the observa- tions of 55 cases, and the exact period of its continuance was 12.7 days. Of the 25 in which the total duration of the cough from the occurrence of the first hoop was noted, 11, or nearly half, showed a duration of eight weeks ; and the duration in the remaining 14 cases varied from four to twelve weeks. CERTAIN CAUSES WHICH PRODUCE HOOPING-COUGH. 353 which it exceeded ten years.1 The occurrence of the disease appears to be influenced to a considerable degree by sex as well as age; and, as is the case with a large number of the non-inflammatory disorders of the nervous system, females suffer from it in a considerably larger proportion than males. Of 100 cases of hooping-cough at the Chil- dren's Infirmary, 55.3 percent, occurred in females, only 44.7 per cent. in males; although the total number of female children to the total number of males among my patients at that institution was only as 50.2 to 49.8. Age and sex exert an evident influence on the mortality of the dis- ease as well as on its prevalence, both being greatest in early child- hood ; though hooping-cough does not seem to be so formidable before the commencement of dentition as it is while that process is going on. Female children are not only more liable to the affection, but it proves more fatal to them than to boys, in the proportion of about 3 to 2.2 Hooping-cough is a disease of all climates; and, though more fre- quent in the cold than in the warm months of the year, yet its epi- demics break out at almost all seasons. The epidemic of 1841-2 reached its acme in the months of December and January; while, in 1845, cases of hooping-cough were by far more numefous in the 1 Of the above 1,367 cases— 41.2 per cent, occurred during the first 2 years of life. 56.7 " " " 3 " 82.9 " " " 5 " 98.4 " " " 10 " The subjoined table shows the proportion borne by these hooping-cough cases to 14,440 cases of all diseases at the same ages, which occurred during the same period at the Children's Infirmary. Cases of hooping-cough constituted— 8.4 per cent, of all cases occurring under the age of 6 months. 10.4 " " from 6 to 12 months. 10.3 " " " 12 " 18 " 9.3 " " " 18 months to 2 years. 12.2 " " " 2 to 3 years. 14.6 " " " 3 "-4 " 13.2 " " " 4 " 5 " 11.2 " " under 5 " 7.2 " " from 10 " .8 " " " 10 " 15 " 2 The subjoined table shows the age at which death took place in 35 fatal cases of hooping-cough:— 6 between 4 and 5 years. 1 " 5 " 6 " 3 " 6 " 7 " 1 " 7 " 8 " 1 " 10 " 11 " 0 under 6 months. 5 between 6 months and 1 year. 6 " 1 and 2 years. 8 " 2 " 3 " 4 " 3 " 4 " This result tallies very closely with that afforded by the Fifth Report of the Regis- trar General, from which it appears that the deaths from hooping-cough in London were to the deaths from all causes in the proportion of— 5.6 per cent, under 1 year old. 5.0 per cent, between 5 and 10 years. 10.6 " between 1 and 3 years. .8 " 10 " 15 " 10.2 " " 3 " 5 " Of the 35 cases that came under my notice, 21 occurred in female, and only 14 in male children ; and the mortality under ten years of age from hooping-cough is, to the total mortality at that age in London, in the proportion of 8.9 per cent, among female, and 6.1 among male children. 23 354 STATE OF THE LUNGS IN HOOPING-COUGH. months of June and July than during any other part of the year. Though little influenced by the season of the year, the outbreak of an epidemic of hooping-cough seldom, if ever, takes place suddenly, and altogether without warning. Sometimes, as already mentioned, it succeeds to an epidemic of measles; but still more frequently it fol- lows an unusual prevalence of catarrh, which gradually assumes a paroxysmal character, and puts on the characters of hooping-cough. In a similar way, epidemic hooping-cough sometimes resolves itself into simple catarrh; the signs of disturbance of the nervous system by degrees disappearing, and the cases presenting the indications of mere bronchial irritation. The question whether hooping-cough is a contagious disease, has long since been set at rest by a general answer in the affirmative. How long it retains this character is an inquiry to which it is not possible to return any very precise reply ; but so long as a child who has suffered from hooping-cough continues to cough at all, even though only once or twice a day, I should be unwilling to restore him to the society of children who have not already had the disease. All chil- dren are not equally susceptible of the contagion, and infants under six months'old appear to be especially indisposed to receive it, either by association with other children, or as the result of atmospheric influence. If carefully kept from contact with other children, infants of tender age will very often escape during the general prevalence of hooping-cough; and in nearly half of the cases of hooping-cough that I have met with in infants under six months old, other children in the family had suffered from it for a week or ten days before the infants showed any symptom of it. You may expect, perhaps, that before I pass to the consideration of the treatment of hooping-cough, I should say something about the morbid appearances to which it gives rise, and about the essential nature of the affection. I know, however, of no morbid appearances peculiar to this disease, nor do I think that much would be gained by a disquisition on its seat, or on the occult cause of its symptoms. It is through the medium of the lungs, or of the brain, that death takes place in nearly every instance of fatal hooping-cough; and almost all the structural lesions of importance are found in one or other of those organs. The vessels of the brain and its membranes are often found over-filled with blood, though even in cases where death has taken place in convulsions, or has been preceded by a comatose condition, these appearances are sometimes much less marked than might have been expected, and occasionally are altogether ab- sent. Softening of the cerebral substance, or other indications of inflammatory action, are very seldom met with; increased vascularity of the organ, with perhaps a small quantity of fluid in the ventricles, being almost the only morbid appearances in the encephalon. It is but seldom that the lungs are found free from disease, though they present no structural changes that can be regarded as character- istic of hooping-cough. The mucous membrane of the bronchi is generally injected; sometimes it is intensely red; while an abundant secretion of thick mucus occupies the cavities of the air-tubes, and CONDITION OF THE PNEUMOGASTRIC NERVES. 355 their calibre is much increased. This dilatation of the bronchi, which sometimes is very remarkable, arises from inflammation of the air- tubes, just as it does in ordinary bronchitis, and is not due, as has been erroneously supposed, to the violence of the child's inspiratory efforts. The emphysematous condition of the lung, which is likewise observed in many cases of fatal hooping-cough, has also been referred to the same forcible attempts at inspiration. MM. Rilliet and Barthez,1 however, have observed, that the supposed violence of the inspiratory efforts during hooping-cough is altogether a mistaken assumption; for the efforts made during the paroxysm of coughing are expiratory, the lungs during a severe seizure being almost emptied of air; while in the inspiratory efforts that succeed, the air at first does not pene- trate beyond the larger bronchi, and is long before it again freely permeates the pulmonary vesicles. The objection raised by these gentlemen to the inspiratory theory as explaining the production of emphysema in cases of uncomplicated hooping-cough, is, I believe, quite unanswerable. The fact, however, still remains that the con- dition is met with, and sometimes in an extreme degree, in the lungs of children who have died of hooping-cough unassociated with other diseases of the respiratory organs. To such cases the expiratory theory* applies pre-eminently; for, during the violent expiratory efforts with a closed glottis which characterize a paroxysm of the cough, the air is driven forcibly towards the upper jjart, and the circumference of the lungs; in other words, towards just those parts which are the least compressed, and which observation shows to be the favorite seats of emphysema. In those other cases of hooping- cough in which extensive collapse of the lungs takes place, the emphysema is produced by just the opposite means; on which indeed I need not dwell now, since I explained them fully^in a former lecture.3 I may, however, just observe, that the forcible expiratory efforts which are so characteristic of hooping-cough, as they tend in one way to the production of emphysema, so in another they exercise a powerful influence in occasioning collapse of the lung; and few cases of hooping-cough terminate fatally in which you will not find after death a more or less considerable portion of lung in this condi- tion. It may be simply collapsed, resuming its natural appearance readily when inflated; or the bronchial tubes may have been the seat of inflammation, and be more or less filled with puriform mucus, when the characters of vesicular bronchitis will be superadded to those of mere collapse or carnification, and air will permeate the organ very imperfectly, or not at all. It cannot be necessary to describe again those other changes which may take place in carnified lung, and which end in the infiltration of pus into its tissue, or in the formation of vomicae, since I treated fully of this subject a few days ago.4 1 Lib. cit., vol. ii. 2d ed. p. 631. 2 See Dr. Jenner's exposition of it in vol. xl. of the Medico-Chirurgical Transactions. 8 Lecture XX., p. 253. 4 It would be unjust to leave this subject without calling the reader's attention to the excellent account of collapse or carnification of the lung contained in Dr. Alder- son's paper on the Pathology of Hooping-Cough, published in the year 1830, in vol. 356 TREATMENT OF THE FIRST STAGE I do not dwell upon other appearances in the chest, such as pleurisy and lobar pneumonia, which are much less often met with, and which have none other than a perfectly casual connection with hooping-cough; but I must notice one morbid condition alleged to have been frequently observed, and which is of the more importance, since it has served as the foundation of a theory of the disease. The pneumogastric nerves have been discovered by various observers redder than natural, and in some cases swollen and softened—appearances which have been regarded as indicating that they had been the seat of inflammation. Even those observers, however, who have noticed this condition, appear to have met with it but seldom, while others have sought for it in vain in a large number of cases. Professor Albers, of Bonn,1 states, that, having examined the bodies of 47 children who died of hooping-cough, he found the nervi vagi perfectly healthy in 43. In 3 the vagus of the right side, and in 1 that of the left side, were slightly reddened; but this redness corresponded to the side towards which the body had been inclined, and in no respect differed from what is observed in the bodies of plethoric persons, and of patients who have died of typhus fever. Out of twenty-four examinations of the bodies of children who have died of hooping-cough, it has only once happened to me to observe any alteration in the appearance of the vagus, though my attention has been directed to it on every occa- sion. In that instance both nerves seemed to be of a decidedly redder color than natural, although they were not otherwise altered. We are, I think, warranted in concluding that an appearance so frequently absent, cannot be one of much moment, that it is probably a post- mortem alteration, and that certainly it is not a phenomenon which can be adduced in support of any particular hypothesis as to ,the nature of therdisease. I have endeavored to describe to you the symptoms of this affection, to make you acquainted with the circumstances in which it occurs, with the course that it usually follows, and with the chief dangers xvi. of the Medico-Chirurgical Transactions. In this paper he not only describes very correctly the anatomical characters of this condition, which had merely been indicated by previous observers, and speaks of it as a state different from pneumonia, which MM. Rufz and Gerhard did four years later, but he also suggests an explanation of its occurrence, which the recent researches of MM. Bailly and Legendre prove not to have been far from the truth. It may be well to quote two passages from this paper: " In many other [cases] I have invariably found the same appearances, uncomplicated with any evidence of pleuritic inflammation. In the lower and posterior portions of the lungs, the structure was rendered very firm.and dense ; the portions which were the subject of this change were exactly defined by the septa ; of a dull red color, devoid of air, sinking instantly in water, and thin slices undergoing no change by ablution. The individual lobules were more dense than in hepatized lungs ; and the cellular membrane between them retaining its natural structure, conveyed to the touch the same sensation that is felt on touching the pancreas.....I apprehend that the appearances detailed differ from those found in peripneumony. In hooping-cough, the lung is always dense and contracted, as if the air had been expelled, and from the throwing out of adhesive matter, the sides of the air-cells had been agglutinated together; while in hepatiza- tion the lung is less dense than in hooping-cough, and is rendered more voluminous than in its natural state."—pp. 90—91. 1 Quoted by Aberle, De Tussi Convulsiva, 8vo. p. 45, Vindobonse, 1843. OF HOOPING-COUGH. 357 that threaten a child while suffering from it. It now remains to ex- amine the treatment which may be best calculated to mitigate its severity, and to ward off or overcome the dangers that attend it. There are few diseases for the cure of which specifics have been more eagerly sought after, or more earnestly recommended, than for that of hooping-cough ; neither is there anything unreasonable in the expectation that a remedy may some day or other be discovered which shall cut short its course with as much certainty as quinine arrests an intermittent fever, or which shall render the constitution insusceptible to its poison as infallibly as vaccination preserves from variola. At present, however, no such remedy has been discovered; and, though the severity of an attack of hooping-cough, or its duration, varies greatly in different individuals, during different epidemics, or at different seasons of the year, yet we are unable by any medicinal agents to produce effects such as in these cases flow from causes quite beyond our control. For the present, then, the treatment of hooping cough must be con- ducted in accordance with the ordinary principles of therapeutics, and we shall study their application best by examining in succession the course which, in each stage of the disease, it will be our duty to pursue. The first stage of hooping-cough is distinguished, as youicnow, by catarrhal symptoms, with some degree of febrile disturbance, and a cough which gradually assumes more and more of a paroxysmal character, until at length it returns in well-marked fits, and is attended by a distinct hoop. In the majority of cases the treatment of this first stage of hooping-cough must be just that of an ordinary catarrh. The child must remain in the house, and it is desirable that it should be confined to its own apartments, both of which should be maintained at a temperature of 60°, so that when it leaves the day for the night nursery, it may not, as is too commonly the case, enter a colder atmosphere, and thus have the irritability of the bronchi increased, and the severity of the cough aggravated. If these precautions be carefully observed, and the diet be light and unstimulating, but little medicine is needed, beyond what may be required to keep the bowels regularly open. If the cough be at all troublesome, a mixture may be given, containing small doses of the ipecacuanha and antimonial wines with a few drops of laudanum, or of the compound tincture of cam- phor1—medicines that I should advise you always to use in preference to the syrup of poppies, the strength of which is very variable, and its action uncertain. If, as is sometimes the case, the child should wheeze a good deal, this symptom will be much relieved by the ad- ministration of an emetic of ipecacuanha every evening or more fre- quently if necessary. It is not always, indeed, that either much care or much medicine is needed; and if hooping-cough come on in a per- fectly healthy child, in whom the process of dentition is completed, and during the warm months of summer, strict confinement to the house may not be necessary. Usually, however, care in this stage is very important, and will do much towards mitigating the severity of 1 See Formula No. 9, p. 245. 358 TREATMENT OF SECOND STAGE OF HOOPING-COUGH. the subsequent course of the disease, while no precautionary measure is of so much moment as the preservation of the child from fluctuations of temperature, and from damp as well as cold. When the first stage of hooping-cough has passed into the second, in which the disease assumes its characteristic features, the condition of the patient must still determine whether any remedies are to be employed, and must likewise influence their selection. It sometimes happens that the cough and hoop are very slight, and the paroxysms but few in the course of the day: and, in such circumstances, medi- cine can well be dispensed with. If the paroxysmal character of the cough be well marked, and the fits of frequent occurrence, but the child in other respects ails little, much benefit will accrue from the use of the hydrocyanic acid. I usually begin with a dose of half a minim of the acid of the London Pharmacopoeia every four hours for a child nine months old ; and so in proportion for older children. The specific influence of the remedy is I think both more safely and also more efficiently exerted by increasing the frequency of its administra- tion, than by adding to the dose, and I should therefore prefer to give half a dose every two hours rather than to double the dose without increasing the frequency of its repetition.1 This remedy sometimes exerts an almost magical influence on the cough, diminishing the fre- quency and severity of its paroxysms almost immediately ; while in other cases it seems perfectly inert; and again, in others, without at all diminishing the severity of the cough, it manifests its peculiar poisonous action on the system, so as to render its discontinuance advisable. I have never but once, however, seen really alarming symptoms follow its use, though I have employed it in many hundreds of cases. In that instance I gave one minim of hydrocyanic acid every four hours to a little boy two years and a half old. He had hooped for four days before he came under my care, and was then suf- fering from rather severe cough, and considerable dyspnoea. He took the acid for four days without any effect being produced either on his system generally or on the cough; but at the end of that time, after taking each dose, he uttered a cry, became quite faint, and would have fallen if not supported. This result having followed three or four times, the child's mother discontinued the medicine, and, of course, I did not resume its employment. Similar though less severe symptoms were produced by the same medicine in the sister of this child, a little girl of five years of age; but in neither instance was the severity of the cough in the least mitigated by it. Though no other instances of the kind have come under my notice, I always give a caution to the parents to diminish the dose of the medicine, or even entirely to dis- continue it, if the child appear faint or dizzy, or bewildered, after its administration ; and I never persevere with the use of the acid if it do 1 (No. 14.) (No. 15.) R.—Acid, hydrocy. dil. Ttliv. $.—Acid, hydrocy. dil. ttliv. Syrupi simplicis 5j. Mist, amygdalae |j.—M. 3j 6tis Aquae destill. 5vij.—M. ^j 6tis horis. horis. For a child 9 months old. USE OF CHLOROFORM. 359 not give a very decided earnest of good within three or four days after its first exhibition. In many instances, although the severity of the cough may be greatly relieved by the hydrocyanic acid, it yet does not enable us entirely to dispense with other remedies. "If there be much wheezing at the chest, an emetic of ipecacuanha should be given once or twice a day, in order to free the air-passages from the mucus which collects in them, often in very considerable quantity, and thus tends, by the obstruction it offers to the free admission of air, to favor the occur- rence of collapse of the lung. The degree to which the child suffers from the accumulation of phlegm in the bronchi must determine whether the emetic be given once or oftener during the day. If it be given but once, the evening should be the time selected for its ad- ministration ; and, after the air-tubes have been thus relieved, the child will often rest well, instead of passing, as it otherwise would do, a restless night, disturbed by dyspnoea and frequent fits of coughing. In other instances, the cough is unattended by much secretion; the child scarcely wheezes at all, and, even after a severe paroxysm, rarely vomits, and never rejects more than a small quantity of phlegm ; but, when night comes on, the cough grows very distressing by its frequent return, even more than by the severity of the paroxysms. When this is the case, a small dose of Dover's powder, or of Dover's powder and the extract of hemlock,1 often soothes this irritability of the air-tubes, aud diminishes the frequency of the cough. If there be a good deal of febrile disturbance, if the cough be hard as well as violent, if it seem to occasion pain, and be unattended by expectoration, while, in the intervals of the paroxysms, a frequent, short, hacking cough dis- tresses the child ; and generally diffused rhonchus is heard throughout the lungs, the hydrocyanic acid may be advantageously combined with small doses of tartar emetic, or of the Yinum Ipecacuanhas. In other cases, if the existence of drowsiness, with a flushed face, becoming livid during the fit of coughing, and the suppression of the previously distinct hoop, betoken the presence of cerebral congestion, the appli- cation of a few leeches to the head will not only greatly relieve these symptoms, but will also diminish both the frequency and severity of the cough, and prepare the way for the more effective employment of the hydrocyanic acid. There are two proceedings which demand a special notice, as having of late years been recommended almost as specifics in hooping-cough. One of them consists in the inhalation of chloroform on the approach of each paroxysm, as a means of cutting it short, or even of entirely preventing its occurrence. There can be no doubt but that just as chloroform sometimes controls^onvulsions, or relieves spasm of the glottis, so it is equally capable of diminishing, or even of arresting, 1 (No. 16.) I£>—Pulv. ipecac, co. gr. ss. Pulv. extracti conii gr. j. Pulv. cinnamomi gr. ij. Sacchari albi gr. iv.—M. Ft. pulvis hora somni capiendus. For a child of two years old. 360 CAUTERIZATION OF LARYNX. the violence of fits of hooping-cough. I have found it of great service in some of those cases of the disease in which the return of each paroxysm of coughing was the signal for the occurrence of general convulsions; but it scarcely need be added that its efficient employ- ment in these circumstances requires the constant presence in the house of some one conversant with its administration. In those almost desperate cases too there is the drawback from its use arising from the fact that, inasmuch as death may take place during any of these convulsive seizures, so its occurrence, at the time when the chloroform was being administered, would almost certainly leave the impression on the minds of the friends that death was due to its employment. If, however, warning is given beforehand of the possibility of this acci- dent, the chloroform may be resorted to as a most valuable resource in desperate cases, though, as in other instances where it is employed at short intervals, tolerance of it is soon established; and it will cease in the course of twenty-four or forty-eight hours to produce any effect whatever. In mild cases of the disease, the results which one com- monly attains are not remarkable; for the sense of suffocation which precedes and accompanies a fit of coughing renders young children intolerant of anything being held near their mouth; while the sense of nausea which the inhalation of chloroform produces so disgusts those who are older that, in spite of the relief which it may yield, I have on several occasions seen older children, who at first had had ready recourse to the chloroform, after a few trials discontinue it, preferring even the unmitigated cough to the nauseating effects of the remedy. Still its trial is free from any objection, and in the course of a chronic ailment there is often an advantage in being provided with means which, though they may be of slight service to the patient, at any rate couvince the friends that we are not indifferent to his sufferings, nor indisposed to try all means for their alleviation. The other measure consists in the local application to the back of the fauces, or directly to the larynx itself, of a solution of nitrate of silver, of a strength varying from gr. xv to 9ij of the salt to an ounce of distilled water, by means of a probang, such as that employed by Dr. Horace Green for the introduction of medicated solutions into the interior of the glottis. This proceeding was first advocated by Dr. Ebenezer Watson, in a paper published in the year 1849,1 and afterwards dwelt on by him more fully in a book which appeared five years afterwards, and in which he complains of his suggestions having been passed over without notice.2 Before the appearance of his book I had made a few trials of his plan, and have subsequently resorted to it sufficiently often to be able to form a fair opinion of its value. I have no doubt but that in very manj^instances the sponge of the pro- bang is actually passed within the glottis; and also that by this mani- pulation, whether completely successful or not, the violence of the paroxysms of the cough is sometimes lessened and their frequency diminished. This result, however, was by no means constant; the 1 Edinburgh Monthly Journal. Dec. 1849. 2 On the Topical Medication of the Larynx, etc. 8vo. London, 1854. See p. 123. USE OF NARCOTICS AND COUNTER-IRRITATION. 361 milder cases were those in which the benefits of the proceeding were most apparent; while, as perhaps might not unnaturally be expected, in those in which there was abiding dyspnoea, or in which any bron- chitic complication existed, little if any good was obtained. The great practical difficulty, however, and one which I am con- vinced will prevent any frequent resort to the proceeding in the case of children, arises from their extreme repugnance to it, and their dread of its repetition. Sometimes by coaxing and promises I suc- ceeded in it daily for three or four days; but no persuasion enabled me to carry its employment further, while on several occasions I saw paroxysms of cough brought on by the mere fear that the solution was about to be applied. There are very few proceedings, indeed, which are so surely and largely beneficial as to repay us for adopting them at the cost of a passion of tears, or an agony of terror, and this is certainly not one of them. Counter-irritation to the chest and spine is a popular remedy for hooping cough, in which many non-professional persons place great confidence, while they employ it through all the stages of the disease. I do not think that you will in general gain much by the employ- ment of counter-irritation until the disease has begun to decline, though it is then often of much service. There are, however, some circumstances in which counter-irritation may be advantageously re- sorted to, even before the affection has attained its greatest degree of severity. The attacks of dyspnoea which sometimes occur during the increase of the disease, are often much relieved by a mustard-poultice to the chest; and if, as occasionally happens, these attacks return, though with varying severity, almost every night for several nights together, the application of a mustard-poultice to the chest, and the immersion of the lower part of the body in a hot bath, on three or four successive evenings, may be of service. In cases of this kind too the daily friction of the chest and spine with an embrocation of soap liniment and the Tinctura Lyttae, so as to keep up a slight degree of redness of the surface, is often beneficial; or that popular remedy, Boche's embrocation, may be used, if the parents of the child fancy, as they often do, that it is possessed of some specific virtue. As a general rule, blisters to the chest are not desirable remedies in young children; but if the cough should be frequent, hard, and painful, or if, in connection with the evidences of congestion of the brain, the cough be suffocative and the hoop suppressed, much good often results from their application. They must not, however, be allowed to remain above four or six hours upon the skin; neither is it desirable to attempt to keep them discharging, on account of the very troublesome sores which they sometimes produce. For the same reason too I do not advise you to employ inunction of the tartar eme- tic ointment, although this proceeding was once highly recommended, and very generally adopted, as a remedy for hooping-cough. Attention to maintain a warm and equable temperature around the child, to prevent the stomach becoming disordered by unsuitable food, and to avoid constipation, will in many instances suffice to conduct a child in safety through the second stage of hooping-cough. If the 362 CASE ILLUSTRATIVE OF DANGER OF OVER-TREATMENT. severity of the cough, or the condition of the child in other respects, seem to call for more decided interference, your motto in the selection and employment of remedies must be, une quid nimis:" and especially must this be your rule in the management of those complications which often render hooping cough so dangerous a disease. In no case is it of more importance to bear in mind this caution as to the danger of over treating a patient who suffers from hooping. cough, than when, at the commencement of the second stage of the disease, a sudden increase of fever, and the supervention of a state of permanent dyspnoea, seem to announce to you that active inflamma- tion has attacked the lungs or air-tubes. It is quite possible that such may be the import of the symptoms, but it is at least as likely that they result from disturbance of the nervous system. In such a case, then, I would advise you to allow nothing but the positive evidence of auscultation to lead you to resort to free depletion and the use of large doses of tartar emetic—remedies to which you might feel dis- posed at once to have recourse. If you feel in doubt, remain for some time with the child, watch it carefully, auscultate it more than once during your visit, and repeat your visit every two or three hours,1 rather than resort at once to measures which, powerful either for evil or for good, may, if unwisely employed, destroy the life they were intended to save. Example teaches louder than precept, and you may learn a useful practical lesson from the following history:— A little boy, about two years old, had had slight catarrh for a fort- night, and towards the end of this time it was thought he had hooped once or twice, though very slightly. He ailed but little, and had had none other than domestic remedies during this period; but one night, without any apparent cause, he became very feverish, his cough grew worse, and his respiration wery hurried. On this account he was de- pleted very freely by leeches, and calomel and antimony were given in large doses for two days, though without any considerable diminu- tion of the dyspnoea. When this treatment was first adopted, it was thought that air entered one lung but scantily; but on the evening of the second day both lungs admitted air equally well, although a good deal of mucous rale attended the respiration. On the morning of tbe third day, the child's face was flushed, and looked much oppressed; his lips were rather livid, his respiration was extremely hurried and irregular; he coughed little, but his cough had a suffocative character, and was not attended by a distinct hoop. The hurried respiration was supposed to indicate the continuance of graver mischief in the lungs than was apparent on auscultation, and antimony was accordingly given in emetic doses. It did not produce much sickness, and the 1 I cannot refrain from directing the attention of junior practitioners to the anec- dote which Dr. Cheyne relates (at page xvii. of the Introduction to his work on Hydrocephalus), of the very different results that followed the practice of two army surgeons, one of whom visited his patients, during the prevalence of an epidemio disease, twice, the other four or five times daily. The moral which Dr. Cheyne drew from tbe tale, though obvious enough, is not sufficiently borne in mind by many who undertake the treatment of children's diseases. TREATMENT OF THE NERVOUS SYMPTOMS. 363 respiration diminished but little in frequency during its employment. On the fourth day the child still breathed very hurriedly, and his inspirations varied from 40 to 60 in a minute, without there being any obvious cause for these great changes in their frequency. On the fifth day the breathing increased in rapidity, while the pulse began to lose power; and not only had the antimony ceased to exert any emetic action, but squills and ipecacuanha failed to induce vomiting. Active measures were suspended towards the evening of this day, and a grain of Dover's powder, given every six hours, somewhat diminished the hurry of the breathing; but it was discontinued after the third dose, on account of the gradually deepening drowsiness of the child. The child, however, still continued heavy and oppressed, the cough became more frequent and more suffocative, the breathing more rapid and more irregular. On the morning of the seventh day, a fit of coughing terminated in convulsions; and from that time until the morning of the eighth day, when the child died, they were extremely violent, frequent in their return, followed by carpopedal contractions, which did not subside in the intervals between them ; while after each convulsion the respiration became more distressingly hurried and irregular. After a time the breathing grew constantly labored, the face became of a deep livid color, the hands were clenched, and the wrists bent upon the forearm; the spine was drawn slightly back- wards, and sensation was quite abolished. At length a slight convul- sive movement passed across the face, and the limbs relaxed in death. Permission was not obtained to make a post-mortem examination. Other cases have come under my notice, in some of which I fell into the error against which I have just tried to warn you: in some I saw the patient too late to rectify the mistake which others had committed, while in some the right course of treatment adopted from the first was followed by success. In a case such as I have related, the want of correspondence between the general symptoms and the auscultatory signs should have deterred from the copious depletion and the free use of calomel and antimony in the first instance, while it still further contra-indicated the employment of antimony in emetic doses subse- quently. Two or three leeches to the head, when the serious symp- toms first came on, would probably have relieved the congested brain; the tepid bath would have soothed the irritability and diminished the fever; and hydrocyanic acid would, most likely, have been of service in quieting the hurried breathing. If much febrile disturbance had still continued, small doses of ipecacuanha, antimony, and hyoscyamus, might have been tried, the antimonial not being given in such doses as to exert any very considerable depressing influence on the system. A stimulating liniment to the chest and spine should have been used several times in the course of the day, and any sudden access of hur- ried breathing should have been met by the application of a mustard- poultice to the chest. The difficulties of diagnosis are sometimes rendered smaller, and the right course of treatment more obvious, by the occurrence of oc- casional carpopedal contractions, or of momentary strabismus from the very-commencement of this nervous dyspnoea; or in other cases 364 TREATMENT OF THE THIRD STAGE by the absence of any auscultatory signs of mischief in the chest, such as could for a moment lead you to refer the hurried breathing to dis- ease going on in the lungs. Even when acute bronchitis really exists, you must not forget the peculiar impress which hooping-cough stamps upon it. You must bear in mind the impediment to the due aeration of the blood which each fit of coughing occasions, and the influence on the nervous sys- tern generally of the imperfect decarbonization of the circulating fluid; how it heightens the irritability of the spinal system; thus exciting tbe hurried and irregular breathing, and rendering the child peculiarly liable to convulsive seizures. If active interference, therefore, be necessary, you would abstract blood very cautiously, while you would employ nitre, ipecacuanha, and James's powder in small doses, as febri- fuges and expectorants, rather than attempt to bring the child rapidly under the influence of antimony. At the same time, the peculiar tendency to obstruction of the air-tubes, and consequent collapse of the lungs, which characterizes hooping-cough, would lead you to en- deavor to keep the bronchi free, by the administration once or twice a day of an emetic of ipecacuanha. You would employ liniments, mustard-poultices, or blisters to the chest, to combat any exacerbation of dyspnoea, and if the paroxysms of cough were severe, you would combine hydrocyanic acid with your other remedies. If the powers appeared to be on the decline, and the child neither expectorated with the cough, nor rejected much phlegm by vomiting, although the bronchi were loaded with mucus, you would at once discontinue antiphlogistic measures, and have recourse to the decoction of senega, with ammonia and squills,1 while you endeavored by a nutritious diet to support your patient's strength. The time allotted to this lecture will not enable me to do more than just indicate the main points to which your attention should be directed; and I must now pass on to notice briefly your conduct in the third stage of the disease. It is now that the cough diminishes in frequency and severity, that the hoop grows less loud and less con- stant, and that auy signs of constitutional disturbance that had existed before by degrees disappear. When the disorder runs this favorable course no medicine is needed, and but few restrictions, beyond such as the avoidance of damp and cold requires. Change of air generally expedites the cure; and if the opportunity offer, and the season of the year be favorable, it should never be neglected. There are many in- stances, however, in which medical treatment in the decline of hoop- ing-cough is of very considerable service. It sometimes happens that the bronchi continue loaded with secretion, which is either expecto- rated, or rejected by vomiting in very considerable quantities after each fit of coughing, while the skin is cold, the tongue moist, and the pulse soft and rather deficient in power. In this condition, alum,2 1 See Formula No. 12, p. 263. 2 (No. 17.) I£.—Alum, sulphat. gr. xxiv. Acid sulph. dil. n\,xij. Syr. rhoeados 5iv. Aquae purse gijss.—M. giij 6tis horis. OF HOOPING-COUGH. 365 long a popular remedy in hooping-cough, is often of much service, diminishing the secretion, arresting the sickness, and rendering the cough much less frequent. It may be given in doses of three or four grains every four or six hours to a child of a year and a half to two years old. This remedy, indeed, may sometimes be used with advan- tage, even before the disorder has begun to decline, if the condition be such as I have just referred to, namely, fever being absent, and the bronchial secretion very abundant, even though the cough is violent. In other cases, in which the cough continues violent after the other symptoms have abated, and in which, though there is no super-abund- ance of secretion in the air-tubes, yet the attacks of cough often end with rejection of a considerable quantity of mucus from the stomach, and loss of appetite and general dyspeptic symptoms are present, the hydrochloric acid is often of much service. It has been recommended as a specific against hooping-cough, in doses of from two to six drachms daily;1 but I have never employed it in other than moderate doses, such as one would prescribe in other circumstances.2 If the cough continue frequent, and the hoop loud, while the only signs of constitutional disturbance are those of mere weakness, iron will generally put a stop to it sooner than any other remedy.3 If, however, there be a degree of feverishness, or of gastrointestinal disorder, which for the present contra-indicates the use of iron, Battley's liquor cinchonas may be given with great advantage, in combination with small doses of hydrocyanic acid ;4 while every attention must of course be paid, by mild alteratives, and other appropriate means, to improve the condition of the digestive organs. It is probably unnecessary to enter into further details, to specify minutely the diet that a convalescent requires, or to refer to the utility of liniments to the chest, or the occasional benefit of anodynes at night. There still remain numerous remedies that have a more or less well-merited reputation in cases of hooping-cough. I must content myself with having pointed out to you the kind of weapons that, in different circumstances, must be employed; and must leave to you the selection of the one whose form and size may, on different occa- sions, seem to you most fitting. The armory is large enough to yield you an ample choice. 1 I have made a few trials of the nitric acid in large doses, as recommended by Dr. Arnoldi, and Dr. Gibbs in his Treatise on Hooping-Cough. Post 8vo. London, 1854, p. 341; but cannot at all subscribe to Dr. Gibbs's statement that " it shortens the disease almost as effectually as quinine does intermittent fever." * (No. 18.) ' 3 (No. 19.) ~Bf..—Acid, hydrochlor. dil. ul,xxxij. R>—Mist, ferri co. $\v. Tinct. opii Tt\iv. Tinct. scillae ttlxvj. Syr. mori $iv. Tinct. conii rr^xl. Aquae purae §iiss.—M. 3"j ter Mist, amygdala? §ij giij.—M. die. 3iij ter die. * (No. 20.) I£.—Acid hydrocy. dil. n\,viij. Liq. cinchonae 3JSS- Syr. aurantii 3Jss. Aquae flor. aurant. ^iij. Aquae destil. 5VJ-—M. 51! *er ^e- All the above are suited for children of two years old. 366 PULMONARY PHTHISIS. LECTURE XXVIII. Pulmonary Phthisis—differences exist between the tuberculous cachexia in the child and in the adult.—Statistical table illustrating its peculiarities in early life.— Anatomical characteristics of pulmonary phthisis in the child—frequency of miliary tubercle and of gray granulations in the lung, independent of each other, and of other forms of tubercle—frequency of tubercular infiltration—rarity of cavities—frequent affection of bronchial glands—description of each of these pecu- liarities—changes in tuberculous bronchial glands—perforation of bronchi, and elimination of tubercular matter. Symptoms of phthisis—their differences from those of the disease in the adult—danger of overlooking its early stage, or of mistaking it for remittent fever, &c.—pecu- liarities of its subsequent course. Bronchial phthisis—its characteristics—remarkable fluctuations in its course—occa- sional unexpected recovery—case of its occurrence, attended with expectoration of tubercular matter—its fatal termination usually preceded by merging of its symptoms in those of general pulmonary phthisis—occasional fatal haemoptysis, but this accident not limited to cases of bronchial phthisis. Phthisis in very early infancy—pulmonary symptoms often obscured by signs of gene- rally defective nutrition. We enter to-day on the examination of one of the most painfully interesting diseases with which we have to do. It is a disease that we not only often see in hospitals, or in the dwellings of the poor, but which has brought grief into the habitations of many among us, and has robbed us of those whom we most dearly loved; while the very mention of its name gives rise to a feeling of utter hopelessness as to its issue. I need hardly say that I propose to-day to call your attention to Pulmonary Consumption or Phthisis, a malady that attacks persons of all ages, of both sexes, and of every rank, and which, under every variety of condition, medicine seems to be equally unable to cure. It may, however, occur to some of you that important though this affection is, yet in speaking of it I am transgressing the bounds that I set myself, when I proposed to treat only of those maladies which are either limited in their occurrence to the period of childhood, or on which the early years of the patient impress some well-marked peculiarity. It is true, indeed, that at whatever age phthisis comes on, it presents the same grand features, it works the same kind of changes, and tends to the same fatal result. But yet the disease in the young subject displays differences from its character in the old, sufficient to attract the notice of the observant; nor are these differ- ences merely curious, but they influence our prognosis and modify our treatment, and hence it is fitting that we devote some time to their examination. DIFFERENCES BETWEEN PHTHISIS IN CHILD AND ADULT. 367 " That great constitutional malady, of which pulmonary consump- tion is only a fragment, plays its part," in childhood as well as in adult age, " most conspicuously in the lungs." In the adult, however, the lungs are so almost invariably the seat of tubercular deposit, that out of 123 cases, M. Louis found but one exception to the rule that if tubercle exist in any viscus, it will be discovered also in the lungs. In the child though the lungs are still the most frequent seat of tubercle, yet M. Louis' law no longer holds good, for MM. Rilliet and Barthez found 47 exceptions to it out of 312 instances in which tu- bercle was discovered in some one or more organs of the body. The first great difference, then, between the tubercular cachexia in child- hood and in adult age, consists in the same organs not being equally liable to it at the two periods of life. The following table will place this difference clearly before you. It shows the proportion per cent, in which different viscera were the seal of tubercle in children and in adults. The figures in the first column are deduced from 312 cases which form the basis of MM. Rilliet and Barthez' essay on the tuberculous cachexia ; those in the second, from the 123 cases on which M. Louis' work on phthisis is founded; and the third contains the results.arrived at by Lombard on an examination of 100 adults. Of 100 instances in which Tubercle was deposited in some of the Viscera, it was present in— Children from 1 TO 15 TEARS. Adults from 20 tears and upwards. According to Rilliet and Barthez. According to Louis. According to Lombard. " bronchial glands .... " small intestines .... " large intestines .... " membranes of the brain " heart and pericardium . 84 79 46 42 40 34 27 22 19 16 15 11 6 3 100 28 33 33 13 2 0 0 10 0 2 0.8 0 0 100 9 19 0 6 1 0 1 0 2 1 2 0 0 This table shows not only that the liability of certain organs to be- come the seat of tubercle is different in childhood from what it is in the adult, but also that tubercle is simultaneously deposited in a greater number of organs in the young than in the old. This greater intensity of the tuberculous cachexia in early life is a fact of much importance. It explains how it happens that death sometimes takes place in the child, before tubercle has anywhere undergone those 368 ANATOMICAL PECULIARITIES OF PHTHISIS IN CHILD. changes which seem almost always to precede the fatal event in the adult.1 1 I have thrown together, into the following note, some details with reference to phthisis in early life, which, though far too few to warrant the deduction of any posi- tive conclusions, may not be without value as furnishing materials for comparison with the results obtained by other observers. Table of 248 Cases, showing the Influence of Sex and Age in predisposing to Pulmonary Phthisis. Under 1 year. From 1 to 2 yrs. From 2 to 3 yrs. From 3 to 5 yrs. From 5 to 10 yrs. From 10 to 15 yrs. Total. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Total Examinations . . .28 Tubercle present in chest in 8 " not present in chest in 21 17 8 9 24 7 17 26 9 17 19 4 15 20 7 13 21 11 10 27 14 13 36 17 19 21 13 8 3 1 2 5 3 2 132 48 84 116 54 62 In two other instances, though the chest was free from tubercle, tubercular deposit existed in the abdomen ; in one boy, aged 3f years, being limited to slight affection of the mesenteric glands; in another, aged 2 years, the tubercular deposit in the abdomen was very extensive. The degree of the tubercular deposit in the lungs was not the same in all cases; but is stated to have been slight in 31, moderate in 23, considerable in 49—propor- tions which were thus distributed:— Under 1 From 1 year. to 2 yrs. From 2 From 3 to 3 yrs. j to 5 yrs. From 5 to 10 yrs. From 10 to 15 yrs. Total. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Slight..... Moderate .... Considerable 0 1 7 0 2 6 2 1 4 0 5 4 2 0 2 1 2 3 6 1 4 6 3 7 6 3 8 6 5 2 1 0 0 1 0 2 17 6 25 14 17 24 In the above 102 cases, the forms assumed by the tubercular deposit were as follows:— © a a <3 " £ ES a as o> S3 a. 5-a i\ ,2 a g.2 a o > =■■3 >.a o ^ c5 o » o 'sS © w "3 * is o S •° 2 * o" £« >* "■ 33 a w Hi sp» Gray granulations 39 21 6 8 4 3 20 Yellow tubercle .... 21 54 9 18 10 8 47 " softened 6 10 12 3 8 12 " in cretaceous state 1 1 Tubercular infiltration . 8 is 3 22 8 6 22 Small vomicae .... 4 10 8 8 15 3 15 Large cavities .... 3 3 1 6 3 9 4 Tubercle of bronchial glands 20 48 12 22 15 9 88 In 19 of the 88 oases in which the bronchial glands were the seat of tubercle, the FREQUENCY OF TUBERCULAR INFILTRATION. 369 These, however, are not the only peculiarities of the disease in early life, but the anatomical characters of tubercle in the lungs (and of this I am now more particularly speaking) differ in some respects in the child from those which are observed in the grown person. The first of these peculiarities consists in the frequency with which gray granulations and crude miliary tubercles exist in the lung inde- pendent of each other, and of any other form of tubercular deposit. In the adult, M. Louis1 discovered miliary tubercles alone in 2 out of 123 cases of phthisis; and gray granulations alone in only 5 more. In the child, MM. Rilliet and Barthez2 found miliary tubercles alone in 107, and gray granulations alone in 36 out of 265 cases; and my own observations, which are based on 102 cases, yield 20 instances of the presence of miliary tubercles alone, and 17 of the presence of gray granulations alone in the tissue of the lungs. The great rapidity with which the deposit and development of tu- bercle often take place in early life, is doubtless one chief cause of this peculiarity. If we examine the lungs of an adult affected with the tuberculous cachexia, we shall often observe their lower lobes containing gray semitransparent granulations; as we advance higher, we shall probably find that the granulations have lost much of their transparency, and that they present a yellowish spot in their centre, while near to the apex of the lung the deposit exists in no other form than that of bodies presenting the whitish yellow color and friable texture characteristic of crude tubercle. These appearances seem to betoken that the deposit of tubercle has taken place slowly and at successive periods, so that those tubercles which occupy the apex of the lung are already approaching maturity at a time when the disease is just beginning to invade the lower lobes. In the child, however, it not seldom happens that all the lobes of both lungs present a nearly equal amount of tuberculous deposit, and that this is seen to be nearly equally advanced in all. Thus we may find the gray granulations diffused in about the same abundance through all parts of the lungs, and all equally transparent; or we may observe each granulation pre- senting a yellow spot in its centre; or the change may be complete, and crude yellow tubercle may be everywhere present. This same fact, of the acute course of tuberculization of the lungs in children, receives a further illustration from the second anatomical peculiarity of the disease; namely, the great frequency with which yellow infiltration of tubercle is observed in early life; MM. Rilliet and Barthez having met with it in 88 out of 265 children, or in 33 per cent.; and I, in 22 out of 102, or in 22.5 per cent. It is a form of degeneration of the lung which seldom exists alone, but is almost pulmonary tissue was unaffected ; and this although thrice the deposit in the glands was universal, and in one of the three cases had gone on to softening. The tubercle of the glands was incipient in . . . .20 " " was general in.....38 " " had reached the stage of softening in . 19 " was in a firm, friable, cheesy state in . 5 " " was undergoing cretaceous change in . 6 1 Recherches sur la Phthisie, p. 3. 2 Op. cit., vol. iii. p. 221 and p. 227. 21 370 COMPARATIVE RARITY OF CAVITIES IN THE LUNGS. invariably associated with gray granulations or yellow tubercle, and usually coexists with a state of very far advanced tuberculization of the bronchial glands. It is often limited to one lobe, generally the upper: or sometimes the middle lobe, in those cases in which the right lung is the seat of the disease. Those portions of the lung which are affected by it become converted into a firm solid mass, having much both of the color and consistence of cheese, presenting a smooth surface when cut, and by its solidity compressing the bron- chial tubes which traverse it, so as considerably to reduce their cali- bre. If the patient's life be prolonged, a process of softening generally takes place; the tissue breaks down, and a cavity is the result, the parietes of which are formed by solid tubercle. At other times, es- pecially if the disease run its course with great rapidity, the lung thus infiltrated seems to undergo a different kind of softening, which does not lead to the formation of a central cavity, but pervades its tissue throughout, which then presents a reddish yellow, or rose-co- lored tint, and breaks down easily into a kind of putrilage, as if the changes produced were the result of a mixture of true pneumonic hepatization, and of tubercular degeneration. Cases of this sort go far towards substantiating the correctness of M. Rokitansky's theory, with reference to the nature of this tubercular infiltration, as com- pared with the ordinary form of tubercular deposit. He conceives that the deposit of tubercle in the form of gray or yellow granulations takes place in the interstitial cellular tissue of the lung; while in the ease of tubercular infiltration the matter poured out into the interior of the pulmonary vesicles during an attack of pneumonia becomes converted into tubercle under the influence of the tubercular cachexia. A third peculiarity of phthisis in the child, as contrasted with the same disease in the adult, consists in the greater rarity of cavities in the lungs during early life. Of 123 cases which form the basis of M. Louis' work on phthisis, cavities were present in by far the majority of instances; and though the numbers are not exactly stated, the exceptions would seem to have been but very few. Out of 265 cases, however, that came under the notice of MM. Rilliet and Barthez, only 76, or 28.6 per cent., presented cavities in the lungs; and they existed in only 23.5 per cent., or in 24 of the 102 cases which came under my own observation. These cavities sometimes resemble those which we usually meet with in the adult; and this is especially the case with children above six years of age, in whom, indeed, the general char- acters of phthisis approximate closely to those of the same disease in the grown person. In other instances, they are not so much cav- erns, as very small excavations {vacuoles, as the French call them), produced by the softening of small tuberculous deposits. Such ex- cavations communicate with the bronchi and with each other, and are sometimes exceedingly numerous, but do not occasion such a destruc- tion of the pulmonary tissue as to produce anywhere a cavity of consid- erable dimensions. Besides these two forms of cavity, there is a third, to which I have already referred, namely, that produced by softening of the yellow tubercular infiltration, which is more commonly met with in very early life than subsequently. Cavities of this kind some ANATOMICAL CHARACTERS OF BRONCHIAL PHTHISIS. 371 times form with great rapidity, and attain a considerable size. The whole of one lobe of the lung may even become converted into a sac, which is often almost quite empty, while its parietes are formed by little besides the pleura and the fibrous capsule of the lung, with a very thin lining of dense tubercular matter. It is far from unusual to meet with cavities of this kind in the bodies of infants only a few months old, who have never thriven, but have presented few signs of phthisis, with the exception of progressive loss of flesh and strength, and some- what hurried respiration. The last anatomical peculiarity of phthisis in infancy and childhood to which I shall direct your attention, consists in the abundant de- posit of tubercle in the bronchial glands, and the changes to which that deposit gives rise. Even in the adult, tubercle is deposited in the bronchial glands in about a fourth of all cases of phthisis; but the de- posit there is subsidiary to its deposit in the lungs. In the child, however, this is far from being always the case; but the disease in the glands is often as important as that in the lungs, sometimes much more considerable. The tubercular deposit does not appear to begin simultaneously, in all the glands, nor to advance in all with the same rapidity; but those about the bifurcation of the trachea, and close to the primary bronchi, are usually the first affected ; and the disease in them often attains a more advanced stage than elsewhere. The state in which the glands are most frequently met with is one of tubercular infiltra- tion, the whole of their substance being converted into a firm, resistant matter, resembling a portion of lung which has been the seat of tu- bercular infiltration; and this even although the number of affected glands be but small, and though the lungs be but little or not at all involved in the disease. Sometimes, however, we may meet with the affection in an incipient state, and it is then usual to find the glands which it has attacked somewhat enlarged and injected, and their tissue infiltrated with fluid, and less firm than natural. The tubercu- lar deposit does not proceed invariably from the centre to the circum- ference, but frequently two or three small deposits may be discerned at different parts of the same gland; or the tubercular matter may be accumulated entirely at one end of the gland, while its other extremity is merely softened and injected. Even when the disease starts from several points, it is not often that the deposit presents the distinctly circumscribed form of miliary tubercle, and still less often that of gray granulation; but it generally presents the character of tubercular infiltration which had taken place at the same time in two or three different situations. Sometimes it is impossible to distinguish any one spot as that from which the disease commenced, but the whole tissue of the gland presents a whitish hue, which appears due to the general infiltration of tuberculous matter. Whatever may have been tbe mode in which the deposit of tubercle began, the tendency of the advance of the disease is to convert the entire substance of the gland into firm tuberculous matter, in which no trace of the original tissue can be detected. The metamorphosis of the gland is attended with considerable increase of its size; the enlargement, however, being 372 PERFORATION OF THE BRONCHIAL TUBES. much greater in the case of those glands which are situated externally to the lungs, than of those which are imbedded in the pulmonary substance. The enlargement of the glands is not attended, as might have been anticipated beforehand, with a thinning of their originally delicate cellular envelop, but it increases in density and firmness, and at the same time acquires a very considerable thickness. Most of the glands which have become converted into tubercle are inclosed within a cyst a line or more in thickness, and extremely resistant; its inner surface being smooth, of a bright rose tint, and sometimes presenting a considerable degree of vascularity. In a large proportion of cases in which tubercle is found in the bronchial glands, it has not passed beyond the crude stage; but if life be not cut short by the advance of phthisis in the lungs, a process of softening next commences; and the softening usually, though not invariably, begins at the centre of the glands, and extends towards their circumference. The softening is seldom found equally advanced in all the glands; but in some, a small central cavity containing liquid tubercle is surrounded by a thick wall of solid matter; while in others the whole substance has been softened, and the gland is no longer anything else than a cyst containing a quantity of puriform fluid. When tubercle deposited in the lung has undergone the process of softening, an effort is made by nature to get rid of the morbid matter, which is expectorated; and the cavity, thus emptied of its contents, now and then cicatrizes, and the patient is cured. The cases of cure, indeed, bear but a very small proportion to those in which death takes place, for in general fresh deposits of tubercle successively un- dergo this softening, until but a comparatively small portion of the lung remains unaffected by the disease; or the abundant secretion from the bronchial tubes exhausts the patient, or death ensues from the degree to which other organs are implicated in the tuberculous cachexia. When the bronchial glands are the seat of the disease, a similar effort is made to eliminate the morbid matter from the system ; and many circumstances concur to render this a more hopeful task than it is when the pulmonary substance itself is the seat of the disease. The means by which this is effected deserve to be examined. When tuberculization of the bronchial glands has attained an advanced stage, we generally observe a process of thickening and infiltration to have commenced in the cellular tissue around each gland, by no means unlike that which takes place in the pia mater at the base of the brain in cases of tubercular hydrocephalus. This cellular tissue often assumes a grayish semi-transparent aspect, and presents a number of minute granules of tubercle diffused through it. By a process of combined inflammation aud tuberculization, the connection between the gland and the adjacent bronchial tube becomes extremely intimate. The cellular tissue in the intervals between the bronchial rings becomes next infiltrated with tubercle, and is then the first part of the wall of the bronchial tube which disappears during a process of absorption that advances from without inwards. The cellular tissue sometimes becomes quite removed before the cartilages of the OCCASIONAL CURE OF BRONCHIAL PHTHISIS. 373 bronchi are much affected; but in process of time they too become absorbed, and the perforation of the tube is then complete; the tu- berculated gland, however, blocking up the aperture in its walls, and projecting into its cavity. The next step consists in the thinning of the envelop of the gland, and the next is the discharge of its contents into the tube; and the cyst then in all probability collapses and be- comes applied to the outside of the bronchus, so a^ to form a part of its parietes. But we are still in want of some exact observations as to this last stage in the cure of bronchial phthisis. This process does not take place with equal frequency in all the bronchial glands; for those which are situated around the trachea, and wholly external to the lung, meeting with no obstacle to their increase in size, often attain a great magnitude without at all com- promising the integrity of the trachea. Those, however, which are in contact with the secondary and tertiary bronchi, and are imbedded in the pulmonary substance (which prevents their attaining any considerable size), not infrequently perforate the tube in the manner above described—and this not only after they have become softened, but even while the tubercle they contain is still in the crude state. Although the progress of the tubercular degeneration is most obvious in those glands which are situated near to the larger air-tubes, yet it is by no means limited to them, but is in many instances ob- served also in the pulmonary glands that are imbedded in different parts of the substance of tbe lungs. They do not, however, become inclosed within a cyst as dense and resisting as that which surrounds the tuberculous bronchial glands; while in a great number of in- stances the pulmonary substance for a short distance around them presents a far more abundant tubercular deposit than is apparent in any other part of the lungs. If a tuberculous gland, thus imbedded in the tissue of the lung, should become softened, the excavation thereby produced may easily be mistaken for a cavity in the lung itself. A pulmonary cavity of such small dimensions, however, is hardly ever solitary, unless it proceeds from the softening of tuber- cular infiltration; but the deposit of tubercle which takes place in the neighborhood of a diseased pulmonary gland is always in the form of distinct deposits—not of tubercular infiltration. Tuberculization of the glands does not occasion perforation merely of the bronchial tubes, but in some rare instances the oesophagus, trachea, and pulmonary artery, have been perforated by the same process as is usually limited to the air-tubes. In some cases in which tuberculization has never advanced far, it comes to a stand-still, and the tubercle itself undergoes the cretaceous change. This, however, is a rare occurrence, for it has come under my notice only in six out of eighty-eight cases; though, on the other hand, it is more frequent than in the lung, in which it has come under my notice in the child only in one instance. In five other instances, the contents of the bronchial glands, though not actually cretaceous, were very dry and friable, as if the more fluid constituents of the tubercle had been removed, and the cretaceous change were about to commence. This change has never come under my notice as having 374 PECULIARITIES IN THE SYMPTOMS taken place in any gland which had attained considerable size in consequence of the deposit of tubercle in it, nor have I ever seen it when the tuberculization of the glands was general, or when the lungs showed evidence of general, or of advanced, phthisical disease. The symptoms of phthisis in early life resemble in many respects those which characterize the disease in adult age, while the points of difference become fewer and fewer in proportion as tbe child grows older, until they cease altogether at the period of puberty. During childhood, however, even those cases which run a course most similar to that of ordinary phthisis in the adult are in general distinguished by the absence of haemoptysis at any stage of the affection—the ab- sence of expectoration, or its very rare occurrence—the comparative slightness of the cough, and the rarity of those colliquative sweats which so much exhaust the grown person. In many instances the child droops, loses its appetite, and flesh, and strength, and complains of vague pain in the chest and abdomen for many weeks before the occurrence of cough excites any apprehension that the lungs are the seat of disease. When the cough does come on, it is slight, short, and dry, and attracts attention by its frequency, rather than by the discomfort which it occasions the child. Its usual amusements cease to occupy the child, who sits about, listless and fretful, in the day- time, while the skin often grows hot and dry, and the lips become parched as night approaches; but there is so little that is definite in these symptoms, that they are not infrequently supposed to indicate the existence of remittent fever, or to be due to the presence of worms in the intestines. It is important to bear in mind that strumous dyspepsia, as it has been called by many writers, is of more frequent occurrence in child- hood than in adult age, and that its symptoms may be all that marks the advance of phthisis in the lungs until within a month or two of the patient's death. A definite commencement can almost always be assigned to an attack of remittent fever; and the great heat of skin, the very rapid pulse, the intense thirst, and the delirium at night which attend it even in its less severe forms, are symptoms which, if borne in mind, would prevent our mistaking for it those slighter and more vague ailments that are experienced during the first stage of phthisis, in all except those rare instances in which the disease runs a very acute course. The referring the symptoms of incipient con- sumption to the presence of worms in the intestinal canal, is a mistake even less excusable: the natural temperature of the skin, and natural frequency of the respiration—the appetite at one time as ravenous as it is deficient at another—the tongue either clean and moist, or else thickly coated—the condition of the bowels, which is generally one of constipation, and the marked relief that almost always follows the action of purgatives—are indications of the presence of worms suffi- ciently characteristic to guard the attentive observer from error. Fluctuations take place in the child's condition, and a casual attack of bronchitis often seems to be the exciting cause of that aggravation of the pulmonary symptoms which is observed before long. The respiration now becomes habitually quicker than natural, instead of OF BRONCHIAL PHTHISIS. 375 merely being easily accelerated, and is often accompanied with con- siderable wheezing; the cough grows more frequent and lasts longer, but is still in most instances unattended by expectoration, owing to the circumstance that the child almost always swallows those matters which the adult would spit up. The loss of flesh, and the decay of strength, advance even more rapidly than the signs of pulmonary dis- ease. Well-marked hectic, however, is infrequent; and if night sweats occur, they are often limited to the head and face. Towards the close of the disease the mouth often becomes aphthous,especially in infants; but though diarrhoea sometimes occurs, it does not often seem to con- tribute so much to the exhaustion of the child as to that of the adult, and that alternation of diarrhoea and hectic sweats, which is so fre- quent in tbe grown person, is seldom or never observed in the child. When death at length takes place, it either occurs from exhaustion, or succeeds to some intercurrent attack of bronchitis or pneumonia. In those cases in which tubercle has been deposited in great abund- ance in the bronchial glands, constituting what is called bronchial phthisis, the symptoms deviate still more from those which are usually observed in the adult. Bronchial phthisis occurs in its best marked form between the ages of two and six years, although, as it is scarcely necessary to observe, tuberculization of the glands is by no means limited to that age. Its symptoms in many instances first become distinctly evident after some severe bronchitic seizure, which either accompanied measles or came on without any apparent exciting cause. In other cases, although the commencement of the affection is not clearly traceable to a single attack of severe bronchitis, yet the patients in whom it occurs had in all probability been subject to frequent returns of catarrh or bronchitis, which, though not alarming in their symptoms, yet left behind them a cough that never entirely subsided. By degrees this cough becomes severer; it returns in paroxysms not unlike those of pertussis; it sometimes induces efforts to vomit, and can scarcely be distinguished from the cough of the earlier stages of hooping-cough. The respiration grows habitually oppressed and wheezing, the face becomes puffed and swollen, the veins of the neck distended, just as in patients with heart disease, and the superficial vessels of the thorax become enlarged, just as those of the abdomen do in cases of ascites, or of mesenteric disease. The great fluctuations which take place in the condition of the patient constitute one of the most striking characteristics of this form of phthisis. Attacks of bronchitis sometimes come on, during which the respiration becomes painfully accelerated and oppressed, and the paroxysmal cough is merged for a time in a constant hacking, or in suppressed attempts at coughing. These bronchitic symptoms, which often seemed to threaten life, and which sometimes actually destroy it, clear up by degrees in the majority of cases, but leave the child with a severer cough and a more hurried respiration than before, while it loses flesh rapidly, and not infrequently sweats a good deal about the head and upper part of the trunk. Accommodation of pos- ture, too, in many instances becomes necessary to the comfort of the little patient, who perhaps can breathe only when supported in its 376 SYMPTOMS OF BRONCHIAL PHTHISIS. mother's lap, or when much propped up in bed. It is seldom, when the disease has reached this degree of severity, that there is not also so large a measure of tuberculous affection of the lungs and other viscera as to render recovery quite hopeless, and the characteristic signs of bronchial phthisis become lost by degrees in those of ordinary consumption. Sometimes, however, a long pause takes place in the progress of the disease, even though thus far advanced; the cough, which had acquired fresh intensity, gradually abates—the respiration is no longer habitually wheezing—the patient can repose in any atti- tude—the flesh lost is regained—and were it not that cough still con- tinues, though less frequent and less severe, that the breathing is more hurried than natural, and that auscultation contributes still further to undeceive us—we might fancy that all ground for anxiety was passing away, and that the child was on the high road towards recovery. In some cases, too, in which symptoms such as have been described are observed, recovery does eventually take place. It is seldom possible to say in any case by what means this recovery is brought about; sometimes, no doubt, the tubercular matter makes its way into the air-tubes, and is got rid of by expectoration. Once I observed the disappearance of most well-marked general signs of consumption, in the case of a girl eight years old, during the copious expectoration of a tenacious mucus, in which were small quantities of a substance like broken-down cheese, or grains of boiled rice, and which alternated with an expectoration of thick, puriform matter, more or less tinged with blood. In the case of this child an attack of measles, while in her seventh year, had been succeeded by cough, the formation of abscesses in her neck, and a frequent puriform, and sanguineous dis- charge from her nose. These abscesses had not been long healed when her mother's alarm was excited by her expectorating blood mixed with the phlegm which she brought up when coughing. Though not much emaciated, the child looked unhealthy; her pulse was very feeble, and there were many small petechias on her extremities. The lungs, however, were tolerably free from disease; for nothing more was heard during auscultation than a good deal of rhonchus mixed with some moist sounds, which were most evident at the upper part of the chest. Expectoration such as I have described continued for nearly three months, in the course of which time the child by degrees lost her cough, and gained strength under the use of steel and other tonics. Two years afterwards no auscultatory signs of disease were perceptible, except a little creaking under both clavicles ; and at the end of five years even this had disappeared. The fatal termination of bronchial phthisis usually takes place in consequence of the lungs becoming seriously involved in the tubercu- lar disease, though life is sometimes suddenly cut off by haemoptysis, owing to the perforation of one of the larger vessels of the thorax by a tuberculated bronchial gland. It must not, however, be sup- posed that this is the only means by which fatal hemorrhage is pro- duced, for it takes place in other instances in precisely the same circumstances as in the adult. Six cases of fatal haemoptysis have come under my notice in children; but in four no examination was PHTHISIS IN VERY EARLY INFANCY. 377 made after death. In the fifth case, which was that of a boy between five and six years old, who died at the end of nine months' illness^ blood pouring in abundance from his nose and mouth, the amount of disease, both of the lungs and bronchial glands, was very considerable; but no large vessel had been perforated, and it was not possible satis- factorily to determine the source of the hemorrhage. In the sixth case, that of a little boy five years old, in whom symptoms of pneu- monia had supervened upon previous signs of phthisis, the source of the bleeding in the single and fatal attack of haemoptysis which took place at a time when he seemed recovering, likewise eluded the most careful anatomical investigation. A very considerable degree of tuberculization of the bronchial glands is by no means uncommon even in very early infancy; but it then generally forms only a part of such extensive tubercular disease, that its special symptoms are lost in those of the general malady. In such cases, too, it frequently occurs that the signs of thoracic disease are almost entirely merged in those of generally defective nutrition. The existence even of a large cavity in the lung may be announced in early infancy by nothing more serious than some acceleration of the breathing and an occasional short cough; while the frequent vomiting—the irregular, often relaxed, condition of the bowels—the unhealthy evacuations—the red tongue, and the aphthous state of the mouth—may direct the attention almost exclusively to the condition of the digestive organs. Many points still remain for our investigation, but we must post- pone their consideration, and the study of the auscultatory phenomena of the disease, to the next lecture. LECTUEE XXIX. Phthisis, continued.—Peculiarities of its auscultatory signs in early life—some of less value than in the adult—influence of tuberculous bronchial glands in exagge- rating the signs of disease of the lung—difficulty in appreciating some signs which are well marked in the adult—sign peculiar to early life. Different forms of phthisis—acute phthisis ; illustrative case—tuberculous pneumonia —bronchitis grafted on phthisis may lead to an over-estimate of the tuberculous disease. Duration of phthisis ; its course sometimes very acute, at others extremely chronic— cases in illustration.—Modes of death in phthisis—head symptoms sometimes precede death, independent of cerebral disease. Prophylaxis, and treatment of phthisis. It would be little better than a waste of your time to enter into a minute description of all the modifications of the respiratory sounds to which the presence of tubercle in the lungs of children may give occasion: our time will be better spent than in such detail, if we 378 PECULIARITIES IN THE AUSCULTATORY SIGNS OF direct our attention to those respects in which the auscultatory signs of phthisis in childhood differ from those which betoken its existence in the adult, or in which the same auscultatory phenomena require a different interpretation at the one period of life, from that which is justly applied to them at the other. The grand difference, indeed, is to be sought in the latter rather than in the former of these respects. Tubercle, at whatever age it is developed in the lungs, gives rise to much the same auscultatory phe- nomena; but many of those modifications of the respiratory sound which would warrant us in pronouncing positively that phthisis existed in the adult, cannot be relied on with the same certainty in the child: still less can they be regarded as proving the existence of so large an amount of disease in the latter case as in the former. It may be stated, then, that— 1st. Many of the auscultatory signs of phthisis deserve less reliance, or have a less grave import, in the child than in the adult. One of the earliest signs of tubercular deposit in the lungs of the grown person is furnished by that peculiar modification of the respi- ratory sound, to which the name of coarse breathing has been applied; and this acquires still greater importance, when associated, as it often is, with dry rhonchus and creaking sounds. Much of the value of this sign depends on its being limited to the infra-clavicular regions, or, at least, on its being heard there with much greater distinctness than elsewhere. Since, however, the deposit of tubercle in the lungs of children is more uniform, and more generally diffused than in the adult, the additional value which the localization of these signs fur- nishes is lost; and it becomes impossible to determine whether the bronchial irritation that they betoken is induced by the presence of tubercle in the lungs, or by some other cause. Prolongation of the expiratory sound beneath the clavicle, and in- terrupted respiration—the respiration saccadee of French authors— which are two of the earliest and most important indications of phthisis in the grown person, are, on the whole, of less value in the child. Their occurrence, indeed, should always excite suspicion as to the existence of phthisis, but they are not infrequently very well marked 'in cases where but slight disorder of the respiratory organs is present; and where the perfect recovery of the child, and its subsequent sound health, prove that tubercular disease either was altogether absent, or at any rate was extremely slight. The exaggeration of these two signs is probably, in some measure, due to a cause which adds greatly to the intensity of some other of those auscultatory phenomena that usually betoken far advanced phthisis. MM. Rilliet and Barthez were, I believe, the first who pointed out the fact that the bronchial glands, when enlarged by the deposit of tubercle, and thus brought into contact with the walls of the chest, which they do not touch in the healthy state, conduct to the ear of the auscultator sounds that in other circumstances are im- perceptible. The air passing through the larger bronchi is now heard, on applying the stethoscope to the walls of the chest, in the supra- PHTHISIS IN CHILDHOOD. 379 scapular, and less often in the infra-clavicular region, and can scarcely be distinguished from bronchial breathing produced by solidification of the pulmonary tissue itself. The sounds which are caused by the presence of mucus in the larger air-tubes are in the same way con- ducted to the ear in other situations than those—such as the root of the lung, where alone they would be heard if the glands were not enlarged. The auscultator may thus be betrayed into the error of supposing that hopeless phthisis exists, in cases where yet the amount of disease in the lungs is but small, and where life may be prolonged for many years. Morbid sounds, too, produced in one lung, may thus be conducted to the wall of the chest on the opposite side, and the extent of disease may, in consequence, be overrated; or the sounds which, when perceived in the front of the chest, may arise from real disease in that situation, being transmitted to the back through the medium of the glands, may thus give rise to the conclusion that far more serious mischief exists than is really the case. The means of avoiding error from this cause consist in the careful comparison of the results of auscultation with those of percussion, and of those of aus- cultation on one day with those which it yields a few days afterwards. If the sounds proceed from solidification of the lung, or from cavities in its substance, the results of auscultation will be as invariable as those of percussion; but if they be merely sounds transmitted from the larger air-tubes, they will be found to vary much on different occasions; while the dulness on percussion in certain parts will con- tinue unchanged, inasmuch as it proceeds from the presence of the enlarged glands. This variability in the results of auscultation is one of the most important indications of bronchial phthisis. It depends not merely on the accidental variations in the sounds produced in the larger air-tubes, but also on the changes which the varying degree of compression of the bronchi, produced by the increase or diminution in the size of the glands, may occasion, and on the variations in the irritation of the air-tubes which this pressure produces. The risk in cases of bronchial phthisis is not so much that of forming an altogether erroneous diagnosis, as of expressing a prognosis far more unfavor- able than the nature of the case actually justifies. In cases where a considerable measure of bronchitis is associated with tuberculization of the glands, we are especially likely to fall into this error, and can avoid it only by much caution, and by frequently repeated ausculta- tion. There are differences of another kind, however, between the re- sults of auscultation in cases of phthisis in the young and old, and which depend— 2c?. On the absence, or difficult appreciation, of some auscultatory phe- nomena in the child, to which much value is attached in the case of the adult— To this head belong the differences resulting from the loss in the child of almost all that information which, in older persons, is af- forded by the different modifications of the vocal resonance. The shrill voice of the child, the small power of modulating it that is 380 CHARACTERISTICS OF PHTHISIS IN CHILDHOOD. possessed in early life, and the consequent difficulty of inducing the patient to utter a few sentences, or even a few words, in the same key, even when fear does not reduce the voice to a mere whisper, take away almost all value from the modifications of the voice-sound in young subjects. The extreme excitability of children tends, as it does^ also in the female subject, to reduce very low the value of mere inequality of breathing between the two lungs; for it is by no means a rare occur- rence for the lung which on one day seemed to admit but little air, to yield the sounds of well-marked puerile respiration on the next day, and for the feeble respiration to have changed sides. Before, there- fore, any conclusion can be drawn from the feebleness of the respira- tion in either lung, its situation, degree, and extent must be confirmed by repeated observation. The finer variations in the sonoriety of the chest are not so easily distinguished in childhood as in more advanced age. The main cause of this appears to be furnished by the extreme resonance of the chest in early childhood, which will admit of very considerable reduction before percussion elicits a sound that the ear would recognize as at all dull. Extremely gentle percussion is much more likely to bring out the more delicate variations of sound than those smart taps of the chest, which, in the grown person, will often answer the purpose sufficiently well. A last source of difference may be mentioned as arising— 3d From the occurrence of some physical signs peculiar to the form which phthisis assumes in early life. The only sign that comes with propriety into this category, is that dulness between the scapulae which is not infrequently produced by the presence of tuberculous glands, and which, when it coexists with tolerable resonance over the upper part of the lungs, and moderately good respiration in these situations, may be regarded as pathognomo- nic of bronchial phthisis. The absence of dulness in this situation, however, does not of itself warrant the inference that the glands are free from disease, but merely that they have not yet attained any very considerable degree of enlargement. It may perhaps be useful, before we proceed to the study of some other peculiarities of phthisis in childhood, briefly to recapitulate the general characteristics of the disease in early life. The chief of these are— 1st. The frequent latency of the thoracic symptoms during its early stages. ■-2d. The almost invariable absence of haemoptysis at the commence- ment of the disease, and its comparatively rare occurrence during its subsequent progress. ' 3d. The partial or complete absence of expectoration. 4th. The rarity of profuse general sweats; and the ill-marked character of the hectic symptoms. 5th. The frequency with which death takes place from intercurrent bronchitis or pneumonia. COURSE OF PHTHISIS SOMETIMES VERY RAPID. 381 Bronchial phthisis is characterized by— 1st. The frequent development of its symptoms out of one or more attacks of bronchitis. 2d. The peculiar paroxysmal cough which attends it, resembling that of incipient pertussis. 3d. The great and frequent fluctuations in the patient's condition, and the occasional, apparently causeless aggravation, both of the cough and dyspnoea. In very early infancy, phthisis is remarkable for the very frequent latency of the chest symptoms, which, through its entire course, are often entirely merged in the signs of impaired nutrition. The most important peculiarities in the auscultatory phenomena of consumption in the child are— 1st. The smaller value of coarse respiration, prolonged expiration, and interrupted breathing, owing to their general diffusion over the chest, and to their occasional existence independent of phthisis. 2d. The apparent, and to some extent the real, exaggeration of the signs both of early and of far-advanced disease of the lungs, in some cases of bronchial phthisis. 3d. The loss of that information which the phenomena of the voice furnish in the case of the adult. 4th. The small value of inequality of breathing in the two lungs. 5th. The difficulty of detecting minute variations in the sonoriety of the chest; and 6th. The existence of dulness in the intercapsular region, together with moderate resonance of the upper part of the chest, and tolerably good respiration there, which are characteristic of the presence of en- larged bronchial glands. Hitherto we have been occupied with the study of the more com- mon forms of phthisis in childhood ; but deviations a^e occasionally met with from the ordinary course of the disease, with which it behooves us to make ourselves acquainted. Phthisis occasionally runs a course so extremely rapid that many of its most characteristic symptoms have not time to manifest themselves. In such cases we are exposed to considerable risk of error, for the history of the patient's indisposition goes back only to a few weeks or days; the evidence of impaired nu- trition is almost or altogether wanting, and the symptoms appear to be those of an acute malady coming on suddenly, rather than those of a slow and wasting disease. A remarkable instance of this came under my notice some years ago, in the case of a little boy, nine months old, who was fat and ruddy, and had always had perfectly good health until the ..10th of April. On that day he was taken with symptoms which his mother supposed to be those of a bad cold. On account of this he was kept in the house, and various domestic remedies were employed, though without any improvement, and on April 24th he came under my notice. There did not then appear to be any urgent symptom, though the child seemed much oppressed at the chest. The case appeared to be one of rather severe catarrh, occurring during the period of den- 382 CASE OF TUBERCULOUS PNEUMONIA. tition. The gums were lanced, and a mixture containing the vinum ipecacuanhae was ordered, to which, finding the symptoms did not abate, small doses of antimonial wine were added on the 27th. On the 30th I was informed that the child was much worse, that his dys- pnoea was greatly increased, and that his hands and feet had been swollen for the last forty-eight hours. I found the little boy breathing fifty times in the minute, with great oppression at the chest, the face much flushed, the skin dry, the trunk hot, the limbs cool, and the v hands and feet much swollen. Auscultation detected generally dif- fused small crepitation through both lungs, with indistinct bronchial breathing at the upper and back part of the left side. Three hours after this visit, the child died without a struggle, on being lifted out of bed for his mother to apply some leeches to his chest. On exami- ning the body after death, a very thick layer of fat was found every- where beneath the integuments. The lungs presented an extreme degree of tubercular degeneration, and many of the bronchial glands were enlarged by the morbid deposit to the size of a pigeon's egg. None of the tubercle in the lungs was softened, but it existed both in the form of yellow miliary tubercle, of tubercular infiltration, and of masses of crude tubercle, formed by the agglomeration of many sepa- rate deposits. The pulmonary substance in the intervals between the tubercular deposits was of a bright red color, in the first stage of pneumonia, and in many parts bordering on the second stage, and there was very considerable injection of the bronchial tubes. The various abdominal viscera contained tubercle, but it was not far ad- vanced in the mesenteric glands. This case represents a class in which there is much hazard of form- ing an erroneous diagnosis. It shows the possibility of tubercular deposit taking place to a very great extent without at all interfering with the general nutrition of the body, and without giving rise to any symptom so serious as to attract the notice of a very careful and affectionate mother. It illustrates also the mode in which the fatal termination of many cases of phthisis in children is brought about, and suggests the inquiry whether there be any means of distinguishing between tuberculous pneumonia, and pneumonia which occurs uncom- plicated with phthisical disease of the lungs. Pneumonia often complicates phthisis in early life, in circumstances where no diagnostic difficulty occurs; but it is of much importance to detect the consumptive element in cases which to the superficial observer present no other symptoms than those of acute inflammation of the lungs. The existence of a considerable amount of tubercular deposit in the lungs may be suspected in those cases in which the degree of oppression of the chest has, from the very commencement of the illness, been altogether out of proportion to the severity of the catarrhal or bronchitic symptoms with which the disease set in. A further evidence of its nature is afforded, if the skin, though very dry, present a less considerable or a less pungent heat than attends simple pneumonia, while the pulse from the very outset is less developed. Suspicion would be strengthened if the frequency of respiration very greatly exceeded the amount of mischief disclosed by auscultation, SIMPLE AND TUBERCULOUS PNEUMONIA. 383 and especially if the rapidity of the breathing, though so great that it would excite the most serious alarm if the case were one of pneumo- nia, should yet continue the same for days together without marked deterioration in the patient's condition. Auscultation also would throw much light on the nature of the case, for the sounds detected in the chest would be the subcrepitant and mucous rales, rather than the small crepitation of pneumonia; while, though the smaller sounds would be discovered at the lower part of the chest, the greatest dul- ness on percussion would generally be detected at the upper part, and bronchial breathing would very likely be perceived more or less dis- tinctly in the same situation. The importance of distinguishing those cases in which inflammation supervenes in a lung already the seat of tubercular deposit, from others in which the organ had been previously healthy, is by no means confined to cases of the severest kind, in which life is imme- diately threatened. In every instance of pneumonia in early life, both your prognosis and your treatment would be greatly modified if there were good ground for believing that tubercular disease had for some time previously affected the lungs. Hence follows the necessity for that very minute inquiry as to the previous health of the patient, and of the other members of the family, on which so much stress was laid at the commencement of this course of lectures. If you learned that several children in the family had already died of phthisis or of some other affection—such as acute hydrocephalus, which you knew to be most intimately associated with the tuberculous diathesis, the possi- bility of the same complication existing in the patient under your care would at once occur to you. This complication would be ren- dered highly probable, if you were to ascertain that the child had been particularly liable to catch cold, or had for some months been seldom free from cough for many days together, or had suffered from cough eyery winter, for two or three years, and had already experienced two or three attacks similar to that you are called on to treat, and which, though severe, had yet subsided by degrees, without the employment of very active measures. The probability would be raised almost to certainty if there existed that want of correspondence between the general symptoms and physical signs, or between the results of aus- cultation and percussion, to which reference has already been made; or if the history of the present illness went back to a period anterior to that which you would be disposed to assign to it, if the affection had been simple pneumonia. The case of tuberculous pneumonia you would deplete more spar- ingly, and would subject to less rigorous antiphlogistic measures, than that of simple inflammation of the lungs. Bearing in mind the influ- ence of enlarged bronchial glands in rendering parts of the chest dull on percussion, and in exaggerating in some respects the morbid sounds, you would not over-estimate the degree or extent of the inflammatory mischief. At the same time you would not allow even a considerable measure of improvement to lead you to speak too decidedly of the ultimate recovery of your patient; since you would not forget that, 384 IRRITATION OF THE BRONCHI. if inflammation do not originate tuberculous disease, it may yet com- municate increased activity to its progress. The overlooking the more serious malady, owing to its symptoms being thrown into the shade by those of the other more curable affec- tion, is not the only error to which you are exposed in cases of infan- tile phthisis. The degree of irritation of the bronchi that exists in different instances, varies exceedingly; sometimes it is so consider- able that when the child is placed under your care, its respiration is wheezing, difficult, and very hurried, its cough violent and exhaust- ing ; while such is the general anxiety of the countenance, and so great is the depression of the vital powers, that the struggle seems as if it could not be long protracted. Percussion detects dulness at the upper part of the chest; the bronchi are so laden with phlegm that air scarcely penetrates beyond the larger tubes, and mucous rale is heard throughout the whole of the lungs, while at their upper part it is so large as to amount almost to gurgling. You regard the case as one of far advanced phthisis, and suppose that softened tubercle is diffused through the whole of both lungs, and that cavities exist at their apex. You form the most gloomy prognosis, and entertain, very probably express the conviction, that a few weeks at furthest will be the period of your patient's life. By degrees, however, the most urgent symptoms subside, and some signs of returning health appear; the respiration grows slower and more tranquil, the cough abates, perhaps almost ceases. The signs of a cavity grow less and less dis- tinct, in proportion as the secretion in the bronchi diminishes; and after some months, while the patient's general condition deviates but little from a state of health, a little dulness at the upper and back part of the chest, unequal breathing, prolonged expiration, or morbid sounds equally slight, are the only auscultatory evidence that the most careful examination can discover of pulmonary disease. Non-professional persons are apt to imagine the mistake in cases of this kind to have been greater than it really was. The error is one as to the degree of the malady rather than as to its kind. In cases that present these symptoms, phthisis has in reality existed, but the chief tubercular deposit has probably been seated in the bronchial glands, and their enlargement gave rise to much of the dulness on percussion, and exaggerated the morbid sounds at the upper part of the chest. From some accidental cause, such as cold or damp, or from the mucous membrane of the bronchi sympathizing with disorder of the digestive organs, or from inappropriate treatment, which aggra- vated the evil it should have relieved, or even without any cause that we can assign, it had come to pass that the air-tubes were in a state of great irritation. The due regulation of temperature, generally ap- propriate treatment, and nature's own healing power, improved the general health and diminished the irritability of the bronchi; while very probably the diseased glands emptied themselves, at least in part, into the air-tubes, and the tubercle was thus eliminated from the system. You should, therefore, always express your opinion very guardedly with reference to the condition of a child suffering from phthisis, until you have confirmed the results of auscultation by its ACUTE PHTHISIS. 385 frequent repetition, and till you have had the opportunity of deter- mining how large a portion of the physical signs is due to the morbid deposit, and how much to that irritation of the bronchi which you may fairly hope to mitigate, if not to remove. The average duration of phthisis in childhood is estimated by MM. Rilliet and Barthez at from three to seven months, though, as they justly observe, its extreme limits vary from two months in unusually rapid cases, to two years and upwards in other instances, in which the course of the disease is very protracted. It is my impression, indeed, that the ordinary duration of phthisis in childhood is less brief than the observations of these gentlemen, made among the children in the Hopital des Enfans at Paris, have led them to believe; though the number of observations on which this impression rests is too limited to warrant my asserting it as a positive fact. Some cases, however, have come under my notice, in which the course of phthisis has been extremely rapid, and others in which the disease has continued for two, three, four, and nearly five years, before it terminated fatally. That form of acute phthisis in which the patient dies as the result of the constitutional malady rather than of local mischief going on in some one organ, is much oftener met with as a sequela of some other disease, such as measles, hooping-cough, or typhoid fever, than as an idiopathic affection. It follows sometimes on the decline of one or other of those disorders, and develops itself out of the convalescence from it, the fever not entirely subsiding, the appetite not returning, the strength not being regained, but the amendment which yesterday seemed to promise, being belied by the deterioration of to-day; and in such circumstances, a month or five weeks will sometimes bring the child to the grave, all its functions suffering so equally, that we feel at a loss as to the one to which we should endeavor chiefly to minister. But though less frequent, the cases are of greater moment, because they are more likely to be misinterpreted, in which this acute tuber- culosis develops itself out of a condition of previous health, though that health is oftener valetudinarianism than vigor. Causelessly, the child loses flesh,-and strength, and appetite, and cheerfulness; it frets about everything, but says it has no pain, that it ails nothing; nor is anything observable save that the pulse is habitually quicker, and the skin habitually hotter than natural. The nights are restless, though the child often wants to lie down in the daytime, and sometimes delirium comes on towards bedtime: while when awake there is a remarkable degree of nervousness, the manner is frightened, almost hysterical. Often this condition gradually passes away as symptoms of hydrocephalus come on, and the case loses its peculiarities as its hopeless nature becomes apparent; though not infrequently, if we exa- mine the body after death, we maybe surprised at finding the evidence of cerebral disease slighter than we had expected, and a little fluid in the ventricles, a little opacity of the arachnoid, and a few granula- tions at the base of the brain, may be all the alterations discoverable. In other instances the symptoms put on more and more the character of fever; the delirium becomes more frequent, and at last constant; 25 386 CASES IN ILLUSTRATION OF CHRONIC PHTHISIS. the prostration extreme, the tongue dry and tremulous, the teeth covered with sordes, and the abdomen full, tender, tympanitic, so that the distinction between the case and one of typhoid fever is almost impossible; and, indeed, the previous history of the patient, and the longer duration of the ailment, constitute almost the only means by which we can discriminate between them. This course of phthisis, too, is not limited to any age, but may even be observed in infants at the breast; and the extreme rarity of typhoid fever at so early an age, would in them still further raise the presumption that the symp- toms were due to the rapid development of tubercle. So little notice has been taken of the chronic form of phthisis in children, that it might be well to relate a few examples of it. In March, 1842, I saw a little girl, six years old, whose father had died of phthisis, and who had had a cough ever since she suffered from measles two and a half years before. Her mother's anxiety had been excited by the increase of this cough, and by the child's losing flesh during the few weeks previous to her coming to me. Auscultation at this time discovered that air entered the lung in the left infra-clavicu- lar region more scantily than in the right, and that the respiration was coarse, and attended with much creaking at the upper part of both lungs. In May, the general symptoms were much improved, and the creaking sounds were no longer heard. For many months the child continued to appear tolerably well, though her cough never ceased entirely; but in the early part of the winter of 1844 her health com- pletely failed. Examination of the chest in the beginning of Decem- ber elicited great deficiency of resonance at the upper part of the left lung, both in front and behind. Bronchial breathing, intermixed with large mucus rade, was heard in the left supra-scapula region, and abundant moist sounds pervaded the lung posteriorly. In the left infra-clavicular and mammary regions the respiration was very defi- cient, and accompanied with distant moist sounds. Extreme coarse- ness of the respiration was the only morbid sound heard at the upper part of the right lung, and the breathing on that side was puerile in other parts. In January, 1845, the child had slight haemoptysis, which recurred occasionally at intervals of a few weeks or months until her death, but was not profuse at any time. In September, 1845, reso- nance was slightly impaired under the right clavicle; and also in a greater degree posteriorly, as far as the angle of the scapula. There was absolute dulness of the left side, as far as the nipple in front, and the angle of the scapula behind. There was no natural breathing in the left lung, but the respiration was bronchial, and accompanied with large mucous rale as low as the nipple; the rale being smaller, and the admission of air scanty, below that point. About the left scapula there were cavernous sounds and distinct gurgling; smaller moist sounds lower down. In the right lung the respiration was puerile in front, except quite at the upper part, where the breathing was coarse, and attended with mucous rale; and posteriorly the same characters were still more marked. It cannot be necessary to detail the results of the subsequent exa- minations of the chest, which showed that disease advanced slowly CASES OF CHRONIC PHTHISIS. 387 in the right lung, though there was at no time proof of the existence of a cavity there. The child's condition fluctuated; sometimes she seemed almost dying under an aggravation of all the symptoms, and then again she rallied, and was able to walk about, and seemed toler- ably comfortable. Life was prolonged until June 1st, 1847; and she had seemed almost as well as usual until a very few days before her death. Unfortunately, permission to examine the body could not be obtained; but the stethoscopic signs enable us to trace back the phthisical disease for more than five years, while the evidence of a large cavity in the left lung was distinct twenty-one months before death took place. Nor is this a solitary case. In January, 1846, I saw a little boy, three years old, who had had cough ever since an attack of typhoid fever in the previous July; and for six weeks before he came under my notice his cough had grown more severe. There was then very marked flattening of the left side of the chest, which yielded a dull sound on percussion in the infra-clavicular and mammary regions; and air entered there very scantily. The same dulness existed on the left side posteriorly; and the scanty breathing was attended with a crumpling sound. In April, moist sounds were evident there; and in May they were becoming larger about the left scapula; and signs of incipient disease were now perceptible in the right lung. In Sep- tember, there was absolute dulness in the left infra-clavicular region, slightly diminishing towards the nipple, and absolute dulness in the left scapular region. Large gurgling was heard in this situation, most marked behind, and rendered very striking during a fit of coughing which was followed by expectoration of about a teaspoonful of pus. From this time to June, 1849, when I last saw him, he con- tinued nearly stationary. The child became considerably stouter than he was when he first came under my notice; but the cough and puru- lent expectoration continued. I auscultated his chest on September 26, 1847, and at that time loud blowing respiration was heard over the whole of the left scapula, accompanied with gurgling; while, lower down, there were large moist sounds, though not amounting to actual gurgling. From that time until August, 1848, the child's health con- tinued tolerably good ; he coughed but little, but suffered from occa- sional attacks of diarrhoea. The left side of his chest was much shrunken, and yielded a dull sound everywhere except just under the clavicle. Air entered but scantily; moist sounds attended it, but the evidences of a large cavity were growing less and less distinct. When I saw him for the last time, the amount of air entering the left lung was not increased, but the moist sounds had almost completely disap- peared. How long the disease may continue, or what may be the ultimate issue of the case, it would be useless to speculate on; though it is by no means unlikely that the child may live, with but little deterioration in his condition, until measles or hooping-cough imparts a fresh stim- ulus to the consumptive disease, or excites some fatal attack of bron- chitis or pneumonia. I used to see occasionally a little boy, who was aged only three years when he first came under my notice, and whom 388 CASES OF CHRONIC PHTHISIS. I had the opportunity of watching till he was eleven years old. When first brought to me he had been suffering from cough ever since an attack of what his mother called inflammation of the lungs, when he was sixteen months old: his cervical glands had recently suppurated; he had unusually well-marked hectic fever, and profuse night-sweats; and a month before I saw him had spit blood once. His right side yielded throughout a dull sound on percussion: breathing in that lung was scanty, and attended by large moist sounds. The child went into Devonshire to pass the winter, and, as I expected, to die there of phthisis; but he returned in better health; he grew tall, and played about like other children, though he seldom passed more than a few months without attacks of a pleuritic character, the pain of which he used to refer to his right side, and which usually subsided in the course of a few days, without any treatment more severe than a mustard-poul- tice, and some diaphoretic medicine. His cough never left him entirely; but both that and the quantity and character of his expec- toration varied, and sometimes he spat a little blood. In October, 1844, the auscultatory signs were as follows: The left lung yielded, as it had constantly done, the sounds of puerile breathing in front; posteriorly, the breathing in that lung was also good, except that there were some moist sounds in the infra-scapular region, and that the breathing had a coarse and almost tubular character about the upper angle of the scapula. In the right lung, in front, the respiration was puerile, with now and then a little distant crepitus, as low down as the lower edge of the second rib, at which point the moist sounds became larger. Posteriorly there were large moist sounds, intermixed with puerile breathing in the supra-scapular region; gurgling, cavern- ous breathing, and bronchial voice about the scapula; and lower down there was very little respiration, and that of a bronchial character, becoming quite inaudible in the lateral region. In the axillary region the respiration was coarse, accompanied with large mucous rales. In March, 1849, I saw him for the last time. He had then continued for more than eighteen months free from any serious pleuritic attack, and from haemoptysis. His respiration was still hurried, but he had gained flesh, and sometimes had walked five or six miles in a day without inconvenience. Auscultation showed too that his disease had been stationary for the previous five years—if, indeed, it had not actually improved. The moist sounds about the left scapula were smaller, and heard over a smaller surface. The indications of a cav- ity in the back part of the right lung continued unchanged, but not increased; while in other respects auscultation gave exactly the same results as before. Other cases of a similar kind have come under my observation, in which the history of phthisis went back for several years, and in which the signs of caverns in the lungs were unmistak- able; the children continuing to lead a sort of valetudinarian exist- ence, improving in health, and gaining flesh and strength in the summer, but losing ground again with the return of winter. In the present condition of our knowledge, it is not possible to state with certainty either the anatomical characters of phthisical cavities of long standing, or the signs which, during the patient's life- MODES OF DEATH IN PHTHISIS. 389 time, would warrant the expectation that the disease will run a tardy course; but it is well to bear in mind that such cases are by no means very rare; that the powers of repair are far greater in the child than in the adult. We must now, therefore, pass on to notice briefly the treatment of the disease, after glancing for a moment at the different modes in which it brings about a fatal issue. In a very large proportion of cases of phthisis, the functions of all the organs of the body become at length so much disturbed, and nutrition generally so impaired, that the patient dies, because the whole machine is worn out. But though this is the case in many instances, yet it often happens, even when the powers have long seemed nearly exhausted, and when the body is wasted almost to a skeleton, that death is far from tranquil, but is preceded by hours of severe agony, for which it is not easy to account. In many cases, and especially in those where the disease runs a rapid course, the fatal termination is due to an attack of intercurrent bronchitis or pneumonia, which is sometimes supposed to have been the patient's only disease, until a post-mortem examination reveals the tubercular degeneration of the lungs, to which the inflammatory affection was but secondary. Death from haemoptysis is rare, and still rarer is the perforation of the lung, by the walls of the cavity giving way at some point, and thus producing pneumothorax. The abdominal symptoms sometimes mask the thoracic, and the patient, who, had life been prolonged, would have sunk eventually under pulmonary phthisis, dies of tubercular peritonitis. Many children, in whom the signs of incipient phthisis have appeared, die of acute hydrocephalus, excited by the membranes of the brain having become the seat of tubercular deposits; and some, in whom the disease has attained a more advanced stage, are suddenly carried off by head symptoms, the cause of which is explained by the discovery of large masses of tubercle in the cere- bral substance. Convulsions, however, sometimes precede death for several hours,"or head symptoms of greater or less intensity constitute the most striking feature in the patient's history for some days before death takes place; and yet an examination of the body throws no light upon the cause of their occurrence. Sometimes too the symptoms that precede death are those of fever of a typhoid character, rather than of serious mischief in the chest. They were so in the case of a little boy, nearly seven years old at death, who had shown the symp- toms of phthisis for more than two years, and the right side of whose chest had during that time presented the indications of gradually increasing tubercular deposit. The disease had advanced slowly, and with long intermissions, though, on the whole, very obviously in- creasing. On November 8th there was a manifest aggravation of his chest symptoms, attended with much fever. On the night of the 12th his mind wandered, and, when sensible, he complained of his head. On the 14th he became delirious likewise during the day; and until his death, which did not take place before Dec. 1, his mind wandered during many hours of every day, while at night he was quite light- headed, extremely restless, and tried to get out of bed, or at other times shrieked loudly, as if in violent pain. In the early part of his 390 TREATMENT OF PHTHISIS. illness he had a frequent, short cough, which subsided as the febrile symptoms increased in intensity; but his respiration throughout continued at about fifty in the minute; and this hurried breathing, coupled with the auscultatory signs, afforded the only evidence of the mischief that was going on within the chest. After death the only morbid appearance of any importance was discovered in the upper lobe of the right lung. Its anterior fourth was perfectly solid and noncrepitant, of a yellowish-red color, owing to the infiltration of tubercle into it. Its posterior three-fourths were of a reddish color, and of a much softer texture; while the slightest pressure with the finger reduced their substance to a putrilage, from which there flowed a dirty reddish liquid, which seemed like a mixture of blood, and pus, and serum. Inflammatory softening of this lobe seems to have been the cause of death, though manifesting itself less by local symp- toms than by the signs of most serious constitutional disturbance. Though the study of phthisis, in its effects and its symptoms, has occupied us during almost the whole of two lectures, yet there need be but little said with reference to its treatment. The main principles by which we are to be guided in its treatment are the same at every age; nor do the differences in the patient's years bring with them many or important modifications in the means by which the principles are to be carried into action. Among the prophylactic measures adapted to early life, none is of more importance than the keeping the infant at the breast for the first twelve or eighteen months of its existence, by which time it will have passed through some at least of the dangers incidental to the period of teething. The task of thus nursing the infant, however, ought not to be undertaken by a mother who has shown any tendency to consumption, or in whose family consumptive disease has been prevalent, but ought at once to be intrusted to a healthy wet-nurse. This rule does not rest on mere theoretical grounds; but actual ob- servation has shown that under some morbid states of "the system the milk undergoes great changes, and loses much of its nutritive pro- perties. In the case of the cow, these changes have been ascertained by Dr. Klencke, of Leipzic, to be very remarkable; and analogical reasoning would warrant the belief that the scrofulous taint in the human subject may give rise to alterations of a similar kind. Dr. Klencke1 confirmed the observation of Sir Robert Carswell and others, that stall-fed cows are very liable to become tuberculous; and found, moreover, that in these circumstances their milk loses much or the whole of its sugar; that the butter and casein diminish, while albumen is found sometimes in as high a proportion as 15 per cent., and elain in the proportion of 1.4 per cent., and that in some cases lactic acid is likewise present. Even if we set aside the assumption of scrofulous disease being actually transmitted through the medium of the milk, of which there is perhaps no clear evidence, it is yet apparent that a very slight degree of such an alteration in its constituents as has just 1 Ueber die Ansteckung und Verbreitung der Scrofelkrankeit bei Menschen durch den Genuss der Kuhmilch, 16mo. Leipzig, 1846. See especially chapter iii. pp. 21-61. TREATMENT OF PHTHISIS. 391 been mentioned must render it very unfit for the nutriment of a delicate infant. It is needless to dwell here on the general rules for feeding and clothing children as they grow older, or to insist on the necessity for the bedrooms being airy and well ventilated. When the damp and cold weather of winter approaches, removal to a warm climate, in which exercise in the open air may still be continued, is much to be preferred to keeping the child for weeks together a prisoner to the house; and as a general rule more is gained by change of climate in early life than in adult age. In children who are old enough to be taught to wear it, I have sometimes seen the respirator of much ser- vice, in enabling them to continue to take exercise in the open air at a season when, in previous years, exposure to the external air had always induced or greatly aggravated the signs of bronchial irritation. Whenever catarrhal symptoms appear, no care can be too great to bestow on the attempt speedily to remove them. In doing so, how- ever, and in the management of all ailments that come on in children who have shown a disposition to consumptive disease, much caution must be used, in order to avoid over-treating them. On this account it is of extreme importance to encounter them at their very com- mencement, when mild measures will suffice for their cure; and, for the same reason, the child should be defended with the most puncti- lious care from the contagion of hooping-cough and of the eruptive fevers—diseases in the course of which serious thoracic complications are so apt to supervene, and to require for their cure most active treatment. In carrying out this plan of unwearied watchfulness, and of atten- tion to minute detail continued for months and years, you will have brighter hopes with children for your patients, than if you were called on to exercise similar precautions in the case of persons more ad- vanced in life. Without raising baseless expectations, too, you may communicate something of hope to the parents, and thus lighten for them their anxious task; nor will the appearance even of decided physical signs of tubercular deposit, nor the evidence that in some parts that tubercle is softened, warrant an absolutely hopeless prog- nosis. Cases such as have been related show how long life may be prolonged in circumstances the most inauspicious; and, where speedy death has been expected, an unlimited reprieve seems almost a pardon. It may suffice to have said thus much about the management of phthisis in childhood; for when the disease is actually developed, we have the same indications as in the adult, and these must be met by similar means. Iron, quinine, and the mineral acids are the most important of our tonic remedies; and for these the extract of bark and the extract of logwood may be substituted, if much tendency exist to a relaxed state of the bowels. In cases where the glands of the neck are affected, and where there seems to be reason for supposing that the disease approximates to bronchial phthisis, the syrup of the iodide of iron may be employed with advantage. Such cases too have seemed to me to profit most by the cod-liver oil; though I must con- fess that my own experience of it does not altogether bear out the 392 TREATMENT OF PHTHISIS. high encomiums which have been bestowed upon it by some practi- tioners. Sometimes I have known it excite diarrhoea; at other times it completely spoils the appetite; while, as a general rule, I think it is not borne well in cases where dyspeptic symptoms are, as is so often the case, at all a prominent feature in the disease. Sometimes too the child's repugnance to the remedy is unconquerable; though this does not often occur. If given in a little orange wine, or orange juice, sweetened with syrup of orange-peel if necessary, its taste is in gene- ral perfectly disguised; while sometimes, nauseous though the oil is, children become really fond of its flavor. The sickness and the paroxysmal cough are best relieved by the hydrocyanic acid, with which the liquor cinchonae of Mr. Battley may be combined,1 in cases where we are afraid to venture on any but the mildest tonics. Among local measures, the use of stimulating liniments to the chest is even more valuable in early life than in the adult; and sometimes the ap- plication of a blister about the size of a shilling, under one or other clavicle, and its frequent repetition, are followed by a very great amendment in the patient's condition, and by a marked improvement in the physical signs furnished by the subjacent lung. I have very rarely employed local depletion, except in the treat- ment of the pneumonia which so often attacks the phthisical patient; but it has then seemed sometimes to be of great service ; and it will probably be safer to trust to a moderate abstraction of blood by leeches, followed by small doses of antimonials, than to administer mercury, or to give antimony in larger doses without previous deple- tion. The habitual cough of phthisis requires small doses of ipecacu- anha wine, combined or not with antimony, and laudanum, or compound tincture of camphor, in small doses—remedies which, on account of their strength being definite, are always to be preferred, in the man- agement of the affections of childhood, to a preparation so variable as the syrup of poppies. Opiates in various forms, and for various pur- poses, may be needed to check diarrhoea, or to relieve suffering; and you must not allow any preconceived notion of the danger of employ- ing opium in infantile diseases to prevent your having recourse to so valuable a medicine. We must here leave this subject, so full of painful interest, and proceed at our next lecture to the study of diseases of the heart in early life. 1 See Formula No. 20, p. 365. Another very useful formula in these cases, and one which has the further advantage of forming a very agreeable vehicle for the cod-liver oil, is the following :— (No. 21.) $.—Acid. nitr. dil. n\xvj. ----Hydrochlor. dil. TTLxxiv. ----Hydrocy. dil. trivia. iEtheris chlorici Tt^xl. Trse. aurantii 5iss. Syrupi simplicis 3ij- Aquae destillatae ad §iv.—M. 3iv 6tis horis. For a child four years old. DISEASES OF THE HEART. 393 LECTUEE XXX. Diseases of the Heart—rarer in childhood than in the adult, and why—but rarity probably exaggerated. Causes of disease of the heart in childhood, rheumatism the most frequent—heart sometimes affected when rheumatic symptoms are very slight—both endocarditis and pericarditis may come on independently of rheu- matism—as sequelae of scarlatina or other fevers—as consequences of congenital defects—as complications of pleurisy—or as purely idiopathic affections—cases illustrative of pericarditis in different circumstances. Endocarditis—symptoms not always well marked—advance of valvular disease some- times very gradual.—Doubt as to whether valvular disease is not sometimes in- dependent of previous inflammation. Prognosis in valvular disease—less unfavorable in child than in adult—power of growing heart to adapt itself to effects of disease and to repair its evil. Anaemic bruits much rarer in early life, but disordered action of heart occurs at all ages.— Summary of conclusions. Among the many causes of suffering and death to which persons in adult age or advancing years are exposed, diseases of the heart and great vessels occupy a very prominent place. The frequency of these affections is, indeed, but very imperfectly shown by our tables of mor- tality, which represent them as occasioning less than one and a half per cent, of the total deaths at all ages in the metropolis; but we know that in a large proportion of cases of rheumatism, asthma, bron- chitis, and dropsy, the real cause of the fatal event is to be found in the cardiac mischief with which those maladies are so often associated. In childhood, however, many of the most influential cause of heart disease are of comparatively rare occurrence; rheumatism is popularly regarded as an affection almost confined to youth and early manhood, as granular degeneration of the kidney is to adult and declining age; while all those forms of atheromatous deposit in the coats of arteries, or in the substance of the valves of the heart, which are a fertile source of suffering, and in their consequences a frequent cause of death, be- long essentially to the processes of decay which accompany the decline of life. But though heart disease is confessedly less frequent in the child than in the youth or in the adult, yet its rarity is not so great. as, judging from the silence concerning it of many writers on the dis- eases of childhood, you might naturally infer. The advance of know- ledge too brings with it every year some fresh illustrations of the occurrence of heart disease in early life, in circumstances where it once would not have been expected. Rheumatism, if less frequent than in the adult, is yet associated with affection of the heart in a greater proportionate number of instances in the child.1 The state of 1 This statement as to the greater comparative frequency of affection of the heart in the course of rheumatism in childhood, may seem to be scarcely borne out by hos- 394 CAUSES OF DISEASE OF THE HEART. the circulating fluid which attends and follows scarlatina seems to pre- dispose to inflammation of the lining or investing membrane of the heart in childhood, in the same manner, though not to the same ex- tent, as does the state which accompanies Bright's disease in the adult. In themselves too, and in their complications, congenital malforma- tions constitute a large class of affections of the heart peculiar to early life; while the microscope has already taught us that fatty degenera- tion of the heart may occur in the infant of some months old, as well as in the man of sixty years. Not many years since it would have been necessary to adduce statistical evidence in support of the asser- tion that disease of the heart was far from being of infrequent occur- rence in early life. This, however, is no longer requisite, for the fact is universally admitted; and I may add that the forty-three cases of disease of the heart, on which the following observations are founded, do not represent much above half of the total number that, during the past twenty years, have come under my notice. Of the above mentioned 43 cases, 17 were instances of pericarditis, either] alone or associated with inflammation of the endocardium, 22 were cases of endocarditis; and 4 of dilatation or hypertrophy of the heart, uncombined with valvular disease. I have purposely excluded from consideration cases of mere malformation of the heart, since, in- teresting though that subject is, it yet is one on which it would be foreign to my purpose to enter. * It would, I conceive, answer no useful end to occupy your time with a minute detail of those characters, either of pericarditis or of inflammation of the endocardium, which are common to all ages, while at the same time it may be of some advantage to point out to you any special difficulties which you may encounter in detecting these affec- tions in early life, and any special circumstances which should make you anxiously watch for their occurrence. In 5 cases of pericarditis, in 2 of acute, and in 4 of chronic endo- carditis, and in 2 more in which both the pericardium and endocar- dium were involved—making a total of 13 out of 39 cases, or exactly 1 in 3—rheumatism was either certainly known, or alleged on good grounds, to have been the starting point of the mischief. Warned by what is known of the tendency of rheumatism to involve the heart, you are not likely to overlook the symptoms of cardiac affection, when fever, and pain, and swelling of the joints, announce the child's illness to be of a rheumatic character, and you will be inexcusable if, in such circumstances, pericarditis or endocarditis escape your obser- vation. But if you will always avoid this error, you" must bear in mind that, in the child, the heart is sometimes affected, even in cases where the extreme mildness of the general rheumatic symptoms would, pital statistics in general. Dr. Fuller, for instance, at p. 274 of his work on Rheuma- tism, 8vo. London, 1852, states the heart to have been involved in 12 out of 22 cases of rheumatism occurring in subjects under 15 ; while the frequency at all ages amounted to 187 out of 379. General hospitals, however, receive very few children under 12; while further, in many of the cases of rheumatic affection of the heart in childhood, the fever and pain and swelling of the joints are so inconsiderable, as to excite little anxiety on the part of the parents, and not to lead them to seek admission for their children into a hospital. CAUSES OF DISEASE OF THE HEART. 395 if your patient be an adult, leave no room for the least apprehension on that score; and that the comparatively slight degree of fever, the small amount of pain in the limbs, and the almost complete absence of swelling of the joints, afford no guarantee that the heart may not become the seat of serious disease. It happens too, less rarely in the case of children than of the adult, that the general indications of rheu- matism follow the heart affection instead of preceding it; so that fever with hurried circulation and distinct friction sound, or endocardial murmur, may exist for two or three days, or even longer, before the occurrence of pain, and tbe appearance of swelling of the joints show that the disease of the heart is only a part of the great malady which has attacked the whole system. Every threatening of rheumatism, therefore, is to be watched with the most anxious solicitude in the young subject, since so serious a complication as disease of the heart may accompany extremely slight general symptoms. Nor must auscultation be neglected in cases of what may seem to be simple fever, since rheumatic inflammation may attack the heart before any other signs of rheumatism have manifested themselves. In 2 cases of pericarditis, in 3 of acute, and 1 of chronic endocar- ditis, or in 6 out of 39 instances, the disease of the heart was traced to an attack of scarlet fever. The cardiac symptoms did not manifest themselves in the acute stage of the affection, but during the progress of desquamation. They were accompanied by fever and anasarca, which, however, did not exceed mere puffiness of the face and ex- tremities, until in two iustances of pericarditis, both of which ran a chronic course, dropsy came on as the consequence of the heart disease. Acute endocarditis supervened in one instance on the decline of the eruption of measles, and was associated with pneumonia, of which the patient died. In two other cases of chronic valvular disease, the symptoms of heart affection developed themselves gradually after con- valescence from measles in one instance, after recovery from typhoid fever in the other; and these, as well as the cases in which disease of the heart supervened during the course of scarlatina, are doubtless to be referred to the category of cardiac disease dependent on an altered state of the circulating fluid, and suggest an additional ground for carefully watching your patients during their convalescence from any form of fever. Congenital malformation of the heart seems to have an important, though not perhaps an easily explicable, influence in predisposing to inflammation of its valves, or of its investing membrane. Thus in one case of acute pericarditis, in one of chronic pericarditis with affec- tion of the endocardium, and in two others of old-standing valvular disease, there was some malformation of the heart which must have existed from birth, though in two instances the symptoms did not appear till long afterwards. In one of these two cases they came on gradually, rather more than two months before the death of the child at eight years old ; in the other, they were first observed at three years old, and death took place at the age of fifteen years. It is well, then, 396 OBSCURITY OF SYMPTOMS OF PERICARDITIS. in cases of heart disease the origin of which is obscure, to bear in mind this possible cause of the affection, and the rather since this consideration may control our treatment, and keep us back from the employment of overactive measures against an ailment which may owe its origin to some cause utterly beyond the power of medicine to remove. Three of the five remaining cases of pericarditis appeared to depend on the extension to the pericardium of inflammation beginning in the pleura; an occurrence which, though not peculiar to early life, is, I believe, more frequent then than at a later period, and also oftener overlooked, from the child's restlessness and distress rendering all attempts at careful auscultation of the front of its chest impracticable. To be aware of the possibility of this occurrence will do much towards preventing you from overlooking it. One case of simple pericarditis, and one of pericarditis coupled with inflammation of the endocardium, and six of endocarditis, were not clearly traceable to any exciting cause, and may therefore be regarded as idiopathic. In two out of the four cases, also, of dilated and hy- pertrophied heart, unconnected with valvular disease, the symptoms supervened gradually, and were not preceded by serious illness of any kind. I do not know of any special symptom of acute inflammation of the pericardium in early life, but I am,sure that it is often overlooked when present; and this, partly from the child's restlessness, partly from its being masked in many instances by the signs of other dis- ease in the chest. To this latter cause it was probably due that I did not detect pericarditis complicating pleurisy of the left side, in a boy six years old, though on his death, two years afterwards, I found a patch of old lymph on the left ventricle, near the apex of the heart, and a good deal of old white lymph coating the right auricle, and white spots at several points about the base of the heart, showing that the pericardium had been the seat of extensive inflammation. The affection of the pericardium was doubtless here, and is probably in most of these cases, secondary to that of the pleura, since the pro- ducts of a far more advanced inflammation are in general found in the latter cavity than in the former. In some instances the two serous membranes would seem to have become affected simultaneously, while in others the indications of pericarditis are perceptible before those of pleurisy appear. In one of four cases which terminated fatally, the patient, a little girl aged sixteen months, was almost moribund when she came under my notice: convulsions came'on in two or three hours, and she died after they had continued for twelve hours. In this instance the attack had commenced eight days previously, with violent sickness followed by severe febrile disturbance and great dyspnoea, though by but little cough. In the second case, that of a little girl aged three and a half years, slight cough and febrile symp- toms had existed for nearly a fortnight, when they suddenly, and without any obvious cause, became greatly aggravated; the cough grew constant, short and hacking; the respiration rose to 72, the pulse to 156 in the minute. The child became extremely restless, CASES OF ACUTE PERICARDITIS. 397 appeared to suffer much, made frequent efforts to vomit, and often crammed her hand down her throat, as though to pull something away which obstructed her breathing. In neither of these cases was the existence of pericarditis suspected. In the last-mentioned case the restlessness of the child precluded careful auscultation; but dulness on percussion, and bronchial breathing, were perceived through the whole of the posterior part of the left side of the chest, and small crepitation was heard on the right side. In a third case, a little boy, seven months old, died in extreme distress at the end of four days, during which his restlessness was extreme, and his cries were con- stant. Auscultation was almost impossible, owing to his extreme disquiet, but after death the lungs were found free from disease; but recent lymph was deposited on both layers of the pericardium, and its sac contained sero-purulent fluid. It was interesting also to observe, on removing the recent lymph from the heart's surface, that the vis- ceral layer of the pericardium was opaque and thickened, and of a dead white color, the evidence of a former attack, which probably took place when the child was three months old, at which time he was alleged to have had pneumonia. In the fourth case, the patient was a little girl five and a half years old, who was reported to have had frequent attacks of inflammation of the chest, but who was in good health at the time of her being seized with vomiting, followed by pain in the head, stomach, and back ; and cough with great fever. These symptoms had continued for three days when she came under my notice. Her face was then anxious, her skin very hot, pulse frequent, quick, and wiry, respiration hur- ried, and she had almost constant hard cough, which occasioned pain at the epigastrium. She complained of pain in the left side, and across the chest. General subcrepitant rale was heard through the whole chest. There was extensive dulness in the prascordial region : a loud, rough, bellows murmur accompanied the first sound of the heart at the apex, and a similar sound was distinguished at the base, where it was suspected to be the commencement of a to-and-fro sound. The child was bled from the arm, leeches were applied over the heart, and two grains of calomel, with one-sixth of a grain of tartar-emetic, were given every three hours; but on the following day her general condition was unchanged—the bruit with the first sound of the heart continued at the apex, and that at the base was now a distinct to-and- fro sound; in addition to which, a loud, pleural friction sound was heard over- both sides of the chest posteriorly. The remedies were continued; but by the next day the child's condition had deteriorated. The results of auscultation were much the same as before, but the pleural friction sound had almost completely disappeared, and percussion yielded a dull sound in both infra-scapular regions. Cir- cumstances prevented my watching the child during the ensuing forty-eight hours, at the end of which time she died—eight days after the commencement of her illness. A post-mortem examination was not made; but there can be no doubt but that it would have disclosed appearances similar to those observed in the other two cases, except that probably evidences of inflammation of the endocardium would 398 DIAGNOSIS OF ACUTE PERICARDITIS. have been associated with those of pericarditis, and that the affection of the pleura would have been found to be secondary to, and less ex- tensive than, that of the heart. There is little danger, in cases which set in with symptoms so severe as those just described, of our falling into serious error, either of diagnosis or of treatment. Everything will point to most serious mischief in the chest; and even should the tender age of the child and its extreme restlessness, prevent careful auscultation, or should the signs of heart disease be masked by those of mischief in the lung or pleura, enough will yet be discovered to show the necessity for immediate and active interference; while, if we bear in mind the possibility of such a complication, that will go far towards preventing us from overlooking its occurrence. I have seen two other instances in which pericarditis secondary to pleurisy supervened in the course of scarlatinal dropsy; and if from these I could deduce any additional sign to guard you against over- looking the pericarditis, it would be that furnished by very marked orthopncea. In one case—that of a little boy aged one year and eleven months—this was especially remarkable; for while in other respects his condition varied much and frequently, and the signs of thoracic mischief differed greatly in their urgency, he constantly maintained the sitting posture, and always most strenuously resisted any attempt to lay him down. This peculiarity continued during an illness of many weeks, and did not cease till his powers completely failed with the approach of death. Concerning rheumatic pericarditis I have no additional remark to make; but on account of its rarity it may be worth while to relate to you a case in which acute inflammation of the pericardium occur- red in a little boy who was four months old at his death, and in whom free communication existed between the two sides of the heart. He did not come under my observation until the day on which he died; but the history which I heard of him was, that he was very livid at birth, that respiration was established with difficulty, and that the dark hue of his surface never went off completely. At times he seemed cheerful, and used to breathe pretty well, but at other times he was seized, without apparent cause, with difficult respiration, during which he became very cold and quite purple, made a grunting noise, and frothed at the mouth. These attacks never came on while he was sucking: they were preceded by crying, though usually he was very quiet. On October 19th, 1848, an attack came on, similar to the previous seizures, though more severe, lasting between one and two "hours, and not being preceded by crying. On the 20th a similar attack came on, and lasted from 4 to 7J P. M., and another returned on the morning of the 24th, at noon of which day he was brought to me. His surface was then generally very pale, but with a marked livid hue of the lips and fingers, and around the mouth. His skin was cool, almost cold, his respiration irregular and very frequent, and his pulse extremely feeble. Auscultation detected no unnatural sound with the heart's action. IDIOPATHIC PERICARDITIS. 399 As he was being carried home a fresh seizure came on, and proved fatal in half an hour. The lungs and pleurae generally were healthy. The pleura, where it is in contact with the pericardium, and that membrane itself, were of a bright red color, with the vessels minutely injected. The sac of the pericardium contained Ij of a dirty, yellow- ish sero-purulent fluid, in which little granules of lymph, like minute grains of rice, were floating. It did not anywhere adhere to the heart, but its parietal layer, which was intensely red, and beset with nu- merous little ecchymoses, was lined through a great extent by a thin layer of lymph. This layer was thicker on the right than on the left half of the pericardium, and especially so about the right auricle. Lymph was also deposited between the left auricle and the root of the pulmonary artery. The pericardium investing the heart was intensely red, and nu- merous small flocculi of lymph covered its surface. Besides this, there was an old white spot, half an inch long by a quarter of an inch broad, at the apex of the left ventricle, having just the character of the white spots of old pericarditis; and there was another small spot on the posterior surface of the right auricle. The foramen ovale was wide open, so as to admit the finger with ease; the pulmonary artery was very small; the ductus arteriosus wide open, and the septum of the ventricle very imperfect: the duc- tus venosus was closed. Reference has already been made to the occasional occurrence of inflammation of the investing or of the lining membrane of the heart independent of any other disease, and unassociated with inflammation of the lungs or pleura. In such cases the indications of disturbance of the respiration are either altogether absent, or comparatively slight, and if auscultation be neglected, or but carelessly performed, disease may, in such circumstances, go on unchecked till it has disorganized the heart, and doomed the patient to a life of remediless suffering. A striking instance of this idiopathic inflammation of the pericardium and lining membrane of the heart came under my notice some time since, in the person of a healthy boy, eleven years old, who, on May 8th, 1843, complained of feeling cold, and began to cough. The chilliness was succeeded by fever, and he continued gradually getting worse till the 13th, when I visited him for the first time. He had had no other medicine than a purgative powder. On May 13th, I found him lying in bed; his face dusky and rather anxious, his eyes heavy, and his respiration slightly accelerated; coughing frequently, but without expectoration; skin burning hot; pulse frequent and hard. He made no complaint, except of slight uneasiness about the left breast. On examining the chest there was found to be very extended dulness over the heart, with slight tenderness on pressure. A very loud and prolonged rasping sound was heard in the place of the first sound, loudest a little below the nipple, though very audible over the whole left side of the chest, and also distinguishable, though less clearly, for a considerable distance to the right of the sternum. The second sound was heard clearly just over the aortic valves, but was 400 IDIOPATHIC PERICARDITIS. not distinct elsewhere, being obscured by the loudness of the bruit. Respiration was good in both lungs. The child was cupped to six ounces between the left scapula and the spine; and a grain of calomel, with the same quantity of Dover's powder, was given every four hours. On the following day it was found that the sense of discomfort in the chest had been relieved by the cupping, and that the child had slept well in the night. He looked less anxious, though his eyes were still heavy and suffused, and his skin was less hot and less dusky. His pulse was 114, thrilling, but not full. There was now slight prominence of the cardiac region, and the heart's sounds were ob- scurer and more distant than on the previous day. The bruit was now manifestly a friction sound, louder at the base than at the apex of the heart, and altogether obscuring the first sound; while the second sound could be heard over the aortic valves. Six more leeches were applied over the heart, and hemorrhage from their bites was so pro- fuse as to occasion some faintness. Mercurial inunction was now superadded to the treatment previously employed, and the child's condition continued through the 15th to be much the same as it had been on the previous day. On May 16th there was some improve- ment in the general symptoms, and the pulse was softer. The friction sound was now no longer audible, but a loud rasping sound was heard in the place of the first sound. The second sound was now distinguishable at the apex of the heart, as well as over the aortic valves, and its characters were quite natural. On the 19th the child's mouth was slightly sore, and the dose of the remedies was diminished. On the 22d, the soreness of the mouth was considerable, and all active treatment was discontinued on that day. The child gradually re- gained his strength, but the bruit accompanying the first sound con- tinued, and was heard a month afterwards, with no other change than being rather softer and more prolonged. Four years afterwards I saw him again. He had continued well in the interval, and had never suffered from palpitation of the heart, nor from any other ailment referable to the chest; but his pulse was small, jerking, and not always equal in force; and the natural character of the first sound was altogether lost in a loud prolonged bruit. In such cases as this the occurrence of the heart disease is not easy of explanation. No sign of rheumatism appeared during the whole course of the affection, nor was it associated with any other disorder, such as scarlatina, which by the alterations that it induces in the composition of the circulating fluid, could be supposed to favor the supervention of inflammation of the heart or other viscera.1 The organs of respiration were unaffected throughout, so that the case could not for a moment be conceived to be one in which the heart disease was secondary, and produced by the extension of the inflammation beyond the limits by which it was originally circum- scribed. But though the cardiac affection came on independently 1 As Bright's disease, for instance, in the adult favors the occurrence of pericarditis, according to the elaborate researches of Dr. Taylor, in vol. xxviii. of the Medico- Chirurgical Transactions. IDIOPATHIC ENDOCARDITIS. 401 of those conditions, which we regard, and with justice, as usually essential to its production, it run as acute a course, and produced injury as extensive, as if it had been excited by any of its ordinary causes. Idiopathic pericarditis, uncomplicated with pleurisy, and sufficiently severe to give rise to symptoms appreciable during the lifetime of the patient, is certainly a very rare occurrence. Unfortunately, I cannot speak with accuracy as to the frequency in early life of those slight inflammations of the pericardium which give rise to the white spots upon its surface, shown by M. Bizot and Mr. Paget1 to be so common in the adult; for I have not always recorded their presence or absence in my notes of dissections. My impression, indeed, is, that while they are rarer in early life than in the grown person, they are much more frequent than the general silence with reference to their presence would lead one to infer, and as the two instances already mentioned, in one of which spots were found on the heart of an infant aged four months, and in the other opacity and thickening of the pericardium in a child aged seven months, and which probably dated back to three months, show. • The total number of cases in which endocarditis, either acute or chronic, was present, was thirty-three. In eleven of these its symp- toms were masked, more or less completely, by complication with pericarditis ; while in the remaining twenty-two instances the affection of the endocardium existed alone. Nine of the twenty-two cases of uncomplicated endocarditis were attended with acute symptoms, while in the remaining thirteen the affection presented itself in a chronic form. In three of the acute cases the disease of the heart came on in the course of rheumatism, and in two it succeeded to scarlatina. In all five of these cases the signs of heart-affection manifested themselves with considerable severity, and consisted in uneasiness about the heart, palpitation, increase of its impulse with inequality of its pulsations on one occasion, irregularity of its action on another; dyspnoea and occa- sional orthopncea. Symptoms so marked as these compelled attention to the condition of the chest, and auscultation at once detected the loud bruit of endocardial inflammation. In the case in which endocarditis accompanied measles its symptoms were masked by those of the pneumonia with which it was associated, and in the instance where it succeeded to convalescence from that dis- ease, no urgent symptoms appeared; while in the two cases of acute idiopathic endocarditis, though there was much heat of skin, some acceleration of breathing, and some increase of the heart's action, yet neither the general nor the local symptoms were at all more urgent than are constantly observed in attacks of simple fever, or of influenza in childhood. In other cases, where the patient did not come under my notice till after the evil had reached a chronic stage, there was so little history of any acute attack of illness preceding it, as to render it impossible to fix the exact date at which it began. It seems, then, Memoires de la Societe Med. d'Observation, tome i. p. 350; and Medico-Chirur- gical Transactions, vol. xxiii. 26 402 TENDENCY OF VALVULAR DISEASE TO INCREASE. that just as in rheumatic endocarditis, the symptoms may vary in degree, and be in one case so severe as to force themselves upon our notice, and in another so slight as almost to elude our observation, so it is in cases where the endocarditis is idiopathic. In cases of acute rheumatism you are aware of this danger; you do not wait till the patient's sufferings inform you that the mischief has been done, but you are on the watch against the first threatenings of its approach, and your sense of hearing gives you earlier information, and surer information, concerning this than all the other signs together. But if the same evil against which you guard thus studiously in cases of rheumatism may occur independently of it, and may scarcely give warning of its approach until it is almost or altogether too late to cure, a measure at least of the same precaution should be observed at all times; and in no instance of febrile disturbance in early life, how simple soever the case may seem, should you consider the examination of the patient complete until after auscultation. With all your care, there will probably still be cases in which the commencement of the heart-affection will escape your notice; in which you will accidentally make the discovery of its existence when auscultating the chest for some other purpose, or in which the gradualsupervention of the signs of valvular disease will call your attention to it long after the ailment has become chronic. The early detection of the disease is of the more importance, since its gradual approach affords no assurance that it may not go on to ruin the health, and at length to destroy the life of the sufferer. Nothing could be more gradual than the advance of the early stages of the disease of the heart, in the case of a little girl, ten years old, who came under my notice in the month of March, some years ago. Her mother stated that, though not robust, she had never had any definite illness, but that for the last year she had been growing thinner, and had suffered from palpitation of the heart, which had by degrees be- come more and more distressing, and that for the past three months she had likewise been troubled with cough. The child, when brought to me, was greatly emaciated; her face was anxious and distressed; her breath short, so that it'was with difficulty that she walked even a short distance; she had frequent short cough, without expectoration, and she suffered much from palpitation of the heart, and a sense of discomfort at the chest. The heart's action was violent; dulness in the praecordial region was extended ; a very loud, harsh, rasping sound accompanied the first sound of the heart, loudest towards and to the left of the nipple, but heard over the whole of the chest, both before and behind. Various remedies brought slight but temporary relief to her sufferings, and she grew worse every month. She became more and more emaciated; the distress at the chest and the palpitation of the heart increased; her cough became more violent, and once she had an attack of haemoptysis. For about a month before her death, the cough altogether ceased, but she was now unable to leave her bed, from increasing weakness; the palpitation continued unmitigated, and her extremities became slightly anasarcous. During the last week of her life, her respiration was extremely difficult, and became increas- NOT ALWAYS DUE TO INFLAMMATION. 403 ingly so till she died, on the 10th of October. The lungs were very emphysematous, and much congested, but not otherwise diseased. The heart was extremely large, but its right cavities did not exceed the natural size; the pulmonary valves were healthy; the edges of the tricuspid valve were slightly thickened ; the left auricle was enor- mously dilated, but its walls were not at all attenuated ; the pulmonary veins were much dilated; the left ventricle was dilated, its walls were thickened; the chordae tendineae of the mitral valve were greatly shortened, so that the valve could not close; the valve itself was shrunken, thickened, and cartilaginous; and there existed likewise slight thickening of the edges of the semilunar valves of the aorta. The symptoms in this case, from the earliest period to which the patient's history goes back, were those of chronic valvular disease with hypertrophy and dilatation of the heart; but no clue is afforded us by which we can guess when the inflammation of the endocardium, probably the first in this train of evils, attacked the heart. The con- stitutional disturbance which attended it was so slight as to escape the mother's notice, and to call for no special complaint from the child; but it is likely that more watchful care would have taken the alarm at some comparatively slight feverish seizure ; that auscultation would have discovered the disease at its commencement; and that treatment would have diminished, though it might not have altogether prevented, the subsequent disorganization of the heart. I have referred to endocarditis as having been, though undiscovered, still the probable cause of the disease of the heart in this instance. But yet there is another explanation of the mischief, and one which some other cases of chronic valvular disease, that I have either watched during life or examined after death would admit of, namely, that the mischief has been produced by some other than an inflammatory pro- cess. We know that this may be the case in the adult; and equally so, T apprehend, in the child; nor is the fact of less practical moment in the one case than in the other. In each instance it influences our treatment, and warns us not to be too active in the use of antiphlo- gistic measures, nor too pertinacious in their continuance, and suggests the probability that what we discover is only the sign of some long- past mischief.1 It is true, indeed, that in very many instances the disease of the valves goes on, as in the poor child whose case I have just related, from bad to worse; inflammation in some instances recurring at inter- vals, and adding something each time to the previous mischief; or the disorganization of the heart advancing slowly but with uninter- rupted course. But, nevertheless, the added experience of each year brings to my notice, more and more frequently, instances in which the signs of cardiac mischief remain stationary, and the sufferings of the child grow less with its increasing years. Nor is it, probably, that in these cases the disease simply does not advance, but many things 1 This supposition, which clears up what otherwise would be very obscure with refer- ence to the cause of some cases of chronic valvular disease, is, as probably scarcely need be stated, propounded by Dr. Stokes in his recent work on Diseases of the Heart, 8vo. Dublin, 1854. See page 146, and following pages. 404 POWER OF THE GROWING HEART seem to show that there is, as Dr. Latham suggests, " a certain protec- tive power possibly inherent in the growing heart, whereby it can ac- commodate its form and manner of increase to material accidents, and so repress or counteract their evil tendencies." Dr Latham1—whose name I cannot mention without the expression of respect and gratitude due to one to whose instructions I owe so much—relates, in illustration of this fact, the history of two young ladies in whom the auscultatory signs of valvular imperfection ex- isted from early childhood, but who never suffered any important disturbance of the general health that could be attributed to it. In- stances still more striking have come under my own observation, in which, not only were the signs of heart disease present, without the evil results that might be apprehended from it, but in which the suf- fering lessened with advancing years; though auscultation still gave assurance that its cause persisted. A little girl, six years old, whose health had never been robust, and who had suffered much from mea- sles and scarlatina, the latter of which left her liable to attacks of what was said to be inflammation of the chest, came under my notice at the end of April, 1846. She was then laboring under urgent dyspnoea, with symptoms of acute bronchitis and, in the course of auscultation, a systolic murmur was heard at the apex of the heart. The bronchitic symptoms by degrees subsided, but dyspnoea continued; the child was wholly unable to rest, except when propped nearly up- right ; she was distressed by palpitation; her cough was frequent, and when worse than usual, she expectorated with it small quantities of florid blood. Her face was pale, but with a livid flush on either cheek; the carotids pulsated visibly, and the jugular veins were distended, while her heart beat at the rate of 150 in the minute. The heart's impulse was increased, and dulness in the praecordial region extended far beyond its proper limits. It was next noted that the smallness of the pulse corresponded ill with the laboring of the heart; and a dis- tinct sense of fremissement, when the hand was laid upon the prascor- dial region, completed the signs of great contraction of the mitral orifice, with hypertrophy and dilatation of the heart. From time to time the child suffered much since then with a return of her old symp- toms ; and, after the lapse of twenty months, the bruit still continued: the hand placed upon the cardiac region was still sensible of a distinct purring tremor, and the pulse was exceedingly feeble. But the heart no longer labored as it used to do; its pulsations did not exceed 110 in the minute, and though the child was still unable to lie flat in bed, the distressing orthopncea had ceased for many months. Her eyelids were no longer puffy, nor her limbs anasarcous, as they were before; her cough troubled her but little, and haemoptysis was very rare. She had gained flesh, was cheerful, and played, though not so boisterously as other children might do, yet with such heartiness, that I could scarcely believe her to be the little suffering thing for whom, a year before, one would have chosen speedy death as the happiest lot that could befall her. 1 On Diseases of the Heart, vol. i. pp. 241-3. TO CHECK ITS PROGRESS. 405 Nor was this gradual recovery of the heart from serious injury less striking in the case of the boy whose history I related to you as an instance of idiopathic pericarditis and endocarditis. Not only did he continue well four years after his recovery, but I saw him again ten years after it, he being then twenty-one years old. The heart's im- pulse was still considerable; the sound continued long and loud and rough, but the young man had no other ailment than occasional palpi- tation, and sometimes slight sense of discomfort at his chest: and this, although he was leading a loose kind of life—strolling over the country as a ballad-singer, often getting wet, and walking long distances of twenty miles and upwards in a day, and this, as he said, without fatigue. Other cases of a similar kind, though less remarkable than these two, have come under my notice, cases which would warrant, I think, a more hopeful prognosis in cases of disease of the heart in childhood than we should be justified in entertaining if our patient were an adult. At the same time, however, it must be borne in mind that the presence of a bruit with the heart's sounds in the child depends more invariably on organic disease than in the adult; inasmuch as those endocardial, arterial, or venous murmurs which are produced by an impoverished state of the blood are very rarely indeed heard in children under seven years old, and are by no means common until that age is attained at which the changes that take place as puberty approaches have commenced, or are on the eve of beginning. I think that I can speak with confidence as to the rarity of such mur- murs in childhood, though I cannot venture to assign a reason for it; since the very slight difference between the composition of the blood in early life and in after years can scarcely be alleged as affording an adequate explanation of the fact. It is probably superfluous to remark, that as in the grown person so also in the child, a bruit may be heard independent of valvular disease, provided so great a degree of dilatation of the heart exist as to render the valves insufficient to close the corresponding openings. Of this, one remarkable instance has come under my notice, in which the absence of valvular disease was ascertained by a post-mortem ex- amination, and I have since met with another case where I am dis- posed to believe that a distinctly audible bruit is due rather to dilatation of the heart than to disease of its valves. Lastly, it may not be out of place to add that disease of the heart is not infrequently apprehended by the friends of our patients in cases where occasional palpitation and dyspnoea on exertion, some- times accompanied with irregularity of the pulse, are the only symp- toms of its existence. Mere deranged action of the heart, however, is by no means uncommon in children of all ages, though rarer before seven years old than subsequently. It is most frequently observed in fragile, excitable children, and is not readily amenable to direct treatment, though it subsides in the course of time under a system of general management calculated to improve the health, and of exercise judiciously regulated, and always kept within such limits as not to occasion fatigue. 406 PECULIARITIES OF THE In conclusion, let me sum up in a few sentences the most important facts concerning disease of the heart in childhood, which I have en- deavored to bring before your notice:— 1st. While disease of the heart is less common in childhood than in the adult, there is no absolute immunity in early life from any of those affections to which the organ in after years is liable. 2d. Of all the causes of heart affection, inflammation is the most frequent; and while all blood diseases predispose to its occurrence, none exert so powerful an influence in exciting it as rheumatism. 3d. While inflammation is by far the most frequent cause of val- vular disease, there is, nevertheless, reason to believe that it is not the sole cause, but that the valves may become disorganized quite inde- pendently of previous endocarditis; and a knowledge of this fact ought to govern our treatment in all cases where the history of the commencement of the affection is at all obscure ; and, 4th. The disposition of valvular disease to increase is not only lia- ble to more frequent exceptions in the child than in the adult, but there is also in early life a special power of repair and of self-adjust- ment in the heart which warrants our expressing a more cheerful prognosis than would be justifiable in cases of cardiac disease occur- ring in the grown person. LECTURE XXXI. Diseases of the Organs of Digestion and Assimilation.—Peculiarities of the digestive organs—they require a peculiar kind of food, the milk—composition of that fluid, its adaptation for the nutriment of the infant—changes in the digestive organs as the child grows older—these changes take place more slowly in the human sub- ject than in animals. Evils of giving other food than the mother's milk until the infant is old enough to bear it—shown by the increased mortality it produces—different modes in which such food acts injuriously—appearances found in bodies of children who have died from imperfect nutrition. Great importance of infants being suckled, even for a short time—difficulty of analysis of the milk—suggestions for determining fitness of a person for duties of a wet- nurse—rules for management of children who are brought up without the breast —substitutes for mother's milk—caution with reference to occasional unhealthy condition of cows' milk. We prefaced our investigation of the diseases of the nervous and respiratory systems with an inquiry into the peculiarities of struc- ture and of function which characterize those organs in early life. A similar inquiry will not be out of place now, as preliminary to the study of the diseases of the organs of digestion and assimilation, and their dependencies. Man, when he has attained to maturity, is able to support his life, DIGESTIVE ORGANS IN INFANCY. 407 and to preserve his health, upon food of various kinds; and the struc- ture of his organs is such as to enable him to live upon an exclusively animal diet, or upon food furnished entirely by the vegetable kingdom. We know that in either case the ultimate elements from which the body is nourished are the same; but that while in the former instance they are furnished as it were ready to hand, they have in the latter to be eliminated by nature's chemistry, through a process which occupies much time, and which requires considerable complexity in the appa- ratus that effects it. Those powers, however, of which the adult is possessed, belong in but comparatively small measure to the infant. The growing animal, indeed, needs proportionably more food than the adult; for not merely is the daily waste to be repaired, and that constant reproduction of the tissues to be provided for which is essential to the maintenance of vitality in all parts of the body, but each day is to bring with it an increase in size and stature. But though in early life an ample supply of food is so necessary, yet the organs by which it is to be assimilated, like those which have other offices to perform, are at that time frail and delicate, and must not be overworked. Their development is incomplete; and even those animals whose digestive apparatus be- comes eventually most complex, are fitted at first for subsisting only on the simplest food. Thus, for instance, the peculiarities which cha- racterize the digestive process in ruminants do not begin till some time after birth: the fourth stomach is the only one called into use, the others are little more than indicated in the new-born animal. Preparations, however, for their future mode of subsistence are early discernible in the herbivora, whose dentition has already commenced at birth, and advances with rapidity to attain its completeness. In the infant, on the other hand, the jaws, which long remain edentulous, the non-developed caecum, and the salivary glands, whose functions seem scarcely to commence for the first few months of life,1 sufficiently indi- cate that it is intended to subsist longer than the young of most ani- mals on food which shall require few changes to be wrought in it. The food, soon converted in the stomach, passes rapidly out of it, and the infant speedily seeks for more, requiring, as every one knows, to be fed far more frequently than the adult; while digestion being per- fected at once, and no necessity existing for those supplementary pro- cesses which the caecum in after life effects, the peristaltic action of the bowels is more rapid, excrementitions matters are quickly expelled, and the healthy infant passes three or four evacuations in the twenty- four hours.2 1 See the observations of Bidder and Schmidt, on the absence of secretion from the salivary glands of young animals, at p. 22 of their work, Die Verdauungs-Safte und der Stoffwechsel, 8vo. Mitau und Leipsig, 1852. 2 I am indebted to my friend Dr. Rolleston, of Oxford, for demonstrating to me the incorrectness of some of the statements adopted in former editions of this work from Schultz's Essay, Ueber den Akt des Erbrechens, &c, in the Analekten uber Kindei- krankheiten, vol. ii. Heft vi. p. 62, with reference to the peculiarities in the form and position of'the stomach during foetal and early infantile life. Dr. Brinton in a note at p. 318 of the article "Stomach," in the Cyclopaedia of Anatomy and Physiology, also notices some exaggeration in Schultz's statements. I cannot, however, mention 403 MILE, THE PROPER FOOD OF THE INFANT. But while the digestive organs are thus adapted to insure the rapid performance of their functions, and to provide for the quick as well as for the complete nutrition of the body, the question naturally suggests itself, Where shall that food be found which, while it yields the necessary sustenance, is yet so easily assimilated as not to require powers of which the delicate organs of the young are destitute? We should search in vain through the animal and vegetable kingdom for any substance completely fulfilling these conditions; but nature has supplied the want, and given to every mother the means of herself nourishing her young. Milk, the proper aliment for the young, expressly prepared for it within its mother's organism, contains, ready combined, all those elements which are necessary, whether for its growth or for the maintenance of its proper temperature, by serving as materials for respiration. The mean of 89 analyses of human milk, by MM. Yer- nois and Becquerel1 yields the following result. It has a specific gravity of 1032.67, and is composed of Water...... . 889.08 Solid matters ...... . 110.92 ;e solid constituents are made up of Sugar ....... . 43.64 Casein and extractive matter . . 39.24 Butter....... . 26.66 Incombustible salts .... 1.38 110.92 How small must be the effort needed to effect the assimilation of this fluid! The chief of its solid constituents, the casein, differs little, if at all, from the albumen of the blood, while in combination with it is a considerable quantity of the phosphate of lime—a salt that enters largely into the composition of the bones. Among its other com- ponents we find butter and sugar, the former of which probably in part contributes to the formation of the fat that is so abundantly de- posited in the healthy infant, while the remainder of it supplies materials for the generation of heat, by being resolved, together with the saccharine matter, into its ultimate elements of carbonic acid and water. This food, too, is not merely suitable for the infant soon after birth, but it continues to be the aliment most proper for it for many months; the casein increasing in quantity as the infant grows older, and the demand for materials to maintain its growth increases. in seeming disparagement the name of one whose scientific career has long since been run, without adding, that in spite of failing health which conducted him to an early grave, Schultz was a most laborious pioneer in those investigations into the processes of digestion which have yielded to those who have followed him such an abundant harvest. 1 The statements with reference to the chemistry of the milk are taken from Scherer's article "Milch," in Wagner's Handworterbuch der Physiologie, vol. ii. p. 448; and from the recent elaborate work of MM. Vernois and A. Becquerel, Du Lait chez la Femme, frc, 8vo. Paris, 1853. See their analysis, and the analyses of former observers, in the table at p. 15 of their work. CHANGES IN THE DIGESTIVE ORGANS VERY GRADUAL. 409 By degrees the stomach alters in form; its muscularity increases; the powers of the digestive organs become greater, and the child grows able to derive support from food in which the nutritive principles are not presented in so simple a form as in the milk. At the ninth month, teeth begin to appear; the first clear evidence of those changes which nature is working in the organism, and the indication that before very long the child will be able entirely to dispense with that elaborately prepared nourishment which it has hitherto derived from its mother. In the human subject the process of dentition not only begins late, but it goes on slowly; the first molar tooth is seldom cut before the commencement of the second year; dentition is not concluded till its end. Nature's object in the laws by which she governs the brute creation appears to be to fit the young animals as soon as possible to provide for themselves, and to shorten the period during which they must depend for sustenance on their mother; and, therefore, they begin to cut their teeth much sooner, and the process is completed within a much shorter time than in the infant. Young rabbits are always pro- vided with two teeth when born, and the others make their appearance within ten days. In the different ruminants, the teeth have either begun to appear before birth, or they show themselves a few days afterwards; and in either case dentition is completed within the first month, and in dogs and cats during the first ten weeks, of existence. For the difference in this respect between the lower animals and man, it seems to me that a moral reason, not altogether visionary, may be assigned: The young animal has to learn nothing more than how to apply those instincts with which Almighty power has endowed it for its own support and the perpetuation of its species ; but the infant is to be trained to become a man; its moral as well as its physical nature is to be cultivated; parental influence is to be the means of doing this, and Providence may have wisely determined that the in- fant shall for months be dependent on its mother for support, in order that her instinctive feelings may lay the firm foundation of that love which causes her to cling to her little one with a fondness that sur- passes all other affection, and which gives her the patience, the gentle- ness, the untiring energy that make her the child's best guardian, friend, and teacher, during its early years. But whether it is right or wrong to seek in something higher than the material for the reasons of this physical law, it yet is a law, and one which cannot be violated with impunity. The infant whose mother refuses to perform towards it a mother's part, or who, by acci- dent, disease, or death, is deprived of the food that nature destined for it, too often languishes and dies. Such children you may often see, with no fat to give plumpness to their limbs ; no red particles in their blood to impart a healthy hue to their skin; their face wearing in infancy the lineaments of age; their voice a constant wail; their whole aspect an embodiment of woe. But give to such children the food that nature destined for them, and, if the remedy do not come all too late to save them, the mournful cry will cease; the face will assume a look of content; by degrees the features of infancy will disclose themselves; the limbs will grow round, the skin pure red and 410 INFANTILE MORTALITY FROM ARTIFICIAL FEEDING. white; and when, at length, we hear the merry laugh of babyhood, it seems almost as if the little sufferer of some weeks before must have been a changeling, and this the real child brought back from fairy-land. Much care, much patience, judicious management in all respects, may, indeed, counteract the otherwise inevitable evils that result from the attempt to bring up infants by hand. The statement, however, just made with reference to the hazard of such an experiment, and to the evil consequences that almost of necessity attend it, is by no means overcharged. M. Villerme, one of the most distinguished statis- ticians of France, has compared the results of the two systems as fol- lowed in three of the principal foundling hospitals in that country.1 At Lyons, each infant, on its reception, is given into the charge of a wet-nurse, and its stay in the hospice does not exceed a very few days, after which it is sent to be nursed in the country. At Eheims, the stay of the infant in the hospice is equally short; but neither while there, nor afterwards when at nurse in the country, is it brought up at the breast. At Paris, the stay of the children in the hospice is often very much longer; but they are usually, though not invariably suckled by wet-nurses. The mortality under 1 year of the children admitted into these institutions is— At Lyons .... 33.7 per cent. " Paris .... 50.3 " Eheims .... 63.9 " These results need no comment, and render it almost unnecessary to adduce any further evidence of the dangers that are inseparable from the attempt to bring up infants on artificial food. One more illustration of the fact, however, may be adduced from the work of a benevolent ecclesiastic, M. Gaillard, on the foundling hospitals of France. He observes: — " At Parthenay, in the department of Deux Sevres, of 153 found- lings, 54 died between the ages of one day and twelve months, or 35 per cent., which is a higher proportion than that presented at Poitiers. At X----, of 244 new-born infants, 197, or 80 per cent., had died by the end of the first year. Struck by the enormous difference between this rate of mortality and that afforded by the hospices at Poitiers and Parthenay, I determined to investigate its cause. I ascertained that in this hospice as much attention is paid to the children, and the nurses are under as strict oversight, as at Poitiers and Parthenay. But at X----none of the children are suckled, but all are fed; and the reason assigned for so doing, is the fear of infecting the nurses with syphilis. Be this as it may, I have been assured by many per- sons connected with the institution, that the fearful mortality just mentioned can be attributed to no other cause than the practice of not suckling the children. The officers of the hospice have tried all 1 De la Mortalite des Enfans Trouves, in Annales d'Hygiene, vol. xix. p. 47. Fur- ther information on this and other allied subjects will be found in a review of the works of Terme, Montfalcon, and others, on the Foundling Hospitals of France, published by the author in the British and Foreign Medical Review for April, 1842. INJURIOUS EFFECTS OF ARTIFICIAL FEEDING. 411 means to remedy this evil, but neither their own efforts, nor those of some most excellent female assistants, have been of the slightest ser- vice ; and the only measure by which they could reduce the mortality, was the having recourse to suckling the children by wet-nurses."1 It can hardly be necessary to say, that these statements are not to betaken as representing the ordinary mortality among infants brought up by hand, since many causes will suggest themselves to you as con- curring to render the life of foundlings especially precarious. Neither, indeed, is the whole of the mortality among other children who have been deprived of the mother's milk, to be attributed to the food which is substituted for it; but in many cases, if the mother do not suckle her infant, she delegates to another the performance of her other maternal duties, and the baby is left to languish in the house of a stranger. That this cause is very influential in producing a high rate of mortality among infants, appears from the fact mentioned by M. Benoiston de Chateauneuf,2 that while among children suckled by their mothers only 18.36 per cent, die within a year after their birth, 29 per cent, of those put out to wet-nurse die during the same period. It is not enough, however, for us to know that food other than the mother's milk is injurious to the young infant; but it behooves us, both as physiologists and as physicians, to push our inquiries further—to ascertain as far as possible the means by which this injurious effect is produced, and to determine what organs of the body suffer most severely, and the mode in which they are affected. Unfortunately, the information which I am able to give you on these points is much less definite than I could wish; for the evils that result from improper food in infancy do not, like some diseases, arrest attention by their alarming symptoms, or by their rapidly fatal result, and hence they have received less than their due share of notice. If improper food be given to an infant, the contractions of the sto- mach are in general speedily excited, and the food is rejected. This eructation of a portion of its food may indeed be noticed even in in- fants at the breast, who have either sucked more than their stomach can conveniently hold, or whose digestive powers are temporarily weakened by some trivial ailment. But the hint which nature gives is too often thrown away on those who have the charge of the infant. Food of the same kind is given again, perhaps in smaller quantity, or with some slight difference in its mode of preparation; and part, or the whole of it, is now retained for a time, though not long enough for its complete assimilation; but if not rejected by vomiting, it passes the pylorus while digestion is but half completed. LTnfortunately, the farinaceous articles of food which are so often selected, on account of their supposed lightness, as fit to form the almost exclusive diet of infants, belong to the class of substances that are assimilated with diffi- culty ; so that a large proportion of the contents of the stomach, in the young child brought up by hand, enter the duodenum in a 1 Recherches sur les Enfans Trouves, &c, par l'Abbe A. H. Gaillard, 8vo. p. 166. Paris, 1837. 2 Considerations sur les Enfans Trouves, Svo. p. 57. Paris, 1824. 412 IMPERFECT NUTRITION OF INFANTS. state wholly unfit to be acted on by the bile. The intestines become irritated by these undigested matters; and, in the effort to get rid of them, diarrhoea is excited ; while, if not speedily expelled, they pass into a state of fermentation or putrefaction, and thus produce those horribly offensive evacuations which are frequently voided by children in these circumstances. It would be natural to expect^ that a child should lose flesh and strength, even if the food given to it were no otherwise objectionable than as being difficultly digested. But not only are the sago, arrow- root, or gruel, with which the child is fed, in themselves less easy of digestion than the milk, which is its proper aliment; they, moreover, when reduced to their ultimate elements, present essential differences from it, and differences by which they are rendered so much the more inapt to nourish the body during the period of its most active develop- ment and growth. It would be out of place to enter here into minute details with reference to the physiology of digestion, or the composi- tion of different articles of food, in order to illustrate this subject; neither, indeed, is it necessary to do so. You are aware that physio- logical and chemical research have proved that food has to answer two distinct purposes in the organism; the one to furnish materials for the growth of the body; the other to afford matter for the maintenance of its temperature; and that life cannot long be supported, except on a diet in which the elements of nutrition and the elements of respiration bear a certain proportion to each other. Now in milk, the proper food of infants, the elements of the former are to those of the latter, according to the approximative estimate of an English chemist,1 in the proportion of 1 to 2; while in arrowroot, sago, and tapioca, they are only as 1 to 26, and even in wheaten flour only as 1 to 7. If to this we add the absence in these substances of the oleaginous matters which the milk contributes to supply the body with fat (and which can be eliminated from farinaceous substances only by a conversion of their elements, to which the feeble powers of digestion in early life are not equal), and the smaller quantity, and, to a certain extent, the different kind of the salts which they contain, it becomes at once ap- parent that by such a diet the health, if not the life, of the infant must almost inevitably be sacrificed. The body wastes most rapidly; for it is forced from its own tissues to supply the nitrogenous elements essential to the maintenance of life, and which its food contains in far too scanty a proportion. Every organ in the body contributes to the general support, and life is thus prolonged, if no kind disease curtail it, until each member has furnished all that it can spare, and then death takes place from starvation; its approach, indeed, having been slower, but the suffering which preceded it not therefore less, than if all food had been withheld. I have dwelt at length upon this, which is the most frequent cause of the atrophy of new-born children: but similar effects are produced when, from any other reason, an infant is imperfectly nourished, 1 Dr. R. D. Thomas, On the Relation between the Constituents of the Food and the Systems of Animals, in vol. xxix. of the Medico-Chirurgical Transactions. INFANTILE ATROPHY. 413 whether, as sometimes occurs, the mother's milk is so deteriorated as to be unsuitable for its support; or whether, as often happens, the child having been weaned prematurely, its digestive organs are un- equal to the task of assimilating the food that has been substituted for the mother's milk. In both cases the abdominal viscera become disordered, nutrition is ill performed, and the child falls into a state of atrophy. On examining after death the bodies of children who have died in these circumstances, the complete absorption of all the fat, and the removal of much even of the cellular tissue, is the point that first attracts our notice. The thoracic viscera present no unnatural, ap- pearance, unless it be that large portions of the lungs are sometimes found in a state of collapse. There is also seldom anything unnatural in the condition of the liver, except the congested state of the organ, the vessels of which, being often loaded with venous blood, form a marked contrast to the generally anaemic appearance of the other viscera. The gall-bladder is usually full of bile—probably because, as in the case of persons who have died of inanition, the empty stomach has long ceased to stimulate it to contraction by its move- ments. The stomach and small intestines are in general nearly empty; the fundus of the stomach is sometimes found more or less softened—a condition the occurrence of which after death is probably favored by the tendency of those kinds of food that are usually given in early life, to pass into a state of fermentation, in the course of which an acid is produced that is capable of dissolving the animal tissues. In some instances where children have been fed on an ex- clusively farinaceous diet, the mucous membrane, even low down in the intestines, has been found covered with a thin coating of starch, which presented the characteristic blue color when tested with iodine.1 The intestines are generally pale, though with patches intermingled of a red or dark gray color; besides which, small circumscribed spots of a bright vascularity are sometimes interspersed through the small intestines, being especially evident at their upper part. Peyer's glands usually appear much more prominent than is natural; some- times they are of a brighter red than the surrounding intestine, and somewhat swollen, and sometimes they are of a dark gray tint, and present a singular punctated appearance. In the large intestines there is also sometimes a remarkable development of the solitary glands, the dark orifice of which renders them very evident; and in a few instances they become still more apparent, from the mucous membrane immediately around each presenting a dark gray color. The appearances, in short, are those of general inanition, coupled with the signs of irritation or inflammation of the whole secreting ap- paratus of the intestinal canal.2 1 According to some experiments by M. Guillot, of Paris, referred to by Dr. Stewart, of New York, in a paper, republished from an American journal, in the Dublin Medi- cal Journal, March, 1845. 2 This account of the post-mortem appearances observed in infants who have been imperfectly nourished, is not merely borne out by the very interesting paper of MM. Friedleben and Flesch, in vol. v. of the Zeitschriftfiir rationelle Medicin, Heidelberg, 414 DIETETICS OF EARLY LIFE. The full consideration of every question connected with the im- perfect nutrition of infants would require little else than a complete treatise on the dietetics of early life. In these Lectures I can aim at nothing more than to bring before your notice a few points of the greatest importance. Although it is very desirable that for the first six months of their existence children should derive their support entirely from their mother, and that until they are a year, or at least nine months old, their mother's milk should form the chief part of their food, yet many circumstances may occur to render the full adoption of this plan impracticable. In some women the supply of milk, although at first abundant, yet in the course of a few weeks undergoes so considerable a diminution as to become altogether insufficient for the child's sup- port; while in other cases, although its quantity continues undimin- ished, yet from some defect in its quality it does not furnish the infant with proper nutriment. Cases of the former kind are not unusual in young, tolerably healthy, but not robust women; while instances of the latter are met with chiefly among those who have given birth to several children, whose health is bad, or whose powers are enfeebled by hard living or hard work. The children in the former case thrive well enough for the first six weeks or two months; but then, obtain- ing the milk in too small a quantity to meet the demands of their rapidly growing organism, they pine and fret, they lose both flesh and strength, and unless the food given to supply their wants be judiciously selected, their stomach and bowels become disordered, and nutrition, instead of being aided, is more seriously impaired. If, however, a healthy wet-nurse be employed to supply the mother's inability to nourish her child, its health will soon return; and by the sacrifice of the infant of the poor woman, the offspring of the wealthy 1846 ; but receives a remarkable illustration in the recent work of M. Bednar, Physi- cian to the Foundling Hospital at Vienna. The observations of the former gentlemen are founded on the examination of fifteen infants, all of whom were under one year old, who were brought up, either exclusively or in great measure, on artificial food, and who died, after long-continued illness, in a state of atrophy, or else sank rapidly under profuse watery diarrhoea. In cases of the former class, a condition regarded by the writers as the result of chronic inflammation of Peyer's glands was the chief morbid appearance ; while in those instances where death took place rapidly, swelling and congestion of the same bodies, betokening, as they believe, their recent inflamma- tion, were almost always present. They found, too, that in all these cases the disease of the colon was comparatively slight, and evidently secondary to the more serious changes in the small intestine. Dr. Bednar's patients were all under three months, many only a few days old, partly suckled by women each of whom had several nurslings, partly fed on artificial food. As might be anticipated, the mortality is high; and of such almost uniform occurrence is swelling of the mesenteric and' Peyerian glands, and even of the solitary glands of the large intestines, that, when treating of diarrhoea, he speaks of this state of the glands as being a condition of no sort of im- portance ; and even expresses the opinion that in the large intestines it is to be re- garded as a physiological rather than a pathological occurrence. No more striking comment could be written on the mischiefs and the dangers of artificial feeding of infants. See pp. 37 and 38 of Bednar's Krankheiten der Neugebornen, Sfc, 1st ed. 8vo. Wien, 1850. The same facts, too, are still further illustrated by the more recent ob- servations of Hervieux on the changes in Peyer's and the solitary glands in new-born infants, published in the Gazette Me'dicale, Fevr. 17, 1856: and several following numbers. IMPORTANCE OF SUCKLING EVEN FOR A SHORT TIME. 415 will be preserved. But many circumstances besides those moral considerations which should never be forgotten before the determina- tion is formed to employ a wet-nurse, may put this expedient out of the question; and it becomes, therefore, our duty to inquire what course a mother should pursue, who has learnt by experience that she is unable to suckle her child for more than a very short period. Knowing the attempt to rear her child entirely at the breast to be vain, the mother may in such a case naturally be tempted to bring it up by hand from the very first. But, how short soever the period may be during which the mother is able to suckle her child, it is very desirable that she should nurse it during that period, and also, that her milk should then constitute its only food. For the first four or five days after the infant's birth the milk possesses peculiar qualities, and not merely abounds in fatty and saccharine matters, but presents its casein in a more easily assimilable form than subsequently.1 It afterwards loses these characteristics; but still, during the first few weeks of life, it contains casein in smaller quantities than enter into its composition at a later period. The secretion, in short, is especially adapted to the feeble powers of the digestive organs soon after birth; and hence the difficulty of providing any good substitute for it is greater in proportion to the tender age of the infant, while art often imitates but ill that gradual increase of the casein, by which the main element of the infant's sustenance is made to bear a constant propor- tion to the demands of its daily growth.2 The same course of conduct would be proper in the case of women whose milk is of so poor a quality that their infants do not thrive upon it, since, though its deficiency in casein may render it unfit for the permanent support of the child, yet that circumstance will not prove prejudicial to it during the first few weeks of its existence. Unfortunately we are not possessed of any ready means by which we can determine, in the majority of instances, that a woman's milk is ill suited for the nourishment of her child; and, in practice, the infant's not thriving is often the first indication that we have of the propriety of a change. Certain qualities, indeed, which healthy milk ought to have, are readily ascertainable. Thus, for instance, it should have a specific gravity of about 1032, and an alkaline reaction; and, after the first month, should be free from colostrum corpuscles; while the oil-globules, which should be present in great number, ought to 1 See on this subject a very interesting paper by Dr. Moore, of Dublin, On the Co- agulability of Human Milk, in Dublin Journal of Medical Sciences, May, 1849. ' Though I have allowed the above paragraph to stand unaltered in this edition, yet it must be observed that the elaborate researches of MM. Vernois and Becquerel do not altogether bear out its accuracy. They deny, on the strength of twenty-six observations on the milk of different women within a fortnight after delivery, that any such excess of sugar, and feeble proportion of casein, then characterize it, as is stated above, on the authority of the late Professor Simon, of Berlin. They admit the exist- ence of a larger quantity of butter, which, however, continues only so long as the co- lostrum corpuscles are still present. It is, however, much to be regretted that they did not institute a series of comparative observations, with reference to this point, on the milk of the cow, since the question involved in the accuracy of one or the other of the opposing statements is of very great practical importance. 416 SUBSTITUTES FOR THE MOTHER'S MILK. be of tolerably equal size, and each distinct from the other. In spite of presenting all these characters, however, the milk may have under- gone very important changes, though of a kind which dexterous chemical analysis will alone discover. An increase in the quantity of the fatty matters in the milk seems, according to the observations of M. Becquerel, to be an almost constant attendant upon all diseases whether acute or chronic, syphilis and far advanced phthisis alone excepted; while acute diseases are attended by a notable increase, and chronic ailments by a still more remarkable diminution of the casein. Such changes in its composition cannot but modify very greatly its suitability as an aliment for the child; while the difficulty of ascer- taining the existence of any of these alterations may at least teach us that the apparently healthy character of the milk is but a very imper- fect guarantee of its real excellence. Still, even though the difficulties of a complete analysis of the milk will generally render the attempt to make it impracticable, and though conclusions drawn from a partial examination will almost certainly be erroneous, there are, fortunately, some general rules fairly dedu- cible from chemical analysis and clinical observation combined, which will generally suffice to guide us aright in the choice of a person to undertake the duties of wet-nurse to an infant whose mother, either from necessity or choice, fails to perform the duty of suckling it her- self. The apparently good health of the woman and her child is of all evidence the most conclusive in favor of her fitness; but M. Bec- querel found the nearest approach to a perfectly physiological state of the milk, in women from twenty to twenty-five years old, multi- para?, of strong constitution, previously well-nourished, brunettes, with small mammae but an abundant secretion of milk, from three to five months after delivery, and in whom the menstrual discharge was suspended. The question, however, which we often have to answer, and to answer, too, sometimes very soon after the infant's birth, is not as to the goodness of a wet-nurse, but as to the best substitute for the mother's milk. Now it is obvious that the more nearly the substitute we select approaches to the character of the mother's milk, the greater will be the prospect of the attempt to rear the infant upon it proving suc- cessful. Discarding, therefore, all those preparations of arrowroot, flour, or biscuit-powder, in which the vulgar repose such confidence, we shall not need any labored argument to convince us that in the milk of some other animal we shall be likely to find the infant's most appropriate food. You will perceive, however, by the subjoined table, that there are many important differences between the milk of all the domestic animals and of the human female ; both in the actual quantities of its constituents, and in their relative proportion to each other. COWS' MILK OCCASIONALLY UNHEALTHY. 417 Table showing the Composition of the Milk in Man and in various Animals.1 Specific gravity. 1000 PARTS CONTAIN— The Solid Constituents are composed of— Fluid. Solids. Sugar. Butter. Casein and extractive matters. Incom-bustible salts. In man In the cow . . " ass . . " goat . . " ewe . . 1032.67 1033.38 1034.57 1033.53 1040.98 889.08 864.06 890.12 844.90 832.32 110.92 135.94 109.88 155.10 167.68 43.64 38.03 50.46 36.91 39.43 26.66 36.12 18.53 56.87 54.31 39.24 55.15 35.65 55.14 69.78 1.38 6.64 5.24 6.18 7.16 The above table shows you that it is only in the milk of the ass that the solid constituents are arranged in the same order as in the human subject; casein preponderating in the milk of the cow and ewe, and butter in that of the goat. On this account, therefore, asses' milk is regarded, and with propriety, as the best substitute for the child's natural food. Unfortunately, however, expense is very frequently a bar to its employment, and compels us to have recourse to cows' milk, as being so much more readily procured. But though the cost may be a valid objection to the permanent employment of asses' milk, it is yet very desirable, when a young infant cannot have the breast, that it should be supplied with asses' milk for the first four or five weeks, until the first dangers of the experiment of bringing it up by the hand have been surmounted. The deficiency of asses' milk in oily matter may, as has been suggested,2 be very much rectified by the addition to it of about a twentieth part of cream. The laxative property which it possesses is not so easily counteracted ; and though Sir Henry Marsh's recommendation of heating it to 212° sometimes removes this quality, yet the experiment has not in my hands been by any means invariably successful. In such cases, however, the addition of about a fourth part of lime-water to the milk will generally suffice to control all tendency to diarrhoea. When cows' milk is given, it must be borne in mind that it contains more casein than human milk, and less sugar; and that it is therefore necessary that it should be given in a diluted state, and slightly sweet- ened. The degree of dilution must vary according to the infant's age ; at first, the milk may be mixed with an equal quantity of water, but as the child grows older the proportion of water may be reduced to one-third. Attention must be paid to the temperature of the food when given to the infant, which ought to be as nearly as possible the same as that of the mother's milk, namely, from 90° to 95° Fahrenheit; and in all cases in which care is needed, a thermometer should be em- ployed, in order to insure the food being always given at the same temperature. Human milk is alkaline; and even if kept for a con- siderable time it shows but little tendency to become sour. The milk 27 1 Vernois and Becquerel, op. cit., p. 167. 2 By Dr. Moore, of Dublin, in his paper already referred to. 418 QUANTITY OF FOOD PROPER FOR INFANTS. of animals in perfect health likewise invariably presents an alkaline reaction, and that of cows when at grass forms no exception to this rule. Comparatively slight causes, however, exert a marked influence upon the milk of the cow in all respects; even in the most favorable circumstances, if the animal is shut up in a city and stall-fed, all the solid constituents of its milk suffer a remarkable diminution; while the secretion further has a great tendency to become acid, or to undergo even more serious deterioration.1 There is evidently no occasion, then, to assume any intentional adulteration of the milk, in order to account for the symptoms of gastric and intestinal disorder so often produced by it in the case of children brought up in large towns. Whenever, therefore, the attempt is made to rear an infant by hand, in circumstances which render it impossible to obtain the milk of cows which are at pas- ture, it is desirable that the milk should be daily tested, and that any acidity should be neutralized by the addition of lime-water, or of pre- pared chalk, in quantity just sufficient to impart to it a slightly alka- line reaction. If the bowels be disposed to be constipated, carbonate of magnesia may be substituted for the chalk. Unfortunately, there seem, as I stated a day or two ago, to be good reasons for believing that the milk of stall-fed cows often undergoes a deterioration much more serious than the merely becoming acescent; and that changes not unfrequently take place in it such as must render it wholly unfit for an infant's food, and calculated only to promote disease. The pos- sibility of their occurrence shows the necessity, when an infant who is brought up by hand fails in health, for making a careful inquiry into the source of the milk with which it is fed; and for examining the fluid, if possible, both chemically and under the microscope, before proceeding to prescribe remedies for ailments which may be caused entirely by the unwholesome nature of its food. The quantity of food proper to be given to an infant at one time, and the total amount which it may be supposed to require in the twenty-four hours, though questions of most obvious importance, have hitherto scarcely received any attempt at solution. The only observa- tions bearing on the subject, with which I am acquainted, were made a few years ago by M. Guillot2 at the Foundling Hospital in Paris. He weighed children both immediately before and immediately after suck- ing, and found that the increase of weight varied from about two to five ounces in children under a month old; and concludes that a thou- sand grammes, or about two pounds and quarter avoirdupois, is the smallest quantity of milk that would suffice for the daily nourishment of a healthy infant during the first month of its existence. The num- ber of children, however, on whom his observations were made, as well as the number of observations on each child, were both far too few to 1 See the analyses of Vernois and Becquerel, op. cit., p. 131, and the results of Dr. Mayer's observations on cows in Berlin and its neighborhood, in a valuable paper on the Artificial Feeding of Infants, in the first volume of the Verhandlungen der Gesell- schaft fur Geburtshulfe in Berlin, 8vo. p. 56, Berlin, 1846 ; and also two papers by Dr. Peddie in the London and Edinburgh Monthly Journal for 1848 ; and the observa- tions of Dr. Klencke, of Leipsic, already referred to at p. 474. 8 Journal fur Kinderkrankheiten, July, 1852, vol. xix. p. 113. ATROPHY OF YOUNG CHILDREN. 419 yield more than a very rough approximation to the truth with refer- ence to this subject. It may suffice, for to-day, thus to have brought before you the main principles by which you must be guided in the attempt to rear a young infant by hand. Details as to the general dietetic management of infancy or childhood would not only carry us beyond the period allotted for this lecture, but would be a departure from our special object—of investigating the diseases of early life. LECTURE XXXII. Atrophy of Young Children—not a special disease, but a condition that may be in- duced by various causes. Thrush, a peculiar affection of the mouth, generally associated with impaired nutri- tion—its characters, different opinions as to its nature—general state of children in whom it occurs. Microscopic researches as to its nature, the deposit produced by a cryptogamic vegetation—conditions that favor its development—inferences as to its treatment. Dentition—high rate of mortality while it is going on—erroneous views with refer- ence to the cause of this, and to the nature of the process—physiology of denti- tion—order of appearance of the teeth—pauses in their evolution—frequently attended with local suffering—various morbid conditions of mucous membrane of the mouth excited by it. Management of children when teething—circumstances in which lancing the gums is likely to be useful—dietetic and medical management—treatment of affections of the mouth—caution with reference to cure of cutaneous eruptions during the time of teething. At our last meeting, we were occupied with various preliminary inquiries, of importance to the thorough understanding of the dis- eases of the digestive organs in early life, on the study of which we are now about to enter. We examined the structural and functional peculiarities of those organs in the young, and endeavored to ascer- tain wherein consists the special fitness of the mother's milk for the nutriment of her infant. We further tried to discover the mode in which other food acts injuriously on the infant, and sought from the knowledge thus acquired to deduce rules for our guidance, whenever it should become necessary to provide a young child with a substitute for that sustenance which nature intended that it should receive. These considerations naturally brought under our notice the symp- toms which betoken that the process of nutrition is imperfectly carried on, and the appearances which, when death takes place from this cause, are revealed on an examination of the body. It may seem to you, however, that the atrophy of young children calls for a more elaborate study than ours of yesterday, and for a more minute account of its symptoms. But to attempt this would be to enter upon almost end- 420 INFANTILE atrophy not a SPECIAL DISEASE. less details, which would leave upon your memory no clear impression. Whether all food is withheld from an infant, or whether it is supplied with food which it cannot assimilate, or whether disease prevents it from digesting food on which a healthy infant would thrive, the main result is the same, and the child dies of inanition. Various accidents may abridge the infant's life, or may make it sink, in one case, in cir- cumstances somewhat different from those which precede its death in another. Sometimes, the vital powers grow so feeble that the inspira- tory efforts no longer suffice to fill the lungs with air; sometimes, the irritable stomach rejects all food, while at other times diarrhoea comes on which no medicine can check. But in these symptoms there is nothing characteristic of one special cause; they may occur alike in the infant who, though healthy when born, was early deprived of its mother's milk, or in the child who is the subject of general tuberculous disease, or whose strength has been exhausted and its digestive powers impaired by dysentery. The symptoms, then, that accompany tbe atrophy of new-born children must be expected to vary much in different cases, while the considerations brought before you in the last lecture will, I think, furnish you with a clue to the complete understanding of them all. Before we pass, however, to the special study of the diseases of the digestive organs and their appendages, I wish to call your attention to that peculiar condition of the mucous membrane of the mouth, popu- larly known as the thrush, which is so frequently met with in connec- tion with the artificial feeding of young infants—so almost invariably associated with the evidences of their impaired nutrition, that the present seems to be the best place for noticing it. If you examine the mouth of a young infant on whom the attempt is being made to bring it up without the mother's milk, you will often observe its mucous membrane to be beset with numerous small white spots, that look like little bits of curd lying upon its surface, but which on a'more attentive examination are found to be so firmly adherent to it as not to be removed without some difficulty, when the subjacent membrane is left of a deep red color, and often bleeding slightly. These specks appear upon the inner surface of the lips, especially near the angles of the mouth or the inside of the cheeks; and upon the tongue, where they are more numerous at the tip and edges than towards the centre. They are likewise seen upon the gums, though less frequently, and in smaller number. When they fir^t appear, they are in general of a circular form, scarcely larger than a small pin's head; but after having existed for a day or two, some of the spots become three or four times as large, while at the same time they in general lose something of their circular form. By decrees these small white crusts fall off of their own accord, usually leaving the mucous membrane where they were seated redder than before—a color which gradually subsides as the mouth returns to its natural condition; or the white specks are reproduced, and again detached, several times before the membrane resumes its healthy aspect. In some cases these specks coalesce, or the deposit, from its first appearance, presents more of the character of a false membrane, THRUSH—ITS GENERAL SYMPTOMS. 421 and the mouth is then seen to be extensively coated with it; though even then, if the deposit is carefully removed, the mucous membrane beneath will be found neither bleeding nor abraded, but merely redder than natural. In these circumstances, the deposit generally loses something of the dead white color characteristic of the smaller spots, and presents a slightly yellowish tint. On the continent, where the severer form of the affection is not infrequently seen, it was supposed, though the opinion is now with propriety abandoned, to be an essen- tially different ailment from the slighter forms of the disease, in which the points of deposit are distinct, while further confusion was intro- duced into the subject by the employment of the term aphthce1 to designate both this affection and another of a perfectly different nature (which I shall speak of hereafter), characterized by inflammation and ulceration of the mucous follicles of the mouth. The term aphthae will be most properly employed as a synonym for this follicular sto- matitis ; while I prefer to restrict the use of the English word thrush2 to the ailment, some of whose characters I have just described, and for which there is at present no correct designation in scientific ter- minology. Children in whom either form of this deposit exists in any consi- derable degree usually appear out of health; and it will generally be found on inquiry that this indisposition had preceded for some days the eruption in the mouth. For the most part such children are emaciated, and present those symptoms that attend upon imperfect nutrition, while the bowels are in general relaxed, and the evacuations of a green color, and very sour. The acridity of the motions some- times irritates and inflames the margins of the anus, and a blush of erythematous redness not infrequently extends over the nates and buttocks, while in some instances a deposit of a similar kind to that in the mouth occupies the edges of the intestine. In spite, however, of the popular notion with reference to this point, the appearance of the deposit at the margin of the anus is of extremely rare occurrence, though redness and soreness at the edge of the bowel are very fre- quent. The deposit in the mouth sometimes renders sucking very difficult, and may even impair deglutition, while the child, thus ob- taining but little food, lies in a state of torpor and drowsiness, the result of its debility. In its more serious form this affection was said to prove fatal to a large number of the inmates of the different foundling hospitals on the continent. Observation has shown, however, that although the deposit exists in the mouth of very many children who die in those institutions, yet their death is due not to the local affection, but to the constitutional disease, of which that is only one out of many evi- dences. 1 The use of the word «9ai by Hippocrates, and its application by him to ulcera- tions of the uterus, plainly shows that in his mind the idea of a breach of surface was always associated with it; though it is very probable that under a mistaken belief of its nature he may also have used the same word to designate true thrush. See Foesius, (Economia Hippocratis, p. 111. 2 A word the etymology of which is uncertain; as is that of its Swedish synonym Torsk, and the Danish and Norwegian Trodske. 422 berg's discovery of CRYPTOGAMIC vegetation. In spite of the exaggerated importance that was long attached to the local affection of the mouth, which was erroneously imagined to be the cause of all the symptoms of disordered health, of which it is in reality merely the accompaniment, much uncertainty existed as to its real nature, though it was generally imagined to be a variety of pseudo-membranous inflammation, not unlike that of croup or diph- theria. This hypothesis, however, which left many peculiarities of the disease unexplained, has been conclusively set aside, and the real nature of this as of so many other ailments has been made quite clear by microscopic research. In the year 1842, Professor Berg, of Stockholm, physician to the Foundling Hospital in that city, communicated to the Swedish Society of Medicine, his discovery of a cryptogamic vegetation in the deposit of thrush; and a German observer, M. Gruby, confirmed M. Berg's researches in a paper addressed in the same year to the Royal Aca- demy of Sciences at Paris, though his views differed in some points from those of M. Berg. From the time of this discovery two oppos- ing views of the nature of the affection have till recently been main- tained. According to the one opinion, the parasitic growth, like the muscardine on the silk-worm, or the confervas developed on other living animals, itself constitutes the essential part of the disease; while, according to the other, the white substance in the mouth is in reality an inflammatory exudation, in which, though confervae may be developed, yet their presence is accidental, and subject to many exceptions. The correctness of the former opinion, which was maintained by M. Berg, and substantiated in great measure by his researches, has now been so generally admitted that I need not further occupy your time with details of the controversy, but will describe as briefly as possible the nature of the affection, as it has been ascertained by means of the microscope; and as it is described by one of the most recent observers, M. Eobin.1 In connection with various disorders of the digestive apparatus in children, and also in the course of some exhausting diseases in the adult, the mucous membrane of the mouth, and sometimes also that of the pharynx and oesophagus, becomes the seat of inflammation, which though by no means severe is yet attended with a change of the secretion from alkaline to acid, and with an abundant production 1 Not to encumber this lecture with the citation of authorities, it may suffice to refer to the valuable essay of Dr. Berg, of Stockholm, analyzed in the Journal fiir Kinderkrankheiten for September and October, 1847, and since translated into German, under the title Ueber die Schwammchen der Kinder, 8vo. Bremen, 1848, as a most able defence of the first mentioned opinion; and to the papers by Dr. Kronenberg, of Moscow, in that journal for February and September of the same year, for observations and arguments tending to support the opposite view. The elaborate essay of M. Seux, in his Recherches tur les Maladies des Enfants, 8vo. Paris, 1855, also claims mention here, for in it every question connected with this affection is treated of with an almost painful minuteness. With reference to the production of confervae on the mucous surfaces of the human body in disease, the fullest account has been given by Han- nover, in Muller's Archiv for 1842, p. 281 ; and by M. Robin in his Histoire Naturelle des Vigitaux Parasites qui croissent sur I'Homme et sur les Animaux vivants, 8vo. Paris, 1853. NATURE AND TREATMENT OF THRUSH. 423 of epithelium. This state of the mucous membrane, though not absolutely essential, is yet in the highest degree favorable to the development on its surface of a fungus, the Oidium albicans, the spo- rules of which in these circumstances increase with great rapidity, and elongate into tubular fibrils, by whose multiplication and accu- mulation, together with the abundant epithelial scales, a thick white layer is formed upon the dorsal surface of the tongue, the palate, the velum, the interior of the cheeks, the lips, and even in some cases the pharynx and oesophagus. It appears, too, that during the first weeks of infancy1 the mucous membrane of the mouth yields, even in a state of health, and wholly independently of whether or no the child is brought up at the breast, an acid reaction, a circumstance which accounts for the far greater liability of infants than of adults to this affection, so that in the former case a very slight disorder would lead to its development, while in the latter it is the sign and the consequence of very serious disease. This account of the affection explains many points previously in- explicable concerning it. It furnishes a reason for the prevalence of thrush in foundling hospitals, and institutions of a similar kind, where the same cups, spoons, &c, are used in common by the child- ren, and often without sufficient attention to cleanliness. That the disease may be produced by the actual transplantation of the sporules from one child to another was conclusively established by M. Berg,2 who tried the experiment in four instances, and found that on each occasion the deposit of the sporules on the mucous membrane of the mouth of a healthy infant was succeeded by the development of the confervas, and the occurrence of thrush. The conditions, then, which generally coincide in the production of thrush, are: 1st. Certain ailments of the digestive organs, dependent on impaired nutrition; 2d. Consequent inflammation of the mucous membrane of the mouth, associated with an increase in the acidity of its secretion, and an unusually abundant formation of epithelium; and 3d. The development on the surface of a cryptogamic vegetation, which is not the cause but rather the result of the child's illness. It follows, then, that in the treatment of this affection, the removal of the constitutional disturbance is of at least as much importance as the ministering to the local malady. Two facts, indeed,3 will serve, without further comment, to place this matter in a very strong light; one is, that in 21 out of 26 examinations of the bodies of children who had died of thrush, the small intestines presented morbid appear- ances, which, though of various kinds, were all analogous to those referred to in the last lecture as dependent on imperfect nutrition and artificial feeding. The other is, that while in the Foundling Hospital at Marseilles the mortality of children affected with thrush is only 5 in 100, in that at Paris it has been stated by different observers as 9 in 10, 109 in 140, 22 in 24, and 25 in 48. Of the two institutions, that at Paris is the more salubrious; but there the appearance of the i Seux, op cit., pp. 18—21. 2 Seux, op. cit., pp. 76-80. » Op. cit., pp. 147 and 218-220. 424 MORTALITY DURING DENTITION. affection of the mouth is the signal for the immediate withdrawal of the child from the breast; while at Marseilles the opposite plan is pursued, and a child, even though previously fed artificially, is at once given to a wet-nurse on the first sign of thrush being discovered. The extreme rarity, too, with which in private practice the thrush in a young infant assumes the characters of a serious affection, furnishes further proof, if it were wanting, that the local ailment is of little moment apart from the complications which impart to it its gravity. It will, therefore, be inexpedient to dwell here on anything more than the local treatment of the case, since its general management must vary as widely as the causes to which the affection of the mouth is due. One point of considerable moment, and to which less care than it deserves is usually paid, is the removing from the mouth, after each time that the infant has fed, all remains of the milk or other food that it has taken. For this purpose, whenever the least sign of thrush ap- pears, the mouth should be carefully wiped out with a piece of soft rag, dipped in a little warm water, every time after food has been given. Supposing the attack to be but slight, this precaution will of itself suffice in many instances to remove all traces of the affection in two or three days. If, however, there be much redness of the mucous membrane of the mouth, or if the aphthous spots be numerous, some medicated topical application is useful. Various detergents have been recommended, among which the mel boracis, and a mixture of the Armenian bole with honey, are very frequently employed. An ob- jection, however, has been raised, and I think on good grounds, to any application into the composition of which honey or other saccha- rine matters enter, on the ground that the tendency of those substances to pass into a state of fermentation will make them favor rather than prevent the formation of confervas in the interior of the mouth. It is my custom to dissolve a scruple or half a drachm of borax in an ounce of water, and to direct that after the mouth has been carefully cleansed with warm water, this lotion should be applied to it on a piece of lint or soft linen. In the milder forms of the affection, the borax lotion usually answers every purpose. Should it, however, appear insufficient, a solution of five grains of the nitrate of silver in an ounce of distilled water may be employed in the same way twice a day, while at other times the solution of borax may be used in the manner just directed. The close connection that subsists between this local affection and the condition of generally impaired nutrition, which engaged our at- tention yesterday, induced me to bring the subject now under your notice. I do not know, however, that any better plan can be adopted, in studying the diseases of the organs of digestion and assimilation, than closely to follow an anatomical arrangement, and to consider, first, the diseases of the mouth, then those of the stomach, then those of the intestines, and lastly those of the other abdominal viscera. It may, perchance, seem to you that, according to this plan, it is not proposed to assign any place of importance to the disorders of dentition, though in our tables of mortality we find teething registered as having occasioned the death of nearly 5 (4.8) per cent, of all children who CHANGES IN THE SYSTEM DURING TEETHING. 425 died in this metropolis under one year old, and of 7.3 per cent, of those who died between the age of twelve months and three years. Many other circumstances, too, tend to increase the impression which this fact naturally makes; for not only do nurses attribute to teething the most varied forms of constitutional disturbance, and mothers ex- press serious apprehensions as the period of dentition approaches, but medical men hold forth to anxious parents the expectation that their child will have better health when it has cut all its teeth. The time of teething, too, is in reality one of more than ordinary peril to the child ; though why it should be so is not always rightly understood. It is a time of most active development of the organism—a time of transition from one mode of being to another, in respect of all those important functions by whose due performance the body is nourished and built up. Statistics,1 embracing the largest numbers, prove the dangers of this period, and warrant us in regarding the completion of the process of teething as a fair subject for congratulation. The error which has been committed with reference to this matter, not merely by the vulgar, but by members of our own profession also, consists, not in overrating the hazards of the time when changes so important are being accomplished, but in regarding only one of the manifestations—though that, indeed, is the most striking one—of the many important ends which nature is then laboring to bring about. A child in perfect health usually cuts its teeth at a certain time and in a certain order, just as a girl at a certain age presents the various signs of approaching puberty, and at length begins to menstruate. In her case we do not fix our attention solely on the menstrual flux; nor, if it fail to appear, do we have recourse to the empirical employment of emmenagogue medicines. We examine into the cause of its ab- sence ; try to ascertain whether it depends on the state of the health in general, or of the uterine system in particular, and regulate accord- ingly our attempts at cure. The epoch of dentition is to be looked at just in the same way as that in which we regard the epoch of puberty. Constitutional disturbance is more common, and serious disease more frequent, at those times than at others; but their causes lie deeper than the tooth which irritates the gum that it has not yet pierced in the one case, or than the womb which has not yielded the due discharge of blood in the other. You might produce hemorrhage from the uterine vessels in the latter instance, or might cut through the gum which inclosed the teeth in the former, with no other effect than that of aggravating the condition of your patient. In speaking of the diseases of the nervous and respiratory systems, your attention has on several occasions been drawn to the greater frequency of some of those affections just at the time when the process of teething is going on; and you will have to remark a similar fact with reference to some of the disorders of the abdominal viscera. These maladies, however, are not peculiar to the time of teething, nor, when they occur at that period, do they present symptoms different 1 See, for instance, the table of mortality at different months, at p. 36 of MM. Quetelet et Smits, Recherches sur la Reproduction et la Mortalite, &c, 8vo. Bruxelles, 1842. 426 ORDER IN WHICH THE TEETH APPEAR. from those which characterize them in other circumstances, while it often happens that the changes which mark the transition from infancy to childhood are accomplished so quietly as to be attended with no notable disturbance of the general health. The great changes which nature is constantly bringing about around us and within us, are the result of laws operating silently but unceas- ingly; and hence it is that in her works we see little of the failure which often disappoints human endeavors, or of the dangers which often attend on their accomplishment. Thus, when nature's object is to render the child no longer dependent on the mother for its food, she begins to prepare for this long beforehand. The first indication of it is furnished by the greatly increased activity of the salivary glands; organs whose function, as I told you in the last lecture, seems for some little time after birth to be wholly in abeyance. If you look into the mouth of a young infant, you will be struck by the very small amount of saliva that moistens its surface—a circumstance which explains in great measure the tendency to dryness which the tongue then presents under the influence of very trivial ailments. About the fourth or fifth month, however, this condition undergoes a marked alteration: the mouth is now found constantly full of saliva, and the child is continually drivelling; but no other indication appears of the approach of the teeth to the surface, except-that the ridge of the gums sometimes becomes broader than it was before. No further change may take place for many weeks; and it is generally near the end of the seventh month, oftener later than earlier, before the first teeth make their appearance. The middle incisors of the lower jaw are generally the first to pierce the gum ; next in order appear the middle incisors of the upper jaw, then the lateral incisors of the upper jaw, and next the lateral incisors of the lower. The first four molars next succeed, and often without any very definite order as to whether those of the upper or of the lower jaw are first visible, though, in the ma- jority of cases, the lower molars are the first to appear. The four canine teeth succeed; and, lastly, the four posterior molars—making, in all, the number of twenty deciduous teeth. We must not, however, picture to ourselves this process as going on uninterruptedly until completed—a mistake into which parents often fall, whose anxiety respecting their children is consequently ex- cited by observing that, after several teeth have appeared in rapid succession, dentition appears to come to a stand-still. Nature has so ordered it, that the process of dentition, beginning at the seventh or eighth month, shall not be completed until the twenty-fourth or thir- tieth ; and has doubtless done so in some measure with the view of diminishing the risk of constitutional disturbance which might be in- curred if the evolution of the teeth went on without a pause. A little observation will show you that, while the irruption of the lower central incisors is generally completed in a week, an interval of six weeks or two months often takes place before the upper incisors make their appearance, which then are quickly followed by the lower late- ral incisors. A pause of three or four months now frequently occurs before we see the first molar teeth, another of equal length previous RULES FOR THE USE OF THE GUM-LANCET. 427 to the appearance of the canine teeth, and then another still longer before the last molars are cut. Though a perfectly natural process, dentition is yet almost always attended with some degree of suffering. Many of us, no doubt, can remember feeling much pain when we cut our wisdom teeth, and chil- dren probably experience the same kind of annoyance. This, how- ever, is not always the case; for sometimes we discover that an infant has cut a tooth, who had yet shown no sign of discomfort, nor any indication that dentition was commencing, with the exception of an in- creased flow of saliva. More frequently, indeed, the mouth becomes hot, and the gums look tumid, tense, and shining, while the exact po- sition of each tooth is marked, for some time before its appearance, by the prominence of the gum: or the irruption of the teeth is pre- ceded or accompanied by a somewhat different condition of the mouth, in which there are much heat, and intense redness of the mucous membrane, an extremely copious flow of thin saliva, and a disposi- tion to the formation of small aphthous ulcerations on the tongue, at the outer surface of the alveolae, or at the duplicature of the lip, though the gums themselves may not be particularly swollen or pain- ful. Either of these states is usually attended with some degree of febrile disturbance, and apparently with considerable suffering to the infant, who is constantly fretful and peevish, or cries out occasionally as if in pain. A third morbid condition of the mouth is sometimes seen, which is usually ushered in or attended by very considerable fever and disorder of the chylopoietic viscera. The gums then be- come extremely hot and swollen, and unusually tender, especially over some tooth or other in particular, and in that situation we find the gum swollen up into a kind of little tumor. Small unhealthy ulcera- tions, with a sloughy appearance, often form upon the summit of the gum, and especially around any tooth which has partly pierced through it. To this affection, which is often very painful, and often difficult of cure, the name of Odontitis Infantum has been applied by some conti- nental writers. In considering the rules by which you must direct the management of children when teething, it can scarcely be necessary to caution you against regarding all diseases that may come on during dentition as of necessity connected with that process, or with the general changes then going on in the organism: still less need I warn you against looking upon all ailments at that time as symptomatic of the local uneasiness which the child suffers in its mouth. Some persons, indeed, act as if they held both these notions to their fullest extent; and, fol- lowing up in practice this coarsely mechanical theory, they lance the gums of every child who has not yet cut all its teeth, almost or alto- gether irrespective of the nature of the affection from which it suffers. Such a proceeding is nothing better than a piece of barbarous empi- ricism, which causes the infant much pain, and is useless or mischievous in a dozen instances, for one in which it affords relief. Still less is the gum-lancet to be employed, merely with the view of expediting the process that nature is engaged in. The gradual protrusion of the teeth occasions the slow absorption of the superjacent gum, and for 428 GENERAL MANAGEMENT OF TEETHING CHILDREN. this process the division of the gum by a scalpel forms at best but a clumsy substitute. The circumstances in which the use of the gum lancet is really in- dicated are comparatively few. You may employ it when a tooth is so nearly through that you can feel sure it will burst the gum in a day or two at latest; for then, by making an incision through the very thin gum, you may certainly spare the infant much suffering. Or, you may lance the gums if they be red, and swollen, and tense, and injected ; but then you scarify them in order that they may bleed, and that their congested vessels may be thus relieved; you do not divide them to let out the imprisoned tooth. In such circumstances it may be necessary to repeat your scarification several times with the same object; and it is therefore well to explain beforehand to the mother the reasons of your proceeding, lest she should expect to see the tooth at once make its appearance. There are, besides, cases in which the general constitutional disturbance that often attends dentition con- tinues for several days, or even weeks, while yet the condition of the swollen gum remains unaltered, and the tooth does not seem to ap- proach nearer to the surface. In such a case you may try the experi- ment of lancing the gums, or you may try it in the case of a child in whom you have already observed that catarrh, or fever, or diarrhoea, has been excited by the approach of each tooth to the surface, and has ceased immediately that the tooth has pierced the gum. Lastly, in the cases of sudden, and apparently causeless convulsion, which are i occasionally met with in children, you will be justified in lancing the gums if you find that the process of dentition is going on with activity; but you would do no good if you lanced the gums during one of those periods of repose which you will remember interrupt from time to time the evolution of the teeth. You must therefore inquire not merely what teeth the child has cut, but also when the last made their appearance ; and must seek for some evidence either that the process is still going on, or that its activity is once more re- commencing, before you would have ground for supposing the source of irritation of the nervous system to be such as your gum-lancet would relieve. If the process of teething be going on perfectly naturally, no inter- ference, medical or other, is either necessary or proper. The special liability of children to illness at that time must indeed be borne in mind, and care must be taken not to make any alteration in the in- fant's food while it is actually cutting its teeth, but rather to choose the opportunity of some one of those pauses to which reference has been made, as occurring between the dates of irruption of the succes- sive teeth, for auy such change. Should the child at any time appear very feverish, some simple febrifuge medicine may be given; as, for instance, a mixture of the bicarbonate of potash not quite neutralized with citric acid, to each dose of which two or three minims of the tinc- ture of hyoscyamus may be added, if the child is very restless and fretful.1 The diet must be carefully regulated; and as the heat of the mouth may induce the child to suck too often, in order to obtain the grateful 1 See Formula No. 2, p. 54. THEIR TREATMENT IN AFFECTIONS OF THE MOUTH. 429 relief of moisture, and by so doing to overload its stomach, water or barley-water should be freely given to it; and the mother should be cautious not to put it too frequently to the breast. If the child have been weaned, still greater care will be required, for it will often be found that it is no longer able to digest its ordinary food, which either is at once rejected by the stomach, or else passes through the intes- tines undigested. Very thin arrowroot made with water, with the addition of one-third of milk, will suit in many cases; or you may occasionally substitute for this, equal parts of milk and water thick- ened by dissolving isinglass in it till its consistence equals that of thick barley-water; or may employ the white decoction of Sydenham with the addition of one part of milk. If the bowels be disordered, half a grain of Dover's powder night and morning will often restrain their over-action; while the child may take during the day a muci- laginous mixture,1 containing small doses of the vinum ipecacuanhas and of some alkali, as the bicarbonate of potash or the liquor potassae. The dysuria from which infants sometimes suffer when teething is relieved by a similar plan of treatment, with the addition of small doses of castor-oil if the bowels do not act regularly; while the tepid bath is often extremely serviceable in diminishing that great heat of skin which exists in many of these cases. That state of the mouth in which small aphthous ulcers appear upon the tongue and about the alveolae is usually connected with disorder of the digestive organs, to the relief of which our treatment must be chiefly directed. It is seldom necessary to do more locally, than to pay great attention to cleanse the mouth every time after the child has sucked or taken food, and afterwards to apply to it a solution of borax, in the manner I pointed out to you at the commencement of this lecture. Now and then the submaxillary glands become swollen and tender while the infant is cutting some of its teeth; but this con- dition generally subsides of its own accord. Sometimes, however, the irritation extends to some of the absorbent glands beneath the jaw or near its angle; and in scrofulous subjects they occasionally inflame and suppurate. In such children, too, strumous ophthalmia and otorrhoea are not infrequently excited by dentition. That severe form of inflammation of the gums to which the name of Odontitis has been given, sometimes occasions great suffering, and may even endanger the child's life, though no instance has come under my own notice in which it actually proved fatal. The gum lancet will here do no good whatever; its employment would be intensely painful, and that unhealthy ulceration which attends the inflammation of the gums would attack the edges of the cut, and thus aggravate instead of relieving the child's sufferings. Local depletion by leeches, however, is extremely useful in such cases. Some writers have sug- gested that the leeches should be applied to the gum itself; but I 1 (No. 22.) R:.—Misturae acaciae 5vj- Liquoris potassae t^xxx. Vin. ipecacuanha? n\xxiv. Syrupi althese giv. Aquae purae 5xiiJ-—M. giij 6tis horis. For a child from 12 to 18 months old. 430 CUTANEOUS AFFECTIONS TO BE TREATED CAUTIOUSLY. have always contented myself with the much easier plan of applying them to the angle of the jaw, and have seldom been disappointed in obtaining very marked relief of all the symptoms. The diet must be most carefully regulated, the state of the bowels attended to, and a mildly antiphlogistic plan of treatment adopted, while the borax lotion may be used locally with advantage. There is, however, one remedy which acts in the various forms of stomatitis almost like a charm, and which proves exceedingly useful even when inflammation of the mouth is associated with the process of teething. This remedy, for the introduction of which into practice, in cases of stomatitis, the profession is indebted to Dr. Hunt,1 is the chlorate of potash, which may be given dissolved in water and sweetened, in the dose of two grains every four hours to a child a year old, with almost a certainty of effecting a cure in the course of four or five days. Two or three exceptions, however, to the ordinary course of even severe odontitis have come under my notice, in which the affection of the gums became chronic, and so continued during the whole period of dentition. The gum in these cases was spongy and livid, like that of a person suffering from scurvy, and so swollen that the teeth were almost hidden by it, while an unhealthy ulceration of its edges surrounded each tooth. In one instance this condition lasted during the whole period of cutting the incisor teeth; but the gum got well during the pause which ensued before the molar teeth made their appearance; while in another scarcely any improvement was apparent until at the age of two years and four months the first den- tition was completed. The children in both of these cases were weakly, and in one of them an eruption of purpura, which appeared at the age of fifteen months, served to assimilate the characters of the ailment even more closely to scurvy, while the only treatment which was beneficial consisted in the employment of acids, quinine, and wine in small quantities. I refer to these cases on account of their singu- larity ; and their occurrence was, indeed, the more remarkable since they were met with in the children of persons in the upper ranks of society, and resident in healthy situations in the country. In conclusion, I may just refer to those eczematous and impetiginous eruptions of the face and scalp which often occur in teething children. The old prejudice which regards diseases of the skin appearing at this time as having in them something salutary, and that consequently it is not desirable to attempt their cure, is not destitute of a certain foundation in fact. Instances of the sudden disappearance of erup- tions on the scalp during the period of dentition, being followed by serious impairment of the general health, by convulsions, or by other signs of mischief in the brain, are far from uncommon. Their removal, therefore, must never be attempted, except by the gentlest means, while every threatening of the supervention of cerebral congestion, or of more serious disease of the brain, must be most closely watched for and most vigorously combated. Sometimes, too, it will be found that whenever the cutaneous affection has made a certain advance 1 Medico-Chirurgical Transactions, vol. xxvi. p. 142. INFLAMMATION OF THE MOUTH. 431 towards cure, the signs of other disease invariably appear. In such a case it is wiser to content yourselves with keeping the local ailment in check, rather than, by persevering in the attempt to cure it, to en- danger in far more serious respects the welfare of the child. LECTURE XXXIII. Inflammation of the Mouth, or Stomatitis—its three varieties. Follicular stomatitis—often a secondary affection—most frequent before dentition is completed—its symptoms—character of the aphthae, or ulceration of the mouth— not a serious disorder.—Its treatment. Ulcerative stomatitis—principally affects the gums—its course usually chronic—has very little tendency to degenerate into gangrene.—Its treatment—the chlorate of potash almost a specific for it. Gangrenous stomatitis—extremely rare, but very fatal—essential differences between it and the other forms of stomatitis—dependent on alterations of the blood, such as occur in fevers—its mode of commencement, symptoms, and course—state of the gangrenous parts on dissection. Treatment—importance of efficient cauterization—what caustics are to be used, and how they are to be applied. The disease does not depend on the administration of mercury. Cynanche Tonsillaris—unusual in young children—its symptoms not peculiar. Hypertrophy of the Tonsils—its frequency and importance in childhood—its symp- toms—extreme dyspnoea sometimes produced by it—modifications it produces in form of mouth and nose—deformity of chest resulting from it, how produced.— Treatment—frequent necessity for excision of tonsils. Retro-pharyngeal Abscess—an affection of great rarity, not confined to childhood— sometimes idiopathic, sometimes succeeds to fevers—its symptoms—illustrative cases—occasional difficulty in its diagnosis.—Treatment. Cynanche Parotidea—most common near period of puberty—epidemic and contagious —its symptoms—metastasis of inflammation rare,—Treatment. Among the local accidents which complicate dentition, we noticed a condition of the mucous membrane of the mouth, which, though not attended by serious danger, is often the source of much suffering to the patient. Inflammation of the mouth, however, is an occurrence by no means confined to the period of teething, but it comes on in children of all ages, assumes very different forms, and leads to very different results in one case from those which characterize it in another. The mucous follicles of the mouth are the chief seat of the disease in one case, the substance of the gum in another, that of the cheek in a third. In the first, the affection issues in the formation of several small ulcers, which heal eventually of their own accord; in the second, an unhealthy pro- cess of ulceration destroys the gums and denudes the teeth, but it is tardy in its advance, and tends to a spontaneous cure; while, in the last, mortification involves all the tissues of the cheek, and spreads 432 FOLLICULAR STOMATITIS: with a rapidity which remedies generally fail to check, and which is arrested at last only by the patient's death. Each of these varieties of stomatitis requires from us more than a passing notice. The first—the follicular stomatitis of some writers, the aphthous stomatitis of others, is met with either as a concomitant or sequela of measles, or as an idiopathic affection. In the former case it depends on the extension to the mouth of a state of inflammation similar to that which gives rise to the eruption on the skin; in the latter, it is often associated with obvious gastric or intestinal disorder. Under either of these conditions it is rare after five years of age; and though it often depends on causes quite independent of dentition, yet from the period when teething has commenced, to the end of the third year, is the time of its most common occurrence ; while in early infancy aphthae are unusual, though genuine thrush, such as I have described in the last lecture, is a frequent ailment. When it constitutes an idiopathic affection, more or less fever, and restlessness, loss of appetite, an un- healthy state of the evacuations, and frequently a relaxed condition of the bowels, precede the local ailment for several days. Attention is generally called to the state of the mouth by the child being observed to suck, or to take food, with manifest pain and difficulty; while at the same time the secretion of saliva is greatly increased, and the sub- maxillary glands are swollen and tender. The mouth is hot, its mucous membrane generally of a livid red, while a coat of thin mucus covers the centre of the tongue. On the surface of the tongue, especially near its tip, on the inside of the lips, particularly on the lower lip and about its fold, on the inside of the cheek, near the angles of the mouth, and less often in other situations also, may be seen several small isolated transparent vesicles, or the ulcers which, after bursting, they leave be- hind. The ulcers are small, of a rounded or oval form, not very deep, but having sharply-cut edges; and their surface is covered by a yel- lowish-white, firmly-adherent slough. When attention is first directed to the mouth, several of these small ulcerations usually exist, for the vesicular stage of the affection appears to be generally very short, while the ulcers are indolent, and sometimes continue for many days without showing any disposition to heal or to increase in size. The eruption of a single crop of vesicles, and the change of those vesicles into minute ulcerations, that heal in the course of time, do not complete the history of this affection, for while the mucous membrane in the situation of some of these ulcers at length resumes its natural condition, other vesicles appear, which again degenerate into little ulcers, and thus keep up the ailment, sometimes for weeks together. In some cases, not above five or six of these little ulcers exist at once, or they may even be less numerous, while it is very seldom that more than fifteen or twenty of them are observable at one time. By the succes- sive appearance of fresh ulcerations, and the coalescence of several, an ulcerated strip of considerable extent sometimes forms, especially at the tip of the tongue, or on the lower lip. When the ulcers are heal- ing no change in their aspect is observable, and they continue to the last covered by the same yellow slough, but by degrees they diminish ITS SYMPTOMS AND TREATMENT. 433 in size; and seldom or never is any cicatrix observable in the situation which they occupied. In some cases the affection is complicated with a herpetic eruption about the edges of the lips, the vesicles of which degenerate into ulcerations similar to those observed in the interior of the mouth, and by their soreness add very much to the sufferings of the patient. Even though no remedies be employed, this affection shows no ten- dency to rapid increase. It is but very seldom that any cryptogamic formation, such as characterizes thrush, takes place on the surface of the ulcerations, or that any tendency appears to the formation of false membrane in the mouth; while even when most severe it is unat- tended by any disposition to gangrene. It is sometimes a source of much annoyance to the child, but need never excite any serious solici'- tude, except when it occurs as a sequela of measles. In that case, however, as was observed some days ago, it occasionally becomes associated with diphtheritic deposits on the fauces, and with ulcer- ative inflammation of the larynx, though our anxiety is then excited less by the affection itself than by its concomitants. In the treatment of this affection, our attention must be chiefly directed to correcting the gastric and intestinal disorder by which it is accompanied; and when this object has been attained, the local ail- ment in many cases speedily subsides. The borax lotion mentioned in the last lecture is one of the best local applications that can be used; but if the ulcerations show no tendency to heal, it may be de- sirable to touch them once or twice a day with a solution of five grains of nitrate of silver in an ounce of distilled water. Between the mild affection we have just been studying and the second form of stomatitis, to the examination of which we are now about to pass, there are comparatively few points of resemblance. This variety of the disease attacks the gums, and sometimes destroys them extensivelj7, unlike the former ailment, which, even though it should continue long, seldom occasions any actual loss of substance. The process, however, by which the destruction of the gums is accom- plished is one of ulceration, not of mortification—a fact which it is of importance to bear in mind, lest we should fall into the error of some observers, who have confounded together, under the name of Cancrum Oris, both this affection and that more formidable malady, true gan- grene of the mouth. To preserve the distinction between the two diseases, it may be well, following the example of some writers, to apply to the former the designation of Ulcerative Stomatitis,.or Noma,1 and to the latter that of gangrenous stomatitis, or gangrene of the mouth. It is by no means a constant occurrence for any special derange- ment of the general health to precede the attack of ulcerative stomatitis, though the children who are affected by it are seldom robust, and in many instances are such as have suffered from deficient food, or from a damp and unhealthy lodging, or from both. In children who are 1 From vo/uat, used by Hippocrates with referenoe to putrid and eroding ulcers. See Foesius, fficonomia Hippocratis, p. 432. 28 434 TREATMENT OF ULCERATIVE STOMATITIS. not very carefully tended, the ulceration has sometimes made consider- able progress before its existence is suspected, and the profuse flow of the saliva or the offensive smell of the breath is the circumstance which at length excites attention. Coupled with these symptoms, too, there is often considerable swelling of the upper lip, and the sub- maxillary glands are frequently swollen and painful. On opening the mouth, the gums are seen to be red, and swollen and spongy, and their edge is covered with a dirty white, or grayish, pultaceous deposit, on removing which their surface is exposed, raw, and bleeding. At first, only the front of the gum is thus affected; but, as the disease advances, it creeps round between the teeth to their posterior surface, and then, destroying the gum both in front and behind them, leaves them de- nuded and very loose in their sockets, but it is not often that they actually fall out. The gums of the incisor teeth are usually first affected, those of the lower jaw more frequently and more extensively than those of the upper; but if the disease be severe, the gums at the side of the mouth become likewise involved, though it is seldom that "the two sides suffer equally. Sometimes, aphthous ulcers, like those of follicular stomatitis, are seen on the inside of the mouth in con- nection with this state of the gums, but oftener it exists alone. On those parts of the lips and cheeks, however, which are opposite to, and, consequently, in contact with, the ulcerated gums, irregular ulcer- ations form, which are covered with a pultaceous pseudo-membranous deposit, similar to that which exists on the gums themselves. Some- times, too, deposits of false membrane take place on other parts of the inside of the mouth, the surface beneath being red, spongy, and bleed-' ing, though not distinctly ulcerated. If the disease be severe and long-continued, the tongue assumes a sodden appearance, and is in- dented by the teeth ; and the cheek, on one or other side, is somewhat swollen, while the saliva, though rather less abundantly secreted than at the commencement of the affection, continues horribly fetid, and is often streaked with blood, the gums themselves bleeding on the slight- est touch. But even if left alone, the affection usually subsides in the course of time, though it may continue almost stationary for days or weeks together, and this notwithstanding that the general health is tolerably good. It would be too much to say that this unhealthy ulceration never degenerates into gangrene; but though a very large number of cases of ulcerative stomatitis have come under my notice, I have seen only one instance in which it was succeeded by true gan- grene of the mouth. When recovery has commenced, the disease ceases to spread; the drivelling of fetid saliva diminishes; the white pultaceous deposit on the gums, or on the ulcerations of the cheek or lips, becomes less abundant; the ulcers themselves grow smaller; and, finally, the gums become firm, and their edges of a bright red, though still for a long time showing a disposition to become once more the seat of the ulcerative process, and continuing for a still longer time to cover the teeth, but very imperfectly. Various internal remedies and local applications have been at dif- ferent times recommended for the cure of this affection. Tonics have been much employed, and the supposed analogy between this state of SYMPTOMS OF GANGRENOUS STOMATITIS. 435 the gums and that which exists in scurvy, has led practitioners to give the preference to remedies reputed to be^ possessed of antiscor- butic properties. Lotions of alum, or the burnt alum in substance, or the chloride of lime in powder, have all been used locally with more or less benefit. It was my custom also to prescribe these reme- dies in cases of ulcerative stomatitis; but since I became acquainted with the virtues of the chlorate of potash, I have learnt to rely upon it almost exclusively. It appears, indeed, almost to deserve the name of a specific in this affection ; for a marked improvement seldom fails to be observed in the patient's condition after it has been administered for two or three days; and in a week or ten days the cure is generally complete. Three grains every four hours, dissolved in water, and sweetened, is a sufficient dose for a child three years old; and five grains every four hours appear to answer as well as a larger dose for a child of eight or nine. If the bowels be constipated, a purgative should be previously administered; but there seems to be no form, nor any stage of the affection, in which the chlorate of potash is not useful. The diet should be light but nutritious, and quinine or other* tonics are sometimes serviceable if the child's health should continue feeble after the' local malady has been cured. Ulcerative stomatitis is an affection of such frequent occurrence, that many instances of it come under my notice every year, especially during the damp autumnal months ; while it is attended with so little danger, that the only case which I have known to prove fatal was one in which gangrene of the mouth supervened upon it. Gangrenous stomatitis, on the other hand, is a disease so rare, that I have only seven times had the opportunity of witnessing it; but so fatal, that in six out of those seven cases the patients died. The larger expe- rience of other observers shows an almost equally unfavorable result, since twenty out of twenty-one cases that came under the notice of MM. Rilliet and Barthez had a fatal termination; and a recent French writer,1 who has collected from different sources 239 cases, which did not all occur in children, states that 176 of the number, or 75 per cent., terminated fatally. The formidable nature of the disease re- quires that we study it more closely, than, considering the rarity of its occurrence, would otherwise be necessary; and it is the more important to do so, in order that we may avoid the not very uncommon error which confounds this dangerous affection with that comparatively trifling ailment—ulcerative stomatitis. The constitutional disturbance which often precedes the other two affections of the mouth that we have just been studying, was seen to be generally of a trivial nature, and never so severe as to excite serious anxiety. Gangrene of the mouth, on the other hand, seldom comes on, except in children whose health has been already much impaired by previous disease, and especially by such diseases as are connected with important changes in the circulating fluid. In strict propriety, indeed, I doubt whether we ought not to remove both this and those other allied affections, in which the skin or the genital 1 Tourdes, Du Noma, &c, 4to. These de Strasbourg, 1848. 436 SYMPTOMS OF GANGRENOUS STOMATITIS. organs become the seat of gangrene, from among the class of local ailments, and refer them to the category of blood diseases. Of twenty- nine cases of gangrene of the mouth, which MM. Rilliet and Barthez either observed themselves, or of which they found mention in the writings of other physicians, only one appeared to be an instance of the disease in an idiopathic form; while in twelve cases it followed an attack of measles. Of the seven cases which I have observed, and three of which I examined after death, two succeeded to typhoid fever, three to measles, one came on in a child whose health had been com- pletely broken down by ague, and one supervened in a tuberculous child, who had been affected for many weeks with ulcerative stomatitis in a severe form. Though not confined to any one period of child- hood, gangrene of the mouth is more frequent between the ages of two and five than either earlier or later. Of the seven cases that came under my own observation, two were in children between two and three years old, two in children aged three, one in a child between , four and five, one at six and a quarter, and one at eight years of age. Of the twenty-nine cases mentioned by MM. Rilliet and Barthez, nineteen occurred between two and five; ten between six and twelve; and M. Tourdes'1 comparison of one hundred and two cases between one and a half and twelve years, likewise yields the greatest number during the third and fourth years. Although all the tissues of the cheek become involved in the course of this affection, yet difference of opinion has existed with reference to the part in which it commences; some observers conceiving that it usually begins in the substance of the cheek, while others regard the mucous membrane as being the part which is invariably the first attacked. So far as my own observation enables me to judge, I am disposed to regard this latter view, which is that of MM. Rilliet and Barthez, and of M. Baron, and which is moreover supported by the minute researches of Professor Albers,2 of Bonn, as generally correct. At the same time, however, I must admit that I have had no very recent opportunity of personally investigating this subject, while a very competent observer, Dr. Loschner,3 physician to the Children's Hospital at Prague, while he admits the occasional commencement of the affection in either way, believes the former to be the more com- mon. According to his observations, the appearance of a swelling, having a hard central spot or nucleus, surrounded by tense, elastic, but less firm tissue, gradually passing off" into the texture of the ad- jacent parts, is the first step in the process; ulceration of the mucous membrane being secondary to this peculiar infiltration of the cellular tissue of the cheek. It is, indeed, very probable that the gangrene sometimes begins in the one way and sometimes in the other; while any dispute concerning it loses almost all its practical moment, if we regard this and other forms of gangrene as resulting from merely 1 Op. cit., p. 31. 2 Archiv f. Physiol. Heilkunde, ix. 7-8, 1850 ; and Schmidt's Jahrb., 1851, No. 2, p. 195. 3 Der Brand im Kindesalter, in the Vierteljahrschrift fur die Prakt. Heilkunde, vol. xv. p. 58. SYMPTOMS OF GANGRENOUS STOMATITIS. ' 437 accidental differences in the mode in which the graver deterioration of the circulating fluid manifests itself. The early stages of the affection are attended by scarcely any suffer- ing, owing to which, as well as to the circumstance that the children in whom it supervenes are almost always laboring under some other disease, or in the course of convalescence from it, it is probably due that the malady is often not discovered until after it has made con- siderable progress. There may for a day or two have been an unusual fetor of the breath, and a profuse secretion of offensive saliva; but the appearance of swelling of the cheek is frequently the first symptom that leads to a careful examination of the state of the mouth. The characters of the swelling of the cheek are almost pathognomonic of gangrene of the mouth. It is not a mere puffiness of the integument, unaccompanied by any change of its color, such as is sometimes ob- served in ulcerative stomatitis; but the cheek is tense, and red, and shining—it looks as if its surface had been besmeared with oil, and in the centre of the swollen part there is generally a spot of a brighter red than that around. The cheek feels hard, and is often so unyielding that the mouth cannot be opened wide enough to get a good view of its interior. The disease is almost always limited to one side, and generally to one cheek. Sometimes, however, it extends to the lower lip; and occasionally it begins in that situation. The upper lip is now and then reached by the progress of the disease, but is never its primary seat. Whatever be the situation of the external swelling, there will generally be found within the mouth, at a point correspond- ing to the bright red ceutral spot, a deep excavated ulcer, with irre- gular jagged edges, and a surface covered by a dark brown shreddy slough. The gums opposite to the ulcer are of a dark color, covered with the putrilage from its surface, and in part destroyed, leaving the teeth loose, and the alveolae denuded. Sometimes, especially if the disease be further advanced, no single spot of ulceration is recogniz- able, but the whole inside of the cheek is occupied by a dirty putrilage, in the midst of which large shreds of dead mucous membrane hang down. As the disease extends within the cheek, a similar process of destruction goes on upon the gum; the loosened teeth drop out one by one, and the alveolar process of the jaw loses its vitality for a more or less considerable extent; while sometimes, though of this I have not seen any instance, a portion of the ramus of the jaw itself becomes necrosed. The saliva continues to be secreted profusely, but shows by the changes which take place in its characters the progress of the disease. At first, though remarkable for its fetor, it is other- wise unaltered; but afterwards it loses its transparency, and receives from the putrefying tissues over which it passes, a dirty, greenish, or brownish color, and at the same time acquires a still more repulsive odor. While the gangrene is thus going on inside the mouth, changes no less remarkable are taking place on the exterior of the face. The red- ness and swelling of the cheek extend, and the deep red central spot grows larger. A black point appears in its midst: at first it is but a speck, but it increases rapidly, still retaining a circular form; it 438 STATE OF THE GANGRENOUS PARTS. attains the bigness of a sixpence, a shilling, a half crown, or even a larger size. A ring of intense redness now encircles it, the gangrene ceases to extend, and the slough begins to separate. Death often takes place before the detachment of the eschar is complete, and it is fortu- nate when it does so, for sloughing usually commences in the parts left behind. The interior of the mouth is now exposed; its mucous membrane and the substance of the cheek hang down in shreds from amidst a blackening mass, and form one of the most loathsome specta- cles that can be conceived; while the horrible stench which the morti- fied parts spread around, makes the task of watching the poor child as repulsive as it is distressing. Happily it is not often that acute suffering of the child occurs to heighten the distress of the sad scene. Usually the patient has but little pain from the very first, but is generally more drowsy than natural, though sometimes the nights are restless; and in those cases in which gangrene of the mouth supervened in the course of typhoid fever, the delirium which existed before continued unmodified. The pulse grows feebler as the disease advances; but gleams of cheerful- ness may sometimes be perceived, even long after the appearance of the black eschar on the cheek has shown the case to be all but hope- less; and the desire for food often continues unabated till within a few hours of the child's death, which generally takes place quietly, though sometimes it is preceded by convulsions. Since gangrene of tbe mouth occurs in the course of a great variety of diseases, the only morbid appearances characteristic of it are those which result from the local mischief. On two occasions I dissected the gangrenous parts very carefully, and the alterations which pre- sented themselves to my notice were precisely the same as have been described by MM. Rilliet and Barthez. The absorbent glands, both superficial and deep-seated, on the affected side, are enlarged, and the cellular tissue of the cheek is infiltrated with serum, which is more abundant the nearer one approaches to the slough. In the substance of the eschar the distinction of parts is no longer easy ; but with care the vessels and nerves may still be traced; and the reason why fatal hemorrhage so seldom cuts short the life of patients suffering from this affection, is at once explained by the clot which plugs up the vessels for some distance on either side of the gangrenous mass. On one oc- casion I found the root of the tongue, the tonsils, pharynx, both sur- faces of the epiglottis, and about an inch of the oesophagus, completely coated with a moderately firm, yellow false membrane, about a line in thickness, easily detached, and leaving the subjacent mucous membrane only a little redder than natural. A few patches of a similar deposit existed in the larynx, but not continuous with that in the pharynx. In this case, great difficulty of deglutition had existed for three days before the death of the child. The association of diphtheria with gan- grene of the mouth is, however, an accidental complication, and not one of frequent occurrence. The arrest of the sloughing is the one point to which in the treat- ment of this affection the attention of all practitioners has been directed. The small amount of success which has attended their efforts is partly TREATMENT OF GANGRENOUS STOMATITIS. 439 attributable to the circumstance that the affection has frequently been overlooked until it has already made considerable progress: in part also to the fact that when recognized, the local remedies employed in order to check the gangrene have either been too mild, or have been applied with too timorous a hand. Unfortunately too there is consi- derable difficulty in applying any caustic effectually to the interior of the mouth; for the tense and swollen condition of the cheek prevents our obtaining easy access to the gangrenous parts. The use of chlo- roform, however, happily removes that other great difficulty which the severe pain attendant on the cauterization formerly opposed to its effectual performance. Ineffectual cauterization, indeed, is useless, or worse than useless; and though every endeavor should be made to prevent the needless destruction of healthy parts, yet of the two evils, that of doing too much is unquestionably less than that of doing too little. It is of importance, moreover, not only that the cauterization should be done effectually, but also that it should be practised early. M. Baron, indeed, speaks of incising tbe slough in the cheek, and then applying the actual cautery to the part; but I am not aware of any instance in which this suggestion has been acted on with a good result. When once the mortification has extended through the substance of the cheek, the chances of arresting its progress must be very few. As the sloughing advances from within outwards, it is to the interior of the mouth that our remedies must be applied; and since the advance of the disease is too rapid to allow of our trying mild means at first, and afterwards resorting, if necessary, to such as are more powerful, we must employ an agent sufficiently energetic at once to arrest its progress. Various caustics have been recommended for this purpose, but none appear to be so well fitted to accomplish it as the strong hy- drochloric or nitric acid. I am accustomed to employ the latter, ap- plying it by means of a bit of sponge, or of soft lint or tow, fastened to a quill; while I endeavor, by means of a spoon or spatula, to guard the tongue, and other healthy parts, as far as possible, from the action of the acid. In the only case that I saw recover, the arrest of the dis- ease appeared to be entirely owing to this agent; and though the alveolar processes of the left side of the lower jaw, from the first molar tooth backwards, died, and exfoliated, apparently from having been destroyed by the acid, yet it must be owned that life was cheaply saved even at that cost. Some increase of the swelling of the cheek almost invariably follows the application of this agent—a circumstance which may at first occasion unfounded apprehension lest the disease be worse. Twelve hours, however, must not be allowed to elapse without the mouth being carefully examined, in order to ascertain whether the disease has really been checked, or whether there is any appearance of mortification in the parts beyond the yellow eschar left by the first application of the acid. The cauterization may now be repeated, if it appear necessary, and even though the disease had seemed completely checked; yet reliance must not be placed on tbe improvement con- tinuing, but the mouth must be examined every twelve hours, for fear the mortification should spread unobserved. During the whole pro- gress of the case the mouth must be syringed frequently with warm 410 MERCURY SELDOM CAUSES GANGRENE OF THE MOUTH. water, or with chamomile tea mixed with a small quantity of the solu- tion of chloride of lime, in order to free it from the putrid matters that collect within it and to diminish as much as possible their offensive odor. Should the case go on well, the frequent repetition of the strong acid will be unnecessary; but the surface may still require its appli- cation in a diluted form, or it may suffice to syringe the mouth fre- quently with the chloride of lime lotion, or to apply the chloride in powder once or twice a day, according to the suggestion of MM. Rilliet and Barthez. In the last three cases of this affection that came under my notice, I likewise employed the chlorate of potash internally, but it did not appear to exert any influence over it; and valuable though the remedy is in ulcerative stomatitis, yet I should scarcely feel dis- posed to rely upon it, to the exclusion of local treatment, in true gan- grene of the mouth. Two cases, however, of cancrum oris succeeding to fever, in children of twelve and thirteen years of age, were treated with most complete success by Dr. Burrows, in St. Bartholomew's Hospital, without the employment of any other local measures than a chloride of soda gargle; but with good diet, wine, and chlorate of potash, in doses of ten grains every four hours. During the whole course of treatment you have another indication to fulfil—namely, to support your patient's strength by nutritious diet, and by the employment of wine and other stimulants, and by the administration of quinine, or of the extract or tincture of bark, or whatever form of tonic may seem best suited to the peculiarities of the case. In conclusion, let me remind you that during the whole progress of the case your prognosis must be regulated by the state of the local disease, rather than by the urgency of the general symptoms. So long as the sloughing is unchecked the affection is tending rapidly to a fatal issue, and this even though the pulse be not very feeble, though the appetite be good, and the child still retain some show of cheerfulness. It might seem to you to be an omission on my part, if I left the subject of inflammation and gangrene of the mouth, without some notice of the supposed influence of mercury in its production. There can be no doubt but that this preparation, even when given in small doses, has in a few instances produced severe ptyalism, inflammation of the mouth, loss of the teeth, and necrosis, more or less extensive, of the lower jaw. In some cases too the inflammation has terminated in gangrene of the cheek which has presented many of the characters that we have just been noticing; and in such circumstances inquests have sometimes been held, and blame has been attached to the medi- cal attendant for alleged want of caution in the administration of so powerful an agent as mercury. Now, although mercury should never be given without necessity, nor its administration continued without watching its effects most carefully, yet I cannot but regard the super- vention of gangrene of the mouth during its use as merely an acci- dental coincidence, or else as the result of some peculiar idiosyncrasy of the patient, such as has been observed in the adult as well as in the child. Nearly 30,000 children, of all ages, have come under my HYPERTROPHY OF THE TONSILS. 441 care during my connection with the Children's Infirmary and the Children's Hospital, and I have administered mercury to any of them who seemed to require it, but hardly ever saw salivation follow its employment before the completion of the first dentition; and never observed that medicine, at any age, produce any affection of the mouth sufficiently serious to cause me a moment's anxiety. An inconvenience—I do not know that it deserves a more serious designation—inseparable from the arrangement of subjects which I have adopted, is that we pass at once from diseases that are very hazardous, to others which are of a comparatively trifling character, or are the sources of discomfort rather than of severe suffering. Of this some of the ailments which remain for our consideration to-day are no inapt illustrations. Inflammation of the soft palate, tonsils, and fauces, constituting Cynanche Toyisillaris, is not strictly limited to any age, nor attended with any special symptoms when it occurs in the child. It is, how- ever, comparatively rare under 12 years of age, and is almost always less severe than at or after puberty, while I scarcely remember to have met with it under 5 years of age—a circumstance which attaches special importance to sore-throat in young children, since it will usu- ally be found to betoken the approach of scarlet fever rather than the existence of simple inflammation of the tonsils. But, though acute inflammation of the tonsils is unusual in early childhood, a sort of chronic inflammation of those glands, which leads to their very considerable enlargement, is far from uncommon; and this hypertrophy of the tonsils, which, in the adult, is little more than an inconvenience, is, in the child, not infrequently the cause of more serious evils. It is seldom traceable to any acute attack of angina, but usually comes on in children who are out of health, feeble, and strumous; or takes place slowly during the latter stages of the first dentition, the irritation of which appears in some cases to be its only exciting cause. Unless accidentally discovered, the enlargement of the tonsils has usually become very considerable before it attracts much notice, and hence it is comparatively seldom observed in children under three years old, though M. Robert, a French surgeon,1 who has written a very excellent paper on the subject, speaks of having noticed it as early as the sixth month. One of the first symptoms that attract attention is the habitually loud snoring of the child during sleep, owing to the enlarged tonsils pressing upon the velum, and thus obstructing the passage of air through the posterior nares, while at the same time the voice becomes thick ; and both of these symptoms are remarkably aggravated during, and for some time after, even slight attacks of catarrh. An amount of enlargement of the tonsils sufficient to cause these symptoms is by no means uncommon, and if it do not exceed this extent the inconve- nience to which it gives rise will in general disappear altogether with the development of the mouth and vocal organs at the period of 1 In the Bulletin General de Therapeutique, May and July, 1843. 442 HYPERTROPHY OF THE TONSILS puberty. Often, however, it is more considerable, and then the tonsils produce a degree of deafness, partly by actual pressure on the Eusta- chian tubes, partly by the state of habitual congestion which they occasion in the parts in their neighborhood ; the respiration, moreover, becomes rather labored, and the child has a constant hacking cough, occasionally aggravated and paroxysmal—two symptoms which I have known to raise on more than one occasion an unfounded appre- hension of phthisis; and to lead in other cases, where some phthisical disease actually existed, to the expression of a more gloomy prognosis than was warranted by the amount of mischief in the lungs. Now and then the difficulty of respiration from mere enlargement of the tonsils has been so considerable as to threaten life. No instance of this, indeed, has come under my own observation, but my friend and former colleague, Mr. Shaw, once had a little boy under his care, who, in addition to constant dyspnoea, suffered from occasional fits of suf- focation arising from this cause; and one of these fits was so severe that in order to preserve the child's life it was necessary to perform laryngotomy. The long existence of considerable enlargement of the tonsils, and the consequent almost complete obstruction to the passage of air through the nostrils, give rise to a peculiar alteration in the form of the parts thus thrown out of use. The nostrils become extremely small, narrow, and compressed; and the peculiar character which the physiognomy thus acquires is further increased by the accompanying modification in the development of the upper jaw. The superior dental arch remains very narrow, so as not to allow adequate room for the teeth, which consequently overlap each other very much, while at the same time the palate becomes unusually high and arched. Nor is this the only mode in which due development is interfered with; but it was noticed thirty years ago by Dupuytren that enlarge- ment of the tonsils and the pigeon-breast very usually go together. The fact was confirmed by others, but I believe that Mr. Shaw1 was the first person to offer an explanation of it. He pointed out how the obstacle to the free entrance of air into the lungs prevents their being filled at each inspiratory effort; so that a vacuum would be formed between them and the walls of the chest, were it not that the pressure of the external air on the yielding parietes of the thorax forces them inwards to occupy the vacant space; and doing so most readily where their resistance is least, namely, at the commencement of the costal cartilages, produces the well-known lateral flattening of the thorax, and prominence of the sternum. The little boy whose case I have just mentioned as necessitating the operation of laryn- gotomy, gave in his own person a striking illustration of the correct- ness of the explanation which I have just given you. " On his ad- mission into the hospital," says Mr. Shaw, "and for several weeks afterwards, it was observed that he had the pigeon-breast form of 1 Medical Gazette, Oct. 23, 1841. See also his remarks in the article Thorax, in the Cyclopaedia of Anatomy and Physiology, p. 1039 ; and also those of M. Robert, in his paper already referred to. SOMETIMES REQUIRES THEIR EXCISION. 443 chest; but after his tonsils were excised, and his breathing had been perfectly free for some time, the sternum subsided to its proper level, and the thorax recovered its natural shape." Enlargement of the tonsils, then, though at first sight it may appear a trivial ailment, is yet one which you must by no means neglect. A weakly child, whose tonsils are but slightly enlarged, will often get rid of his ailment as he gains health and strength, or at puberty will completely outgrow it. Any slight attack of cold, however, is apt to be followed by the increase or the return of the enlargement; and though this may often be kept in check by the application of pow- dered alum once or twice a day to the tonsils, or by touching them every day or two with the solid nitrate of silver, yet on the whole the tendency is towards the increase rather than the lessening of the evil. In no case, indeed, in which the hypertrophy of the tonsils is consid- erable, or of long standing, have I found these measures, or the paint- ing the exterior of the throat just above the angle of the jaw, with tincture of iodine, of much service, and excision of the tonsils is then the only remedy. Whether this be had recourse to at once, or whether you will wait a few years till the child is older and better capable of that slight amount of self-control which is desirable for the perform- ance of the operation, must depend on the size of the tonsils, on the amount of inconvenience which they occasion, and on the presence or absence of any marked deformity of the chest. There is one circum- stance, however, which would always induce me, independent of other grounds, to advise the immediate excision of enlarged tonsils; namely, the existence of a constant or frequent cough, or the presence of any other symptom warranting a suspicion of phthisical disease in the chest. The enlarged tonsils not only mechanically interfere with the ready entrance of air into the lungs, but keep up a constant irritation of the air-passages, and thus maintain a condition most unfavorable to the arrest of tubercular disease in the chest; while on more than one occasion I have seen most threatening symptoms disappear with great rapidity after their removal. If, after the tonsils have been re- moved, the chest is long in regaining its natural form, the use of dumb- bells, and the careful practice of gymnastic exercises, are often of much service. Dupuytren's recommendation too, to stand the child with its back against a wall, and then placing the hand upon the most prominent part of the sternum, to press firmly upon it during each expiratory effort, remitting the pressure during inspiration, in order that the child may fill its chest as completely as possible, I have found to be, in spite of its seeming roughness, extremely valuable as an ad- ditional means of removing the deformity of the pigeon-breast. In the year 1840, Dr. Fleming, of Dublin,1 called attention to the occasional occurrence of abscess behind the pharynx, which, pressing forward against the trachea, gives rise to urgent dyspnoea, and some- times even produces suffocation. Isolated cases of this accident had, indeed, fallen under the notice of previous observers, but by none, 1 Dublin Journal of Medical Science, vol. xvii. p. 41. 414 RETROPHARYNGEAL ABSCESS. with the exception of Dr. Abercrombie,1 had they been made the sub- ject of special remark; while to Dr. Fleming unquestionably belongs the merit of having laid down distinct rules for its diagnosis, and clear directions for its treatment. Since Dr. Fleming's paper was published, many other instances of the affection have been recorded, especially by M. Mondiere2 and M. Duparcque,3 the latter of whom also pointed out certain distinctive differences between cases where the matter ac- cumulates behind the pharynx, and others in which it collects lower down, behind the oesophagus; and by Dr. Allin,4 an American phy- sician, who in a very able paper has collected the statistics of fifty- eight cases of the affection. Neither form of it is exclusively confined to early life: yet it happens in children with sufficient frequency to entitle it to some notice in a course of Lectures on the Diseases of Childhood.5 There are a few instances on record of the formation of retro- pharyngeal abscess as the result of direct injury; or of its occurrence in connection with disease of the cervical vertebrae. Leaving, how- ever, these exceptional cases out of consideration, the affection may be said to present itself either as a sequela of fever, or as an idiopathic disease; the latter much more frequently than the former. In either case the characteristic indications of its existence are difficulty in swallowing and in breathing; often accompanied with a peculiar sound in respiration, though not with the stridor of croupy breathing, nor the loud clangor of croupy cough. These symptoms are aggravated in the recumbent posture, any attempt to assume which is followed by immediate threatening of suffocation; though, in spite of this, the affection often continues with unabated severity, but yet without 1 Edinburgh Medical and Surgical Journal, vol. xv. 1819, p. 260. 2 L'Experience, Jan. 20, 27, and Fevrier 3, 1842. 3 Annales d'Obstetrique, Dec. 1842, p. 242. 4 New York Journal of Medicine, vol. vii. Nov. 1851, p. 307. 5 M. Mondiere states that 11 out of 18 patients whose history he collected had not reached adult age, and that 7 were between 11 weeks and 4V years old ; and M. Du- parcque mentions that in 10 out of the 30 cases to which he refers, the age of the patients was less than 4£ years. Unfortunately, however, M. Mondiere's references are very incomplete, and M. Duparcque gives none at all. In this respect Dr. Allin's paper leaves nothing to be desired. In all the instances in which the age is not expressly stated in his tables, it is yet apparent from the context that the patient had reached adult age, or at least had passed the period of puberty. If to the 58 cases that he mentions 9 others be added from different sources, we obtain the following results :— Under six months old ........ 5 Between six months and one year, or stated to be infants . 8 " one year and two ....... 3 " two " three ....... 2 " three " five ....... 5 " five " ten ....... 1 " ten " fifteen.......2 Above fifteen ....... 41 67 Of the nine additional cases it may be stated that four in the adult are recorded by M. Mondiere in his paper in L'Experience ; two in the child are reported by Dr. Aber- crombie in the Edinburgh Journal; one in an infant is related by Dr. Nolt in the Deutsche Klinik, and republished in Schmidt's Jahrbiicher, vol. lxxvi. 1852, p. 236 ; the remaining two are those which came under my own observation. CASES OF RETROPHARYNGEAL ABSCESS. 445 destroying life, for several days together, and presents in this respect a very important difference from the course of croup. Moreover, a remarkable stiffness of the neck, and retraction with immobility of the head, are present in many instances ; while though the glands are not enlarged there is often a distinct swelling of the lateral parts of the neck, which is frequently more apparent on one than on the other side. If in these circumstances the finger be carried over the root of the tongue, and down towards the pharynx, a firm, somewhat elastic swelling will be detected, closing more or less completely the canal of the pharynx, and projecting forward over the opening of the glottis, so as to interfere with the access of air to the lungs. Sometimes on opening the mouth and depressing the tongue, the swelling can be distinctly seen almost or quite in the mesial line, pressing forward the velum palati, and obviously encroaching greatly on the entrance of the windpipe; but sometimes the tumor is situated too low down to be brought into view, while in other cases the mouth cannot be opened sufficiently to allow of the back of the throat being seen ; and the tumor can then be detected only by the finger. Only two cases of the affection have come under my own observa- tion. The first patient was an idiot girl, five and a half years old, who was attacked by mild scarlatina on January 24th. During the course of the fever no remarkable symptom presented itself, but on its decline the child complained much of her mouth, frequently put her hand to it, and refused all except liquid food on account of its hurting her; but on looking into her throat, neither redness nor swell- ing was perceptible. About the 7th of February swelling appeared near each angle of the lower jaw, but rather lower down than in the situation of the parotid gland. The swelling on the left side subsided on the applica- tion of a few leeches, but that on the right side increased, and at the same time the difficulty in deglutition became more distressing. By the 13th of February the dysphagia had become very much increased; the child could swallow only by gulps, and at each effort she was greatly distressed for breath; though at other times she lay in a half- conscious state, with labored respiration, and frothing slightly at the mouth. On the 16th the child was still worse: her respiration was very difficult, though not attended by the violent struggle for breath which is so often observed in cases of croup; a dirty-yellowish puri- form matter, rendered frothy by air, now collected as a sort of foam at her mouth, and deglutition almost choked her; but still there was no swelling of the tonsils, and the swelling of the side of the neck was so tense that I did not think it possible for matter to be any- where near the surface. On the following day she died, apparently as much from exhaustion as from asphyxia; it having for some days been impossible to give her more than a very small quantity of nou- rishment. Immediately on dividing the cervical fascia on the right side, a quantity of thick, yellow, healthy pus poured out. This matter had burrowed close to "the oesophagus to within little more than an inch of the clavicle; and also in an oblique direction behind the cesopha- 446 CASES OF RETRO-PHARYNGEAL ABSCESS: gus towards the left side, completely detaching it from its connections on the right side though not on the left. It passed up behind the oesophagus and pharynx quite to the base of the skull, a few shreds of cellular tissue bathed in pus being all that remained of their posterior attachments. The tonsils were not enlarged, and the glottis was neither red nor swollen, but quite natural. In the other case the affection was idiopathic, and the child a boy only 8 months old. He became dull, drooped, and appeared to have a stoppage in his nose which rendered respiration difficult. After these vague symptoms had lasted for a month, the child began to swallow with difficulty and deglutition sometimes was quite im- possible, while his respiration, habitually difficult, became especially so when he was asleep. For five weeks he was treated for some supposed head affection with aperients, cold lotions to the head, &c; and for another week, his symptoms having increased in severity, his case was regarded by another practitioner as one of bronchitis. At the end of six weeks from his first indisposition the boy came under my notice. He was lying asleep in his mother's arms, his head rather thrown back, his face very pale and somewhat puffy, his mouth wide open, and his tongue turned up to the roof of his mouth. His breathing was labored, and attended with an extremely loud, constant cluck, not at all resembling the stridor of croup. This sound was louder and his breathing was more difficult when asleep than while awake, though both were very marked even then, and the entrance of air into the lungs was imperfect, especially on the left side. The child sucked moderately well, leaving off to breathe very fre- quently, but managing to swallow, and not returning the milk either through the nose or mouth. On passing my finger down the throat, I felt a hard body at the root of the tongue, which seemed to occupy the space completely, and on depressing the tongue I saw the uvula and velum forced for- ward by a body oompletely occupying the isthmus of the fauces. The surface of this tumor was generally red, but one or two yellow spots appeared on it, as if due to the presence of matter showing through a thin investment; and a sharp-pointed bistoury, the blade of which was defended by plaster, being plunged into it, nearly an ounce of yellow pus escaped, and the tumor immediately collapsed. Air now entered the chest freely; the child sucked readily, and soon fell asleep, breathing quietly. The'same evening, his respi- ration becoming once more less tranquil, his mother put her finger down his throat, and pressed, as she had been directed, against the side of the abscess, when a little pus escaped, with immediate relief to the child. On the day after the puncture the swelling was the size of a hazel-nut, situated almost completely to the left of the mesial line. It felt hard to the touch, but a little pus could be squeezed out of it on pressure; and this continued to be the case for about three days, the swelling itself not entirely disappearing for nearly three weeks, though it produced no further symptom, and the child has since continued perfectly well. Though in the first case the affection was not recognized during life, ITS DIAGNOSIS AND TREATMENT. 417 yet in it no less than in the second the characteristic symptoms of retro-pharyngeal abscess were clearly manifest. Such, too, 1 believe to be the case in the great majority of instances, though there are cir- cumstances which now and then somewhat obscure the diagnosis. In the first place, there does not seem to be any uniformity in the cha- racter of the earlier symptoms—fever and cerebral disturbance at- tending it in some cases, dyspnoea being the prominent symptom in others: so that suspicion as to the real nature of the disease is often lulled to sleep, and the true import of the dysphagia or of the difficult breathing is not apprehended even when it becomes manifest. Moreover, the duration of the earlier symptoms is very various; and while the disease sometimes runs a chronic course, in other cases it attains an extreme degree of severity in two or three days, and even destroys life within that period by the intensity of the cerebral disturbance which sometimes accompanies it. Nor is this all; but dysphagia, though generally insisted on as a pathognomonic symptom of the affection, is sometimes not very remarkable; while now and then, as in one of the cases related by Dr. Abercrombie, and in that detailed by Dr. Peacock, it was altogether absent. In the latter case, too, owing to the peculiar form of the abscess, no tumor was discovered on inspection of the throat, nor was any perceived even on introduction of the finger. This, however, is an extremely unusual occurrence. M. Duparcque enumerates the following symptoms as peculiar to cases where the abscess has formed behind the oesophagus — 1st. Severe pain, produced even by moderate pressure on the larynx and upper part of the trachea. 2d. The circumstance that such pressure produces entire suspension of respiration. 3d. Displacement of the larynx forwards and to the right. I cannot, however, from my own experience, say anything as to the special significance of these symp- toms, though they are certainly such as one would anticipate meeting with, where the seat of the abscess is lower than the pharynx. From the uncertainty of its early signs it is not possible to lay down any definite rules for the treatment of the first stage of this affection. In some instances, indeed, it is probably not recognized at all, but comes to an end by the matter making for itself a way before the more formidable symptoms of dyspnoea and difficult de- glutition have manifested themselves, and escaping through the nares. This occurred in the case of a child one month old,1 related by Dr. / Fleming; and I also observed it in a child aged 15 months, in whom fever, attended with much heaviness of head, fretfulness and drowsi- ness, for which no cause could be assigned, and whijh did not seem to be the symptoms of any known cerebral affection, suddenly dis- appeared on the fourth day, after a very profuse discharge of pus from the nostrils. In the subsequent stages of the affection, when its nature has become clearly obvious, the indication is a very simple one; and there is seldom much difficulty in carrying it out. The abscess is to be 1 Loc. cit., p. 58. 418 CYNANCHE PAROTIDEA. punctured, and with the escape of the matter all the formidable symptoms at once disappear. For this purpose a sharp-pointed bis- toury, the blade of which is protected by sticking-plaster wrapped round it, answers generally perfectly well: but for cases where the seat of the tumor is very low down, or where there is difficulty in opening the mouth, a trocar and a canula, such as Dr. Fleming em- ployed for the purpose, may be preferable. The only additional caution which I have to offer for the subsequent management of the patient is that for a day or two pressure be occasionally made with the finger on the tumor, in order to keep the sac of the abscess com- pletely empty, since otherwise the matter may collect again, and give rise to a renewal of the former symptoms. Inflammation of the parotid gland—the Cynanche parotidea of scien- tific writers, called mumps by the vulgar—is an affection met with among children and young persons, concerning which a few words only need be said ; and I know of no more suitable place than the present for introducing them. It attacks young persons after seven years of age much oftener, and with much greater severity, than infants or very young children. Though it sometimes occurs as a sporadic affection, it is more commonly met with as an epidemic: and being likewise propagated by contagion, it not infrequently attacks most of the inmates of a boarding-school, or of any other public institution in which large numbers of the youth of either sex are collected together. The seat of the disease is in one or both parotid glands, and in the ad- joining cellular tissue; but if the attack be at all severe, the submax- illary and other salivary glands generally become involved during its progress. It generally sets in with the ordinary symptoms of slight fever or catarrh, which are followed in about twenty-four hours by stiff- ness of the neck and pain about the lower jaw, any movement of which, either for the purpose of speaking or of mastication, is obviously attended with considerable suffering. At the same time too a swelling makes its appearance about the angle of the lower jaw, sometimes on one side only, at other times on both; and this swelling increasing rapidly in size, occasions great disfigurement of the face. The swelling is usually very tense, but the color of the skin is in general unaltered, except in some cases in which the glands on both sides, being swollen, and pressing much upon the veins, the return of blood from the head is impeded, and the face assumes a flushed appearance. If the swell- ing be very considerable, deglutition for a short time is rendered so difficult as to be almost impossible, and the tongue becomes dry from the child breathing with its mouth open ; but the secretion of saliva is neither morbidly increased nor diminished. If the disease be severe the child suffers much, is very feverish, and may even be light-headed; but in the course of forty-eight hours from the appearance of the swelling it reaches its height, and the fever begins to subside and the swelling to diminish. The time of the final disappearance of the swelling is very variable, being five or six days in some cases, ten days or a fortnight in others; while in some instances the glands on one side are affected first, and when the attack is subsiding there, those of the opposite side become affected in a similar way, and the dura- TREATMENT OF CYNANCHE PAROTIDEA. 449 tion of the ailment is thus protracted. The occurrence of suppuration in the neighborhood of the gland is a rare termination of the inflam- mation ; but is, I believe, oftener met with in infants and young children than in those who are approaching the period of puberty. On the other hand, metastasis of the disease from the parotid to the mamma, the testicle, or the brain, of all of which instances are re- corded by different writers, appears to be rare in proportion to the tender age of the patient. The most formidable of those metastases, indeed—that to the brain—would seem to be an accident very seldom met with; and neither of it, nor of the translation of the disease to the mamma or the testicle, can I say anything from personal ex- perience. The treatment of this affection is in general very simple, and re- quires the judicious selection of precautionary measures rather than active interference. Mild antiphlogistic medicines, with the applica- tion of warmth locally, are all that is usually needed, and local deple- tion is neither necessary nor useful. The period during which much distress and much difficulty of deglutition exist is generally very short; so that even in severe cases it will be our wisest course to await the spontaneous subsidence of the swelling. If suppuration should take place in the cellular tissue about the gland, a warm poultice must be substituted for the fomentations previously employed. Even when the gland remains enlarged, as it sometimes does for some time after the subsidence of the febrile symptoms, it is yet in general the best plan to let it alone, since the swelling is sure eventually to disappear of its own accord. With reference to the management of the metastases of the disease I have no observations to make, further than that inflammation of the brain, however induced, is not an affection with which we can safely temporize; while a mild and palliative treatment will generally answer every purpose, when either the mamma or the testicle has become the seat of the affection. 29 450 VOMITING IN EARLY INFANCY. LECTURE XXXIY. Diseases of the Stomach.—Vomiting often symptomatic of disease elsewhere—occa- sionally occurs suddenly in a previously healthy infant without signs of general illness—its treatment—is often one out of many symptoms of indigestion.—In- fantile dyspepsia—sometimes connected with general debility of the system; at others, dependent on special disorder of the stomach—its symptoms and treat- ment. ■v Softening of the Stomach—discovered after death in various degrees—different theo- ries as to its nature—great frequency in early infancy—Dr. Elsasser's explanation of this fact—probably not correct to the full extent. H^matemesis and Mel.2ena—very rare—sometimes connected with injury to the child during labor—their occurrence often difficult of explanation—illustrative cases.— Spurious haematemesis. The diseases to which the stomach is liable in early life are neither numerous nor important, although its functions are more or less dis- ordered in the course of most of the affections of childhood. Vomit- ing, indeed, is more frequent in the infant than in the adult, and the greater irritability of the stomach continues even after the first few months of existence are past, and does not completely cease during the early years of childhood. Hence it happens, as we have already seen, that vomiting is sometimes one of the first symptoms of inflam- mation of the lungs or pleura, while it frequently usners in the erup- tive fevers, and marks the early stages of cerebral disease. Causes more purely local produce a similar effect, and vomiting often attends upon infantile diarrhoea, and is associated with signs of intestinal dis- order, especially when such disorder has been excited by improper food. But besides these cases, in which the disorder of the stomach is either the result of disease seated elsewhere, or in which the dis- turbance of its function is sufficiently explained by the nature of the ingesta, instances are sometimes observed in which the stomach be- comes so irritable as almost always to reject its contents, or in which, though the food taken be not brought up again, the organ is unable to effect its digestion. It sometimes happens that young infants are suddenly seized with vomiting, which, though violent and frequently repeated, is attended by few or no indications of general intestinal disorder. The child in such cases seems still anxious for the breast, but so great is the irri- tability of the stomach that the milk is either thrown up unchanged, immediately after it has been swallowed, or it is retained only for a very few minutes, and is then rejected in a curdled state; while each application of the child to the breast is followed by the same result. It will generally be found, when this accident takes place in the pre- viously healthy child of a healthy mother, that it has been occasioned INFANTILE DYSPEPSIA. 451 by some act of indiscretion on the part of its mother or nurse. She perhaps has been absent from her nursling longer than usual, and, re- turning tired from a long walk or from some fatiguing occupation, has at once offered it the breast, and allowed it to suck abundantly; or, the infant has been roused from sleep before its customary hour, or it has been over-excited or over-wearied at play, or, in hot weather, has been carried about in the sun without proper protection from its rays. The infant in whom, from any of these causes, vomiting has come on, must at once be taken from the breast, and, for a couple of hours, neither food nor medicine should be given to it. It may then be offered a teaspoonful of cold water; and should the stomach retain this, one or two more spoonfuls may be given in the course of the next half hour. If this be not rejected, a little isinglass may be dissolved in the water, which must still be given by a teaspoonful at a time, frequently re- peated ; or cold barley-water may be given in the same manner. In eight or ten hours, if no return of vomiting take place, the experiment may be tried of giving the child its mother's milk, or cow's milk diluted with water, in small quantities, and from a teaspoon. If the food thus given do not occasion sickness, the infant may in from twelve to twenty-four hours be restored to the breast; with the precaution, however, of allowing it to suck only very small quantities at a time, lest the stomach being overloaded, the vomiting should again be pro- duced. In many instances where the sickness has arisen from some acciden- tal cause, such as those above referred to, the adoption of these pre- cautions will suffice to restore the child's health. If, however, other indications of gastric or intestinal disorder, have preceded the sickness, or be associated with it, medicine cannot be wholly dispensed with. According to the age of the child, a quarter, half, or a whole grain of calomel may be laid upon the tongue, while sucking is forbidden, and the plan already recommended is in other respects strictly carried out. If the vomiting have already continued for several hours before the adoption of any treatment, a small mustard poultice may likewise be ap- plied to the epigastrium. In about a couple of hours after the calomel has been given, the child may have a teaspoonful of a mixture containing small doses of the bicarbonate of potash and chloric ether, or of ether and of hydrocyanic acid; and this may be continued every three or four hours so long as any unusual irritability of the stomach remains. Sickness, however, is not always a solitary symptom, unattended by other indications of gastric disorder, but is sometimes associated with the signs of general impairment of the digestive powers. In its graver forms, indigestion is associated with greatly impaired nutrition, and with all those serious results which are characteristic of the atrophy of young children. But it sometimes happens that, though the child does not lose much flesh, yet digestion is ill performed, and various dyspeptic symptoms appear, which would be troublesome rather than alarmino-, if it were not that they are often connected with the stru- mous diathesis, and are the first indications of a state of constitution in which, after the lapse of a few months, pulmonary phthisis is very apt to supervene. 452 INFANTILE DYSPEPSIA. In some of these cases there is complete anorexia, the infant caring neither for the breast nor for any other food that may be offered it. It loses the look of health, and grows pale and languid, although it may not have any especial disorder either of the stomach or bowels. It sucks but seldom, and is soon satisfied ; and even of the small quan- tity taken, a portion is often regurgitated almost immediately. This state of things is sometimes brought on by a mother's over-anxious care, who, fearful of her infant taking cold, keeps it in a room too hot, or too imperfectly ventilated. It follows also, in delicate infants, on attacks of catarrh or diarrhoea, but is then for the most part a pass- ing evil, which time will cure. In the majority of cases, however, the loss of appetite is associated with evidence of the stomach's inability to digest even the small quantity of food taken, and there exists more or less marked gastric or intestinal disorder. Anorexia too is far from being a constant attendant upon infantile dyspepsia; but in still more numerous instances, although the power of assimilating the food is in a great measure lost, yet there is an unnatural craving for it, and the infant never seems so comfortable as when sucking. But though it sucks much, the milk evidently does not sit well upon the stomach; for soon after sucking, the child begins to cry, and appears to be in much pain until it has vomited. The milk thrown up is curdled, and its rejec- tion is followed by immediate relief, but at the same time by the desire for more food, and the child can often be pacified only by allowing it to suck again. In other cases, vomiting is of much less frequent occur- rence, and there is neither craving desire for food, nor much pain after sucking, but the infant is distressed by frequent acid or offensive eructations; its breath has a sour or nauseous smell, and its evacua- tions have a most fetid odor. The condition of the bowels that exists in connection with these different forms of dyspepsia is variable. In cases of simple anorexia, the debility of the stomach is participated in by the intestines ; their peristaltic action is feeble, and constipation is of frequent occurrence, though the evacuations do not always present any marked deviation from their character in health. Constipation, however, though a frequent, is not an invariable attendant on indiges- tion, but the bowels in some cases act with due regularity. If the in- fant be brought up entirely at the breast, the evacuations are usually liquid, of a very pale yellow color, often extremely offensive, and con- tain shreds of curdled milk, which, having escaped through the pylorus, pass unchanged along the whole tract of the intestines. In many instances, however, the infant having been observed not to thrive at the breast, arrowroot or other farinaceous food is given to it, which the digestive powers are quite unable to assimilate, and which gives to the motions the appearance of putty or- pipe-clay, besmeared more or less abundantly with intestinal mucus. The evacuations are often party-colored, and sometimes one or two unhealthy motions are fol- lowed by others which appear perfectly natural; while attacks of diar- rhoea often come on, and the matters discharged are then watery, of a dark, dirty green color, and exceedingly offensive odor. Dyspeptic infants, like dyspeptic adults, often continue to keep up their flesh much better than could be expected, and in many cases TREATMENT OF DYSPEPSIA FROM GASTRIC DISORDER. 453 eventually grow up to be strong and healthy children. Still, the con- dition is one that not merely entails considerable suffering upon the child, but, by its continuance, seriously impairs the health, renders the child but little able to bear up against any intercurrent disease, and develops the seeds of latent phthisis. Within the space that can be allotted to each subject in these lec- tures, it is not possible to do more than just glance at some of the main points to be borne in mind in the treatment of infantile dyspep- sia. Those cases, the chief symptom of which consists in the loss of appetite, usually require, and are much benefited by, a generally tonic plan of treatment. All causes unfavorable to heal.th must be exa- mined into, and, as far as possible, removed. It must be seen that the nursery is well ventilated, and that its temperature is not too high; while it will often be found that no remedy is half so efficacious as change of air. Next, it must not be forgotten that the regurgita- tion of the food is due in great measure to the weakness and conse- quent irritability of the stomach; and care must therefore be taken not to overload it. If these two points be attended to, benefit may then be looked for from the administration of tonics. These tonics may either be such as the infusion of orange-peel with a few drops of sulphuric acid and of some tincure;1 or, should any disposition to diarrhoea have appeared, the extract with the compound tincture of bark will be preferable ;8 or, if the stomach be very irritable, the liquor cinchonse in combination with small doses of hydrocyanic acid3 may be given with advantage, when any other medicine would be rejected. As the general health improves, the constipated condition of the bowels so usual in these cases will by degrees disappear. Even if the symptom should call for medical interference, it is not by dras- tic purgatives that its cure must be attempted. A soap suppository will sometimes excite the bowels to daily action; or friction of the abdomen twice a day with warm oil, or with a liniment composed of one part of Linimentum Saponis, one of olive oil, and two of tincture of aloes, will sometimes have the same effect. Should it become necessary to give aperients internally, the decoction of aloes sweet- ened with liquorice, and mixed with caraway or aniseed water, gene- rally answers the purpose very well;4 while the employment of mercurials must be restricted to cases in which there is very evident deficiency in the biliary secretion. A different plan must be adopted in those forms of indigestion which depend on some cause other than mere debility of the system. The rule, indeed, which limits the quantity of food to be taken at one time is no less applicable here, for the rejection of the curdled milk may be the result of nothing more than of an effort which nature 1 (No. 23.) 3 See Formula No. 20, p. 365. R.—Acid, sulph. dil. n\xvj. 4 (No. 24.) Tinct. aurantii co. 3j. B,.—Decoct, aloes co. 3vj. Syrupi 3j. . Extr. glycyrrhizse 9j. Inf. aurantii gj. Aqme anisi 3ij.--M. & vel 31J p. r. n. Aq. cinnamomi 3ij.—M. 3j ter die. For a child a year old. For a child a year old. 1 See Formula No. 3, p. 56. 454 TREATMENT OF DYSPEPSIA FROM GASTRIC DISORDER. makes to reduce the work that the stomach has to do witkiu the powers of that organ. But when, notwithstanding that due attention is paid to this important point, uneasiness is always produced by taking food, and is not relieved till after the lapse of twenty minutes or half an hour, when vomiting takes place, or when the infant suf- fers much from flatulence and from frequent acid or nauseous eructa- tions, it is clear that the symptoms are due to something more than the mere feebleness of the system. It is not, however, in these cases, the mere fact of the infant vomiting its food, or of the milk so vomited being rejected in a coagulated state, which indicates the stomach to be disordered, but it is the circumstance of firmly coagulated milk being rejected with much pain, and after the lapse of a considerable interval from the time of taking food, which warrants this conclusion.1 The coagulation of its casein is the first change which the milk of any animal undergoes when introduced into the stomach, though the coagulum formed by human milk is soft, flocculent, and not so thoroughly separated from the other elements of the fluid as the firm, hard curd of cow's milk is from the whey in which it floats. In a state of health, the abundantly secreted gastric juice speedily redissolves the chief part of the casein, while the subse- quent addition to it of the alkaline bile converts it into an albuminate of soda; and, being thus assimilated as nearly as possible to the cha- racter of one of the chief elements of the blood, it is easily absorbed by the lacteals, and passes into the mass of the circulating fluid. Milk tends, however, to undergo changes spontaneously, which pro- duce its coagulation, and the occurrence of these changes is greatly favored by a moderately high temperature, such as that which exists in the stomach. But the alterations in the fluid which attend upon this spontaneous coagulation are very different from those which are brought about in it by the vital processes of digestion. A free acid becomes developed abundantly within it, and the acid thus generated shows none of the solvent power of gastric juice, but by its presence impedes rather than favors digestion. Every nurse is aware that a very slight acidity of the milk with which the infant is fed will suffice to occasion vomiting, stomach-ache, and diarrhoea, and the result, as far as the child is concerned, must be much the same whether the acetous fermentation had begun in the milk before it was swallowed, or whether it commences afterwards, in consequence of the disordered condition of the stomach and the absence of a healthy secretion of gastric juice. The nature of the food is the first point that requires attention in the management of these cases of infantile dyspepsia. If the child had been fed on cow's milk, the symptoms may have been produced by the gastric juice being unable to redissolve the hard curd formed by the coagulation of its casein. In this case, the infant may sometimes be restored to health without the employment of any medicine, by 1 The physiology and chemistry of the digestion of the milk* will be found fully treated in the article Milch, in Wagner's Handworterbuch der Physiologie, and in Elsasser's essay, Ueber die Magenerweichung der Sauglinge, 8vo., Stuttgart, 1846. They are the authorities for the statements in the text. DIET OF DYSPEPTIC INFANTS. 455 diluting the milk, by substituting asses' milk for it, or even by giving whey for a day or two, until the stomach recovers its powers of digest- ing casein. The addition of a small quantity of some alkali—as the carbonate of potash, or prepared chalk, or lime-water—to the milk is another precaution which should not be omitted, since, while it does not at all interfere with digestion, it tends to prevent the matters taken into the stomach so readily undergoing the acetous fermentation. The indiscriminate employment of alkalies as medicines is, however, not to be recommended; they are of service combined with minute doses of laudanum, when the irritability of the stomach is extreme, as in those cases which were referred to at the commencement of this lec- ture; they are also useful in cases of a more chronic kind, where the sour smell of the evacuations and the frequent occurrence of acid eructations indicate the presence of an excess of acid in the primae, viai. I do not give them by themselves, but in combination with some tonic, as the infusion of columba, to which the extract of dandelion and the tincture of rhubarb may be added, if, as sometimes happens,1 the functions of the liver appear to be but ill performed. Vomiting of the milk in a coagulated state is no proof of the pre- sence of an excess of acid in the stomach. It may indicate a condition in which the secretion of the gastric juice is either disordered or in- sufficient, and in which the acetous fermentation is set up in the con- tents of the stomach, because the organ is inadequate to the proper discharge of those vital functions which would prevent its occurrence. Such cases—and they are many, and among them may be classed all those in which the breath is offensive and the infant is distressed by nauseous eructations—are benefited by the mineral acids in combina- tion with some bitter infusion, as, for instance, the infusion of cascarilla with hydrochloric acid.2 I have often observed the action of the bowels become regular, and the appearance of the evacuations healthy, during its administration. The use of mercurials, indeed, so generally re- sorted to in order to correct some real or fancied disorder of the liver, has become too indiscriminate a practice. The diarrhoea, with very pale light yellow evacuations, that comes on in some of these cases is often arrested by a spare diet and by the administration of very small doses of sulphate of magnesia and tincture of rhubarb, such as five grains of the former and ten minims of the latter, three times a day, to a child a year old.3 In cases where diarrhoea has been long con- tinued, or where the evacuations are very white and resemble putty, • (No. 25.) z (No. 26.) R.—Sodse sesquicarb. gr. xxiv. B>—Acid, hydrochlor. dil. tthxvj. Extr. taraxaci £)ij. Syr. aurantii 5j. Tinct. rhei 3j. Tinct. aurantii 3j. Inf. calumba? 3xj. Inf. cascarillse 3x.—M. 3j ter die. Aqua? carui 3iv.—M. Sij bis die. 3 (No. 27.) R.—Magnesias snlphatis 5j- Tinct. rhei 39- Syr. zingiberis 3j- Aquae carui gix.—M. 3J *er die. For children a year old. 456 SOFTENING OF THE STOMACH. mercurials are generally needed, as they are, also, in those cases where the horribly offensive odor of the evacuations proves that the contents of the intestines have been undergoing a process akin to putrefaction. The mercury and chalk powder, in small doses night and morning, is the mildest preparation that can be given. Sometimes, however, it causes nausea or vomiting, and very small doses of calomel must then be substituted for it; while, if the mercurial should excite the bowels to overaction, this tendency may generally be checked by combining it with Dover's powder. The same rules must guide us in the management of children in whom, though they be still at the breast, the symptoms of dyspepsia make their appearance. Disorder of the digestive function is, how- ever, much less common before weaning than afterwards. It may depend on the mother's milk being from some cause or other ill adapted to the support of the child; and hence the condition of the parent's health must in all these cases engage our attention. With these general rules I must dismiss the subject of indigestion, content to have pointed out the principles that should guide you. It must be left to your own experience in future years to supply the details. I have touched on the subject too only with reference to the infant, for as the child grows older and its food becomes the same as that of the adult, the symptoms of disorder of its digestive organs become the same too, and require a similar treatment. In many works on the diseases of childhood we meet with an enu- meration of rather obscure symptoms, which are stated to indicate the existence of gastritis or gastro-enteritis, and to be followed by more or less considerable softening of the stomach or intestines, or of both. A similar condition of the stomach was observed by John Hunter in the adult, and was conceived by him to be the result of the action of the gastric juice upon the tissues after death. The carefully conducted experiments of Dr. Carswell have completely confirmed the opinion of Mr. Hunter with reference to the agent by which this softening is effected; while they have further shown that it is inde- pendent of the person's previous health. Some writers, among whom may be mentioned those eminent authorities M. Cruveilhier and Pro- fessor Eokitansky, have, however, dissented in a measure from these views, and have endeavored to distinguish between two kinds of soft- ening, one of which they regard as a post-mortem occurrence; the other, which is that chiefly observed in infancy, they consider to be the result of disease. Softening of the stomach varies in degree from a slight diminution in the consistence of the mucous membrane, to a state of complete diffluence of all the tissues of the organ, in which it breaks down under the finger on the slightest touch, or even gives way of its own accord, and allows of the escape of its contents into the abdomen. When the change is not far advanced, the exterior of the stomach presents a perfectly natural appearance, but on laying it open, a color- less, or slightly brownish, tenacious mucus, like the mucilage of quince seeds, is found closely adhering to its interior, over a more or less considerable space at the great end of the organ, and extending along SOFTENING OF THE STOMACH AND INTESTINES. 457 the edges of its rugae. This mucus is easily washed away, and the muscular coat of the stomach in those parts to which it had adhered is then left almost or altogether bare, and denuded of its mucous mem- brane. When the change has gone further, the stomach at its great end presents a semi-transparent appearance, though not uniformly so, but in streaks running in the direction of the rugae; the destruction of the tissues having in those situations reached deeper than elsewhere, and involved a portion of the muscular as well as the mucous coat of the organ. If roughly handled, the stomach in many cases gives way, an irregular rent taking place at its great end, where the coats of the organ are found to be soft and pulpy, and to break down easily under the finger. In the next degree, the coats of the stomach are found to have been already dissolved in some parts, so that the con- tents of the organ have escaped into the abdominal cavity. The whole of the great end of the stomach, and a considerable extent of the pos- terior wall, are now reduced to a gelatinous condition, in which no .distinction of tissues is apparent; and the parts thus altered are either transparent and colorless, or else of a pale rose red hue. The interior of the organ sometimes presents a similar tinge, even beyond the limits to which the softening of its tissue has extended. This, how- ever, is by no means constantly observed, while in no case is there any injection of the vessels of the stomach, or any evidence of its having been the seat of real inflammatory action. The opaque and brownish appearance of the tissues—characteristic of pulpy soften- ing—is but seldom met with in infancy. Softening of the intestines, though much less frequent than soften- ing of the stomach, is observed in similar circumstances, and presents much the same characters. The exterior of the intestines is generally anaemic, and the softened parts present no trace of increased vascu- larity, but are either colorless, or of a pale rose hue. The mucous membrane in their interior is neither ulcerated nor abraded, but is found in some parts to be much softened, or even altogether absent in small patches. The muscular coat too is sometimes destroyed, though no abrupt edge marks the limits of its destruction, but there is a gradual attenuation of the tissue down to the spot where the perito- neum is laid completely bare. Several of these softened patches are generally met with in the same subject, and at some of them the bowel is often found to have given way, or it breaks down in the attempt to lay open its cavity. The allegation, that softening of the stomach in the adult occurs with greater frequency in persons who have died from some diseases,1 than 1 The very elaborate work of MM. Herrich and Popp, Der plotzliche Tod aus inneren Ursachen, 8vo. Regensburg, 1848, contains, at p. 330, a table of 140 cases in which softening of the stomach was found after death from different causes and at various ages. In no instance were symptoms observed that would have enabled any one to pronounce beforehand that softening of the stomach would be discovered after death. In by far the greater number of the cases the stomach was empty, showing that the occurrence very often did not depend on digestion going on at the time of death ; while the period of childhood, the rapid course of the fatal disease, and death from cerebral affections were the only circumstances which appeared to have any clearly appreciable influence'in favoring its production. 458 H^EMATEMESIS AND HELENA. in those who have died from others, has led to the hypothesis that in the former case a diseased and superabundant secretion of gastric juice during the life of the individual had caused the softening of his stomach after death. . The same hypothesis has been applied to account for its peculiar frequency in infancy, since at no period of life is gastric dis- order so common as then. Some writers have advanced still further, and have endeavored to connect the existence of a softened state of the stomach after death with certain well-marked symptoms of dis- order of its functions: for my own part, however, I have not been able to discover any peculiarity in the character of such symptoms, nor even any constancy in their occurrence. The much greater frequency of softening of the stomach and intes- tines in infancy and early childhood than in adult age, and the greater amount and wider extent of the alterations, have received consider- able elucidation from the recent researches of Dr. Elsasser.1 He found that a much more rapid action upon animal tissues than that exerted by the gastric juice, was put forth by any substance capable of under-. going the acetous fermentation, combined with pepsin. Such sub- stances are furnished by the milk as well as by the various farinaceous and saccharine matters on which infants almost exclusively subsist. The tendency of these substances to undergo the acetous fermentation is checked by the presence of healthy gastric juice, while, as we know by experience, it takes place very readily in infants who are dyspeptic, and to a very remarkable degree in many cases of infantile diarrhoea. Facts bear out to a very great extent the opinion of M. Elsasser. Out of 104 cases of softening of the stomach that came under the notice of two very eminent German Physicians, MM. Herrich and Popp, 72 were met with in the period of infancy or early childhood. My own notes on this point, though too few to be of any weight, yet point to a similar conclusion; for of 14 cases of softening of the stomach or intestines, or of both, observed out of a total of 61 cases in which the condition of those viscera was carefully recorded, 11 were met with in children under two years of age; while out of a total of 339 examinations of infants under the age of three months in the Foundling Hospital at Vienna, M. Bednar2 met with 100 in- stances of softening of the stomach or intestines; in 61 of which death had taken place from diarrhoea. I need scarcely add that this theory of M. Elsasser's is only supplementary to Mr. Hunter's and is perfectly reconcilable with the correctness of his observations, and of those of Dr. Carswell. Among those rare diseases, too seldom met with for any person to have what can be called real experience about them, may be men- tioned the vomiting and purging of blood occasionally observed in infants and young children. In the greater number of cases the oc- currence has taken place within a few days after birth,3 sometimes 1 Die Magenerweichung der Sauglinge, 8vo. Stuttgart, 1846. 2 Die Krankheiten der Neugebornen, &c, 8vo. p. 76. Wein, 1850. 3 Within 6 days in 17, and within 36 hours in 9 out of 20 cases collected by M. Rilliet, in his Essai sur les H6morrhagies Intestinales chez les Nouveaux-nes, published in Gaz. Med. de Paris, No. 53,1848 ; and reproduced in vol. ii. of the second edition of his and M. Barthez' Traits des Maladies des Enfants, pp. 295-310. ILLUSTRATIVE CASES. 459 within a few hours, and in some instances has followed a tedious or difficult labor, in which the head of the child has been much com- pressed, or its abdomen has been pressed on, or otherwise injured during attempts at its extraction ; while in other cases the difficult establishment of respiration has seemed to be the predisposing cause of the hemorrhage. Very often, however, no reason can be assigned for it; and the vomiting of blood, sometimes associated with its dis- charge per anum, has been unattended with other indications of dis- order of the abdominal viscera. In most cases the haematemesis has not recurred above two or three times in any quantity; and the children, though at first very much exhausted by the loss of blood, have, in about half the cases, eventually recovered. In a few in- stances, however, recovery has been partial, and the children have sunk into a cachectic condition, in which they died. When death has taken place from the immediate effects of the hemorrhage, the liver and the abdominal veins have sometimes been found gorged with blood, and blood has been found within the'intestines, or extra- vasated between their coats, constituting what has been termed abdo- minal apoplexy—appearances which have been supposed to indicate that some impediment to the establishment of the new course of the circulation which the blood should follow after birth had given rise to the accident. I have nothing to say about the treatment of an accident which in general occurs too causelessly to furnish indications for its prevention, and too suddenly to allow of the employment of measures for its arrest; but I will give you the result of my scanty experience con- cerning it, which amounts to three cases. In one of these cases the hemorrhage occurred, without apparent cause, soon after birth, and ceased spontaneously; while in the other two it took place at a later period, and approached in its characters more nearly to similar oc- currences in adult age. The subject of the first observation was a male child, who was born of a healthy mother, after a short and easy labor, at 11 A. M. on September 23d, 1845. The infant was well grown, and apparently strong and healthy, and continued so till 2| A. M. on the 24th, when, without any previous sickness, or other indication of illness, he vomited nearly half a teacupful of blood. This vomiting was not attended by any pain, nor was any large quantity of blood rejected afterwards, but the child continued at intervals of not more than an hour to throw up small quantities of dark greenish matter, resembling meconium, and mixed with mucus; and on the morning of the 25th he vomited a small portion of coagulated blood, as big as the top of the little finger. Between the time of the child's birth and the morning of the 25th, the bowels acted seven times; the motions were rather scanty, and consisted entirely of meconium. The child sucked well, did not appear in distress; its surface was warm, and its abdo- men neither full nor tender. The matters vomited did not decompose, although they were kept for some days; and when examined under the microscope, they were seen to be made up of a great number of 460 H^EMATEMESIS AND MELJNA. granular globules, with which were intermixed some scales of tessel- lated epithelium. The 27th of September was the last day on which the dark solid matter like meconium was vomited; but the child continued to be sick occasionally until October 7th, although the attacks of sickness did not seem to be excited by sucking, but occurred in general when the stomach was empty, and ended with the rejection of a small quantity of mucus, occasionally of a greenish color. The bowels were rather constipated, and the evacuations for the first week after the child's birth continued very dark colored ; they afterwards assumed a more natural color; but the bowels remained very constipated during the whole of the child's life. The child never throve; it lost flesh, occasionally vomited the milk, had a frequent and troublesome cough; its strength decayed, and it died exhausted on April 28th, 1846, at the age of seven months. On examining the body, nothing was found to explain the child's illness: there was no tubercle in any organ; the viscera were anasmic; no trace of inflammatory action was visible anywhere. A few lobules in both lungs were in a collapsed condition ; the small intestines presented several recent intussusceptions; and the stomach was remarkably small, and undeveloped in form as well as in size; but no other morbid appearances existed in any part of the body. In the second case, the child, likewise a boy, had perfectly good health till he was two months old, when he began to appear stuffed at his chest, and had frequent, though not severe, cough. At the age of ten weeks, he brought up a small quantity of dark blood while cough- ing, and afterwards had frequent attacks of retching and vomiting, independent of cough. During these attacks he brought up a dark- red fluid, like blood, sometimes in as large a quantity as two-thirds of a teacupful. On February 17, 1844, after these symptoms had continued for four days, I saw the child, whose face was slightly flushed, and the expression of his countenance dull. His abdomen was full and rather tender, especially in the right hypochondriac region; his urine was very high-colored, and his evacuations were quite white. From February 17, to April 13, the child remained under my care, and during this time the above-mentioned symptoms continued, although with a gradual amelioration in the child's condi- tion. Within a week after I first saw him, he had a severe convulsive seizure, and attacks of a similar kind occurred a great many times afterwards, independent of any obvious cause. The bowels were always constipated; the evacuations usually very white, though occa- sionally almost black, sometimes accompanied with a slight discharge of blood; and blood was now and then voided unmixed with fecal matter. The stomach became very irritable, and the child suffered from frequent vomiting; the matters rejected being untinged with blood for days together, and then, without any apparent reason, blood was abundantly mingled with them. Sometimes the infant cried much, and appeared in very great pain; and these attacks often terminated in the rejection of a considerable quantity of nearly pure blood. The face soon lost its flush, and became pale; but the puffiness continued, ILLUSTRATIVE CASES. 461 and was evidently due to a slight degree of anasarca. From the tender age of the child, I was unable to obtain any of his urine, in order to ascertain whether or not it contained albumen. Tbe treat- ment followed was directed to diminish the abdominal tenderness, by the application of a couple of leeches over the right hypochondrium, and to overcome the constipated state of the bowels, and induce the healthy action of the liver, by the employment of small doses of mer- curials, and of the sulphate of magnesia, to which it became sometimes necessary to add the administration of an active purgative. In May, 1844, the child was sent to Margate, where the convulsive attacks, and other symptoms, altogether ceased. On his return to London, after a stay of six months at the sea-side, his health failed—partly, as it seemed, in consequence of his mother's poverty preventing her from supplying him with proper food. In November, 1846, when much out of health, and suffering from diarrhoea, he came again under my care, but died suddenly of hemorrhage into the arachnoid.1 There was no appear- ance in the abdominal viscera after death which threw any light on the cause of the hsematemesis and melaena, for which the child had suffered for so many months during his early infancy. The subject of the third observation was a little boy, the child of a healthy father but strumous mother, who had thriven well at the breast till he was four months old, when he cut some of his incisor teeth; and his health had seemed less good since that period. There was, how- ever, no marked ailment until he was weaned, at nine and a half months; but after that he drooped, became much less cheerful, and his evacuations were seen to be white and unhealthy. He was in this condition when ten months and a week old; his abdomen, though large, was generally soft; but pressure in the left hypochondrium seemed to give pain; and careful examination detected a tumor there of the size of a small apple. On the evening of the same day on which he was first seen, the bowels having acted spontaneously in the morning, the child suddenly, and without any effort or straining, voided between three and four ounces of pure blood, partly fluid, partly coagulated. The discharge of blood occasioned faintness, and left the child very pallid, but apparently not suffering. He slept tolerably well during the night, but the ensuing morning, at 7 A. M., voided nearly the same quantity of blood as on the previous evening, unmixed with feces, but apparently somewhat diluted with intestinal mucus. Some warm water thrown up the bowel returned, stained with blood, but unmixed with fecal matter; as did a second enema administered six hours afterwards. In the course of the same day he had two scanty evacuations, both composed almost entirely of bloody mucus, and with such slight admixture of adhesive, white, fecal mat- ter, almost like putty in appearance, that I did not feel my anxiety lest the case should turn out to be one of intussusception of the intes- tines entirely removed until nearly twenty-four hours afterwards, when, after a dose of castor oil, two tolerably healthy evacuations were passed. The tenderness of the abdomen had now completely subsided, the > The particulars of his last illness are given in Lecture V., p. 56. 462 SPURIOUS H^EMATEMESIS. swelling in the left hypochondrium (possibly the enlarged and con- gested spleen) had entirely disappeared; and the child, in spite of the quantity of blood it had lost, appeared much better than before the hemorrhage occurred. This amendment, however, was not of long duration ; no hemor- rhage, indeed, returned, but the child had an attack of very severe diarrhoea, attended with great emaciation and much abdominal pain, which lasted for nearly six weeks. After the diarrhoea ceased, the child still continued weak, and thin, and suffering, and died con- vulsed in the middle of June, after vague head symptoms of two days' duration. In the last case no post-mortem examination could be made, so that we are uncertain what connection, if any, subsisted between the hemor- rhages at the outset of the child's illness, and the obstinate diarrhoea which came on soon after, and had so large a share in occasioning its death. One thing, at any rate, these cases illustrate, and one worth bearing in mind—viz., that formidable as the occurrence is, and large as the quantity of blood which is lost may be, still the immediate danger to life is far less than, but for this evidence to the contrary, we should most naturally apprehend.1 It will not be necessary to do more than allude to cases of what has been called spurious hsematemesis, in which an infant vomits blood drawn from some crack or ulceration of its mother's nipple, or which has been furnished by some little vessel cut in dividing the frasnum linguae, or in performing some other operation on its mouth. You would at once suspect the source of the blood vomited after the ope- ration on the infant's mouth; and an examination of the mother's nipple in a case of hasmatemesis will guard you against the other possible source of error. 1 This affection is, however, much more serious in infancy than in adult age; for of 23 cases referred to by M. Rilliet (loc. cit., p. 307), 11 had a fatal termination. ICTERUS OF NEW-BORN CHILDREN. 463 LECTURE XXXY. Icterus of New-born Children—generally a trivial affection—not usually depend- ent on intestinal disorder, but on imperfect perfoi'mance of functions of skin and respiratory organs—sometimes results from absence or closure of hepatic or cystic ducts—is then associated with great tendency to hemorrhage, and proves speedily fatal. It occasionally occurs in children in the same circumstances as in the adult. Constipation sometimes results from mechanical obstruction of intestines—which may be congenital—as from imperforate anus or impervious rectum.—Varieties of these malformations—their general symptoms—special signs of each—their comparative dangers and appropriate treatment. Obstruction of intestines from causes not congenital—strangulated hernia very rare in infancy—intussusception of intestines—its symptoms—usually more character- istic than in the adult—its generally fatal result—but occasional spontaneous cure. Suggestions for its treatment. It is curious to watch the changes which take place in the color of the infant during the first few days after its birth, and to notice how the vivid red fades by degrees into the pale rose tint of the skin of a healthy baby. But there is often a transition state between the two, when the skin, neither red nor pale, has a dull yellow tinge, which comes on about the third day after birth, and, deepening for a day or two, subsides, but very gradually; the child, however, all the time seeming quite well, the bowels acting properly, and the urine not being high colored. Though to this condition the name jaundice has been applied, it yet is no real jaundice; but is merely the result of the changes which the blood, in the over-congested skin, is under- going : " the redness fading as bruises fade, through shades of yellow, into the genuine flesh color." This icteroid tinge of the skin is unassociated with the altered hue of the conjunctiva, which is seldom absent when the functions of the liver are disordered; and it has, therefore, been proposed1 to distin- guish the physiological change in the color of the skin, which takes place after birth, by the name of local icterus, and to apply the term of general icterus to cases in which the yellow hue of the surface is an indication of hepatic disorder. Even the general icterus, however, is not often of serious moment, though the assumption that it is a perfectly natural state in which the skin and other secreting organs are called on for a few days to assist in disposing of the bile, until the demand for it to minister to the digestive functions becomes equal to its abundant supply, is shown to be erroneous by the circumstance that jaundice does not affect per- 1 Seux, op. cit., p. 280. 464 INFANTILE JAUNDICE SOMETIMES DEPENDENT fectly healthy children, who have been born at the full time, have been nourished exclusively at the mother's breast, and been sheltered from cold without being overburthened with clothing or confined in a viti- ated atmosphere. In the Dublin Lying-in Hospital, where the children are defended by the most watchful care from the evils either of cold or of a vitiated atmosphere, the occurrence of infantile jaundice is rare; while in the Foundling Hospital, at Paris, jaundice is so common that comparatively few infants escape it. Almost all the children at the Foundling Hospital have been exposed to the action of cold while being brought to the institution, and suffer from the combined influ- ences of cold and bad air while inmates of it; causes which interfere very seriously with the due performance of the functions of the skin and of the respiratory organs. The children in whom jaundice is most frequent and most intense, are the immature and the feeble; while in none is it so often met with, or in such an intense degree, as in infants affected with induration of the cellular tissue, in whom the yellow color is often so deep as to be manifest in the serum infiltrated into their cellular tissue, or poured out into the cavities of their chest or abdomen. Interruption of the function of the skin, and great impairment of that of the lungs are, as you know, the grand characteristics of that affection; while in many instances of it the foetal passages are still pervious, and the blood circu- lates in part through channels which ought to have been closed from the time of birth. These facts seem to substantiate the opinions en- tertained by many writers of high authority, that the jaundice of young children is not due to any cause primarily seated in the liver, but rather to the defective respiration, and the impaired performance of the functions of the skin, of which the hepatic disorder and consequent jaundice are but the effects. As the respiratory functions, and that of the skin increase in ac- tivity—which they will do if the cause of their imperfect performance be but slight or temporary—the jaundice disappears of its own accord. Great attention must be paid during its continuance to avoid exposure of the child to cold, while no other food than the mother's milk should be given. If the bowels be at all constipated, a grain of hyd. c. creta may be given, followed by a small dose of castor oil, and the aperient will often seem to hasten the disappearance of the jaundice; but in a large number of cases even this amount of medical interference is not needed. Besides these cases, however, in which the jaundice is at most but a very trivial ailment, instances are sometimes met with where it is a symptom of very serious import. Thus, for. instance, it has been ob- served to attend upon the peritonitis of new-born infants, and on that enteritis which, like the affection of the peritoneum, is one of the endemic diseases of foundling hospitals. It sometimes depends on inflammation of the liver, occasionally on phlebitis or the umbilical veins—diseases, all of them, to which in private practice we are strangers. Lastly, it is occasionally due to congenital absence of the hepatic or cystic biliary ducts, or to the obstruction of those ducts by inspissated bile. ON MALFORMATION OF BILIARY DUCTS. 465 When dependent on the former of these causes, death takes place sooner or later; and though now and then life is prolonged for several weeks or months, during which time, as might be expected, the evac- uations are destitute of bile, yet, in the majority of instances, the fatal issue takes place within a fortnight after birth, and this in consequence of hemorrhage from the umbilicus immediately after the separation of the funis. It is characteristic of the bleeding which occurs in these circumstances that it is not furnished exclusively—sometimes, indeed, not at all—from the umbilical vessels, but is rather a constant oozing of blood from the granulating surface of the navel. The blood, too, is almost completely destitute of the power of coagulation, so that it is neither restrained by styptics, nor controlled by tying the umbilical vessels. The only means, indeed, on which we can rely for checking the bleeding is.the ligature en masse, as it has been termed, or, in other words, the transfixing the integuments at the root of the navel with a couple of hare-lip pins, and twisting around them several coils of strong silken ligature. In the only case of this form of hemorrhage which has come under my observation, the bleeding was suppressed by these means, though the child died, apparently exhausted, in the course of the ensuing twenty-four hours, or about thirty-six hours after the separation of the navel and the commencement of the bleed- ing. Of course, when bleeding is dependent on a congenital malform- ation of the hepatic ducts, all interference is useless, as far as the preservation of the child's life is concerned; but, at the same time, the death of an infant from hemorrhage will leave a more painful impression on the parents' minds than its sinking somewhat later from the remote though inevitable consequences of the condition. Now and then, too, in spite of the coexistence of hemorrhage and jaundice, the former has been checked, and the latter has disappeared; the child completely recovering; and, in other instances which terminated fa- tally, though the umbilical vessels have been found open, and no clots within their canals, and the foetal passages for the blood still pervious, yet the bile ducts have sometimes been found quite pervious, and ar- ranged in a perfectly natural manner. In some rare instances, as has been mentioned, life is prolonged ; and when that is the case, a condition of general atrophy comes on, attended with enlargement of the abdomen in both hypochondriac re- gions ; and some intercurrent attack of diarrhoea generally exhausts the feeble powers when only a few months have passed. Some years ago, through the courtesy of Mr. Jones, of Tenby, I saw a remarkable case of this kind, where life was prolonged for six and a half months, in spite of absence of the gall-bladder; but in almost all .instances death takes place within the first two months. In the case which I have just referred to, no hemorrhage took place at any time; but, on the third day after birth, the surface began to be yellow, and, at the end of three weeks, the yellow tinge was very deep. At the same time a swelling, of the size of an egg, was first noticed in the right hypochondriac region; while the evacuations from the second day after birth were white, like cream, and the urine was habitually high- colored. 30 466 INFANTILE JAUNDICE. The child was thirteen weeks old when I first saw her; she was small, ill-thriven, sallow, icteroid, but not intensely jaundiced. Her abdomen measured twelve inches and three quarters at the umbilicus, and fourteen and one-third, two inches lower down. This enlargement was due to a tumor which dipped down on the right side, nearly into the pelvis, sloping off on the left side, so as to project much less there, though its hard edge was still distinctly traceable. In three months more the child died, much emaciated, while its abdomen was distended by a pint and a half of fluid in the peritoneal cavity. The spleen was said to be much larger than natural, forming a prominent tumor in the left iliac and lumbar regions. Its color was darker, and its tissue firmer than natural. On examination of the liver, which was much enlarged, and weighed eleven ounces and a half, it was ascertained that the gall-bladder was absent, and in its place were two small sacs without any outlet, one of them of the size of a pea, the other twice as large, containing a tenacious matter of a greenish color, and not unlike inspissated bile; while the hepatic ducts were impervious and greatly dilated. The interest of such cases is chiefly that which they offer to the morbid anatomist; but one sad and somewhat strange peculiarity with reference to them is, that they are apt to be met with in several suc- cessive children of the same parents. I knew a lady who lost in succes- sion three out of five children, soon after their birth, with most intense jaundice, which in one instance was ascertained to be associated with malformation of the biliary ducts; in the second, no examination was made after death; and in the third, malformation was said, though scarcely on adequate authority, not to have existed. The same fact receives a fresh illustration from the circumstance, that in twenty-six out of seventy-nine cases of umbilical hemorrhage in the new-born infant, collected by Dr. Smith,1 of New York, other children of the same parent had died from the same untoward accident. Jaundice may also occur in older children in the same circumstances as in adults, and associated with similar symptoms; the evacuations being white, the urine high-colored, and more or less pain and ten- derness being experienced in the hypochondriac region. Such cases are most frequently met with during the summer or autumn, especi- ally at times when diarrhoea is prevalent, the skin sometimes assuming a generally yellow tinge as the purging subsides; while in other in- stances the jaundice occurs as an idiopathic affection, though appa- rently due to the same causes as have produced diarrhoea in other children. In the instances that have come under my notice, the skin has not 1 In New York Journal of Medicine, July, 1855, vol. xv. p. 73. Four times it oc- curred in two children of the same parents, twice in three, and thrice in four. Further information on the subject of umbilical hemorrhage with jaundice will be found in a paper by Dr. A. B. Campbell, in the Northern Journal, August, 1844 ; in the valuable paper of Mr. Ray, in Med. Gazette for March, 1849 ; in that of Dr. Manley, in the same journal for May, 1850 ; in the dissertation of M. E. Dubois, of which an abstract is given in the Arch. G(n. de Medecine for October, 1849 ; in an essay by Dr. Bowditch, iu the American Journal of Medical Science, January, 1850 ; and in a lecture by M. Roger, of Paris, republished in the Journal fiir Kinderkrankheiten, July, 1853. TREATMENT OF JAUNDICE IN CHILDREN. 467 assumed a very deep yellow tinge, and the constitutional symptoms have seldom been severe. Now and then, however, considerable febrile disturbance precedes the appearance of the jaundice for two or three days; the skin is dry, though not very hot, vomiting occurs; and the child complains much of headache and dizziness, and rests ill at night, or awakes in a state of alarm. The resemblance between these symptoms and some of those which occur in cases of real cere- bral disease, is almost sure to excite much apprehension in the mind of the parents,' and may even render it a difficult task for you to form a correct diagnosis. The following circumstances will, however, usu- ally suffice to preserve you from error: the attack has not, in most instances, been preceded by those indications of generally failing health which so often exist during many days before the symptoms of hydro- cephalus manifest themselves, and it is not attended either by the anxious expression of countenance, the heat of head, or the intolerance of light, by which cerebral disease is accompanied. Though the sleep may be disturbed, it is usually less so than in hydrocephalus; the pulse is less frequent; and though the child vomits occasionally, it does not suffer from constant nausea. When to these symptoms tenderness on pressure in the hypochondriac region is superadded, with the ap- pearance in a day or two of high-colored urine and of white evacuations, and, lastly, of the yellow tinge of the skin, no further possibility of error remains. The treatment of jaundice in the child calls for but very simple remedies. If it be accompanied by much tenderness in the hypo- chondriac region, a few leeches may be applied in that situation with much advantage. If, however, this be not the case, the employment of small doses of the sulphate of magnesia, in combination with the tincture of rhubarb, every four or every six hours, with three grains of the hyd. c. cret& for a child of five years old, at bedtime, will gene- rally suffice to restore the patient to health in the course of four or five days. Should the appetite continue bad, and the child fretful and languid, after the subsidence of the jaundice and the return of the evacuations to a more healthy character, the compound infusion of roses, either alone or in combination with small doses of sulphate of magnesia will be found of much service. In some cases, however, removal to the country, or to the sea-side, appears to be absolutely necessary to the child's complete recovery. Far more frequent, however, than cases of actual jaundice are in- stances of what is popularly termed sluggish liver in children, in which the bowels are usually constipated, and the evacuations almost always pale and deficient in bile. Without being positively ill, children thus affected are usually sallow and look out of health; their appetite is variable, and their tongue never quite clean, but slightly coated with yellowish fur. In such cases it not unfrequently happens that mer- curials become almost a domestic remedy, and that calomel is the aperient constantly resorted to as often as the costive bowels require the employment of medicine. Other cases, too, of a somewhat dif- ferent kind are not unusual, in which calomel is again considered as 468 TREATMENT OF JAUNDICE IN CHILDHOOD. the pauacea. They are the cases of children, generally somewhat older than those who constitute the former class, whose general health is good and their bowels are usually regular, but who, every few weeks or months, are attacked by a severe headache accompanied with bilious vomiting, which lasts for several hours' and then subsides, leaving the patients in a state of extreme exhaustion, from which they do not re- cover for many days. Cases of this latter class are far less serious than the others.. They are for the most part instances of congestion of the liver, brought on either by some error in diet, or, as is far more commonly the case, by a system of habitual overfeeding. It is by no means necessary for the production of these symptoms that the food should be improper, or that its quantity should be very excessive, but it quite suffices that it should be a little in excess of the actual necessities of the system, and of the power of the digestive organs to assimilate. In these cases there can be no sort of objection to the administration of a dose of calomel to arrest the sickness, and by its purgative action to assist in relieving the liver; but it is the careful regulation and due restriction of the diet which will alone prevent the frequent recurrence of the attack. Cases of the other kind are by no means so simple. They are met with in delicate children; often in those in whose family there exists some taint of scrofulous or tubercular disease; and in them not un- frequently the symptoms of habitual intestinal disorder, and defi- ciency of the biliary secretion, become at last merged in the signs of general tuberculosis or of tabes mesenterica. I do not know what is the actual state of the liver in these cases, but I am sure that the empirical recourse to mercurials, which do but remove for a short time some of the symptoms of a deep-seated constitutional dis- order, is not a judicious proceeding. In a large proportion of in- stances, indeed, with increased health and strength, there comes almost spontaneously an improved state of digestion, and a more efficient performance of the functions of the liver. And to this amendment of the general health our first endeavors must in these circumstances be directed—air, situation, climate; all those points, to which in cases of threatening tubercular disease our attention is always turned, are here too of far more importance than mere medicine, though that of course cannot be dispensed with. I often find the nitro-muriatic acid1 specially serviceable, both as a tonic, and also as a remedy, which acts upon the liver and increases the secretion of bile; while, if an aperient is needed, the powdered aloes, or powdered extract of rhubarb, will either enable us to dispense with mercurials altogether, or at least will allow us to give them in smaller doses than otherwise we should be compelled to employ. Sometimes, however, this treat- ment seems of no avail, and we are compelled to put the patient on a regular course of mercurials. This has seemed to be best done by the employment of small doses of the bichloride of mercury; not alone, but in combination with the infusion of bark, or the liquor 1 See Formula No. 21, p. 392. CONSTIPATION FROM MALFORMATION OF INTESTINES. 469 cinchonas and liquor taraxaci;* and from the steady continuance of this treatment I have seen recovery take place, even where little appeared to promise a favorable issue. The danger of tuberculosis is the one great risk which in these cases must be borne in mind; low diet, violent purgatives, must be avoided, and the constitutional symptoms rather than the mere amount of disorder of the functions of the liver, must govern our prognosis and regulate our conduct. I have nothing to add to what has already been said on the subject of constipation—which is to be regarded as a symptom of various dis- eases rather than as a special idiopathic affection. To this rule, how- ever, an exception must be made in those cases in which the due action of the bowels is prevented by some mechanical impediment. Such an impediment is, in some rare instances, presented by congenital malformation of the intestines, whose calibre has been found greatly diminished, or their canal completely obstructed, or even their con- tinuity altogether interrupted. These occurrences, although of great interest and importance, from their relation to the laws that regulate foetal development, yet for the most part afford no scope for the inter- ference of medical or surgical skill. But while we pass over, as foreign to our purpose, the general study of these malformations, we must take some notice of one variety of them, in which the obstacle to the escape of the feces is situated low down in the large intestine, since their diagnosis is often easy, and their cure not always beyond the resources of our art. The cause of the obstruction in these cases is not always of the same kind, nor is the patient in every instance exposed to the same amount of danger. But three different classes of the malformation may be recoo-nized, in each of which our prognosis must somewhat differ, although in almost all it must be doubtful, and in many extremely unfavorable. To the first class may be referred all those cases in which the rec- tum is perfect, but the canal is closed either by a false membrane obstructing its orifice, or situated higher up in the intestine, or by the cohesion of the opposite sides of the gut. The second class includes cases in which, although the natural aper- ture is absent, yet the intestine terminates by opening into the urethra, bladder, or vagina. To the third class belong those instances in which the intestinal canal is not merely occluded, but also malformed, or altogether absent for a more or less considerable extent. The affection in any form is so rare, as to render a correct estimate of the comparative frequency of its varieties by no means easy. Dr. Collins observed only one instance of it out of 16,654 children born in » (No. 28.) $..—Liq. hydr. bichlor. £j. ----Taraxaci 3ij. Liq. cinchona 3j- Tinct. aurantii 5j. Syrupi 5iij. Aquae destil. §iij.—M. 3iv bis die. For a child three years old. 470 VARIETIES OF MALFORMATION OF LARGE INTESTINES, Dublin Lying-in Hospital during his mastership;1 and Dr. Zohrer, of Vienna,2 mentions, that he met with it only twice out of 50,000 new- born children. A comparison of 75 cases derived from different sources yields 17 belonging to the first class, 29 to the second, and 29 to the third; but it is probable that many instances of simple closure of the anus have passed unrecorded, while all the instances of more serious malformation have been described. Whatever be the seat of the obstruction, its existence is betrayed by much the same train of symptoms in all cases. Attention is first excited by the infant not having voided any meconium, although from twelve to twenty-four hours may have elapsed since its birth. A dose of castor oil or of some other aperient, given with the view of exciting the bowels to action, fails of producing this effect, while it is either returned by vomiting, or, if not actually rejected, it causes nausea and retching. Before long, the child shows indications of uneasiness, and has attacks of pain, in which it cries, and seems to suffer much. In some cases it remains quiet in the intervals between these attacks, and seems drowsy, but in other cases it appears to be in a state of constant discomfort, which it betrays by a whimpering cry. The attempt to suck is almost always followed by retching, fre- quently by actual vomiting; and attacks both of retching and vomit- ing often come on when the stomach is quite empty. In some cases nothing more is thrown up than a little mucus, which is sometimes of a greenish color; while in other instances vomiting of meconium takes place: but this occurrence is by no means constant. The ab- domen becomes distended and tympanitic, and grows larger and more tense the longer that life continues, while at the same time the child's discomfort is much aggravated by any pressure upon it. The rest- lessness increases, and the attacks of pain grow more severe, the child often making violent straining efforts during their continuance; but as the powers of life decline, these efforts become more feeble, though the retching and vomiting often continue to the last. The period at which death takes place varies much, for though, in the majority Of instances, the child dies within a week from its birth, yet cases are on record in which it has survived for several weeks; and an instance has been mentioned to me by Mr. Arnott, in which he saw a child live for seven weeks and three days, although the colon terminated in a blind pouch, and the rectum was entirely absent. Death usually occurs under a gradual aggravation of the previous symptoms; but now and then it is ushered in by the sudden supervention of a state of collapse, owing to the over-distended intestine having given way. This is, however, a rare occurrence, for I find mention of it having happened only in three out of the seventy-five cases to which I have referred. Coupled with the general signs of intestinal obstruction, there are in each case some special indications of the peculiar form of malforma- tion to which the obstruction is due. If the anus be merely closed by 1 System of Midwifery, p. 509. 1 Oesterr. med. Wochenschr.; and Canstatt's Jahresber. fur 1842, Bk. i. S. 456. AND THEIR COMPARATIVE DANGER. 471 a membrane, or by the cohesion of its edges, the collection of the meconium above may give rise to the formation of a distinct tumor between the buttocks, while sometimes the dark color of the meconium shows through the thin integument by which its escape is prevented. In other cases, the anus itself is well formed, but the introduction of the finger or of the bougie into the rectum detects the existence of some obstruction within the gut. Again, in other instances, there is no trace of an anus, or a small depression is all that marks the situa- tion which it should occupy, the rectum either ending in a blind pouch or communicating with the vagina, urethra, or bladder. Although the diagnosis in all cases is sufficiently easy, yet the carry- ing out the very obvious indication of relieving the patient by pro- viding for the escape of the contents of the intestines is often very difficult; and, even when accomplished, its result is in many instances extremely uncertain. If the obstruction be situated at the orifice of the anus, a crucial incision through the membrane which closes it, or the introduction of a trocar, will afford immediate relief. Our prog- nosis also may, in these circumstances, be very favorable; for, of fifteen cases of this kind, all but one had a favorable issue. After the open- ing has been established, however, some attention must be paid to prevent its becoming closed or much contracted. For this purpose, it has been recommended that a tent should be kept in the anus for some days, though to this it has been objected that a constant straining effort is thereby produced, and the frequent introduction of the finger or of a bougie into the passage is therefore recommended, as preferable to leaving any body constantly within it.1 If the obstacle be occasioned by a membrane seated higher up in the rectum, we may still hope to succeed, though our prognosis must be more guarded, since two out of four cases of this description had a fatal result. In one of the fatal cases, it appeared that rupture of the intestine had already taken place before any operation was per- formed ; in the other, the death of the child was accounted for by the discovery of a second septum higher up in the rectum than that which had been divided. The existence of an anus and a small extent of gut above it, although a decidedly favorable feature in a case, does not warrant quite so hope- ful a prognosis as we might in the first instance feel disposed to adopt. The probabilities, indeed, are that the distance is not great between the end of the rectum and the cul-de-sac in which the anus terminates; yet a considerable space may intervene between the two, or, as in a case which Mr. Arnott was so good as to communicate to me, the rec- tum may be found altogether absent, the colon terminating in a blind 1 I may just mention having seen great pain and difficulty in defecation produced in an infant aged seven months by congenital smallness of the anal opening. For the first three months of life the child had not suffered from this condition, but afterwards when the motions began to be slightly more consistent, constipation became very troublesome defecation difficult, painful, and attended by great tenesmus, while the evacuations were not infrequently streaked with blood. The opening admitted the finger with difficulty, and its edges tightly constringed it, while the rectum above was much dilated and permanently distended with feces. The daily employment of a bougie relieved the inconvenience, which I refer to here only on account of its rarity. 472 OPERATIONS FOR THE CURE extremity, and floating loose in the abdominal cavity. In the majority of instances, the two blind pouches are connected together by the inter- vention of an eighth or a quarter of an inch of dense cellular tissue, which sometimes presents an almost ligamentous character; and in some cases the end of the large intestine is situated anterior to the extremity of the cul de-sac that leads from the anus. Owing to this latter circumstance, the operation for the relief of this condition has sometimes failed, the instrument, although introduced deep enough, yet passing behind the distended bowel. Out of nine cases of this kind, eight had a fatal termination, the bowel on four occasions not having been reached at all, while once the opening made in it was too small to allow of the free escape of the meconium. It may be added that, in three of the fatal cases, there existed such contraction of the calibre of different parts of the large intestine as would of itself have opposed a serious obstacle to the child's recovery. In twelve cases, the anus was absent; and in some of these in- stances no trace of it existed; while the rectum terminated in a cul- de-sac at from one to two inches from the surface. In five of these cases, the attempt to open the intestine was successful, and the child eventually did well; while in two other cases, although temporary relief followed the operation, yet symptoms of inflammation of the bowels came on, which terminated fatally in the course of a few days. In three instances, it was not found possible to reach the bowel; and in two others, although an opening was made, yet its size was insuf- ficient to afford a free vent to the accumulated meconium; and the fatal issue, though deferred, was not prevented. Failure to reach the intes- tine seems to have depended either on the trocar not having been introduced sufficiently deep, or on its having been directed too far backwards. The danger of hemorrhage, or of wounding the bladder, of which some operators seem to have been apprehensive, is not much to be feared; for I find but one instance on record in which the blad- der was accidentally wounded, and not one of fatal or even of serious hemorrhage. Better success also appears to have been obtained in those cases in which a sufficiently deep and free incision was made with a bistoury in the direction of the rectum, than in those in which a trocar was at once introduced. The suggestion of M. Amussat, that in these cases the blind sac of the intestine should be drawn down, and its cut edges attached by sutures to the margin of the external skin, in order to prevent the infiltration of fecal matter between the end of the rectum and the wound in the integuments, and to diminish the danger of the aperture closing, is worth bearing in mind. It was adopted with apparent advantage by Mr. Waters in a case of this kind recorded by him in the Dublin Journal for May, 1842, on which he operated with success; and I was a witness to its advantages in a little boy on whom Mr. Shaw operated successfully a few years since at the Middlesex Hospital. A few years ago, too, I was present at the post-mortem examina- tion of a child, aged 14 months, whose history illustrated very forcibly the importance of the precaution to which I have just referred. The rectum was imperforate at birth, though an anus existed. Eelief was OF IMPERFORATE RECTUM. 473 readily afforded by puncture with a trocar; but no attempt was made to bring down the intestine to the edges of the opening. The child soon passed from under observation; and, when seen again, it was asserted that no evacuation had taken place for a month, and that for a long time constipation had been growing more and more obstinate. The child died speedily—its abdomen being enormously distended both with feces and flatus. The circular fibres of the large intestine had undergone the most extraordinary hypertrophy, doubtless to enable them to overcome the resistance offered to the expulsion of their contents—a task to which at last they had proved unequal. This resistance was seen to be due to the contraction of the original opening just above the anus, while the intestine was quite permeable beyond—a misadventure which might have been obviated by care in the performance of the operation, and by watchfulness afterwards. Besides these cases in which the malformation was confined to the rectum, I find mention of three others in which the rectum was en- tirely absent, and the intestine terminated in a cul-de-sac as high up as the colon. In two other cases in which the attempt to discover the rectum failed, the life of the child was preserved by the establish- ment of an artificial anus. M. Amussat has of late recommended that, in all cases in which fluctuation cannot be detected through the skin, an artificial anus should at once be formed in the left lumbar region, as being a safer proceeding than the attempt to open the bowel from the perineum. When we consider, however, the loathsome na- ture of the infirmity to which a person is condemned in whom an artificial anus exists, we shall probably be disposed still to regard the operation for its formation as a last resource, to be employed only in the event of our failing to discover the rectum by an operation insti- tuted on the perineum. In some cases, although the anus is absent, yet the intestine is not imperforate, but opens either into the vagina in the female, or into the bladder or urethra in the male subject. In either case, the malforma- tion is due to a similar cause, namely, an arrest of development, whereby the separation between the bowel and the sinus uro-genitalis has never been completed. The malformation in the female subject is not attended with immediate danger to life; and fortunately it ad- mits of cure in the great majority of instances. I find, indeed, that, in seven out of ten cases of this description, an operation was at- tempted, and that in every instance it proved successful. In some cases, the mere establishment of the natural opening of the anus, with the introduction of a tube into the rectum, was sufficient to effect a cure; but a more complex operation was in general necessary, the principle of which consisted in dividing all the parts from the vagina into the rectum; though the details of the proceeding, and the means whereby a re-union of the two canals was prevented, varied in differ- ent cases. The result is very much more unfavorable when a communication subsists between the intestine and the bladder or urethra in the male; for eio-ht out of eleven cases of the former kind, and the same number out of nine of the latter kind, ended in the death of the infant. The 474 OPERATIONS FOR CURE OF IMPERFORATE RECTUM. connection with the bladder is generally established by means of a very slender canal which enters that viscus at or near its neck ; but in one instance in which the rectum was wanting, the colon terminated by opening with a wide aperture into the upper part of the bladder. A slender duct is likewise the usual channel of communication between the rectum and the urethra, and this duct generally enters the mem- branous portion of the urethrfl, just in front of the prostate. Cruveil- hier, however, met with an instance in which the rectum opened under the glans penis; and a somewhat similar case, in which there was a small aperture through which meconium passed in front of the scrotum, came under the notice of Mr. South, and is mentioned by him in his edition of Cheliush Surgery. The existence of a communication between the rectum and the urethra, or bladder, is generally indicated by the urine voided being tinged with meconium ; but it seldom happens that the contents of the intestines are discharged by the urethra with freedom sufficient to preserve the child from the suffering and danger that attend upon an imperforate state of the rectum. Even when life has been pro- longed for some time, yet the infant's death is in general merely deferred, for the symptoms of obstruction appear, and at length prove fatal, after the feces have acquired a firmer consistence than they pos- sessed during the first few months of existence. These cases, too, do not appear to be favorable for an operation, since the rectum usually terminates high up, and in five out of ten cases in which it is stated that the attempt was made to puncture the intestine, this attempt was unsuccessful. In Mr. South's case the rectum was punctured by a trocar introduced an inch deep, and though much difficulty was expe- rienced in keeping the passage free, yet the child survived and grew up to manhood. Of the other two successful cases, one of which is recorded by Mr. Miller,1 and the other by Mr. Fergusson,2 both were cured only with much trouble and difficulty. For a full account of the difficulties these gentlemen had to contend with, and the means by which they overcame them, I must refer you to the history of the cases in the Edinburgh Medical Journal. A third successful case has since been recorded by Professor Wutzer, of Bonn,3 in which there was no trace of anus, and the incision was carried an inch and three- quarters before the intestine was reached. I saw the child in this case when nine months old; he was a healthy infant, and passed his evacu- ations generally per rectum, though a small quantity of feces was still frequently intermixed with his urine. An insuperable obstacle to the action of the bowels may occur in children, just as it sometimes does in older persons, either from the strangulation of an external hernia, or from the invagination of a portion of intestine. Although hernia is by no means an uncommon affection in early life, yet it is, I believe, a very rare occurrence for the intestine to become strangulated. Such an accident, however, may take place, 1 Edinburgh Medical and Surgical Journal, No. 98, p. 61. 2 Ibid., vol. xxxvi. p. 363. 3 Rheinische Monatschift fur praktische Aerzte, June, 1851. INTUSSUSCEPTION OF THE INTESTINES. 475 even in very young infants, of which a case related by Mr. Fergusson, in which he operated for strangulated inguinal hernia on an infant only seventeen days old, may be mentioned as a striking illustration. Bearing in mind its possibility, therefore, you would examine auy infant or child, in whom abdominal pain, vomiting, and obstinate con- stipation came on, just as carefully as you would an adult in similar circumstances, lest it should be found out, when too late, that the symptoms had been due to some unsuspected external hernia. The strangulation of an external rupture probably a rarer accident in early infancy than the occurrence of intussusception of one or more portions of the intestines. This condition, indeed, is frequently met with in the bodies of children who have died of various diseases, and wholly independent of any symptoms of disorder of the bowels during the patient's lifetime. Sometimes a single intussusception exists, but oftener there are several; ten, twelve, and even more, have occasion- ally been observed in the same subject. They are almost invariably confined to the small intestine, are most numerous in the ileum, and though seldom involving more than three or four inches, have been found to include more than double that extent of bowel. Their great frequency, the absence of any symptom of them during life, and of any indication of inflammation about the intestines after death, all confirm the general opinion that they take place during the act of dying. But while this form of intussusception limited to the small intestine, and producing no symptoms during life, is extremely common in early childhood, few accidents are rarer than the invagination of the large intestine, so that MM. Rilliet and Barthez state that they have not met with it even once in 500 post-mortem examinations of chil- dren between the ages of two and fifteen years. In early childhood, the various causes which in the adult may produce insuperable ob- struction of the bowels seem not to exist; and our diagnosis is made easier, I think that I may even say our prognosis less absolutely hopeless, from a knowledge of the fact that the symptoms of intestinal obstruction in the infant point almost invariably to invagination of the large intestine. .Children in whom intussusception takes place are generally infants under a year, often under six months old.1 Their previous history does not in general display any liability either to constipation or to '• Of twenty-five cases observed or collected by M. Rilliet, in his valuable essay on this subject, published originally in the Gazette des Hopitaux, 1852, but reprinted at p. 306 of the 1st vol. of his work on Diseases of Children, seven occurred in children of six months or under, six more during the first year, seven between five and ten years old, and five between ten and fifteen. My own experience is limited to the observation of four cases : one in a male child aged six months ; a second, in another aged fourteen months ; a third in a girl ten years old ; and a fourth ma girl aged twelve years. The first three, in whom the invagination was seated in the large in- testines, recovered; the third of the number under inflation of the intestine. The same proceeding was tried in the fourth, though without much expectation of benefit, since the intussusception was believed to be seated in the small intestine ; and it was found after death, which took place on the ninth day from the commencement of the symptoms, that it involved three inches of small intestine at about a foot above the ileo-caecal valve. 476 SYMPTOMS OF INTUSSUSCEPTION. diarrhoea ; nor, in the greater number of instances, has the manifesta- tion of the symptoms followed the administration of any aperient medicine. Sudden and violent vomiting, followed by loud cries, and other indications of uneasiness, which, ceasing for a time, return at uncertain intervals, and are accompanied by violent straining, and efforts to empty the bowels, are tbe earliest symptoms of the accident. At first some feces are voided during these efforts, but afterwards the matters discharged from the bowels are either mucus tinged with blood,1 or else pure blood, and that sometimes in considerable quanti- ties. If an enema be given, the fluid thrown up immediately returns, it appearing not properly to enter the intestine; while on one or two occasions the existence of an obstruction has been discovered on in- troducing the finger into the rectum. The vomiting is almost imme- diately renewed whenever either food or medicine is given, but fecal matters are seldom if ever discharged by the mouth. The child has intervals of quiet, from which it is roused by the returns of pain; it is often thirsty, and though the sickness continues unabated, yet it seems eager for the breast, and sucks frequently. The condition of the abdomen is variable; and though a distinct tumor may be de- tected in some cases, at a spot which is found afterwards to corre- spond to the situation of the intussusception, yet it happens, in at least as large a number of instances, that the most careful examination fails to detect anything unnatural in its state, and that it continues uniformly soft up to the time of the patient's death. The continuance of the intussusception leads to the exhaustion of the infant's strength; its pulse grows more and more feeble, its face becomes anxious and sunken, and it falls in the intervals between its attacks of pain into a quiet, half-comatose condition. In the majority of cases convulsions come on a few hours before death, which always takes place within a week, oftener in from forty-eight to seventy-two hours. Now and then, however, instead of going on from bad to worse, the symptoms abate, the pain ceases, the vomiting subsides, the bowels act sponta- neously, and were the indications of invagination less characteristic, we might, on seeing the speedy and"complete recovery of the patient, almost doubt whether our first diagnosis had not been erroneous. Such a case was that of a little boy of fourteen months old, well- nourished and previously healthy, who was suddenly attacked at 5 A. M. on June 12th, 1855, by pain and sickness. He at that time passed one fecal motion, but the pain continued, and at 8.30 A. M. he voided a second, which consisted of pure blood. At 10 A. M. I saw him ; he looked very ill, his face was extremely anxious, he shivered sometimes, the pain returned at intervals, and he was still frequently sick. The abdomen was neither full nor tender except in the caecal region, where there was a firm oblong tumor, about the size of a hen's egg, very tender to the touch. A linseed poultice was applied over the abdomen, hydrocyanic acid was given to allay the sickness, and 1 The credit of drawing attention to the value of the intestinal hemorrhage in these cases as a sign of intussusception, belongs to Mr. Gorham, whose essay on this affec- tion, in No. 7 of the Guy's Hospital Reports, may be consulted with profit. TREATMENT OF INTUSSUSCEPTION. 477 the child was allowed only a very small quantity of drink at a time to allay the thirst, which was very urgent. In eight hours the child was better, the bowels had acted twice spontaneously, and but very little blood was contained in the evacuations. On the next morning all traces of the tumor had disappeared, and the abdomen was equa- bly soft, and tolerant of pressure; and no symptom recurred from this time to excite any apprehension. Another somewhat similar case came under my notice in a child aged six months, in whom symptoms equally characteristic, with the exception of the abdominal tumor, which was not present, likewise ceased spontaneously. Such a result is nevertheless not to be gene- rally looked for, and M. Rilliet states the results of fifteen cases occur- ring in children between four months and four and a half years of age to yield ten deaths to five recoveries. The treatment of intussusception in the child must be conducted on the same principle as would govern our conduct if the patient were an adult, though, as the symptoms enable us to arrive at a tolerably certain knowledge of the nature of the case earlier in the infant than in the grown person, we should be absolutely without excuse if we were to persevere in the use of active purgatives in order to overcome tbe constipation. It was during the suspension of the active remedies which had been previously employed, that the second of the two cases which I have referred to took a favorable turn; and the studious avoidance of any other than soothing measures was succeeded by the spontaneous disappearance of the symptoms and removal of the abdo- minal tumor in the other. I should regard the supervention of the symptoms of intussusception as calling for the immediate discontinu- ance of all aperient medicines administered by the mouth; and for the steady adoption of a soothing plan of treatment. Warm poultices to the abdomen, hydrocyanic acid, for the sake not merely of its powe^ in allaying sickness, but also of its generally sedative properties, and the administration of opium in small doses to control the pain and allay the spasm, would be the remedies to which I should trust, while I should insist oh all food being given in extremely small quantities. If at the end of twelve or at most of twenty-four hours, the symptoms had not disappeared, I should without further delay resort to the inflation of the intestine with air, as a means of mechanically unfold- ing the invagination likely to be more effectual than the employment of large enemata, which yet in some instances has proved successful. In two of the cases which have come under my own observation, this proceeding was resorted to; in one (that to which Dr. Watson has referred to in his Lectures)1 it was followed by the disentanglement of the involution, and the child's recovery; in the other, where the small intestine was concerned, the experiment, as might be expected, was unsuccessful, and the child died. With reference to the question of surgical interference, I know of no observations on the child that tend specially to elucidate it. One point, however, deserves consideration; namely, that as in infancy the 1 4th ed., vol. ii. p. 496. 478 DIARRHCEA: seat of the obstruction is almost invariably in the large intestine, the uncertainty as to the possibility of liberating it which, in the adult, often causes hesitation, does not beset us here. I am not acquainted with any data from which to determine the comparative risks of gas- trotomy at different periods of life; but it is not without moment to know that that detachment of the invaginated portion of bowel, and subsequent recovery of the patient which now and then happen in the adult and the child, appears never to occur in the infant, who sinks before such processes have time to take place. LECTURE XXXVI. D14RRHCEA.—In two forms, the simple and inflammatory—causes of the affection— influence of age—of process of dentition—of temperature, and season of the year. Symptoms of simple diarrhoea—not usually a dangerous affection—occasional hazard from great exhaustion that it produces—cessation of purging sometimes inde- pendent of real amendment—danger of secondary diarrhoea. Inflammatory diarrhoea—occasional want of correspondence between the symptoms and morbid appearances—latter observed chiefly in large intestine—very similar to those discovered in dysentery of the adult. Symptoms of inflammatory diarrhoea—occasional disturbance of nervous system at the outset—progress of the disease—its tendency to a chronic course. Life some- times cut short by intercurrent bronchitis—by head symptoms—by relapse after temporary amendment. * In a systematic course of lectures like the present, subjects of very various interest and importance come successively before us. We were engaged yesterday in the study of some affections which for- tunately are of very rare occurrence ; but to day we pass to the ex- amination of one of the most common, and at the same time one of the most serious disorders of infancy and childhood. The importance of diarrhoea in early life, indeed, is not to be estimated merely by the number of deaths which our tables of mortality represent it to have occasioned; for the figures that they display would warrant our dis- missing it with a comparatively short notice.' But we shall come to a very different conclusion, if we consider the frequency of the affec- tion, and the slight causes which often suffice to induce it; the dangers to health which result from its long continuance; and the greatly increased hazard to which its supervention in the course of some other disease exposes the patient. Under the common name of diarrhoea, many of the older writers on 1 According to the Fifth Report of the Registrar-General, the deaths in London from diarrhoea, dysentery, and cholera, as compared with the total deaths from all ascer- tained causes were, in children under one year old, in the proportion of 3.9 per cent.; between one and three, 2.3 per cent. ; from three to five, 6 per cent. ; from five to ten, 1.1 per cent.; and from ten to fifteen, 1 per cent. ITS TWO FORMS—THE SIMPLE AND INFLAMMATORY. 479 the diseases of children have included all cases, without distinction, in which there is an unnatural increase in the alvine discharges. On the other hand, some among the moderns, rejecting the word diarrhoea from their medical nomenclature, have treated only of certain inflam- matory affections of the intestines, of which they believe the flux to be symptomatic. Neither of these arrangements, however, is free from objection, for while the former draws no adequate distinction between cases in which the disorder of the functions of the bowels is the result of some accidental and temporary cause, and others in which it is the consequence of organic disease, the latter involves an attempt to distinguish, on purely anatomical grounds, between affections which present the same symptoms and require the same treatment. In the present state of our knowledge, it will perhaps be the safer way to attempt no further subdivision than into the two grand classes of simple diarrhoea, or catarrhal diarrhoea, as it has been termed by some writers, and inflammatory diarrhoea or dysentery. Even in this arrangement it must be confessed that there is something arbitrary, for the two affections are closely allied to each other. In the child, as in the adult, they often prevail at the same time—they are to a considerable degree dependent on the same causes, and are in a measure amenable to the same remedies; while the milder complaint not unfrequently passes into the more severe. Before we proceed, therefore, to the study of the special characters of either affection, it may be well to examine into some of those conditions which are alike favorable to the production of both. The following table, deduced from 2129 cases of diarrhoea or dys- entery that came under my notice at the Children's Infirmary, shows that the age of the child has much to do with the. occurrence of the affection:— Were to all cases of diarrhoea Were to all diseases at Cases of diarrhoea in children at in children under 15 y'rs, the same age, in the the following ages. in the proportion of— proportion of— Under 6 months .... 9.7 per cent. 16.1 percent. Between 6 and 12 months 15.7 a 20.0 a " 12 " 18 . 20.9 a 26.8 it " 18 months and 2 year3 13.9 it 25.4 u " 2 and 3 years . 12.1 it 15.0 it " 3 " 5 " . 11.2 <( 9.3 ii " 5 " 10 " . 11.5 u 7.9 11 " 10 " 15 " . 4.7 tt 7.7 a You will observe that the period of the greatest prevalence of diar- rhoea coincides exactly with that time during which the process of dentition is going on most actively, and that exactly half of all cases of diarrhoea occurred in children between the ages of six months and two years. So close, indeed, is the connection between teething and diarrhoea, that a French physician, M. Bouchut,1 found that only 26 out of 138 children entirely escaped its attack during the period of their first dentition, while 46 suffered from it very severely. The 1 Manuel Pratique des Maladies des Nouveaux-Nes, 2d ed., 8vo. p. 530, Paris, 1852. 480 SYMPTOMS OF SIMPLE DIARRHCEA. older writers on medicine, whose notice this fact did not escape, attributed the disturbance of the bowels to a sort of sympathy be- tween the intestinal canal and the gums, swollen and irritated by the approach of the teeth to their surface. The frequent observation of cases in which an attack of diarrhoea attends the irruption of each fresh tooth, and ceases when it has cut through the gum, shows that such an hypothesis is not altogether without foundation. But besides the influence of nervous irritation in quickening for a time the peristaltic action of the bowels, and thus inducing diarrhoea, it must be borne in mind that there exists during the period of teething a more abiding cause, which strongly predisposes to its occurrence. All parts of the digestive canal, and of its dependencies, are now undergoing an active evolution to fit them for the proper assimilation of the varied food on which the young being will soon have to sub- sist. Just as the salivary glands now begin to secrete and pour out saliva in abundance, so the whole glandular system of the intestines assumes a rapidity of growth, and an activity of function, which under the influence of comparatively slight exciting causes, may pass the just limits of health. In too many instances, causes fully adequate to excite diarrhoea are abundantly supplied in tbe excessive quantity or unsuitable quality of the food with which the infant is furnished; for it is forgotten that its condition is one of transition, in which something more than ordinary care is needed, while, in accordance with that mistaken humoral pathology so popular among the vulgar, the profuse secretion from the irritated glands is regarded as the result of a kind of safety-valve arrangement whereby nature seeks to moderate the constitutional excitement attendant upon teething. But, besides those conditions seated within the organism which predispose to diarrhoea, and those occasions furnished from without by the food with which the child is supplied, atmospheric influences constitute a third, and a very important class of causes, which at one time render diarrhoea very frequent, and at another greatly check its prevalence. On a comparison of the result of eight years' observation at the Children's Infirmary, I find that In the 3 months, Nov., Dec., and Jan., diarrhoea formed 7.9 per cent, of all cases of disease. Feb., March, and April, " 9.5 " " " May, June, and July, " 15.3 " " " Aug., Sept., and Oct., " 23.0 " " The above-mentioned causes dispose alike to diarrhoea and dys- entery; but among the dwellings of the poor in this metropolis, as in every large city, conditions abound which often stamp on the disease the characters of the more serious malady. Before investigating them, however, we may first study the symptoms of the milder affection, which, though much the more frequent, yet, if uncomplicated, is seldom or never fatal. When the attack comes on in perfectly healthy children, it often sets in quite suddenly, with vomiting of the contents of the stomach, and afterwards of mucus, which sometimes has a yellow or greenish color. The sickness does not in general continue, though exceptions SIMPLE DIARRH03A. 481 are met with in some of the more severe cases, in which the stomach remains very irritable during the whole period that the affection lasts. In either case, the vomiting is almost immediately succeeded by in- creased action of the bowels, the matters discharged being at first the healthy feces ; but they soon assume a bright yellow color, like that of the yolk of egg, and are often intermixed with slime, or in other cases they present a frothy appearance. The bright yellow color of the evacuations, often, though by no means always, changes to green under exposure to the air; while, if the diarrhoea should continue, the feces present in many instances a green color when voided, similar to that which is frequently produced by the administration of mercury. In other cases the green and yellow colors appear intermixed in the evacuations, while the presence in them of numerous white specks, the casein of the undigested milk, shows that the function of the stomach is interfered with by the same cause as produces the over- action of the bowels. The source of the green color of the evacua- tions has not' yet been quite satisfactorily determined. In some cases, it probably depends on the action of the acids of the alimentary canal upon the coloring matter of the bile; but the late Dr. Golding Bird's investigations have proved it not to be always due to this cause, and have rendered it probable that, in many instances, it results from the presence of altered blood in the evacuations. As the child returns to health, the feces become less watery, and then resume their yellow color; or stools of a natural character alternate with others of a green color and unhealthy aspect, or in which a very large quantity of mucus is present. The action of the bowels, too, becomes less fre- quent, and the child often regains its usual health in four or five days, though sometimes a disposition to diarrhoea is left behind, and the disorder is liable to be re-excited by very slight causes. In the majority of cases this over-action of the bowels is not attended by much fever or constitutional disturbance, though, if it should come on during teething, the general feverishness of the child is often some- what aggravated. The appetite is usually much impaired, while the thirst is often considerably increased, and the child seems very desir- ous of cold water. The tongue is moist, in general thinly covered with mucus, through which the papillae appear of a brighter red than natural; but the tongue is neither very red, nor much coated. The abdomen is soft, seldom either full or painful; and the pain which attends the diarrhoea is very variable; sometimes it is completely absent, the stools being expelled without either effort or suffering; while in other cases pain comes on severely at intervals, and then ceases so soon as the bowels have acted. Although there is seldom much tenesmus, yet a slight degree of it attends upon simple diar- rhoea in the child much more frequently than in the adult. There is, as might be anticipated, a loss of the natural look of health—the face grows pale, the eyes appear sunken, and the child becomes fretful and languid—while, if the attack set in severely, a day or two sometimes suffices to reduce the child to a state of extreme weakness and ex- haustion; and in young infants, all the symptoms of spurious hydro- cephalus sometimes make their appearance. 31 482 INFLAMMATORY DIARRHCEA, OR DYSENTERY. The diarrhoea that occurs in connection with the irritation occasioned by teething is in general more gradual in its onset, and slower in its progress than that which depends on some more transient cause. It is likewise often associated with catarrhal symptoms; and both the catarrh and diarrhoea frequently continue, until the tooth, having pierced the gum, the irritation of the mucous membranes subsides; but to be renewed when a fresh tooth approaches the surface. Although the dangers attendant on simple diarrhoea, especially when it occurs in healthy children, are not considerable, yet the affec- tion is one which it is never wise to make light of. On more than one occasion I have seen an infant reduced by it to a state of such extreme exhaustion as seriously to endanger life. Diarrhoea, indeed, is the exciting cause of the great number of cases of that spurious hy- drocephalus,1 in which cerebral disturbance from debility simulates real inflammatory disease of the brain. In such circumstances, too, the diarrhoea has not infrequently ceased for some time before the other more alarming symptoms made their appearance. The cessation of diarrhoea may be due, not so much to the quieting of irritation, as to the exhaustion of the nervous energy which is essential to the performance of their secretory function by the glands of the intestines, or to the due maintenance of the peristaltic movements of the bowels. In infants prematurely weaned or improperly fed after being taken from the breast, we often see this fact exemplified in the cessation some twelve or twenty-four hours before death of the diarrhoea, from which they have been suffering for weeks together. Nor must we ever make too sure that, because purging has ceased, therefore danger is over; or venture to relax oftr watchful care, until the continuance of amend- ment, for twenty-four hours or more, shows that there is indeed no longer anything to fear. This, however, is not the only danger to which previously healthy children are exposed by an attack of simple diarrhoea; for if not quickly checked, it sometimes assumes the more serious characters of dysentery, and occasions severe and long-continued suffering. When diarrhoea supervenes in children who are recovering from some dis- ease, such as measles, in which a tendency to relaxation of the bowels often marks the period of convalescence, or who have been suffering from a protracted ailment, such as hooping-cough, it sometimes occa- sions the patient's death, although it may leave behind in the intesti- nal canal no traces of serious mischief. Still more frequently is this the case with infants who have been brought up by hand, or who have thriven badly at the breast. A troublesome purging, continuing for weeks together, exhausts the strength of such infants, and at length occasions their death; but yet the intestinal canal in many instances presents no trace of more serious mischief than an unusual degree of distinctness of the follicles of the small intestines, and of the solitary glands of the colon and rectum. In proposing, at the commencement of this lecture, to distinguish between simple and inflammatory diarrhoea, 1 yet was forced to acknow- 1 See Lecture. XI. p. 128. MORBID APPEARANCES IN INFANTILE DYSENTERY. 483 ledge that the distinction was one rather of degree than of kind; or perhaps it would be more correct to say, that our observation has not hitherto been minute enough to enable us to draw the line of demar- cation strictly between the two affections. Even MM. Killiet and Barthez,1 whose opportunities have been so extensive, and whose in- dustry is so untiring, confess their inability to refer the symptoms that attend upon the different varieties of diarrhoea to any distinct and invariable anatomical lesions. They remark that not merely are exceedingly different appearances discovered after death in cases where the same symptoms have been observed during life, but that likewise there is often no proportion between the intensity of the two; and that sometimes no morbid appearances are found, even where well- marked symptoms had existed. Usually, indeed, in cases where the morbid appearances are slight, the symptoms during life have not been severe. Occasionally, however, the reverse has occurred; and the diarrhoea has been intense, the pain considerable, and the abdomen tense and tympanitic. MM. Killiet and Barthez state, that out of 127 children who had died of different diseases, 84 had presented the symptoms of inflammatory diarrhoea, or entero-colitis, and the charac- teristic appearances of that affection were manifest on an examination of their intestines after death: in 24, though no symptoms had existed during life, similar changes were discovered; while in 19, the signs of disease were present during life, but its morbid appearances were absent. It is true that these observations refer to children above two years of age, and to cases in which diarrhoea had occurred as a second- ary affection; but my own observation would lead me to believe that a similar statement might be made with reference to younger children, and to cases of idiopathic diarrhoea. These circumstances prevent our deducing from the results of ana- tomical investigation those practical conclusions which we should other- wise be inclined to draw from them; but they do not warrant us in altogether omitting to inquire what changes we shall be most likely to meet with in cases of fatal diarrhoea. These changes will be found chiefly, though not exclusively, in the large intestine; and though usually much less serious than those which are observed in cases of fatal dysentery in the adult, they yet present very similar characters. In those cases in which the structural alte- rations have been least considerable, the attention is arrested less by any great increase of vascularity in the intestine, than by the remark- able distinctness of the orifices of the solitary glands, which appear like almost innumerable dark spots upon the surface of the mucous membrane. In many cases, and especially in those in which the diar- rhoea was profuse at the time of the patient's death, not merely are the openings of these follicles unusually distinct, but the glands them- selves are enlarged, and project like small millet seeds, or small pins' heads, beyond the level of the surrounding tissue. This enlargement of the solitary glands is usually associated with increased vascularity of the mucous membrane; which does not, however, assume the > Op. cit., vol. i. pp. 509-12 ; and 2d ed., vol. i. pp. 747. 484 MORBID APPEARANCES IN INFANTILE DYSENTERY. characters of a general erythematous redness, but is confined to that part of the membrane which covers each gland, or which surrounds its base. If the disease advance further, ulceration succeeds to this inflammation of the glands. A small, circular, or slightly oval spot, appears upon their summit, and increases in size and depth, until it has destroyed the glandular structure and the mucous membrane, and has produced a deep cup-like depression or ulceration, the base of which is formed by the muscular coat of the intestine. On one occa- sion I observed, in the midst of enlarged and ulcerated glands, some others equally large, but on which the excavated ulcer had not yet formed; their summit presenting a small round or oval spot, of a yellowish color—most probably a minute slough not yet detached from the surface. Besides that loss of substance which results from the ulceration or sloughing of the glands themselves, a process of thinning and destruction likewise affects other parts of the mucous membrane, especially in those situations which correspond to the edges of the intestinal rugas. In some parts the membrane appears to be merely attenuated, while in others it seems to have entirely dis- appeared, though the limits of its destruction are not marked by the same well-defined edges as circumscribe the ulcers of the glands; nor is the loss of substance so deep. On the inner surface of an intestine thus affected may be seen a number of narrow, white lines, inclosing between them islets of mucous membrane, and often having such an arrangement as to give to those portions of membrane the form of irregular parallelograms. This superficial destruction of the mucous coat of the intestine is often much more complete in the rectum and in the sigmoid flexure of the colon, than elsewhere; and when this is the case, the surface of the bowel presents an uniformly rough appear- ance. It is also in the lower part of the large intestine that the ulce- rative process is most frequent and most extensive; and if care be not taken to examine the last few inches of the rectum, we may come to the mistaken conclusion that ulceration is altogether absent, in cases where more careful investigation would have easily convinced us of its existence. On one occasion, I found the disease in the lower part of the large intestine to be so far advanced that the interior of the sigmoid flexure of the colon and of the rectum presented an irregular tuberculated suuface, of an ash-gray color, which appeared eaten into holes by a number of small, circular pits, or ulcers, with sharply-cut edges. Besides these changes in the exterior of the large intestine, a thickening of its submucous coat is almost always observable, when- ever the diarrhoea has continued for any considerable length of time. It is in the rectum and sigmoid flexure of the colon that this thick- ening is most perceptible; and in this situation a gelatinous-looking matter is sometimes deposited in such abundance beneath the mucous membrane, as to prevent the intestine from becoming collapsed when it is divided. But it is not merely in the morbid appearances presented by the large intestines, but also in the subsidiary changes observed in other parts of the intestinal canal, that the close relation is manifested between the diarrhoea of the infant and dysentery of the adult. The changes SYMPTOMS OF INFLAMMATORY DIARRHfEA. 485 in the small intestine are almost always confined to the lower part of the ileum, and become more striking the nearer we approach to the ileo-csecal valve. They consist in a more or less intense redness of the mucous membrane, which sometimes appears thickened, and pre- sents something of a velvety appearance, studded over with numerous dark spots—the orifices of the solitary glands. In other instances, the surface of the reddened mucous membrane appears slightly rough- ened, as if sprinkled over with fine sand; while near to the caecum this roughening is often greater, the membrane appearing elevated into rough, orange-colored prominences, separated by narrow lines of a dead white color, which mark the situations where, by the de- struction of the mucous membrane, the adjacent tissue is exposed. Besides this affection of the mucous membrane, of the ileum, Peyer's glands are not infrequently very well marked in the lower part of the small intestine; and their surface presents a punctated appear- ance, due to the unusual distinctness of the orifices of the sacculi which compose each gland. Occasionally a few of them are congested and swollen, and once or twice I have observed one or two spots of ulceration on that cluster of Peyer's glands which is situated close to the ileo-caecal valve; but in every instance the affection of the small intestine has appeared to be secondary, and quite subsidiary, to the disease in the colon. Lastly, I may observe, that the mesenteric glands, even in the vicinity of the diseased large intestine, deviate but little from a state of health, being at most a little larger, and of a somewhat redder color, than usual—a condition which contrasts remarkably with their serious affection in cases of typhoid fever in childhood, where yet the intestinal lesion is often much less consider- able. The symptoms of inflammatory diarrhoea sometimes become deve- loped very gradually out of what had seemed at first to be nothing more than a simple looseness of the bowels; but, in the majority of cases, they present, almost from the outset, a graver character than those of simple diarrhoea, and are associated with more serious con- stitutional disturbance. When the attack comes on suddenly, it often commences with vomiting; and though in many instances the sickness does not recur frequently, yet sometimes the irritability of the stomach continues, for twenty-four or forty-eight hours, to be so extreme, that every drop of fluid taken is immediately rejected; and that frequent efforts at vomiting are made even when the stomach is empty. Violent relaxation of the bowels occurs almost simultaneously with the vomiting; and the child sometimes has as many as twenty or thirty evacuations, or even more, in the course of twenty-four hours. The motions are at first fecal; but they soon lose their natural cha- racter, and become intermixed with slime, often streaked with blood. At first they are abundant, and are often expelled with violence; but before long they become scanty, though sometimes they still gush out without much effort on the part of the child. The character of the evacuations again changes: in the severest cases they not only lose their fecal appearance, but become- like dirty green water, with which neither blood nor intestinal mucus is intermingled. Usually, 486 THE ACUTE FORM OF DYSENTERY. however, when the first violence of the purging has a little abated, although some serous stools may still be avoided, yet the evacuations consist chiefly of intestinal mucus, intermixed with a little feces, and more or less streaked with blood. The scanty mucous stools are generally expelled with much straining and difficulty; a few drops of blood sometimes follow them; and once or twice, at an early period of the attack, I have known an infant void as much as a tablespoonful of pure blood. The constitutional symptoms which accompany an attack of this description are usually very severe: the skin becomes dry and very hot, though unequally so; the pulse is quickened, often very much so; the head is heavy; the child fretful and irritable if disturbed, though otherwise it lies drowsily on its nurse's lap, with its eyes half open, and scarcely closing the lids even when they are touched with the finger. Now and then, too, the disturbance of the nervous system at the commencement of one of these attacks of diarrhoea is so con- siderable, that a state of excitement alternates with one of stupor, that convulsions seem impending, and that there are distinct carpo- pedal contractions, or startings of the tendons of the wrist or forearm. Now and then, too, I have known convulsions actually occur, and be succeeded by a comatose condition, from which the child never recovered to more than a sort of semi-consciousness; exhaustion speedily following the first violent disturbance of the nervous system. The abdomen is usually full, and rather tympanitic, but seldom-very tender; nor does the child seem to suffer much pain, though some- times a degree of tormina appears to precede each action of the bowels. The tongue at first is moist, coated slightly with mucous fur; its papillae are often of a bright red, as are also its tip and edges; while, if the disease continue, the redness becomes more general, and tbe tongue grows dry, though it is not often much coated. The thirst is generally intense, the child craving for cold water, and crying out for more the moment that tbe cup is taken from its lips; and the thirst is quite as urgent even in those cases where the stomach is so irri- table that it immediately rejects whatever is swallowed. There is scarcely any affection in which the loss of health and of flesh is so rapid as in the severer forms of diarrhoea; and a period of twenty-four hours will in some cases suffice to reduce a previously healthy infant to a condition in which its eyes are sunken, its features sharp, its limbs shrunken, and its strength so impaired, that, though I have never seen an instance of it myself, I can yet well understand that death may sometimes take place in the course of a few hours from the commencement of the attack. This rapidly fatal termination is far from unusual in some of the Southern States of America, where diarrhoea, under the various names of cholera infantum, the summer complaint, or gastro-follicular enteritis, annually destroys many thou- sands of children.1 1 The essential identity of this disease with the infantile diarrhoea of our own and other temperate climes is conclusively established by Dr. Parker, of New York, in a paper published in the American Monthly Journal for May, 1857. SYMPTOMS OF CHRONIC DYSENTERY. 487 A rapidly fatal termination, however, is not that which is in general observed in this country; but, how urgent soever the symptoms may have been, there is in most instances a spontaneous subsidence of them in the course of forty-eight hours at furthest; or a measure of abatement of their severity follows the use of remedies. The sickness entirely ceases; the bowels act much less frequently, probably not above ten or twelve times in the twenty-four hours; but they act irregularly, five or six evacuations being passed within an hour or two, and then no action of the bowels occurring for four or five hours together. The appearance of the motions likewise varies, and appa- rently without cause, being mucous, green, watery, intermingled with blood, all in the course of a single day, and with no accompanying modification in the infant's symptoms. The tenesmus in general con- tinues; and in weakly children, or in those who have previously suffered from diarrhoea, prolapsus ani not unfrequently occurs; though this accident happens less commonly in infants than in children of two or three years old. There is much uncertainty in the further course of the affection, and in the way in which it tends in one instance towards recovery, and in another to a fatal issue. Many fluctuations generally interrupt the progress of those cases which terminate favorably; while, when it eventually proves fatal, the affection often assumes a chronic cha- racter, and does not end in death until after the lapse of several weeks. In such chronic cases, the patient's condition, though progressively tending from bad to worse, presents but little difference from day to day. The loss of flesh goes on until the child is reduced to a degree of emaciation as great as is ever witnessed even in the most advanced stage of mesenteric disease or pulmonary consumption, though its extreme attenuation is sometimes concealed by the anasarcous swelling of its face and hands. The appetite fails completely, or becomes very capricious; and the child refuses to-day the food which yesterday it took with eagerness. In course of time, the desire for drink is lost too; for though there may be no return of vomiting, yet nausea is excited by everything which the child takes. The tongue grows red and dry, coated with brown or yellow fur towards its root, or aphthae appear upon its tip and edges, or the whole inside of the mouth be- comes coated with thrush. The diarrhoea continues much as it was before, except that the action of the bowels is now almost immediately excited by either food or drink. The evacuations are usually of a green color, often particolored, and though generally watery, yet they vary both in their consistence and in their other characters, without apparent cause. Slime, blood, and pus, are sometimes present in the stools, at other times absent; and it does not often happen that puru- lent matter is present in large quantity in the evacuations or for many days together, though I have observed this in some cases that recovered as well as in others which had a fatal termination. The body is no longer able to maintain its proper temperature, but the extremities are almost invariably cold ; small indolent abscesses oc- casionally form about the buttocks; and on one occasion I saw an eruption of large vesicles, like those of pemphigus, make their ap- 488 FATAL RELAPSE OF DYSENTERY. pearance on the hands, arms, and neck of an infant eight months old, about ten days before her death. In the condition of weakness to which the child is now reduced, a slight aggravation of the diarrhoea, or a return of vomiting, suffices to put out its feeble life; or, even should no such accident occur, death takes place from pure exhaustion. But various causes may abridge this protracted course of the affec- tion ; and hence it results that death not infrequently takes place be- fore the mischief in the intestines has become so serious as it is usually found to be in cases of fatal dysentery in the adult. Bronchitis is one of the most frequent of these intercurrent maladies, while the symptoms that attend it are often so slight, that danger to the patient from this source is very frequently overlooked. It happens, indeed, in many cases, that almost from the outset of an attack of diarrhoea, the mucous membrane of the respiratory organs sympathizes with the irritation of the intestinal canal, and from the very commencement of its illness the child has slight cough, the continuance or even the aggravation of which attracts but little notice. Unless, therefore, aus- cultation is carefully practised, and often "•repeated, there is little in such cases to call attention to the state of the respiratory organs until the accumulated secretions in the bronchi have already seriously in- terfered with the entrance of air into the pulmonary vesicles, and have occasioned the collapse of a considerable extent of the substance of the lungs. Life is sometimes cut short by other causes in the course of infantile diarrhoea. The disturbance of the nervous system that attends the attack issues now and then in convulsions, and these convulsions end in a state of stupor which terminates in death—an occurrence fortu- nately rare, but of which instances may be observed during those hot seasons of the year when bowel complaints are usually epidemic. Less rare than a fatal termination of this kind is the infant's death under symptoms of a gradually deepening coma, which may have supervened on the suppression of the diarrhoea, or on its great miti- gation. Many of the symptoms by which this condition is accom- panied are such as to indicate the exhaustion of the infant's powers; but happens in many instances that there is an occasional flush of the face, or a temporary heat of skin, or some other passing sign of an attempt at reaction, just sufficient to mislead the practitioner and to betray him into a vacillating line of practice that proves fatal to his patient. Lastly, there are cases, and those by no means few, in which the onset of a severe attack of diarrhoea has been promptly met and judi- ciously treated, in which the symptoms have yielded, and the child has appeared convalescent. Some slight error in diet, however, a variation in the temperature, or the too early withdrawal of medicine, is followed by a return of the vomiting and purging; or the relapse may take place without our being able to assign for it any adequate cause. The active symptoms which attended the original seizure are absent now; the evacuations, though very watery, generally contain neither blood nor slime; but medicine is often wholly unable to check them. The vital powers fail speedily, and death often takes place in EPIDEMIC DYSENTERY. 489 three or four days from this exacerbation of the symptoms; while an examination of the body after death shows no evidence of recent mis- chief in the intestines, but only the traces left by the first attack, and these manifestly in course of disappearance. We must postpone until the next lecture, the very important sub- ject of the treatment appropriate to all the varieties of diarrhoea and its different complications. LECTURE XXXVII. Diarrhgsa, continued.—Close resemblance between inflammatory diarrhoea and the dysentery of the adult—local conditions favoring its occurrence, as damp, want of drainage, &c. Treatment of simple diarrhoea—of diarrhoea in connection with teething—use of as- tringents. Treatment of inflammatory diarrhoea—in its acute stage—treatment of certain symp- toms—as the irritability of the stomach, the cerebral symptoms—indications for the use of stimulants—of astringents—management of the chronic stage—use of enemata—diet in this stage. Management of intertrigo excited by diarrhoea—and of prolapsus ani. Those of you who were present at yesterday's lecture could hardly fail to be struck by the close resemblance which exists between the severer forms of infantile diarrhoea and the true dysentery of the adult. In both cases similar morbid appearances are discovered, occupying the same parts of the intestinal canal; in both the symptoms during life are almost identical, their resemblance being disturbed mainly by the greater excitability of the nervous system in early life; whence it arises that convulsions and other signs of serious cerebral disorder are often observed in the infant affected with diarrhoea, while they are but seldom noticed in the adult suffering even from severe dysentery. But this difference is one of degree rather than of kind, since the morbid poison, whatever be its nature, to which dysentery is due in the adult, produces in favorable circumstances disorders of the nerv- ous system analogous to those which we may have frequent opportu- nities of observing in the infant. If dysentery, for instance, break out epidemically in a large prison, the inmates of which have had the excitability of their nervous system increased by the debilitating in- fluence of long confinement; tremors, cramps, spasms, convulsions, or stupor, may attend upon the affection, and death may take place under symptoms that betoken disturbance of the brain or spinal cord. You will find ample proof of this in Dr. Latham's account of the Disease at the Penitentiary in the year 1823; and in Dr. Baly's Gulstonian Lectures on Dysentery, which are based on observations at the same establishment. Among the striking examples of this complication related by those writers, some are recorded in which, though death 490 INFANTILE DYSENTERY took place, neither the brain nor the spinal cord presented any sign of disease. Just of the same kind, and equally independent of any ap- preciable change of structure, are the nervous symptoms that often come on in the course of infantile diarrhoea. I shall have presently to refer to the important practical bearings of this fact, when we come to consider the treatment of diarrhoea and its complications. Before we pass to that subject, however, we must inquire whether there are any special conditions that tend to engender the severer forms of bowel complaint in childhood, over and above those general causes of diarrhoea to which your attention was directed in the last lecture. I believe that such special conditions do exist—that they abound in the locality where most of my observations have been made—and that they are precisely the same as prevailed far more extensively in this metropolis at the time that the bloody flux annually carried off large numbers of its inhabitants. In almost every country and climate, and in circumstances in many respects very different, dysentery has been known to occur, but in each instance it has been possible to connect the prevalence of the disease with some source or other of malaria. Although, while I was physician to the Finsbury Dispensary, a large amount of disease among children came under my notice, yet my acquaintance with those severer forms of infantile diarrhoea which approach to the cha- racters of dysentery, and which give rise to similar lesions, has been derived almost exclusively from observations made in Lambeth and the adjoining parishes.1 The children in both districts are alike sub- jected to the evils of improper and insufficient food, and of close and ill-ventilated dwellings; but in the latter there are superadded certain very important influences of a local character. A considerable por- tion of the district on the Surrey side of the Thames lies below high- water mark; and the kitchens and cellars of some of the houses near the river become flooded at unusually high tides. The sewage through- out is very defective; in many parts it is effected entirely by open drains, while in some places there are mere cesspools, which have no communication with any drain whatever. Cases of infantile dysen- tery do not occur with the same frequency in all parts of this district, but they are most numerous and most severe wherever these noxious influences are most abundant. Proof, too, of the intimate connection that subsists between these conditions and the occurrence of infantile dysentery is afforded by cases such as the following:— With the return of every spring, a poor woman brought to me her younger children suffering from diarrhoea, which they seemed to outgrow when about three years old. This diarrhoea was always obstinate, very apt to assume a dysenteric character, and was almost sure to return if medicines were discontinued before the return of the cold season. On one occasion, her infant, aged about fifteen months, who had had diarrhoea severely in the previous autumn, suffered a 1 To this statement I may now add, that since the opening of the Hospital for Sick Children, the patients of which come from much the same district as that inhabited by my former patients at the Finsbury Dispensary, the severer forms of infantile dysen- tery have again come less frequently under my notice. DEPENDENT ON LOCAL CAUSES. 491 return of it with the returning warmth of spring. The infant's symptoms were very alarming, and the child had frequent convul- sions; on which account I visited her at home. I then found that the infant spent the whole of the day in a back room on the ground floor which looked out upon a little yard, at the bottom of which there was a large cesspool, whence there came a most offensive smell during the whole of the warm weather. I urged the mother to remove her infant from this room, and to occupy instead a front room on the first floor in the same house, which looked upon the street. When this had been done, the convulsions ceased almost at once, and the diarrhoea was not long before it disappeared. I attended this woman's children for other affections, on several occasions during the ensuing eighteen months, but after their removal to the more whole- some room I heard nothing of their suffering from diarrhoea. I may just add, that in similar circumstances I have met with few instances of the sudden and apparently causeless occurrence of convulsions, in two or three children of the same family. Some years since a little girl, five years old, was seized with convulsions, which recurred fre- quently for between two and three days, leaving her in a state of stupor. By degrees the symptoms of very severe typhoid fever developed themselves out of this disturbance of the nervous system : the disease during the whole of its course presented an adynamic cha- racter, and required the free employment of wine and stimulants. , While she was convalescent, the health of her elder sister, who was eight years old, began to fail, and before long she experienced con- vulsive attacks of an anomalous character not unlike fits of hysteria, which returned at intervals of two or three days for several weeks together, three or four fits sometimes occurring in the course of a single day. These seizures were accompanied by much debility, and they disappeared by degrees under the use of preparations of iron, and a generally tonic plan of treatment. In studying the treatment of diarrhoea and dysentery in early life, we will pass successively in review the different forms of the disease; beginning with the simplest and least dangerous, and passing to the more formidable varieties of the affection, and to those complications which add so greatly to its hazard. In a large proportion of cases of simple infantile diarrhoea, the ail- ment tends to subside in a day or two, and finally to cease of its own accord. While, therefore, in consideration of the tender years of the patient, no such case can be regarded as altogether trivial, yet in many instances but little medical interference is needed. Great care, however, is required in this, as well as in the more serious forms of diarrhoea, to prevent the affection being aggravated by any error of diet, or even by the infant being allowed to partake too freely of food otherwise suitable for it. If, therefore, the sickness with which the attack sets in have not altogether subsided, the child should be taken completely from the breast for a few hours, and should have nothing more than a few spoonfuls of water or barley-water, till the irritabil- ity of the stomach has abated. If the disposition to vomit have com- pletely ceased, it will yet be right to put the infant less frequently to 492 TREATMENT OF DIARRH03A IN TEETHING. the breast; while it is supplied, if thirsty, with water, or barley-water, in small quantities at a time. In children already weaned, a similar plan must be carried out; solid food being for a time withdrawn, and thin arrowroot, or barley-water and milk, in equal parts, being sub- stituted for it. If the attack be clearly traceable to some improper article of food, a dose of castor oil will sometimes get rid of the irritant cause and of the diarrhoea together. Unless this is the case, however, it is better not to give the aperient, since its action, in these circum- stances, is somewhat uncertain ; and instead of relieving, it may aggra- vate the diarrhoea. Provided there be neither much pain nor much teuesmus, and the evacuations, though watery, are fecal, and contain little mucus and no blood, very small doses of the sulphate of magnesia and tincture of rhubarb have seemed to me more useful than any other remedy;1 and I seldom fail to observe from it a speedy diminu- tion in the frequency of the action of the bowels, and a return of the natural character of the evacuations. In these cases also I have tried the sulphuric acid, which has of late been so much vaunted as almost a specific in catarrhal diarrhoea. I have given it in doses of four minims every four hours, to infants a year old, sweetened, and mixed with caraway water. Though successful in some instances it has in my hands failed to control the diarrhoea more frequently than the sul- phate of magnesia and rhubarb mixture : and the only cases where it seemed to possess a decided superiority over that remedy were those which were attended with frequent vomiting and great irritability of , the stomach. In the diarrhoea that comes on in connection with teething, it has seemed to be better to pursue a somewhat different plan. It is usually attended by a greater amount of constitutional disturbance than is observed in the diarrhoea of younger infants, and by some degree of febrile excite- ment. There is, likewise, in many instances, a considerable disposition to catarrhal affection of the respiratory mucous membrane, which needs to be carefully watched, lest by its increase it should become a source of serious danger to the child. The diarrhoea in the majority of these cases comes on gradually, and its subsidence takes place gradually too. Now and then the gum may appear at one spot so tense and swollen as to induce us to scarify it; and if the tooth be very near the surface, this proceeding may sometimes greatly diminish the diarrhoea, by re- lieving the irritation which excited it. Any such marked benefit, however, is quite an exceptional occurrence; and unless the state of the gums be such as of itself to indicate the propriety of scarifying them, it would be a cruel and useless piece of empiricism to subject the child to the distress of the operation. Instead of the saline and rhubarb mixture which I have just mentioned, I usually employ in these cases small doses of ipecacuanha in combination with an alkali; and think that I have found great benefit from this plan. Three or four drops of liquor potassae, and the same quantity of vinum ipecacu- anhas, mixed with mucilage,2 and given in a little milk about every four hours, is a suitable dose for an infant a twelvemonth old. At 1 See Formula No. 27, p. 455. 2 See Formula No. 22, p. 429. TREATMENT OF INFLAMMATORY DIARRHCEA. 493 the same time the child should be placed in a tepid bath every night; and a powder of one grain of Dover's powder and one of mercury with chalk, given to it afterwards, will often be found to procure for the little patient, previously restless and fretful, some hours of quiet repose. If the child should appear much exhausted, a slight stimu- lant, such as four or five drops of the spirit of nitrous ether, may be advantageously combined with each dose of the mixture; and in all cases of simple diarrhoea it behooves us to watch most carefully against the powers becoming too much depressed, either by the profuseness of the purging or by its continuance. Supposing in any case that a considerable degree of looseness of the bowels should continue after the lapse of two or three days, astringents must be resorted to; and I know of none better than the extract of logwood, in combination with tincture of catechu.1 The logwood, moreover, is something besides a mere astringent; it is a very valu- able tonic in all cases where gastrointestinal disorder has existed, and it is one which children take readily. It is, however, not very popu- lar in the nursery, because it imparts to the evacuations a deep pink color, which leaves an indelible stain upon the napkins—a circum- stance which it is as well to mention when you prescribe the medicine. The mercury and chalk and Dover's powder may be still continued at bedtime, if the evacuations, though less frequent, be still slimy and unhealthy. If either the evacuations or the infant's breath have a sour smell, three grains of the sesquicarbonate of soda may be added to each dose of the mixture; or, if the child be not wholly fed at the breast, a drachm of prepared chalk may be stirred up with each pint of milk given to it; and after the powder has been allowed to settle, enough will still remain suspended in the fluid to counteract any slight acidity in the alimentary canal. If, after the bowels have become quite regular, some tonic should still be required, the extract of bark, with small doses of the tincture,2 will be one of the best that can be given. You will observe that all the remedies mentioned occupy but a very small compass—a point the importance of which is never to be forgotten in prescribing for children. But there are cases which wear a much more serious aspect than those the treatment of which we have hitherto considered. Even in true inflammatory diarrhoea, however, depletion is but seldom needed; for either the abdominal tenderness is inconsiderable, or, if the attack set in with great severity, it will be generally found to have occasioned so much depression as to contraindicate the abstraction of blood Still, in cases of recent date, if the abdominal tenderness be considerable, and if it be associated with much heat of skin and febrile disturbance a few leeches may be applied in either iliac region. The child should 1 (No. 29.) R^.—Extr. hsematoxyli 3J. Tinct. catechu 5ij. Syrupi sj. Aquse carui gix.—M. £j ter die. For a child a year old. * See Formula No. 3, p. 56. 494 TREATMENT OF INFLAMMATORY DIARRH03A. be carefully watched for some hours afterwards, in order to prevent any excessive loss pf blood; since considerable hemorrhage not infre- quently follows the application of leeches to the abdomen, and it is not always very easily arrested. -On this account, I think you may find it the better plan to apply the leeches to the margin of the anus, in which situation they will relieve the bowels at least as much, while the bleeding from them will be completely under your control. In the majority of instances the pain and tenderness of the abdomen are much eased by the application of a large hot bran poultice; the fre- quent renewal of which often affords great comfort to the child. If the irritability of the stomach be not so great as to prevent its administration, no medicine is of such general application, or of such essential service, in these cases, as a mixture containing a small quan- tity of castor oil diffused in mucilage, with the addition of a few drops of tincture of opium, which I was led to use in the inflammatory diar- rhoea of children from observing the great benefit which followed its employment by my friend, Dr. Baly, in the treatment of dysentery among the prisoners in Milbank Penitentiary.1 Although this medicine may relieve all the symptoms considerably, and although the general state of the child may be much improved, yet it sometime happens that a considerable degree both of tenesmus and of purging continue. These symptoms will now be more effectu- ally soothed by an opiate enema than by any other means. Three minims of laudanum will form an enema of sufficient strength for an infanta year old; and this should be given suspended in half an ounce of mucilage, since a more bulky injection is almost sure to be immediately expelled. Supposing the symptoms not to yield to these means, or that the case presented from the first a great degree of severity, small doses of hyd. c. cretfi, and Dover's powder may be given every four hours, in addition to the castor oil mixture, which, however, should now be given without the laudanum. In some cases, the irritability of the stomach is so great that almost everything taken is speedily rejected; and, when this condition is present, none of the medicines already mentioned can be borne. In these circumstances, a small nustard poultice should at once be applied to the epigastrium; the child should be taken from the breast; a teaspoonful of cold water, or cold barley-water, should be given at intervals; and a powder of a third of a grain of calomel, and a twelfth of a grain of opium, should be laid upon its tongue every three hours. The sickness will generally subside in four or five hours, though the stomach often remains too irritable to bear any change in the remedies, and the greatest caution will be needed in restoring the infant to the breast. It may be necessary, indeed, to confine the child 1 (No. 30.) $.—01. ricini 3j. Pulv. acaciae 5ss. Sacchari albi 5ss. Tinct. opii rnjv. Aquae flor. aurant. 3vij-—M. :jj 4tis horis. For a child a year old. USE OF STIMULANTS. 495 for twenty-four or thirty-six hours to cold barley-water, cold water thickened with isinglass, the white decoction of Sydenham, or equal parts of cold milk and water; and, when the child has been seen early in the disease, I have never observed any evil to follow the per- severance for this short period in a rigorous diet. The tepid bath employed twice a day, or even more frequently, will be found of great service in soothing that general irritability of the nervous system which often continues through the whole course of the affection, and which sometimes issues in convulsive seizures, or in other symptoms that are occasionally mistaken for the indications of real cerebral disease. It cannot be necessary to reiterate here the often-repeated caution against regarding the symptoms of disturbance of the nervous system as being always the signs of active cerebral disorder, calling for depletion to relieve the congestion of the vessels of the brain, and for antiphlogistic measures to moderate the excited state of the circulation. At the very commencement of this course of lectures,1 I endeavored to set before you the various circumstances in which convulsions come on in early life; and some days ago2 I tried to delineate the characteristic features of spurious hydrocepha- lus. On that occasion, I related the history of two children, both of whom had been attacked by severe diarrhoea. In one case, the child passed every few minutes from a state of listless drowsiness to a con- dition of extreme restlessness and alarm; the tendons of the forearm were in a state of subsultus; and general convulsions seemed impend- ing. In the other case, the irritability of the nervous system was rapidly subsiding under the general exhaustion of the vital powers; and probably in a few hours more the infant would have sunk into a profound coma, from which no means would have been adequate to rouse it. The tepid bath and an opiate enema in the first-mentioned case, and the free employment of stimulants in combination with small doses of Dover's powder in the second, speedily averted dangers that had seemed so threatening. I need not, however, tread again over all the ground we have already passed, but will content myself with repeating the remark I then made—that if, in cases of this kind, you fall into the error of regarding the cerebral symptoms as the signs of active disease, and withhold the Dover's powder or the opiate enema, that might have checked the diarrhoea and soothed the irritability, while you apply cold lotions to the head, and give the child nothing more nutritious than barley-water in small quantities, because the irritability of the stomach, which results from weakness, seems to you to be the indication of disease of the brain, the restlessness will be- fore long alternate with coma; and the child will die either comatose or in convulsions. As to the time when stimulants are to be given, or the quantity in which they are to be employed, no definite rule can be laid down. Each case must be treated for itself; and to be treated successfully it must be watched most closely. The necessity for stimulants may arise suddenly, or the need of their administration may be but tem- ' Lecture HI. p. 37. * Lecture XI. p. 128. 496 TREATMENT OF CHRONIC DIARRH03A. porary; while the infant's state in the morning affords, in cases of severe diarrhoea, no sure criterion by which to judge what its condi- tion will be at night. In general, it is not until the active symptoms have begun to decline that stimulants are needed, nor even then are they required in a large number of instances. I have, however, met with some instances in which they were absolutely necessary as early as the second or third day of the disease. This has occurred in cases in which there was great irritability of the stomach, as well as violent action of the bowels; in which no medicine could be borne except the calomel and opium powders, nor any drinks except such as were given cold. In such circumstances a state of extreme debility is sometimes very rapidly induced, and the vomiting, which at first was a sign of the gastric disorder, continues, when it is nothing else than an effect of the general exhaustion. About half a drachm of brandy given every two or three hours to a child of a year old, in a quantity of a few drops at a time, mixed with the cold milk and water, or the thin arrowroot with which it is fed, will often have the effect of arresting the sickness, as well as of rallying the sunken energies of the system. No stimulant has appeared to answer the required ends better than brandy; and, when sufficiently diluted, children take it very readily. Occasionally, however, when it has been necessary to continue it for some time, it has seemed to produce pain in the stomach, and even to nauseate the child; and in this case the compound tincture of bark, or the aromatic spirits of ammonia, or the two together, may be sub- stituted for it; and there is seldom much difficulty in administering them, if they are mixed with milk and sufficiently sweetened. The proper time for the employment of aromatics and astringents is not during the acute stage of the affection; but when the disease has already begun to decline, these remedies will be found of most essen- tial service in checking that looseness of the bowels which otherwise is very apt to degenerate into a state of chronic diarrhoea. In these circumstances the logwood and catechu mixture, mentioned at an early part of this lecture, is a very valuable medicine. If, notwithstanding its employment, the bowels still continue to act with excessive fre- quency, small doses of the compound powder of chalk and opium may be given twice a day,1 or the use of the opiate enema may be continued if there be much tenesmus. By these means, coupled with the most sedulous attention to the child's diet, and the greatest care in allowing either animal broths or meat or other solid food, a com- plete cure will usually be brought about in the course of two, or at the latest of three weeks. There are some cases in which, after the disease has passed its acute stage, it still retains much of its dysenteric character; the bowels not merely acting with undue frequency, but the evacuations containing mucus, pus, or blood, and their expulsion being attended with very considerable tenesmus. The strength in such chronic cases is very 1 (No. 31.) R.—Pulv. cretae co. c. opio J}j. Inf. catechu co. giss.—M. ^j bis vel ter die. For a child a year old. TREATMENT OF CHRONIC DIARRHOEA. 497 greatly reduced, and emaciation goes on to a greater degree than in almost any other affection, with the exception of phthisis and mesen- teric disease; while the bowels are excited to almost immediate action by even the simplest food. The treatment of these cases is attended with considerable difficulty; recovery, when it does take place (and it is consolatory to know that it often does, even from a condition apparently desperate), is brought about very slowly, and each remedy employed seems speedily to become ineffectual. Throughout their course two objects are to be borne in mind—one being to check the diarrhoea; the other to support the child's strength during the time required for nature to effect the cicatrization of the ulcerated mucous membrane, and to restore it to a state of health. The utility of mer- curial preparations has appeared to me to be almost exclusively con- fined to the early stage of dysentery, and to cease when the disease has passed into the chronic form. On the other hand, astringents may now be employed with the most marked benefit, and, when one fails, another may be substituted for it. In cases where the stomach has been very irritable, so that almost everything has been speedily re- jected, I have sometimes employed the gallic acid in combination with laudanum,1 and have seen much benefit from its use. At other times I have given the acetate of lead with opium2—a combination which retains its efficacy, when given in the form of mixture, notwithstand- ing the decomposition that takes place. The sulphate of iron com- bined with opium3 is another highly useful remedy in these cases, and appears to have the advantage over the sulphate of zinc, which has likewise been used in similar cases, of not exciting the irritability of the stomach. Our remedies are not to be confined to those administered by the mouth, for much may be done towards relieving the symptoms and curing the disease by suitable enemata. In some cases of unmanage- able diarrhoea, M. Trousseau employs an enema of nitrate of silver in the proportion of a grain to an ounce of distilled water, which I have sometimes tried in combination with a few drops of laudanum with very good effect. I have employed the gallic acid in enema in a similar manner, ard throughout any case of chronic diarrhoea, occa- sion will often arise for altering our remedies in various ways, not so much to meet any changes in the character ot the symptoms, as be- cause all medicines, even the most appropriate, after having been em- i (No. 32.) 2 (No. 33.) R.—Acidi gallici gr. viij. R.—Plumbi acetat. gr. vj. Tinct. cinnamomico. gj. Aceti destillati rr\xx. Tinct. opii rt^viij. Tinct. opii n\,viij. Syrupi ^ij. Muc. acaciae gij. Aquae cinnamomi ^v. Syrupi zingib. 3j. Aquae puree Si.—M. 3ii 6tis horis. Aquae purae Sxiij.—M. 3ij 6tis horis * 3 (No. 34.) R.—Ferri sulphatis gr. iv. Tinct. opii tt^vj. Syrupi aurantii ^ij. Aquae carui 3x.— M. gij 6tis horis. The above are all suited for children one year old. 32 498 DIET IN CHRONIC DIARRHCEA. ployed for a time, seem to lose their power. In the majority of instances I have begun with the administration of clysters of laudanum diffused in mucilage, or in a small quantity of starch, while occasionally, in protracted cases, where the tenesmus was very distressing, I have used the black wash as a vehicle for the laudanum; and on one occa- sion, in which a copious discharge of pus continued for several days in a little boy two years old, this symptom was greatly relieved by the administration, twice a day, of an enema containing two grains of sulphate of zinc. The support of the child's strength is a matter of no less import- ance in chronic dysentery than the suppression of the diarrhoea. The great weakness of the patient and the manifest distaste for nourish- ment of all kinds often render it necessary to continue the use of brandy for several days, or even for several weeks. For an infant not weaned, there can be no better food than that which is furnished by the breast of a healthy nurse. In the majority of cases, however, the child has been either in great measure or altogether weaned before tbe affection came on, and consequently it is a less easy matter to supply it with suitable food. Farinaceous articles, such as arrowroot, sago, &c, are less easily assimilated in early life than in adult age, and in cases of this kind they not infrequently pass through the alimentary canal unchanged. Milk, too, does not always agree, and is sometimes rejected almost at once, unless it be given in a state of extreme dilution. In these circumstances we must not hesitate to give strong beef or veal tea in small quantities, but at short intervals, to the patient, for, though it be true that the bowels are often excited to increased action, in cases of chronic diarrhoea or dysentery, by animal broths, yet this is a smaller hazard than that of the child dying for want of sufficient nutriment. I may add that, when prepared with care, and quite free from salt or any seasoning, and when given cold, I have seldom ob- served any serious increase of the diarrhoea to follow their use in these circumstances. In some of these cases, however, we encounter an additional difficulty, owing to the child's distaste for almost every kind of food, which it either positively rejects, or, having taken a little, seems to be nauseated by it, and refuses any more, and this even though its eager manner and its plaintive cry plainly announce its hunger. In these circumstances there is still one article of food—raw meat—which is often eagerly taken, and almost always perfectly well digested.1 Prof. Weisse, of St. Petersburg,2 first recommended its employment in children suffering from diarrhoea after weaning, and it has since then been very frequently given by other physicians in Ger- 1 The greater digestibility of raw meat than of that which has been cooked consti- tutes, doubtless, its great advantage in these cases. The fact, though contrary to the opinions formerly entertained on the subject, appears to be substantiated, not merely by carefully conducted experiments on artificial digestion, but also by observations on the subject for which opportunity was afforded by a case resembling that of the Cana- dian who was for so long a time under the notice of Dr. Beaumont. See a dissertation, Succi Gastrici Humani Vis Digestiva ope Fistulae Stomachalis Indagata. Auctore Ernesto de Schroeder. Dorpat, 1853. The author comes to the conclusion, " carnem crudam in ventriculo hominis facilius quam carnem coctam dissolutam esse." 2 Journal f. Kinderkrankheiten, vol. iv. 1845, p. 99. TREATMENT OF INTERTRIGO AND OF PROLAPSUS ANI. 499 many in cases of long-standing diarrhoea. The lean either of beef or mutton, very finely shred, may be given in quantities at first of not more than two teaspoonfuls four times a day to children of a year old, and afterwards, if they crave for more, a larger quantity may be allowed. I have seldom found any difficulty in getting children to take it—often, indeed, they are clamorous for it. It does not nauseate, if given in small quantities, neither does it ever aggravate the diar- rhoea, while in some instances it has appeared to have been the only means by which the life of the child has been preserved. With re- turning convalescence the desire for this food subsides, and the child can without difficulty be placed again on its ordinary diet. Two accidents are occasionally met with in connection with pro- tracted diarrhoea in infants and young children, concerning each of which a few words must be said. It is not unusual to observe a general erythematous redness of the buttocks and nates in infants suffering from severe diarrhoea, and sometimes the irritation of the acrid feces produces an attack of intertrigo, and a serous fluid exudes abundantly from the inflamed skin. This condition, which is the occasion of very considerable suffering to the child, almost always depends upon a neglect of that most scrupulous cleanliness which is of such essential importance in early life. In order to prevent its occurrence, the nates and buttocks must be sponged with warm water immediately after each evacuation; the surface may afterwards be smeared with a little zinc ointment, while any part at which the skin seems disposed to crack should be dusted over with the oxide of zinc in powder. These simple precautions will usually suffice to prevent a condition which, in some of the hospitals of Paris, where such sedulous care is almost impossible, degenerates into a state of unhealthy ulceration that exhausts the infant's powers, and sometimes contributes to its destruction quite as much as the diarrhoea in the course of which it came on. Prolapsus of the anus is another troublesome accident which some- times takes place in the course of protracted diarrhoea. It abates, however, almost always, as the diarrhoea diminishes, and generally ceases altogether as the child regains its strength. When there is a disposition to it during the acute stage of the affection, this may often be controlled if the nurse be instructed to support the margin of the anus during each evacuation, and thus to prevent the descent of the bowel, while the opiate enema which relieves the tenesmus is of most essential service, by thus removing the cause of the prolapse. The child's attendant should also be taught how to return the bowel if it should come down ; and this is best effected by means of gentle pressure with a napkin wrung out of eold water. If, as the diarrhoea abates, the prolapse should still continue, and especially if the gut should come down independent- of efforts at defecation, it may be necessary to make the child wear a compress and bandage to prevent its descent. In such cases, too, an enema consisting of a small quantity of some astringent such as the decoction of tormentilla, should be administered cold once or twice a day; and no instance has come under my notice 500 PERITONITIS. in which these measures, persevered in for a few weeks, have not sufficed to remove this troublesome ailment.1 LECTURE XXXVIII. Peritonitis—sometimes occurs during foetal existence, or in very early infancy—is then possibly dependent on syphilitic taint—when epidemic in large institutions, is often connected with infantile erysipelas. Peritonitis in after-childhood—a rare occurrence—generally secondary to some febrile attack—case illustrative of its symptoms, which are much the same as in the adult—occasional—escape of the fluids effused, through the abdominal walls, and recovery of the patient.—Inflammation sometimes circumscribed, especially in connection with disease about the appendix caeci—illustrative cases.—Treatment of peritonitis. Chronic peritonitis—almost always a tubercular disease.—Morbid appearances—symp- toms—their vagueness—pauses in the advance of the disease—various and often obscure forms which it assumes—close analogy between its symptoms and those referred to tubercular disease of the mesenteric glands. Tabes Mesenterica—rarity of extensive disease of the glands—slightness of its symp- toms when uncomplicated.—Treatment of it, and of tubercular peritonitis. From the study of the affections of the mucous lining of the intes- tinal canal, we pass by a natural transition to that of the diseases of its serous investment. Peritonitis, however, which is not very com- mon as an idiopathic affection at any period of life, is still more rare during the greater number of the years of childhood; while its symptoms do not deviate in any important respect from those which characterize it in the adult. It would be idle to spend our time in speculating on the reasons for the rarity of inflammation of the perito- neum in early life. Tbe tendency of inflammatory disease in child- hood appears, indeed, to be to attack the mucous rather than the serous membranes—a fact of which we have another illustration in the comparative rarity of acute pleurisy in the child. Some con- nection may perhaps be thought to subsist between the great irrita- bility of the intestinal mucous membrane, and its proneness to disease during the greater part of childhood, on the one hand, and the immunity from disease which the peritoneum exhibits during the same period. At any rate, it is certain that in the new-born infant, in whom the former peculiarity has not yet become developed, inflam- 1 It does not come within my province to discuss the surgical treatment of long- standing prolapsus ani. Cold enemata, however, or any proceedings not addressed to the paralyzed state of the sphincter itself are in such cases entirely useless ; and the removal of some of the folds of skin at the margin of the anus, or the application of the actual cautery at four opposite points in that situation, are the only measures likely to be of service. With reference to the latter proceeding, which has the advan- tage of being the less severe, and in the young child is said to be generally effectual, see a paper by M. Duchaussez, in the Archives de Mtdecine, September, 1853. PERITONITIS IN EARLY INFANCY. 501 mation of the peritoneum is of more common occurrence than in sub- sequent childhood. Inflammation of the peritoneum, giving rise to adhesions between the intestines, and to the effusion of lymph and serum into the cavity of the abdomen, occurs sometimes even during intra-uterine life, and occa- sions the death of the foetus. It is not possible to say with certainty to what cause the disease should be attributed at a time when the being is sheltered from all those influences from without which may excite inflammation after birth; but it is worthy of notice that in many instances of peritonitis in the foetus, traces of syphilitic disease are observed upon it; or there is clear evidence of the existence of venereal taint in the mother. In such cases, the inflammation of the serous lining of the abdomen is probably due to the altered state of the circulating fluid—a cause to which, in after life, inflammation of the serous membranes is frequently owing. In the only instance of non-congenital peritoneal inflammation that has come under my notice in early infancy, there was no other cause than this to which it could be attributed. In this case a little boy, five weeks old (whose mother had twice before been confined prematurely with stillborn children), began to have snuffles at the age of three weeks. In the course of the next week a few copper-colored spots appeared about his face; his scrotum next grew sore, then his voice became hoarse and his lips cracked; and at the end of the fourth week he grew sick, and his abdomen enlarged and became tender. When brought to me, the child was extremely small; he was greatly emaciated; the skin of his face wrinkled; his appearance distressed; his chin covered with copper- colored blotches; the angles of his mouth were ulcerated; his lips cracked; and small sores beset his scrotum. His abdomen likewise was very large: it was remarkably prominent about the umbilicus, and its superficial veins were much enlarged. It was extremely tense; somewhat tympanitic; and though dull in places, it yet did not yield the impression of distinct fluctuation anywhere. The abdomen was exceedingly tender to the touch, but the child seemed in pain also at other times; he had been very sick for nearly a week, and vomited almost immediately after sucking, besides which he threw up a yellow fluid at other times. His bowels were purged several times a day. His mother, who did not suffer at that time from any syphilitic symp- tom, was put upon a mild mercurial course, with iodide of potassium and sarsaparilla; and the mercury with chalk was likewise adminis- tered to the child. By degrees, as the syphilitic spots faded, the ab- domen grew less tender and less swollen—it became soft; and in the course of time the infant regained perfect health. The symptoms in this case ran a chronic course; but peritonitis of an acute character, and tending to a rapidly fatal termination, is some- times observed to occur among very young infants when collected together in large numbers, and under conditions unfavorable to health. A French physician, M. Thore,1 during a year's observation at the 1 De la Peritonite chez les Nouveau-nes, in the Archives Gen. de Med. for August and September, 1846. 502 ACUTE PERITONITIS IN CHILDHOOD. Hospice des Enfans Trouves at Paris, found that acute peritonitis ex- isted in about six per cent, of the infants who died at that institution. The disease, such as he observed it, seems to be exclusively an affec- tion of early infancy, since, though the hospic*e contains children of all ages, yet no child above the age of ten weeks was attacked by it, while thirty-five out of fifty-nine were less than a fortnight old. The previous health of the children had in some instances been good, but in many cases the peritonitis appeared as a consequence or complica- tion of some other affection. A sudden tympanitic swelling of the abdomen was often the first symptom of the disease, and was soon associated with vomiting of a greenish matter; which phenomenon, however, was seldom of long continuance. The bowels were gener- ally constipated throughout, the respiration and pulse soon became accelerated, and the heat of skin increased, while the child evidently suffered pain in the abdomen. With the advance of the disease the countenance altered, the skin grew cold, and the pulse feeble; and in the majority of cases the child died within twenty four hours, while life was not in any instance prolonged beyond the third day. The appearances found after death were much the same as those which characterize peritonitis in the foetus. In none of the sixty- three cases which were examined was there any puriform matter in the abdominal cavity, but only a dirty serous fluid, in which flocculi of lymph were often floating; while the intestines were more or less coated with false membrane, which was especially abundant about the spleen and liver. Pleurisy was found associated with the peritonitis in a third of the cases; and the frequency of this complication is another point of resemblance between the disease as it occurs during foetal life and in early infancy. Its causes, too, appear to be such as act through the medium of the circulating fluid ; for in seventeen out of sixty-three cases the peritonitis followed on erysipelas, and in four on phlebitis of the umbilical vein—affections which, it is known, are immediately dependent on epidemic causes, and are excited by tbe same atmospheric conditions as induce puerperal fever in lying-in women. The influence of such agencies is still farther shown by the fact that forty-two per cent, of the cases of peritonitis recorded by M. Thore occurred during the months of April and May, while the others were somewhat unequally distributed over the remainder of the year. When the child grows older it is no longer so susceptible of noxious influences as before; and when they come into play, the mucous mem- brane of the bowels suffers, rather than their serous investment. Hence, acute idiopathic peritonitis becomes a very rare disease in child- hood; and peritoneal inflammation usually occurs as a sequela of some affection which has been attended with considerable alteration in the circulating fluid. It sometimes succeeds to an attack of scarlatina; and the possibility of its occurrence should lead us to look with great suspicion upon any complaint of pain in the abdomen made by chil- dren during their convalescence from that disease; while, though the danger of its supervention after other febrile affections is less consid- erable, the risk is by no means to be forgotten. CASE OF ACUTE PERITONITIS. 503 The symptoms and course of the disease appear to be much the same whether it occurs as a primary or as a secondary affection ; but there is a great difference between the severity of the symptoms and the amount of danger to which the patient is exposed, in different cases. I do not recollect ever to have witnessed more intense suffering than was endured by a little boy, nine years old, who, after recover- ing from fever, yet seemed to regain his health by but slow degrees, and had almost habitual constipation. He came under my notice on May 25, and was much benefited by alterative and slightly aperient medicines; when he was suddenly, and without any known cause, seized on the 3d of June with profuse diarrhoea, and severe pain in the abdomen. On the following day, when I saw him, his face was haggard and anxious, and his abdomen excessively tender; while the diarrhoea continued even more profusely than before. Some leeches were applied to the abdomen, and calomel and Dover's powder were given every four hours; but the leeches drew but little blood, and though the purging ceased, the pain in the abdomen increased in severity. On the 5th of June I found the boy lying on his back, with his legs stretched straight out; while the slightest movement, or any attempt to sit up, produced excruciating pain. The abdomen was tympanitic, very tender to the touch, and especially so just below the umbilicus. The pulse was frequent and sharp; the tongue moist, and uniformly coated with yellow fur. Leeches were again applied, in greater numbers than before; and the mercurial was given every three instead of every four hours. Towards evening he was rather better, but the pain, which was referred especially to the neighbor- hood of the umbilicus, came on severely during the night, and was aggravated in paroxysms. He had passed no urine for many hours; but only half a pint was drawn off by the catheter, and this was dark- colored, and had a very strong smell. The bowels had acted only once, and then scantily. The same remedies were continued, but the child's condition continued to grow worse; and during the night he was in such pain that he frequently shrieked aloud so as to alarm the neighborhood. On the morning of the 7th he had turned round upon his right side, and lay with his knees drawn up towards his abdomen, his head supported in his mother's lap; his face expressed the most intense suffering, and he shrieked frequently with pain. The abdo- men was much distended, and so tender that it could not endure the slightest touch. The pulse had become frequent and thready. He had made water twice of his own accord. The abdomen was now covered with a large blister: beef-tea and brandy were given to sup- port the vital powers; and while the mercurial was continued, an endeavor was made, by a full dose of opium, to procure a temporary abatement of the child's sufferings. When seen at 6 P. M. he had vomited frequently a dark-green fluid, and had passed three natural liquid evacuations. He was lying in the same attitude as before, dozing with half-closed eyes, his forehead wrinkled, the corners of his mouth drawn down terror and pain stamped on his countenance—seeming as if dying, till roused by a return of pain, when he called with loud 504 ACUTE GENERAL PERITONITIS. and piteous cries on his mother for help. His pulse was now smaller, and more thready. During the night his sufferings were unceasing; towards morning he became quieter, and died quietly at 9 A. M. on June the 8th. On opening the abdomen, thin pus, unmixed with lymph, poured forth in great abundance. It quite concealed the intestines from view, and must have amounted to at least a quart. The peritoneum lining the abdominal walls was highly vascular, especially in the hypogastric region; that covering the intestines had lost its natural transparency, was softer, and seemed thicker, but was not much injected. There was no lymph effused on any part of the parietal peritoneum, nor were there any adhesions between the intestines; but the spleen and liver, the latter especially on its convex surface, were coated with lymph. The whole tract of the intestines was examined with great care, and was found to be quite healthy; the mucous membrane being rather pale. There was some crude tuberculous matter in the mesenteric glands. The right side of the chest contained a pint of pus, similar to that in the abdomen; the right pleura was intensely vascular; and this condition was especially remarkable in that part of it which lined the diaphragm ; a patch of lymph, of small extent, formed a connection between the two surfaces of the lung, while the right lung generally had a rather thick coating of false membrane. Some tubercles in the bronchial glands, and a compressed state of the substance of the right lung formed the rest of the morbid appearances. There can be no doubt but that, in the early stages of this case, a more active plan of treatment ought to have been adopted. It is re- lated however, not as an illustration of the therapeutical principles by which you should be guided, but as affording a remarkably good specimen of the symptoms of acute peritonitis. The inflammation of the pleura was doubtless secondary to that of the peritoneum, and the effusion into the cavity of the chest probably coincided with the time when the child assumed the position on his right side. We learn from this case, that pain, coming on suddenly, referred particularly to one part of the abdomen, but extending over the whole, greatly aggravated on pressure, or on the slightest movement, so as to compel the patient to remain in the recumbent posture, with the legs extended and motion- less, characterizes the disease. The abdomen before long becomes tympanitic, and this tympanites, if considerable, greatly aggravates the patient's sufferings. The state of the bowels varies; frequently they are relaxed at the outset of the illness; sometimes they continue so throughout, while they are but rarely constipated. Vomiting is not a constant symptom; and when it does occur, the irritability of the stomach varies, both in its degree as well as in the time at which it appears. The symptoms sometimes continue to increase in severity until death takes place; at other times they undergo a sudden diminu- tion, or even cease altogether; though this seeming amendment is at- tended, or rapidly followed, by sinking of the vital powers, and soon afterwards by the patient's death. Acute general peritonitis is fortunately very rare in childhood— only four other instances of it have come under my notice; and still SYMPTOMS OF ACUTE GENERAL PERITONITIS. 505 rarer is its termination by the effusion of pus into the cavity of the abdomen. Even in these apparently hopeless circumstances, however, nature does sometimes make an effort to cure. The active symptoms diminish in intensity; the abdominal parietes grow thin at some spot, where a passage at length is formed through which the pus is dis- charged, and recovery sometimes slowly follows—the result of a pro- cess precisely analogous to that which nature has recourse to in pleurisy, when she brings about the evacuation of the fluid through an opening spontaneously formed in the parietes of the thorax. An instance of this mode of cure of peritonitis, in a child seven years old, was related by Dr. Aldis, at a meeting of the Medico-Chirurgical Society, in No- vember, 1846.1 A few similar cases may be found in medical journals;2 and two have come under my own observation—one in the person of a little child, whose history I formerly related3 as affording an illustra- tion of that rare affection, inflammation of the sinuses of the dura mater; the other in a girl aged eight years, in whom, however, the peritonitis was chronic in its character, and associated with tubercular disease. The peritoneal inflammation which comes on during scarlatinal dropsy is not in general of a very active character, and seldom pro- duces any morbid appearance of greater gravity than numerous slight adhesions between the intestines. It generally succeeds to ascites; and the abdominal affection seldom exists alone, but is usually asso- ciated with pleurisy, and abundant serous effusion into the chest; and the symptoms of disease of the respiratory organs very often mask those of abdominal inflammation, which latter, indeed, seem in many instances to have but a very subsidiary share in bringing about the patient's death. Besides those cases in which the peritonitis is general, there are others in which the inflammation is circumscribed to a part, and some- times but a small part, of the peritoneum. Now and then, peritonitis affecting only a very small extent of surface proves rapidly fatal (though no such instance has come under my own notice); but usually there is a correspondence between the severity of the symptoms and the extent of the disease. I imagine the inflammation to have been circumscribed in some cases, in which the principal pain was referred to one part of the abdomen, while the tenderness was almost limited to that situation, in which, moreover, the abdomen did not become generally tense or tympanitic, and all the symptoms yielded with tolerable readiness to the employment of remedies, though the dispo- sition to pain and tenderness in one spot was some time before it wholly disappeared. Lastly, some notice must be taken of a highly dangerous form of peritonitis, circumscribed in some cases, but general in others, which succeeds to inflammation of the ccecum, or of its vermiform appendix. This affection, however, of comparatively rare occurrence at any age, 1 Reported in the London Medical Gazette, November, 1846. 2 For instance, Bernhardi, in Preuss. Med. Zeitung, 1842, No. 10; and Beyer, Cas- per's Wochenschr., 1842, No. 5. * See Lecture VIII. p. 105. 506 PERITONITIS—CASE. presents no such peculiarities in early life as to require any very lengthened description. It has come under my observation only four times; the patients in every instance were male children, of the respective ages of seven, eight and a half, nine, and three and a half years. In the first two cases it terminated fatally; in the third it ended after protracted suffering in the formation of an abscess in the right iliac region, which was opened a little above the centre of Pou- part's ligament, the child eventually recovering; while I am ignorant of the issue of the fourth case. In the first fatal case, no foreign body, nor any intestinal concretion was discovered; but in the second, a small concretion which weighed two grains was found impacted in the extremity of the vermiform appendix, which was ulcerated around it, although no escape of the intestinal contents had taken place. The main symptoms are the same in all cases. First, there is dis- order of the bowels which sometimes are constipated, less often relaxed; but in either case there is pain in the abdomen, which passes at first for that of ordinary stomach-ache, though a little inquiry will ascertain that it is more abiding, and that besides it is chiefly referred to the right side, and is still experienced there, even when elsewhere it has ceased for a season. Next, there comes, it may be in one day, or it may be not until after four or five, an increase in the severity of the pain, attended with tenderness on pressure over the abdomen, and this tenderness is more marked on the right side than elsewhere. Treatment perhaps mitigates it, but as it does so serves at the same time to bring out more clearly the characteristic features of the ail- ment. The right side of the abdomen now becomes tense and swollen, and hard, and dull on percussion, which though borne elsewhere, causes much pain in this situation. The prominence of the right side sometimes assumes the form of a distinct, somewhat elongated tumor, reaching down to the ramus of the pubis, upwards nearly into the right hypochondrium, and backwards towards, but not in general into the lumbar region, while the integument above it presents a peculiar unyielding brawny hardness. In addition to the swelling in this situation, it will now be observed, that while the child is able to extend the left leg without pain, so much suffering is induced by any attempt to stretch out the right, as to compel him at once to desist, and the posture which he adopts is accordingly peculiar, one leg usually extended, the other drawn up towards the abdomen, and all the abdominal muscles kept as rigidly immovable as those of a marble statue. While these peculiarities stamp, almost beyond the possibility of error, the nature of the ailment, it may yet run its further course in different ways, and to various issues. The extension of the inflamma- tion to the general peritoneum may speedily prove fatal; having be- trayed its existence, not by intestine pain, but by a state of .general collapse, in which while the skin is cold, and the pulse scarcely per- ceptible, the intellect is clear, and the temper unruffled. It was thus I saw a little boy die, who was eight and a half years old, and who, though liable to constipation, was as well as usual till August 11th. TREATMENT OF PERITONITIS. 507 He then had stomach-ache, which was not relieved by an aperient, and on the next day was more severe, though chiefly referred to the right side of the abdomen. On the 13th, some leeches mitigated the pain, but their application produced extreme faintness. On recover- ing from this faintness, there was no longer any intense tenderness of the abdomen, but the two most remarkable symptoms were a peculiar tension of the abdominal muscles, and inability to move the right leg without pain. Swelling, too, was now apparent in the right pubo- iliac region, and on the 14th, this was still more marked, while, though there was no increase of pain, the pulse had risen in frequency to 130. In the afternoon of that day, after scanty relief from the bowels, consequent on the administration of an enema, the child, without pain, sank into a state of collapse, in which his pulse became almost imperceptible, and his surface was bathed with cold sweat. In four hours he rallied somewhat, and his face, though pale and anxious, by no means suggested that dissolution was impending, for his man- ner was quite calm, and his gentle consideration for others, which had formed part of his very lovely character, was quite remarkable. His pulse, however, was like a thread, and his surface cold like that of a cholera patient. He said that he had scarcely any pain, and that his great distress was from thirst, which no fluids quenched, though he took water abundantly, and very seldom vomited. He grew colder and colder, his pulse became more and more feeble; now and then he wandered for a moment, but was self-possessed the moment he was spoken to, and the last words he said just before his death, which took place eight hours after the state of collapse came on, were, " Thank you, sir," to one who gave him a draught of water. The death which came so gently, though so quickly, seemed due in this case not to the intensity of the inflammation, but to its extension over the whole of the peritoneum. This, however, does not appear to be the most com- mon issue of the affection, but more generally the mischief remains circumscribed to the neighborhood in which it originated. It did so in the other fatal case to which I have referred, though the irritation extended to the chest, and pleurisy of the right side, which issued in abundant sero-purulent effusion, contributed largely to bring about the death of the child. Sometimes the inflammation subsides, the tenderness abates, the swelling disappears, and convalescence gradu- ally takes place. I believe, however, that unless the mischief be very slight, resolution is a rare occurrence, and that suppuration of the cellular tissue about the caecum, and the formation of an abscess, which points either in the lumbar or the iliac region, is the mode in which recovery is usually effected ; a mode tedious indeed and pain- ful, but one that, judging from one's experience of iliac abscesses in the female sex, one would count on as almost always certain, though slow.1 The indications for treatment, in cases of acute peritonitis, are so clear, that it would be superfluous to occupy much time in laying 1 The papers of Dr. Burne, in vols. xx. and xxii. of the Medico- Chirurgical Trans- actions, still contain the most valuable information of which we are possessed on this subject. 508 CHRONIC PERITONITIS. down rules for your guidance. You have to deal with the active in- flammation of parts in which acute disease cannot go on long without destroying life. Depletion, both general and local, and the employ- ment of mercury, combined with opium or Dover's powder, in order to mitigate the suffering which attends on the disease, are the reme- dies to which you must have recourse, and which you must employ with an unsparing hand. When the abdominal tenderness has been mitigated by bleeding, a warm poultice, frequently renewed, will often afford considerable comfort; and in some cases of local peritonitis I have seen the warm hip-bath give much relief. The error into which you are likely to fall in the management of these cases is not that of pursuing a wrong course, but of following the right one with too little vigor. In the peritonitis that follows scarlatina, the symptoms are often less urgent than in other circumstances; but you will bear in mind, that when the function of the kidneys is disturbed, and urea is circu- lating in the blood, the serous membranes are very apt to become inflamed, and you will, therefore, keep on the look-out for any indica- tion of their suffering. I shall hereafter have to point out to you, that in this, as well as in so many other cases, prevention is not only better, but easier than cure ; and that if on the first appearance of the dropsy consecutive on scarlet fever, you have recourse to active anti- phlogistic measures, you will, in the large majority of cases, escape the risk of these secondary inflammations. The circumscribed inflammation of the peritoneum which is associ- ated with mischief in the caecum or its appendix, calls for very guarded treatment. The tendency of the ailment, even when it ter- minates most favorably, is to run a slow course, and unless you could remove the local irritation in which it originated, it would be idle to expect that you could cut it short by heroic measures. The applica- tion of a few leeches over the caecum, and their repetition once or twice at intervals of two or three days, the sedulous employment of a warm poultice, and the administration of small doses of calomel with opium or Dover's powder, while the bowels are kept regular by castor oil, and the diet consists entirely of milk and farinaceous substances, constitute all that we can venture on during the active stage of the inflammation. When that has passed, and the abiding swelling, hard, and tense, and tender, remains behind, indicating that the inflammation has ended in the formation of matter, the support of the patient's strength, the employment of bark, the use of wine and animal broths (though still we must be most careful in allowing solid food), are no less indicated; while, even at the best, we must not look for the speedy approach of the matter to the surface, or expect other than a very tedious conva- lescence. Acute peritonitis, indeed, in all its forms, like the acute inflamma- tion of any other tissue, may subside but not altogether oease; it may pass into a chronic state, and the patient may still suffer from the consequences of the disease long after the disease in its original form has disappeared. But it is not to an affection of this kind that I wish to call your notice in speaking of chronic peritonitis; but to a dis- MORBID APPEARANCES OF TUBERCULAR PERITONITIS. 509 ease, the progress of which is slow from its commencement, which is weeks or months in running its course, but which yet demands your closest attention, since in a very large number of cases that course is to a fatal issue. It is not, however, its tardy progress which alone distinguishes the chronic from the acute inflammation of the peritoneum, but the former is almost invariably associated with the tuberculous cachexia, and, indeed, generally succeeds to the deposit of tubercle upon the serous membrane of the abdomen. The occasional recovery of a child in whom the symptoms of chronic peritonitis have existed by no means disproves that connection between it and phthisical disease, of which dissection in fatal cases affords such convincing proof. The bodies of children who have died of this affection are usually found to be exceedingly emaciated; and their face retains after death the suffering expression which it had worn during their protracted illness. The lungs and bronchial glands contain tubercle in greater or less abundance, and the pulmonary disease is sometimes so far advanced as to have obviously had no small share in bringing about the fatal event. On dividing the abdominal parietes, long, slender, cellular adhesions are often found connecting the peritoneum to the subjacent viscera; while in other instances the peritoneum and intestines are agglutinated together, so as to render it difficult thoroughly to expose the abdominal cavity. The intestines, too, are closely connected by adhesions, some of which are very easily broken down, while others are so firm that the coats of the bowels give way in the attempt to separate them. This difference does not depend on the age of the adhesions (although in this respect they vary greatly, some being ap- parently of very recent date, others of long standing) so much as on their nature. Those connections which are formed by the mere effu- sion of lymph, even when from age they have acquired considerable firmness, can generally be broken down without much difficulty ; and, at any rate, the attempt will not produce rupture of the intestines. When, however, different portions of the bowel are matted together so inseparably that it is easier to lacerate than to detach them from each other, it will be found that something more than the mere effusion of lymph has produced this union. It will be seen to have been effected by means of a yellow, granular matter, like that which connects tbe op- posite surfaces of the arachnoid in a case of tubercular hydrocephalus, and made up, like it, in part of lymph, in part of tubercular deposits. Adhesions are thus formed between the opposite surfaces of the peri- toneum, at first of small extent, but fresh deposits of tubercle soon take place in the vicinity, and the attendant inflammatory process unites together a still greater extent of intestine. Nor is this all; but, in time, the tubercle thus deposited undergoes a process of softening, in the course of which the muscular tissue of the intestines becomes destroyed, and their mucous membrane may thus eventually be perfo- rated, so that distant parts of the intestinal canal, which at first were merely adherent together, are sometimes brought by this means into direct communication with each other. The abdomen generally con- tains a small quantity of transparent serum; but if, as sometimes 510 SYMPTOMS OF TUBERCULAR PERITONITIS. happens, life should have been cut short by the supervention of acute peritonitis upon the old disease, the effusion may be of a puriform or sero-purulent character; though this is seldom abundant. In addition to the evidences of inflammatory action presented by the peritoneum, that membrane and the various abdominal viscera are the seat of a more or less generally diffused tubercular deposit. In some instances the peritoneum lining the abdominal walls is greatly thickened and abundantly beset with small, gray, semi-transparent granulations, or even with yellow tubercle, usually in the miliary form, though sometimes small distinct patches of tubercle are inter- spersed. In the majority of cases, however, the affection of the parietal peritoneum is less considerable, and almost invariably the deposit on it is greatly exceeded by that on other parts of the membrane. That part of the peritoneum which lines the diaphragm, or the abdominal walls in the immediate vicinity of the spleen, is one of the favorite seats of tubercular deposit, which in these situations generally puts on the form of small, yellow, miliary tubercles, not that of gray granula- tions. In some instances the omentum is the seat of the chief tuber- cular deposit; and though it usually assumes the miliary form, yet now and then masses of crude tubercle of considerable size are met with in, this situation. The peritoneum covering the liver and spleen seldom fails to show an abundant deposit of tubercle; and tubercles usually abound in the substance of the latter organ. The mesenteric glands likewise are tuberculous, though the degree of their degenera- tion, and the size which they have in consequence attained, vary much in different cases. The same remark holds good with reference to the amount of tubercular disease in the interior of the intestines, which, though in some cases very considerable, yet is not so in by any means the majority of instances, while it bears no invariable relation either to the degree of the affection of the peritoneum, or to that of the me- senteric glands. Perforation of the intestines, too, is produced in these cases from without inwards, not by destruction of the coats of the bowel by a tubercular ulceration on its interior. In cases of this affection, those vague indications of decaying health which characterize the early stages of the tuberculous cachexia often precede any symptom of special disorder of the abdominal viscera. But this is not always the case; for in some instances the child begins, without any previous indisposition, to complain of occasional pains in the abdomen, which last but for a moment, and which causes the less anxiety from the appetite being good, the bowels regular, and the general cheerfulness undisturbed. In the course of a short time, however, the appetite fails, or becomes capricious; the bowels begin to act irregularly, being alternately constipated and relaxed; while the motions, always abundant, are usually unnatural in character— dark, loose, and slimy. The child now grows restless and feverish at night, its thirst is considerable, and the abdominal pain becomes both more severe and more frequent in its recurrence. Sometimes the sto- mach grows very irritable, and food taken is occasionally vomited; but this symptom is often absent; while the tongue, throughout the early stages of the affection, continues for the most part clean and COURSE OF TUBERCULAR PERITONITIS. 511 moist, and deviates but little from its appearance in health. The symptoms just enumerated seldom continue long without being ac- companied with a marked change in the size of the abdomen; and sometimes the alteration in the abdomen takes place rather suddenly, and is one of the earliest signs of the affection from which the child is suffering. The abdomen becomes large, tense, and tympanitic, while its parietes often seem glued to the subjacent viscera; and that mani- pulation which causes no discomfort, even when practised somewhat roughly on the big abdomen of a rickety child, is sure to occasion uneasiness, often even considerable pain, when tried with ever so much gentleness in the child suffering from chronic peritonitis. In this, as in other forms of tubercular disease, the progress from bad to worse seldom goes on uninterruptedly. Pauses take place in its course, though each time they become shorter; and signs of amend- ment now and then appear—but they, too, promise less and less with each return. The child loses flesh; the face grows pale, and sallow, and anxious; the skin becomes habitually dry, and hotter than natural, and the pulse is permanently accelerated. The abdomen does not grow progressively larger; often, indeed, it shrinks in the more advanced stages of the disease, and at the same time it becomes more and more tense, although this tension varies without any evident cause, and sometimes disappears for a day or two, to return again as causelessly as it disappeared. When the tension is diminished, the abdomen yields a solid and doughy sensation, and the union between the con- tents of the abdomen and the abdominal walls becomes very percep- tible. In many cases, too, a vague sense of fluctuation may be detected in the hypogastric region, which seems more distinct at one time than at another, is never as marked as is the fluctuation in cases of ascites, and is doubtless due, as suggested by MM. Rilliet and Barthez,1 to the transmission of the shock by the agglutinated mass of intestines from one side of the abdomen to the other. The superficial abdominal veins now become enlarged in many instances, and the skin grows rough, desquamates, and looks as if it were dirty. The pain in the bowels retains the same colicky character as before, but it returns very frequently, and is sometimes exceedingly severe, while the child is never free from a sense of uneasiness. The tenderness of the abdo- men, however, but seldom increases in proportion to the increase of pain. The bowels are in general habitually relaxed, though the degree of the diarrhoea, as well as the severity of the abdominal pain, vary much in different cases. As the disease advances, the child becomes confined to bed, and is at length reduced to a state of extreme weakness and emaciation. Death is often hastened by the concomitant affections of the lungs, or, more rarely by the occurrence of tubercular hydrocephalus; but should this not be tbe case, the patient may con- tinue for many weeks in the same condition, till life is destroyed, after a day or two of increased suffering, by some renewed attack of peri- toneal inflammation, or till, in other instances, the child sinks, almost painlessly, from sheer exhaustion. 1 Op. cit., tome iii. p. 784. 512 TABES MESENTERICA—A RARE AFFECTION: Such, now, is the ordinary course of tubercular peritonitis; but, just as it would not be possible to draw a picture of pulmonary phthi- sis which should represent with perfect accuracy every case of the disease, so it is with our attempt to delineate the features of this malady. Its main diversities, of which the differences in the appear- ances found after death are far from affording a satisfactory explana- tion, consist in the various degrees in which pain is experienced, in the rapidity in the course of the affection, and in the alternation of constipation with diarrhoea, or sometimes in the complete substitution of the one condition for the other. One form of tubercular peritonitis, in which its early stages are very likely to be unnoticed, is that which it assumes when it supervenes upon one of the eruptive fevers, usu- ally upon measles. The diarrhoea, the feverishness, the loss of flesh are regarded merely as attendants upon a tardy convalescence. The abdominal pain, probably by no means severe, is supposed to be of little moment; and the abiding tenderness is altogether overlooked. The chief safeguard against this error is found in our being fully alive to the possibility of the danger, and in the most sedulous watching of every child whose convalescence is tedious. Another class of symp- toms which should excite our suspicion are those which are sometimes presented by children who, having suffered from dyspepsia, become liable to occasional attacks of colic and constipation, the severity of the pain being out of proportion to the duration of the previous con- stipation, the effect of purgatives in inducing action of the bowels being uncertain, and the relief which follows their operation neither immediate nor complete. Lastly, the disease is sometimes observed attended by scarcely any pain; the child grows pale and thin, and has occasional diarrhoea, but makes no complaint of pain, or at most of nothing beyond a sense of stuffing and fulness of the belly; but ema- ciation goes on, perhaps, rapidly; the diarrhoea becomes habitual, and medicine loses much of its control over it; the strength fails, and the little one dies, worn out and weary, but quietly and without pain. It would be easy, but I do not think it necessary, to relate a history illustrative of each of these varieties of the disease. They would each point to the same moral—that, under all modifications of symptoms, when a child loses flesh, and has in conjunction with that emaciation, abiding, even though but slight, tenderness of the abdomen on pres- sure, you are to suspect the existence of tubercular peritonitis. Some of you have probably been struck by the many points of re- semblance between the symptoms that have just been described and those which are often enumerated as characteristic of mesenteric dis- ease. Nor is it at all surprising that a very close analogy should subsist between chronic peritonitis and tabes mesenterica, since not only are both affections the results of the tubercular cachexia, but in both the abdominal viscera are chiefly involved in the disease, and both are in consequence characterized by a remarkable impairment of the func- tions of nutrition. It was natural, too, that in former times, when morbid anatomy was less carefully cultivated than at present, the attention of the observer should have been chiefly drawn to the in- creased size and altered structure of the mesenteric glands—appear- ^ ITS SYMPTOMS. 513 ances which must have been often discovered on an examination of the bodies of children who had died after a slow wasting of their flesh, attended with more or less enlargement of the abdomen and disturb- ance of the bowels. The physiology of those days, too, knew of no means whereby the absorption of the chyle could be effected except through the medium of the mesenteric glands; and the coarse appli- ances which then subserved the purposes of anatomical investigation did not suffice to show that, even when these glands outwardly pre- • sent a considerable degree of tuberculization, their lymphatics in many instances are still pervious. We know that the nutrition of children is often much impaired from other causes besides tubercular disease, and that, when the diges- tive organs perform their functions ill, nothing is more common than for the abdomen greatly to exceed its natural size. Our predecessors had observed similar facts; but, owing to the imperfection of their physiological knowledge, they drew from them erroneous conclusions. Disease of the mesenteric glands was in their eyes the almost exclu- sive cause of the atrophy of children; and a preternatural enlarge- ment of the belly was looked upon by them as an almost infallible sign that such disease had already begun. Tabes mesenterica was consequently regarded as a very common affection; and, though its frequency is now well known to have been much overrated, yet the appearance of those symptoms that were once supposed to be charac- teristic of it still excites much needless alarm among non-professional persons. The mere presence of tubercle in the mesentery is, it must be owned, of very common occurrence, since MM. Rilliet and Barthez met with it in nearly half of all children in whom that morbid deposit existed in some or other of the viscera. But though the existence of tubercle in the glands be thus frequent, its presence in any considerable quan- tity is extremely rare, since, according to the same authorities, it was found in abundance only in one out of every sixteen children, some of whose organs contained tubercle. The general character of tuberculous mesenteric glands is much the same with that of tuberculous bronchial gland, but the former are usually surrounded by a more delicate cyst; and although their size seldom exceeds that of a chestnut, yet they occasionally undergo a degree of development which far exceeds that of tuberculous bronchial glands, and three or four of them coalescing together, sometimes form a mass as big as the fist, or even bigger. The effects produced even by an advanced degree of tuberculization of the mesenteric glands are smaller than might be anticipated, and much smaller than those which result from a considerably less amount of disease of the bronchial glands. Nor will this at all surprise us, if we bear in mind the difference between their anatomical relations. The bronchial glands are not merely situated in a cavity which is bounded by comparatively unyielding parietes, but the viscera with which they are in contact are solid and resisting, and they are, more- over, adherent to the trachea and the larger air-tubes, so that any in- crease of their size is sure to produce compression of parts whose v-^_ 33 514 TREATMENT OF TUBERCULAR PERITONITIS functions are of vital importance. The mesenteric glands, on the contrary, are contained in a cavity whose yielding walls allow them to increase readily in size, while the loose attachments of the mesentery still further permit them to attain even to considerable dimensions, without pressing upon any viscus; so that it is an exceedingly unusual occurrence for them to cause the perforation of any part of the intes- tines, or even for them to contract adhesions to their exterior. To these causes it must be attributed that there is no symptom pathognomonic of tubercle of the mesenteric glands, except their being perceptible through the abdominal parietes. This, however, they never are during the early stage of the affection; and though on one or two occasions I have felt a tumor in the abdomen, which, from its being associated with the evidence of tuberculous disease in other organs, I have been led to attribute to the enlarged mesenteric glands, yet in these cases I have not had the opportunity of confirming the diagnosis by an examination after death. There can, however, be no doubt but that they do sometimes become perceptible through the abdominal walls, though at a season when, their cure being hopeless, little practical use can be made of the certainty of our diagnosis. In its earlier stages no symptoms at all are present, or only the indica- tions of that general tuberculous disease of which the affection of the mesentery is usually but a subordinate part. At a later period, when the disorder of the digestive organs attracts attention, the symptoms are generally much the same with those of chronic peritonitis, save that, if the peritoneum be free from disease, the abdomen is in most cases both less tense and less tender. I the less regret that so little time remains for the consideration of the treatment of chronic peritonitis and of tabes mesenterica, since the subject may be dismissed in a few words. In each of these affections two periods may be distinguished. During the first, while our diag- nosis is still uncertain, general principles guide our conduct, and lead us to subject the child to the same dietetic and hygienic management as we should adopt if we feared the approach of any other form of phthisis. In the second, the advancing mischief has removed all doubt from our minds, but at the same time has chased almost all hope from our spirits; and we now minister to symptoms as they arise, and try to mitigate sufferings which we can seldom cure. The dyspeptic symptoms, the unhealthy appearance of the evacua- tions, and the frequency with which diarrhoea occurs, enforce the necessity for the diet being as mild and unstimulating as possible. The abdominal pain which is experienced in tubercular peritonitis is almost always relieved by the application of a few leeches; but even local depletion must not be practised without absolute necessity; and in many instances a large poultice to the abdomen, frequently re- newed, will remove pain, the severity of which at first seemed to call for the abstraction of blood. Now and then, however, symptoms of acute peritonitis come on in children who have manifested previously unmistakable signs of tubercular disease, and nevertheless yield to free local depletion, and the administration of mercury. I would therefore advise you not to allow any notion, how well founded soever, AND TABES MESENTERICA. 515 of the probable connection of the symptoms with tubercular disease, to betray you during the presence of acute symptoms into an inert course of treatment; nor, I may add, into the too positive expression of a gloomy prognosis. Still, these are exceptional cases; and our treatment in the majority of instances is confined to relieving the more urgent symptoms. Next in importance to the pain, or sometimes even more important, is the diarrhoea, which we must try by all means to keep in check; and for this purpose few astringents are better than the logwood and catechu mixture mentioned in the last lecture. Sul- phate of irou and opium, in the form either of pills or mixture, may be given if the diarrhoea be very obstinate, though we may be com- pelled to abandon their use, from finding that they add to the fever, and thus aggravate the patient's illness; but I have not observed the mere suppression of the diarrhoea by astringents to be followed by any exacerbation of the other abdominal symptoms. Astringents, how- ever, are far from being the only remedies to be employed; but mer- curials in a mild form, and continued for a long period, have often seemed to be of much service. When the tenderness of the abdomen has been sufficiently relieved to admit of it, I generally direct the use of a liniment twice a day, consisting of the linimentum hydrargyri, soap liniment, and olive oil, in equal parts, which has seemed useful as a counter-irritant even independent of the mercury which enters into its composition. It is generally better to apply the liniment by soaking a piece of lint in it twice a day and spreading it over the abdomen; covering it with oiled silk; or if the pain be considerable an ointment of two drachms of the extract of belladonna, and six drachms of mercurial ointment may be applied in the same manner, and often with much benefit. Besides this I usually give equal parts of the hydr. c. cretil and Dover's powder once or twice a day. The Dover's powder prevents the mercurial from irritating the bowels, and also allays the restlessness and feverishness at night—an end to which the use of the tepid bath every evening likewise conduces, often in an eminent degree. The comfort of the child is frequently much pro- moted by wearing a well-adapted flannel bandage over the abdomen both by night as well as by day; and the support this affords may be increased with advantage by a piece of thin whalebone at either side. If diarrhoea be absent, or if, though it be present in a slight degree, the skin be very hot and dry, and the child very thirsty and feverish, the tepid bath, the mercurial with Dover's powder, and small doses of liquor potassae and ipecacuanha, are the remedies on which I chiefly rely; and to these the extract of dandelion may often be added with advantage. If it seem likely that a mild tonic will be borne, a mix- ture containing the extract of dandelion, extract of sarsaparilla, and sesquicarbonate of soda,1 may be given; or the liquor cinchonae or the • (No. 35.) I£.—Extracti taraxaci 3ij- Sodae sesquicarbonatis 3j. Extr. sarzae $iv. Syr. aurantii ^iv. Decoct, sarzae co. gv.—M. ,^vj ter die e lacte. For a child four years old. 516 INTESTINAL WORMS. infusion of calumba may be employed for the same purpose; or the combination of the bichloride of mercury with bark, which I recom- mended a short time ago.1 It is only with much caution that we can administer chalybeates in these cases, and after having found that the milder vegetable tonics are well borne. The ferrocitrate of quinine, or the citrate of iron, are the preparations which it will generally be desirable to employ in the first instance; and even their effect should be watched attentively. When well borne, the cod-liver oil is, I think, more useful in this than in any other form of the tuberculous cachexia in early life. The cases in which it causes nausea or diarrhoea are comparatively few, and its effects in fattening children who were greatly emaciated are sometimes very remarkable. In conclusion, I need hardly mention the importance of change of air, and the benefits likely to result from a sojourn on the sea-coast; for you know how much more powerful nature's remedies are in diseases of this kind than the remedies of man's devising. LECTURE XXXIX. Intestinal Worms—their varieties, symptoms, and treatment. Diseases of the Urinary Organs.—Inflammation of the kidneys.—Albuminous ne- phritis—generally follows one of the eruptive fevers, oftenest scarlatina—its symp- toms—modes in which it proves fatal—condition of the urine—appearances after death—essential nature of the changes in the kidneys.—Treatment. Calculous disorders—frequent in early life—deposits in the urine in childhood almost always consist of the lithates.—Other causes of dysuria besides gravel and cal- culus.—Treatment of dysuria in early life.—Lithic acid deposits connected with chronic rheumatism in children—symptoms of ill health associated with them— importance of not overlooking them. Diabetes—true saccharine diabetes very rare in early life—simple diuresis less un- common—symptoms of disordered health that attend both affections.—Treatment. Incontinence of urine—circumstances in which it occurs.—Treatment. Our study of the diseases of the digestive organs would be incom- plete if we took no notice of those parasitic animals which frequently inhabit the alimentary canal in children. It will not, indeed, be neces- sary to say much respecting them; for we know that the older medical writers greatly overrated their frequency and importance, when they saw the proofs of their existence in almost every variety of gastric and intestinal disorder, and even commonly attributed to their presence many forms of serious disturbance of the nervous system. Still, they are in many instances the occasion of considerable discomfort; they often aggravate, or even give rise to, disorder of the digestive organs, while the irritation excited by their presence being propagated to the 1 See Formula 28, p. 469. SYMPTOMS OF INTESTINAL WORMS. 517 spinal cord, sometimes produces convulsions or other formidable nerv- ous symptoms. Although intestinal worms axe much more common in early life than in adult age, yet no species of them is peculiar to the child, but they belong to one or other of the five sorts ordinarily met with in the grown person.1 The ascaris vermicularis, or small threadworm, which lives princi- pally in the rectum, is by far the most common of all these entozoa, and is very troublesome, from the local irritation which it excites. The long threadworm, the tricocephalus dispar, appears much less fre- quently in the evacuations: it inhabits the upper end of the large intestines, and in some cases coexists with the presence of ascarides in the rectum. When it is present alone, I am not aware that it gives rise to any unpleasant symptoms. The ascaris lumbricoides, or round worm, is of much less common occurrence than the small threadworm, though observed more frequently than the tricocephalus: it dwells in the small intestines, and sometimes, entering the stomach, is rejected by vomiting. Occasionally only one of these worms is present, and though there are oftener several, yet it is but seldom that they exist in the child in very considerable numbers. The tapeworm, of which there are two kinds, the taenia solium and taenia lata, is much the rarest of these entozoa in early life, and is seldom met with in children under seven years of age, though once or twice I have known it to exist in infants who were still in part nourished at the breast; and I appre- hend it is altogether more frequent in early life in this country than in France,2 or at least than in Paris. Various symptoms have been said to indicate the presence of worms in the intestines, but most of them are of small value; and nothing short of actually seeing the worms can be regarded as affording con- clusive evidence of their existence. No one who is at all familiar with the disorders of early life will be disposed to attach much weight to symptoms such as the altered hue of the face, the appearance of a livid circle around the eyes, the loss of appetite, or its becoming irregular or capricious. Many causes besides the presence of worms give rise to a tumid state of the abdomen, to colicky pains, and to occasional sickness and vomiting; and itching of the nose or anus, though often present when the intestinal canal is infested with worms, yet is some- times the occasion of much annoyance independently of their exist- ence. An irregular or intermittent pulse, widely dilated pupils, occa- sional drowsiness, with uneasy rest at night, and starting during sleep, 1 The work of Dr. Kiichenmeister, Die Parasiten, etc. 8vo., Leipsig, 1855, contains the fullest details concerning the anatomy and physiology of intestinal worms, and particularly all those ingenious observations by which the development of the taenia from the cysticercus cellulosee has been established. Its translation by the Sydenham Society has rendered the book accessible to all readers. i MM. Rilliet and Barthez, op. cit., 2d ed. vol. iii. p. 862, pass over tapeworm with- out notice, on account of its extreme rarity in early life. At Geneva, however, M. Rilliet states that he has seen it several times, even in an infant of fifteen months, while, though I have kept no exact account of the instances of it which have come under my notice, the occurrence of tapeworm in children from five to ten years old is far from having been extremely uncommon. 518 CONVULSIONS A SYMPTOM OF INTESTINAL WORMS. are evidences of disturbance of the nervous system, but do not specially indicate the presence of worms as the cause of such irritation. The small threadworms, which are of all the most frequent, pro- duce a most distressing itching and irritation about the anus, which always become more troublesome at night than they are in the day- time, and frequently prevent the child for hours from getting to sleep. Sometimes, too, they give rise to a troublesome diarrhoea, attended with considerable tenesmus, while in female children they occasionally creep up the vulva, and not merely cause much irritation there, but excite a leucorrhceal discharge, which ceases on their expulsion. The round worms often give no evidence at all of their presence, so long as they are but few in number, and as the child affected by them is otherwise healthy ; the discharge of a lumbricus by stool, or its expulsion by vomiting, being often the first indication of their ex- istence. The common opinion, indeed, which associates inordinate appetite with the presence of lumbrici, is probably not devoid of truth, since these creatures appear to live on the contents of the in- testines, not, as the tapeworm does, on the juices of the living struc- tures themselves. The more marked symptoms of gastro-intestinal disorder are dependent either on the presence of a great number of these parasites (an occurrence which seems to be far rarer in this country than in many parts of the continent, especially in Italy), or on some circumstance exciting in them an unusual restlessness, and causing them to wander from one part of the intestines to another. According to the excitability of the patient, and according also to the course taken by the worm, the symptoms thus produced will be more or less formidable. The diarrhoea that sometimes attends the expul- sion of lumbrici, is of all the accidents the least serious, or rather it is by tbe supervention of diarrhoea, or its artificial induction, that these intruders are most frequently got rid of. Much discomfort often pre- cedes their expulsion by vomiting, though sometimes I have known a worm to be rejected almost without warning, and with very little difficulty or annoyance. Strange instances, indeed, are on record of these worms getting into the oesophagus, and thence passing out by the nostrils; and of death being produced by their entering the larynx; but such are wholly exceptional accidents, from which no inference can be deduced as to the ordinary consequences of their presence. Violent convulsions, and other cerebral symptoms, are alleged to be more frequently produced by the presence of lumbrici than of any other varieties of these entozoa. It chances, however, that the most formidable convulsions which I ever observed to be ex- cited by worms, were due to the presence of an immense number of small threadworms, and ceased immediately on their expulsion. M. Legendre,1 too, has called attention to the great frequency of symp- toms of disorder of the nervous system in connection with the pre- 1 Sur les symptomes nerveux que determine le Taenia—tire des Archives de Medecine, 1850, and a second paper in the Archives for December, 1854. In this latter paper he gives the particulars of several cases of convulsions in children from the presence of taenia, and has collected statistics to show that the rarity of this worm in early life has been somewhat exaggerated. TREATMENT OF INTESTINAL WORMS. 519 sence of tapeworm ; " such symptoms having been present in 20 out of 33 cases. They consisted, in twelve instances, of more or less fre- quently repeated convulsive seizures, which eight times assumed the character of epilepsy, four times of hysteria ; while on eight occasions the convulsive movements were partial, and affected either the face or one of the limbs." It would seem, then, that the presence of worms of any kind, just like any other source of irritation, may excite convulsions, or may disturb in other ways the functions of the nervous system. In the symptoms themselves, there does not seem to be anything which could enable us at once to distinguish between convulsions produced by the presence of worms and those dependent on some other cause. In most instances, however, it will be found that the child has passed worms frequently before the cerebral symptoms made their appear- ance, while the absence of any other adequate cause for their occur- rence, should at once direct our attention to the possibility of their arising from this source; and an examination of tbe evacuations will seldom fail to discover evidence to justify our suspicions. The symptoms of taenia are not pathognomonic of that peculiar form of entozoon, but are common to it and to the lumbrici, with the exception, perhaps, that tapeworm is apt to produce a more decided impairment of the general health, and that from the difficulty in ob- taining its complete expulsion its symptoms are usually more per- sistent. When once, however, our suspicions are excited, we are seldom long without receiving complete confirmation of them in the appearance of joints of the worm intermingled with the evacuations, since, when the creature has attained to maturity, the spontaneous detachment of portions of it from time to time is a purely physiologi- cal occurrence. The different varieties of worms are not to be got rid of by the same treatment; nor is the cure of all equally easily effected. In- ternal remedies are of comparatively little use against the small threadworm, though their destruction is by no means difficult if they are attacked by enemata in the lower bowel which they chiefly inha- bit. Enemata of lime-water usually answer for this purpose extremely well, or if the ascarides are very numerous, or have been frequently reproduced, the remedy may be made more efficacious by the addition to six ounces of lime-water of two drachms of the tincture of sesqui- chloride of iron. Kuchenmeister, to whose elaborate treatise on bel- minthology I have already referred, speaks of having employed santonine in an enema in the proportion of from four to eight grains; but I have no experience of its employment in this manner. He fur- ther gives a hint as to the expediency in cases which are at all obsti- nate of introducing a long elastic tube, in order that the fluids injected may reach such of these creatures as have travelled high up beyond the sigmoid flexure of the colon. Though I have never employed santonine in an enema, I. have in obstinate cases given two or three grains of it at night, for two or three nights, following it in the morn- ing by an aperient, with decided advantage; while, when once tbe threadworms have been got rid of, the use of preparations of iron is 520 TREATMENT OF INTESTINAL WORMS. often of much service in preventing their fresh development. Iron in these circumstances acts, I believe, not merely as a tonic, but also, by its admixture with the secretions, it renders the intestinal mucous membrane unsuitable to serve as a nidus for the reproduction of the worms. A vast number of remedies have been employed for the cure of the round worm and tapeworm, some of which are mere drastic purgatives, and act by dislodging the worms, while others exercise a directly poisonous influence on them, and destroy as well as expel them. In the treatment of taenia, remedies of the latter class are absolutely necessary, since, unless the head of the creature be de- tached from its hold on the intestinal mucous membrane, no permanent cure is effected, and .the detached joints are speedily reproduced. Mere mechanical irritants, such as tin filings, appear, according to Dr. Kuchenmeister's researches, to be absolutely useless as far as the destruction of worms is concerned, though by no means without a mischievous influence on the coats of the intestines. For the round worm, a very efficacious proceeding, and one which has the advantage of not distressing the child, consists in giving a small dose of santonine, as two or three grains for a patient six years old, over night, and a full dose of castor oil the next morning, and repeating this two or three times in succession, and I have never myself seen from the use of santonine any of the unpleasant symptoms which some persons have experienced from its employment. I have not satisfied myself that santonine exercises any very de- cided influence upon tapeworm ; for the cure of which, as well as of lumbrici, when the persistence of thp symptoms leads to the suspicion that they have not all been got rid of, the kousso, the oil of male fern, or the kamella, is far more effectual. For the success of any of these remedies against tapeworm it is, however, very necessary that the intestines should be previously well emptied of their contents. This is best accomplished by giving a dose of castor oil some three hours after an early dinner, and afterwards allowing the child only a small cupful of milk during the remainder of the day; the vermifuge being given on the following morning fasting. The great bulk of the kousso almost excludes it from use when our patients are children, and it may be added that Kuchenmeister's investigations seem to show that it is actually inferior in efficacy to several other anthelmintics. I believe turpentine to be a very efficacious remedy, but the violent effects which it sometimes produces, as well as the temporary intoxi- cation which follows its administration in a large dose, have withheld me from giving it to children. Still, it is to be borne in mind as a most energetic vermifuge; while the unpleasant symptoms that follow it are not dangerous, and soon pass away, especially if the turpentine be given with an equal quantity of castor oil. The oil of male fern has proved itself more efficacious in my hands than any other medi- cine incases of taenia; and at present my judgment is suspended between its merits and those of the recently introduced vermifuge, the kamella, of which I have made several trials, though not in suffi- cient numbers to decide accurately on its value. I have almost com- ALBUMINOUS NEPHRITIS. 521 pletely abandoned the use of the pomegranate bark, in spite of the strong evidence borne to its utility,1 in consequence of the bulk of the decoction, which I have found it impossible to induce children to take in sufficient quantity, and sufficiently often repeated to be of much service. Kuchenmeister, however, speaks of a watery extract which is prepared in India, and which possesses great efficacy; but of this I have at present had no experience. Closely connected with the disorders of the digestive organs are those affections to which the urinary apparatus is liable. Unfortunately, special difficulties attend their investigation in early life, and hence the information which it is in my power to give you with reference to these diseases is less complete than I could have desired. Nephritis, or acute inflammation of the substance of the kidney, is exceedingly rare, as an idiopathic affection, in early life. MM. Rilliet and Barthez2 decline attempting to give any description of its symp- toms, on account of the very few instances of it that have come under their observation, although they refer to some cases in which the con- gested, swollen, and indurated state of the kidneys after death seemed to indicate that those organs had been the seat of acute inflammatory action. M. Rayer3 relates an instance or two where the presence of purulent deposits in the kidneys of infants a few days old gave posi- tive evidence of their inflammation ; but no symptoms observed during the lifetime of these children had called attention to their urinary organs. He mentions it, moreover, as a disease of very unusual occurrence in early life, and adds, that though he has seen cystitis follow the application of a blister in early life, yet in these cases there was no sign of the irritation having extended to the kidneys. Rare, however, though general inflammation of the kidneys may be, there is one form of inflammatory disease of those organs which is frequent in its occurrence, and which we have of late years learned to look upon as the almost invariable attendant, and as the probable cause, of acute dropsy, in whatever variety of circumstances it may supervene. The advance of knowledge, indeed, is every year sug- gesting fresh doubts and difficulties with reference to this albuminous nephritis (as it is termed, from the invariable presence of albumen in the urine whenever this disease exists), and there seem to be reasons for believing that the presence of this abnormal element in the urine by no means constantly implies that disease of the kidney itself has been the first in the train of morbid processes, but that it may be due to very slight, temporary, and secondary functional disorders of those organs. The frequent presence of albumen in the urine during the course of typhus fever, its occasional existence even in typhoid fever and in measles, render it in the highest degree probable that in those diseases, and in scarlet fever also, the presence of albumen in the urine may be primarily dependent on some altered condition of the circu- lating fluid, and not be in the first instance attributable to, nor even 1 See paper by Mr. Breton, in Med.-Chir. Trans., vol. xi. p. 301; and Kuchenmeister, op. cit., p. 122. * Op. cit., 2d ed. chap. xvii. p. 33. * Traite des Maladies des Reins, 8vo. vol. i. p. 417. Paris, 1839. 522 ALBUMINOUS NEPHRITIS FOLLOWS SCARLATINA. of necessity associated with, disease of the kidney. Anatomical in- vestigation, too, has brought to light various forms of kidney disease, all of which may be associated with the presence of albumen in the urine, and has proved almost beyond a question that the chronic form of disease which may be discovered in the scrofulous child, or which may exist in the old drunkard, is not of necessity—is probably not in general—an advanced stage of the same disease as gives rise to albu- minous urine after exposure to cold, or as is usually associated with it during the convalescence from scarlet fever. I believe, however, that in spite of all the changes in opinion with reference to disease of the kidney which recent investigation has brought with it, there is no more fitting place than the present to treat of that acute anasarca which is attended by albuminous urine, nor any term more appropriate than that of albuminous nephritis, by which to designate that state of the kidney which generally, if not invariably, accompanies and produces it. The greater number of cases of this disease which have come under my notice in children occurred during convalescence from scarlatina, though I have met with it both after measles and after typhoid fever. Now and then, too, I have seen acute idiopathic dropsy succeed to exposure to cold or wet in the child just as it does in the adult. There is also a chronic form of the disease observed in cases of general tuber- culosis, but in them the amount of anasarca is usually inconsiderable, while the intimate structural changes in the kidney are probably dif- ferent from those which take place in its acute forms. I know of no statistical data such as would enable us to estimate with accuracy the proportion of cases of scarlet fever in which drop- sical symptoms supervene, or to determine the precise relation which subsists between the severity of the disease, or the abundance of the rash, and tbe liability to dropsy afterwards. The usual statement, that it is rare after severe scarlet fever, and frequent after cases of the disease in a mild form, is, I believe, correct; but my impression is, that in other respects there is no constant relation between the charac- ters of the disease and liability to dropsy or immunity from its occur- rence. It is an accident, rare in some epidemics of scarlet fever, frequent in others; and its fatality is liable to at least as great varia- tion as its frequency; for it appears that while in the first quarter of 1848 only 7 per cent, of the mortality of scarlatina was owing to the consecutive dropsy, 20 per cent, of the deaths from scarlet fever in the last quarter of the same year were due to that cause.1 That cold and interruption of the cutaneous function favor the oc- currence of dropsy after scarlatina, is a fact supported by universal testimony ; and that the maintenance of the functions of the skin, and the securing an unvarying temperature about the patient during con- valescence from the fever, will almost certainly prevent it, is also abundantly proved. The early adoption of a stimulating plan of diet 1 As deduced from data in the Registrar-General's Office, by Dr. Tripe, whose papers on Scarlatinal Dropsy, in the British and Foreign Medico-Chirurgical Review for Janu- ary and July, 1854, are models for inquiries of this kind in laborious research, lucid arrangement, and cautious inference from well-ascertained premises. SYMPTOMS OF ALBUMINOUS NEPHRITIS. 523 or treatment during convalescence from scarlet fever is also reputed to have a marked influence in inducing dropsy after it. It must be remembered, however, that injudicious management in this respect seldom goes alone, but is usually associated with carelessness in other points; so that the influence of this cause cannot be exactly estimated. I am, however, quite sure, that the employment of stimulants in such cases of severe scarlatina as appear to indicate their administration, and even the freest use of wine in such circumstances, in no respect increases the risk of dropsical effusion occurring subsequently. The date of appearance of the dropsy is liable to very considerable variation, occurring sometimes within the first week, at other times as late as the end of the third week, or even later. In the great majority of instances, however, its symptoms appear after the end of the first, but before the completion of the second week; while it but seldom happens, if its appearance is delayed till far into the third week, that its symptoms are formidable, or that its course is acute. It sometimes sets in with considerable febrile disturbance, but even then has a great tendency to assume a chronic character, while in by far the majority of cases its attack is gradual, and its advance is slow. In these circumstances, the child who had passed through the fever perhaps with less than the average amount of suffering, and who for a day or two had seemed rapidly advancing to convalescence, begins to droop, grows languid, feverish, and restless. The skin becomes dry and hot; the process of desquamation is arrested while still in- complete; the appetite is lost, though the thirst is often considerable; the bowels become constipated and the urine diminished in quantity, although.the desire for voiding it is very frequent. After these signs of interrupted convalescence have continued for two or three days, or even longer, the face becomes slightly swollen, a puffiness appear- ing about the eyelids in the morning, which probably disappears later in the day; so that in many instances the attention of the parents is not particularly directed to the child's condition until oedema has ex- tended to the hands and feet. The degree of anasarca varies much in different cases, and likewise fluctuates at different periods in the same patient. Usually, though by no means invariably, there is a distinct relation between the degree of swelling and the severity of the gene- ral symptoms; and few cases terminate fatally in which there is not considerable serous effusion into the different cavities of the body. In very mild cases the febrile disturbance is inconsiderable, the anasarca slight, and confined to the face; and after a few days of poorliness the kidneys resume their proper functions, the anasarca disappears, and the child's health returns. In severe cases the symptoms exist for a longer time; the swelling extends to the cellular tissue of most parts of the body, the secretion of urine is extremely scanty, and sometimes, though certainly in the smaller number of instances, there are com- plaints of pain in the back, or more frequently of tenderness on pres- sure in the lumbar region. The danger of the affection, however, depends almost entirely on its complications; for if they do not destroy the patient, amendment generally becomes apparent in the course of a week or ten days, the urine gradually increasing in quan- 524 MODES OF DEATH FROM ALBUMINOUS NEPHRITIS. tity and becoming less albuminous, the anasarca next diminishing, and the patient regaining health; though in cases where the attack has been severe, traces of albumen often remain in the urine long after all signs of ailment, with the exception of those of simple de- bility, have disappeared. The fatal termination of the disease is due in most instances either to the abundant effusion of fluid into the chest, to the occurrence of pleurisy or pneumonia, or to the supervention of convulsions, such as sometimes occasion death in cases of Bright's disease in the adult. Of these three causes, the first is by far the most frequent, and in thir- teen out of nineteen fatal cases of which I have a record, was the chief, often the sole cause of death. One child died of convulsions, which left, however, no trace behind other than somewhat increased vascu- larity of the membranes of the brain; two children died from pneu- monia, which came on suddenly, and passed with great rapidity into the third stage; while in the three remaining instances, pleurisy, asso- ciated once with pericarditis, destroyed the patient. When death takes place from effusion into the chest, the anasarca has usually been considerable from the outset; and, in the course of a few days, after having undergone apparently causeless fluctuation, it becomes extreme as well as universal; the features are disfigured by the dropsy, the legs greatly swollen, and the abdominal parietes much infiltrated; while fluctuation often becomes perceptible in the abdo- men. The quantity of water voided is very scanty; it is high-colored, very albuminous, and sometimes contains blood; while it is now and then suppressed for several hours together; and in one instance none whatever was secreted for thirty-six hours before the patient's death. Pain in the back is sometimes complained of; but the chief suffering is referred to the chest; the respiration is labored and accelerated; the child is distressed by a frequent, short, hacking cough, and be- comes unable to assume the recumbent posture. In these circum- stances, life is sometimes prolonged for several days, though in a state of great suffering, remedies proving unable either to relieve the dropsy, or to increase the action of the kidneys, death at length taking place under a sudden but usually short aggravation of the disorder of the respiratory organs—an abundant affusion of serum into the pleura, generally associated with oedema of the pulmonary tissue, being the only important appearances discovered on a post-mortem examina- tion. This effusion sometimes takes place with so little previous warning as to occasion the sudden death of children whose symptoms had not presented any special urgency, and had not seemed to war- rant serious anxiety. It was so in the case of a little boy eight years old, in whom slight anasarca appeared on the nineteenth day, after a moderately severe attack of scarlet fever. On the third day from the appearance of the dropsy, the child walked to and from the Infirmary for Children, a distance of two miles; and, though he appeared op- pressed and exhausted, he yet manifested no symptom of particular urgency. He had a somewhat restless night, but seemed better rather than worse in the morning, when he arose to relieve his bowels, which acted scantily. Soon after being replaced in bed, he began to strug- MODES OF DEATH FROM ALBUMINOUS NEPHRITIS. 525 gle faintly, and in less than five minutes was dead. The presence of half a pint of fluid in the cavity of each pleura, and the consequent compression and condensation of the lower part of each lung, were the only appearances which could account for the child's sudden death. Other instances of almost equally sudden death in cases of dropsy after scarlet fever have come under my observation. The pos- sibility of such an occurrence should lead us always to watch a patient with great care in whom the want of due resonance, or the absence of clear respiration in either infra-scapular region, informs us that fluid is present in the chest, since the scanty effusion may increase with extreme rapidity, and symptoms which had seemed of little moment may, in a few hours, jeopardize life, or even destroy it. A slight degree of inflammation of the pleura giving rise to increase of its vascularity, or to a scanty deposit of lymph on its surface, is very often observed in connection with the abundant effusion of fluid into the cavity of the chest. Acute pleurisy terminating in the forma- tion of pus, or pneumonia running rapidly into the third stage of the disease, is a less frequent but by no means a less formidable compli- cation of albuminous nephritis. The occurrence of either of these affections is often independent of the existence of anasarca, though it is, I believe, always associated with an albuminous state of the urine, and preceded by those general febrileisymptoms which almost invari- ably accompany that affection when it succeeds to scarlatina. Both diseases run in these circumstances an exceedingly rapid course; and I have known death take place, and nearly the whole of one lung pass into the second and third stages of pneumonia, within thirty-six hours from the appearance of the first symptom of disorder of the respira- tory organs—a fact which gives a peculiar gravity to all affections of the chest succeeding to scarlet fever. Lastly, death is sometimes due to convulsions, similar to those which take place occasionally in the adult in the course of granular degeneration of the kidneys. In the child, however, this accident is very unusual; while, even when it does take place, it does not in general lead to a fatal result; inasmuch as, of four cases which came under my own observation, three recovered ; and of thirteen, particu- lars of which are collected by M. Rilliet,1 ten issued in the recovery, only three in the death, of the patient. These convulsions are sudden in their occurrence, coming on without any premonitory symptoms, though they are sometimes immediately preceded by violent head- ache. They are followed by more or less complete unconsciousness; and a repetition of the attack takes place almost invariably in the course of from one to three hours. The violence of the fits varies. The first is not, in general, so severe as those which succeed to it; and the degree to which consciousness returns in the intervals between the fits is uncertain ; though, whenever recovery takes place, the com- plete restoration of all the powers, both of mind and body, proves that no abiding injury has been inflicted on the brain. In one of the four cases which came under my notice, the fits completely ceased in 1 Op. cit., vol. iii. p. 185. 526 CHANGES IN THE URINE. six hours; while, in the third case, death took place in a state of coma eleven hours after the occurrence of the first fit, and two hours and a half after the cessation of the third. When recovery takes place, the restoration of the cerebral functions is not only complete, but rapid; and, if the child survive twenty-four hours from the first con- vulsive seizure, we may, I think, look upon the danger from that source as at an end; though it must not be forgotten that the same state of blood as predisposes to the convulsive attack is a very influential cause of inflammation of the serous membranes, and that, as happened in one case which came under my own observation, the patient may outlive danger from the one source only to sink under that arising from the other. Supposing the patient to escape the dangers arising from these various causes, convalescence eventually takes place, the dropsy seldom persisting, at the longest, above a fortnight or three weeks; though the child often remains long afterwards languid and feeble, with a weak pulse and an anaemic aspect, while any serious compli- cation may obviously enough retard recovery almost indefinitely. Accidental exposure to cold too may suffice, even months after appa- rent convalescence, to disorder once more the functions of the kidneys, to reproduce an albuminous condition of the urine, attended as before with anasarca, though the dropsical symptoms are not in general con- siderable. The symptoms of constitutional disturbance already described, and which in the main are those of inflammatory dropsy, are associated with changes in the composition of the urine, as well as, in most in- stances, with a diminution in the quantity of the secretion. In very slight cases, in which the dropsical symptoms are scarcely indicated, or in which there is simply a little poorliness retarding the rapid advance of convalescence, the urine may be a little less transparent than natural, and present very slight traces of albumen on examina- tion. It has, indeed, been doubted whether the presence of slight traces of albumen for a very short time, possibly not more than twenty-four hours, is not invariable during some period or other of the convalescence from scarlet fever; and the tendency of recent researches is to lend increased probability to the supposition. Be this as it may, however, the 'changes in the urine are from the first much more considerable, or very speedily become so, in all instances in which any marked constitutional disorder is present. Though transparent when passed, it is of a deeper color than natural, and speedily becomes turbid on cooling, when it deposits a more or less abundant precipitate. It has a strong acid reaction ; somewhat ex- ceeds the usual specific gravity of healthy urine; is at first rendered clear by the application of heat, but again becomes cloudy as the albumen which it contains is coagulated, and falls down in a flocculent precipitate. If the attack be more severe, the urine, which is very scanty, is of a brown or smoke color, deep red, or coffee colored, and throws down a deposit chiefly of a reddish-brown color; which, how- ever, does not entirely disappear when heated, while albumen is pre- sent in it in extreme abundance. It is to the presence of the coloring ALTERATIONS IN THE KIDNEYS. 527 matter of the blood that this dark hue of the urine is to be attributed; but in some instances blood is present in very great abundance, and for a season the case is strictly one of hasmaturia; thpugh the symptom in this extreme degree is usually transitory, not continuing for above thirty-six or forty-eight hours at a time, but recurring sometimes causelessly more than once during the patient's illness. Usually, though not invariably, the presence at any time of a large quantity of blood in the urine indicates a very serious disturbance of the func- tions of the kidney, and forebodes a slow and imperfect convalescence. On the other hand, an extreme degree of anasarca and haematuria are by no means generally associated; nor does the complete disappearance of blood from the urine constantly imply a corresponding improve- ment in the patient's general condition. Of all indications furnished by the urine none is of such constantly evil import as a marked dimi- nution in the quantity of that secretion, especially when such dimi- nution takes place suddenly; and in whatever other respects the state of a patient may differ, complete suppression of urine for a period much exceeding twelve hours almost invariably announces the speedy approach of death. Microscopic examination of the urine in cases of this disease dis- covers crystals of lithate of ammonia, mucous corpuscles, epithelium scales, casts of the urinary tubules, and in many instances blood- globules but very little altered. These matters, however, disappear by degrees as the patient's symptoms abate, as the quantity of the urine increases, and its natural appearance returns; though long after it looks healthy, and has ceased to throw down any deposit, it may be shown by chemical reagents not to be entirely free from albumen; and I have found traces of its presence more than two years and a half after an attack of scarlatinal dropsy. The degree of alteration presented by the kidneys in fatal cases appears to depend partly on the duration of the disease, partly on the imme- diate cause of the patient's death, being more considerable when it has resulted from the dropsy itself than when it has been produced by some intercurrent inflammation. When least affected, the kidneys are swollen, dark, heavy, and gorged with venous blood; but not otherwise altered. In a more advanced stage of disease their surface presents a pale color and mottled appearance, and is sometimes dis- tinctly granular, while spots of vascularity, remarkable for the stellated arrangement of the small vessels of which they are composed, are dispersed over it. On a section being made, a marked contrast is observable between the pale, fawn-colored, cortical structure of the organs, and their deeply-injected tubular parts; while the lining of their pelvis and infundibula generally displays a greatly increased vascularity. The granular appearance characteristic of the second stage of Bright's disease is also still more obvious on a section of the organs than it was on the examination of their surface, while the change in their tissue is further shown by the facility with which it tears or breaks down under the finger. The time required for the production of these changes in the kidneys varies much. I have seen them present in a remarkable degree in the case of a little boy aged 528 PATHOLOGY OF THE DISEASE. five and a half years, who died of serous effusion into his chest on the twenty-second day from the appearance of the rash of scarlet fever, and the thirteenth from the commencement of the dropsy; but this is the only occasion, in my experience, on which such extensive alterations have been wrought within so short a period. No instance has offered itself to my notice in which the changes characteristic of the third stage of Bright's disease have been found after death ; for though children may continue feeble and much out of health long after the acute stage of the disease has passed away, and may even die of its remoter consequences, yet I believe that the fatal issue, in such circumstances, is usually brought about by the development of tuberculosis, not by the progressive advance of disorganization of the kidney. The use of the microscope has of late enabled us to advance a step further than we otherwise could have done towards understanding the pathology of this disease. It has shown us that the morbid process begins in the cortical part of the inflamed kidney, the urinary tubules of which are stimulated to an increased production of their epithelial lining, or even to a pouring out of solid fibrinous matter into their cavities. The urine carries away with it some of these matters, and thus frees the tubules for a time ; but as their contents are reproduced in quantities too large to be thus eliminated, some of the tubules be- come plugged and impervious, sometimes even so over-distended that they give way, and are completely destroyed. Nor is this all, but the capillaries of the organ necessarily bear a part in the mischief. At first, from over-congestion, they become dilated and varicose, and afterwards (in part, probably, from the formation of fibrinous clots within them, in part as the result of a process of adhesive inflamma- tion) they become obstructed or even obliterated. Supposing this morbid process to have gone on to any considerable extent, the kid- ney must be left by it permanently injured; while even its slighter degrees must for a time seriously disturb the functions of the organ. In the earlier stages of the disease, the presence of albumen in the urine is in part due to the actual escape of blood from the overloaded capillaries of the kidney, in part to the temporary suspension of its functions. If at a later period, when the urine has lost its preterna- turally deep color, and has regained much of its healthy appearance, albumen should still exist in any quantity, there will be reason for apprehending that some serious injury has been inflicted on the organ. At the same time, the reparative power characteristic of early life tends, I believe, to the ultimate removal of the mischief, and warrants a more hopeful prognosis as to the ultimate complete recovery of a child from the effects of scarlatinal dropsy, than would be justifiable in a case of albuminuria in the adult. The treatment of this affection is, on the whole, that of inflammatory dropsy, from what cause soever it may arise. If it have set in with severity, the urine being high-colored, extremely scanty, and loaded with albumen, the abstraction of blood is almost indispensable, and from four to six ounces may be taken from the arm of a child five or six years old. It will, I believe, seldom, if ever, be necessary to re- TREATMENT OF ALBUMINOUS NEPHRITIS. 529 peat the general depletion, though, if no improvement follow, and especially if there be pain or tenderness in the loins, cupping or the application of leeches in that situation should be resorted to. Whether bleeding be requisite or not, the great object to which our treatment must be directed is the re-excitement of the cutaneous function; and in proportion as we succeed in this shall we avert danger and expe- dite convalescence. For this purpose the hot-air bath is one of the most efficacious means with which I am acquainted; it not only stimulates the skin much more powerfully than the warm water bath, but has the further advantage that it can be employed without re- moving the patient from bed, and consequently without the risk of catching cold. It may be used once or twice in the twenty-four hours, and seldom fails, even when its action is most transitory, in inducing, for the time at least, a copious perspiration. Among internal reme- dies, the tartar emetic deserves to hold the highest rank ; and I know of no medicine to the utility of which, in the acute stage of scarlatinal dropsy, there are so few exceptions. It should be given in nauseating doses every four hours; and at bedtime, if headache or a constipated state of the bowels does not contraindicate its use, a small dose of Dover's powder may be advantageously combined with it. When, by the employment of these means, the skin has been excited to action, the anasarca has ceased to increase, and the albumen in the urine has much diminished, some of the milder diuretics may be combined with the mixture—as the acetate of potash, the extract of taraxacum, the spirits of nitrous ether, or the benzoic acid, of which latter remedy I have recently made much use, while at the same time the dose of the tartar emetic may be reduced; but any change of the urine to a darker color, or the increase of albumen in it, should be regarded as indicating the propriety of discontinuing them, and of returning to the previous treatment. My experience does not lead me to form a favorable opinion of the utility of cathartics in the treatment of this affection. They are un- certain in their action, their operation is often attended by much dis- tress to the child, and by unavoidable risk of catching cold, while the occurrence of diarrhoea is a very troublesome and very unmanageable complication. On this account, therefore, I think it preferable to give aperients only when a constipated condition of the bowels absolutely requires their employment. In very mild cases of dropsy it suffices to give the antimony in small doses, so as to produce merely its diaphoretic effects; while in cases of long standing the feebleness of the patient's pulse and the occasional irritability of his stomach often completely contraindicate its use. In those instances too, in which the quantity of blood in the urine is considerable, the restraining its discharge from the kidneys becomes the first indication. For this purpose the gallic acid, in doses of five grains every four hours for a child of five years old, is the best remedy that we can employ; while a small dose of antimony may still be given in the evening, at the time when the hot-air bath is used, with the view of helping to keep up the proper action of the skin. In the chronic stage of the disease, even though no blood be present in 34 530 DYSURIA—CALCULOUS DISORDERS. the urine, yet if the quantity of albumen be large, the gallic acid will again be indicated in preference to any other remedy. With reference to the complications of the disease, I do not know that their association with scarlatinal dropsy furnishes any special indications for their treatment, though it certainly destroys much of the hopefulness which we might otherwise feel with reference to the success of our remedies. The remark applies with especial force to the inflammatory affections that sometimes supervene in its course, and more particularly to the pneumonia, which though not a very frequent, is a most dangerous accident, and one in which, if depletion and tartar emetic fail, I know not to what remedy to have recourse. In the three cases of convulsions which recovered, large depletion was resorted to, and in both instances with success. In one of the cases, however, consciousness did not return till after the bowels had been very freely acted on by elaterium, though the depletion alone put a stop to the convulsions. The child who died was in a state of such exhaustion at the time when the convulsions came on, as seemed to forbid depletion, but I have since regretted that no attempt was made to arrest them by means of the inhalation of chloroform. The convalescence from scarlatinal dropsy requires much care in restoring the child to its usual diet, and long continued precaution against cold and damp, together with great attention to maintain the active performance of the cutaneous functions; on which account it is always desirable that flannel be worn next the skin. In mild cases the observance of these precautions is all that is needed; but in many instances the child is left weak and bloodless, and with its digestive powers much enfeebled. In these circumstances tonic remedies are always indicated, and either the extract of bark or the tincture of the sesquichloride of iron will generally be found most appropriate, while wine is not infrequently needed to restore the appetite, which in many instances seems completely lost. I need not, however, pursue this subject in minute detail: the great principles which should govern your conduct must already be sufficiently obvious. Although most diseases of the urinary organs are less common in children than in grown persons, yet calculous disorders are far more frequent in early life than in adult age. It appears, indeed, from some statistical data furnished by Dr. Prout, that out of 1256 patients received into the Bristol, Leeds, and Norwich hospitals, for the pur- pose of being operated on for stone, 500, or nearly 40 per cent., were under ten years of age. If we bear in mind the intimate connection that subsists between the assimilative and the excretory functions, it will not surprise us that in early life, when the former, though so active, are so readily disturbed, the latter should be often thrown into disorder. Very slight and very temporary causes often suffice to occasion deposits in the urine of children; and these deposits almost always consist either of the amorphous lithate of ammonia, or of the small reddish-brown crystals of lithic acid. These deposits, indeed, are not of much moment, and one might perhaps say that tbe younger the infant the less is their importance, since the presence of lithic acid in DYSURIA—CALCULOUS DISORDERS. 531 considerable quantity in the kidneys of new-born children seems to be almost a physiological condition. Its frequency was first noticed, some years ago, by Professor Schlossberger; and his original state- ments have been confirmed both by his own subsequent researches, as well as by those of Professor Martin, of Jena.1 Dr. Schlossberger, on an examination of 199 children who died within thirty days from birth, found lithic acid gravel in the tubuli uriniferi of 32 per cent, of the number, in many, but not all of whom, some degree of icterus had existed. The frequency of this condition is probably connected with the peculiar changes in the processes of assimilation which take place after birth; and any interruption to their performance, or any disturb- ance of the cutaneous function, increases, as in the case of infantile icterus, the probability of its occurrence. The same causes exert a similar influence both in infancy, and also to a considerable degree even in subsequent childhood. A trifling cold, slight gastric disorder, or the feverishness and general irritation which sometimes attend upon dentition, not infrequently produce these deposits, while they disap- pear as soon as the brief constitutional disturbance subsides. While it lasts, however, the condition of the child is often one of very con- siderable suffering, each attempt to make water being attended by much pain, the patient crying and drawing up its legs towards its abdomen; while frequently a few drops only of urine are voided at each time. Now and then, the suppression of urine is complete for twelve, eighteen, or twenty-four hours; but this seldom happens, ex- cept in children previously much out of health, and in whom, in these circumstances, the febrile symptoms and the constitutional disturbance are very severe, the bowels usually constipated, and the evacuations very unnatural in appearance. But besides cases of this acute kind, which occur almost exclusively in infants in whom the process of dentition is not yet complete, similar symptoms are often observed in older children; and though at first of a much less urgent character, they are yet of more serious import, since they frequently indicate the existence of a calculus in the bladder, instead of betokening a merely temporary excess of lithic acid deposits in the urine. In many instances, the formation of lithic acid in the kidneys goes on without giving rise to any very obvious symptoms; and I have but rarely seen a child suffer from pain of that severe character which in the adult not unfrequently accompanies the descent of a calculus from the kidney to the bladder. Sometimes, however, after frequent attacks resembling seizures of ordinary colic, a child begins to mani- fest the symptoms of stone in the bladder; and in these circumstances it is probable that the previous attacks of abdominal pain were due to the disordered function of the kidneys, rather than to any primary affection of the intestinal canal. The occurrence of colic in children of three or four years old, indeed, should always direct our most sedu- lous attention to the state of the urine, which will very often be found to deviate widely from a healthy condition—frequently to abound in lithic acid gravel. ' Archiv f. physiol. Heilkunde, vol. ix.; also Schmidt's Jahrbucher, Dec. 1850, p. 333. 532 TREATMENT OF DYSURIA. The symptoms of stone in the bladder are much the same at all ages : the pain in voiding urine, and, immediately afterwards, the fre- quent desire to pass water, the occasional abrupt stoppage of the stream of urine, and the irritation about the penis, owing to which the child keeps its hand almost constantly on its genitals, can hardly fail to awaken suspicion as to the nature of the case. Before subjecting the child, however, to the fright and pain which the introduction of a sound into its bladder is sure to occasion, it should be first ascertained that the patient's sufferings are not due to the prepuce being extremely long and its orifice very narrow. The existence of that malformation sometimes prevents the ready escape of the urine; while the edges of the foreskin becoming irritated and sore, any attempt to make water is rendered exceedingly painful, and the symptoms present a most deceptive resemblance to those of stone in the bladder. The presence of ascarides in the rectum likewise sometimes occasions a degree of irritation about the bladder, which is by no means unlike that pro- duced by calculus; and against this possible source of error it be- hooves us likewise to be on the watch. The treatment of dysuria in early life, connected, as the affection almost always is, with an excess of lithic acid in the urine, is suffi- ciently simple. Those acute attacks which come on during infancy, and for the most part during the period of teething, and which are attended with much fever, with a constipated or otherwise disordered condition of the bowels, and with severe suffering, obviously call for antiphlogistic and soothing measures. The warm bath is often very serviceable in these cases in relieving the febrile symptoms; besides which, the occasional immersion of the child in hot water, as high as the hips, soothes the pain which is so apt to attend upon every attempt to empty the bladder. The bowels should be acted on freely by castor oil; and afterwards, no medicine has appeared to me to afford so much relief to pain, or so effectually to excite the kidneys to action, as the castor-oil mixture which I have already mentioned to you, in combination with small doses of liquor potassae, laudanum, and nitrous ether. Barley-water, milk and water, and thin arrowroot, should constitute the child's nourishment during the severity of its attack; and even when the symptoms are on the decline, much pru- dence must still be exercised in keeping to a very mild and unstimu- lating diet. It is generally wise to continue the use of alkalies for some time after the active symptoms have subsided; and small doses of liquor potassae, either alone or in combination with the vinum ipe- cacuanha?, may be given three or four times a day in a little milk. Once or twice I have seen a sudden suppression of urine, attended with great aggravation of the child's sufferings, follow after the exist- ence of severe dysuria for two or three days; and have found this occurrence to be due to the mechanical obstruction of the urethra by a small calculus which had become impacted in its canal. The dys- uria which is produced by the excessive length of the prepuce can be relieved only by the removal of a portion of the superfluous fore- skin ; while, when it is excited by ascarides, an enema of liquor calcis, EXCESS OF LITHATES IN THE URINE. 533 with a dose or two of castor oil, will often produce an immediate cure of symptoms which had been very troublesome. The treatment of calculus in the bladder hardly requires special notice here; but you will bear in mind that the calculi which form in childhood are just of that kind on which medicinal agents are best calculated to act; and that we have but little reason for dreading those changes in the precipitate thrown down from the urine which take place in later life. The deposits that take place and the calculi that form in childhood, consist almost invariably of the lithates, and hence we may employ the alkaline carbonates without apprehension ; and under their continued use I have seen very copious sediments com- pletely and permanently disappear from the urine. Their action, however, is far too slow to be relied on in any case where unequivo- cal signs are present of the existence of a stone of considerable dimensions; while, fortunately, the anaesthetic agents which we now possess, by depriving the operation of lithotomy of the pain that once attended it, have robbed it of many of its terrors. The importance of lithic acid deposits in the urine, is, however, by no means dependent on the temporary suffering associated with its elimination, in some instances; or the dangers of the formation of vesical calculus, in others. Deposits of lithic acid are observed in the urine of children, as the consequence and the indication of a state of general constitutional disorder, which manifests itself by dyspeptic symptoms and imperfect nutrition, which is often associated with chronic cutaneous affections, and not infrequently succeeds to some attack of rheumatism. I have already told you that rheumatism' in the child runs its course frequently with a much smaller amount of local pain, and with less swelling of the joints, than generally attend it in the adult. Its remote effects also very seldom show themselves in those abiding pains which characterize chronic rheumatism in the grown person, but in a state of general ill health such as that to which I have just referred. A child is brought to you with a vague history of failing health; of loss of flesh, of variable appetite, sluggish bowels, and occasional night perspirations. On further inquiry you learn that he is nervous and excitable in the highest degree; sometimes depressed and sullen, at other times so high-spirited as to be almost uncontrollable: each of these fluctuations in his condition, whether for better or worse, is found to be more marked at some seasons of the year than at others; and often also modified by change of resi- dence, his health being manifestly worse in cold weather, and in ex- posed situations, than in a sheltered spot, and during the summer season. Anxiety lest consumptive disease should be impending is often needlessly entertained in these cases; but if you examine the urine you will at once find the clue that will help you to their thorough understanding. The urine will be found acid, of a very high specific gravity, 1025 or upwards, depositing on cooling abundant red crys- tals of lithic acid, and on the addition of nitric acid giving evidence, by the speedy crystallization that takes place, of the presence of an excess of urea. On close inquiry you will probably learn that some months previously the child had had an attack of rheumatism, not 534 DIABETES. necessarily very severe, and that since then his health had never been so good as before; or, if not, you will almost certainly find that rheu- matism is a disease from which, in some or other of its numerous forms, members of his parents' family have suffered. It is to cases such as these that the term of the lithic acid diathesis1 is applicable. The treatment of this condition does not require much notice. A residence in a sheltered and warm situation, and the habitual wearing of flannel next the skin, are two points of much importance. A third, of at least equal moment, is the careful regulation of the diet, which should be simple, unstimulating, and moderate in quantity. With reference to medicine, the alkalies and alkaline carbonates may be given with a vegetable bitter, if some decided tonic appears neces- sary; but you must bear in mind, and clearly explain to your pa- tient's friends, that the condition is not one to be overcome in a short time by a few potent remedies, but one which will require watching and care, and a well considered system of diet and regimen, to be carried on for months and years, and from which it is scarcely safe to depart before the time of puberty has been passed in safety. I re- ferred to it, not because I had any special cautions to give you about its treatment, but to call your attention to a set of symptoms, the real signification of which may be readily overlooked. An unnaturally profuse flow of urine occurs at all ages as a tempo- rary symptom in the course of many disorders. Its permanent in- crease, when associated with certain changes in the composition of the fluid, and the presence of saccharine matters among its elements, con- stitutes diabetes. This disease, although not common at any period of life, yet occurs in the adult sufficiently often for us to become familiar with its characters, and to dread it as one of the most formidable re- sults of disorder of the assimilative processes. In the child, however, it is an exceedingly rare affection; for Dr. Prout, out of his immense experience in diseases of the urinary organs, states that he has seen but one instance of it in a child of five years old, and only twelve in young persons between the ages of eight and twenty years, out of a total of 700 cases of diabetes.2 One case only has ever come under my observation, in a little girl aged three years and a half, whose brother haq\ died at the age of two years, and her sister at two years and a half, with precisely the same symptoms as she presented; and, from the first appearance of which to their fatal termination in both cases, only six weeks elapsed. The child whom I saw had been droop- ing for about two months, and was losing flesh very rapidly, but had not then begun to experience the urgent thirst of a diabetic patient. She was pale, thin, and rather sallow; her tongue was slightly coated, but not at all characteristic of her disease. Her urine, of which she passed about four pints in the twenty four hours, had a specific gravity of 1045, became of a dark color when boiled with liquor potassae, and yielded, with Trommer's test, indications of sugar in abundance. 1 It is almost superfluous to remind the reader of Dr. Todd's remarks on this sub- ject in his Croonian Lectures—On Gout, Rheumatism, &c. 2 On Stomach and Renal Diseases, 5th edit. 8vo. p. 36, note. SYMPTOMS AND TREATMENT OF SIMPLE DIURESIS. 535 The parents, who had lost all heart, in consequence of the death of their other children, could not be persuaded to restrict her diet, or to put her on any plan of treatment; and I never saw the child but on one occasion. Simple diuresis, indeed, is less rare than true saccha- rine diabetes; and I have seen some instances in which, coupled with serious gastric and intestinal disturbance, there was so considerable an increase in the secretion of urine as to constitute a prominent symp- tom of the disease. In these cases, however, considerable disorder of the digestive organs had for some time preceded the excessive flow of urine; and Dr. Prout states that, in the earlier stages of infantile diu- resis, the urine is loaded with lithates, and diminished in quantity; though, as the disease advances, the quantity of urine becomes con- siderably increased; and it sometimes contains albumen, or in rarer cases yields signs of sugar. So far as my observation goes, indeed, the disturbance of the functions of the kidney is in these cases purely secondary, and subsidiary to the gastric and intestinal disorder. The quantity of urine has either been speedily diminished under a due attention to diet and the regulation of the digestive organs, or the symptoms have become merged by degrees in those of phthisis, which has gradually developed itself. My experience concerning these affec- tions amounts, in short, to this—that, whenever the processes of diges- tion and assimilation are seriously disturbed for any considerable time in early life, the functions of the kidney are very apt to become excessive in degree, as well as disordered in kind. Further, such disorder is especially likely to occur just at that period when the sim- ple but highly animalized food of the suckling is exchanged for the more varied diet of the infant after weaning. And^ lastly, its exist- ence may be suspected whenever, coupled with more or less marked indications of gastrointestinal disorder, there is a rapidly increasing emaciation, for which no adequate cause appears. It will, however, often happen, even when the amount of urine greatly exceeds the healthy average, that the parents of an infant take no notice of the circumstance, imagining it to be either an accidental and unimportant occurrence, or accounting for it as the natural result of the thirst, which induces the child to drink very abundantly. Hence, unless you make special inquiries with reference to this point, you may remain in ignorance of a very important symptom. When once you have become aware of the existence of this affec- tion, its treatment is attended by no particular difficulty, and, if under- taken sufficiently early, will often prove successful. The state of the bowels requires most careful attention; mild alteratives are frequently serviceable; but drastive purgatives are very unsuitable. The hydr. c. creta\ in combination with Dover's powder, is often very useful in promoting a healthy condition of the evacuations; while the Dover's powder alone is also beneficial in calming the child's excessive irrita- bility, as well as in diminishing the amount of urine secreted. Dr. Prout adds a caution, however, with reference to the use of opiates in these cases, as well as to the sudden withdrawal of fluids, since a sup- pression of urine may follow the incautious adoption of these mea- sures ; and that condition is almost sure to end in coma and death. 536 INCONTINENCE OF URINE—ITS TREATMENT. Change of air to a dry and temperate situation, especially on the sea- coast, is of much importance; and the tepid or warm sea-water bath is often beneficial; while tonics of various kinds are generally of serv- ice. The different preparations of iron appear to have advantages over other medicines; and Dr. Venables, who was the first to call the attention of the' profession to this affection, bestows high com- mendation on the phosphate of iron. Dr. Prout insists, moreover, on the importance of a suitable diet, into which albuminous matters should enter freely, in preference, though not to the entire exclusion, of those which contain gelatine. Milk should form a chief element in the diet; while, of farinaceous matters, those are to be preferred which have undergone the fermentative process. These precautions, too, must be observed, not for a short period only, but until the child has for some time regained its health, since a slight error is very likely to be followed by a serious relapse. Incontinence of urine is a very distressing infirmity from which child- ren sometimes suffer, and which, in many instances, it is found very difficult to cure. In most cases this inability to command the flow of urine exists only in the night-time, but sometimes it is present also by day; and both forms of the affection are met with in children of both sexes and of all ages, even up to the period of puberty. The nocturnal incontinence of urine is often associated with the presence of an*excess of lithic acid in the secretion; and in such cases the first step towards remedying the infirmity consists in correcting the morbid state of the fluid. Now and then it appears to be dependent upon the irritation produced by ascarides in the rectum, while in the majority of cases, so long as the affection is recent, a connection may be clearly traced between it and gastro-intestinal disorder. If not remedied, however, all the other functions of the body may return to a healthy state, while yet the incontinence is perpetuated by a kind of habit which it is found very difficult to break through. The involuntary discharge of urine by daytime as well as night is a still more troublesome affection. Sometimes there is an absolute want of control over the bladder; so that the urine is almost constantly dribbling away; while in other cases the desire to pass water is dis- tinctly felt at certain short intervals; but the patient is unable to resist this desire even for a minute. This affection, too, is sometimes asso- ciated with a morbid condition of the urine; in other instances it seems to depend on a state of general weakness; while in some cases there is no apparent cause, either general or local, to which it is pos- sible to ascribe it. Cases of this last kind are of all the most trouble- some; they are sometimes met with in several members of the same family, especially in girls, though, according to my experience, the other more curable forms of incontinence are much more common in male children. In the cure of nocturnal incontinence of urine much may often be "gained by attention to certain precautionary measures; such as limit- ing the quantity of drink taken at the last meal, preventing the child from lying on his back when in bed (a position which seems greatly to favor the occurrence of the accident), and rousing him from bed to ABDOMINAL TUMORS. 537 empty his bladder two or three times in the night. If the urine be loaded with lithates, the diet must be most carefully regulated, and medicines must be given to restore the urine to a healthy state, and to insure the due performance of the functions of the digestive organs. Tonics are often extremely useful afterwards, and there is none from which I have seen so much benefit as from the tincture of the sesqui- chloride of iron. At the same time, cold sponging to the back and loins is often decidedly serviceable; and if the case resist these milder measures, the frequent application of a blister to the sacrum seldom fails to do great good. In very obstinate cases the tincture of cantha- rides is of service; and once or twice I have employed with advantage large doses of the nitrate of potash, according to the recommendation of Dr. Young, of Chester; but, as a general rule, the employment of these stimulant diuretics is not desirable; and I should prefer to them the administration of small doses of strychnine, or of the extract of nux vomica, from which I have on two or three occasions seen most decided benefit. LECTURE XL. Abdominal Tumors.—Enlargement of abdomen not always the result of actual disease —causes to which it may be due.—Abdominal tumors—from enlargement of the liver, by albuminous deposit, by hydatid growths, by malignant disease—from malignant disease of the kidney—from enlargement of the spleen—from psoas abscess.—Cases in illustration. Infantile Syphilis—its symptoms—characters of the syphilitic cachexia—morbid ap- pearances supposed to be due to it—tendency of the symptoms to return after apparent cure.—Treatment. Discharges from the vulva and vagina of female children—how to be distinguished from gonorrhoea—associated with debility and strumous habit—difficult of cure. —Treatment. Among the anatomical peculiarities of early life, none is more re- markable than the great size of the abdomen, as contrasted with the undeveloped state of the thorax, on the one hand, and of the lower extremities on the other. Though most striking in the new born infant, it still continues to a great degree during the whole of the first years of childhood; nor does it altogether disappear until, with ad- vancing age, the pelvis enlarges, the spinal column acquires its pro- per curvature, the limbs gain their due development, and the chest expands in a measure commensurate with the demands made upon the thoracic viscera for the vigorous performance of their functions. The anxiety of non-professional persons is often needlessly excited by the large size of the abdomen in childhood, while those even who are conversant with medicine do not always bear in mind the very different causes to which an increase of its bulk may be due. It will, 538 ABDOMINAL TUMORS. therefore, I think, be no waste of time to notice briefly the circum- stances in which enlargement of the abdomen may occur in childhood, and to give you what little information I may be able to furnish with reference to those diseases that occasion distinct abdominal tumors. The abdomen sometimes appears preternaturally large, wholly independent of any disorder of the general health, but as the result of the child's growth and development having gone on slowly, so that its body retains its infantile proportions but little altered at the age of two or three years. If, as often happens, this tardy development should be associated with feeble health, with a somewhat impaired performance of the digestive functions, and with a constipated condi- tion of the bowels, flatus is almost sure to collect in the intestines, and the enlargement of the abdomen is thus rendered still more con- siderable. With such a state of health, too, some of the minor degrees of rickets are often associated; and even though no serious deformity mark the existence of the disorder, yet to its influence are due the undeveloped chest and the small pelvis; while the contracted and misshapen thorax, which is produced by the advance of the disease, makes the abdominal enlargement appear more striking, and causes the child, according to MM. Rilliet and Barthez' apt comparison, to resemble the toy tumblers which Italian image boys sell about the streets. In cases such as have been referred to, you will save yourselves and your patient's friends much needless anxiety, if you bear in mind that tabes mesenterica is exceedingly rare before five years of age, while this condition of general abdominal enlargement is met with chiefly between the commencement and the end of the first dentition. Further, you will find that, in these circumstances, the abdomen is perfectly soft and painless: you will learn that no symptom of tubercle has shown itself; while, if you strip the child, which in doubtful cases you ought to do, you will probably see more or less distinct indications of the action of rickets, either in deforming the skeleton, or in disor- dering its proportions. Enlargement of the abdomen is a much more frequent attendant on tubercular peritonitis than on mesenteric disease. The tense, and tympanitic, and painful state of the abdomen, the sensation of adhe- sion between the abdominal walls and the subjacent viscera, the loss of flesh, the frequently recurring diarrhoea, the febrile symptoms, and tbe more or less well-marked indications of tubercular disease which attend it, usually stamp the nature of that affection too clearly for the attentive observer to fall into error. But besides these cases, in which there is a general enlargement of the abdomen, there are others in which its increase of size is mainly due to the presence of a distinct and well-defined tumor. A good many instances of this sort have come under my notice at different times, though, as often happens in Dispensary and Hospital practice, the number of those is but small in which I have had the opportunity of watching the affection to its close, and of confirming or correcting by an examination after death the diagnosis formed during the life- time of the patient. ALBUMINOUS ENLARGEMENT OF THE LIVER. 539 One not very uncommon cause of abdominal tumor is enlargement of the liver, which sometimes undergoes a very great increase of its bulk, without any obvious reason, and sometimes even unattended with any serious disturbance of the general health. I remember a little girl, about ten years old, who was received into St. Bartholo- mew's Hospital on account of very great enlargement of her abdomen. She looked very pale, and the distension of the superficial veins of her chest and abdomen, and the livid congestion of her face, showed that there existed some serious obstacle to the circulation. Her abdo- men had been gradually enlarging for many months, and at the time of her admission into the hospital the margin of the liver was dis- tinctly traceable below the umbilicus; her bowels were habitually constipated, but the evacuations were natural in appearance, and the child was well nourished, cheerful, and active, being but little annoyed by her great size. I saw her again two years afterwards, and her condition was then quite unaltered. Cases of a similar kind have since come under my notice in children of very different ages, and accompanied with very various degrees of disorder of the general health. In every instance there were obvious indications of a scro- fulous habit; and in some, nutrition was but ill performed. The dis- ease, however, which consists not in a simple hypertrophy of the organ, but in the interstitial deposit of an albuminous matter, does not usually produce any serious result so long as it is limited to the liver, or to that organ and the spleen. But in some instances a similar deposit takes place in the substance of the kidneys, blocking up their tubules, and interfering with the proper discharge of their functions ; albumen then appears in the urine, whi^h is secreted in very small quantities, anasarca and ascites come on, and death takes place even- tually, as the result of the renal disease, not of the mere affection of the liver. This affection sometimes comes on at a very early period; I have seen the spleen enlarged by it in an infant of nineteen months, in whom there was a distinct history of a tumor in the left hypochondriac region ever since the age of six months; while the recent investiga- tions of Dr. Gubler1 prove that it frequently accompanies congenital syphilis; the liver having, in some cases, been found presenting the characteristic alterations within five weeks after birth. Dr. Budd2 speaks of it as a concomitant of scrofulous caries of the bones; but in none of the seven cases of which I have preserved a record did this complication exist. All that we can at present determine about it is, that it is a sign and a consequence of the scrofulous or of the syphi- litic cachexia, generally slow in its development, and comparatively unimportant in its results so long as the kidney is unaffected by it; but then becoming dangerous to life, and being amenable to no kind of treatment. Fresh air, appropriate diet, and the iodides of potassium and iron, are the only remedies which I have employed; and under 1 Memoires de la Societe de Biologic Paris, 1853. 8vo. p. 25. 2 In his Treatise on Diseases of the Liver, at p. 304; where, and in Henoch's Klinik der Unterleibs-Krankheiten, vol. i., Berlin, 1852, p. 130, is to be found the best account of this affection. 540 HYDATID TUMOR OF THE LIVER. their use I have seen much improvement take place in the general ' health, and some diminution in the size of the enlarged viscus ; but when the kidney is involved, I have never seen any abiding amend- ment, while the patient's state has generally fluctuated in proportion as the secretion of urine was more or less abundant. I once met with a hydatid tumor of the liver in a girl aged thirteen and a half years, in whom, two years- and a half previously, a swelling had begun to form at her right side, without any sign of general indisposition, though the subsequent increase of the growth had been attended with occasional attacks of severe pain. At the time of my seeing her, she had gone through a variety of treatment, which con- sisted chiefly in leeching and the inunction of iodine ointment, with- out any benefit; but her general health was good, although she was small for her age. On removing her dress, the lower part of her chest and the upper part of her abdomen were seen to be much en- larged by a growth, the lower margin of which could be felt a little above the umbilicus, and which seemed larger on the right than on the left side. At this time the circumference of her chest, on a level with the nipple, was 25| inches, and 25 inches four inches lower down; but three years and a half later, and a short time before her death, she measured 32 inches at the former, and 33 at the latter point. Even when I first saw her, the respiratory murmur ceased to be audible on a level with the nipple, and the cavity of the chest became still more encroached on with the advance of the disease. Fluctuation was distinctly perceptible over nearly the whole of the tumor in the chest as well as in the abdomen, and continued so during the whole of the patient's life. It was in May, 1840, that the patient first came under my notice, and no change whatever took place in her condition until February, 1842. At that time, after severe pain in the tumor had been experienced for several days, a fresh growth made its appearance, of about the size of a breakfast-cup, to the left of the umbilicus, and a little above it. In July following the patient began to lose flesh, her appetite failed, and she began to suffer fre- quent attacks of palpitation. At this time, and often subsequently, the child complained of pain and numbness, extending down the right arm. Notwithstanding the progressive increase of the tumor, the patient's health continued tolerably good for the succeeding seven- teen months, though she grew but little, and no signs of approaching puberty appeared. In the middle of December, 1843, symptoms of gastric disorder showed themselves; the child suffered much from flatulence, had occasional diarrhoea, severe pain in her abdomen, great feverishness, and her mind wandered a little at night. The skin grew jaundiced, and her water became very high colored; while the attacks of pain, chiefly referred to the epigastrium, sometimes were so severe that the patient fainted from their intensity. Slight cough came on, and for three weeks before death she was unable for a mo- ment to assume the recumbent posture. Her strength gradually failed, and she died on Jan. 28,1844, during an unusually severe attack of pain. On opening the abdomen, from which a gallon and a half of FUNGOID DISEASE OF THE LIVER. 541 transparent yellow serum escaped, the enormously large liver was brought into view. It reached down to somewhat below the false ribs of the left side, not quite so low on the right, and extended up- wards on the left, pushing the diaphragm before it to rather above the upper margin of the second rib, and on the right side to a little above the level of the third. This enlargement seemed made up of the left lobe, for the right lobe, rather dark but otherwise healthy, was found pushed downward by it into the right flank. The surface of the enormously enlarged left lobe was of a pale color: on making an incision into it, it was found to have formed a sac, the parietes of which were about a third of an inch thick, containing a gallon of viscid yellow fluid, and a number of hydatids, of large size. The sac itself appeared to be formed by the parent hydatid, the parietes of which were firmly adherent to the substance of the liver. At the anterior edge of the right lobe of the liver, just to the right of the gall-bladder, was a yellowish-white tumor of the size of a walnut, which, on being cut into, was seen to be composed of dead and shrivelled hydatids; they were folded together, one within the other, like the coats of an onion, except that, in order to reduce the space they occupied as much as possible, they were plicated. The two or three outer layers had begun to be the seat of cretaceous deposits. The gall-bladder contained a little pale fluid bile. The lungs were healthy, though much compressed. The valves of the heart were quite healthy, but the pericardium was universally, and in some parts very firmly, adherent to its substance, the result, doubtless of inflammation, which most likely came on at the time when the child began to complain of palpitation of the heart. The other viscera were quite healthy. I have seen the liver enlarged by disease, which I believe to have been of a malignant character, on three occasions; but in one only of the number had I the opportunity of confirming the diagnosis by examination after death. In that case the affection was attended by vague indications of abdominal disease, in which there was nothing that pointed especially to any one viscus; while the morbid growth, having originated from the under surface of the right lobe of the liver, was supposed, from the relations which it presented, to be due to enlargement of the mesenteric .glands. The patient was a little boy, who was eight months old when the first indications of disordered health appeared, in diarrhoea, fretfulness, and loss of flesh and ap- petite; and at the age of nine months his mother noticed some solid masses in the abdomen, though from the commencement of his illness his belly had been hard and rather tender. The child lived to the age of one year; and for the last six weeks of his life, during which time I had the opportunity of watching him, he suffered from diarrhoea, which was occasionally very profuse. He became extremely emaciated, and his skin assumed an exceedingly sallow color; but the evacuations, though relaxed, were otherwise natural. No hemorrhage took place from the intestines, and the urine was found to be perfectly natural whenever it was tested. During the last month of his life he had a slight cough and wheezing respiration ; but death seemed due 542 MALIGNANT DISEASE OF THE KIDNEY. to the constant diarrhoea and the severe pain which the child suffered ; his exhaustion being doubtless in great measure the consequence of the blood which should have nourished his body being diverted to supply the enormous mass of fungoid disease of the liver. During the six weeks that the child was under my observation, his abdomen increased from twenty-one to twenty-five inches in circum- ference; and the tumor, the surface of which was uneven, was always much larger on the left than on the right side. It turned out, how- ever, on an examination after death, that the left lobe of the liver was almost completely healthy, but that it had been driven up under the ribs by the enlarged right lobe ; which part of the organ was converted into a soft, white, brain-like matter, intermingled with which were portions of a firmer, highly vascular, fibrocellular substance. The disease, in short, consisted of a mixture of carcinoma medullare and carcinoma fasciculatum. A few deposits of medullary cancer, one of them as big as a walnut, existed also in the right lung, but the other viscera were healthy. Malignant diseases of the kidney is another occasional cause of ab- dominal tumor in children, and of this I have met with three instances. The first occurred in a boy, who died at the age of two years and ten months; the second in a girl, who was fourteen months old at death; and the third likewise in a girl, who died at the age of six years and nine months. In the first case, at the same time that the child became languid and fretful, his abdomen was observed to be enlarging. For a few days in the early part of his illness he was reported to have passed bloody urine; but this symptom did not recur during the sub- sequent progress of the disease. In proportion as his abdomen in- creased in size, he became more and more emaciated: he had occasional attacks of diarrhoea, but nevertheless his appetite continued craving; and it was not till ten months after the first symptom had been noticed that the child died, exhausted. In the second case, the disease ran a much more rapid course, and death took place in ten weeks from the appearance of the first symptom. The child was attacked by fever- ishness, gastric disorder, and occasional vomiting, which had not continued more than a week when her mother noticed a tumor in the abdomen. When these symptoms came on, she was well nourished, but she lost flesh rapidly in proportion as her abdomen increased in size; her evacuations were often very unnatural, but at no time was there either diarrhoea or haematuria. Towards the end of her life she became, very fretful, and seemed occasionally to suffer severe pain in the abdomen; but her death took place suddenly, and without any si en of her health being worse than it had appeared to be for some days before. In two cases the left, in one the right kidney, was the seat of the disease; the local symptoms were very similar in all three instances, and consisted in the presence of a solid tumor occu- pying the lumbar region, and extending from the spine across the abdomen towards the opposite side, and reaching upwards beneath the ribs, and downwards towards, and in the first case even into, the pelvis. In one instance, the tumor had been supposed, before it came under my notice, to be formed by the enlarged spleen. This error, TUMOR FROM PSOAS ABSCESS. 543 however, may be avoided if it is borne in mind that the spleen pre- sents a sharp edge towards the mesial line, while the contour of the kidney is rounded; and further, that the spleen does not reach back into the lumbar region so completely as the kidney. On examining the body after death, the nature of the disease was seen in each in- stance to be precisely the same, being a mixture of cerebriform matter and of tbe peculiar structure of fungus hsematodes, while the kidney was considerably bigger than the head of an adult; its size being partly due, in the third case, to the presence of three cysts of con- siderable size; a complication which one knows to be by no means unusual in soft cancer of other organs. In the case of the third child, symptoms of vague disorder of the health, failing appetite, and loss of flesh, preceded for six weeks the appearance of a tumor in the left side of the abdomen. About three months from the first sign of indisposition a large quantity of blood was voided with the urine, and haematuria continued of frequent occurrence throughout the whole of the patient's illness. Life in this instance lasted for ten months from the appearance of the tumor; and death at length took place in a state of coma. Scarcely any pain was experienced throughout the whole course of the illness, though the tumor was somewhat tender to the touch, and the enormous size to which it attained caused discomfort by pressing on the stomach, and preventing it from retaining more than very small quantities of food. Emaciation, as in the other cases, was extreme before death, and some anasarcous swelling of the limbs was present; while the child's strength was exhausted by frequent return of diarrhoea. In connection with this subject, I must warn.you of the possibility of mistaking the swelling formed by a psoas abscess for that produced by enlargement of the kidney. When psoas abscess occurs in young children, its early stages may readily be overlooked, partly because the patient is unable to describe those vague sensations of uneasiness in the loins by which it is attended—partly because impairment or loss of the power of walking is so common a result of indisposition of any kind in early life that it seems scarcely necessary to seek for any special cause to explain its occurrence. The gradual failure of the health, the loss of flesh, and the occasional disturbance of the bowels, are symptoms that attend upon various disorders of the abdominal viscera, and that present nothing pathognomonic of any. The tumor, like that formed by enlargement of the kidney, occupies the lumbar region, projecting forwards into the abdomen; while fluctuation in the abscess is often so obscure, as to be scarcely, if at all, perceptible. The tumor of psoas abscess, however, reaches less high up in the ab- domen than that formed by enlargement of the kidney; its contour is usually more circular, less oval, and the tenderness over it is in general greater, than in cases of malignaut disease of the kidney. As the affection advances, and the matter gravitates into the thigh, or points in the lumbar region, its nature becomes clearly manifest; but though, as far as the final issue of the case is concerned, an error of diagnosis is but of little import, it is yet very desirable for your 544 ENLARGED SPLEEN own reputation that you should not, at any period, have fallen into a mistake as to its nature. In this country, and especially in the neighborhood of London, where the severer forms of intermittent fever seldom occur, we do not very often meet with instances of that enlargement of the spleen which is common enough even among children in malarious districts, and usually, though not invariably, succeeds to previous attacks of ague. The only instance of it, as a sequela of ague, which I have had the opportunity of observing, was presented by a little girl, six years and a half old, who had lived at Fernando Po from the age of two years and a half, having had dysentery at three years old, and frequent attacks of fever subsequently. The enlargement of her spleen had first become apparent at five years of age; and when I first saw her, a few weeks after her return from Africa, it had attained so consider- able a size that her abdomen measured twenty-one inches and a half in circumference. The spleen in this case reached from under the ribs quite down into the pelvis, and forwards as far as the mesial line of the abdomen. Independently of the patient's history, which in a case of this kind would be of itself sufficient to prevent an erroneous diagnosis, the relations of the swelling were characteristic; for, although situated at the side of the abdomen, it did not extend back- wards into the lumbar region so as to fill up completely, as an en- larged kidney would do, but a considerable interval existed between the posterior margin of the tumor and the vertebral column. Cases of enlargement of the spleen as considerable as this are, how- ever, occasionally met with in early life, quite independently of the influence of malaria, but in connection with that morbid state of the circulating fluid to which the name of leucaemia has been applied. For the most part I believe this condition date3 back to early infancy, and I have known considerable enlargement of the spleen associated with it in a child only three months old; and though in the majority of cases which I have observed, the age of the patients varied from nine to fifteen months, yet the size that the spleen then presented clearly showed that its enlargement must have begun long before that time. The early age at which this condition has been noticed, clearly negatives its supposed dependence on protracted lactation;1 while its occurrence among the children of the wealthier classes, as well as among those of the poor, shows that it depends on constitutional causes, not merely on bad air, or other unfavorable hygienic influences. In its minor degrees the enlargement of the spleen is not infrequently overlooked, and I have sometimes discovered it where it had not been at all suspected, but where the pallor of the child, the peculiar waxen hue of its surfaces, its failing strength, and loss of flesh, yet unasso- ciated with the evidences of tuberculosis, betrayed to those who were familiar with its features the real nature of the ailment. In such cases the enlarged spleen sometimes returns to its proper size in pro- portion as the health of the child improves; as it often does under a 1 An idea suggested by Dr. Battersby, to whose article on Enlargement of the Liver and Spleen in Children, in Dublin Med. Journal, May, 1849, p. 308, we are indebted for calling the attention of the profession to cases of this description. IN CONNECTION WITH LEUC^IMJA. 545 tonic treatment combined with the employment of preparations of iron and quinine. When the depravation of the blood, however, is very considerable, no amendment follows treatment; while not only does the enlargement of the spleen become more and more consider- able, but in very many instances the liver also participates in the change; and two distinct tumors may then be perceived in the abdo- men : the one of an elongated form, seated on the left side, and often dipping down into the pelvis; the other at a more rounded form, principally occupying the right side, and not descending so low. When the enlargement is very considerable, the circulation through the ab- dominal vessels is interfered with, and the superficial veins in conse- quence become enlarged ; but it is decidedly unusual for ascites to be produced. The smoothness of surface of these tumors, and their equable firmness serve to distinguish them from growths of a malig- nant kind; all of which, by the by, are of far greater rarity than those of which I am now speaking. It now and then happens, in connection with this affection, that a great disposition to hemorrhage manifests itself; and this not only in the appearance of petechias on the surface, but also in the occurrence of formidable or even fatal epistaxis, or hsematemesis. I have not observed any instance of this occurrence myself, though I remember a little girl dying in these circumstances under the care of my col- league, Dr. Jenner; and I believe that this accident is to be looked for in children of five years old and upwards rather than in infants. They indeed generally fade away with no very definite symptoms, but grow feebler and feebler, just as women with large ovarian tumors may often be observed to do, when the blood which should nourish the body is diverted to the supply of the morbid growth. The appe- tite usually keeps up, and not infrequently the bowels continue regu- lar, though diarrhoea occasionally takes place; and the loss of strength, the increasing pallor, and the more and more waxen hue of the sur- face, are in general more remarkable than even the loss of flesh, though towards the end of life that too is often very considerable. Slight irregular febrile disturbance is seldom absent as the disease advances, and seems, just as in cases of general tuberculosis, to con- tribute not a little to exhaust the patient. I do not know indeed how more shortly or more correctly to sum up the symptoms of this affec- tion, than by saying that they are those of general tuberculosis, but with greater pallor of the surface, less apparent suffering or distress, less disturbance of any one set of functions, less rapid loss of flesh ; and with an enlargement of the spleen, which gives a clue to the understanding of the whole train of phenomena. The prognosis in these cases is generally unfavorable; I should imagine it to be far more so in these circumstances than when the affection of the spleen is the result of the influence of malaria. I have already referred to the kind of treatment which is appropriate, and which should be steadily continued for months, without the indul- gence of too sanguine expectations of speedy amendment. I will only add that the raw meat to which reference has already been made as of so much service in cases of diarrhoea, is also of special use in 35 516 SYMPTOMS OF INFANTILE SYPHILIS. some of these cases; being in general readily taken, and perfectly well assimilated. According to the plan which we proposed to follow in this course of lectures, it remains for us now to study, in conclusion, the febrile diseases of infancy and childhood. There is one affection, however, too important to be passed over in silence, although it cannot be assigned to any of those classes into which, for convenience sake, we distributed the diseases of early life. I propose, therefore, to devote the remaining half hour of to-day to the study of infantile syphilis, and to defer till to-morrow the consideration of the fevers and exan- themata. Syphilis, as it occurs in the infant, presents many important dif- ferences from the characters which it assumes in the adult; nor is there in this anything to excite our surprise, if we bear in mind the very different circumstances in which, in the two cases, the poison infects the organism. In the adult, the manifestations of the disease are almost always the result of the direct inoculation of the system with the venereal virus. In the child, infection by that mode seldom occurs; and the communication of the disease from the mother to her -child during its birth, which was once supposed to be the ordinary >mode of origin of infantile syphilis, is now justly regarded as of such rarity, that we can only say that it is not impossible. The infection of a child by sucking the milk of a syphilitic nurse, is, to say the least, a very unusual occurrence; and the weight of evidence is de- cidedly against its ever taking place. Cases, indeed, are by no means unusual in which the nipple of a previously healthy nurse having been excoriated by the mouth of a syphilitic nursling, the disease is communicated to her own child, who shares the breast with its foster- brother: but between this accident and the direct transmission of syphilis by the milk, there is obviously no analogy. In by far the greater number of cases the infant has, without doubt, contracted the disease in the womb, although its indications comparatively seldom show themselves until at least fourteen days after birth. In many of these cases the mother has, during her pregnancy, been the subject of primary syphilis, or if not, has presented well-marked secondary symptoms; and under either of these conditions we can understand that her infected blood may deteriorate that of her infant, and give rise to consequences more or less analogous to those from which she has recently suffered herself. Cases, however, are now and then met with, in which the venereal taint appears to have been derived entirely from the father; the mother, as far as can be ascertained, not having suffered at any time either from primary or secondary symptoms, although she has given birth to an infant affected with all the charac- teristic marks of syphilitic disease.1 Through whichever of these media the infant becomes infected with syphilis, symptoms of the same kind appear, though there is no inva- riable order in which they show themselves; and coryza is its earliest 1 Ample evidence of this is collected by M. Diday, at p. 22 of his Trait4 de la Sy- philis des Enfans Nouveau-Nes. 8vo. Paris, 1854. SYMPTOMS OF INFANTILE SYPHILIS. 547 indication in one case, a cutaneous eruption in a second, ulceration about the corners of the mouth in a third. When we consider the frequency with which abortion or premature labor appears to be due to the influence of the syphilitic poison, it might naturally be expected that cases should be by no means unusual in which infants at the moment of their birth should present evidences of the venereal taint. This, however, is very seldom the case—so seldom, indeed, that I do not remember to have met with an instance of it; neither has any case come under the notice of M. Trousseau, of Paris,1 whose appoint- ment at the Hopital Necker in that city gave him most ample oppor- tunities for observing the diseases of early infanc}7. Children, although irtfected with syphilis, and in whom the signs of the disease speedily show themselves, are yet generally well nourished, and apparently in good health, at the time of birth. This, too, is observed to be the case even where the mother has suffered severely from secondary symp- toms—has already aborted frequently, or has given birth prematurely to dead children whose cuticle was peeling off—a condition generally regarded, though far from being satisfactorily proved, to be an effect of the venereal poison. When she at length produces a living child, there is nothing for the first two or three weeks after its birth to dis- tinguish it from the offspring of the most healthy parents. After the lapse of that time the first symptom of disease shows itself; and most commonly this is nothing, more than the occurrence of a degree of snuffling with the child's breathing, and slight difficulty in sucking— the signs, in short, of ordinary coryza.2 Now and then, as I stated some days ago,3 no other indication of syphilis appears; but never- theless the coryza does not yield until after the child has been brought under the influence of mercurial remedies—a fact which would seem to show that, although unaccompanied with other signs of venereal taint, the snuffles of young infants are sometimes produced by that cause. In the majority of instances, however, the coryza does not continue long without characteristic signs of disease appearing about the nostrils themselves, and without syphilitic eruptions breaking out upon the surface of the body. The mucous membrane of the nostrils secretes a yellow ichorous matter, sometimes slightly streaked with blood, which, drying, obstructs the opening of the nostrils, and renders breathing and sucking very distressing to the child. The voice, too, before long becomes affected, and assumes a peculiar hoarse tone, which has been not inaptly compared to the sound of a child's penny trumpet, and which, when you once have heard, you will at once recognize as almost pathognomonic of syphilis. This change of voice depends no doubt on the affection of the throat, which you will often see, in common with the interior of the mouth, to be red and shining, 1 See his very valuable memoir on Infantile Syphilis, in the Archives Gen. de Mede- cine for October, 1847. * Diday has collected the particulars of 158 cases, in which the date of the appear- ance of the first symptom of syphilis was accurately noticed. It showed itself in 86 within the first month, and in 110 within six weeks, while there were but 12 instances in which it was deferred beyond the third month. Op. cit., p. 164. 3 In Lecture XIX. p. 244. 548 PROGRESS OF and to present many superficial ulcerations. The skin of the upper lip, over which the discharge from the nostrils runs, often becomes excoriated, or if not, it assumes a peculiar, yellowish-brown color, like the hue of a faded leaf. Should the disease be unchecked, large patches of the skin upon the face and forehead put on this appearance, which seems due to a kind of staining of the part, and is unaccom- panied with any alteration of its texture. Both lips before long be- come affected: a number of minute perpendicular fissures take place in them, which bleed whenever the infant sucks; and small ulcera- tions appear at either angle of the mouth. It generally happens, however, before these effects of the disease have become very obvious about the mouth, that the skin in various parts presents appearances equally characteristic. Though not limited to any situation, the erup- tion of syphilis usually makes its appearance about the buttocks and nates, in the form of small, circular, shining spots of a coppery-red color, having a slightly shining surface, and disposed to become some- what rough at their centre from the desquamation of the epidermis in that situation. The spots in the neighborhood of the anus often degenerate into small, soft, spongy ulcerations, with a slightly elevated base; the margins of the anus become fissured; and the skin about the scrotum and along the inside of the thighs grows red, sore, cracked, shining, and denuded of its epidermis. The eyes grow weak, the margins of the eyelids sore, and a scanty, adhesive, puriform secre- tion is poured out from the Meibomian glands, attended with but little redness of the conjunctiva. Sometimes, too, the hair of the head drops off, as small, red, sometimes slightly elevated spots, extend over the scalp. The child is generally by this time reduced to the last stage of weak- ness and attenuation; but even when the disease proves fatal, it does not, as in the adult, affect the bones. I have chanced, indeed, to see one instance of destruction of the bony palate from this cause in an infant of a few months old; but so rare is the occurrence, that the late Mr. Colles, of Dublin,1 notwithstanding his immense experience, states that he had never observed it. Should life be prolonged after the disease has reached an advanced stage, its further manifestations con- sist in the formation of small pustules about the mouth, especially upon the lower lip and chin, which destroy the cutis, and leave the surface after they have healed much scarred by their cicatrices. The epidermis, too, in some bad cases peels off the hands and feet; it generally becomes thickened to a kind of a crust, like that which forms on the hands in psoriasis palmaria, and then, cracking, falls off in patches, leaving the skin fissured, and sometimes deeply ulcerated at the bend of the wrist, or at the flexures of the fingers and toes. The new and delicate epi- dermis in its turn undergoes a similar thickening, and becomes detached in the same manner, or else it continues white and thin, but shrivelled, and looking like the sodden and wrinkled skin of a washerwoman's hand, and, peeling off in little fragments, leaves the cutis, especially at 1 Practical Observations on the Venereal Disease, 8vo. p. 271. London, 1837. INFANTILE SYPHILIS. 549 the tips of the fingers and toes, red, and bleeding slightly, even on the gentlest touch. Although such are the effects that may flow from infantile syphilis when it runs its course unchecked, it yet happens but rarely that we meet in any case with all the symptoms that have just been described. Most serious constitutional disturbance is associated with the local mischief, and the child often falls a victim to the former, when the outward signs of syphilitic disease are yet comparatively slight. It wastes rapidly, it suffers from sickness, or its bowels become much purged; it is constantly fretful and uneasy; the advance of ossifica- tion is arrested; the head feels soft, and the anterior fontanelle is large; —circumstances which sometimes lead to the suspicion that chronic hydrocephalus has come on, though, if the poison of syphilis should be eradicated from the system, the completeness of the patient's reco- very shows that no serious cerebral disease had existed. In children affected by this syphilitic cachexia, not only are the loss of flesh, and that withered aspect which gives to infancy the appearance of old age, very remarkable, but also the bloodless state of the conjunctiva, and the yellow, waxen hue of the skin, like that of a person who has been reduced to the most extreme degree of anaemia. Even in children who have survived their earliest infancy, and in whom the disease, though not completely eradicated, has yet been kept in check, this color of the skin continues, and seems, indeed, to be an almost pathognomonic sign of the affection from which they are suffering. When imperfectly cured, other indications of the disease remain besides the impairment of the general health, the loss of flesh, and the peculiar color of the skin; or at least, if not constantly present, they show themselves from time to time, reappearing at uncertain intervals, without there being any fresh cause for their manifestation. Such symptoms are the return of the small copper-colored spots, which, however, seldom reappear in considerable numbers; the general loss of hair; the existence of a slight degree of coryza ; the appearance of one or two soft tubercular elevations, with ulcerated summits, about the organs of generation, or the outbreak of a very severe and un- manageable intertrigo. In other instances, there are few local signs of the disease beyond the occurrence of small ulcerations at each angle of the mouth, or the development of large, soft, condylomata at the verge of the anus, or in a few instances the formation of exceedingly troublesome ulcerations, having a slightly elevated base, between the fingers and toes, which last appearances seem to belong to the tertiary rather than to the secondary consequences of syphilitic disease. The duration of the disease, and the mode in which it proves fatal, vary in different cases; for while death sometimes takes place speedily under the first outbreak of its symptoms, life is in other instances pro- longed for several months. In cases of this kind the more marked signs of the disease recede for a time, either spontaneously or under medical treatment, but the evidences of the syphilitic cachexia con- tinue • the child never regains its health, glandular enlargements take place, and it either dies phthisical, or else drags out a miserable exist- 550 TREATMENT OF INFANTILE SYPHILIS. ence until some intercurrent disease, as pneumonia or diarrhoea, super- venes and destroys it. Within the last few years anatomical research has discovered certain organic affections of the viscera connected with the syphilitic cachexia, to which the fatal termination of the disease is, at any rate in some measure, to be attributed. Suppuration of the thymus gland, the formation of small indurated nodules throughout the lungs passing rapidly into a state of suppuration, and the occurrence of that albu- minous degeneration and enlargement of the liver of which I spoke at the commencement of this lecture, are the more important changes with which the researches of MM. Dubois,1 Depaul,2and Gubler,3have made us acquainted. With reference to the alterations in the lungs, their relation to genuine lobular pneumonia seems to be uncertain, and it also appears to be somewhat doubtful whether their connection with infantile syphilis is anything more than the result of mere acci- dental complication; but the evidence of the dependence of the affec- tion of the thymus and of the liver on the syphilitic poison must be regarded as conclusive. Though the consequences of infantile syphilis are so serious if it be either let alone or inefficiently treated, a fatal result seldom takes place if remedies are employed before the syphilitic cachexia has become fully established, and if treatment, when once begun, is perse- veringly continued for some time after the complete disappearance of every symptom. This, indeed, sometimes implies the continuance of treatment for two or even three months; for so long as any symp- tom remains, be it only a slight spot of eruption, or a small condyloma about the anus, the suspension of remedies will be certainly followed by the reappearance of the whole train of symptoms. Even after the apparent cure of the affection, it is not wise hastily to omit all medi- cines, since, just as in the adult, the symptoms have a great tendency to recur. Mercury, in some form or other, appears to be indispensable to the cure of this affection. It has been recommended by some writers not to administer it directly to the child, but to content ourselves with bringing the mother's system gently under the mercurial influence, and to cure the infant through her medium. In some slight cases this may suffice, and in almost all the cure of the infant is materially expedited by the administration of the remedy to its mother; but I think that, as a general rule, it is expedient to give mercury likewise to the child. For internal administration, I prefer the hydrargyrum cum creta to any other form of the remedy, and give it in doses of a grain twice a day to a child of six weeks old, combining it with two or three grains of chalk if the bowels be disturbed at the time of com- mencing the treatment, or if they become so during its continuance. I have never found it seriously disagree, though sometimes it causes sickness, in which case small doses of calomel, or of the solution of 1 Gaz. Med. de Paris, 1850, p. 392. 2 Ibid., 1851, p. 288. 3 Memoires de la Societe de Biologie, 1853, p. 25. See also, with reference to these subjects, the recent work of M. Diday, already referred to. DISCHARGES FROM THE VAGINA AND VULVA. 551 corrosive sublimate, may be substituted for it. In some cases, what- ever be the form of mercurial employed, its protracted use occasions such great irritability of the stomach, that we are compelled to dis- continue the remedy. Usually, the child becomes able to take it again after a pause of two or three days; but if this should not be the case, we must leave it off, and content ourselves with ordering a scruple of mercurial ointment to be rubbed into the thighs or the axillae twice a day, or with letting the child wear the mercurial belt. This simple contrivance, which consists in nothing else than swathing a piece of flannel, the inner surface of which is smeared daily with unguentum hydrargyri, around the abdomen of the infant, is spoken of by those who have employed it most as being an exceedingly efficacious method of bringing the system under the influence of mercury, and as free from all the risks of disordering the child's health which attend upon the internal administration of that remedy. In hospital practice I confess that I have scarcely tried its merits; for I found that while I could give powders without suspicion, the mercurial ointment was known; and inconvenience arose from the remedy betraying the nature of the disease. This objection might probably have been got rid of by coloring the ointment with cinnabar; but my experience of the gray powder was, on the whole, so satisfactory that I felt the less anxious to try a new plan of treatment. As a local application to the sores, the black wash usually agrees better than anything else ; but the large soft condylomata, which form about the anus, often require to be touched with the solid nitrate of silver. It very often happens that as the syphilitic symptoms disap- pear the health of the child becomes perfectly restored under the use of no other remedy than mercury. If this be not the case, however, some tonic medicine or other must be given. If tbe bowels be disor- dered, the liquor cinchonae, or the extract of sarsaparilla, will be found very useful. If there be no gastric or intestinal irritation, minute doses of iodide of potassium may be given in combination with the extract of sarsaparilla; but if the syphilitic cachexia be well marked, and the child have suffered long from the disease, or have had frequent returns of its symptoms, no remedy has appeared to be so serviceable as the iodide of iron, which may be given in the form of syrup, and is in most cases taken by the child very readily, while it is seldom found to disagree. I may here conclude my remarks about an affection which, perhaps, in strict propriety, scarcely comes within my province; but, before closing to-day's lecture, I should wish to say a few words about those muco-purulent discharges from the vagina and vulva, in young girls, which were once erroneously supposed to be due to some impure cause ;:i an opinion which, though now justly abandoned by the profession, still retains its hold among the vulgar. Discharges of pus, or of mucus mingled with it, take place in fe- male children of all ages, from the time when dentition commences down to the period of puberty, but are most frequent between the ages of two and seven years. They are almost always essentially chronic in their character, being associated in general with very little 552 TREATMENT OF THE DISCHARGES. swelling of the sexual organs, and with little or no pain; but proving extremely annoying from their disposition to continue for a long time, from their obstinate resistance to jemedies, and their great tendency to recur under very slight exciting causes. Even when the discharge is very profuse, there is no great redness of the parts from which it is poured out; while it will be seen to be furnished almost entirely by the inner surface of the labia, by the nymphae and the vulva gene- rally, but to come scarcely at all from the canal of the vagina. The slight degree of swelling of the parts; the source of the discharge almost exclusively from the parts anterior to the hymen; and the absence of dysuria, or the very slight degree in which it has attended the onset of the affection, coupled with the integrity of the hymen, and the absence of all appearances of injury, are sufficient to distinguish this affection from gonorrhoea. Sometimes, indeed, when this discharge has come on during teething, it has been preceded by considerable dysuria; but older children rarely suffer more than a degree of itching and smarting of the parts, which is troublesome from its persistence rather than from its severity. When it occurs during dentition, the discharge is not in general abundant, and ceases so soon as the tooth has cut through the gum, though probably returning with a renewal of the irritation. Sometimes it occurs in children who are much troubled by ascarides, when it is kept up in many instances, not merely by the irritation excited by their presence in the rectum, but in a measure, also, by their creeping about the vulva. In some instances it takes place as a sequela of the eruptive fevers, especially of scarla- tina ; and, though I have never met with it in these circumstances, except as a chronic ailment, accompanied by great general debility, cases have been related1 in which it came on with acute symptoms on the decline of the eruption. Generally, however, it neither succeeds to any previous fever, nor is dependent on any local cause, but occurs in strumous children in connection with general impairment of health, or following some considerable fatigue. Where no special cause can be assigned for its occurrence, its appearance is yet, in general, preceded for a day or two by some slight increase of indisposition; such as an attack of feverishness, or catarrh, or diarrhoea. Be the cause what it may, our great difficulty in almost every in- stance is to effect a permanent cure, so that the suspension of our remedies may not be followed by a return of the discharge. When it is connected with teething, or with the presence of worms, the in- dications are plain enough, and the cure is in general comparatively easy. Simple but abundant ablution with tepid water, repeated every hour or two on the first appearance of the discharge, will, in conjunc- tion with appropriate general treatment, not unfrequently suffice for its complete arrest. If the discharge, however, continue for more than one or two days, astringents must be had recourse to, such as the liquor plumbi dilutus, or lotions of sulphate of zinc, or of alum, each of which may be employed for a few days, and then changed for another. At the same time frequent cold sponging of the nates and 1 By Dr. Cormack, in the London Journal of Medicine, Sept. 1859. FEVERS. 553 vulva should be employed; and it must be impressed on the child's attendants that no lotion whatever can supply the place of frequent ablution. Now and then, when at the onset of the discharge there has been more dysuria than common, I have given small doses of copaiba and liquor potassae, and have obtained from their administra- tion just the same kind of relief as those remedies afford in acute vaginitis in the adult. Such cases, however, are quite exceptional; and usually tonics, and especially preparations of iron, are the only internal remedies which are required, while it is in general necessary to begin their administration early. These medicines, especially if associated with change to the seaside, and sea bathing, usually suffice, even in the most obstinate cases, to effect a cure. It is, however, in general a wise precaution to continue the employment of frequent ablution, and, in addition, to sponge the parts twice a day with alum lotion, even for weeks after the discharge has completely ceased; while once I found the employment of a lotion of a scruple of nitrate of silver to an ounce of water, necessary to arrest a discharge which had bid defiance to all other remedies. LECTURE XLI. Fevers—chiefly belong to the class of the Exanthemata. Mistakes with reference to simple fever in childhood—its identity with fever in the adult. Infantile Remittent Fever, identical with Typhoid Fever, which is a fitter name, occurs in two degrees—symptoms of its milder form—of its severer form—signs of convalescence—modes of death.—Diagnosis.—Treatment. Intermittent Fever or Ague—peculiarities characterizing it in childhood. We come now to the last part of this course of lectures; namely, to the study of the febrile diseases incidental to infancy and childhood. They belong, for the most part, to the class of the Exanthemata— diseases characterized, as you know, by very well-marked symptoms, by a very definite course, and by usually occurring only once in a person's life. These peculiarities have always obtained for them the notice of practitioners of medicine, and few of the affections of early life have been watched so closely, or described with so much accuracy, as smallpox, measles, and scarlatina. Hence it will be unnecessary to occupy so much of your time with their investigation as we have devoted to the study of other diseases which, though not so important, have yet been less carefully or less completely described. While the well-marked and unvarying features of the eruptive fevers, however, have forced those diseases on the attention of all observers, the more fluctuating characters of continued fever have been so masked by the differences between youth and age, that the affection as it occurs in early life was long almost entirely overlooked, and its nature was, in many respects, still longer misapprehended. 554 INFANTILE REMITTENT: Many, indeed, even of the older writers on medicine, have spoken of fevers as occurring among children at all ages; but under this name they confounded together several diseases in which febrile disturbance was merely the effect of the constitution sympathizing with soma local disorder. This mistake was committed with especial frequency in the case of various affections of the abdominal viscera; many of which are attended by a considerable degree of sympathetic fever, while their symptoms, in other respects, are often so obscure that the imperfect diagnosis of former days failed to discover their exact na- ture. As medical knowledge increased, many of these disorders were referred to their proper place; but, nevertheless, the descriptions given of the so-called remittent fever, worm fever, and hectic fever of children, present little of a definite character, and are evidently the result of a blending together of the symptoms of various affections. The disease described under these various names was supposed to be a symptomatic fever, excited by gastric or intestinal disorder, and limited in the period of its occurrence to early life; while the absence of the well-marked shivering which usually attends the onset of fever in the adult, the rarity of any efflorescence on the surface of the body, and the comparatively low rate of mortality which it occasions, led persons altogether to overlook the close connection between it and the continued fever of the adult. It was not to be wondered at that the identity of continued fever at different periods of life should escape observation, so long as the various types of the disease in the adult, though separated by essen- tial differences, were yet confounded together. The recognition of the distinctive character of typhus and typhoid fevers was a necessary step towards this object; and this once taken, the analogy between the latter affection in the adult, and remittent fever in the child, could not long remain unnoticed. To M. Killiet1 we are indebted for a most elaborate inquiry into this subject, which shows so close a resemblance to subsist between the two diseases, as must, I think, remove all doubt with reference to thejr identity. They both occur independently of any cause which we are able to detect, the occa- sional influence of contagion alone excepted; they both run a definite course, and have the same duration, while both, though generally affecting isolated individuals, have also their seasons of epidemic pre- valence. Though varying in severity, so that in some cases confine- ment to bed for a few days is scarcely necessary, while in other cases the patient hardly escapes with his life, yet medicine has not been able to cut short the course even of their mildest forms. And, lastly, though the local affections associated with both vary much in different cases, yet in every instance we meet with that assemblage of symp- toms which makes up our idea of fever. Or if, from the examination of tbe symptoms during life, we pass to the inquiry into the traces left by the disease on the bodies of those to whom it proves fatal, we shall find still further evidence of the close relation that subsists be- 1 De la Fievre Typhoide chez les Enfants: These de la Faculte, 1840; and Traite des Maladies des Enfants, vol. ii. p. 663. IDENTICAL WITH TYPHOID FEVER. 555 tween the fever of the child and that of the adult. Enlargement, tumefaction, and ulceration of Peyer's glands, constitute one of the most frequent morbid appearances in both diseases, and in both, the changes that these glands are found to have undergone are more advanced and more extensive in proportion to their nearness to the ileo-caecal valve. In both, too, the mesenteric glands are enlarged, swollen, of a more or less deep-red color, and manifestly increased in vascularity ; while the softened state of the spleen, the gorged condi- tion of the lungs, and the congestion of the membranes of tbe brain, are appearances common to both diseases. There is, however, no more relation between the severity of the intestinal lesion, and the intensity of the symptoms in the fever of the child, than in that of the adult; and there is no ground for regarding the disease as the mere effect of the constitution sympathizing with a certain local mischief in the former case, which may not be equally alleged with reference to the latter. The symptoms in both "are the expression of the influ- ence of the disease on the whole economy, of the disorder, which it occasions in the principal functions of the body, and are an essential part of the disease itself, rather than the secondary effects of certain lesions of the bowels."1 If, however, this be so, it will tend greatly to the avoidance of errors which time has rendered popular, if for the future we altogether dis- card the term, infantile remittent fever, from our scientific nomencla- ture, and speak, as many French writers do, only of typhoid fever, in children. The different degrees of severity which a disease may present in different cases do not in general form a good basis on which to found any classification of its varieties; but in the case of typhoid fever the differences are so great between its milder and its severer form as^ to warrant our adopting them as a ground for its subdivision into two classes. In cases of the first or milder kind, the disease usually comes on very gradually, often so much so that the parents of a child who is attacked by it are unable to name any fixed time as that at which the illness began. The child loses its cheerfulness, the appear- ance of health leaves it, the appetite fails, and the thirst becomes troublesome; by daytime it is listless and fretful, and drowsy towards evening, but the nights are often restless, or tbe slumber broken and unrefreshing; while all these symptoms come on without any evident cause, and are not accompanied by any definite illness. When once the attention of the parents has been excited to the condition of the child, it is soon ascertained that the skin is often hotter, and almost always drier than natural, though now and then rather profuse sweats break out causelessly on the surface, and continuing for an hour or two, leave the patient in no respect relieved by their occurrence. The bowels are sometimes loose even at the onset of the disease, or if not they are in general readily disturbed by medicine; a very mild aperient being not infrequently followed by three or four actions of the bowels daily for tbe next two or three days. In a few instances 1 Chomel, Lecons de Clinique Medicale"; Fievre Typhoide, p. 231, 8vo. Paris, 1834. 556 TYPHOID FEVER—SYMPTOMS OF ITS MILDER FORMS. there is a condition of rather obstinate constipation at the onset of the disease, requiring active measures to overcome it; but this is not often the case, and when it does occur, it is, I think, more frequently in the severer than in the milder form of the disease. The appearance of the evacuations is almost always unhealthy, and they are usually relaxed and very offensive. The tongue is generally rather deficient in moisture, red at the tip and edges, thinly coated on the dorsum with white mucus, through which the papillae appear of a deep red color. The abdomen is soft, though there is some flatus in the intes- tines, and pressure is usually borne without pain. These characters often continue through the whole course of the affection, though sometimes, after the middle of the second week, pressure in either iliac region, especially the right, appears to cause suffering. The pulse is generally accelerated from the very commencement of the illness; sometimes it is very much so, but there is by no means a constant relation between the heat of skin and the rapidity of the pulse. Occasionally there is slight cough, but this symptom is very frequently absent in the milder cases of the disease. As the symp- toms which constitute this affection come on very gradually, so they often continue for several days with little, if any, change from day to day, though the patient is far from seeming equally ill at all times of the day; and this periodical exacerbation and remission of the symp- toms obtained for the disorder the name of remittent fever. In some instances two distinct exacerbations and remissions may be observed in the course of every twenty-four hours, but in the majority of cases only one is well marked. The child, who during the day has been listless and poorly, but yet not incapable of being amused, and has had the appearance of a patient convalescent from illness, rather than of one still suffering from disease, becomes flushed and uneasy, and feverish, as evening approaches; and sometimes slight horripilation ushers in the evening exacerbation of fever. He seems drowsy, and begs to be put to bed, where sometimes he sleeps, though seldom tranquilly, till morning. In the second week, the nights generally become worse than they were at an earlier stage of the disease; the child's skin is very dry and hot, he sleeps with his eyes half open, talks in his sleep, wakes often to ask for drink, and occasionally has slight delirium. Early in the morning he wakes pale and unrefreshed, but about 9 or 10 o'clock seems to have recovered something of his cheerfulness, and for the succeeding three or four hours appears toler- ably well; but as evening approaches he seems weary and drowsy, again the febrile paroxysm occurs, and the succeeding night closely resembles the night before. Sometimes, in addition to the evening exacerbation, there is a second one, though less severe, at about 11 o'clock in the morning; from which the child has hardly recovered before the severe evening attack comes on. As the case advances towards recovery, the morning attack disappears long before the evening paroxysm ceases to recur; and it happens not infrequently that a slight threatening of the evening exacerbation continues to return for some time after the child has seemed in other respects quite well. It is during the second week of the disease that the rose spots TYPHOID FEVER — ITS SEVERER FORMS. 557 characteristic of typhoid fever generally make their appearance, if they appear at all; but they are often very few in number, and not infrequently are altogether absent. Towards the end of the second, or the beginning of the third week, the symptoms begin to abate, the bowels act more regularly, the appearance of the evacuations becomes more natural, the tongue grows cleaner and uniformly moist, the thirst diminishes, and the evening exacerbations of fever become shorter and'less severe; while the child's cheerfulness by day gradually re- turns, and his face resumes the aspect of health. Convalescence, how- ever, after even a mild attack of the disease, is rarely established before the end of the third week, w1iile the child is in general left extremely weak, and greatly emaciated; the loss of flesh and strength being quite out of proportion to the severity of the illness, and the progress to complete recovery being usually very slow. It sometimes happens, that, having set in with comparatively mild symptoms, the typhoid fever assumes a serious character in the course of the second week. In the majority of instances, however, the severer form of the disease gives some earnest of its severity at a very early period. It commonly sets in with vomiting, accompanied, in many cases, by headache, or by a remarkable degree of drowsiness and heaviness of the head. Coupled with these symptoms, there are those indications of fever which attend the milder forms of the disease, though in this case with a proportionate increase in their severity; and sometimes distinct rigors may be observed alternating with the heat of the surface, or preceding the evening exacerbations of the fever. In the greater number of instances, the vomiting with which the illness sets in does not return after the second or third day of the patient's illness; but to this there are occasional exceptions; and as the sickness is usually more severe in cases in which constipation is present, there is some risk of mistaking the real nature of the affection, and of re- garding the irritability of the stomach as a sign of approaching cere- bral disease. Now and then, too, the drowsiness at the onset of the disease is so overwhelming that I have known a child fall asleep two or three times during breakfast, while his dizziness and inability to walk steadily still further strengthened the impression that he was suffering from some affection of the brain. Either of these occurrences, however, is unusual; and, though listless and drowsy, the child is in general unwilling to keep his bed, while by night he is commonly very restless, waking often in a state of alarm, or talking much in his sleep. The countenance before long begins to wear the peculiar heavy appear- ance of a fever patient, and by the end of the first or the beginning of the second week the child is usually found to have sunk into a state of stupor, from which he seems unwilling to be roused. The skin of the trunk is now almost constantly hot as well as dry; the tempera- ture being often higher than in any other disease, with the exception of scarlatina, and in a few instances ranging as high as 105° Fah. My own observations with reference to the date of appearance of the erup- tion on the surface are neither sufficiently numerous nor sufficiently accurate for me to rely on their authority. MM. Billiet and Barthez observe that it very seldom appears as early as the fourth day, from 558 TYPHOID FEVER: the sixth to the tenth being the most common date of its appearance; while both the period during which it remains visible, and the number of spots are liable to great variation. In by far the greater number of cases the eruption at any one time is extremely scanty; not infre- quently, in spite of careful daily examination of my patients in the Children's Hospital, two or three spots only have been discovered; and even these have remained visible for only two or three days; though fresh spots not infrequently appear as the others fade, for seve- ral successive days. Now and then I have observed an abundant eruption, thirty or forty spots being scattered at one time over the whole abdomen, but this is altogether an exceptional occurrence. I have observed this abundant eruption only in severe cases of the fever, but there is no constant relation between the amount of erup- tion, and the severity of the fever; and in some of the severest cases, the most careful examination has failed to discover the characteristic spots at any stage of the disease. In a few cases profuse sweats take place, but they do not seem to have anything of a critical character. The pulse is very frequent, and I have known it to continue at nearly 140 in the minute, for several days together, during the increase of the fever in a child eight years old. A frequent, short, hacking cough often occurs during the first week; and rhonchus, sibilus, and occasional large crepitation, are heard, in many cases, in both lungs. Now and then, too, the respiration continues much accelerated for several days, without any other sign of serious pulmonary disease being present, and gradually regains its proper frequency as the febrile symptoms subside. Tenderness of the abdomen is generally very evident before the first week is passed, but frequently there is no complaint of pain, even in severe cases, except on pressure; though that seldom or never fails to elicit evidences of uneasiness, often to excite distinct complaints. During the first week, the condition of the abdomen is usually natural and soft, even though slightly tender; it afterwards becomes somewhat distended with flatus, and a sense of gurgling is often perceptible on pressure in one or other iliac region; but it rarely becomes greatly tympanitic. Diarrhoea is usually present, though it is not in general severe, the bowels not acting above four or five times in the twenty-four hours. The tongue is usually more thickly coated at the commencement than in the milder forms of the disease; a dry streak soon appears down the centre, and by degrees the tongue becomes uniformly dry, red, and glazed ; or less often it is partially covered with sordes. In the course of the second week the patient generally sinks into a more profound stupor, a condition which alternates in many cases with delirium. Sometimes the mind wanders occasionally almost from the commencement of the disease, in other cases delirium is a very temporary symptom, occurring only at night, or when the child during the daytime wakes from sleep. Now and then, though not generally, the delirium is of a noisy kind, but the child not infrequently tries t<5 get out of bed; and both the restlessnes and delirium, though generally present in bad cases during the daytime, are aggravated in a marked degree at night. Once or twice I have known violent delirium come on towards evening, the SYMPTOMS OF ITS SEVERER FORMS. 559 child crying and shouting aloud during nearly the whole night, and sinking into a state of stupor by day. The child now seems nearly or quite unconscious of all that goes on around it; its evacuations are passed unconsciously, and it often seems dead to the sensation of thirst, by which, in the early stages of the disease, it was so much distressed; but this stupor of fever, is so different from the coma which supervenes in affections of the brain, and the insensibility which characterizes it is so much less profound, that one can hardly be mistaken for the other. Once only I have seen couvulsions occur in a child between two and three years old; who together with his two brothers suffered from very severe typhoid fever. The convul- sions which recurred on two successive days at the middle of the third week of the fever, were succeeded by paralysis of one side, which continued, though gradually diminishing, for four days. The child was unconscious even before their occurrence, and continued so for several days, though he eventually recovered. Even when the dis- ease is most severe, neither subsultus nor floccitation is frequent, though it often happens that during the tedious and fluctuating con- valescence the child picks its nose till it bleeds, or makes the tips of its fingers, or different parts of its body, sore by picking them. The, patient is by the end of the second week, sometimes earlier, reduced by the continuance of these symptoms to the most extreme degree of emaciation, and to a condition apparently hopeless; but there is no other disease incidental to childhood from which recovery so often takes place, in spite of even the most unfavorable symptoms. The signs of recovery are, in the main, the same as betoken the recovery of an adult suffering from fever; but the amendment has seemed to me always to be gradual, and in no case the result of any critical oc- currence. Moisture begins to reappear upon the edges of the tongue, the pulse loses its frequency, the delirium ceases by degrees, more quiet rest is enjoyed at night. Such signs of improvement may in general be looked for about or before the middle of the third week, but for days after their appearance the child's unconsciousness in many instances continues. He does not speak; he neither knows nor notices any one; and the mother, longing once more for her little one's fond look of recognition, and each day being disappointed of it, mistrusts the assurances that we may have given her, and loses heart and hope at a time when danger is really almost passed. At length it comes—a look, a smile, a gesture—but still no word; and slowly, very slowly, do the intellectual powers return, or does speech come back again. The first signs of amendment, however, may be taken as giving almost certain promise of complete recovery; but it is well to bear in mind that there is no disease of early life in which the mental faculties, though time brings them back at length uninjured, yet remain so long in a state of feebleness and torpor as in typhoid fever. Though the first signs of improvement, too, are very seldom deceptive, yet the fever in these severer cases can scarcely be con- sidered as passed before the thirtieth day; sometimes not till even a week later; while the patient's convalescence is almost always very slow, and interrupted by many fluctuations. 560 DIAGNOSIS OF TYPHOID FEVER. In the few cases—and according to my experience they are but few—in which typhoid fever in children terminates fatally,1 death is seldom the result of complications such as not infrequently supervene in the course of fever in the adult; but the vital powers give way under the severity of the constitutional affection, the symptoms of which assume more and more of a typhoid character. It is towards the end of the second, or at the beginning of the third week, that death in these circumstances is most likely to occur. I have seen it take place as late as the twenty-ninth day in one instance, and at the end of the fifth in another ; but in both of these instances gangrene of the mouth came on after the more alarming general symptoms had begun to subside; and to this the death of the child was chiefly due ; while on another occasion perforation of the intestine destroyed a child on the thirty-sixth day after the attack, when apparently ad- vancing favorably towards recovery. Now and then a fatal termina- tion takes place after the lapse of little more than a week from the commencement of the illness, under signs of cerebral disturbance, which throw the general febrile symptoms into the shade; great rest- lessness and agitation, with loud cries, being succeeded by convul- sions, and they, in their turn, being followed by coma, in which the child dies; while an examination after death discovers nothing more serious than a somewhat greater vascularity than natural of the brain and its membranes. The diagnosis of the disease has been rendered needlessly difficult by the loose manner in which the name remittent fever has been ap- plied to a variety of affections. Still, it must be confessed that there are several maladies between which and typhoid fever points of simi- larity exist in some parts of their course that may easily deceive the unwary. The resemblance is often very close between the milder varieties of the fever and some of those cases of gastro-intestinal dis- order, by no means unusual in young children, which are excited by errors of diet, and are either associated with diarrhoea or preceded by it. Something may be done, however, towards guarding against error in all doubtful cases, by bearing in mind that typhoid fever occurs more than twice as often in boys as in girls; that it is rare before five years of age, exceedingly uncommon before the age of two; and, when it does happen in such young subjects, can almost always be traced to contagion. The various forms of gastric disorder then attending or following dentition may, with almost absolute certainty, be determined to be local ailments, producing more or less constitu- tional disturbance, and thus essentially different from typhoid fever. But even in cases where the patient's age is not such as to raise a pre- sumption one way or the other, the degree of loss of strength, and the rapidity with which it becomes apparent, the dry heat of tbe skin, and its intensity at the time of the exacerbations of the fever, the marked 1 The mortality of 1 in 10, which is that given by MM. Rilliet and Barthez as occurring in their private practice, is considerably higher than that which I have experienced even among dispensary and hospital patients. The mortality of 1 in 4 in the Hopital des Enfants, at Paris, is obviously due rather to intercurrent diseases contracted in the hospital than to the fever itself. DIAGNOSIS OF TYPHOID FEVER. 561 disturbance of the sensorium, and the delirium at night, are charac- ters by which typhoid fever may be known, and whose absence would suffice to disprove the existence of that disorder. General tubercular disease, running an acute course, may indeed be taken for remittent fever; and the distinction between the two affections is sometimes attended by very considerable difficulty,1 especially if the case is not seen until the symptoms have become severe. Even then, however, something may be gathered for our guidance from the absence of rose spots, from the abdomen being generally flat, often shrunken, and from diarrhoea being absent, or at any rate not having occurred in acute tuberculosis until all the symptoms have assumed an extreme degree of severity. Auscultation too will often show good reason for suspecting the real nature of the case; or the previous history of the child will afford some clue with reference to it; though I believe that, with every care, instances will sometimes occur in which doubt will remain as to the real nature of the case until removed by examination of the body after death. There are two other affections, between which and typhoid fever, though their resemblance is far less decep- tive than that of acute tuberculosis, it is often far from easy to distin- guish, while, unfortunately, the practical evils that follow from a wrong diagnosis are of a very serious nature. When speaking, however, of hydrocephalus and of pneumonia,2 I dwelt so fully upon the circum- stances that might lead you to mistake either of those diseases for typhoid fever, and of the characteristics which belong to the last- named affection, that it can scarcely be necessary to do more than refer you to the observations made on those occasions. I am anxious, however, before we pass to the treatment of the dis- ease, to guard against an error which may possibly arise, from my having pointed out certain well-marked distinctions between the cere- bral symptoms of hydrocephalus, and those which accompany typhoid fever. Now, although it is perfectly true that the disturbance of the brain in the latter case is the result of mere functional disorder, which, with the abatement of the fever, will, in general, by degrees pass away, still it is not to be forgotten that serious, and even fatal, cerebral affec- tion occasionally attends it. It is not, indeed, commonly at an early stage of the fever that we need be anxious on this account, for danger- ous cerebral complications seldom occur before the middle of the second week, sometimes even later; while now and then they succeed to a sort of imperfect convalescence, from the signs of which we had already begun to hope that the most anxious period was passed. The indications of their supervention are various, and often of such a kind as, considering the character of the child's previous illness, may fail to excite that attention which otherwise they would attract. The more than ordinary excitability of the patient, the peculiar noisiness of his delirium, and the ungovernableness of his temper, should arouse our suspicions, even in the case of an ill-managed and wayward child, in whom these symptoms may in part be due to mere petulance. 1 See remarks on this subject in Lecture XXIX. p. 386. 2 See Lecture VII. p. 85 ; and Lecture XXI. p. 273. 36 562 TREATMENT OF TYPHOID FEVER. Sometimes, however, the mode of approach of serious head mischief is even more treacherous. The fever has already abated, the tongue has grown somewhat moister, the delirium is less constant, the rest- lessness less distressing, and the child even has some quiet sleep; but he lies often grinding his teeth, or there is frequent machonuernent, or slight twitchings of the facial muscles occur occasionally. The eyes grow less intolerant of light, and as the child opens them once more, the parents please themselves with its fancied improvement, fondly imagining that it looks around and notices again. The pupils, however, are more dilated than natural, and act more sluggishly; the pulse presents a slight irregularity or intermission ; sensibility to ex- ternal objects lessens; and coma steals on almost imperceptibly, while in other cases all the symptoms of hydrocephalus by degrees develop themselves. Tbe unobserved supervention of pneumonia is guarded against by daily careful auscultation: the existence of diarrhoea tells too plainly of the abdominal complication for that to be overlooked; but when so much disturbance of the nervous symptom is part and parcel of the affection, some excess of it may readily pass without due import- ance being attached to it. When, then, you may ask, are we to be- come anxious about the head? I should say, whenever delirium is present, not merely during the night, or on waking from slumber in the daytime, but whenever it also continues during the day, or when there is during the day an extremely excitable and unmanageable con- dition, though not amounting to actual delirium. Or, secondly, when- ever, with the abatement of the fever, the cerebral symptoms do not diminish in proportion ; or some new, even though very slight, indi- cation of disorder of the nervous system appears, although the excite- ment manifest in the earlier stages of the affection may have almost or altogether passed away. These symptoms may, indeed, speedily subside, or they may yield, and probably will, to judicious treatment, but they indicate a source of danger against which you cannot be too carefully or too unceasingly on the watch. Thus much concerning the disease; now, in conclusion, as to its treatment. In the management of typhoid fever in the child, just as of fever in the adult, the grand object to which our attention ought to be turned is to carry the patient through an affection which we cannot cut short, with as small an amount of suffering and danger as possible. " Medicus curat, natura sanat morbum," says an old Latin adage; and in no disease is it of so much importance as in fever, that we should assign to our art its proper position as the handmaid of nature. The gradual approach of the disorder, in the great majority of instances, of itself points out the propriety of that expectant mode of treatment which is generally the most appropriate during the first week of the child's illness. The languid and listless state of the little patient, his headache and drowsiness, often lead him to wish to remain in bed all day long; but there is no reason for confining him to bed, if, during the period of remission of the fever, he should prefer to sit up. The impaired appetite often renders any other directions about the diet unnecessary, than a caution to the parents or nurse not to TREATMENT OF TYPHOID FEVER. 563 coax or tempt the child to take food, which it is, and will probably for some days continue to be, entirely unable to digest. The heat of skin and the craving thirst are the two most urgent symptoms in the early stages of the affection. The first of these is generally relieved by the tepid bath at 90° or 92° every morning, and by sponging the surface of the body several times a day with lukewarm water. The desire for cold drinks is often very urgent, and no beverage is half so grateful as cold water to the child. Of this it would, if permitted, take abundant draughts; but it should be explained to the attendants that the thirst is not more effectually relieved by them than by small quantities of fluid, while pain in the abdomen is very likely to be caused by the over-distension of the stomach. The cup given to the child should therefore only have a dessert or tablespoonful of water in it, for it irritates the little patient to remove the Vessel from its lips unemptied. In the milder forms of the disease, and during the first week, medicine is little needed; but a simple saline may be given, such as the citrate of potass in a mixture to which small doses of vinum ipecacuanhas may be added, if, as sometimes happens, the cough be troublesome. If the bowels act with due frequency, and the ap- pearance of the evacuations be not extremely unhealthy, it is well to abstain from the employment of any remedy that might act upon them, for fear of occasioning diarrhoea, which is so apt to supervene in tbe course of this affection. For the same reason, if an aperient be in- dicated, drastic purgatives are not to be given, but a moderate dose of castor oil should be administered. Now and then, however, cases are met with in which the bowels remain confined during a great part of the affection, and in which such purgatives as senna are not only borne, but are absolutely necessary. They, however, are purely exceptional cases; and it will generally suffice, if there exists any tendency to constipation, to give a small dose of the mercury and chalk night and morning, and during the daytime a small quantity of the tartrate of soda or sulphate of magnesia, dissolved in some simple saline mixture, every six or eight hours. The unhealthy state of the evacuations that exists in a large number of cases is generally associated with a disposition to diarrhoea, which becomes a more prominent symptom in the second than it was in the first week of the disorder. Equal parts of the hydrargyrum cum cret& and Dover's powder are the best means of relieving both these morbid conditions; the remedy being given either once or twice a day, or more frequently, according to the urgency of the symptoms. The amount of abdominal pain and tenderness must be ascertained every day; and a few leeches must be applied to either iliac region if the tenderness seem considerable, or if the child appear to suffer much from pain in the abdomen, or if the diarrhoea be severe. If depletion be needed, the application of but a small number of leeches will ge- nerally meet the requirements of the case, while copious bleeding is neither useful nor well borne. Even in children of ten years old I never apply above four or six leeches, and it is very seldom that any occasion arises for a repetition of the bleeding. The application of poultices of linseed meal or scalded bran to the abdomen, and their 564 TREATMENT OF HEAD-SYMPTOMS—DEPLETION. frequent repetition, is a very valuable means of relieving the griping pain which often distresses children; and in most cases it is desirable to make trial of them before having recourse to depletion. There is but one other class of symptoms likely to occur during the first week of the fever, to the management of which I have not yet referred ; namely, those signs of cerebral disturbance which are some- times so serious as to call for treatment. The early occurrence of delirium, though it generally implies that the disease will assume a rather serious character, yet does not of itself indicate the necessity for taking blood from the head ; but if the child be quiet and gener- ally rational during the daytime, and, though dull, yet not in a state of stupor, while the delirium at night is of a tranquil kind, and in- terrupted by frequent and tolerably quiet slumber, it will generally suffice to apply cold to the head, and to keep the apartment cool and absolutely quiet. The irritability, excitability, and restlessness at night, accompanied by loud and noisy delirium, from which the child gets scarcely any respite all night long, are frequently arrested at once by an opiate. Unless some abdominal complication should forbid its employment, the tartar emetic is in these cases a most valuable adjunct to the opium.1 A draught containing five minims of laudanum, and a quarter of a third of a grain of tartar emetic, will be a suitable ano- dyne for a child of five years old, and may be repeated night after night with almost magical effect. When the delirium at night is suc- ceeded during the daytime by an almost equally distressing condition of excitement, accompanied with a burning skin, and a very frequent though feeble pulse, the continuing the tartar emetic in slightly nau- seating doses, combined with smaller quantities of laudanum every four hours, will often be of essential service. If, however, there be any injection of the conjunctivae, or if the head be in a marked degree hotter than the surface generally, or if any other indication of disor- der of the brain be present besides the delirium and excitement, leeches should be applied to the head—though depletion should in these cases be used sparingly; and after the abstraction of blood by the applica- tion of half a dozen leeches, we should return to the tartar emetic and opium, remembering that we have no active inflammation to combat, nor even that intense cerebral congestion which we occasionally meet with in other circumstances, and safety from which is found only in very active depletory measures. Depletion is also called for in cases, not very commonly met with, in which even at an early period of the disease there is a great degree of stupor and apathy, with a dilated and sluggish pupil, but little com- plaint of thirst, and none of headache or local suffering. By the cau- tious abstraction of blood we may here sometimes anticipate the development of the more alarming head-symptoms, which, if we leave the patient alone, lulled into a false security by the absence of any signs of active mischief, will not fail before long to manifest them- 1 The remarks of Dr. Graves, in his Lectures on Clinical Medicine, vol. i. p. 207, on the use of Tartar Emetic and Opium in Fever, are little less applicable to its manage- ment in the child than in the adult. TREATMENT OF TYPHOID FEVER. 565 selves. As a general rule, indeed, it must be our object in the manage- ment of this fever to anticipate the head-symptoms as far as possible, to keep down the excitement and quiet the delirium by tartar emetic and opium, or by the local abstraction of blood; a purely expectant course of practice is neither wise nor safe. The head-symptoms, which come on slowly and almost imperceptibly at a more advanced stage of the disease, are sometimes very unmanageable. Depletion is no longer of service, but blisters may be applied to the occiput and nape of the neck with advantage; they should, however, not be kept on so long as to produce complete vesication; but only for a time sufficient to obtain their counter-irritant effect, and to allow of their reapplication in the same neighborhood, if not upon exactly the same spot, on the next day. The unfavorable termination of the disease in this stage is, I apprehend, due, in the great majority of cases, to the development of some previously latent tendency to tubercular hydrocephalus; while the more active head-symptoms, which are met with at an earlier period, are often merely the result of functional disturbance, and therefore generally yield to well-considered treatment. In mild cases of the disease, the expectant treatment usually appro- priate during its earlier stages, may be continued throughout its course ; great caution being exercised, as the child begins to improve, to pre- vent its committing any error in diet. When severe, however, the second week often brings with it a train of symptoms that require many modifications in the plan of treatment. The vital powers need to be supported, and the nervous system requires to be tranquillized; and this is to be attempted by means similar to those which we should employ in the management of fever in the adult. The mere diluents which were given during the previous course of the disease must now be exchanged for beef or veal tea or chicken broth, unless the exist- ence of severe diarrhoea contraindicate their administration ; in which case we must substitute arrowroot, milk, and isinglass, for animal broths. In a large proportion of cases nutritious food is all that will be required; but wine is sometimes as esseutial as in the fevers of the adult; and the indications for giving it are much the same at all ages, while its influence on the patient must be the only measure of the quantity to be administered; and I have on some occasions given as much as twelve ounces of wine and four ounces of brandy daily, to children not above ten years old, and believe that this copious use of stimulants alone preserved their life. Even though wine be not neces- sary, I generally give some form of stimulant during the second and third weeks of the affection. The prescription1 that I usually follow is one much praised in such circumstances by Dr. Stieglitz, of St. Petersburgh, the chief ingredients of which are ether and hydrochloric acid. It seldom disorders the bowels if they be not much disturbed 1 (No. 36.) I£.—Acid, hydrochlor. dil. TTLXxxij. Spt. aeth. co. 3j» rr\,xx. Syr. rhaeados ^iv. Mist, camph. giiiss.—M. giv 6tis horis. For a child five years old. 566 INTERMITTENT FEVER OR AGUE. at the time of commencing its administration; Avhile if this be the case, a small dose of Dover's powder, as a grain or a grain and a half at bedtime, will be doubly useful, both in checking the tendency to diar- rhoea, and in procuring sleep for the child, who, without it, would pro- bably be watchful and delirious all night long. Whilst any severe abdominal symptoms are present, I abstain from the use of the acid mixture, but give the mercury with chalk, and Dover's powder, every four or six hours, to which I occasionally add an opiate enema at bedtime, and support the strength by food and wine as may be necessary. The only complication that is apt to be troublesome is the bron- chitis. Usually, however, the cough to which this gives rise is an annoying rather than a dangerous symptom ; and it is in general more harassing at the commencement of the affection, and again when con- valescence is beginning, than during that time when the graver symp- toms are present. A little ipecacuanha wine, nitrous ether, and compound tincture of camphor, will usually relieve it, to which it may occasionally be expedient to add the application of a mustard poultice to the chest. The convalescence is often extremely tedious; tbe child is left by the disease not only extremely weak and emaciated, but with its digestive powers greatly impaired. It is often many days before the stomach is able to digest any solid food; even a piece of bread will sometimes irritate tbe intestines, and bring on a return of diarrhoea. The appetite seems sometimes quite lost; tonics either do no good, or are actually injurious by rekindling the fever; or symptoms super- vene which seem to threaten the development of tubercular disease, a consequence that not very seldom follows severe attacks of remit- tent fever. In such circumstances, change of air, and the removal, if possible, to the sea-side, are often the only means of restoring the child to health; a means which you may recommend with the more confidence since it hardly ever fails to be successful. I know of no better place than the present for making a few re- marks to you concerning intermittent fever or ague as it occurs in early life. In some countries, as you know, this disorder affects persons at all ages, but in healthier regions it is found commonly to spare the two extremes of life, and to attack but seldom either the aged or the very young. Accordingly, in this country, ague is seldom ob- served in infancy and childhood, and is so uncommon in this metro- polis that in the only instances of it which have come under my observation in early life, the disorder was not contracted in London. Considering its rarity, therefore, I should not occupy your time by speaking of ague, if it were not that it presents certain peculiarities in early life, and those of a kind to render its nature obscure, and to lead you altogether to overlook its existence, or to mistake it for some other disease. These peculiarities consist in the ill-marked character, or even the complete absence of shivering, the place of which is taken by a condition of extreme nervous depression, or sometimes even by a disturbance of the nervous system issuing in convulsions'—in the severity and long continuance of the hot stage, • SMALLPOX. 567 and in the absence of any distinct sweating stage, the child recovering by degrees, but without the well-marked crisis which marks the cessation of each fit of ague in the grown person. When to this is added that the child always appears more ailing between the fits than is usual with the adult, that dulness, heaviness, and fretfulness, with some degree of febrile disturbance, continue in the intervals, and that the periodicity of the attacks is not so regular as in the adult, you will at once see that an erroneous diagnosis is very possible, I might almost say very pardonable. The youngest child whom I have seen suffering from ague was not quite two years old, and in his case the rigors were so slight that they did not attract the mother's notice till her attention was especially called to their occurrence. In proportion to the tender age of the child are the above-named peculiarities distinctly marked, while after the age of five years the few cases of ague which I have seen scarcely differed from the same disease in the adult. The treatment of the affection is the same in the child or infant as in the grown person, and quinine is no less a specific for it in the one case than in the other. The tendency to relapse, however, I believe to be very great in early life, and I have known ague return after the lapse of several months, on removal to a district which though healthy, and free from ague, was yet somewhat lower and less dry than the child's previous residence. On this account much care is needed, and that continued for a considerable period, in the selection of the dwelling of a child who has to all appearance perfectly recovered from an attack of intermittent fever. LECTURE XLII. Smallpox—checked but not extirpated by vaccination—its chief mortality among children—rate of mortality in cases of the disease undiminished during the last fifty years.—Its symptoms—their early differences from those of the other exan- themata—characters and progress of the eruption—peculiarities of confluent smallpox—dangers attending the maturation of the pustules, and the secondary fever.—Treatment. Modified smallpox—its low rate of mortality—its peculiarities. Chicken-pox—its symptoms, and differences from smallpox. Until the commencement of this century, the disease to which I wish to-day briefly to call your attention possessed a degree of im- portance far greater than that which attaches to it at present. Before the introduction of vaccination, the smallpox was a disease of almost universal prevalence, causing at the least eight per cent, of the total mortality of this metropolis, and disfiguring for life thousands whom it did not destroy. Its loathsome character, and its formidable symp- toms when it attacked the constitution at unawares, led to the adop- 568 smallpox: tion of variolous inoculation, by which the disease was communicated in a mild form, and under favorable conditions; and persons having undergone comparatively little suffering, and having been exposed to still less danger, enjoyed by this means almost complete immunity from subsequent attacks of smallpox. But, great as its benefits were, variolous inoculation perpetuated at all times, and in all places, a dis- ease which would otherwise have obeyed the general law of epidemics, and would have had its periods of rare occurrence as well as those of widespread prevalence. Thus, as has been well observed, while the advantages of the practice were great and obvious to the indi- vidual, to the community at large they were very doubtful. No such drawback exists to detract from the benefits of vaccina- tion, though unfortunately our present experience does not altogether justify the sanguine expectations entertained concerning it by its first promoters. Peculiarities of climate oppose a serious barrier to its successful introduction into some countries,1 and even in our own land individuals are occasionally met with in whom vaccination alto- gether fails, or over whom it seems to extend but a partial or a tem- porary protective power. But I will not enter on the question of the merits of vaccination, nor of the circumstances that impair its preservative power, or call for its repetition: for though the subject is one important alike to the physician and the philanthropist, I have had no opportunities of forming a judgment concerning it which are not alike open to you all. In the writings of the late Dr. Gregory, physician to the Small- pox Hospital, in the treatise on vaccination, by Dr. Steinbrenner, to which the Institute of France ajudged a prize in 1835, and in the still more recent Report to the Board of Health, drawn up by Mr. Simon in 1857,2you will find everything that either large experience or un- wearied research can bring to its elucidation. One fact, which it behooves us always to bear in mind, is, that, albeit the prevalence of the disease has been greatly checked by vaccination, smallpox is still one of the most fatal maladies of this country; and further, that it selects its victims, as heretofore, chiefly from among children and young persons—nearly three-fourth of the fatal cases of this affection occurring before the age of five, and more than nine- tenths before the age of fifteen years. In spite, too, of the increase of medical knowledge during the past fifty years, the proportion of smallpox cases that terminate fatally has been estimated by the best authorities to be as great now as it was half a century ago. To some 1 Dr. Duncan Stewart's valuable Report on Smallpox, in Calcutta, and Vaccination in Bengal, 8vo. Calcutta, 1844, shows conclusively that the peculiarities of the Indian climate present obstacles to vaccination such as greatly to detract from its value; while it is to be feared that they are of a nature which the greatest care will never wholly overcome. 2 Nothing can more conclusively establish the immensity of the boon which vacci- nation has conferred on society, than the contrast which Mr. Simon's report exhibits between the mortality from smallpox before and after its introduction. " The fatality of smallpox in Copenhagen is but an eleventh of what it was ; in Sweden little over a thirteenth; in Berlin and in large parts of Austria but a twentieth ; in Westphalia but a twenty-fifth. In the last-named instance, there now die of smallpox but five persons, where formerly there died a hundred." See p. xxiii. of the Report. ITS SYMPTOMS. 569 extent, perhaps, the very diminution in the frequency of the disease may have had an unfavorable influence on its issue in individual cases: for practitioners, meeting with it now less often than medical men in former days were wont to do, are not so familiar with the meaning of those minuter variations in its symptoms, from which im- portant practical conclusions might be drawn, by those who knew how to interpret them aright. Let me therefore urge you to watch every case of this formidable disease that may come under your observation with most minute care, lest you misinterpret the symptoms, or mistake the treatment of some patient affected with it, whose well-being may be dependent on your skill. For my own part, I cannot pretend to give you more than an outline sketch of its characters, and must refer you to the writings of others who have had greater opportunities of watching it than have fallen to my share, to fill up the portrait. The early symptoms of smallpox are those of approaching fever, n and if any other febrile disorder be prevalent at the time of their occurrence they may possibly be taken for the indications of an ap- proaching attack of the prevailing epidemic. There are, however, some peculiarities in the mode of onset of smallpox which are suffi- ciently characteristic of it even in the child, and which generally dis- tinguish it from either of the other eruptive fevers. The sickness with which it sets in is in general severe, and the disorder of the stomach often continues for forty-eight hours, during which time vom- iting recurs frequently. In measles there is comparatively little gas- tric disorder; and the vomiting that often ushers in scarlatina, though frequently severe, is not of such long continuance. In young children we lose those complaints of intense pain in the back which in the case of older patients often awaken our suspicion; but on the other hand, the severity of the cerebral disturbance is an important feature in the early stage of the disease. At the commencement of measles, the brain is in general but little disturbed; in scarlatina, delirium often occurs very early; but in smallpox the condition is one rather of stupor than of delirium, while convulsions sometimes take place, and continue alternating with coma for as long a period as twenty- four or thirty-six hours. Lastly, though the skin in smallpox is hot, it is neither so hot nor so dry as in scarlet fever; the tongue does not present the peculiar redness, nor the prominence of its papillae, which are observable in scarlatina; neither is there any of the sore-throat which forms so characteristic a symptom of that disease. The early stages of smallpox are not attended with the catarrhal symptoms which accompany measles: the eruption of measles usually appears later, that of scarlet fever always sooner, than the eruption of small- pox , while its papular character is in general sufficiently well marked to distinguish it from the rash of either of those diseases. It never appears in less than forty-eight hours from the first sign of indisposi- tion, often not till after a somewhat longer time. It shows itself in the form of a small papulae, which are first discernible on the face, forehead, and wrists, whence they extend to the trunk and arms, and lastly to the lower extremities. These papulae are at first slightly 570 PROGRESS OF THE ERUPTION red, somewhat acuminated elevations, so minute that they may be easily overlooked on a hasty examination, but yet conveying a dis- tinct sense of irregularity to the finger when passed over the surface. They increase in size, and in the course of forty-eight hours assume a vesicular character, and contain a whey-like fluid; while, instead of a conical form, they now present a central depression. During another period of forty-eight hours, or thereabouts, these vesicles go on enlarging, their central depression grows more and more apparent, and their contents become white and opaque: they are no longer ves- icles, but have become converted into pustules, each of which, if they be distinct, has an areola of a red hue around its base. As the pus- tules enlarge, the face, hands, and feet become swollen, and a general redness of the surface succeeds to the more circumscribed areola which had previously surrounded each separate pustule. As the size of the pustules increases, they lose that central depression which they had presented while vesicles; they assume a spheroidal form, or even be- come slightly conical. The next change observable in them is an alteration of their color from a white to a dirty yellow tint, which they continue to retain until the desiccation of the eruption com- mences. This token of the decline of the disease is first apparent on the face, where, as you will remember, the eruption is earliest ob- servable; while on the hands and feet, probably owing to the thick- ness of the epidermis in those situations, this change is longest delayed, and the pustules there attain a greater size than in any other situation. The maturation of the pustules usually occupies from the commencement of the fifth to the commencement of the eighth day of the eruption, or from the eighth to the eleventh day of the disease, when the process of desiccation begins. A few of the smaller pustules dry up and become converted into crusts, which afterwards drop off; but the greater number of them burst, and the pus that they discharge, together with a very adhesive matter which they continue to secrete, for two or three days, contribute to form the scab, which incrusts, more or less extensively, the surface of a smallpox patient during the decline of the disease. When this scab falls off, which it does in from three to five or six days, the skin appears stained of a reddish- brown color, which often does not disappear for several weeks; but it is only in cases where the pustule has gone so deep as to destroy a portion of the true skin, that permanent disfigurement, the so-called pitting of the smallpox, is produced. It is only in cases of discrete smallpox, in which the eruption is but moderately abundant, and the pustules consequently run their course without coalescing with each other, that the above-mentioned changes can be distinctly traced. In the confluent variety of the disease, in which the pustules are so numerous that they run together as they increase in size, the characteristic alterations in the individual pustules cannot be followed. In those situations where the eruption is conflu- ent, the pustules never attain the size which separate pustules often reach; they do not become so prominent, nor do their contents in general assume the same yellowish color, but several of them coalesce to form a slightly irregular surface of a whitish hue; while, when the OF SMALLPOX. 571 stage of desiccation comes on, each of these patches become converted into a moist brown scab, which is many days before it is detached. Nor is it merely at those parts, such as the face, where the eruption is actually confluent, that its character is modified, but, even where the pustules are distinct, their advance goes on more slowly, and the maturative stage is longer in being completed, than in less severe cases of the disease. It is, moreover, in cases of confluent smallpox that the ulceration of the pustules most commonly invades the true skin, and that serious disfigurement is most likely to take place; while, further, the degree of danger to life is.in almost direct proportion, in every case of smallpox, to the amount of confluence of the eruption. The appearance of the eruption of smallpox is attended with a . great abatement, sometimes with the almost complete disappearance of those signs of constitutional disturbance with which the disease set in; and in mild cases the child shows few other signs of illness than are furnished by the eruption on the skin. But, with the matu- ration of tbe pustules, the secondary fever, as it is called, is excited, and the period of the greatest danger to the patient now comes on. The skin once more grows hot; the pulse rises in frequency; rest- lessness, thirst, and all the phenomena of inflammatory fever, develop themselves, and continue with more or less intensity for about three days. These symptoms afterwards diminish, and finally disappear as the pustules burst, and tbe stage of desiccation is accomplished. It is, however, only in cases of a favorable kind that the secondary fever runs so mild a course. In confluent smallpox the secondary fever is always more severe than in tbe discrete form of the disease, though it comes on later, in consequence of the more tardy maturation of the pustules. Often, indeed, it assumes a typhoid character; the pulse becomes extremely frequent and feeble; the tongue dry and brown ; and the patient dies delirious. In other instances the maturation of the pustules goes on for a day or two with very slight reaction ; and were it not that this extreme mildness of the secondary fever, in cases where the eruption has been abundant, is itself a suspicious circum- stance, we should be disposed to express, without hesitation, a most favorable opinion as to the patient's condition. Suddenly, however, the pulse begins to falter; the pustules, which before seemed full, collapse; the extremities grow cold; and in a few hours the patient dies. This fatal change is sometimes ushered in by a fit of convul- sions; at other times it is preceded by a condition of extreme rest- lessness, which contrasts remarkably with the quietude of the child's manner for the two or three previous days; and it is well to bear in mind that the supervention of either of these two symptoms during the maturative stage of smallpox is the almost certain herald of speedily approaching death. One other not infrequent source of dan- ger during this period arises from the pustules which have formed on the mucous membrane of the mouth, fauces, and air-passages. In almost every case of smallpox, a few spots of the eruption may be seen upon the tongue and on the interior of the mouth; while an in- spection of the bodies of patients to whom it has proved fatal has shown that the pustules form likewise on the interior of the larynx 572 TREATMENT OF SMALLPOX. and trachea—sometimes in considerable numbers. It is to the pre- sence of pustules in these situations that the hoarse or altered voice, and the difficulty of deglutition, which are observed in most cases of severe smallpox, are due; as well as that short hacking cough which sometimes proves a very troublesome symptom. The ptyalism, too, which occurs in many instances, is apparently owing to the salivary glands sympathizing with the irritated and inflamed state of the mucous membrane of the mouth. In cases which run a fortunate course, these symptoms have come on about the third or fourth day of the eruption, and having increased in severity until the eighth or ninth, then pro- gressively decline. In less favorable circumstances, however, they continue to grow worse; the voice becomes perfectly extinct, and deglutition almost impossible; and the patient dies from the obstacle which the inflammation and swelling of the lining membrane of the larynx present to the free access of air to the lungs; though the symptoms are seldom or never those of active inflammatory croup. You will find in the writings of those whose opportunities of ob- serving smallpox have been considerable, the description of many other modes in which it occasionally proves fatal. Thus, it is some- times associated with a great tendency to hemorrhage; petechiae appearing on the surface of the body, and the pustules assuming a black color, from the extravasation of blood into them. In other instances, gangrene attacks the feet or some other part of the body. But these are occurrences which it has not been my lot to witness, and I will not therefore take up your time by detailing them at second- hand. Let us now glance for a few minutes at the treatment to be pursued in this disease. You know that before the time of Sydenham, physi- cians adopted a heating regimen in cases of smallpox; excluding fresh air from the chamber, covering the patient with blankets, and administering stimulating medicines and cordial drinks. To this practice the then prevalent theory of fermentation, and of nature's efforts in disease being directed to eliminate the peccant matter from the blood, had given occasion. In accordance with these notions, it was assumed that the more abundant the eruption, the more complete would be the separation of these noxious matters, and consequently the better the chance for the patient's well-doing. The observation of nature, however, taught Sydenham that the very reverse was the case—that the more abundant the eruption, the greater the danger— the fewer the pustules, the more favorable the prospect of the patient's recovery. A cooling regimen, therefore, is now universally adopted in the early stage of the disease, and fresh air is freely admit- ted into the chamber, in order to prevent if possible a copious eruption, while the same end is sought to be still further promoted by keeping the bowels gently open, by a spare diet, and by mild antiphlogistic medicines. Depletion, which even in the adult is not to be practised merely with the hope of thereby diminishing the quantity of the erup- tion, is still less to be resorted to in the child, unless evidently called for by symptoms of severe cerebral disturbance; such as convulsions fre- quently recurring, or ending in coma. Such occurrences as those, TREATMENT OF THE SECONDARY FEVER. 573 however, demand not merely the abstraction of blood, but its removal with an unsparing hand; for as I told you at the commencement of these lectures, the cerebral congestion which attends the onset of the eruptive fevers, if not speedily relieved, may prove very quickly fatal. Cases of an opposite kind are sometimes met with in which the patient, before the appearance of the eruption, is in a state of depression so great as to call for warmth to the surface, or for the hot bath, for dia- phoretic medicines, and sometimes even for stimulants. In this, how- ever, there is nothing more than we may occasionally witness in a patient completely prostrated during the first stage of typhus fever, and needing perhaps the free administration of wine and ammonia to preserve him from death. With the outbreak of the eruption there ensues a lull in the symp- toms, and a period now succeeds during which we have nothing else to do than to leave Nature to her workings undisturbed. Even in cases of confluent smallpox, there is in many instances not a single symptom just at this time which could either excite solicitude or call for treatment, and you must therefore take care not to allow yourself at this moment to be betrayed into the hasty expression of a very favorable prognosis, which the supervention of the secondary fever may perhaps in a day or two most grievously belie. If, however, the number of pustules should be but small, the secondary fever will be slight: our favorable opinion may, in these circumstances, be ex- pressed with some confidence, and most probably no deviation from our previous expectant plan of treatment will be required during the subsequent progress of the disease. If the eruption be more abun- dant, and the accompanying secondary fever consequently severe, an antiphlogistic plan of treatment must be carried out more strictly, while in all cases the restlessness which is so common a symptom during the maturative stage of smallpox must be controlled by the administering of Dover's powder, or of some other form of opiate, once or twice a day. In cases of confluent smallpox, the patient needs to be very closely watched during the maturation of the pustules, for on the second or third day of this process the vital powers sometimes suddenly fail. The first indications of any such occurrence, which would be furnished by a great aggravation of the previous restlessness, by the subsidence of the swelling of the face and hands, the paleness of the skin in the interval between the pustules, and the collapse of the pustules themselves, attended with a sinking in the temperature of the surface, and a great diminution in the power of the pulse, call at once for energetic employment of stimulants, for the administration of wine, and the substitution of nutritious food for the previous mea- gre diet. A similar course must also be pursued whenever the secon- dary fever shows any disposition to assume a typhoid character, while irrespective of any unfavorable symptoms, it is not infrequently expe- dient, if the eruption be abundant, to give beef-tea, and to adopt other means for supporting the strength from the fifth or sixth day of the eruption—a period corresponding, as I hardly need remind you, with the eighth or ninth day of the disease. Various local means have been recommended to be adopted at an 574 TREATMENT OF SEVERAL LOCAL SYMPTOMS. early stage of the disease, with the view of preventing the full deve- lopment of the pustules, and consequently of preserving the patient from the disfigurement produced by the pitting of the eruption. The cauterization of each individual pock with the nitrate of silver is a process impracticable from its tediousness, while there is some dis- crepancy in the results which different persons allege that they have obtained by applying mercurial ointment or plaster, or by washing the surface which it is wished to defend with a solution of corrosive sublimate. The weight of evidence appears to me, however, to be in favor of some proceeding of this kind ; and that which seems to have been the most successful, is the application of the mercurial plaster at a period not later than the third day from the outbreak of the eruption. Attention must be paid to the state of the eyes, which often suffer much during attacks of the smallpox, though Dr. Gregory states that the conjunctiva never becomes the seat of the pustules. From the time when the swelling of the face begins, during the maturation of the eruption, the eyelids are often so much swollen as completely to clo.se the eyes, while their edges are glued together by a tenacious secretion from the Meibomian glands. The patient will be much re- lieved by bathing the eyes frequently with warm water, and any pustules that occupy the margins of the palpebral should be carefully cauterized with the nitrate of silver. The condition of the mouth and throat must not be neglected. If old enough, the child may be made to gargle with the infusion of roses, while, should it be too young to do this, the endeavor must be made to keep the mouth and throat free from the secretions which collect there, by washing or syringing them frequently with warm water, and by applying a weak solution of chloride of lime to the fauces. If difficult respiration should come on, in consequence of the affection seriously involving the larynx and trachea, the patient's con- dition, according to the testimony of almost all writers, is rendered nearly hopeless. The intense itching of the eruption during the latter part of the period of maturation, and the stage of desiccation, not only distresses the patient exceedingly, but is often the occasion of subsequent dis- figurement, in consequence of the desire to scratch being irresistible, and the pustules being converted by abrasion of their heads into troublesome ulcerations. The application of sweet oil, cold cream, or spermaceti ointment, will do something towards allaying the irritation; but you will often find it necessary to muffle the hands of children, in order to prevent their producing troublesome sores by scratching themselves. Tbe convalescence from smallpox is often very tedious; the patient's recovery is frequently interrupted by various intercurrent affections, and the latent seeds of scrofulous disorder are in many instances called into tictivity by its attack. These, however, are occurrences which present nothing of a-special character, and it is therefore unnecessary to make any observation with reference to their treatment. Although previous vaccination usually confers upon the sj'stem a complete immunity from subsequent attacks of smallpox, yet to this SMALLPOX AFTER VACCINATION. ^ 575 rule there are occasional exceptions. In many instances, indeed, the occurrence of smallpox after alleged successful vaccination may be ac- counted for by the careless performance of that operation, by the use of lymph taken from the arm at too late a period, or by the produc- tion in some way of a spurious instead of a genuine vaccine vesicle. ♦ It must be confessed, however, that when every allowance has been made for these casualties, the number of cases of smallpox occurring after successful vaccination is proportionably much greater than the number in which a second attack of smallpox is experienced by those who have either had that disease casually, or in whom it has been produced by variolous inoculation. It would occupy far more time than we have at our command, if we were to attempt to enter upon the inquiry as to the causes of the failure in the protective power of vaccination. Different views have been taken by very high authori- ties upon this subject; but there is one important fact concerning which nearly all are agreed, namely, that the liability to a subsequent attack of smallpox is almost incalculably diminished by re-vaccination. Considering, then, how simple the operation is, and how nearly pain- less its performance, while the benefit to be obtained by it is so in- estimable, I would strongly urge you to re-vaccinate all persons turned twelve years old, even though they had been vaccinated with the most complete success in their infancy.1 But although we should take a comparatively low estimate of the value of vaccination, and confess to the fullest extent the failure in its complete preservative virtue, we shall yet find, in the modifying and mitigating influence which it exerts over smallpox, more than enough to make us value it as a priceless boon. Twenty years ago, small- pox raged epidemically at Marseilles, where it attacked almost ex- clusively persons under 30 years of age. M. Favart,2 who sent an account of this epidemic to the Academy of Medicine at Marseilles, estimated the number of the inhabitants of that city under 30 years of age at 40,000. Of these, about 30,000 had been vaccinated, 2000 had bad smallpox casually or by inoculation, and 8000 had had neither variola nor cowpox. Of this last class 4000, or 1 in 2, were attacked by smallpox, and 1000 of them, or 1 in 4, died. Of those who had had smallpox previously, only 20, or 6 in 1000, were again affected; but 4 of these, or 1 in 5, died; while of the vaccinated, although 2000, or 1 in 15, had it, yet it proved fatal only to 20, or 1 per cent. The influence of vaccination in rendering attacks of smallpox which may succeed to it, so much less severe, and so much less 1 For facts showing the preservative influence of re-vaccination, see Steinbrenner, Traite sur la Vaccine, 8vo. pp. 683-734, Paris, 1846. The report of Mr. Simon, to which reference has already been made, contains a mass of most conclusive evidence illustrative both of the value of vaccination, of the share which imperfect vaccination has in the production of its apparent failures, and lastly, of the extreme importance of re-vaccination as a means by which, if it were but systematically practised, small- pox would be almost or altogether exterminated. The papers of Mr. Marson and Dr. Balfour, originally published in the Medico-Chirurgical .Transactions, but reprinted in the appendix to the report, have afforded specially valuable elucidation of these last two points. 2 As reported by Steinbrenner, op. cit., p. 166. 576 VARICELLA, OR CHICKEN-POX. dangerous, than the unmodified disease, does not in many instances manifest itself in any diminution of the intensity of the primary fever. The symptoms with which modified smallpox sets in are often as severe as those of the unmodified disease, and are also in general of * the same duration. So soon as the eruption begins to make its ap- pearance, however, the difference between the two diseases usually becomes apparent. In many instances, notwithstanding the sharp onset of the patient's illness, the eruption is exceedingly scanty, not more than from twenty to a hundred pustules appearing over the whole body. In other instances, the eruption is much more abundant, and in a few exceptional cases the pustules are actually confluent. But even when they are most numerous, the pustules seldom fail to follow a different course from that which they pursue in ordinary variola, and run through their different stages within little more than half the period required by the eruption of unmodified smallpox. The small size of the pocks, the frequent absence of the central de- pression, their imperfect suppuration, and their speedy desiccation, are the chief local characters of this affection; while the almost com- plete absence of the secondary fever, is both its grand constitutional peculiarity and the main source of the patient's safety. Besides tbe modified smallpox to which reference has just been made, there is another and still milder affection often observed in children, to which, from the extreme lightness of the symptoms that usually attend it, the diminutive appellation of varicella, or chicken-pox, has been given. Much difference of opinion has existed with reference to the relations borne by this disease to smallpox; and even at the present day writers are not quite agreed whether to regard it as an extremely mild form of variola, or as an affection altogether distinct from it. The weight of evidence, however, is decidedly in favor of the opinion that varicella is an affection distinct from, and wholly independent of smallpox, not being produced by any modification of the poison of that disorder, nor affording any kind of protection from its attacks. Varicella is almost exclusively a disease of childhood, and in the great majority of cases it occurs prior to the completion of the first dentition. Its initiatory fever, which is scarcely ever severe, is some- times altogether wanting, so that the appearance of the eruption on the surface is the first occurrence that calls attention to the child's condition. Now and then, however, exceptions occur to this mildness in the onset of the disease; and I have occasionally seen children (chiefly those in whom the process of dentition was going on with activity at the time of the attack) suffer for twenty-four or thirty-six hours from febrile symptoms quite as severe as those which precede the attack of measles, or as accompany a sharp attack of influenza. The duration of this premonitory stage of chicken-pox is somewhat uncertain; the vesicles which characterize it making their appearance after twenty-four hours in some cases,"not for thirty-six or forty-eight hours in others; while, as already mentioned, the eruption is occa- sionally the first symptom of the existence of the disease. The eruption usually consists of more or less numerous, minute, V. MEASLES.... 577 circular vesicles, containing a transparent serum, irregularly dis- tributed over the face, head, shoulders, and trunk, but rarely appear- ing on the lower extremities; and, even when present in considerable abundance, being very seldon confluent at any part. For two or three days they increase somewhat in size, but their contents then become turbid and milky; about the fourth or fifth day they shrivel, and then dry up into a light, pulverulent scab, which falls off* on the eighth or ninth day of the disease. It very seldom happens that any cicatrix is left after the detachment of the scab of varicella, unless the skin has been irritated by the patient scratching it in order to relieve the itching, which is sometimes very troublesome. Besides these differences between the eruption of chicken-pox and that of variola, another, and still more striking peculiarity of the former disease con- sists in the appearance of two or three successive crops of vesicles, so that after the third day of the affection vesicles may be observed close to each other in all stages of their progress. The disease is one so void of danger, that it requires hardly any treatment beyond the adoption of a mild antiphlogistic regimen; and no complications occur during its course, nor sequelae remain after its disappearance, concerning which anything more need be added. LECTURE X1111. • Measles once confounded with scarlatina, though essentially different diseases— share of contagion in producing it.—Symptoms of measles—its dangers depend chiefly on its complications—with convulsions, with inflammation of the lungs, which occurs at different stages of the disease.—Sequelae of measles.—Treatment. Scarlatina—great differences in its severity in different cases—its three varieties— scarlatina simplex—scarlatina anginosa—sources of danger in it—its disposition to assume characters of scarlatina maligna—occasional rapid course of that variety—modes in which it proves fatal—complications and sequela? of the dis- ease.—Diagnosis.—Treatment, use of inunction—treatment of complications. Prophylaxis, use of belladonna. When the short-lived prejudices which at first were entertained against vaccination had been removed, men passed, as they not seldom do, to the opposite extreme, and over-estimated the worth of that dis- covery which they had before undervalued. Physicians rejoiced in it, as a means of getting rid forever of a disease which might well be counted among the opprobria of their art—philanthropists exulted in the probable extermination of one of the most fearful scourges of the human race, and statisticians counted the increase brought to the population, and drew up elaborate tables to illustrate their bright anticipations of the future.1 In these over-sanguine calculations, how- 1 As an instance of which may be mentioned the work of Duvillard, De l'Influence de la Petite-Verole sur la Mortalite, 4to. Paris, 1806. 37 578 MEASLES AND SCARLET FEVER NOT SAME DISEASE. ever, they almost entirely lost sight of the fact, that not all who were preserved from smallpox would be added to the useful population of the country, but that the life of many would be prolonged only for a short season, to be cut off soon by some other disease, against which neither science nor fortunate accident has hitherto discovered a talis- man. Experience has proved the truth of what calm reflection might have suggested, "and with the diminution in the frequency of smallpox there has been an increase, though not to an equal extent, in the pre- valence of measles and scarlatina. It is not easy to state with exactness the amount of mortality which these two diseases occasion, for though they are never altogether absent from a large city like London, yet their frequency and their fatality vary much in different years. At one time they occur spora- dically, and are then in most instances mild in their character, and readily amenable to treatment; while at another time they prevail as epidemics, and are attended with alarming symptoms, which it is often not in the power of medicine to control. Dr. Gregory, who, in his work on the Eruptive Fevers, has collected together with much labor the statistics of these diseases, presents us with a table, from which it appears that, on an average of five "years, very nearly six per cent, of the mortality of London is due to measles and scarlatina. This num- ber, indeed, is not so great as at once to impress us with the formida- ble nature of these two affections; but it should not be forgotten, that (according to the Fifth Beport of the Begistrar-General) 81 per cent. of this mortality occurs in children under five, and 97 per cent, in children under ten years old ; while no figures can accurately represent the instances in which death is occasioned by their complications or sequelae. These two diseases present many points of resemblance—so many, indeed, that they were long supposed to be but varieties of the same malady; and the essential differences between them were not recog- nized till within the last seventy j^ears. It is, however, on many accounts important to distinguish between them—for not only are they not attended by the same degree of danger, but this danger arising from dissimilar causes, the treatment which they require is in many respects different. We shall presently examine into some of those peculiarities in their symptoms on which we chiefly rely in forming our diagnosis between the two affections; but I may even now state some of the broad distinctions between them. Measles is still more eminently than scarlet fever a disease of early childhood—for of 1293 deaths which it occasioned in London in 1842, 93.8 per cent, occurred in children under five years old, and 99 per cent, in those under the age of ten; while of 1224 deaths from scar- latina 31 per cent, occurred after five, and 10 per cent, after ten years of age. Though there are great fluctuations both in its prevalence and in the mortality which it occasions, yet its variations in these respects are less considerable than those of scarlet fever; while the number of persons who pass through life without having experienced its attack is smaller than of those who die without ever having been affected with scarlatina. But though this is the case, and though we CONTAGION OF MEASLES —ITS SYMPTOMS. 579 observe the disease to occur in many instances where we are unable to trace the influence of contagion, there yet seems good reason for the belief that in every case it has been communicated through some medium or other. Facts such as the absence of the disease for the period of thirty years from the Cape of Good Hope,1 and its develop- ment after the arrival there of a vessel from Europe, in which several cases had occurred during the voyage, substantiate the correctness of this opinion. The strongest proof of it, however, is afforded by the circumstances in which measles prevailed in theFeroe Islands in 1846,2 after an interval of 65 years. They were then introduced into one of these islands by a workman, who leaving Copenhagen on March 20th, reached the Feroe Islands on the 28th, apparently in good health, but fell ill with measles on the 1st of April. His two most intimate friends were next attacked; and from that time the disease could be traced from hamlet to hamlet, and from island to island, until 6000 out of a total population of 7,782 had been attacked by it; age bring- ing with it no immunity from the contagion, though the disease was found to spare all who in their childhood had suffered from it at the time of the previous epidemic. It is probable, then, that the extreme contagiousness of measles is the reason of its greater prevalence, and that it is so peculiarly a disease of early life, not so much on account of any special susceptibility to it then, as because the suble materies morbi is so widely diffused as to leave little chance of any escaping it. Though a more universally prevalent disease, however, than scar- latina, it is fortunately less dangerous, its mortality not exceeding 3 per cent, of the patients attacked by it; while the average rate of mortality from scarlet fever is estimated at least double that amount. When measles prove fatal, too, it is very seldom tbe fever itself which occasions the patient's death, but generally its complication with in- flammatory disease of the respiratory organs. Scarlet fever, on the contrary, destroys its victims in all stages of the disease; and in many of the worst cases, in which death takes place early, no organic chauge is left behind which the scrutiny of the anatomist can discover. Within a period of 13 or 14 days (according to the observations made on this subject in the Feroe Islands) from the reception of the contagion, the eruption of measles makes its appearance. But though this period is tolerably constant, the duration of the premonitory symptoms is very variable; the fourth day being that on which the rash most frequently appears, but the extremes varying as widely as 24 hours, and 13 days, according to the careful observations of M. Killiet. In the premonitory symptoms themselves, there is little besides their greater severity to distinguish them from those of ordi- nary catarrh. A child, previously in perfect health, becomes suddenly restless, thirsty, and feverish, and, if able to talk, generally complains of headache. The eyes grow red, weak, and watery, and are unable to bear the light; the child sneezes very frequently, sometimes almost 1 Mentioned by Dr. Copland, in his Dictionary, art. Measles, vol. ii. p. 822. 2 Of which an account, by the commissioner from the Danish Government, Dr. Pannum, is given in the Archives Gen. de Med., April, 1851. 580 COMPLICATIONS OF MEASLES: every five minutes, and is troubled by a constant, short, dry cough. Usually, on or about the fourth day from the commencement of these symptoms, a rash makes its appearance on the face, whence it extends in the course of about forty-eight hours to the rest of the body and the extremities, travelling in a direction from above downwards. The rash is made up of a number of minute, deep red, circular stigmata, not unlike flea-bites, slightly elevated, especially on the face, and though close together, yet usually distinct from each other; the skin in the interspaces between them retaining its natural color. On the cheeks, the spots sometimes become confluent, and then form irregular blotches about a third of an inch long by half that breadth; while the spots elsewhere often present an indistinctly crescentic arrangement. The eruption fades in the same order as that in which it appeared, and after the lapse of forty-eight hours from its appearance, at which time it is at its height on the trunk, it is beginning to disappear from the face. On the seventh day of the disease the rash grows faint on the body generally, and on the eighth, or, at latest, the ninth day, it has entirely vanished, leaving behind either a little general redness of the surface, or a few yellowish-red spots, corresponding to some of the situations which the eruption itself had occupied. In some cases a partial desquamation of tbe cuticle takes place after the rash has dis- appeared ; but this is by no means constant, while, when it occurs, the epidermis separates in minute branny scales, never in large por- tions, as it often does after scarlatina. Unlike smallpox, in which the appearance of the eruption is im- mediately followed by the subsidence of all the previous symptoms, the constitutional disturbance of measles is often not at all alleviated on the outbreak of the rash. The reverse, indeed, is frequently the case; and in many instances, for twenty-four or forty-eight hours afterwards, the fever is aggravated, and the cough more troublesome than before, while the voice often becomes hoarser, and the throat is somewhat sore in consequence of the inflammation of the palate and fauces, which may be seen to be the seat of a punctated redness, re- sembling that produced by the eruption on the skin. The aggravation of the symptoms, however, when it does occur, is only temporary; and on the sixth day of the disease, if not sooner, an amelioration in the patient's condition becomes apparent; the fever diminishing, the cough growing looser and less frequent, and moist sounds becoming audible in the lungs, where previously nothing was heard but rhonchus or sibilus. This amelioration goes on slowly from day to day, and in ten days or a fortnight from the first symp- tom of illness, convalescence is, in favorable cases, fully established. Such as I have described, and sometimes even less severe, are the symptoms of uncomplicated measles; a disease attended by discom- fort rather than danger, and requiring judicious nursing more than actual medical interference. But to this favorable course of the dis- ease there are numerous exceptions, and these are more frequent in some epidemics than in others. Occasionally, though very rarely, the outbreak of the eruption is preceded by convulsions, which sub- side even before the rash becomes visible, and are not succeeded by IMPERFECT APPEARANCE OF THE RASH. 581 any more abiding symptom of cerebral disorder. Only one instance of this, however, has come under my notice; and that was in a child aged two years and ten months, in whom also an attack of chicken- pox a year before had been ushered in by convulsions. The fits in this case ceased of their own accord, though the rash of measles did not come out till twenty-four hours afterwards. There are, however, a few instances on record of the supervention of convulsions after the eruption has shown itself, and of their succeeding each other rapidly till the patient's death; and others in which the sudden dis- appearance of the rash had been succeeded by violent convulsions. Dangerous complications of measles, however, but seldom present themselves on the side of the nervous system, but generally assume the form of disorders of the respiratory organs. The cough, and hoarseness, and suppressed voice which accompany the onset of mea- sles, are sometimes so marked as to raise the apprehension that croup is about to come on; and now and then this actually occurs, though in the great majority of instances the symptoms apparently so threat- ening subside readily under small doses of antimonial and anodyne medicines. The risk, indeed, either of real cynanche trachealis coming on, or of that form of ulcerative laryngitis to which I referred some days ago1 attacking the patient, is much greater when the erup- tion is on the decline, or even at a later period, constituting a sequela of the disease more often than an actual complication. The most serious as well as the most frequent complication of measles is that with bronchitis or pneumonia. This is not equally frequent at all periods of the disease, being much commoner about the third or fourth day of the eruption than at an earlier time; while on the decline of the disease it is likewise that sequela against which we have to watch with the most sedulous care. When pulmonary inflammation comes on early in the disease, the retrocession of the eruption from exposure to cold is its most frequent cause, though sometimes it seems to occur causelessly; its symptoms developing themselves simultaneously with the outbreak of the rash. In that case, however, the rash almost invariably fades earlier than it should do, and disappears in thirty-six or forty-eight hours ; no desquamation succeeding to it, nor any roughness of the skin remaining behind; while the pulmonary affection runs its course rapidly to a fatal issue. In other instances the rash comes out imperfectly, and presents from the first a dark, livid hue, almost like that of the rash in some cases of malignant scarlet fever; while coupled with this there are great oppression and extreme dyspnoea; and sub-crepitant rale, more or less abundant, is perceptible in the chest. Cases of this congestive form of measles are, I believe, less common now than they were some forty years ago, when the fevers which our fathers treated seemed to require free venesection, and actually benefited by its employment. I will therefore relate to you a well-marked instance of it, both to point out its general characters, and also to impress upon you the necessity for occasionally adopting a much more active mode of treat- 1 See Lecture XXV. p. 329. 582 COMPLICATIONS OF MEASLES. ment than is applicable to the great majority of the cases of measles which at present come under our notice. A little girl, ten years of age, had had slight catarrhal symptoms for a few days, when she was attacked on the evening June 7th, 1843, by shivering, pain in the head, and a feeling of sickness. Her head pained her much, and she was very drowsy on the two following days, and on the tenth she came under my notice, when, though no eruption had appeared on the surface, yet the child's history, coupled with the severity of her catarrhal and febrile symptoms, left little room for doubting that she was about to have an attack of measles. On the evening of the eleventh the rash appeared, and twenty-four hours afterwards I visited the child at her mother's request, who told me that though the rash was fully out, yet the respiration was greatly oppressed. The child was lying in bed, her face puffy, covered by an abundant purple-red rash, of an almost livid hue. Tbe rash was in patches of an irregular form and size, running into each other; while a few small, slightly elevated, dark purple stigmata were scat- tered here and there, and a few also were collected together into a crescentic arrangement. On the arms and legs the rash had not the patchy appearance, but an immense number of distinct stigmata, very like petechias, except that they were a little larger, and slightly raised, covered the skin. The eyelids were much swollen, and glued to- gether by a thick, gummy secretion; the lips were dry, the teeth covered with sordes, the tongue very red, dry, and glazed in the centre, with a thin coating of yellow fur at the edges; and the nares were perfectly dry. The pulse was 110, hard; respiration sixty in the minute, hurried, loud, and wheezing, interrupted by very frequent hard and short cough. The child was very drowsy, but sensible when roused, and she then complained of pain in the chest, and of great soreness of all her limbs. Air did not enter the lungs freely, and, on a deep inspiration, sub- crepitant rade was heard in both infra-scapular regions, especially in the right. The child was at once bled to syj, which, however, did not cause faintness, and was ordered one-sixth of a grain of tartar emetic every four hours. The good effects of these measures was not immediately apparent, but in the course of some six hours the child felt relief. Early on the following morning I saw her, and found that the rash had com- pletely lost its patchy character, and was now universal over the whole body, while it was of a bright red color, almost as vivid as the rash of scarlet fever. The tongue was no longer glazed and dry, nor were the teeth covered with sordes, while the respiration, though still fifty- six in the minute, was neither so hurried nor so oppressed as on the previous day, and the cough had lost much of its hardness. The auscultatory symptoms, however, were not much altered. The anti- monial plan of treatment was continued, but as on the following day the cough was harder, and the sub-crepitant rade more abundant, oiv of blood were taken by cupping from between tbe scapulae, and from this period no unfavorable symptom manifested itself. This case, however, and cases similar to it, may be regarded as COMPLICATIONS OF MEASLES. exceptional. In most instances, either the slight cough which accom- panied, the early stage of measles increases in severity with the pro- gress of the disease, and the signs of thoracic mischief creep on gradually till they assume an alarming character about the fifth^ or sixth day of the disease; or in other cases the symptoms of affection of the chest do not manifest themselves at all till the eruption is already declining. I believe that the chest complication is generally serious in proportion as it comes on early and sets in severely ; though still more hazardous are the relapses which sometimes succeed to im- provement, even after it has persisted for three or four days, and which are peculiarly unmanageable, and issue with great rapidity in extensive hepatization of the lung. The symptoms to which inflam- mation of the lungs at the decline of measles gives rise are sometimes very slight, so slight that nothing short of careful daily auscultation will in many instances suffice to detect it. Two circumstances which are especially calculated to mislead, are the fact that the pneumonia is often unattended by much cough or dyspnoea, while it is frequently associated with considerable sympathetic disturbance of the stomach and bowels. The course of the affection of the lungs in these cases is usually chronic; the child loses flesh, becomes the subject of an irregular hectic fever, and when at length the thoracic symptoms be- come more apparent than at first they had been, and when the cough grows more frequent, and is -attended by some expectoration, the case so closely resembles one of tubercular phthisis that it is extremely difficult to avoid an erroneous diagnosis. That extreme susceptibility of the mucous membranes, to which are due the persistence of the cough, the supervention of bronchitis, or the occurrence of ulcerative inflammation of the fauces and larynx, on the decline of the rubeoloid eruption, very frequently extends to the intestinal canal, and gives rise to diarrhoea. The character of the attack corresponds in general to those which some days ago I described under the name of catarrhal diarrhoea, and in the greater number of instances its symptoms yield readily to treatment. Among the poor, however, who in accordance with the notions of humoral pathology current among the vulgar, generally regard looseness of the bowels after fever as a salutary provision of nature, I have not infrequently met with cases of neglected diarrhoea, in which the symptoms have put on a dysenteric character, and have either seriously threatened life, or in some instances have actually destroyed it. Sometimes, too, the acute stage of diarrhoea is succeeded by an habitual chronic relax- ation of the bowels, not only serious in itself, but still more so from its persistence, not infrequently issuing in the developement of phthisi- cal disease. This last hazard is one which, though perhaps overrated by the older observers, who had not the means which we now possess of forming a correct diagnosis, is yet a very real one, and one too against which it behooves us to be on our guard, not simply during the decline of the eruption, but also throughout the whole period of conva- lescence. Phthisis coming on early in the disease often runs an acute course developing itself apparently out of the fever itself, and being 5S4 TREATMENT OF MEASLES. often difficultly distinguished from the inflammatory affection of the lungs, of which I have already spoken. When it comes on later its course is more chronic, its symptoms are more easily recognizable as those of ordinary phthisis, and the child's history is that of an incom- plete recovery from measles having been succeeded by progressive failure in health, and by the gradual appearance of consumption, which proves fatal in some months, or a year, or even not till after a longer period from the occurrence of the fever. The clanger of measles, you must have already seen, depends almost exclusively on its complications, and as in their absence there is little to excite alarm, so also there is little to call for treatment. In mild cases, indeed, scarcely anything is needed beyond confinement to a warm chamber, a spare diet, and gentle antiphlogistic remedies. The cough, which is the most troublesome symptom—frequently, indeed, the only one that calls for much attention—is often very much re- lieved by the application for three or -four hours of a small blister, no bigger than a shilling, to the trachea, at the point just above the sternum; and this slight counter-irritation, which seldom produces any vesication of the surface, may be repeated during the course of the affection. If more than this be needed, small doses of antimonial and ipecacuanha wine, with laudanum or the compound tincture of camphor, may be given every few hours. The imperfect desquama- tion that sometimes takes place as the eruption declines, is often at- tended with very distressing itching of the whole surface; while the cough is sometimes frequent and troublesome at night, and the child is thus prevented from sleeping. To relieve these troublesome symp- toms, as well as to check that tendency to diarrhoea which often comes on at the decline of measles, it is desirable to follow the plan pursued by Sydenham, and to give an opiate every night—a small dose of Dover's powder being the best form in which it can be administered, while the warm bath every evening both soothes the patient and ex- ; the completion of the desquamative process. But though these simple measures are amply sufficient in the great majority of cases, we yet must not allow ourselves to be betrayed into inertness when any indications of mischief in the chest make their appearance. Such symptoms sometimes come on early in the disease, and before the eruption has well appeared, the child seeming much oppressed, and experiencing considerable dyspnoea, although the aus- cultatory evidences of disease in the chest may be but small. This nervous dyspnoea is often relieved by the application of a mustard poultice to the chest, and by placing the child in a hot bath—a pro- ceeding which will very frequently be followed by the appearance of the rash abundantly over the whole surface. Should these measures, however, fail to produce relief, or should the symptoms from the first be alarming, the distress and dyspnoea very considerable, and the rash not merely scanty, but of a dark or livid hue wherever it has appeared, as in the case I just now related to you, the abstraction of blood is urgently required; and general depletion should, in such circum- stances, be employed in preference to merely local bleeding. If bron- chitis or pneumonia should come on at a later period of the disease, SCARLET FEVER. 585 when the rash has already fully appeared, or is beginning to decline, the question of bleeding, as well as of the mode in which the deple- tion shall be practised, must be determined entirely by the severity of the chest symptoms, and is little if at all modified by any consi- derations drawn from tbe circumstance of their supervening during the course of another disease. The unfavorable conditions under which infants are placed in the Hopital des Enfans at Paris, have in- duced, on the part of French physicians, a dread of depletion in the course of measles which is certainly not justified by the characters that the disease presents in this country. A repetition of depletion is, however, not generally either necessary or useful, especially if the first abstraction of blood be followed up, as it ought to be, by the free employment of tartar emetic. The dyspnoea, which is frequently exacerbated towards evening in the course of the pneumonia and bronchitis that accompany measles, is generally much relieved by mustard poultices; but the application of blisters in these circum- stances is hazardous, since the sores which they produce are often very intractable; and the irritation and suffering they occasion prove, in many instances, seriously prejudicial to the children. It is import- ant, too, to bear in mind that little reliance can be placed on mercurial remedies in the treatment of active rubeolous pneumonia, though small doses of the hydr. c. cretS, with Dover's powder, are often exceedingly useful in cases where a hepatized state of the lung is left behind after the subsidence of the fever, and of the more acute inflammatory symptoms. I spoke so fully some days since concerning the treatment of croup succeeding to measles, that it cannot be necessary to repeat the remarks which were then made; neither need I add anything to what I said on a former occasion about cancrum oris—which distress- ing affection occasionally supervenes on its decline. The period of convalescence, too, and the ailments which I have referred to as some- times coming on at that time, require no special notice now. I have described the dangers; the general principles of medical treatment must guide your endeavors either to avert or to remove them. I will now, in conclusion, briefly sketch the more striking features of scarlet fever. Like measles, it is a disease chiefly occurring in early childhood, and the highest mortality from it takes place during the third year of life.1 It differs, however, from measles, as I have already stated, in not being so generally prevalent at all times, but usually assuming an epidemic form for a season, and then for months disap- pearing altogether. Its characters also are more variable than those of measles, and one epidemic is often marked by certain distinguish- ing features quite dissimilar from those which characterized a previous, or jvhich may be observed in a succeeding epidemic. Even when it occurs in a sporadic form its characters are very variable. It presents itself in one case as an ailment so trifling as scarcely to interrupt a child's cheerfulness even for a day; in another it is so deadly, that medicine is unable to stay its course even for a moment, and that it destroys life in a few days, sometimes even in a few hours. i See Table by Dr. Tripe, in Med.-Chir. Review, Jan. 1854, p. 238. 586 SYMPTOMS OF SCARLATINA SIMPLEX. These remarkable variations in the character and severity of the affection, and in the symptoms which attend it, have given rise to its subdivision into the three varieties of scarlatina simplex, scarlatina anginosa, and scarlatina maligna. In the first of these the patient experiences an attack of fever, often very mild, always of very short duration, and accompanied by the appearance of a bright scarlet rash over the whole surface, and generally by a slight degree of sore-throat. In the second the fever is more intense, and subsides less speedily, while, as its name implies, the attendant sore-throat is very severe; and in the third the fever generally assumes a typhoid character, sloughing of the inflamed tonsils not infrequently occurs, and a variety of complications in many instances supervene, by which the danger is still further aggravated. In cases of scarlatina simplex the attack is usually ushered in by vomiting, which is in many instances often repeated, and which is accompanied by very intense heat of skin, by great rapidity of the pulse, by headache or heaviness of the head, and by so considerable a degree of sensorial disturbance as to give rise to delirium in many children who are old enough to manifest this symptom. On the following day, often within twenty-four hours from the commence- ment of the patient's illness, the rash of scarlatina makes its appear- ance. It usually shows itself first on the neck, breast, and face, whence it extends, in the course of twenty-four hours, to the trunk and extremities. Its color is a very bright red, due in part to a gene- ral flush of the skin, in part to the presence of innumerable red dots or spots, which look like minute red papillae, though often they com- municate no sense of roughness to the hand. To this, however, there are occasional exceptions; the rash on the chest and body presenting sometimes, when at its height, a slightly papular character; and now and then minute sudamina are intermingled with the eruption. In some instances the redness of the surface is universal, but in other cases the rash appears in patches of uncertain size and irregular form, which never affect any definite shape, and never present a clearly circumscribed margin. For three days the rash usually continues to become of a deeper color, and more generally diffused over the whole surface; it then slowly declines, but does not wholly disapppear until the seventh, or sometimes the eighth day of the disease. The appear- ance of the eruption is not in general succeeded by any immediate diminution in the other symptoms; but on the contrary, they often increase in severity until the eruption has reached its acme, when they slowly decline with the disappearance of the rash. Sometimes, indeed, when the case is very mild, the fever abates so soon as the rash is fully out; and the child regaining its cheerfulness on the third day, shows no further signs of illness, though the rash remains visible for two or three days longer. Now and then, too, especially in young infants, the affection throughout consists of little more than of an eruption on the skin, the presence of which is almost, occasionally altogether, the only evidence of their having been attacked by a disease sometimes so deadly. Such, however, are exceptional cases; and in most instances, even when the disease is mild, a slight degree SYMPTOMS OF SCARLATINA ANGINOSA. 587 of soreness of the throat comes on on the second or third day; the palate and tonsils appear red, the latter are generally somewhat swollen, and deglutition is slightly impeded. The tongue also is pre- ternaturally red, and its papillae, which are very prominent, project through the white or yellowish fur which coats it, and thus form an appearance as characteristic of scarlatina as the rash itself. The red- ness fades from the fauces, and the fur disappears from the tongue, as the eruption declines; but the prominence of the papilla? often con- tinues for some days longer, and the tongue presents a vivid red color, and appears raw, as if from the absence of its ordinary mucous coating. As the rash subsides, desquamation of the epidermis generally com- mences, the cuticle peeling off from the hands and feet in large flakes, though on the face and trunk the desquamation usually takes place in furfnraceous scales. Both its degree and duration vary much in different cases; sometimes it is over in five or six days, while in other cases the cuticle is reproduced, and then desquamates several times in succession, and the process is thus protracted for three or four weeks, or even longer. It is not possible to assign a cause for these differences. Some epidemics of scarlatina are characterized by the abundance of the desquamation, and its almost universal occur- rence, while at other times it is scanty, and often wanting. The danger of this disease is by no means in proportion to the abundance of the rash, but rather to the degree of the affection of the throat, the severity of which is the distinguished feature of scarlatina anginosa. In this form of the affection the premonitory symptoms are usually much more severe than in the scarlatina simplex; they are also often of longer duration, the rash not showing itself until the end of the second, and sometimes even not until the third day. It is, moreover, less generally diffused over the surface than in the milder variety of the disease, but appears in the form of large scarlet patches irregularly distributed over different parts of the body, especially on the back. In some cases, too, of this variety of scarlet fever, though I think more commonly in the adult than in the child, the rash is altogether wanting, fever and sore-throat alone characterizing the disease. In such cases its real nature is sometimes not suspected until other members of the same family are seized with similar symptoms, coupled with a well-marked scarlatinal rash; or, until perhaps the occurrence of dropsy during convalescence awakens suspicion as to the nature of the previous illness. Almost from the commencement of the attack, soreness of the throat is experienced, attended with difficulty of deglutition, and often with considerable stiffness of the neck, and pain and difficulty in moving the lower jaw, due in part to the swelling of the submaxillary glands. On examining the throat, it is seen to be intensely red, and the tonsils are both red and swollen. The swelling of the tonsils increases rapidly until they almost block up the entrance of the pharynx, and thereby render the attempt to swallow so difficult that fluids are often returned by the nose. An adhesive mucus collects about the back of the throat, and often seems to cause great annoyance to the patient, and specks or patches of lymph form upon the tonsils, and look like sloughs covering ulcers, 588 SYMPTOMS OF SCARLATINA MALIGNA. though, on detaching them, it is seldom that any breach of surface appears beneath. In some of the severest cases, a very troublesome coryza comes on, and an adhesive, yellowish matter is secreted in abundance by the mucous membrane of the nares, whence it runs down upon the upper lip, excoriating the skin over which it passes, and causing still more serious suffering by the obstacle that it presents to free respiration. In some epidemics the inflammation extends to the parotid glands, and to the cellular tissue about the neck, the parts thus affected becoming rapidly swollen, and acquiring a great size and a stony hardness. In some cases this affection is confined to one side; in others, both sides are attacked in succession, while sometimes both are involved simultaneously, and the integuments under the chin and in front of the neck become likewise inflamed, and tense and swollen; and the lower jaw is so firmly fixed, that the attempt to swallow is rendered almost impracticable, and the patient is exposed to a new source of danger, from the difficulty of taking nutriment in quantity sufficient to support the feeble powers of life. Coupled with this severe local affection, there is, as might be expected, a corres- ponding intensity in the constitutional disturbance. The h»eat of the skin is very great, the pulse extremely frequent, and though not small, is yet from an early period very easily compressed; the senso- rial disturbance is considerable, and the restlessness extreme. The tongue does not present that appearance which I mentioned as being characteristic of scarlatina in its milder form, but is coated with a brown fur, though red at its tip and edges, and often becomes dry at a very early period of the disease—partly, no doubt, in consequence of the swelling of the tonsils and of the glands compelling the patient to breathe with his mouth open. In cases where the throat affection is very severe, the dyspnoea arising from the difficult entrance of air into the lungs seems some- times to be the chief cause of the patient's death; though it is very rarely, even when the pharyngitis is most intense, that the larynx presents any signs of having been seriously involved in the mischief. In the greater number of instances, however, that terminate fatally, the local symptoms do not seem to be by any means the sole cause of death, but the fever assumes more and more of a typhoid character, and this even though the throat affection should not increase in severity, but should even retrograde. On the other hand, cases of simple scarlatina anginosa generally have a favorable issue; for in spite of the severe sore throat the constitutional disorder retains the characters of active inflammatory fever, and begins to subside in three or four days at the latest; abating as the local symptoms themselves subside, which they generally do about this time. The sore-throat too, though it comes on early, increases rapidly, and soon attains a great severity, is yet not accompanied in the majority of instances by great swelling of the submaxillary glands, which do not assume that stony hardness; nor do the surrounding integuments acquire that swelling or tension which are observed in less favorable cases. Be- tween the severer forms of scarlatina anginosa, and that still more dangerous variety of the disease to which tbe name of malignant has OCCASIONAL RAPIDITY OF ITS COURSE. 589 been applied, the differences are often rather of degree than of kind. In malignant scarlet fever, howrever, the sore-throat, though a general, is by no means a constant symptom; death takes place in some in- stances before it has manifested itself with much severity, whilst in many other cases it is only one of several symptoms which threaten the patient's life. Cases of scarlatina anginosa, even when running the least favorable course, occupy some days before the dangerous character of the disease becomes fully developed. The malignant form, however, sets in with ill-omened symptoms, and these sometimes are so intense as to carry off the patient in less than forty-eight hours. I mentioned one such case at the commencement of these lectures,1 in which convulsions succeeded by coma destroyed in a single day a previously healthy boy, of two years of age. In other instances, the onset of the disease announces itself by sudden and intense collapse, from which the patient rallies, but sinks under it in one or two days. Dr. Henry Kennedy, in his very excellent account of the epidemic of scarlatina which pre- vailed at Dublin between 1834 and 1842,2 relates some instances of this occurrence far more striking in character than any which have come under my own notice. Among others, he narrates the case of a little girl, four years old, who was seized with the usual symptoms of the epidemic; in about eight hours she lost the power of swallow- ing, and this was followed by a state of coma, alternating with con- vulsions of one side of the body. When seen, there was no pulse to be felt at the wrist, the hands and feet were cold and perfectly livid, and the patient's condition was very like that of a person in the last stage of Asiatic cholera, except that her body was covered by a dark- colored eruption. Six hours before death, which took place before the end of the second day, diarrhoea made its appearance, and con- tinued up to the moment of dissolution.3 Though no instance comparable with this in the suddenness and completeness of the collapse has presented itself to my observation, I have met with several in which it was apparent, almost from the moment of the seizure, that there was scarcely any chance of the child's recovery. The frequency of such cases varies much in different epidemics, as do also the characters of the symptoms by which the malignancy of the disease announces itself. In some instances, as in that just related, the complete collapse is not succeeded by any attempt at rallying the energies of the system; in others convulsions destroy the patient; in another class uncontrollable diarrhoea sets in almost at the commencement, and speedily exhausts the patient's powers; in others petechia? and vibices appear on the surface, or hemorrhage takes place from the bowels—the tokens and consequences of the changes in the circulating fluid; while in other instances typhoid symptoms come on on the second or third day; and death takes place long before the termination of the first week, with phenomena such as one would scarcely expect to meet with earlier than the second or third week of severe typhus fever. One or other of these types is 1 Lecture IV. p. 45. 2 Dublin, 1843, 12mo. 3 Op. cit., p. 62. 590 COMPLICATIONS OF MALIGNANT SCARLET FEVER. that which in each epidemic of severe scarlet fever characterizes the majority of the worst cases, but isolated cases of the disease sometimes occur sporadically, marked by its worst features, or present themselves as exceptions to the generally mild character of some epidemic of the disease. Of this I saw a striking example some years ago in a large public school some miles from London, in which scarlet fever became prevalent. Almost all of the cases, which occurred among lads from fourteen to eighteen years of age, were extremely mild; but one youth, more robust than most of the others, sank from the moment he was taken, and died with typhoid symptoms before the end of the third day. His case stood by itself, unlike any of those v/hich pre- ceded or which followed it. Even in the malignant form of scarlatina, however, it is seldom that death takes place with this extreme rapidity; but the patient more commonly survives to the end of the sixth or seventh day, and in these circumstances the affection of the throat generally goes on increasing in severity. The inflammation of the tonsils in these cases terminates in the formation of excavated, ragged, unhealthy ulcera- tions, which I have occasionally found also in the pharynx, and at the upper part of the oesophagus; or sometimes a more extensive slough- ing involves the parts at the back of the throat. The tongue and soft palate are found denuded of their epithelium; the papilla? of the tongue very prominent, and those at its base, as well as the lingual glands in that situation, extremely enlarged, and covered by a dirty tenacious mucus. The coryza, to which reference was made just now, is generally very severe, while the mischief at the back of the throat sometimes extends to the air-passages; and I have found the mucous membrane at the under surface of the epiglottis, and about the ary- tenoid cartilages, much injected and thickened; a condition which, during life, was sufficient to occasion intense dyspnoea, and to give rise, on each attempt at deglutition during the last twenty-four hours of the child's life, to a struggle for breath which threatened every moment to be fatal. The swelling of the parotids in some of these cases increases with very great rapidity, and forms not infrequently, by the implication of the integuments of the neck, a sort of collar of brawny hardness, which interferes alike with deglutition and respira- tion. These swellings are remarkable for the slight tendency which they show to suppurate; and even after they have attained a very considerable size, and have been in great measure instrumental in occasioning the child's death, I have found the parotids much enlarged, of a rose red color, infiltrated with thin serum, and a dirty sero- purulent fluid also pervading the cervical cellular tissue, but no true pus either in the substance of the gland itself or in the surrounding cellular tissue. Now and then, however, suppuration takes place, not in the substance of the glands themselves, but in the surrounding cellular tissue; and the quantity of pus which is formed there is sometimes very considerable. The destruction of tissue, too, is not always the result of mere suppuration, but a process of sloughing sometimes destroys the cellular membrane very extensively; and, by involving the large vessels of the neck, has caused the child's sudden SEQUELS OF SCARLET FEVER. 591 death from hemorrhage—an occurrence, indeed, which I have not met with, but which came thrice under the observation of Dr. H. Kennedy, of Dublin, whose excellent account of the epidemic which prevailed in that city will well repay your attentive perusal. As in other blood diseases, so in scarlatina, we meet now and then with secondary inflammation of the joints, which may even go on to the formation of pus. It is, however, not a common occurrence; but I saw the hand thus affected in a child who died on the sixth day of the disease, and in another child, who had recovered from scarlatina, in the course of which inflammation attacked the right shoulder-joint, the humerus remained perfectly anchylosed. Both the pericardium and endocardium are also sometimes affected, but in this stage of the disease that special tendency to inflammation of the serous membranes which is afterwards observed does not manifest itself. Pneumonia, indeed, is a more frequent affection, running its course without any marked symptom, though a large portion of one or both lungs may be found after death in a state of hepatization. The other post-mortem appearances observed in scarlatina are to a great degree identical with those observed in malignant fevers gene- rally. The blood is usually semi-coagulated, of the appearance and consistence of gooseberry-jelly, or even altogether fluid, and the coats of the vessels are often stained by it. The mucous membrane of the bronchi, stomach, oesophagus, and trachea, is often of an intensely red color, though nothing can be more arbitrary than the extent, de- gree, and situation of this redness. The texture of the kidneys and heart is also often very much softer than natural, so as to tear very readily; and once I found the heart exceedingly flaccid, its tissue in- filtrated with reddish serum; and not merely tearing easily, but even being so soft that the finger could be pushed through its walls with the slightest effort. Such are the chief modes of death from scarlet fever, and such the more important appearances discovered afterwards: at least as far as my personal observation extends—though I scarcely need remind you that there are but few diseases of which the characters are liable to greater variations; so that no account, how minute soever, can be taken as a true portraiture of more than just that one form of the fever with which its describer may chance to be most familiar. Unhappily the first few days of the disease do not by any means comprise the whole period of danger, but even though the patient should survive the peril of the fever, a long catalogue of sequelae remains, some of which may endanger or even destroy life. Some- times, indeed, the patient passes through the first week of the disease with few or no symptoms to excite anxiety; and then, when the rash is on the decline, the parotid glands swell, grow hard, and intensely painful, and on one or two occasions I have seen the integuments covering them become gangrenous; or sloughing ulcers form on the tonsils, which had not seemed to be very much inflamed previously; an acrid discharge takes place from the nostrils, and death follows in the course of four or five days. In the majority of instances, how- ever, the glandular swellings which come on after the lapse of a week 592 DIAGNOSIS OF SCARLET FEVER. from the commencement of the disease, though tedious and painful, yet do not endanger life. Occasionally, indeed, death occurs in con- sequence of the matter formed by the inflammation of the glands, or of the cellular tissue around them, burrowing backwards behind the pharynx instead of pointing externally, and constituting retro-pharyn- geal abscess: an affection concerning which I spoke to you a few days ago.1 Coupled with the swelling of the parotid glands, or even independ- ently of it, inflammation of the internal ear is often met with as a con- sequence of scarlatina. This otitis terminates in abundant purulent discharge, which sometimes continues for many weeks; and occasion- ally it completely destroys the organ of hearing, and renders the patient hopelessly deaf for the remainder of his life. I have already spoken, in a previous lecture,2 of that very frequent and very serious occurrence, the dropsy which succeeds to scarlet fever, and need not, therefore, refer to that subject now. But there are other cases, in which, without any definite local complication, the convalescence from scarlet fever is fluctuating and protracted. In such cases the bowels are irregular in their action, alternately relaxed and constipated; the evacuations unhealthy; the tongue red and raw; and aphthous ulcerations sometimes appear on the inside of the mouth ; while an irregularly remittent fever harasses and weakens the child. These symptoms, however, which closely resemble those that some- times come on during convalescence from measles, are of much less frequent occurrence as consequences of scarlatina. The diagnosis of scarlatina is not in general attended with much difficulty; and the points of difference between it and measles are so well marked, that it is not easy to understand how the two diseases should so long have been confounded together. Their period of in- cubation is different; that of scarlatina not exceeding a week, that of measles extending to two. Their premonitory symptoms are very dissimilar—those of measles closely resembling the signs of a severe catarrh; while the attack of scarlatina is announced by sickness, suc- ceeded by intense heat of skin, by sore-throat, great sensorial distur- bance, and extreme rapidity of the pulse. There is no other disease of childhood, indeed, in which the two last-named symptoms super- vene so speedily after the commencement of illness; and their occur- rence will often enable you, even before the appearance of the rash, or any complaint of sore-throat, to form a correct conclusion with reference to the nature of the affection. The premonitory stage of measles usually continues for three or four days—that of scarlet fever, in its regular form, only for twenty-four hours; while the other symp- toms that appear in cases of scarlet fever, in which the rash is delayed, are such as quite to forbid the supposition of the patient being affected with measles. The character of the two eruptions is so dissimilar, that I need not here dwell on their peculiarities, nor do more than re- mind you that, while in measles the great danger to life arises from the supervention of bronchitis or pneumonia, the two great sources of 1 See Lecture XXXIII. p. 445. 2 See Lecture XXXIX. p. 522. TREATMENT OF MILD SCARLET FEVER. 593 hazard in scarlet fever are the affection of the throat during its pro- gress, and the occurrence of dropsy after its decline. With a few words on the treatment of scarlatina, I will bring this subject, and the present course of lectures, to a close. The milder forms of the disease require, as you know, but little interference; and you fulfil every indication by keeping the child in a cool and well- ventilated chamber, placing him on a spare diet, giving some mild antiphlogistic medicine during the progress of the fever, and sponging the surface occasionally with tepid water, if the heat of the skin be considerable. For the past two years, however, I have been accustomed to substi- tute for tepid sponging the inunction of suet into the whole" surface twice a day; and my experience leads me very strongly to recommend the adoption of this practice. I was led to try it by the strong encomi- ums which the late Professor Mauthner, of Vienna, bestowed upon the use of inunctions in these cases, as originally advocated by Dr. Schnee- man, of Hanover.1 It seems to relieve the sense of heat, so distressing to the patient, more effectually than tepid or cold sponging, however often repeated; while it has the further advantage of not requiring repetition above twice in the twenty-four hours, by which the patient is spared much otherwise unavoidable fatigue. To the hand of a by- stander it seems to have the effect of removing the pungent heat so remarkable in most cases of scarlet fever, and of keeping the skin sup- ple and comparatively cool, though I am not prepared to say whether it exerts any real influence on the temperature of the surface as esti- mated by the thermometer. It does not prevent the desquamation of the cuticle after the decline of the eruption, nor does its most diligent employment exclude the occurrence of albuminous urine; though I think it considerably lessens the amount of the former, and diminishes the risk of the latter assuming a serious character. This immunity from bad symptoms, however, is doubtless in great measure due to the circumstance that the cases in which the inunc- tion was employed were those which came earliest under treatment, and in which, consequently, opportunity existed for carrying out a judi- cious management of the disease through all its stages. I believe it promotes the patient's comfort, and lessens the risks of some of the ordinary sequelae of the disease; but the extravagant laudations which this proceeding has received from some medical men induce me to add that I do not consider it as anything more than a useful adjunct to appropriate treatment, and in no sense a substitute for it. During the period of development of the rash, the inunction should be prac- tised twice a day; when the eruption is on the decline its employ- ment once in the twenty-four hours is generally sufficient; whilst if the desquamation is at all abundant, the hot-air bath is of the greatest 1 In a work published at Hanover, in 1848, and of which an analysis is given in the Journal fur Kinderkrankheiten, March, 1848, p. 214. With no previous knowledge of the observations of others, Mr. W. Taylor, of London, was accustomed, from the year 1829, as he states in a little work published in 1850, to adopt a very similar course in the treatment of various febrile diseases, for which he regards it as almost a panacea. 38 594 TREATMENT OF ITS SEVERER FORMS. service in facilitating its completion, and maintaining the activity of the skin. How slight soever the attack of scarlet fever may have been, the patient ought not to be allowed to leave his bed in less than ten days, nor his room in less than three weeks from the commence- ment of the attack, while the urine ought to be tested for albumen twice a day, in order that the first threatening of so serious an evil as scarlatinal dropsy may at once be met by appropriate treatment. During the whole of the stage of convalescence, or so long at least as the skin shows any trace of desquamation, even though the child is allowed to leave its bed, the inunction should be continued every morning, while the child should be placed in a warm-bath every even- ing, and well rubbed with a soft towel on being placed in bed again. During the whole of this time the diet must be mild and unstimulating, and due attention must be paid to the state of the bowels". For some time after, much caution must be exercised in not allowing the child to go out when the air is cool, and in avoiding all errors of diet, while it is also expedient that flannel should be worn next to the skin for a considerable period after apparent convalescence from scarlet fever. I know that these precautions may appear to you overstrained—they often do to our patients, but I can only say that every year of added experience leads me to insist upon them more and more, just as each year shows me more of the dangers of scarlatinal dropsy, and of its in- tractable character. Even in severer cases of the disease, you must not be in too great a hurry to resort to active measures, for you will remember that a some- what stormy onset is characteristic of all but the very mildest forms of scarlatina. That disturbance of the sensorium, for instance, which, when the child is sufficiently old, shows itself by the early occurrence of delirium, must not lead you to have recourse hastily to depletion, either general or local, in order to quiet the disorder of the brain. The results afforded by depletion in scarlet fever, even when the disease occurs in the adult, are by no means encouraging; and'in the child the loss of blood in these circumstances is even less well borne; so that, unless the patient be robust and plethoric, the cerebral distur- bance very serious, and the evidences of congestion of the brain very marked, you should content yourselves with the application of cold to the head, perhaps employing cold affusion, if the symptoms be very urgent. It is indeed many years since I employed depletion in the course of scarlet fever, though, as I have already mentioned, the ab- straction of blood is frequently needed in the dropsy which constitutes its most formidable sequela. In the malignant forms of the disease there is often very considerable disturbance of the sensorium, great restlessness alternating with a state of stupor; but the frequent and feeble pulse at once forbids depletion in such cases, and points out the necessity for adopting every means to support the feeble powers of life. It is very likely that the low type which a disease such as scar- latina is almost sure to assume in the crowded dwellings of the poor, has rendered my practice, in this respect, somewhat different from that which might be advantageously pursued in the case of children more favorably situated. To the same circumstances it is also probably due TREATMENT OF ITS SEVERER FORMS. 595 that, in a large proportion of cases, I have found it desirable to give ammonia almost from the outset of the disease; a practice which has been recommended as universally applicable, and which (though the remedy does not deserve the indiscriminate encomiums that have been lavished on it) you will do well to follow, whenever the pulse presents the characters of frequency and softness.combined. The state of the throat must be carefully watched in every case of scarlet fever; and whenever there is much swelling of the tonsils, if the child be too young to gargle, a slightly acidulated lotion should be injected into the throat, by means of a syringe, every few hours, in order to free it from the mucus which is so apt to collect there, and to be the source of much discomfort. If there be much deposit of lymph upon the tonsils, it is generally desirable to apply strong hydrochloric acid, mixed with honey, in the proportion of about one part of the former to six of the latter, by means of a dossil of lint, or a camel's hair pen- cil, two or three times in the twenty-four hours; but the strength of the application must be increased if the tonsils be ulcerated, or if any disposition to sloughing should appear. The coryza, which is so dis- tressing and so ill-omened a symptom in cases of severe scarlatina, is best treated by throwing a small quantity of a solution of gr. j or gr. ij of nitrate of silver in 3j of distilled water, up the nostrils every four or every six hours. The glandular swellings are very difficult to relieve, though their development sometimes seems to be retarded by painting the skin over them, two or three times a day, with tincture of iodine. When considerable, they do not seem to be benefited by leeches; the employment of which is also contraindicated by the fee- ble state of the patient's powers; while they show very little disposi- tion to suppurate, and consequently are not relieved by lancing ; so that the constant application of a warm poultice is often all that can be done to afford ease to the patient. Children in whom the local affection is severe, or in whom the disease assumes a malignant char- acter, require all those stimulants, and that nutritious diet, which we are accustomed to give to patients in certain stages of typhus fever; though, unfortunately, the best devised means will, in many such cases, prove ineffectual. It may be well to add a few words in conclusion with reference to the alleged virtues of belladonna as a prophylactic against scarlatina. Hahnemann, the founder of the homoeopathic system, first introduced it into practice, being induced to try it by certain resemblances which he believed to exist between its effects and the ordinary symptoms of scarlet fever. Other practitioners, without subscribing to homoeopa- thic opinions, have yet adopted this proceeding, and aver that infini- tesimal doses of belladonna do in reality exert the marvellous pro- tective powers which the drug was said to possess. The evidence of its virtues, however, is in the last degree unsatis- factory. There are many recorded instances of its failure when tried on a large scale, while the strongest advocates of its use have never put its virtues to the obvious and simple test of administering the remedy to half of a given number of persons placed in similar circum- stances as to age, health, and exposure to contagion, and comparing 596 PROPHYLAXIS OF SCARLATINA. the results thus obtained. In the only instance with which I am personally acquainted where this mode of inquiry was adopted, the results, though the experiment was on too small a scale to justify a positive conclusion, seemed to show that the protective power of belladonna was absolutely null. I cannot do better than relate the experiment which was made at the Boyal Military Asylum at Chelsea, by Dr. Balfour, in the words in which he was good enough to com- municate it to me. Scarlet fever having broken out in the institution, Dr. Balfour determined to try the virtues of belladonna. "There were," he says, "151 boys of whom I had tolerably satisfactory evi- dence that they had not had scarlatina; I divided them into two sections, taking them alternately from the list, to prevent the impu- tation of selection. To the first section (76) I gave belladonna; to the second (75) I gave none; the result was that two in each section were attacked by the disease. The numbers are too small to justify deductions as to the prophylactic power of belladonna, but the ob- servation is good, because it shows how apt we are to be misled by imperfect observation. Had I given the remedy to all the boys, I should probably have attributed to it the cessation of the epidemic."1 To these remarks I need add nothing. They convey a most im- portant lesson, but one which I fear we are all too apt to forget, in the study and in the practice of medicine. 1 Any one who still feels a lingering faith in the prophylactic powers of belladonna, will do well to read the very careful and candid inquiry into the evidence on both sides of the question, published by Dr. Warburton Begbie, in the British and Foreign Medico-Chirurgical Review for January, 1855. ADDITIONAL LECTURES. LECTURE I. On Sudden Death in Infancy and Childhood.1—Introduction.—Time when study of children's diseases is likely to be most useful.—Subject chosen as exemplifying some of the peculiarities of early life.—Sudden death in the young often inde- pendent of serious alterations of structure.—Dependent on spasm of respiratory organs, as in spasmodic croup and hooping-cough—on mere disorder of respira- tion, as in collapse of lung, or in pneumonia, or in hydrothorax.—Death from asthenia—in diarrhoea, in pneumonia, etc.—Rarity of sudden death from disease of the brain, and why.—Conclusion. The founders of the Children's Hospital proposed to themselves a threefold object—to relieve the sick; to train young women for the efficient discharge of the duties of children's nurses; and, lastly, to promote a more accurate knowledge of the diseases of early life among practitioners of medicine, and especially among those who are about soon to enter on the active exercise of that profession. For the past seven years the first two of these objects have been to some extent accomplished: many a sick child has been restored to health within these walls, for the out-patients have amounted to 56,476, and the in-patients to 2,211; while a few young women, though far fewer than we could wish, have received a training that will render them useful, helpful to themselves or to others, if sickness enters their home. Various difficulties, however, have hitherto prevented the ful- filment of the third, and certainly not the least important, of these purposes; and as a place for medical instruction the Hospital for Sick Children has as yet done but little. The managers of the institution, my colleagues, and myself, all feel that we must at least wipe away the reproach of not having attempted to accomplish what we yet pro- fess most earnestly to desire; and accordingly it devolves on me to- day to commence a system of regular instruction in the peculiarities of nature, symptoms, and treatment of the diseases of early life. I will not occupy your time in the attempt to prove that the dis- eases of childhood require a kind of study such as is not commonly bestowed on them by students during their pupilage; such, indeed, I might say, as they rarely have the opportunity of bestowing. Our 1 Delivered at the Hospital for Sick Children, Nov. 12,1859, and published in the London Medical Times and Gazette, for Nov. 26, 1859. 598 ON SUDDEN DEATH large hospitals are still inadequate to meet the necessities of the adult population, and it is not the fault either of their managers, or of their medical officers, that children form in them but a very small minority of the patients who there present themselves to your observation. Nor, indeed, could this well be wished otherwise—for the characters of disease are more easily read in the adult than in the child; and not till you can interpret the first with facility are you likely to decipher the hieroglyphics in which the latter are inscribed. It is not, therefore, at the outset of your medical studies, that a visit to the Children's Hospital is likely to yield you its full benefit; but, after you are acquainted with the general physiognomy of disease, it will profit you much to learn how its symptoms are modified, and its course is altered in early life; and how the dangers, against which it behooves you most to be on your guard, are not altogether the same in infancy and childhood as in adult age. An exemplification of some of these peculiarities in early life will be furnished us if we inquire into the circumstances which commonly attend Sudden Death in Infancy and Childhood. A thorough investigation into this subject in all its bearings would imply most minute research into some of the most difficult problems in physiology and pathology; a task for which I must own myself unequal, and one for which a single hour affords no sufficient time. But still, regarded even in its most obvious bearings, it must always be well worth the while of the practitioner of medicine to know when to be on the look-out for sudden danger, or when, on the other hand, he may rest quiet in the certainty that, be the perils of a disease what they may, they will increase by but slow degrees, and ample warnings will precede their fatal issue. The occurrence of sudden death in infancy derives part of its im- portance from the frequency with which it happens. It appears tbat out of 627 instances in which death took place suddenly within the London registration district in 1854, 236 were cases of infants under a year old. From that time, however, until with advancing years the processes of decay begin, sudden death is an accident of extreme rarity —so rare, indeed, that between the age of one and five years only thirty-six instances of its occurrence were met with; or not more than an eighth of the number stated to have happened in the first year of life. These statistics, however, do not by any means represent the subject in the full extent of its practical importance; for we are con- cerned, not with those cases only in which a state of apparent health is cut short by unexpected death; but also with those still more numerous instances in which disease, seemingly not grave, or at any rate apparently attended by no pressing danger, ends all at once in death. When sudden death occurs in the aged, or in those in middle life, the anatomist is generally able to point to some definite cause of its occurrence: the cerebral vessels, rendered fragile by calcareous de- posits in their coats, have suddenly given way, and allowed of the effusion of blood upon the brain; or an unsuspected aneurism has burst, or the heart's walls themselves, weakened by fatty degeneration, IN INFANCY AND CHILDHOOD. 599 have torn; or some ulcer of the stomach or intestines has perforated the thin membrane, and the escape of the intestinal contents into the abdominal cavity has produced intense peritonitis, and speedy, if not immediate death. The machinery, in short, is found to have been at fault; its movements have ceased, as do those of the watch whose main-spring is broken. In childhood, however, we scrutinize the frame, a few moments since so full of life, now still forever, and yet fail to discover why it has ceased to move: the cause which stopped it had done no irremediable damage, had left, perhaps, scarcely a trace of its effects; it was but momentary in its action, and could we set the machinery once more in movement, there seems no cause why it should not again perform its functions as harmoniously as before. Or, if we do find some flaw in its completeness, yet, even that is seldom such as time might not have remedied, still more seldom such as by its nature to give account of the suddenness with which all the processes of life were arrested. A little boy, eight months old, had cut two teeth at six and a half months, had always seemed well, save that now and then his hands were a little clenched, and his thumbs drawn into the palm. His bowels were slightly constipated; a small dose of castor oil was given him. He swallowed it readily, but had scarcely done so when he stretched out his tongue, his face turned livid, but was scarcely at all distorted; he did not struggle, he uttered no cry—scarcely a sound passed from him, and he was dead!—dead with no trace of disease; from mere momentary spasm, which, for a few seconds, stopped his breath; which, had it ceased sooner, would have left no cloud upon his face, nor quelled for a quarter of an hour his cheerfulness. I have related this case, not merely because it serves as a specimen of the way in which in early infancy life is not infrequently cut short without any trace of local mischief being discoverable; but because it illustrates the fact that it is by sudden interference with the respira- tory process that such death is oftenest produced. The suddenly fatal apoplectic seizures which we observe in the adult, scarcely ever occur in early life, nor do we often meet, except in instances of congenital malformation, with sudden death dependent on disease of the heart. But in the course of all affections which seriously interfere with the process of respiration sudden death is a contingency for which we should always be prepared, and this especially in proportion as the disturbance of breathing partakes of a spasmodic character. Now, of all the forms of spasmodic disorder of respiration, that to which the name of spasmodic croup, or laryngismus stridulus, has been given, is by far the most frequent; and to it, probably, three out of four of the sudden deaths of children under one year old, are due. It is not that this ailment is generally fatal; for in proportion to the frequency of its occurrence, the mortality which arises from it is small; but it is that the fatal event is apt to be very sudden, which accounts for the anxiety wherewith its symptoms are watched by those who understand their import. In early life, as you are aware, the excitability of the nervous system is far greater than in later years; and slight causes make a 600 ON SUDDEN DEATH deeper impression, and produce a more profound disturbance, while the controlling power of the brain is smaller than it becomes in after life. In infancy, too, the sources of irritation are especially numerous: the branches of the trifacial nerve during the whole period of teething; the pneumogastric nerve, whenever, with a change of diet, food is taken that is not well assimilated; the spinal nerves, when intestinal disorder, or diarrhoea is produced, are so many centres, whose disturb- ance when once excited betrays itself in the thumbs drawn into the palm, in the somewhat hurried breathing, in the partially closed larynx, and the peculiar crowing sound which that occasions with each inspi- ration, and which disturbance need increase but a little—but for a moment—to produce complete closure of the larynx, and sudden death. For days—for weeks, perhaps—these trivial symptoms may continue; and if I now insist on their importance, it is because they are often accompanied by but little disorder of the general health—because they are seldom dependent on disease of the brain, or remediable by reme- dies directed towards it—because they often are so slight that the anxiety of parents is hardly excited by them, and the watchfulness even of the doctor is apt to fall asleep. I do it, also, because the avoid- ance of the dangers they betoken depends on the observance of a number of minute particulars which may seem scarcely worth the notice: because sudden noises, which startle; a rapid change of tem- perature, which chills the surface, though only for a moment; a rude awakening from sleep; or even an over-hasty or an over-full meal, which interferes with the descent of the diaphragm; any cause, in short, that deranges the regular rhythm of the respiratory movements, may give rise to spasm, and this spasm may prove suddenly fatal. In the out-patients' room of this hospital you will see many such cases; and it is no bad exercise to learn to notice and to interpret signs that would readily escape the eye of the unobservant; although they are the indications of a state of system in which, while the pros- pect of well-doing vastly preponderates, yet the chances of sudden death are never to be lost sight of. In cases of this description, too, when once convulsions have occur- red, a new element soon comes into play, which aggravates the danger and increases the frequency of the attack. The blood imperfectly de- purated, if the disturbance of respiration has been considerable, seems in itself to exercise an injurious influence, by increasing the irritability of the nervous system, and thus promoting the return of the attacK. If once convulsions have occurred, the probability of their recurrence is much increased; and the oftener they have happened, the more often are they likely to return, and the graver is the prognosis which you are compelled to form. This rule holds good, too, not with refer- ence merely to spasmodic croup, but with reference to all spasmodic affections of the respiratory organs, and hooping-cough affords one of its best exemplifications. In some fit of coughing more violent than any of the others, the spasm of the larynx is of longer continuance, the face grows livid, a fruitless expiratory effort is made, and before the spasm relaxes a convulsion takes place. This convulsion is but very seldom a solitary one. You notice that for hours it is succeeded IN INFANCY AND CHILDHOOD. 601 by very accelerated breathing; by which, however, the blood is very imperfectly depurated, as you see by the lips, which never resume their natural color. At length the disturbance once more reaches its climax, and another, and then another convulsion occurs, with a gra- dually diminishing interval, until death takes place. If, in such cir- cumstances, you watch a child, you will notice how carefully it avoids every movement—how it remains in the same posture, occupied appa- rently altogether with the business of carrying on its respiration as gently and quietly as possible. Change its posture rapidly, excite it by sudden entrance into the room, disturb it by a violent emetic— interfere, in short, in any way with the regular steady performance of its respiratory movements—and convulsions will come on, and in these convulsions death is likely to take place. Some years ago I learnt this lesson in the case of a little boy, six years old, in whom hooping-cough set in with great oppression of the respiration, though that was out of proportion to the signs of local mischief detected on auscultation. I treated him with greater activity than I should now do, and gave him tartar emetic, which failed, how- ever, to reduce the frequency of his respiration, or to improve his condition. Still, his state was one suggestive rather of anxiety for the future than of present danger. He was breathing carefully, anxiously, as though respiration were a function which required all his attention for its performance. Wishing to auscultate him, I had him lifted out of bed on to his mother's knee; but scarcely had he assumed the upright posture when a fit came on, in which he struggled much, his face became livid, almost purple; and though in less than three minutes the convulsion was over, it left him ashy pale, with a very feeble pulse, and perspiration streaming from every pore. He lived for thirty-six hours longer, but his respiration never resumed its natural frequency; a second fit occurred, six hours after the first; and then a third, which rendered his pulse still feebler. He lay now on his back, uttering a piteous moan, his face livid and miserable, his eyes dim, and though his pupils acted naturally, he yet complained that he "wanted more light." A fourth fit lasted several hours, and left him insensible; with the death-sweats on his face, and his eyes distorted, then came a fifth, which lasted for but a few minutes, when he died tranquilly. There were here no morbid appearances in the brain, the lungs were extensively congested, and their lower lobes were in the first stage of pneumonia. The blood was imperfectly aerated; but, even so, while no demand was made for more adequate performance of the respira- tory function, dangerous symptoms did not appear. The child's pos- ture was suddenly altered, his circulation quickened, attempts at more frequent respiration in order to keep pace with the increased necessi- ties of the system did but issue in an attack of spasm, and another, and still another, returned causelessly, till at length what we can scarcely call other than a needless death occurred. There would be no difficulty, if time allowed, in multiplying illus- trations ; but it is scarcely necessary to do so, and we may sum up 602 ON SUDDEN DEATH the chief conclusions, to which thus far we have been conducted, as follows:— 1. That sudden death in infancy and early childhood is most frequently dependent on spasmodic disturbance of the respiratory process. 2. That the occurrence of a single convulsion from such spasms renders it in the highest degree probable that others will follow it; and consequently implies a far greater risk of sudden death than exists so long as no such convulsion has taken place. 3. That when any spasmodic disorder of respiration is present, it is impossible to be too careful in avoiding any sudden impression on the nervous system, any sudden change of temperature, any hasty altera- tion of posture ; in short, any cause whatever by which the respiratory process may be disturbed. The next fact, to which I desire to call your attention, is tbe occa- sional occurrence of sudden death wholly independent of spasm, but in consequence of the sudden attack or extensive invasion of the respiratory organs by disease. One of the simplest illustrations of this occurrence is met with in those instances in which the lung has been but imperfectly expanded at birth; the child in such circumstances lingering with lessening powers and increasing weakness, till life comes to an end after the lapse of a few hours, or days, or weeks. Such death is very often sudden, and not infrequently preceded by convulsion; and this, although nothing in the infant's condition a few hours previously, had indicated that it was less well, or that anything had diminished its chances of surviving its early difficulties. Something of the same kind you may occasionally observe when— in the course of an attack of bronchitis or pneumonia—a large extent of lung has suddenly become collapsed, and the amount of breathing surface has thus been lessened considerably, and all at once. Such an accident is likely to happen in proportion to the tender age of the child, and its possibility is always to be borne in mind as governing your prognosis, and as suggesting an explanation of the otherwise in- explicable death of a patient. The frequent visits to a young infant suffering from pneumonia, the often-repeated auscultation, the minute watching of little indications of its condition, have reference to such contingencies;—the attention to its posture, the keeping its chest somewhat elevated, the not allowing it to lie long on one side, but shifting it frequently from the one to the other—are precautions prompted by a knowledge of the fact that collapse of the lung may take place suddenly, and that its sudden collapse may be followed by sudden death. Now and then, though far more rarely, mere bronchitis or mere pneumonia is the occasion of sudden death in early life; and this sometimes even when neither the extent of tissue involved, nor the stage which the inflammation has reached, is adequate to account for the fatal issue of the case. Just twenty years ago I saw a little boy, aged one year and eight months, who was reported to have had a slight feverish attack for a IN INFANCY AND CHILDHOOD. 603 few days before he came under my care. This still persisted, and on auscultating him a slight mucous rale was heard at the base of both lungs. At the end of four days he seemed a little better; at 5 P. M. he took some food with appetite, but at 9 P. M. he suddenly became faint, seemed dying, and actually died at two o'clock in the morning. No explanation of this sudden death was furnished by the post-mortem examination, which discovered only that the lower lobes of both lungs were in the first stage of pneumonia. In M. Louis' Memoir on Sudden Death, that distinguished physician, though treating of it in the adult, subjoins in a note1 the history of a little girl four years old, who was suddenly seized by convulsions when apparently in perfect health, on January 4th. The convulsions were brought on apparently by a violent quarrel. She soon recovered from them, but was attacked thirty-six hours afterwards by shivering, followed by heat, cough, and pain in the left side where the ausculta- tory evidences of pneumonia were perceptible. She improved under treatment, and on January 11th was decidedly better. In the evening she was cheerful, sat up in bed and played with her toys as if she were well. At ten o'clock she went to sleep, woke and coughed at midnight and at three in the morning. On the latter occasion the cough soon ceased, and the child began talking to her mother, and complained that she had not stayed with her all the night. While uttering the word she died. In this case it was thought that the right half of the cerebellum was somewhat less firm than the left; but the only condition which could be termed actually morbid, was presented by the lower lobe of the left lung, which was in a hepatized state for rather less than half of its extent. I have related these cases in order to impress on your minds that the degree or extent of pulmonary inflammation is not an absolute measure of its danger in early life; but that sometimes death occurs suddenly as an indirect result of the interference with the respiratory process. I can only tell you the fact; I regret that I do not know of any criterion by which to distinguish the cases in which this sudden termination is most likely to happen. Another class of cases in which disorder of respiration may be fol- lowed by sudden death comprises those instances where serous effusion takes place suddenly into the cavity of the pleurse. A little boy, not quite three years old, whose health had never been very robust, was brought as an out-patient to the Children's Dispen- sary, in Lambeth, on June 11, 1847, on account of a chronic impeti- ginous eruption on his scalp. On the night of June 12th he suddenly became hot, and his chest was much oppressed, but on the following day he was well enough to be out at play in the garden, and on the 15th was drawn a mile and a half in a perambulator to and from the dispensary, when I saw him for the first time.' He looked pale and ill, was feverish, and breathed with a wheezing noise; but there was nothing about him indicative of serious mischief; and in the hurry of 1 Memoires ou Recherches sur diverses Maladies. 8vo. Paris, 1826, p. 501, note. 604 ON SUDDEN DEATH prescribing for a large number of patients, I regarded him as probably a phthisical child, who had caught cold recently; I ordered some simple medicine for him, and at 1 P. M. he returned home. At three o'clock the same afternoon he suddenly became much worse, was very faint, breathed with extreme difficulty, and died at eight o'clock the next morning. Some serous fluid was present in the abdomen, and about Ivj in either pleura, by which the lower lobes of both lungs were so compressed as to be almost destitute of air; but there were no signs of inflammatory action, and no other morbid appearance. In some of the cases death is far more sudden. A little boy, aged eight years, was attacked by moderately severe scarlatina. Slight anasarca appeared on the 19th day, which had somewhat increased, but was accompanied by no urgent symptom, on the 22d day, when he walked a distance of two miles without suffering serious fatigue. After a rather restless night, he rose to relieve his bowels, and there was so little suggestive of danger in his condition, that his mother left him for a few minutes alone. On her return, he seemed faint, the bowels having acted but scantily. He was replaced in bed, when he immediately began to struggle faintly, and in five minutes was dead. The lungs were compressed by abundant serous effusion into each pleura, and the pericardium also contained four ounces of fluid; but there were no other morbid appearances, with the exception of some congestion of the kidneys. In any case, then, of dropsical effusion in early life, it behooves you to bear in mind the possibility of its very rapid increase; of the out- pouring of serum into the cavity of the chest so suddenly and with so little warning as to endanger or even to destroy life. Just, too, as I have warned you in other circumstances, that hurried movements, bringing with them sudden changes in the circulation, and sudden demands on the respiratory function, cannot be too carefully avoided; so, in these cases, is the same precaution pre-eminently necessary. If the child had not travelled in its perambulator in the one case, had not been allowed to get out of bed unaided in the other, death would probably not have occurred when it did—would possibly not have occurred at all. It seems, then, contrary to what were most probably your precon- ceived impressions, that sudden death in early life is most commonly due to some disturbance, direct or indirect, of the respiratory function; that either sudden spasm arrests it, or, disease having interfered with its perfect accomplishment, some sudden demand for its complete • exercise issues in the sudden stand-still of the whole machinery. Neither, indeed, does disease of the brain itself stand next in import- ance among the causes of sudden death; but after these cases, in which death may be said, in technical language, to take place from apncea, come those in which it depends on asthenia; in which life goes out for want of nervous power to keep the vital functions in activity. It is in this manner that sudden death is apt to occur in diarrhoea; it is thus, too, that it sometimes takes place in early infancy when over active treatment has been adopted for the cure of pneumonia or bronchitis; or when, independent even of over-treatment, the attention IN INFANCY AND CHILDHOOD. 605 has been so engrossed by the disease that due care has not been taken to provide for the nourishment of the patient. This class of sudden deaths, though by no means rare, may be said to be almost needless, inasmuch as its occurrence may, by due foresight, be almost always guarded against. The accident is perhaps more likely to happen and more difficult to prevent in the course of diarrhoea than of most other disorders, since the infant is exhausted not merely by the abundant discharges, but also in many instances by the severe "pain which ac- companies them. The danger, too, is great in proportion to the tender age of the infant; and it is in relapses of diarrhoea that the hazard is most considerable, and the warnings which foreshow it are the slight- est. A return of the disorder of the bowels, which for some hours, or for one or two days, had seemed diminishing, has rekindled the appre- hension of relatives: when, once again there comes a diminution of the previous apparent distress, a lessening of the restlessness, a quiet- ing of the previous plaintive moan; and though the diarrhoea is not much diminished, yet at any rate the disorder of the bowels is not growing worse, and probably has at no time been so considerable as at its first onset. The apparent good is hailed with joy; the fact that this change may after all import evil, not good, is lost sight of; the little things which show their real meaning are not noticed, probably not observed, for they are nothing more than a slight dilatation of the pupils—so slight that in the darkened chamber it is not noticed; an apathy to external objects and sounds, which seems perhaps to be only the good result of the hushed stillness maintained around the darling's cot; a loss of the power of generating heat, which the tender officiousness of the mother renders almost imperceptible. Such, how- ever, are often the only precursors—the harbingers, if you understood their mission, of the sudden collapse which, in an hour or two, is fol- lowed by a death as quiet often as a falling asleep. Even these premonitions are not always seen, but when young infants are already much exhausted, the disturbance of the nervous system, slight though we may fancy it, which accompanies the action of the bowels may suffice to upset the whole balance of the functions. A slight convulsion, a sudden dilatation of the pupils, a momentary sigh, and all is still in death. Should I do nothing more, I shall be well content to-day, if I can impress upon you how little things are to be noticed, little precautions to be observed, little dangers to be avoided in the diseases of infancy and childhood. Though it is in the course of diarrhoea that the danger of sudden death from exhaustion is most to be watched against, yet your own experience will suggest to you many other circumstances in which you are likely to encounter it. You will meet with it in cases of pulmonary inflammation; the disorder of the respiratory function of itself disturbing the nervous system, and predisposing to the same occurrence which your active treatment (necessary perhaps at first, though now too long continued) tends in another way to produce. I remember being called to see an infant three months old, who had had a slight attack of bronchitis complicating measles, for which it 606 ON SUDDEN DEATH had been treated very judiciously by its medical attendant. The mis- chief in the chest was clearing up, the child was much better ; anxiety was almost over; when suddenly the inspirations became again hur- ried, the pulse extremely rapid, the child took no notice, it seemed dying. The explanation of these symptoms, however, was not far to seek; the infant was at the breast, but its mother herself was ill, her secretion of milk scanty; her babe had but little power to suck, and got but little even of the small amount of nourishment which there was for her; in a few hours more her death all but suddenly would have taken place. A few drops of brandy revived her, a meal of ass's milk renewed her strength, and in a few hours the transition from imminent peril to perfect safety was complete. One word more of caution applicable to the management of con- valescence from all exhausting diseases in early life. Too great care cannot be taken that no needless exertion is made, no sudden change of posture permitted, no protracted withdrawal of nourishment allowed even during the hours of sleep. Some years since, I watched a little boy through severe remittent fever; the grave symptoms were at an end, and though the child was extremely weak, convalescence was fairly established. He had restless nights, however, on which account a small dose of Dover's powder was given him towards evening. He slept the better for it, though still waking up, and taking food during the night. On the third night the same dose was again given him, he slept so well that his nurse did not like to disturb him; she lay down beside him and slept too, when morning came he was dead; he had passed away quietly in his sleep. I have never since forgotten the danger, nor omitted to caution the attendants of a child, that they must still be watchful, even when recovery seems most certain. And now I have enumerated a great variety of circumstances in which sudden death may take place, but yet have not spoken of dis- ease of the nervous centres themselves as tending to its production. I did so advisedly; for in spite of the extreme susceptibility of those organs to disturbance from causes almost numberless, yet it scarcely ever happens that structural changes are discovered in them sufficient to account for sudden death; though, as I scarcely need remind you, actual organic disease of the brain is even more frequent in the child than in the adult. Of twenty-one instances of sudden death which occurred in infants under three years old in the city of Ratisbon, MM. Herrich and Popp,1 whose official duty it was to make an examination of all such cases, did not meet with one in which any important mor. bid appearance was discovered in the brain. For this fact I imagine the two most important reasons are— 1st. That in early life the cerebral vessels have not undergone those changes by which, in later years, their coats are rendered brittle, and they are disposed to give way. 2d. That the unossified skull, while it allows during infancy and early childhood, of a greater fluctuation in the quantity of blood cir- culating through the brain than is possible when ossification is com- 1 "Der plotzliche Tod aus inneren Ursachen." 8vo. Regensberg, 1848, p. 12'3. IN INFANCY AND CHILDHOOD. 607 plete, yet, at the same time, renders such changes far less serious; the yielding fontanelles and unclosed sutures allowing of the ready adapta- tion of the organ to its varying contents. Even the actual effusion of blood into the cavity of the arachnoid seldom causes immediate death, - but oftener is the first step in the production of a hydrocephalus which lasts for months or years, a standing illustration of the power of the skull to accommodate itself in early life to great changes in its con- tents, and of the brain to discharge its functions under conditions which, at first sight, would seem of necessity to preclude their per- formance. That most intense congestion too consequent on sunstroke, of which we see instances now and then even in our temperate clime, generally subsides in the course of a few hours; and oftener than might have been expected it passes away without leaving behind any evidence of abiding mischief having been inflicted on the organ whose circulation had been so rudely disturbed. Now, from this sketch, very short and very imperfect as I full well know it to be, some lessons of practical value may still be gathered. Of them the chief are— 1st. That in the great majority of instances, when death suddenly befalls the infant or young child, it is an accident; it is not a neces- sary inevitable result of any disease from which it is suffering. 2d. That the danger of this accident happening may often be fore- seen, and that such foresight is not hard to attain by any who will cultivate the habit of minute observation. I read a few days since of how the elephant-hunters in Ceylon,1 when tracking that sagacious beast through its native forests, since on account of his acute sense of smell "it is indispensable to go against the wind in approaching him; when the wind is so still that its direction cannot otherwise be dis- cerned, will suspend the film of a gossamer to determine it, and shape their course accordingly." And so you too will find that things which seem as slight almost as the gossamer film may serve to indicate, to those who watch them well, changes as momentous as those on which depends death or recovery. 3d and lastly. As small things portend the danger, so small things go far towards warding it off—food, warmth, posture, quiet; little matters, such as you may think the nurse's office more than yours, are those which over and over again turn the scale upwards or down- wards, and many an infant's life has been saved or lost by observing , or neglecting points which one is but too apt to lose sight of as utterly beneath the dignity of science. 1 Sir E. Tennent's "Ceylon," vol. ii. p. 337. 606 ON CEREBRAL SYMPTOMS LECTURE II. On Cerebral Symptoms Independent of Cerebral Disease.1—Importance of the subject, and difficulties which attend it.—Three classes of cases in which the brain may be disturbed without disease : in fevers, in inflammation of the thoracic viscera, in various disorders of the digestive organs.—Rules for discriminating in each between the signs of sympathetic disorders of the brain, and the symptoms of its real disease. Of all the inquiries which, in private practice, the parents of a sick child will put to you, there is none that will be made so often or so eagerly as this: "Do you think his brain is affected?" The answer which you give to this question will at once convey a sense of un- speakable relief, or will produce a feeling of blank hopelessness; either, perhaps, excessive, but either most natural. Without doubt the importance of a correct reply is very great, for your prognosis and your line of treatment are dependent on it, and an error, even though corrected in twenty-four hours, may be irreparable. I think, then, that the time will not be misspent which we devote to-day to an examination of the different circumstances wherein we are most likely to meet with the symptoms of cerebral disorder independent of real cerebral disease. Now you may encounter such symptoms in two different conditions: either in the course of acute affections simulating active disease of the brain, or in the course of chronic ailments, where there may seem to be reason for apprehending the advance of slow disorganization; and each class of cases demands a separate consideration. Before examining either class of cases in detail, I would, however, remind you that in the child, as in the adult, the brain is disturbed more- or less in the course of every acute affection of the general system; and further, that in proportion to the youth of the child there will be an apparent sameness in the characters of such disturbance, and a consequently increased difficulty in determining the cause whereon it depends. Thus, for instance, whether one of the exanthe- mata is about to come on, or influenza, or inflammation of the lungs; or whether the illness is a mere febrile attack consequent on dentition, there will in all these circumstances alike be a hot skin, and a frequent pulse, a loss of cheerfulness, a heavy head, a disposition to drowsiness, and yet a state of unrest; symptoms, in short, which are just the same with those that in the infant would attend the early stage of actual disease of the brain. But while I refer to this fact as one never to be lost sight of in the 1 Delivered at the Hospital for Sick Children, Dec. 3, 1859, and published in the London Medical Times and Gazette, for Dec. 24,1859. INDEPENDENT OF CEREBRAL DISEASE. 609 endeavor to discover the true import of the cerebral disturbance which accompanies almost every form of acute illness in early life, my special object to-day is to point out to you some of the circum- stances wherein, in infancy or early childhood, a correct diagnosis is peculiarly difficult. I propose to notice very briefly— 1st. The cerebral symptoms that usher in the attack, or accompany the early stages of fevers. 2d. Those which at the onset of acute inflammations of the thoracic viscera, sometimes throw the evidences of the real disease into the shade; and, 3d. Those dependent on some disorder of the abdominal viscera, which though not always itself of an acute character, yet gives rise to sudden disturbance of the nervous system, and to symptoms that simulate active cerebral disease. Such are sometimes the conse- quences of unsuitable food, of diarrhoea, of colic, and of intestinal worms. Afterwards, if time allows, I purpose 4th. To make a few observations on the more chronic ailments, in which cerebral symptoms are likely to be observed, and their import is apt to be misapprehended. Now with reference to cases of the first class; namely, to those in which cerebral symptoms usher in the attack, or accompany the early stage of fevers, I may observe, and the remark holds good in other cases also, that in proportion to the suddenness of the onset, and the violence of the character of such symptoms, is the probability of their depending on real disease of the brain so much the smaller. A severe attack of convulsions is rarely an early symptom—is almost never the first symptom of real acute disease of the brain. Its occurrence, therefore, always raises a presumption that its cause is to be sought in some source of irritation external to that organ; that, how much soever, the immediate urgency of the case may require remedies addressed to the brain, the ultimate dangers of the disease will be found to depend on some other cause, to arise from mischief seated elsewhere than in that part which at first seemed to be the most suffering. The early stage of the eruptive fevers sometimes affords a very remarkable illustration of the amount of disorder of the nervous system, which may precede or accompany the full outbreak of the rash. During the first day of the eruption of measles, for instance, one or two attacks of convulsion sometimes occur, though they usually pass away without being followed by protracted coma, or by any abid- ing signs of cerebral disorder. In these cases the previous existence of the morbillous catarrh, often even the presence of faintly-marked stigmata of the rash, the general heat of skin more intense upon the trunk than even about the head, will usually preserve from error, and you may speak with confidence as to the probably speedy dis- appearance of the cerebral symptoms. Far more serious, however, are the signs of cerebral disturbance by which smallpox and scarla- tina are occasionally ushered in: the transition from apparent health 39 610 ON CEREBRAL SYMPTOMS to violent convulsions being sudden, and apparently causeless, the fits themselves most formidable, and the coma by which they are succeeded very profound. Such was the case of a little girl, two years old, who until the day before that on which I saw her had never had an hour's illness. She had eaten a hearty dinner, and though she vomited soon afterwards, did not seem otherwise indisposed, and slept well in the night. Immediately on waking in the morning, however, she had a fit, during which she was insensible, much con- vulsed; and insensibility, with occasional convulsions, and great heat of skin, continued for the ensuing twenty-four hours. Depletion, both general and local, the latter twice repeated, was followed, at the end of twelve hours more, by considerable diminution of the con- vulsive movements; and forty hours after the first fit the child fell asleep, and dozed quietly for a few hours. She awoke sensible, and continued so. On my visit in the morning I found her quiet and sensible, without any sign of convulsion; her face was very pale; her head, before so hot, was now quite cool; her pulse had sunk in fre- quency, and had lost its fulness. An eruption of a papular character had appeared on the hands, arms, inside of the thighs, and slightly on the face. This eruption was the smallpox, and the disease ran its course without an unfavorable symptom. The comparative rarity of smallpox may be some excuse for my not having been prepared for the possibility of the convulsions de- pending in this case on the cause to which they were really due; but it is well to bear in mind that in every instance where cerebral symptoms come on without obvious reason in early life, inquiry should be made as to the date of previous vaccination, and the arm should be examined for its evidence in the cicatrices left by its per- formance. A similarly stormy onset, however, is sometimes observed in cases of scarlet fever; and then it usually preludes an attack of a malignant kind, characterized by speedy loss of power and tending to an early death. This occurrence, indeed, never very common, is most rare when scarlet fever is merely sporadic, but in epidemics of the disease it happens more frequently, and this even although the general characters of the disease are of a mild—not at all of a malig- nant—type. "In the autumn of 1831, and during the early part of 1832," says Dr. Von Ammon,1 " scarlatina prevailed epidemically at Dresden. The cases which at first presented themselves to my notice were, for the most part, mild in character, and ran a favorable course; but, at the same time, I met with some instances where death took place very rapidly, and under peculiar symptoms of cerebral disturbance, in children who neither during life nor after death, showed the slight- est trace of scarlatinoid eruption. At first I felt in doubt as to the cause and nature of the rapidly fatal head affections; for I did not anyhow connect them with scarlet fever, while the disease differed from inflammation of the brain in the extreme rapidity of its onset, 1 Bes chreibung einen Scharlach-epideminz a Dresden, in Analekten fur Kinderkr. Vol. iii. Heft 11, p. 43. INDEPENDENT OF CEREBRAL DISEASE. 611 in the fact that, notwithstanding the intensity of the headache, it was unaccompanied either by nausea or vomiting, that the bowels were not constipated, and that the pulse beat with such frequency that it was almost impossible to count it, while the attitude of the patient was not at all such as is usually assumed by any one suffering from acute cerebral inflammation." Dr. Yon Ammon then goes on to say how a post-mortem examina- tion of one of these cases led him to the suspicion, which afterwards became a certainty in his mind, that these were really instances of scarlatina; that the impression of the poisoned blood upon the brain and spinal cord destroyed life before time had elapsed sufficient to allow of the ordinary manifestations of the disease. The possibility that the clue to the understanding of symptoms of formidable cere- bral disorder is to be found in the approach of one of the eruptive fevers, enforces the necessity for learning in every case the history of a child's previous ailments, and renders it even more imperatively your duty to do so at a time when scarlatina is epidemically preva- lent. Bapid, too, as is sometimes the advance of inflammation of the brain, its progress is commonly far slower than that of the cerebral symptoms which accompany the onset of the fever, while almost in- variably some characteristic or other of the mere local inflammation would be absent, some anomaly would show itself such as excited the suspicion of the German physician, and ought to awaken yours. But besides the instances just referred to, in which the temporary violence of the cerebral symptoms suggests the idea that active in- flammation of the brain is present, there are others of less rarity where, though the feeling of anxiety as to the real nature of the dis- ease is less urgent, it is yet of longer duration. Such are the cases in which, during the early stage of typhoid fever, the symptoms of cerebral disturbance so preponderate, that for some days a doubt may be entertained as to whether the fever is sympathetic with disease of the brain, or the brain is disordered as a consequence of the fever. The question, in short, is between tubercular hydrocephalus and typhoid fever. Now, something may be gathered from the age of the child, at least towards raising a presumption one way or the other, for the older the child is, the more likely is the disorder to be typhoid fever, the younger it is, the more likely to be hydrocephalus; and I strongly recommend you in doubtful cases to put the issue between these two definite diseases, and not to indulge your indolence, and put to sleep doubts which you feel unable to solve by talking to your- self or to your patient's friends of gastric fever, worm fever, and so on—terms to which no definite import is attached either by your- selves or by others. There is not time to pass in review minutely, all the diagnostic symptoms which mark typhoid fever, and serve, in spite even of much cerebral disturbance, to distinguish it from hydro- cephalus. It may, however, suffice to remind you that vomiting is generally absent, is never obstinate, nor succeeded by long-continued nausea; that the bowels are often relaxed, never obstinately consti- pated ; and that the evacuations are light-colored, fecal, but usually watery. Further, the abdomen is full, usually tender, and flatus is 612 ON CEREBRAL SYMPTOMS always to be felt in the intestines; the tongue is not often much coated, it is red at the tip and edges, and early shows a tendency to become dry. The skin is very hot, the heat is pungent, the pulse is frequent, and continues so throughout, but is never irregular nor in- termittent. Even the very cerebral symptoms have their character- istic features; for the early occurrence of delirium, which is so general in typhoid fever, is another point wherein it differs from hydrocephalus, in which much pain of the head, much drowsiness, a marked change of temper and disposition, yet coexist with a perfect intelligence. "Surely," you may say, "these differences are marked enough; to dwell on them is superfluous, nay, wearisome; the help we want is in real diagnostic difficulties, not in cases so obvious, whose right inter- pretation is so easy." Believe me, gentlemen, nine-tenths of the errors of diagnosis are made in easy cases—in cases whose features are sufficiently marked for recognition, if the observation had been trained to notice them, or the mind been disciplined to the inquiry in every instance: Why do I believe the disease to be this, why not that, or the other ? The power of intuition and the habit of guessing are two very different things, though sometimes mistaken for each other. The former is now and then the reward of years of patient observation; humility and diligence are its parents. The latter is engendered between indo- lence and self-conceit; he who takes up with it, whatever be his abilities, forfeits all chance of ever attaining the other; he adds not to his knowledge from being right, he gathers no lesson from being wrong; for him experience yields no fruit, age brings to him no wisdom. There is a second class of cases in which the predominance of symp- toms of cerebral disturbance sometimes masks the real nature of the disease, and such cases are met with among the acute inflammations of the thoracic viscera. Bisk of being led astray would, indeed, be almost entirely avoided, if you made it an invariable rule, in all the acute ailments of early life, to regard your examination as incom- plete until after you had made a careful auscultation. The symptoms of disturbance of respiration are indeed often too marked to be over- looked; the cough, the pain in the chest, and the hurried breathing render mistake impossible; but it now and then happens at the com- mencement of pleurisy, and in pneumonia, especially of the upper lobes, that the nervous system sympathizes so deeply as to draw away the attention from those symptoms, which, though obvious enough to him who seeks for them, do not stand out so prominently as to attract the first hasty glance. Pneumonia and pleurisy, especially the latter, occasionally set in with a convulsion; but you will, I trust, remember the caution which I have already given as to the sudden violence of cerebral symptoms, indicating that the brain is disturbed by some eccentric cause rather than by mischief seated in that organ itself. Pleurisy, more particularly when affecting the right side, is sometimes ushered in by vomiting, and this vomiting seems all the more suspicious, if it has just preceded, or just followed, an attack of INDEPENDENT OF CEREBRAL DISEASE. 613 convulsions. It is accompanied by fever and by intense headache; the child cries aloud, or screams much in its sleep, and if it is old enough for the symptom to be observed, delirium is not unlikely to be present. The cough may be but slight, or altogether absent, and even the pain not considerable, and it is then quite possible that the disturbed breathing may be put down to that sympathetic disorder of respiration, to which the name of " cerebral breathing" has been ap- plied. Need I say that it is much harder to correct a diagnostic error into which one has fallen than by care to avoid it in the first instance. If the case is one of pneumonia affecting the upper lobes, severe head- ache, drowsiness, great heat of head, though found, if carefully ob- served, not to be greater than of the surface elsewhere, all serve to mislead. Delirium, too, is very often present if the child is old enough for that symptom to manifest itself; and the mind of the attendant fluctuates in such cases between the ideas of cerebral congestion, of hydrocephalus, and of typhoid fever; one impression preponderating at one part of the day, another at a different one; but the true view of the case not presenting itself to the mind at all. In the case of pleurisy, even though the mistake is discovered late, the child will probably survive, and the distended side, the adaptation of posture, the subsi- dence of the fever, and the disappearance of the head symptoms are tolerably sure to put the doctor, though tardily, on the right track. In pneumonia the error is even more serious, for the disease is more formidable, and the longer continuance of cerebral disturbance is likely to keep up the mistake. In its later stages, too, the convulsion and the coma which sometimes come on as the results of the imperfect depuration of the blood, perpetuate the misapprehension, which, per- haps, a post-mortem examination alone brings to light. Now, without going into minute detail, for which there is no leisure, I may observe that in these cases you will find something always wanting of those symptoms which characterize real cerebral disease. Perhaps there has been a convulsion; but it was not followed by coma, nor by paralysis of either side. Vomiting has occurred, but it has soon subsided. The head is hot, but yet not hotter than the rest of the surface, and it is unaccompanied by violent pulsation of the carotids. The light may be unpleasant, but it is not shunned with that intense sensitiveness to its presence which closes the eyelids even in the darkened chamber. Again, though the breathing is sometimes hurried in case of cerebral disease, yet here the hurry is constant; if the case is one of pneumonia it is extreme, and between the hurried breathing and the rapid pulse a constant proportion is observed, while, though the cough may be but slight, some cough is almost surely present. Such, and such-like, are the criterions by which, if you test the symptoms in these doubtful cases, you will run but small risk of not coming to a right conclusion. Nearly forty years ago a French physician1 wrote an essay, the object of which was to illustrate what he termed the predominance of 1 " Recherches relatives a la Predominance des Organes Digestifs des Enfans sur le Cerveau. Par J. Sablairolles." 8vo. Paris, 1826. 614 ON CEREBRAL SYMPTOMS the digestive organs over the brain in childhood, and he appended to it the details of forty-eight cases in corroboration of his opinions. Now, although like all other books written to develop one idea, this is somewhat°one-sided in its views, and, perhaps, a little overcharged in its statements, yet the main point is correct—namely, that The third class of cases in which symptoms of cerebral disease are provoked by disorders of the digestive organs is very numerous and very important. . A slight acquaintance even with the practice of medicine will have familiarized you with various symptoms of disturbance of the nervous system which derangements of the digestive organs and their append- ages bring with them. Such are the unquiet sleep, the night-terrors, the grinding of the teeth, the sleeping with half-closed eyelids, the thumbs drawn more or less into the palm, which one often observes in infancy and early childhood, and some of which are seldom alto- gether absent during dentition, or when changes are first made in the diet of infants. But there are besides two distinct classes of symptoms to which disorders of the digestive organs, when severe, may give occasion—namely, convulsions on the one hand, and on the other, that form of cerebral disturbance characterized by mingled exhaustion and irritation, to which the name of the hydrocephaloid disease, or spurious hydrocephalus, has been given. Convulsions from this cause are generally the result of unsuitable food, or of an over-full meal in infancy or early childhood; though other sources of irritation, as that of worms, or even of a calculus in the kidney, may produce them. Those which depend on indigestible food, are sometimes so severe as to threaten life, or even actually to destroy it. They nearly proved fatal in the case of a little boy, five years old, previously healthy, who on July 9th, 1846, dined off some boiled salmon, of which the rest of the family partook more heartily than he, without any ill effects. At ten o'clock on the following morning, having slept well during the night, he was suddenly seized by a violent convulsion, in which his whole surface became exceed- ingly livid, and his lips of a deep purple hue. His respiration was greatly affected, he seemed as if he could not get air enough into his chest to keep him alive, and he appeared every moment as if he would be suffocated; while his pulse was feeble and frequent, and the tem- perature of his body low. Under the influence of the cold douche to his head, his breathing became less laborious, his lips regained much of their natural florid color, the convulsions greatly diminished, and the child began to make some half-conscious movements. It was now possible to give him an emetic, which caused free vomiting twice, and the rejection of some of the undigested salmon. The child was next placed in a hot mustard bath ; while in it the convulsions completely ceased, after having lasted three hours and a half. He was now put in bed', where he slept quietly for four hours, and awoke quite well. Now that which took place here you may observe not very rarely, and with symptoms of equal severity, in early infancy, when perhaps the error in diet has been so trivial that you can scarcely realize the possibility of its producing such formidable results. The fact, how- INDEPENDENT OF CEREBRAL DISEASE. 615 ever, that in any given instance the convulsions depend on such a cause, may usually be gathered, partly from the history, which in early life is all the more important from the patient's inability to speak for himself, but still more from our observation of their charac- ters. They are apt to be violent, accompanied with much spasm of the extremities, clenched hands, or the thumb drawn forcibly into the palm, and the great toe widely separated from the other toes. They are associated with spasm of the larynx, which often remains closed till suffocation seems impending, and with much trouble of the respi- ratory movements; in other words, with evidence of all the spinal system of nerves being in a state of great irritation. Almost always, too, the abdomen in such cases is distended, often extremely tympa- nitic, and there is frequent escape of flatus from the intestines. These peculiarities, if borne in mind, will often give you a clue to the mean- ing of a violent and apparently causeless convulsive attack. They indicate the source of the disturbance to be eccentric, and thus both guide your treatment, and influence your prognosis, enabling you to hold out the hope that if the child do but surmount its present danger, recovery will be complete as well as speedy. I referred to a second class of symptoms dependent on disorder of the digestive organs; symptoms less formidable in appearance, per- haps, but more delusive, by which irritation and exhaustion together simulate the effects of inflammatory disease of the brain. It is in diarrhoea, and especially in relapses of diarrhoea, that these two con- ditions are associated in the greatest degree, and that the risk of error is, perhaps, most considerable. One case in illustration of it must suffice, for time draws short. A little girl was seized with diarrhoea on August 8th, which at first was severe, but soon yielded to treatment, and she was again conva- lescent ; when, on the 15th, vomiting and purging returned with great violence, and were attended with much febrile disturbance. On the following day she was still worse in all respects, but was not brought to me again until the 17th. She then looked exceedingly ill; her face was sallow, but with a flush on each cheek, and her eyes were deeply sunk. She lay in a half-dozing state, with her eyelids half closed, and the eyeballs turned upwards, so that nothing but the sclerotica was visible; but from this condition she awoke frequently and suddenly in a state of great alarm, and looking as if she were about to have a fit of convulsions. Her skin was hot, and very dry; her pulse very frequent, but not strong ; and there was some subsultus of the tendons of the wrist. The abdomen was rather tympanitic; the tongue red, coated with white mucus; the thirst was great; the vomiting very frequent, and the bowels acted two or three times in an hour, the evacuations having the appearance of dirty water. The persistence of the diarrhoea, and the great frequency of the action of the bowels, coupled with the fact that I had observed the case from the commencement, would have rendered error inexcusable. But such cases may come under our notice only when the evidence of cerebral disturbance is already very striking, and when, perhaps, the 616 ON CEREBRAL SYMPTOMS diarrhoea is no longer very urgent—perhaps may for a few hours have altogether ceased: in such circumstances error is very possible, and its consequences may be very disastrous. If you regard the cerebral symptoms as the signs of active disease, and withhold the Dover's powder, or the opiate enema, that might have checked the diarrhoea, and soothed the irritability, while you apply cold lotions to the head, and give the child nothing more nutritious than barley- water in small quantities, because the irritability of the stomach, which results from weakness, seems to you the indication of disease of the brain—the restlessness will before long alternate with coma, and the child will die either comatose, or in convulsions. This is not indeed the only form which this spurious hydrocephalus assumes, although it is that in which the signs of irritation so mask those of exhaustion as to render the risk of mistake most serious; while the time during which the error can be rectified is in these cases very brief. In a larger number of instances this condition comes on much more slowly, since it results from the gradual influence of im- perfect nutrition; and in these circumstances the signs of irritation of the nervous system which characterize its early stages are less marked, though not on that account less deceptive. In the infant brought up by hand, or imperfectly nourished at the breast, the first stage some- times continues for weeks, attracting perhaps little notice; giving rise, indeed, to a vague suspicion that something is wrong, but yet this suspicion so indefinite that neither the parent nor the doctor pushes the inquiry far enough to decide what that something is; or, possibly, commencing dentition bears the blame of the whole set of symptoms. I would have you, too, bear in mind, that in these cases dentition may really have much to do with the production of the symptoms, though not exactly in the way which at first suggests itself. The insufficient or unsuitable food heightens the irritability of the nervous system, and renders it preternaturally sensitive to the disturbance which teething seldom fails to bring with it. This disturbance acts, though more slowly, just as does that which accompanies diarrhoea; it exhausts the nervous power by all the manifestations of reaction which it produces, as the continued galvanic current wears out for a time the contractility of the muscles. The symptoms do not betoken real disease of the brain, though they closely resemble those which it occasions; so closely, indeed, that to read their import aright, you sometimes need go back for weeks, or even months, to gather the child's early history, and to learn how it has been fed, and how it has thriven from its birth. You will find, too, both in the past and in the present, intermingled with the general signs of cerebral disturbance, the evidences also of spinal irritation such as I have already referred to; and they should always lead you to suspect that the brain is disturbed in sympathy with some cause external to it. Irritability, restlessness, feverishness, a flushed face, a frequent pulse, undue sensitiveness of the surface, moaning, starting in sleep, all point to disorder of the nervous system, but they do not specially point to disease of the brain: their real meaning must be gathered from a INDEPENDENT OF CEREBRAL DISEASE. 617 consideration of the whole condition of the patient. That condition will be found to vary very much; the face will not be always flushed, nor the head always hot, nor the fontanelle always tense or pulsating. Vomiting may occur, but it will be occasional; the bowels will be relaxed rather than constipated; the abdomen not shrunken, but distended with flatus; a state which should always turn your atten- tion from the brain itself to some source of irritation external to it; since, as the distinguished German physician, Goelis has remarked, a collapsed stat^of the abdomen, and the absence of flatus from the intestines, are signs almost pathognomonic of hydrocephalus. Often, too, the carpopedal contractions and the laryngeal spasm are present, or have existed, to warn you as to the real nature of the case; while the pulse, though feeble and frequent, retains its regularity of force and rhythm, and thus differs remarkably from the irregular, inter- mittent, or unequal beats which are among the earliest and least fallacious signs of real cerebral disease. If misinterpreted, and con- sequently wrongly treated, the stage of exhaustion comes on by degrees, and with it a stealthy stupor. The flush no more returns to the surface, the extremities grow cold, the pulse becomes feebler, the pupils permanently dilated, the respiration sighing, the voice husky, deglutition difficult; symptoms which, if the earlier stage was misin- terpreted, will probably be regarded as the signs of the last stage of hydrocephalus; though the depressed fontanelle, the cool head, the pulse still frequent in spite of its feebleness, the abdomen still con- taining flatus, the bowels still loose, will tell at once a different tale to some other practitioner, who, with no larger experience than your own, yet with a mind unbiassed by a foregone conclusion, comes to the case, and at once reads its meaning aright. I had wished to have said something about cases of a chronic character, in which symptoms occur that give rise to unfounded suspicion of disease of the brain, but there is to-day no time to do more than enumerate some of them. Such are the groundless suspi- cions which parents often entertain, and which the doctor himself is not always as quick as he might be to negative, in cases of essential paralysis in infancy and childhood. Such are the fears excited by the temporary though often long-continued dulling of the faculties, which often follows fever or some exhausting illness. Such are the apprehensions which fits of waywardness or altered temper excite; such, too, on the other hand, is the dread which the excitability of a child whose faculties are just awaking to the wonders of the world around him, sometimes occasions his relatives; and such, lastly, is the morbid anxiety with which the severe neuralgic headache of child- hood is watched by persons who can scarcely be persuaded but that suffering so intense, and the return of which medical care so often fails to prevent, must needs depend on a cause as serious as it obvi- ously is difficult of removal. You see, gentlemen, my catalogue is a long one, and I think not unimportant. I must hope at some future time to pass it in review, as I have to-day tried to do with the other class of cases of a more 618 ON CEREBRAL SYMPTOMS, ETC. acute kind. Some of the details may, I fear, have seemed tedious; but my excuse is, that the errors against which I have tried to warn you are the same as in past years I have myself committed. I have not stated imaginary dangers. I have tried to warn you against such as have proved themselves to me very real ones, and to make you to the best of my powers the inheritors of my own experience. INDEX. Abdomen, examination of, in sick children, 20 shrunken, in acute hydrocephalus, 80 Abdominal tumors, from general enlargement of abdomen, 537 suspected sometimes when not present, 538 from enlarged liver, 539 hydatids of the liver—case, 540 fungoid disease of the liver—case, 541 kidney—cases, 542 psoas abscess—caution as to diagno- sis, 543 enlargement of the spleen, 544 Abscess, retro-pharyngeal. See Retropharyn- geal abscess. Acute hydrocephalus. See Hydrocephalus. Ague, peculiarities and treatment of, in child- hood, 566 enlargement of spleen in connection with, 544 Air, vitiated, cause of infantile trismus, 153 Albuminuria. See Kidneys, inflammation of. Alkalies, their use in infantile dyspepsia, 455 Anaemia, bruits due to, very rare in child- hood, 405 Angina maligna. See Diphtheria. Antimony, general rules for employment of, 31 in treatment of bronchitis, 261 pneumonia, 276 croup, 305, 332 chorea, 184 dropsy after scarlatina, 528 and opium, in head symptoms of remit- tent fever, 564 Anus, prolapsus of, in course of chronic diar- rhoea, treatment of, 499 imperforate. See Rectum, imperforate. Aphthae. See Thrush. Apoplexy, symptoms less dangerous in child than in adult, 56 Arachnoid, peculiar condition of, in acute hydrocephalus, 71 granulations of, in hydrocephalus; their tubercular nature, 73 lining the ventricles, granular state of, 111 hemorrhage into the, 59, 63 changes of the effused blood, 63 obscurity of its symptoms, 64 cases of, 64 chronic hydrocephalus an occasional result of, 64, 114 Asphyxia, of new-born child, often due to cerebral hemorrhage, 57 treatment of, 58 Asthma thymicum. See Spasm of the glottis. Astringents, use of, in treatment of diarrhoea, 496 Atelektasis pulmonum. See Lungs, imperfect expansion of. Atrophy of brain. See Brain, atrophy of. Infantile. See Infants, atrophy of. Auscultation, general rules for, 20 in acute inflammations of thoracic viscera, necessity of, 612 Backwardness, distinguished from idiocy, 214 Belladonna, as prophylactic of scarlatina, 595 in treatment of chorea, 184 Blisters, rules for management of, 33 in treatment of acute hydrocephalus, 96 pneumonia, 278 croup, 309 hooping-cough, 361 Brain in infancy, peculiarities of its circula- tion, 38 controlling power over spinal cord not manifest, 42 disease of, symptoms of, 39 importance of vomiting as a sign of, 41, 48 paralysis from, diagnosis of, 192 rarity of sudden death from, and why, 606 disorder of, sympathetic, in pneumonia, 131 in jaundice, symptoms of, 467 atrophy of, with premature ossification of skull, 124 in course of long illness, 125 partial—case of, 126 cancer of, 142 congestion of. See Congestion of the brain. dropsy of. See Hydrocephalus. hemorrhage into substance of—cases of. See Cerebral hemorrhage. hydatids of, 142 hypertrophy of, 119 its symptoms, 119 its connection with rickets, cretinism, and idiocy, 121 ,... state of brain in, 121 diagnosis from chronic hydrocepha- lus, 122 occasional cure of chronic hydroce- phalus by, 114 treatment of, 122 partial, 124 620 IND EX. Brain in infancy— inflammation of, deaths from, at different ages, 68 progress of knowledge concerning, 69 two kinds of, simple and scrofulous, 70 consequent on diseases of bones of skull. Seet Encephalitis and Hy- drocephalus. sinuses of—case of, 105 malformation of, 124 connection of chronic hydrocephalus with, 107, 110, 115 softening of, in hydrocephalus, not due to imbibition, 74 tubercle of, its frequency in childhood, 133, 135 anatomical characters of, 133 changes it undergoes, 134 capillary apoplexy in, 66 in cases of acute hydrocephalus, 77 symptoms of, 136 illustrative tables (note), 137 premonitory, 136—139 peculiar character of convulsions in, 43, 138 varieties in course of the disease, 139 deposit occasionally external to the brain—case of, 140 diagnosis, 141 treatment of suspected cases of, 141 ventricles of, changes of their lining in acute hydrocephalus, 75 rules for discriminating between signs of sympathetic disorder and symptoms of real disease, 615 Bronchial Phthisis, anatomical characters of, 371 process of cure of, 372 perforation of bronchi, &o., 373 symptoms of, 375, 381 auscultatory, peculiarities of, 378, 381 exaggerated by intercurrent bron- chitis, 384 occasional recovery from, 376 modes of death in, 376 Bronchitis, points of difference in child and adult, 246 morbid appearances of bronchi in, 246 dilatation of bronchi in, 247 nature of vesicular, 248 affection of pulmonary tissue in, 249 symptoms of, 256 similar to those of pneumonia, 250, 272 sudden supervention of collapse of lungs in, 257 when chronic, may simulate phthisis, 263 intercurrent, exaggerates symptoms of phthisis, 384 treatment of, depletion in, 260 tartar emetic in, 261 nervous dyspnoea in, 262 convalescence from, 263 complicating measles, treatment of, 584 hooping-cough, 344 treatment of, 363 inflammatory diarrhoea, 488 capillary, its nature and symptoms, 257 case illustrative of, 259 results of auscultation in, 260 Bronchitis, capillary— average duration of, 260 treatment of, 263 Bronchio-pneumonia, import of the term, 246, 267 its symptoms, 272 Calculus, frequency of, in childhood, 530 symptoms of, 532 treatment of, 533 Cancer of brain, 142 kidney, 542 liver, 541 lung, 542 Cancrum oris. See Stomatitis, gangrenous. Case-taking, rules for, 22 Castor Oil, use of small doses of, in diarrhoea, 494 Catarrh, influence of age and of season of year in its production, 244 its special importance in infancy, 255 symptoms of, 245 treatment of, 245 epidemic, or Influenza, 264 suffocative. See Bronchitis, capillary. Cephalhematoma, its character and changes, 60 case illustrating process of cure of, 61 diagnosis and treatment of, 61 subaponeurotic, 62 Cerebral circulation, its peculiarities in in- fancy, 38 congestion. See Congestion of the brain. hemorrhage, 56' frequent cause of asphyxia, 57 generally capillary, 57 into substance of brain, 66 capillary in cases of tubercle, 67 into sac of arachnoid, 59, 63 treatment of, 67 external to skull. See Cephalhema- toma. respiration, meaning of the term, 41 symptoms independent of cerebral disease, 608 Chest, elasticity of walls of, 223 examination of, in sick children, 20 Chicken-pox, essential differences from small pox, and symptoms, 576 relation of, to hooping-cough, 351 Children, high mortality of, 17 peculiarities of their diseases, 17 rules for conducting examination of, 18 feebleness of inspiratory power in, 222 imperfect expansion of lungs in new-born, 224 rules for treatment of their diseases, 27 system of instruction in the treatment of diseases of, 597 Chlorate of potash, in treatment of stomatitis, 430, 435 Chloroform in treatment of convulsions, 167 hooping-cough, 359 Chorea, rare in early childhood, 176 influence of sex and other causes in pro- ducing it, 177 symptoms of, 178 affection of heart in, 179 duration of, 181 morbid appearances in, 180 treatment of, 182 use of antimony in, 184 INDEX. 621 Chorea, use of— belladonna in, 184 partial—case of, 185 Chronic Hydrocephalus. See Hydrocephalus. Cod-liver Oil, in treatment of phthisis, 391 Cold, influence of exposure to, 222 mode of applying to head, 52 external application of, in acute hydro- cephalus, 95 affusion in congestion of brain, 52 Congestion of the brain, its frequency, 45 first stage of many cerebral diseases, 46, 49 apparent, how distinguished after death from real, 70 fatal, may leave very slight post-mortem appearances, 46 active, causes of, 46 cases of, at onset of eruptive fevers, 46 case of, from exposure to sun, 48 symptoms of, 48 its stages and modes of termination, 49 treatment of, 50 rules for depletion in, 50 use of purgatives in, 52 cold affusion in, 52 passive, causes of, 46, 54 case illustrative of symptoms of, 55 treatment of, 55 Constipation, from congenital malformation of intestines, 469 from strangulated hernia, 474 from intussusception. See Rectum, im- perforate, and Intussusception. Convalescence after exhausting diseases in early life, cautionary advice in, 606 Convulsions in child answer to delirium in adult, 41 deaths from, at different periods of life (note), 42 symptomatic value of, considered, 41-45 due to predominance of spinal system in early life, 42 description of a fit of, 44 importance of ascertaining their cause, 43 in hydrocephalus, 81 relation of to epilepsy, 168 independent of disease of brain, 154 two forms of, 155 associated with fatty liver, 159 treatment of, 156 chloroform in, 167 complicating hooping-cough, 347 from intestinal worms, 519 malaria, 491 in scarlet fever, 46, 589 scarlatinal dropsy, 525 salaam convulsion, 168 rarely a symptom of acute disease of brain, 609 case of sudden ushering in smallpox, 610 consequent on disorders of digestive or- gans—case, 614 Copper, sulphate of, in advanced stages of croup, 307 Coryza, symptoms of, 242 malignant, case in illustration of, 242 its treatment, 243 its connection with syphilis, 244 Coryza— sometimes sole symptoms of infantile sy- philis, 547 Cough, peculiar, in disease of brain, 41 at onset of hydrocephalus, 83 paroxysmal, in course of capillary bron- chitis, 258 in bronchial phthisis, 335, 375 spasmodic, in bronchial phthisis, intesti- nal irritation, cerebral inflammation, 335 peculiar, in croup, 298 Cretinism, connection of, with hypertrophy of brain, 121 frequent misuse of term, 204 Croup, definition of the disease, 292 different diseases included under name of, 294 peculiarity of the field in which many of the author's observations were made (note), 293 influence of age, sex, climate, Ac. in caus- ing it, 295 morbid appearances, 296 peculiarities of croup after measles, 297, 331 symptoms of, onset, and first stage, 298 second stage, pathognomonic sound of voice and cough, 298 third stage, delusive appearances of improvement, 300 results of auscultation in, 300 spasmodic dyspnoea in, 306, 333 duration of, and prognosis in, 301, 302 danger of relapse in, 302 treatment of, premonitory symptoms of, 303 depletion in, 304 employment of antimony in, 305 calomel in, 305 inflammation of lungs in course of croup, 306 danger of over treatment in, 305 convalescence from the disease, 306 advanced stages of, 307 use of sulphate of copper in, S07 caution with reference to emetics in, 307 use of blisters in, 308 bronchotomy in, 309 difference of results in England and France, 309 reasons for not rejecting it, 311 malignant variety of. See Diphtheria. with predominance of spasmodic symp- toms, 333 illustrative case, 334 spasmodic. See Spasm of the glottis. suddenness of death in, 599 Cri hydrencephalique, 80 Cry in infancy, its two periods, 22 characteristic, in imperfect expansion of the lungs, 226 Cynanche laryngea, cynanche trachealis. See Croup. parotidea, symptoms of, 448 treatment of, 449 tonsillaris, 441 Dentition, tardy in human subject, 409 order of appearance of the teeth, 426 pauses in its course, 164, 426 622 INDEX. Dentition— development of the digestive system dur- ing, 480 disease frequent during, 18 high mortality during, and reasons for it, 424 affections of mouth during, 427 connection of, with diarrhoea, 482 congestion of brain frequent during, 48 occurrence of paralysis during, 187 connection of, with spasm of the glottis, 157 diagnosis of pneumonia supervening dur- ing, 274 dysuria during, 531 treatment, use of the gum-lancet, 427 constitutional, 428 of affections of mouth during, 429 of eruptions of scalp, &c, caution concerning, 430 of diarrhoea during, 492 Depletion, general rules for, 27 excessive, its peculiar danger in infancy, 28, 131 in congestion of brain, 51 in acute hydrocephalus, 93 in bronchitis, 261 in pneumonia, 275 in pleurisy, 290 in croup, 304 from head in hooping-cough, 359 in spasm of the glottis, 165 in inflammatory diarrhoea, 493 in peritonitis, 508 from head in typhoid fever, 564 in affections of the chest in course of mea- sles, 584 caution concerning, in affection of head in scarlet fever, 594 in dropsy after scarlet fever, 528 Diabetes, rarity of, in childhood, 542 symptoms of^ connection with dyspepsia, 543 treatment of, 544 Diarrhoea, its frequency and importance, 478 table illustrating, 479 influence of age on; of dentition, 479 of season on, 480 of locality on; malaria, 490 two forms of, 479 simple or catarrhal, symptoms of, 481 during teething, 481 danger from exhaustion, 481 of supervention of dysentery, 482 inflammatory, or dysentery, 482 its resemblance to dysentery in the adult, 489 morbid appearances, chiefly in large intestine, 483 in other parts, 484 symptoms of acute attack of, 485 occasional rapidity of course of, 486 chronic course of, 487 various causes and modes of death from, 488 relapses of, 488 supervention of cerebral symptoms from exhaustion in course of—cases, 129 complicating hooping-cough, 350 sometimes associated with congestion of the brain, 54 Diarrhoea— possibility of its occurrence in hydroce- phalus, 95 delusive symptoms in relapses of—case, 615 treatment of simple form, 491 sulphuric acid in, 492 during teething, 492 in its decline, 493 inflammatory form; depletion, 493 vomiting, and of nervous symptoms, 494 use of stimulants in, 495 aromatics and astringents, 496 chronic stage of, 497 diet in, 498 intertrigo in, 499 prolapsus ani in, 499 Digestive system, peculiarities of, in early childhood, 406 changes in, with advancing years, 409, 479 deaths from diseases of, and from other causes, compared (note), 220 disorder of, associated with diabetes, 543 Diphtheria, 315 its relation to true croup, 294, 317 symptoms, 316, 319 two forms, primary and secondary, 318 its affinity to bood diseases, 321 duration, and modes of death, 322 sequelae, 322 relation to scarlatina, 324 treatment, 327 secondary to measles, 329 morbid appearances, 331 treatment, 331 Disease, peculiarities of, in childhood, 17 difficulties of investigating, 18 hereditary tendency to, important, 23 rules for treatment of, 27 Dropsy after scarlatina. See Kidneys, inflam- mation of. Dura mater, inflammation of sinuses of, 105 Dyspepsia of infants, symptoms of, 451 treatment, when dependent on de- bility, 453 gastric disorder, 453 use of alkalies in, 455 strumous, as a symptom of phthisis, 374 Dyspnoea, nervous, in course of bronchitis, 262 hooping cough, 340, 345 treatment of, 362 Dysuria of young children, 531 treatment of, 532 from calculus in urethra; from long pre- puce, 532 Ear, inflammation of internal, 102 symptoms of, 103 diagnosis from inflammation of brain, 103 extending to brain, 104 treatment, 104 Eclampsia nutans, 168 Electricity, in treatment of paralysis, 197 Emetics, in treatment of croup, 304, 307, 332 caution with reference to their use, 308 Emphysema, its association with pneumonia, 253 relation of hooping-cough to its produc- tion, 355 INDEX. 623 Encephalitis, or simple inflammation of the brain, 70, 97 its differences from hydrocephalus—cases illustrative of, 98 morbid appearances in, 100 its occurrence rare, 100 treatment of, 101 Endocarditis, 40i effects of, tendency to increase—cases, 402 occasional amelioration in—cases. See Heart, diseases of. Epilepsy, its frequency in childhood, 169 causes of, 170 affection of mind in, 171 general characters in childhood, 172 prognosis in, 173 treatment of, 174 general management in, 175 Exanthemata, general characteristics of, 553 Facial Hemiplegia in new-born infants, 198 Feeding, artificial, of infants, high mortality from, 410 its injurious effects explained, 411 morbid appearances produced by, 413 rules for, when necessary, 416 quantity of food, 418 caution as to occasional un- healthiness of cow's milk, 390, 418 Fevers in childhood, chiefly exanthemata, 553 continued fever, same in child and in adult, 554 identity of remittent and typhoid fever. See Typhoid fever. Galvanism, in treatment of paralysis, 197 Gangrene of the lung. See Lung, gangrene of. mouth. See Stomatitis, gangrenous. Gastric disorder, diagnosis of, from pneumo- nia, 273 pleurisy, 288 remittent fever, 560 Glottis, spasm of. See Spasm of. Tubage of (note), 312 Gums, lancing of, rules for, during teething, 428 caution needed in cases of spasm of the glottis, 164 Gymnastics, use of, in epilepsy, 175 chorea, 183 paralysis, 197 Hall, Dr. Marshall, mode of treating in- fantile asphyxia, 58 Haematemesis, circumstances in which it oc- curs, 458 illustrative cases, 459 spurious, 462 Haemoptysis rare in phthisis of children, 374 cases of fatal, 376 Hemorrhage from umbilicus in new-born child- ren, 465 Heart, diseases of, 393 frequency in childhood underrated, 393 connection with malformations, 395 acute rheumatism most frequent cause of, 394 associated with scarlatina; with pleurisy, 394, 395 Heart, diseases of— connection of, with chorea, 179 idiopathic, 399 sometimes independent of inflammation, 402 their tendency to increase, 402 occasional pauses in advance of, 404 rarity of anaemic bruits, 405 conclusions concerning, 406 Hectic, rare in phthisis of children, 375 Hemiplegia, facial, in new-born infants, 198 Hernia, strangulated, in infants, 474 Hip-joint disease, diagnosis from partial palsy of leg, 192 Hooping-cough, essentially a disease of child- hood, 336, 352 symptoms of—the hoop, 337, 341 catarrhal stage, 339 varying at onset of, 339 nervous dyspnoea in, 340, 345 at its acme, 340 nocturnal exacerbations of, 340 indications of amendment and dete- rioration, 342 cough often diminished by intercur- rent febrile affections, 344 complication of, with bronchitis and pneu- monia, 343 disorder of nervous system, 345 congestion of brain, 54 convulsions, 41, 347 tubercular hydrocephalus—case illus- trative of, 348 diarrhoea, 350 irritable stomach and vomiting, 346, 350 measles and varicella, 351 duration of, 351 its catarrhal stage, 339 recurrence of, 352 causes of; influence of sex and age, 352; (note), 353 season and temperature, 353 contagion, 354 deaths from, at different ages (note), 353 from different complications (note), 343 morbid appearances in, 354 production of emphysema in, 355 state of the lungs, Alderson's obser- vations (note), 355 pneumogastric nerves, 356 treatment of, of first stage, 357 of second stage ; use of hydrocyanic acid, 358 sedatives, 359 chloroform in, 359 cauterization of larynx in, 360 counter-irritation and blisters, 361 third stage, 364 the nervous dyspnoea; danger of over- treatment—case in illustration, 362 bronchitis complicating, 364 decline of, 365 Hydatids of brain, 142 Hydrocephaloid disease, Dr. M. Hall's account of, 128 supervention of, in course of diarrhoea, 129 pneumonia, and consequent on cere- bral congestion, 130 624 INDEX. Hydrocephaloid disease— cautions against mistaking its symptoms, 131, 614 rules for its prevention and treatment, 132 Hydrocephalus, acute, or scrofulous inflam- mation of the brain, 70 ages at which it occurs, 91 predisposition to, in phthisical families, 91 morbid appearances in, two kinds of, 70 table of 43 dissections of (note), 76 at base of brain, 71 granulations of the membranes, 72 their tubercular nature, 73 state of cerebral substance in, and relation to fluid in ventricles, 74 softening not due to imbibition of fluid, 75 result of inflammation ; its rela- tion to changes in lining of ventricles, 75 tubercular deposits in brain in, 77 complications of, 78 symptoms of first stage of, 78, 617 second, 79 third, 80 vary in different cases, 82 approach sometimes very gradual, 82, 86 symptoms of, obscure in phthisical subjects, 83 three stages of, not always distinct, 90 occasional occurrence of diarrhoea in, 95 diagnosis of, from inflammation of internal ear, 103 night terrors, 202 remittent fever, 85 remissions in, irregular, 86, 89 gastric disorder, 86 pneumonia, 273 pleurisy, 287 prognosis in, very unfavorable, 86 appearances of improvement delusive, 88 occasional recovery from, 87 caution as to sleep in, 88 duration of, 89 treatment of, prophylaxis of, 91 depletion in, 93 purgatives in, 94 use of mercurials, and application of cold in, 94, 95 use of tartar emetic ointment in, 96 diet, use of narcotics, application of blisters in, 95, 96 of last stage of, 97 chronic, circumstances in which it occurs, 107 occasional result of cerebral conges- tion, 49 connected with malformation of the brain, 108, 110 external and internal, 108 internal, symptoms of, 108 changes of skull in, 109 progress and termination of, 110 age at which it comes on, 110 post-mortem appearances in, 111 frequent connection with inflam- mation—cases, 111-114 Hydrocephalus, chronic, internal— sometimes arrested, rarely cured, 114 external, its various causes, 114 diagnosis from hypertrophy of brain, 122 treatment of, 115 Gblis's plan and use of compres- sion, 116 by puncture, 117 spurious. See Hydrocephaloid disease. Hydrocyanic acid in treatment of hooping- cough, 358 Hypertrophy of brain. See Brain, hypertro- phy of. Hypochondriasis in childhood, 205 Hysteria in childhood, 207 Icterus neonatorum. See Jaundice. Idiocy, distinguished from backwardness, 214 causes of, 216 symptoms of, 217 mental faculties in, 218 education in, 218 association of with hypertrophy of brain, 121 with congenital atrophy of brain, 124 Induration of the cellular tissue, symptoms of, 238 appearances after death, 239 connection of, with collapse of the lung, 240 treatment of, 240 Infancy, frequency of sudden deaths in—case, 598 Infants, artificial feeding of, injurious; high mortality from, 410 injurious action of explained, 411 farinaceous substances unsuit- able for, 416 atrophy of, causes of various, 412, 419 post-mortem appearances in, 413 Influenza, its peculiarities in childhood; treat- ment, 264, 265 Inoculation of smallpox, comparative advan- tages and evils of, 567 Intellect, temporary weakening of, after long illness, 125 Intermittent fever, peculiarities of, in child- hood, 564 Intertrigo in course of chronic diarrhoea, treat- ment of, 499 Intestinal worms. See Worms. Intestines, softening of, 457 Intuition and guessing, difference between, 612 Intussusception of intestines, symptoms of, 475 diagnosis of, 476 treatment of, 477 Inward fits, meaning of the term, 44 Jaundice of new-born infants, 463 influence of cold and bad air in causing it, 464 sometimes depends on obstruc- tion or malformation of biliary ducts, 465 treatment of, 464 of children sometimes associatad with head symptoms, 467 treatment of, 467 INDEX. 625 Kidneys, simple inflammation of, 521 inflammation of, with albuminuria, 521 as sequela of scarlatina, 522 composition of urine in, 526 post-mortem appearances, results of the microscope, 527 treatment of, 528 gravel and calculus in, very frequent in children, 530 lithic acid very frequent in new-born children, 530 formed during teething, 531 associated with dyspeptic symptoms, 533 albuminous, degeneration of, 539 fungoid disease of, 542 Laryngitis stridula. See Croup. ulcerative. See Croup. Larynx, cauterization of in croup, 331 in hooping-cough, 360 Leeches, rules for application of, 28 for applying to the head, 93 for employment of, in congestion of brain, 51 Leucaemia, enlargement of spleen in connec- tion with, 544 Leucorrhoea of young children. See Vulva, discharges from. Lithates, formation of, in new-born children, 530 during dentition, 531 connection of, with dyspepsia and rheuma- tism, 533 treatment of excess of, 534 Liver, fatty, connection of with infantile con- vulsions, 159 albuminous enlargement of, 539 its connection with syphilis, 539, 550 hydatids of, 540 fungoid disease of, 541 Lungs, elasticity of, 223 imperfect expansion of, 224 conditions under which it occurs, 224 anatomical characters, and ef- fects of inflation on the lung, 225 symptoms of, 227 cases illustrative of, 227 diagnosis of, from congenital phthisis, 229 treatment of. See Lungs, collapse of. carnification of. See Lungs, collapse of. collapse of, erroneously regarded as pneu- monia, 231 anatomical characters and symptoms of this supposed lobular pneumo- nia, 232 effects of inflation on lung, 232 researches of Bailly and Legendre, and of Gairdner, on it, 233 cases illustrative of its occurrence, 234 occurs from similar causes in adults as in children, 236 observations of its occurrence in the aged, 237 its supervention in course of bron- chitis, 257 40 Lungs, collapse of— in hooping-cough, 355 association with it of induration of the cellular tissue, 240 congestion and other changes of substance of, in course of bronchitis, 249 disease of, from infantile syphilis, 550 inflammation of substance of. See Pneu- monia abscess of, 249, 252 emphysema of, 253, 355 acute oedema of, 279 generally succeeds to scarlatinal dropsy—illustrative cases, 280 post-mortem appearances, 280 treatment of, 281 chronic oedema of, 282 gangrene of, case illustrative of, 282 to be regarded as a blood disease, 284 symptoms of, 284 treatment of, 285 tubercle of, table of 102 cases of, 369 miliary and gray granulations, often exist alone, 369 yellow infiltration frequent, 369 cavities from, rare, 370 small cavities, or vacuoles, 370 frequent affection of bronchial glands, 371 of bronchial glands, characters of, 371 sometimes got rid of, and how, 372 perforation of bronchi, &c. from, 373 Malingering in childhood, 206 Measles and scarlatina, mortality from, 578 resemble, but essentially different, 578 essentially a disease of early childhood, 578 contagion of, 579 symptoms of, 579 characters of the eruption, 580 congestive form of, 581 diagnosis of, from scarlatina, 578, 592 complications of, with bronchitis and pneumonia, 582 croup, 329 in early stage of, 581 in desquamative stage of, 329 relation of, to hooping-cough, 351 treatment of, 584 of symptoms of affection of chest in, 584 % of croup in, 331 cauterization of larynx in, 331 Meat, raw, in infantile diarrhoea, 498 Meltena. See Hsematemesis. Meningitis, acute. See Encephalitis. tubercular. See Hydrocephalus. of spinal cord, cases illustrative of, 145 post-mortem appearances in. See Spinal Cord. Mercury, rules for its employment, 29 in treatment of acute hydrocephalus, 94 pneumonia, 276 croup, 305 infantile syphilis, 550 Microcephalus, 124 Milk, human, composition of, 408, 416 and of animals, compared, 416 626 INDEX. Milk- peculiar adaptation of, to nourishment of child, 408 its spontaneous coagulation in the sto- mach, 454 healthy, characteristics of, 415 deterioration of, in scrofulous subjects, Klencke's remarks on, 390 best substitutes for, 416 of cow, occasionally unhealthy, 390, 418 Mind, peculiarities of, in childhood, 204 disorders of, 205 from over-work, 209 perversion of moral faculties in, 205, 211, 214 in epileptics, 171 in chorea, 179 Moral insanity in children, 211, 214 management of, 211 Mumps, 448 Narcotics, general rules for employment of, 32 in treatment of acute hydrocephalus, 95 Neuralgia, in childhood, 199 Nervous system, diseases of, extremely fre- quent in early life, 37 frequency of, accounted for, 38 deaths from, at different ages (note), 42 and from other causes (note), 220 symptoms of, 39 difficulties of study of, 38 disorders of, complicating diarrhoea, 129, 481, 488 treatment of, 494 influence of malaria in producing, 490 excitability of in early life, 599 imperfectly depurated blood a cause of irritability of—case, 600, 601 Nephritis, simple, 521 albuminous. See Kidneys, inflammation of. Night terrors of children, description of an attack of, 201 not indicative of primary mischief in the brain—cases, 202 dependent on gastric disorder, 203 treatment of, 203 Noma. See Stomatitis, ulcerative. Nurse, statements of, not to be undervalued, 24 Odontitis infantum. See Dentition. ffidema of lungs. See Lungs, oedema of. Opium, general rules for its employment, 32 in treatment of hooping-cough, 359 and antimony in head symptoms of re- mittent fever, 564 Otitis. See Ear, inflammation of. Otorrhoea, importance of head symptoms in, 103 chronic, treatment of, 105 Pacchionian bodies, difference from granu- lations of arachnoid (note), 73 Paracentesis of chest, in pleurisy, 291 Paralysis, import of, less serious in child than in adult, 186 sometimes congenital, 186 of portio dura from injury in birth, 198 causes of, 187 results of thirty-two cases, and tabular view of, 189 Paralysis— recovery from, uncertain; diagnosis of, 192 prognosis in, 193 deformity consequent on, 193 treatment of, 195 Passion, ungovernable, in childhood, 210, 211 Percussion, general rules for, 21 Pericarditis, usually connected with rheuma- tism, 394 sometimes associated with pleurisy—cases of, 396 idiopathic—case of, 399 not always discovered during life. See Heart, diseases of. Peritonitis in the foetus sometimes connected with syphilis, 501 in early infancy, 501 sometimes acute and epidemic, 502 in childhood, acute, idiopathic, rare, 500, 503 symptoms—case illustrating, 503 discharge of pus through ab- dominal walls in, 105, 505 secondary to scarlatina, 505 to inflammation of caecum—cases of, 505 treatment of, 507 chronic, usually tubercular, 509 morbid appearances in, 509 symptoms and general course of, 510 varieties in its onset and course, 511 relations of to tabes mesenterica. See Tabes mesenterica. Phlebitis, of sinuses of dura mater, 105 umbilical vein not a cause of trismus, 153 Phthisis, differences between disease in child and adult, 366 tables illustrative of various peculiarities (note), 368, 369 affects different organs in child; illustra- tive table, 367 assumes different forms, 369 symptoms of, their peculiarities, 374, 380 auscultatory, 378, 381 congenital, 229, 377 in early infancy, 377 bronchial, 375, 381 spasmodic cough in, 336 auscultatory, 378, 381 diagnosis of, from worms and remittent fever, 374, 378 tuberculosis pneumonia, 381 import of frequent attacks of catarrh, 245 duration of, 385 rapid course of, 385 chronic course of—cases, 386 prognosis of more hopeful in child than in adult, 391 in bronchial phthisis—case of reco- very from, 376 death from, various modes of, 389 head symptoms, sometimes obscure in, 83 supervention of hydrocephalus in, 83, 91 head symptoms—case, 389 treatment of, prophylaxis, 390 Pia mater, its changes in acute hydrocepha- lus, 71 Pleura, effusion into, after scarlatina, 524 INDEX. 627 Pleurisy, acute idiopathic, very rare in early childhood, 285 post-mortem appearances of, 285 symptoms and physical signs of, some peculiarities in, 286 diagnosis of, from head affection, 287 affections of the abdomen, 288 pneumonia; its difficulty, 273, 289 treatment of, 289 paracentesis of chest in, 290 diaphragmatic, obscurity of symptoms of, 288 chronic, 291 Pneumonia, causes and frequency of; illus- trative table, 254, 255 post-mortem appearances in, 251 termination in abscess, 252 gangrene, 253 association with emphysema, 253 idiopathic, symptoms of first stage of, 267 second, 268 third, 270 results of, death in second stage, oc- casional, 269 imperfect recovery from third stage, occasional, 270 auscultatory signs of, 271 recurrence of, 255 diagnosis of, from pleurisy, 273, 289 hydrocephalus, 273 head symptoms in, 130 gastric disorder, 274 typhoid fever, 274 dentition, 274 treatment of, depletion in, 275 tartar emetic in, 276 mercurials in, 276 stimulants and blisters in, 278 secondary to bronchitis ; a point of differ- ence from disease in adult, 246 symptoms of, 273 various diseases, 255 measles, 581 hooping-cough, 343 lobular, cases properly so called, 249 description under this name of col- lapse of the lung, 231 tuberculous, characteristics of, 382 Prescribing, general rules for, 273 Psoas abscess, characters of tumors formed by, 543 Puerile breathing not heard in early infancy, and why, 223 Pulse, great variations in its frequency, 20 frequency of, in infancy and childhood, 231 and of respiration, diminished during sleep, 25 and that of respiration to be com- pared in sick children, 19 peculiarities in hydrocephalus, 80, 84, 89, 90 Purgatives, remarks on different kinds of, 163 in congestion of brain, 52 in acute hydrocephalus, 94 Rectum, imperforate, three varieties of, 469 its rarity; its symptoms, 470 circumstances modifying prognosis, 471 various operations for its cure, 472 Remittent fever, identical with typhoid fever. See Typhoid fever. Retro-cesophageal abscess, 447 Retro-pharyngeal abscess, 443 symptoms, and cases of, 444 diagnosis of, 447 treatment, 447 Rheumatism, connection of, with chorea (note), 177 acute, followed even when slight by heart disease, 395 chronic, its connection with excess of li- thates in the urine, 533 Respiration, peculiarities of, in early life, 221 its frequency in infancy and childhood, 221 feebleness of inspiratory power, 222 similarity of its characters in infancy and old age, 237 frequency of, and of pulse, diminished during sleep, 25 its general" characters to be noticed in sick children, 19, 22 peculiarities of, in cerebral disease, 41 organs of, death from diseases of, and from other causes, compared (note), 220 susceptibility of their mucous mem- brane, 242, 244 this susceptibility less at birth than afterwards, 242 Revaccination, reasons in favor of, 575 Rickets, connection of, with hypertrophy of brain, 121 Salaam convulsion, 168 Scalp, sanguineous tumor of. See Cephalhe- matoma. Scarlatina, varieties of, 585 simplex, symptoms of, 586 characters and progress of the eruption, 586 anginosa, symptoms of, affection of throat in, 587 maligna, symptoms of, 588 affection of throat and parotids in, 590 various complications of, 591 supervention of endocarditis in course of, 394 post-mortem appearances in, 591 diagnosis of, from measles, 592 sequelae of—retro-pharyngeal abscess, 445 dropsy, 522 exciting causes of, 522 symptoms of, 523 composition of urine in, 526 state of kidneys in, 527 causes of death in, 524 treatment of, 593 use of inunction in, 593 caution as to depletion in head affec- tions in, 594 the coryza and affection of throat in, 595 dropsy, 528 prophylaxis of, 595 Sedatives in treatment of hooping-cough, 359 Sleep, frequency of pulse and respiration di- minished during it, 25 its characters to be observed in sick child- ren, 19 caution concerning, in hydrocephalus, 88 628 INDEX. Smallpox, influence of inoculation and of vaccination on, 567 mortality from, 568 symptoms of, and diagnosis from other eruptive fevers, 569 progress of the eruption, 570 peculiarities of the confluent form, 570 secondary fever, its dangers, 571 treatment of, 572 the secondary fever of, 573 local symptoms—prevention of pit- ting, 574 after vaccination, its usually mild cha- racter, 575 peculiarities of its course and symp- toms, 576 Spasm of the glottis, 157 symptoms of, 160 carpopedal contractions in, 161 various causes of, 157—160 case illustrative of its connection with en- larged thymus gland (note), 334 treatment of, 163 caution as to lancing the gums in, 164 case illustrative of occasional neces- sity for depletion, 165 caution as to sudden exposure to air, 166 the paroxysm, 166 Speech, temporary loss of power of, after long illness, 125 Spinal cord, predominance of, in early life, 42 special obscurity of disease of, in the child, 142 Dr. Weber's observations on vascularity of, 152 irritation and congestion of—cases, 143 membranes of, usually involved in simple encephalitis, 100 inflammation of its membranes sometimes epidemic, 144 cases illustrative of inflammation of, 145 acute inflammation of substance of, 148 chronic inflammation of substance of, 149 softening of, generally connected with disease of vertebrae, 149 remarkable case of without disease of the bones, 150 Spleen, albuminous enlargement of, 539, 544 Stimulants, use of, in treatment of diarrhoea, 495 Stomach, peculiarities of, in infancy, 407 softening of, different opinions concerning, 456 characters of, 456 alleged influence of mode of death on, 458 its frequency in infancy, theories ac- counting for, 458 Stomatitis, three varieties of, 431 follicular, symptoms and course of, 432 treatment of, 433 ulcerative, or noma, symptoms and course of, 433 tendency to pass into gangrene very slight, 434 treatment of, 434 gangrenous, fatality of, 435 its connection with blood diseases, 436 does not depend on administration of mercury, 440 Stomatitis, gangrenous— point of departure of gangrene, 436 symptoms and course of, 437 morbid appearances in, 438 treatment; importance of cauteriza- tion, 438 Sudden death in infancy mostly dependent on spasm of the respiratory process, 602 dependent on mere disorder of respira- tion, 602 from serous effusion into pleural cavity— cases, 603, 604 from asthenia in diarrhoea, pneumonia, Ac, 604, 605 an accident; not inevitable result of dis- ease, 607 Sulphate of magnesia, use of small doses of, in diarrhoea, 492 Sulphuric acid, in diarrhoea, 492 Syphilis, infantile, 546 dependent on congenital taint, 546 relation of, to foetal and infantile perito- nitis, 501 symptoms of, 546 coryza sometimes the only one, 244, 547 rarity of affection of bones, 244, 548 syphilitic cachexia, 549 relapses and tertiary symptoms, 549 affections of liver, thymus, &c. in, 550 treatment of, 550 local applications in, 551 Tabes mesenterica, relation of to tubercu- lar peritonitis, 512 anatomical characters of, 513 symptoms not pathognomonic of, 514 treatment of, and of tubercular peri- tonitis, 514 Tartar emetic ointment as counter-irritant in hydrocephalus, 96 Temperature, in infancy and childhood, 222 in pneumonia, 268 in typhoid fever, 557 Thirst, indications of, in the infant, 25 Thrush, its characters described, 420 disorder of health attending it, 421 microscopic characters of, 422 causes and treatment of, 423 Thymic asthma. See Spasm of the glottis. Thymus, suppuration of, in infantile syphilis, 550 Tongue, in infants, how to examine the, 22 Tonsils, inflammation of, 441 hypertrophy of, its symptoms, 441 its influence on the form of the mouth, and chest, 442 its treatment, 443 Tracheotomy, in croup, 309 difference of results in England and - France, 309 objections to performance of, 311 reasons for not rejecting, 312 conditions of success, 313 after-management, 314 Trismus, infantile, symptoms of, 151 post-mortem appearances in, 152 opinions as to its cause, 153 modes of prevention, and of treat- ment, 154 INDEX. 629 Tubercle of brain. See Brain, tubercle of. of mesenteric glands. See Tabes mesen- terica. Tubercular peritonitis. See Peritonitis, chro- nic. Tumors, abdominal. See Abdominal tumors. Typhoid fever, identity of, in child and adult, 554 post-mortem appearances of, 555 symptoms of, milder form of, 555 appearance of eruption in,'557, 558 severer form of, 557 delirium in, 558 cerebral mischief in, 560, 562 convulsions in, 559 death rare in, 560 signs of recovery from, 559 diagnosis of, from simple gastric dis- order, 560 from acute tuberculosis, 385, 561 hydrocephalus, 85, 611 from pneumonia, 274 treatment of, 562 abdominal symptoms in, 563 cerebral disturbance in, 564 diet and stimulants in, 565 Umbilicus, discharge of pus from, in perito- nitis, 105, 505 hemorrhage from, in new-born children, 466 Urea, excess of, 533 Urine, incontinence of—causes, 536 treatment, 536 Vaccination, drawbacks from its universal success, 567 Vaccination-— great benefits of, 568 adoption of, followed by increase of mea- sles and scarlatina, 578 Varicella. See Chicken-pox. Variola. See Smallpox. Vertebrae, disease of the cervical, extending to brain, 101 affection of spinal cord in cases of, 149 Vomiting, in infants, its frequency accounted for, 450 treatment of, 451 as a sign of dyspepsia, 451 in course of diarrhoea, 486, 494 treatment of, 494 important as a sign of cerebral disease, 41, 48 in first stage of hydrocephalus, 78 persistent, of great importance as a sign of hydrocephalus, 86 in hooping-cough, 346, 350 of blood. See Haematemesis. Von Ammon's account of severe cerebral dis- turbance preceding scarlatina, 610 Vulva, discharges from, 551 circumstances in which they occur, 552 treatment of, 552 Waterstroke, meaning of the term, 90 case of, 98 Whytt, Dr., his observations on acute hydro- cephalus, 69 Worms, intestinal, five varieties of, 517 symptoms of, 517 ' convulsions from, 518 treatment of, 519 630 INDEX TO FORMULA. NO. Acid mixture for hooping-cough ....... xviii. iEthereal stimulant, for fever ....... xxxvi. Alterative, saline ......... xxvu. tonic...........xxvm. xxxv. Alum mixture for hooping-cough ...... xvii. Antimonial, nauseating ........ xm. Aperient ........... V. aloetic...........xxiv. febrifuge .......... I. saline ........... VI. Astringent ........... xxix. aromatic, opiate ......... xxxi. gallic acid, opiate ........ xxxn. lead and opium ......... xxxin. sulphate of iron and opium ....... xxxiv. Cinchona and hydrocyanic acid mixture ..... xx. Cough mixtures..........vm. ix. x. Decoction blanche ......... iv. Demulcent ............xxn. Expectorant, stimulating ........ xn. Febrifuge, aperient ......... I. calmant .......... n. Hooping-cough, alum mixture for ...... xvn. acid mixture for ......... xviii. Hydrocyanic acid ......... xiv. xv. with bark.......... xx. Iron, expectorant mixture for chronic bronchitis or hooping- cough ........... xix. Liniment, stimulating, for the chest ...... XI. Nitro-muriatic acid mixture ....... xxi. Oleaginous, opiate, for diarrhoea.......xxx. Opiate powder .......... xvi. Saline, antimonial ......... xm. Sedative, hydrocyanic acid ........ xiv. xv. opiate powder ......... xvi. Stimulant, aethereal.........xxxvi. expectorant .......... XII. Tan-bath ........... Tonic, alterative..........xxxv. aperient .......... vn. astringent .......... in. chalybeate . . . • . . . . . ■ IV. alum and sulphuric acid ....... xvn. chalybeate, expectorant ....... xix. cinchona, and hydrocyanic acid ...... xx. hydrochloric acid ......... xviii. nitro-muriatic acid ........ xxi. vegetable, alkaline ........ xxv. with mineral acids.......xxm. xxvi. THE END. 'Jijf'-s.- BLANCHARD & LEA'S MEDICAL AID SURGICAL PUBLICATIONS. TO THE MEDICAL PROFESSION. 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Visiting Medical Officer to the York Retreat. A MANUAL OF PSYCHOLOGICAL MEDICINE; containing the History, Nosology, Description, Statistics, Diagnosis, Pathology, and Treatment of INSANITY. With a Plate. In one handsome octavo volume, of 536 pages, extra cloth. $4 00. The increase of mental disease in its.various torms, and the difficult questions to which it is constantly giving rise, render the subject one of daily enhanced interest, requiring on the part of the physician a constantly greater familiarity with this, the most perplexing branch of his profes- sion. Yet until the appearance of the present volume there has been for some years no work ac- cessible in this country, presenting the results of recent investigations in the Diagnosis and Prog- nosis of Insanity, and the greatly improved methods of treatment which have done so much in alleviating the condition or restoring the health of the insane. BENNETT (HENRY), M. D. A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. Sixth American, from the fourth and revised English edition. In one octavo volume, of about 500 pages, extra cloth. $3 75. (Just Ready.) This standard work, which has done so much to introduce the modern and improved treatment of female diseases, has received a very careful revision at the bands of the author In his preface he slates: " During the past two years this revh ion of former I. bors has been my principal occupa- tion, and in its present state the work may be considered to embody the matured experience of the many years I have devoted to the study of uterine disease." BROWN (ISAAC BAKER), Surgeon-Accoucheur to St. Mary's Hospital, &e. ON SOME DISEASES OF WOAIEN ADMITTING OF SURGICAL TREAT MENT. With handsome illustrations. One vol. 8vo., extra cloth, pp. 276. $160. Mr. Brown has earned for himself a high reputa- tion in the operative treatment of sundry diseases and injuries to which females are peculiarly subject. We can truly say of his work that it is an important addition to obstetrical literature. The operative suggestions and contrivances which Mr. Brown de- scribes, exhibit much practical sagacity and skill, and merit the careful attention of every surgeon- accoucheur—Association Journal. We have no hesitation in recommending this book to the careful attention of all surgeons who make female complaints a part of their study and practice. —Dublin Quarterly Journal. BOWMAN (JOHN E.), M.D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited by C. L. Bloxam. Third American, from the fourth and revised English Edition. In one neat volume, royal 12mo., extra cloth with numerous illustrations, pp.351. $2 00. (Now Ready, May, 1863.) Of this well-known handbook we may say that it retains all its old simplicity and clearness of ar- rangement and description, whilst it has received ject in view lucidly detailed and explained. And this new edition is not merely a reprint of the last. With a laudable desire to keep the book up to tne scientific mark of the present age, every improve- ment in analytical method has been introduced. In conclusion, we would only say that, familiar from long acquaintance with each page of tht former issues of this little book, we gladly place beside them another presenting so many acceptable im- provements and additions.—Dublin Medical Press. from the able editor those finishing touches which the progress of chemistry has rendt red necessary.— London Med. Times and Gazette, Nov. 29, 1662. Nor is anything huiried over, anything shirked ; open the book where you will, you find the same careful treattnentof the subject manifested, ana the best process for the attainment of the particular ob- BY THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- LYSIS. Third American, from the third and revised London edition. With numerous illus- trations. In one neat vol., royal 12mo., extra cloth. 5 vi 00 (Just Ready.) This favorite little manual has received a very thorough and careful revision at the hands of a competent editor, and will be found fully brought up to the present condiiion of" chemical science. Many portions have been rewritten, the subjects of the blow-pipe and volumetric analysis have re- ceived special attention, and an additional chapter has been appended. Students of practical chem- istry will therefore find it, as here ofore, a most convenient und Condensed text-book and guide in the operations of the laboratory. BEALE ON THE LAWS OF HEALTH IN RE- LATION TO MIND AND BODY. A Series of Letters from an old Practitioner to a Patient. In one volume, royal 14mo., extra cloth, pp. 290 80 cents. 'V,?.H^AN'S PHYSIOLOGY OF ANIMAL AND VEGETABLE LIFE; a Popular Treatise on the Functions and Phenomena of Organic Lite. In one handsome royal 12mo. volume, extra cloth, with over 100 illustrations, pp. 234. B0 cents. AND SCIENTIFIC PUBLICATIONS. 5 BUMSTEAD (FREEMAN J.) M. D., Lecturer on Venereal Diseases at the College of Puysicians and Surgeons, New York, &c. THE PATHOLOGY AND TREATMENT OF VENEREAL DISEASES, including the results of recent investigations upon the subject. Second edition, thoroughly re- vised and much improved. With illustrations on wood. In one very handsome octavo volume, of about 700 pages. $4 75 (Now Ready.) To sum up all in a few words, this book is one which no practising physician or medical student can very By far the most valuable contribution to thiB par- ticular branch of practice that has seen the light within the last score of years. His clear and accu- rate descriptions of the various forms of venereal disease, and especially the methods of treatment he proposes, are worthy of the highest encomium. In these respects it is better adapted for the assistance of the every-day practitioner than any other with which we are acquainted. In variety of methods proposed, in minuteness of direction, guided by care- ful discrimination of varying forms and complica- tions, we write down the book as unsurpassed. It is a work which should be in the possession of every practitioner.—Chicago Med. Journal. Nov. 1861. Tne foregoing admirable volume comes to us, em- bracing the whole subject of syphilology, resolving many a doubt, correcting and confirming many an entertained opinion, and in our estimation the best, completest, fullest monogiaph on this subject in our language. As far as the author's labors themselves are concerned, we feel it a duty to say that he has not only exhausted his subject, but he has presented to us, without the slightest hyperbole, the best di- fested treatise on these diseases in our language [e has carried its literature down to the present moment, and has achieved his task in a manner which eannot but redound to his credit.—British American Journal, Oct. 1861. We believe this treatise will come to be regarded as high authority in this branch of medical practice, and we cordially commend it to the favorable notice of our brethren in the profession. For our own part, we candidly confess that we have received n.any new ideas from its perusal, as well as modified many views which we have long, and, as we now think, erroneously entertained on the subject of syphilis. well afford to do without.—American Med Times, Nov. a, 1861. The whole work presents a complete history of venereal diseases, comprising much interesting and valuable material that has been spread through intd- ical journals within the last twenty years—the pe- riod of many experiments and investigations on the subject—the whMe carefully digested by the aid of the author's extensive personal experience, and offeted to the profession in an admirable form. Its completeness is secured by good plates, which are especially full in the anatomy of the genital organs. We have examined it with great satisfaction, and congratulate the medical profession in America on the nationality of a work that m*y fairly be sailed original.—Berkshire Med. Journal, Dec. 1861. One thing, however, we are impelled to say, that we have met with no other book on syphilis, in the English language, which gave so full, clear and impartial views of the important subjects on wnich it treats. We cannot, however, refrain from ex- pressing our satisfaction with the full and perspicu- ous manner in which the subject has been presented, and the careful attention to minute details, so use- ful—not to say indispensable—in a practical treatise. In conclusion, if we may be pardoned tne use of a phrase now become stereotyped, but which we here employ in all seriousness and sincerity, we-do not hesitate to express the opinion that Dr. Bumstead's Treatise on Venereal Diseases is a » appendix; and this of itself, it seems to us, is fully worth the cost of the volume—Louisville Medical Review. AND SCIENTIFIC PUBLICATIONS. 7 CARPENTER (WILLIAM B.), M. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from the last and revised London edition. With nearly three hundred illustrations. Edited, with addi- tions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsyl- vania Medical College, &c. In one very large and beautiful octavo volume, of about nine hundred large pages, handsomely printed, extra cloth, $5 25. For upwards of thirteen years Dr. Carpenter's I Toeulogize thisgreat work would be superfluous. work has been considered by the profession gene- We 6hould observe, however, that in this edition rally, both in this countryand England, as the most ( the author has remodelled a large portion of the valuable compendium on the subject of physiology former, and the editor has added much matter of in- in our language. This distinction it owes to the high r language. This distinction it owes to the hig attainments and unwearied industry of its accom- plished author. The present edition (which, like the :ast American one, was prepared by the author him- self), is the result of such extensive revision, that it may almost be considered a new work. We need hardly say, in concluding this brief notice, that while the work is indispensable to every student of medi- cine in this country, it will amply repay the practi- tioner for its perusal by the interest and value of its Contents.—Boston Med. and Surg. Journal. This is a standard work—the text-book used by ali medical students who read the English language. it has passed through several editions in order to keep pace with the rapidly growing science of Phy terest, especially in the form of illustrations. We may confidently recommend it as the most complete work on Human Physiology in our language.— Southern Med. and Surg. Journal. The most complete work on the science in our language.—Am. Med. Journal. The most complete work now extant in our lan- guage.—JV. O. Med. Register. The best text-book in the language on this ex- tensive subject.—London Med. Times. A complete cyclopaedia of this branch of sciencs. —N. Y. Med. Times. The profession of this country, and perhaps also of Europe, have anxiously and for some time awaited siology. Nothing need be said in its praise, for its the announcement of this new edition of Carpenters merits are universally known; we have nothing to i Human Physiology. His former editions have for say of its defects, for they only appear where the I many years been almost the only text-book on Phy science of which it treats is incomplete.—Western Lancet. The most complete exposition of physiology which any language can at present give.—Brit, and For. Med.-Chirurg. Review. The greatest, the most reliable, and the best book siology in all our medical schools, and its circula- tion among the profession has been unsurpassed by any work in any department of medical science. It is quite unnecessary for us to speak of this work as its merits would justify. The mere an- nouncement of its appearance will afford the highest pleasure to every student of Physiology, while its on the subject which we know of in the English perusal will be of infinite service in advancing language.—Stethoscope. I physiological science.—Ohio Med.andSurg. Jouth. BY THE SAME AUTHOR. ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- LOGICAL ANATOMY. Second American, from a new and revised London edition. With one hundred and ninety illustrations. In one very handsome octavo volume, leather, pp. 566. $4 00. In publishing the first edition of this work, its title was altered from that of the London volume* by the substitution of the word " Elements" for that of " Manual," and with the author's sanction the title of "Elements" is still retained as being more expressive of the scope of the treatise. BY THE SAME AUTHOR. PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from the Fourth and Revised London edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations, pp. 752. Extra cloth, $5 00. This book should not only be read but thoroughly studied by every member of the profession. None are too wise or old, to be benefited thereby. But especially to the younger class would we cordially commend it as best fitted of any work in the English language to qualify them for the reception and coin- prehension of those truths which are daily being de- veloped in physiology.—Medical Counsellor. Without pretending to it, it is an encyclopedia of the subject, accurate and complete in all respects— a truthful reflection of the advanced state at which the science has now arrived.—Dublin Quarterly Journal of Medical Science. A truly magnificent work—in itself a perfect phy- siological study.—Ranking's Abstract. This work stands without its fellow. It is one few men in Europe could have undertaken; it is one no man, we believe, could have brought to so suc- cessful an issue as Dr. Carpenter. It required for its production a physiologist at once deeply read in the labors of others, capable of taking a general. critical, and unprejudiced view of those labors, and of combining the varied, heterogeneoub materials at his disposal, so as to form an harmonious whole. We feel that this abstract can give the reader a very imperfect idea of tbe fulness of this work, and no idea of its unity, of the admirable marjier in which material has been brought, from the most various sources, to conduce to its completeness, of the lucid- ity of tne reasoning it contains, or of the clearness of language in which the whole is clothed. Not the profession only, but the scientific world at large, must feel deeply indebted to Dr. Carpenter for this great work. It must, indeed, add largely even to his high reputation.—Medical Times. BY the same author. (Preparing.) PRINCIPLES OF GENERAL PHYSIOLOGY, INCLUDING ORGANIC CHEMISTRY AND HISTOLOGY. With a General Sketch of the Vegetable and Animal Kingdom. In one large and very handsome octavo volume, with several hundred illustrations. BY THE SAME AUTHOR. A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH AND- DISEASE. New edition, with a Preface by D. F. Condie, M. D., and explanations of scientific words. In one neat 12mo. volume, extra cloth, pp. 178. 60 cents. 8 BLANCHARD & LEA'S MEDICAL CONDIE (D. F.), M. D., Sec. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fifth edition, revised and augmented. In one large volume, 8vo., extra cloth, of over 750 pages. $4 00. In presenting a new and revised edition of this favorite work, the publishers have only to state that the author has endeavored to render it in every respect " a complete and faithful exposition of the pathology and therapeutics of the maladies incident to the earlier stages of existence—a full and exact account of the diseases of infancy and childhood." To accomplish this he has subjected the whole work to a careful and thorough revision, rewriting a considerable portion, and adding several new chapters. In this manner it is hoped that any deficiencies which may have previously existed have been supplied, that the recent labors of practitioners and observers have been tho- roughly incorporated, and that in every point the work will be found to maintain the high reputation it has enjoyed as a complete and thoroughly practical book of reference in infantile affections. A few notices of previous editions are subjoined. We pronounced the first edition to be tbe best Dr. Condie's scholarship, acumen; industry, and practical sense are manifested in this, as in all his numerous contributions to science.—Dr. Holmes's Report to the American Medical Association. Taken as a whole, in our judgment, Dr. Condie's Treatise is the one from the perusal of which the practitioner in this country will rise with the great- est satisfaction.—Western Journal of Medicine and Surgery. One of the best works upon the Diseases of Chil- dren in the English language.—Western Lancet. We feel assured from actual experience that no physician's library can be complete without a copy of this work.—N. Y. Journal of Medicine. A veritable pediatric encyclopaedia, and an honoi to American medical literature.—Ohio Medical and Surgical Journal. work on the diseases of children in the English language, and, notwithstanding all that has heen published, we still regard it in that light.—Medical Examiner. The value of works by native authors on the dig- eases which the physician is called upon to combat, will be appreciated by all; and the work of Dr. Con- die has gained for itself the character of a safe guide for students, and a useful work for consultation by those engaged in practice.—N. Y. Med. Times. This is the fourth edition of this deservedly popu- lar treatise. During the interval since the last edi- tion, it has been subjected to a thorough revision by the author; and all new observations in the pathology and therapeutics of children have been included in the present volume. As we said before, we do not know of a better book on diseases of chil- We feel persuaded thatthe American medical pro- dren, and to a large part of its recommendations we fession will soon regard it not only as a very good, yield an unhesitating concurrence.—Buffalo Med. but as the very best "Practical Treatise on the [Journal. Diseases of ChiIdren."-^WlertCan Medical Journal Perhaps the mostfull and complete work now be- In the department of infantile therapeutics, the fore the profession of the United States; indeed, we work of Dr. Condie is considered one of the best may say in the English language. It is vastly supe- which has been published in the English language, riortomostof its predecessors.—Transylvania Med. —The Stethoscope. {Journal CHRISTISON (ROBERT), M. D., V. P. R. S. E., Sec. A DISPENSATORY; or, Commentary on the Pharmacopoeias of Great Britain and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- tions Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- proved, with a Supplement containing the mos) important New Remedies. With copious Addi- tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M. D. In one very large and handsome octavo volume, extra cloth, of over 1000 pages. $3 50. COOPER (BRANSBY B.), F. R. S. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large octavo volume, extra cloth, of 750 pages. $2 00. COOPER ON THE ANATOMY AND DISEASES OF THE BREAST, with twenty-five Miscellane- ous and Surgical Papers. One large volume, im- perial 8vo., extra cloth, with 252 figures, on 36 plates. S3 00. COOPER ON THE STRUCTURE AND DIS- EASES OF THE TESTIS, AND ON THE THYMUS GLAND. One vol. imperial 8vo., ex- tra cloth, with 177 figures on 29 plates. $2 50. CnX^R ON FEVERS; THEIR DIAGNOSIS, PATHOLOGY, AND TREATMENT. In one octavo volume, leather, of 600 pages. 81 75. C%.02!&AT DE L'ISERE ON THE DISEASES Ot 1-LMALES, and on the special Hygiene of their Sex. Translated, with many Notes and Ad- ditions, by C. D. Meigs, M. D. Second edition, revised and improved. In one large volume, oc- tavo, leather, with numerous wood-cuts. pp. 720. CARSON (JOSEPH), M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MFDTPA AND PHARMACY, delivered in the University of Penn^vlvania WiTh ,h ,MJ?I)10A the Modus Operandi of Medicines. Third edition revised fn ™* h» a three Lecturf8 on (Now Ready?) $2 50. ' remed- ia one handsome octavo volume. CURLING (T. B.), F. R.S., Surgeon to the London Hospital, President of the Hunter'ian Society Ac A PRACTICAL TREATISE ON DISEASES OF THE TESTIS qpwHMA r< TIC CORD, AND SCROTUM. Second American, from the second and™.. V* ,FT a' ,,#.. ^ha.d8om.octavovolume,extraclo^^ AND SCIENTIFIC PUBLICATIONS. 9 CHURCHILL (FLEETWOOD), M. D., M. R. I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With Notes and Additions, by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Children," &c. With 194 illustrations. In one very handsome octavo volume, of nearly 700 large pages, extra cloth, $4 00. This work has been so long an established favorite, both as a text-book for the learner and as a reliable aid in consultation for the practitioner, that in presenting a new edition it is only necessary to call attention to the very extended improvements which it has received. Having had the benefit of two revisions by the author since the last American reprint, it has been materially enlarged, and Dr. Churchill's well-known conscientious industry is a guarantee that every portion has been tho- roughly brought up with the latest results of European investigation in all departments of the sci- ence and art of obstetrics. The recent date of the last Dublin edition has not left much of novelty for the American editor to introduce, but he has endeavored to insert whatever has since appeared, together with such matters as his experience has shown him would be desirable for the American student, including a large number of illustrations. With the sanction of the author he has added in the form of an appendix, some chapters from a little "Manual for Midwives and Nurses," re- cently issued by Dr. Churchill, believing that the details there presented can hardly fail to prove of advantage to the junior practitioner. The result of all these additions is that the work now con- tains fully one-half more matter than the last American edition, with nearly one-half more illus- trations, so that notwithstanding the use of a smaller type, the volume contains almost two hundred pages more than before. No effort has been spared to secure an improvement in the mechanical execution of the work equal to that which the text has received, and the volume is confidently presented as one of the handsomest that has thus far been laid before the American profession; while the very low price at which it is offered should secure for it a place in every lecture-room and on every office table. Were we reduced to the necessity of having but tne work on midwifery, and permitted to choose, we would unhesitatingly take Churchill.—Western Med. and Surg. Journal. It is impossible to conceive a more useful and ilegant manual than Dr. Churchill's Practice of Midwifery.—Provincial Medical Journal. Certainly, in our opinion, the very best work on he subject which exists.—N. Y. Annalist. No work holds a higher position, or is more de- serving of being placed in the hands of the tyro, the advanced student, or the practitioner.—Medical Examiner. Previous editions have been received with mark- ed favor, and they deserved it; but this, reprinted from a very late Dublin edition, carefully revised and brought up by the author to the present time, does present an unusually accurate and able expo- sition of every important particular embraced in the department of midwifery. * # The clearness, directness, and precision of its teachings, together with the great amount of statistical research which its text exhibits, have served to place it already in the foremost rank of works in this department of re- medial science.—N. O. Med. and Surg. Journal. In our opinion, it forms one of the best if not t e very best text-book and epitome of obstetric science which we at present possess in the English lan- guage.—Monthly Journal of Medical Science. The clearness and precision of style in which it is written, and the greatamountof statistical research which it contains,have served to place it in the first rank of works in this departmentof medical science. —N. Y. Journal of Medicine. This is certainly the most perfect system extant. It is the best adapted for the purposes of a text- book, and that which he whose necessities confine dim to one book, should select in preference to all )thers.—Southern Medical and Surgical Journal. A better book in which to learn these important points we have not met than Dr. Churchill's. Every page of it is full of instruction; the opinion of all writers of authority is given on questions of diffi- culty, as well as the directions and advice of the learned autnor himself, to which he adds the result of statistical inquiry, putting statistics in their pro per place and giving them their due weight, and no more. We have never read a book more free from professional jealousy than Dr. Churchill's. It ap- pears to be written with the true design of a book on medicine, viz: to give all that is known on the sub- ject of which he treats, both theoretically and prac- tically, and to advance such opinions of his own as he believes will benefit medical science, and insure the safety of the patient. We have said enough to convey to the profession that this book of Dr. Chur-' chill's is admirably suited for a book of reference for the practitioner, as well as a text-book for the student, and we hope it may be extensively pur- chased amongst our readers. To them we most strongly recommend it. — Dublin Medical Press. To bestow praise on a bookthat has received such marked approbation would be superfluous. Weneed only say, therefore, that if the first edition was thought worthy of a favorable reception by the medical public, we can confidently affirm that this will be found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much in- terest and instruction in everything relating to theo- retical and practical midwifery.—Dublin Quarterly Journal of Medical Science. A work of very great merit, and such as we can confidently recommend to the study of every obste- tric practitioner.—London Medical Gazette. Few treatises will be found better adapted as « text-book for the student, or as a manual for thi frequent consultation of the young practitioner.-- American Medical Journal. BY the same author. (Lately Published.) ON THE DISEASES OF INFANTS AND CHILDREN. Second American Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M. D. In one large and handsome volume, extra cloth, of over 700 pages. $4 00. In preparing this work a second time for the American profession, the author has spared no labor in giving it a very thorough revision, introducing several new chapters, and rewriting others, while every portion of the volume has been subjected to a severe scrutiny. The efforts of the American editor have been directed to supplying such information relative to matters peculiar to this country as might have escaped the attention of the author, and the whole may, there- fore, be safely pronounced one of the most complete works on the subject accessible to the Ame- rican Profession. By an alteration in the size of the page, these very extensive additions have been accommodated without unduly increasing the size of the work. BY THE SAME AUTHOR. ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- CULIAR TO WOMEN. Selected from the writings of British Authors previous to the close of the Eighteenth Century. In one neat octavo volume, extra cloth, oi about 450 pages. $2 50. 10 BLANCHARD & LEA'S MEDICAL CHURCHILL (FLEETWOOD), M. D., M. R. I. A., 4Vc. ON THE DISEASES OF WOMEN; including those of Pregnancy and Child- bed. A new American edition, revised by the Author. With Notes and Additions, by D Fran- cis Condie, M. D., author of "A Practical Treatise on the Diseases of'Children." With nume- rous illustrations. In one large and handsome octavo volume,, extra cloth, of 768 pages. $4 00. This edition of Dr. Churchill's very popular treatise may almost be termed a new work, so thoroughly has he revised it in every portion. It will be found greatly enlarged, and completely brought up to the most recent condition of the subject, while the very handsome series of illustra- tions introduced, representing such pathological conditions as can be accurately portrayed, present a novel feature, and afford valuable assistance to the young practitioner. Such additions as ap- peared desirable for the American student have been made by the editor, Dr. Condie, while a marked improvement in the mechanical execution keeps pace with the advance in all other respects which the volume has undergone, while the price has been kept at the former very moderate rate: It comprises, unquestionably, one of the most ex- j extent that Dr. Churchill does. His, indeed, is ths act and comprehensive expositions of the present I only thorough treatise we know of on the subject; state of medical knowledge in respect to the diseases and it may be commended to practitioners and stu- of women that has yet been published.—Am. Journ Med. Sciences. This work is the most reliable which we possess on this subject; and is deservedly popular with the profession.—Charleston Med. Journal, July, 1857. We know of no author who deserves that appro- | the British press.—Dublin Quart. Journal. bation, on "the diseases of females," to the same I dents as a masterpiece in its particular department. —Tht Western Journal of Medicine and Surgery. As a comprehensive manual for students, or a work of reference for practitioners, it surpasses any other that has ever issued on the same subject froa DICKSON (S. H.), M. D., ProfessoT of Practice of Medicine in the Jefferson Medical College, Philadelphia. ELEMENTS OF MEDICINE; a Compendious View of Pathology and Thera- peutics, or the History and Treatment of Diseases. Second edition, revised. In one large and handsome octavo volume; of 750 pages, extra cloth. $3 75. The steady demand which has so soon exhausted the first edition of this work, sufficiently shows that the author was not mistaken in supposing that a volume of this character was needed—an elementary manual of practice, which should present the leading principles of medicine with the practical results, in a condensed and perspicuous manner. Disencumbered of unnecessary detail and fruitless speculations, it embodies what is most requisite for the student to learn, and at the same time what the active practitioner wants when obliged, in the daily calls of his profession, to refresh his memory on special points. The clear and attractive style of the author renders the whole easy of comprehension, while his long experience gives to his teachings an authority every- where acknowledged. Few physicians, indeed, have had wider opportunities for observation and experience, and few, perhaps, have used them to better purpose As the result of a long life de- voted to study and practice, the present edition, revised and brought up to the date of publication, will doubtless maintain the reputation already acquired as a condensed and convenient American text-book on the Practice of Medicine. DRUITT (ROBERT), M.R. C.S., Sec. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. Anew and revised American from the eighth enlarged and improved London edition. Illustrated with four hundred and thirty-two wood-engravings. In one very handsomely printed octavo volume of nearly 700 large pages, extra cloth, $4 00. A work which like Druitt's Surgery h«s for so many years maintained the position of n lead- ing favorite with all classes of the profession, needs no special recommendation to attract attention to a revised edition. It is only necessary to state that the author has spared no pains to keep the work up to its well earned reputalion of presenting in a small and convenient compass the latest condition of every department of surgery, considered both as a science and as an art; and that the services of a competent American editor have been employed to introduce whatever novelties may have escaped the author's attention, or may prove of service to the American practitioner. As several editions have appeared in London since the issue of the last American reprint, the volume has had the benefit of repeated revisions by the author, resulting in a very tnorough alteration and improvement. The extent of these additions may be estimated from the fact that it now contains about one-third more matter than the previous American edition, and that notwithstanding the adoption of a smaller type, the pages have been increased by about one hundred, while nearly two hundred and fifty wood-cuts have been added to the former list of illustrations. A marked improvement will also be perceived in the mechanical and artistical execution of the work, which, printed in the best style, on new type, and fine paper, leaves little to be desired as regards external finish; while at the very low price affixed it will be found one of the cheapest volumes accessible to the profession. This popular volume, now a most comprehensive I nothing of real practical importance-has been omit- work on surgery, has undergone many corrections, ted ; it presents a faithful epitome of everything re- improvements, and additions, and the principles and : lating t > surgery up to the present hour. It is de- the practice of the art have been brought down to \ servedly a popular manual both with the student the latest record and observation. Of the operations and practitioner__London Lancet, Nov. 19, 1859. in surgery it is impossible to speak too highly. The descriptions are so clear and concise, and the illus- trations so accurate and numerous, that the student can have no difficulty, with instrument in hand, and book by his side, over the dead body, in obtaining a proper knowledge and sufficient tact in this much In closing this brief notice, we recommend as cor- dially as ever this most useful and comprehensive hand-book. It must prove a vast assistance, not only to the student of surgery, but also to the busy practitioner who may not have the leisure to devote neglectedUepartmentof medicaledueation.—firm's* himself to the study of more lengthy volumes.— and Foreign Medico-Chirurg. Review, Jan. I960 In the present edition the author has entirely re- written many of the chapters, and has incorporated the various improvements and additions in modern surgery. On carefully going over it, we find that London Med. Times and Gazette, Oct. 22,1859. In a word, this eighth edition of Dr. Druitt's Manual of Surgery is all that the surgical student or practitioner could desire. — Dublin Quarterlf Journal of Med. Sciences, Nov. 1859. AND SCIENTIFIC PUBLICATIONS. 11 DALTON, JR. (J. C), M. D. Professor of Physiology in the College of Physicians, New York. A TREATISE ON HUMAN PHYSIOLOGY, designed for the use of Students and Practitioners of Medicine. Third edition, revised, with nearly three hundred illustrations on wood. In one very beautiful octavo volume, of 700 pages, extra cloth, $5 U0. (Just Ready, 1864.) ** The rapid demand for another edition of this work sufficiently shows that the author has suc- ceeded in his efforts to produce a text-book of standard and permanent value, embodying within a moderate compass all that is definitely and positively known within the domain of Human Physiology. His high reputation as an original observer and investigator, is a guarantee that in again revising it he has introduced whatever is neces-ary to render it thoroughly on a level with the advanced science of the day, and this has been accomplished without unduly increasing the 6ize of the volume. No exertion has been spared to maintain the high standard of typographical execution which has rendered this work admittedly one of the handsomest volumes as yet produced in this country. It will be seen,' therefore, that Dr. Dalton's best i own original views and experiments, together with efforts have been directed towards perfecting his a desire to supply what he considered some deficien- work. The additions are marked by the same fea- cies in the first edition, have already made the pre- tures which characterize the remainder of the vol- sent one a necessity, and it will no doubt be even ume, and render it by far the most desirable text- more eagerly sought for than the first. That it is book on physiology to place in the hands of the ! not merely a reprint, will be seen from the author's student which, so far as we are aware, exists in statement of the following principal additions and the English language, or perhaps in any other. We alterations which he has made. The present, like therefore have no hesitation in recommending Dr. ; the first edition, is printed in the highest style of the Dalton's book for tne classes for which it is intend- printer's art, and the illustrations are truly admira- ed, satisfied as we are that it is better acapted to ble tor their clearness in expressing exactly what their uee than any other work of the kind to which ' their author intended.—Boston Medical and Surgi- they have access.—American Journal of the Med. ' cal Journal, March 28, 1881. Sciences, April, 1861. ... . . . . .. ,il_ ...... It is unnecessary togive a detail of theadditions; It is, therefore, no disparagement to the many j suffice it to say, that they are numerous and import- books upon physiology, most excellent in their day, ' ant, and such as will render the work still more to say that Dalton's is the only one that gives us the valuable and acceptable to the profession as a learn- science as it was known to the best philosophers j ed and original treatise on this all-important branch throughout the world, at the beginning of the cur- j of medicine. All that was said in commendation rent year. It states in comprehensive but concise t of the getting up of the first edition, and the superior diction, the facts established by experiment, or style of the illustrations apply with equal force to other method of demonstration, and details, in an this. No better work on physiology can be placed understandable manner, how it is done, but abstains in the hand of the student.—St. Louis Medical and from thediscussion of unsettled or theoretical puints. ' Surgical Journal, May, 1861. Herein it is unique; and these characteristics ren j Thege additions, while tes .ifying to the learning der it a text-book without a rival, for those who ! and mdu8try of the author, render the book exceed- desire to study physiological science as it is known | ingly U8eful as the moBt cornplete expose of a sei- to its most successful cultivators. And it isphysi-■ , en°ce of which Dr. Dal ton is doubtless the ablest ology thus presented that lies at the foundation of representative on this side of the Atlantic—New correct pathological knowledge; and this in turn is , Orleans Med Times, May, 1861. the basis of rational therapeutics; so that path >lo- i ' . ' gy, in fact, becomes of prime importance in the I. A second edition of this deservedly popular work proper discharge of our every-day practical duties, having been called for in the short space of two —Cincinnati Lancet, May, 1861. years, the author has supplied deficiencies, which existed in the former volume, and has thus more Dr. Dalton needs no word of praise from us. He ' completely fulfilled his design of presenting to the is universally recognized as among the first, if not profession a reliable and precise text- book, and one the very first, of American physiologists now living, which we consider the best outline on the subject The first edition of hi.-admirable work appeared but of which it treats, in any language__N. American two years since, and the advance of science, his Medico-Chirurg. Review, May, 1861. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. &c. In four large super-royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound, with raised bands. $14 00. *** This work contains no less than four hundred and eighteen distinct treatises, contributed by ■ixty-eight distinguished physicians, rendering it a complete library of reference for the country practitioner. The most complete work on Practical Medicine •xtant; or, at feaBt, in our language.—Buffalo Medical and Surgical Journal. For reference, it is above all price to every prac- titioner .—Western Lancet. One of the most valuable medical publications of the day—as a work of reference it is invaluable.— Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a work for ready and frequent reference, one in which modern English medicine is exhibited in the most | their own doctrines with high and just authority.— advantageous light.—Medical Examiner. I American Medical Journal. The editors are practitioners of established repu- tation, and the list of contributors embraces many of the most eminent professors and teachers of Lon- don, Edinburgh, Dublin, and Glasgow. It is, in- deed, the great merit ot this work that the principal articles have been furnished by practitioners who have not only devoted especial attention to the dis eases about which they have written, but have also enjoyed opportunitiet for an extensive practi- cal acquaintance with them and whose reputation carries the assurance of their competency justly to appreciate the opinions oi others, while it stamps DEWEES'S COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occasional cases and many engravings. Twelfth edition, with the author's laBt improvements and corrections In oneoctavovolume, extra cloth, of 600 pages $3 50. DEWEES'S TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILD REN. The last edition. In one volume, octavo, extra cloth, S48 pages. $2 80 DEWEES'S TREATISE ON THE DISEASES OF FEMALES. Tenth edition. In one volume, octavo extra cloth, 532 pages, with plates. $3 00. 12 BLANCHARD & LEA'S MEDICAL DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. ENLARGED AND REVISED EDITION OF 1865—(Just Ready.) MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, and Den- tistry. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of the Terms, and the French and other Synonymes; so as to constitute a French as well as English Medical Lexicon. Thoroughly revised and very greatly modified and augmented. In one very large and handsome royal octavo volume, of 1048 doubl*»-oolumned pages, in small type; strongly done up in extra cloth, $©' 00; leather, raised bands, f 6 75 Preface to the New Edition. " The author has again been required to subject his Medical Lexicon to a thorough revision. The progress of Medical Science, and the consequent introduction of new subjects and terms, demanded this; and he has embraced the occasion to render more complete the etymology and accentuation of th« terms. On no previous revision has so much time and labor been expended by him. Some idea may be formed of this, from the fact, that although the page has been augmented in all its dimensions, not fewer than betw< en sixty and seventy pages have been added. "As the author has remarked on former occasions, it has ever been his ardent wi»h to make the work a satisfactory and desirable—if not indispensable—lexicon, in which the inquirer may search, without disappointment, for every term that has been legitimated in the nomenclature of the science; and he confidently presents this edition as having more, claims on the attention of the practitioner and student than its predecessors. "Once more the author gladly seizes the opportunity afforded him to express his grateful acknow- ledgments for the vast amount of favor which has been extended to the Dictionary." January, lbbS. The object of the author from theoutset has not been to make the work a mere lexicon or dic- tionary of terms, but to afford, under each a condensed view of its various medical relations, and thus to render the work an epitome of the existing condition of medical science. Starting with this view, the immense demand whicn has existed for the work has enabled him, in repeated re- visions, to augment its completeness and usefulness, until at length it has attained the position of a recognized and standard authority wherever the language is spoken. This has only been accom- plished by the earnest determination to bring each successive edition thoroughly on a level with the most advanced condition of contemporary medical science, and on no previous occasion has this demanded a more patient and laborious effort than in rendering the present edition fully equal to the wants of the student of the present day, and in no previous editions has the amount of • ew matter introduced been so large. While, therefore, ihe reader who merely desire* a vocabulary explaining the terms in common use can safsfy himself with the smaller works, such as Hoblyn's, the student and practi'ioner who wish a work to which they can at all times refer with unfailing confidence for all which it is the province of such a book to supply, must still, as heretofore, keep the latest edition of " Dunglison's Dictionary" within reach. The mechanical execution of this edition will be found greatly superior to that of previous im- pressions. By enlarging the size of the volume to a rnya] octavo, and by the employment of a small but clear type on extra fine paper, the additions have been incorporated without materially increas- ing the bulk of the volume, and the matter of two or three ordinary octavos has been compressed into the space of one not unhandy for consultation and reference. A few notices of the previous edition are subjoined. This work, the appearance of the fifteenth edition of which it has become our duty and pleasure to announce, is perhaps the most stupendous monument of labor and erudition in medica! literature. One would hardly suppose after constant use of the pre ceding editions, where we have never failed to find a sufficiently full explanation of ever) medical term, that in this edition "about six thousand subjects and terms have been added," with a careful revision and correction of the entire work. It is only neces- sary to announce the advent of this edition to make it occupy the place of the preceding one on the table of every medical man, as it is without doubt the best and most comprehensive work of the kind which has ever appeared.—Buffalo Med.Journ., Jan. 1858. The work is a monument of patient research. skilful judgment, and vast physical labor, that will perpetuate the name of the author more effectually than any possible device of stone or metal. Dr. Dunglison deserves the thanks not only of the Ame- rican profession, but of the whole medical world.__ North Am. Medico-Chir. Review, Jan. 1858. A Medical Dictionary better adapted for the wants of the profession than any other with which we are acquainted, and of a character which places it far above comparison and competition.—Am. Journ. Med. Sciences, Jan. 1858. We need only say, that the addition of 6,000 new terms, with their accompanying definitions, may be said to constitute a new work, by itself. We have examined the Dictionary attentively, and are most author, and have furnished us with a volume indis- pensable at the present day, to all who would find themselves au niveau with the highest standards of medical information.—Boston Medical and Surgical Tournal, Dec. 31, 1857. Good lexicons and encyclopedic works generally, ire the most labor-saving contrivances which lite- rary men enjoy; and the labor which is required to produce them in the perfect manner of this example s something appalling to contemplate. The author tells us in his preface that he nas added about six thousand terms and subjects to this edition, which, before, was considered universally as the best work of the kind in any language— Silliman's Journal, March, 1858. A complete and thorough exponent of medical terminology, without rival or possibility of rivalry. —Nashville Journ. of Med. and Surg., Jan. 1858. It is universally acknowledged, we believe, that this work is incomparably the best and most com- plete Medical Lexicon m the English language. Comment and commendation are unnecessary, as no one at the present day thinks of purchasing any other Medical Dictionary than this.—St. Louis Med. and Surg. Journ., Jan 1858. It is the foundation stone of a good medical libra- ry, and should always be included in the first list of books purchased by the medical student.—Am. Med. Monthly, Jan. 1858. It is scarcely necessary to remark that any raedi- happy to pronounce it unrivalled of its kind. The | cal library wanting a copy of Dunglison's Lexicon erudition displayed, and the extraordinary industry I mu8t be imperfect.—Cin. Lancet, Jan. 1858. which must have been demanded, in its preparation Thepresentedition we may safely say has no equal and perfection, redound to the lasting credit of its I in the world.-Pentnsufar Med. Journal, Jul. 1858. AND SCIENTIFIC PUBLICATIONS. 13 DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and exten- sively modified and enlarged, with five hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes, extra cloth, of about 1500 pages. $7 00. In revising this work for its eighth appearance, the author has spared no labor to render it worthy a continuance of the very great favor which has been extended to it by the profession. The whole contents have been rearranged, and to a great extent remodelled; the investigations which of late years have been so numerous and so important, have been carefully examined and incorporated, and the work in every respect has been brought up to a level with the present state of the subject. The object of the author has been to render it a concise but comprehensive treatise, containing the whole body of physiological science, to which the student and man of science can at all times refer with the certainty of finding whatever they are in search of, fully presented in all its aspects; and on no former edition has the author bestowed more labor to secure this result. We believe that it can truly be said, no more com- plete repertory of facts upon the subject treated, can anywhere be found. The author has, moreover, that enviable tact at description and that facility and ease of expression which render him peculiarly acceptable to the casual, or the studiaus reader. This faculty, so requisite in setting forth many graver and less attractive subjects, lends additional charms to one always fascinating.—Boston Med. and Surg. Journal. The most complete and satisfactory system of Physiology in the English language.—Amer. Med Journal. The best work of the kind in the English lan- guage.—Silliman's Journal. The present edition the author has made a perfect mirror of the science as it is at the present hour. As a work upon physiology proper, the science of the functions performed by the body, the student will find it all he wishes.—Nashville Journ. of Med. That he has succeeded, most admirably succeeded in his purpose, is apparent from the appearance of an eighth edition. It is now the great encyclopaedia on the subject, and worthy of a place in every phy- sician's library.—Western Lancet. BY the same author. (A new edition.) GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a Medical Text-book. With Indexes of Remedies and of Diseases and their Remedies. Sixth Edition, revised and improved. With one hundred and ninety-three illustrations. In two large and handsomely printed octavo vols., extra cloth, of about 1100 pages. $6 50. The work will, we have little doubt, be bought and read by the majority of medical students; its size, arrangement, and reliability recommend it to all; no one, we venture to predict, will study it without profit, and there are few to whom it will not be in some measure useful as a work of refer- ence. The young practitioner, more especially, will find the copious indexes appended to this edition of great assistance in the selection and preparation of suitable formula;.—Charleston Med. Journ. and Re- view, Jan. 1858. In announcing a new edition of Dr. Dunglison's General Therapeutics and Materia Medica, we have no words of commendation to bestow upon a work whose merits have been heretofore so often and so justly extolled. It must not be supposed, however, that the present is a mere reprint of the previous edition: the character of the author for laborious research, judicious analysis, and clearness of ex- pression, is fully sustained by the numerous addi- tions he has made to the work, and the careful re- vision to which he has subjected the whole.—N. A. Medico-Chir. Review, Jan. 1858. by the same author. (A new Edition.) NEW REMEDIES, WITH FORMULA FOR THEIR PREPARATION AND ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo volume, extra cloth, of 770 pages. $4 CO. One of the most useful of the author's works.— Southern Medical and Surgical Journal. This elaborate and useful volume should be found in every medical library, for as a book of re- ference, for physicians, it is unsurpassed by any other work in existence, and the double index for diseases and for remedies, will be found greatly to •nhanceits value.—New York Med. Gazette. The great learning of the author, and his remark- able industry in pushing his researches into every source whence information is derivable,have enabled him to throw together an extensive mass of facts and statements, accompanied by full reference to authorities; which last feature renders the work practically valuable to investigators who desire to examine the original papers.—The American Journal of Pharmacy. ELLIS (BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions, derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Eleventh edition, carefully revised and much extended by Robert P. Thomas, M. D., Professor of Materia Me- dica in the Philadelphia College of Pharmacy. In one volume, 8vo., of about350 pages. $2 75. (Just Issued.) On no previous edition of this work has there been so complete and thorough a revision The extensive changes in the new United Stales Pharmacopoeia have necessitated corresponding alter- ations in the Formulary, to conform to that national standard, while the progress made in the materia medica and the arts of prescribing and dispensing during the last ten years have been care- fully noted and incorporated throughout. It i< therefore presented as not only worthy a continuance of the lavor so long enjoyed, but as more valuable than ever to the practitioner and pharmaceutist. Those who possess previous editions will find the additional matter of sufficient importance to warrant their adding the present to their libraries. 14 BLANCHARD & LEA'S MEDICAL ERICHSEN (JOHN), Professor of Surgery in University College, London, dec. THE SCIENCE AND ART OF SURGERY; being a Treatise on Stjrgioai Injuries, Diseases, and Operations. New and improved American, from the second enlarged and carefully revised London edition. Illustrated with over four hundred engravings on wood. In one large and handsome octavo volume," of one thousand closely printed pages, extra cloth, J6 00. The very distinguished favor with which this work has been received on both sides of the Atlan- tic has stimulated the author to render it even more worthy of the position which it has so rapidly attained as a standard authority. Every portion has been carefully revised, numerous additions have been made, and the most watchful care has been exercised to render it a complete exponent of the most advanced condition of surgical science. In this manner the work has been enlarged by about a hundred pages, while the series of engravings has been increased by more than a hundred, rendering it one of the most thoroughly illustrated volumes before the profession. The additions of the author having rendered unnecessary most of the notes of the former American editor, but little has been added in this country; some few notes and occasional illustrations have, however, been introduced to elucidate American modes of practice. It is, in our humble judgment, decidedly the best «iep of the operation, and not deserting him until the book of the kind in the English language. Strange j final issue of the case is decided.—Scthoscopt. that just such books are notbftener produced by pub tic teachers of surgery in this country and Great Britain Indeed, it is a matter of great astonishment but no less true than astonishing, that of the many works on surgery republished in this country within the last fifteen or twenty years as text-books for medical students, this is the only one that even ap- proximates to the fulfilment of the peculiar wants of youngmen just entering upon the study ofthisbranch ofthe profession.— Western Jour of Med. an ' Surgery. Its value is greatly enhanced by a very copious Embracing, as will be perceived, the whole surgi- cal domain, and each division of itself almost com- plete and perfect,each chapterfull and explicit, each subject faithfully exhibited, we can only express out estimate of it in the aggregate. We consider it an excellent contribution to surgery, as probably the best single volume now extant on the subject, and with great pleasure we add it to our text-books.— Nashville Journal of Medicine and Surgery. Prof. Enchsen's work, for its size, has not been urpassed; his nine hundred and eight pages, pro- well-arranged index. We regard this as one of the fusely illustrated, are rich in physiological, patholo- most valuable contributions to modern surgery. To i gical, and operative suggestions, doctrines, details, one entering his novitiate of practice, we regard ii j and processes; and will prove a reliable resource the mosi serviceable guide which he can consult. He for information, both to physician and surgeon, in the will find a fulness of detailleadinghim through every ' hour of peril.-— N. 0. Med. and Surg. Journal. FLINT (AUSTIN), M. D., Professor of the Principles and Practice of Medicine in BelWue Hosp. Med. College, New York. PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT- ING THE RESPIRATORY ORGANS. In one large and handsome octavo volume, extra cloth, 636 pages. $4 00. by the same author. (Now Ready.) A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. In one neat octavo volume, of about 500 pages, extra cloth. $3 25. We do not know that Dr. Flint has written any- thing which is not first rate; but this, his latest con- tribution to medical literature, in our opinion, sur- passes all the others. The work is most comprehen- sive in its scope, and most sound in the views it enun- ciates. The descriptions are clear and methodical; the statements are substantiated by facts, and are made with such simplicity and sincerity, that with- out them they would carry conviction. The style is admirably clear, direct, and free from dryness, With Dr. Walshe's excellent treatise before us, we have no hesitation in saying that Dr. Flint's book is the best work on the heart in the English language. —Boston Med. and Surg. Journal. FOWNES (GEORGE), PH. D., Sic. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. With one hundred and ninety-seven illustrations. Edited by Robert Bridges, M. D. In one large royal 12mo. volume, of 600 pages, extra cloth, $2 00. The death of the author having placed the editorial care of this work in the practised hands of Drs. Bence Jones and A. W. Hoffman, everything has been done in its revision which experience could suggest to keep it on a level with the rapid advance of chemical science. The additions requisite to this purpose have necessitated an enlargement of the page, notwithstanding which the work has been increased by about fifty pages. At the same time every care has been used to maintain its distinctive character as a condensed manual for the student, divested of all unnecessary detail or mere theoretical speculation. The additions have, of course, been mainly in the depart- ment of Organic Chemistry, which has made such rapid progress within the last few years, but yet equal attention has been bestowed on the other branches of the subject—Chemical Physics and Inorganic Chemistry—to present all investigations and discoveries of importance, and to keep up the reputation ofthe volume as a complete manual ofthe whole science, admirably adapted for the learner. By the use of a small but exceedingly clear type the matter of a large octavo is compressed within the convenient and portable limits of a moderate sized duodecimo, and at the very low price affixed, it is offered as one of the cheapest volumes before the profession. Dr. Fownes'excellent woTk has been universally The work of Dr. Fownes haB long been before recognized everywhere in his own and thisnountry, the public, and its merits have been fully appreci- as the best elementary treatise on chemistry in the ated as the best text-book on chemistry now in English tongue, and is very generally adopted, we existence. We do not, of course, place it in a rank believe, as the standard text- book in allcur colleges, superior to the works of Brande, Graham, Turner, both literary and scientific—Charleston Med. Journ. Gregory, or Gmelin, but we say that, as a work and Review for students, it is preferable to any of them.—Lon- don Journal of Medicine. AND SCIENTIFIC PUBLICATIONS. 15 FISKE FUND PRIZE ESSAYS —THE EF- FECTS OF CLIMATE ON TUBERCULOUS DISEASE. By Edwin Lbe, M.R.C.S , London, and THE INFLUENCE OF PREGNANCY ON THE DEVELOPMENT OF TUBERCLES By Edward Wakren, M. D , of Edenton, N. C. To- gether in one neat 8vo volume, extra cloth. *1 00. FRICK ON RENAL AFFECTIONS; their Diag- nnsis and Pathology. With illustrations. One volume, royal 12ino., extra cloth. 75 cents. FERGUSSON (WILLIAM), F. R. S., Professor of Surgery in King's College, London, Sec. A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third and enlarged London edition. In one large and beautifully printed octavo volume, of about 700 pages, with 393 handsome illustrations, leather. $3 50. GRAHAM (THOMAS), F. R. S. THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applica- tions ofthe Science in the Arts. New and much enlarged edition, by Henry Watts and Robert Bridges, M. D. Complete in one large and handsome octavo volume, of over 800 very large pages, with two hundred and thirty-two wood-cuts, extra cloth. $5 00. **# Part II., completing the work from p. 431 to end, with Index, Title Matter, &c, may be bad separate, cloth backs and paper sides. Price $3 00. , From Prof. E. N. Horsford, Harvard College. i afford to be without this edition of Prof. Graham's It has, in its earlier and less perfect editions, been Elements.—Silliman's Journal, March, 1858. familiar to me, and the excellence of its plan and j From Prof. Wolcott Gibbs, N. Y. Free Academy h^Whe^rnvSratZ88 °f ^ diSCU8si0n8' The work is an admirable one in all respects, and have long been my admiration. | itg republication here cannot fail to exert a positive No reader of English works on this science can , influence upon the progress of science in this country. GRIFFITH (ROBERT E.), M. D., &c. A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- ministering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceu- tists. Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and handsome octavo volume, extra cloth, of 650 pages, double columns. $3 75. It was a work requiring much perseverance, and ] This is a work of six hundred and fifty-one paees when published was looked upon as by far the best work of its kind that had issued from the American press. Prof Thomas has certainly "improved." as well as added to this Formulary, and has rendered it additionally deserving of the confidence of pharma- ceutists and physicians.—Am. Journal of Pharmacy VVe are happy to announce a new and improved edition of this, one ofthe most valuable and useful works that have emanated from an American pen. It would do credit to any country, and will be found of daily usefulness to practitioners of medicine; it is better adapted to their purposes than the dispensato- ries.—Southern Med. and Surg. Journal. It is one ofthe most useful books a country practi- tioner can possibly have.—Medical Chronicle. unbracing all on the subject of preparing and admi-i nistermg medicines that can be desired by the physi- cian and pharmaceutist.— Western Lancet. The amountof useful,every-day matter,for a prac- ticing physician, is really immense.—Boston Med and Surg. Journal. This edition has been greatly improved by the re- vision and ample additions of Dr Thomas, and is now, we believe, one of the most complete works of its kind in any language. The additions amount to about seventy pages, and no effort has been spared to include in them all the recent improvements. A work of this kind appears to us indispensable to the physician, and there is none we can more cordially recommend.—IV. Y. Journal of Medicine. GROSS (SAMUEL D.), M. D. ' Professor of Surgery in the Jefferson Medical College of Philadelphia, &c. ELEMENTS OF PATHOLOGICAL ANATOMY. 'Third edition, thoroughly revised and greatly improved. In one large and very handsome octavo volume, with about three hundred and fifty beautiful illustrations, of which a large number are from original drawings, extra cloth. $4 00. The very rapid advances in the Science of Pathological Anatomy during the last few years have rendered essential a thorough modification of this work, with a view of making it a correct expo- nent of the present state ofthe subject. The very careful manner in which this task has been executed, and the amount of alteration which it has undergone, have enabled the author to say that " with the many changes and improvements now introduced, the work may be regarded almost as a new treatise," while the efforts of the author have been seconded as regards the mechanical execution of the volume, rendering it one of the handsomest productions of the American press. BY THE SAME AUTHOR A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE G-LAND, AND THE URETHRA. Second Edition, revised and much enlarged, with one hundred and eighty- four illustrations. In one large and very handsome octavo volume, of over nine hundred pages, extra cloth, $4 00. Philosophical in its design, methodical in its ar-1 agree with us, that there is no work in the English rangement,ample and sound in its practical details,, language which can make any just pretensions to it mayin truth be said to leave scarcely anything to be its equal.—N. Y. Journal of Medicine. be desired on so important a subject— Boston Med. A voiume replete with truths and principles ofthe iitmost value in the investigation of these diseases.— and Surg Journal Whoever will peruse the vast amount of valuable practical information it contains, will, we think, American Medical Journal. 16 BLANCHARD & LEA'S MEDICAL GROSS (SAMUEL D.), M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia, &o. Enlarged Edition. Now Beady. A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Opera- tive. Illustrated by over Thirteen Hundred Engravings. Third edition, much enlarged and carefully revised In two large and beautifully printed royal octavo volumes, of 2200 pages; leather. $15 00. (Now Ready.) The exhaustion within five years of two large editions of so elaborate and comprehensive a work as this is the best evidence that the author wa« not mistaken in his estimate of the want which existed of a complete American System of Surgery, presenting the science in all its necessary details and in all its branches. That he has succeeded in the attempt to supply this want is shown not only by the rapid sale ofthe work, but also by the very favorable manner in which it has been received by the organs ofthe profession in this country and in Europe, and by the fact that a tran>lation is now preparing in Holland—a mark of appreciation not often bestowed on any scien- tific work so extended in size. The author has not been insensible to the kindness thus bestowed upon his labors, and in revising the work for a third edition he has spared no pains to render it worthy of the favor with which it has been received. Every portion has been subjected to close examination and revision; any defi- ciencies apparent have been supplied, and the results of recent progress in the science and art ol surgery have been everywhere introduced; while the series of illustrations has been still further enlarged, rendering it one of the most thoroughly illustrated works ever laid before the profession. To accommodate these very extensive additions, the form of the work has been altered to a royal octavo, so that notwithstanding the increase in the mattei and value ofthe book, its size wi.l be found more convenient than before. Every care has been taken in the printing to render the typographical execution unexceptionable, and it is confidently expected to prove a work in every way worthy of a place in even the most limited library of the practitioner or student. Has Dr. Gross satisfactorily fulfilled this object? A careful perusal of his volumes enables us to give an answer in the affirmative. Not only has he given to the reader an elaborate and well-written account of his oivn vast experience, but he has not failed to embody in his pages the opinions and practice of Burgeons in this and other countries of Europe. The result has been a work of such completeness, that it has no superior in the systematic treatises on sur- gery which have emanated from English or Conti- nental authors. It has been justly objected that these have been far from complete in many essential particulars, many of them having been deficient in i thankful to him for hfs extraordinary labors in our confess we were by no means prepared for the work which is before us—the most complete treatise upon surgery ever published, either in this or any other country, and we might, perhaps, safely say, the most original. There is no subject belonging pro- perly to surgery which has not received from the author a due share of attention. Dr. Grots has sup- plied a want in surgical literature which has long been felt by practitioners; he has furnished us with a complete practical treatise upon surgery in all its departments. As Americans, we are proud ofthe achievement; as surgeons, we are most sincerely behalf.—N. Y. Review and Buffalo Med Journal. The great merit of the work may be stated as follows. It presents surgical science as it exists at the latest date, with all its improvements ; and it discusses every topic in due proportion. No- thing is omitted, nothing is in excess.—Chicago Med. Examiner, May, 1860. We cannot close this brief notice of Dr. Gross's most valuable and excellent compendium of Sur- gery without again drawing attention to it, as we did in our notice of his first edition, as an evidence of the progress our American brethren are making towards establishing a literature of their own.— Dublin Quarterly Journal, Feb. 1863. It has been characterized by the representative press and by individual surgeons of the highest eminence, both at home and abroad, as " the btst systematic work on surgery ever published in the English language;" and that the profession at large have given substantial proofs of their agree- ment to this verdict, is sufficiently evident from the fact that translations into European languages have been called for, and that so shortly after its first appearance, and at a time most unfavorable to literary "enterprise," the Philadelphia publishers have found it pay to issue a " second edition, much enlarged and carefully revised."—American Med. Monthly, May, 1862 We are much gratified to be able to announce a new edition of this Cyclopaedia of Surgtry. Con- sidering the large size of the work and its expen- siveness, the extremely rapid sale and exhaustion of an entire edition, not only proves the value of the work, and its adaptation to the wants of the profession, but it speaks well for the intelligence of American surgeons.—American Medical Times, May, 1862. A valuable and even necpssary addition to every surgical library.—Chicago Med. Journ., Dec. 1859. A system of surgery which we think unrivalled in our language.—British American Journal. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PAS- SAGES. In one handsome octavo volume, extra cloth, with illustrations, pp. 468. 92 75. s >me of the most important points which should characterize such works Some of them have been elaborate—too elaborate—with respect to certain diseases, while they have merely glanced at, or given an unsatisfactory account of, others equally important to the surgeon. Dr. Gross has avoided this error, and has produced the most complete work that has yet issued from the press on the science and practice of surgery. It is not, strictly speaking, a Dictionary of Surgery, but it gives to the reader all the information that he may require for his treatment of surgical diseases. Having said so much, it might appear superfluous to add another word; but it is only due to Dr. Gross to state that he has embraced the opportunity of transferring to his pages a vast number of engravings from English and other au- thors, illustrative ot the pathology and treatment of surgical diseases. To these arc added several hun- dred original wood-cuts. The work altogether com- mends itself to the attention of British surgeons, from whom it cannot fail to meet with extensive patronage.—London Lancet, Sept. 1,1860. Of Dr. Gross's treatise on Surgery we can say no more than that it is the most elaborate and com- plete work on this branch of the healing art which has ever been published in any country. A sys- tematic work, it admits of no analytical review; but, did our space permit, we should gladly give some extracts from it, to enable our readers to judge ofthe classical style ofthe author, and the exhaust- ing way in which each subject is treated.—Dublin Quarterly Journal of Med. Science. The work is so superior to its predecessors in matter and extent, as well as in illustrations and style of publication, that we can honestly recom- mend it as the best work of the kind to be taken home by the young practitioner.—Am. Med. Journ. With pleasure we record the completion of this long-anticipated work. The reputation which the author has for many years sustained, both as a sur- geon and us a writer, had prepared us to expect a treatise of great excellence and originality; but we AND SCIENTIFIC PUBLICATIONS. 17 GRAY (HENRY), F. R. S., Lecturer on Anatomy at St. George's Hospital, London, Sco. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. Carter, M. 1)., late Demonstrator on Anatomy at St. George's Hospital; the Dissections jointly by the Author and Dr. Carter. Second American, from the second revised and improved London edition. In one magnificent imperial octavo volume, of over 800 pages, with 388 large and elaborute engravings on wood. Price in extra cloth, $7 00; leather, raised bands, $8 00. The speedy exhaustion of a large edition of this work is sufficient evidence that its plan and exe- cution have been found to prestnt superior practical advantages in facilitating the study of Anato- my. In presenting it to the profession a second time, the author has availed himself of the oppor- tunity to supply any deficiencies which experience in its use had shown to exist, and to correct any errors of detail, to which the first ediiion of a scienlific work on so extensive and complicated a science is liable. These improvements have resulted in some increase in the size ofthe volume, while twenty-six new wood-cuts have been added to the beautiful series of illustrations which form so distinctive a feature of the work. The American edition has been passed through the press under the supervision of a competent professional man, who has taken every care to render it in all respects accurate, and it is now presented, without any increase of price, as fitted to maintain and extend the popularity which it has everywhere acquired. work of Mr. Gray to the attention of the medical profession, feeling certain that it should be regarded as one of the most valuable contributions ever made With little trouble, the busy practitioner whose knowledge of anatomy may have become obscured by want of practice, may now resuscitate his former anatomical lore, and be ready for any emergency. It is to this class of individuals, and not to the stu- dent alone, that this work will ultimately tend to be of most incalculable advantage, and we feel sat- isfied that the library ofthe medical man will soon be considered incomplete in which a copy of this work does not exist.— Madras Quarterly Journal of Med. Science, July, 1861. This edition is much improved and enlarged, and contains several new illustrations by Dr. Westma- cott. The volume is a complete companion to the dissecting-room, and saves the necessity of the stu dent possessing a variety of " Manuals."—The Lon- don Lancet, Feb. 9, 1861. to educational literature.—N. Y. Monthly Review. Dec.1859. In this view, we regard the work of Mr. Gray as far better adapted to the wants of the profession, and especially of the student, than any treatise on tnatomy yet published in this country. 11 is destined, we believe, to supersede all others, both as a manual of dissections, and a standard of reference to the student of general or relative anatomy. — N. Y. Journal of Medicine, Nov. 1859. In our judgment, the mode of illustration adopted in the present volume cannot but present many ad- vantages to the studentof anatomy. To the zealous The work before us is one entitled to the highest i disciple of Vesalius, earnestly desirous of real im- praise, ind we accordingly welcome it as a valu able addition to medical literature. Intermediate in fulness of detail between the treatises of S.iar- pey and of Wilson, its characteristic merit lies in the number and excellence of the engravings it contains. Most of these are original, of much larger than ordmary size, and admirably executed. The various parts are also lettered after the plan adopted in Holden's Osteology. It would be diffi- cult to over-estimate the advantages offered by this mode of pictorial illustration. Bones, ligaments, muscles, bloodvessels, and nerves are each in turn provement, the book will certainly be of immense value; but, at the same time, we must also confess that to those simply desirous of "cramming" it will be an undoubted godsend. The peculiar value of Mr. Gray's mode of illustration is nowhere more markedly evident than in the chapter on osteology, and especially in those portions which treat of the bones of the head and of their development. The study of these parts is thus made one of comparative ease, if not of positive pleasure: and those bugbears ofthe student, the temporal and sphenoid bones, are shorn of half their terrors. It is, in our estimation, figured, and marked with their appropriate names; ' an admirable and complete text-book for the student, thusenablingthestudenttocomprehend,ataglance, | and a useful work of- reference for the practitioner; what would otherwise often be ignored, or at any its pictorial character forming a novel element, to rate, acquired only by prolonged and irksome ap- | which we have already sufficiently alluded.—Am. plication. In conclusion, we heartily commend the i Journ. Med. Sci., July, 1859. GIBSON'S INSTITUTES AND PRACTICE OF SURGERY. Eighth edition, improved and al- tered. With thirty-four plates. In twohandsome octavo volumes, containing about 1,000 pages, leather, raised bandi. $6 50. GARDNER'S MEDICAL CHEMISTRY, for the use of Students and the Profession. In one royal 12mo. vol., cloth, pp. 396, with wood-cuts. 81. GLUGE'S ATLAS OF PATHOLOGICAL HIS- TOLOGY Translated, with Notes and Addi- tions, by Joseph Leidy, M. D. In one volume. very large imperial quarto, extra cloth, with 320 copper-plate figures, plain and eolored, $4 00. HUGHES' INTRODUCTION TO THE PRAC- TICE OF AUSCULTATION AND OTHER MODES OF PHYSICAL DIAGNOSIS. IN DIS- EASES OF THE LUNGS AND HEART. Se- cond edition 1 vol. royal 12mo., ex. cloth, pp. 304 SI 00. HOLLAND'S MEDICAL NOTES AND RE- FLECTIONS. From the third London edition. In one handsome octavo volume, extra cloth. 83 50. HORNER'S SPECIAL ANATOMY AND HIS- TOLOGY. Eighth edition. Extensively revised and modified. In two large octavo volumes, ex- tra cloth, of more than 1000pages, with over 30i illustrations. $6 00. HILLIER (THOMAS), M. D., Physician to the Skin Department of University College Hospital; Physician to the Hospital for Sick Children, &c. &c. HAND-ROOK OF SKIN DISEASES, FOR STUDENTS AND PRACTI- TiONERS. In one neat royal 12mo. volume, of about 300 pages, with two plates; extra cloth, price $2 #>. From the Author's Preface. " My object has been to furnish to students and practitioners a trustworthy, practical, and com- pendious treatise, which shall comprise the greater part of what has long been known of cutaneous diseases, and of what has been more recently brought to light by English, French, and German dermatologists, as well as to embody the most important results of my own experience in reference to these diseases " The author's position both as a lecturer, writer, and practitioner in this department of medicine, is a guarantee of his ability to accomplish his object in presenting a condensed and convenient manual, which shall comprise all that the general practitioner requires for his guidance. A text book well adapted to the student, and the information contained in it shows the author to be au nneau with the scientific medijine of the day.— London Lancet, Feb. 25, 1865. 18 BLANCHARD & LEA'S MEDICAL HAMILTON (FRANK H.), M. D., Professor of Surgery in the Long Island College Hospital. A PRACTICAL TREATISE ON FRACTURES AND DISLOCATIONS. Second edition, revised and improved. In one large and handsome octavo volume, of over 750 pages, with nearly 300 illustrations, extra cloth, $5 00. (Just Ready, May, 1863.) The early demand for a new edition of this work shows that it has been successful in securing the confidence of the profession as a standard authority for consultation and reference on its import- ant and difficult subject. In again passing it through the press, the author has taken the opportu- nity to revise it carefully, and introduce whatever improvements have been suggested by further experience and observation. An additional chapter on Gun-shot Fractures will be found to adapt it still more fully to the exigencies ofthe time. Among the many good workers at surgery of whom America may now boast rot the least is Frank Hast- ings Hamilton; and the volume before us is(we say it with a pang of wounded patriotism) the best and handiest book on the subject in the English lan- guage. It is in vain to attempt a review of it; nearly as vain to seek for any sins, either of com When we say, however, that we believe it will at once take its place as the best book for consultation by the practitioner; and that it will form the most complete, available, and reliable guide in emergen- cies of every nature connected with its subjects; and also that the student of surgery may make it his text- book with entire confidence, and with pleasure also, mission or omission. We have seen no work on from itsagreeable and easy style—wethink our own practical surgery which we would sooner recom- Opinion may be gathered as to its value.—Boston mend to our brother surgeons, especially those of Medical and Surgical Journal, March 1, 1860. '' the services," it those whose practice lies in dig- tj,c WOrk is concise, judicious, and accurate, and tricts where a man has necessarily to rely on his adapted to the wants of the student, practitioner, own unaided resources. The practitioner will find and investigator, honorable to the author and to the in it directions for nearly every possible accident, easily found and comprehended ; and much pleasant reading for him to muse over in the after considera- tion of his cases.—Edinburgh Med. Journ. Feb. 1861. This is a valuable contribution to the surgery of most important affections, and is the more welcome, inasmuch as at the present time we do not possess a single complete treatise on Fractures and Dislo- cations in the English language. It has remained for profession.—Chicago Med. Journal, March, 1860. We regard this work as an honor not only to ita author, but to the profession of our country. Were we to review it thoroughly, we could not convey to the mind of the reader more forcibly our honest opinion expressed in thefew words—we think it the best book ot its kind extant. Every man interested in surgery will soon have this work on his desk. He who does not, will be the loser.—A^ew Orleans our American brother to produce a complete treatise j Medical News, March, 1860. upon the subject, and bring together in a convenient Dr Hamilton is fortunate in having succeeded in form those alterations and improvements that have fining the void, so long felt, with what cannot fail been made from time to time in the treatment of these ! t0 be at once accepted as a model monograph in some affections. One great and valuable feature in the ] respect8 and a work of classical authority. We work before us is the fact that it comprises all the BjnceTeiy congratulate the profession of the United Improvements introduced into the practice of both gtateg on the appearance of such a publication from English and American surgery, and though far from one of their number. We have reason to be proud omitting mention of our continental neighbors, the of it as an original work, both in a literary and sci- author by no means encourages the notion—but too entjgc pomt Qf view, and to esteem it as a valuable prevalent in some quarters—that nothing is good unless imported from France or Germany. The latter half of the work is devoted to the considera- tion of the various dislocations and their appropri- ate treatment, and its merit is fully equal to that of the preceding portion.—The London Lancet, May 5, | wiVeVy known at homeas anauthontative teacher I860. • from which every one may profitably learn, and as It is emphatically the book upon the subjects of j affording an example of honest, well-directed, and which it treats, and we cannot doubt that it will i untiring industry in authorship which every surgeon continue so to be for an indefinite period of time. [ may emulate.- Am. Med. Journal, April, 1860. guide in a most difficult and important branch of study and practice. On every account, therefore. we hope that it may soon be widely known abroad as an evidence of genuine progress on this side of the Atlantic, and further, that it may be still more HODGE (HUGH L.), M. D., Professor of Midwifery and the Diseases of Women and Children in the University of Pennsylvania, &C. ON DISEASES PECULIAR TO WOMEN, including Displacements of the Uterus. With original illustrations. In one beautifully printed octavo volume, of nearly 500 ' pages, extra cloth. $3£)0. We will say at once that trie work fulfils its object capitally well j and we will moreover venture the assertion that it will inaugurate an imnroved prac- tice throughout this whole country. The secrets of the author's success are so clearly revealed that the attentive student cannot fail to insure a goodly por- tion of similar success in his own practice. It is a credit to all medical literature; and we add, that the physician who does not place it in his library, and who does not faithfully con its pages, will lose a vast deal of knowledge that would be most useful to himself and beneficial to his patients. It is a practical work of the highest order of merit; and it will take rank as such immediately.—Maryland and Virginia Medical Journal^ Feb. 1661. This contribution towards the elucidation ofthe pathology and treatment of some of the diseases peculiar to women, cannot fail to meet with a favor able reception from the medical profession. The character of the particular maladies of which the work before us treats; their frequency, variety,and obscurity: the amount of malaise and even of actual suffering by which they are invariably attended; their obstinacy, the difficulty with which they are overcome, and their disposition again and again to recur—these, taken in connection with the entire competency of the author to render a correct ac- count of their nature, their causes, and their appro- priate management—his ample experience, his ma- tured judgment, and his perfect conscientiousness- invest this publication with an interest and value to which few of the medical treatises of a recent date can lay a stronger, if, perchance, an equal claim.— Am. Journ. Med. Sciences, Jan. 1861. Indeed, although no part of the volume isnotemi- nently deserving of perusal and study, we think that the nine chapters devoted to this subject, are espe- cially so, and we know of no more valuable mono- graph upon the symptoms, prognosis, and manage- ment of these annoying maladies than is constituted by this part of the work. We cannot but regard it as one ofthe most original and mist practical works of the day ; one which eyery accoucheur and physi- cian should most carefully reid; for we are per- suaded that he will arise from its perusal with new ideas, which will induct him into a more rational practice in regard to many a suffering female, who may have placed her health in his hands.—British American Journal, Feb. 1661. The illustrations, which are all original, are drawn to a uniform scale of one-half the natural size. AND SCIENTIFIC PUBLICATIONS 19 HODGE (HUGH L.), M. D., Late Professor of Midwifery, &c. in the University of I'ennsylvania. PRINCIPLES AND PRACTICE OF OBSTETRICS. In one large quarto volume of over 550 prges, with one hundred and fifty-eight figures on thirty two beautifully exe- cuted lithographic plates, and numerous wood-cuts in the text. $14 00. (Now Ready.) This work, embodying the results of an extensive practice for more than forty years, cannot fail to prove ofthe utmost value to all who are engaged in this department of medicine. The author's position as one ofthe highest authorities on the subject in this country is well known, and the fruit of his ripe experience and long observation, carefully matured and elaborated, must serve a< an invaluable text-book for the student and an unfailing counsel for the practitioner in the emergencies which so frequently arise in obstetric practice. The illustrations form a novel feature in the work. The lithographic plates are all original, and to insure their absolute accuracy they have all been copied from photographs taken expressly for the purpose. In ordinary obstetrical plates, the positrons of the fetus are represented by dia- gram* or sections of the patient, which are of course purely imaginary, and their correctness is scarcely more than a matter of chance with the artist. Their beauty as pictures is thereby increased without corresponding utility to the student, as in practice he must for the most part depend for his diagnosis upon the relative positions of the foetal skull and the pelvic bones of the mother. It is, therefore, desirable that the points upon which he is in future to rely, should form the basis of his instruction, and consequently in the preparation of these illustrations the skeleton has alone been used, and the aid of photography invoked, by which a series of representations has been secured of the strictest and most rigid accuracy. It is easy to recognize the value thus added to the very full details on the subject ofthe Mechanism of Labour with which the work abounds It may be added that no pains or expense have been spared to render the mechanical execution of the volume worthy in every respect ofthe character and value ofthe teachings it contains. HABERSHON (S. O.), M. D., Assistant Physician to and Lecturer on Materia Medica and Therapeutics at Guy's Hospital, &c. PATHOLOGICAL AND PRACTICAL OBSERVATIONS ON DISEASES OF THE ALIMENTARY CANAL, (ESOPHAGUS, STOMACH, CAECUM, AND INTES- TINES. With illustrations on wood. In one handsome octavo volume of 312 pages, extra cloth $2 25. HOBLYN (RICHARD D.), M. D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. A new American edition. Revised, with numerous Additions, by Isaac Hays, M. D., editor of the" American Journal ofthe Medical Sciences." In one large royal l2mo. volume, cloth, of over 500 double columned pages. $1 50. To both practitioner and student, we recommend use ; embracing every department of medical science this dictionary as being convenient in size, accurate down to the very latest date.—Western Lancet. in definition, and sufficiently full and complete for Hoblyn's Dictionary has long been afavontewith ordinary consultation.-CAaWes«o* Med. Journ. ug It'ig the best hoJok of de£nition8 we have, and We know of no dictionary better arranged and j ought always to be upon the student's table.— adapted. Itisnotencumbered with theobsoleteterms Southern Med. and Surg. Journal. of a bygone age, but it contains all that are now in I JONES (T. WHARTON), F. R. S., Professor of Ophthalmic Medicine and Surgery in University College, London, Sec. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY". With one hundred and seventeen illustrations. Third and revised Ameri- can, with additions from the second London edition. In one handsome octavo volume, extra cloth, of 455 pages. $3 00. Seven years having elapsed since the appearance of the last edition of this standard work, very considerable additions have been found necessary to adapt it thoroughly to the advance of ophthal- mic science. The introduction ofthe ophthalmoscope has resulted in adding greatly to our know- ledge ofthe pathology ofthe diseases ofthe eye, particularly of its more deeply seated tissues, and corresponding improvements in medical treatment and operative procedures have been introduced. All these matters the editor has endeavoured to add, bearing in mind the character of the volume as a condensed and practical manual. To accommodate this unavoidable increase in the size ofthe work, its form has been changed from a duodecimo to an octavo, and it is presented as worthy a continu- ance of the favour which has been bestowed on former editions. A complete series of "test-types" for examining the accommodating power of the eye, will be found an important and useful addition. JONES (C. HAND FIELD), F. R. S., &. EDWARD H. SIEVEKING, M.D., Assistant Physicians and Lecturers in St. Mary's Hospital, London. A MANUAL OF PATHOLOGICAL ANATOMY. First American Edition, Revised. With three hundred and ninety-seven handsome wood engravings. In one large and beautiful octavo volume of nearly 750 pages, extra cloth. $3 50. As a concise text-book, containing, in a condensed i obliged to glean from a great number of monographs. form, a complete outline of what is known in the i and the field was so extensive that but few cultivated domain of Pathological Anatomy, it is perhaps the | it with any degree of success. As a simple work best work in the English language. Its great merit ■ of reference, therefore, it is of great value to the consists in its completeness and brevity, and in this student of pathological anatomy, and should be in respect it supplies a great desideratum in our lite- I every physician's library.— Western Lancet. rature. Heretofore the student of pathology was | 20 BLANCHARD or LEA'S MEDICAL KIRKES (WILLIAM SENHOUSE), M.D., Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c. A MANUAL OF PHYSIOLOGY. improved London edition. With two hundred 12mo. volume, extra cloth, pp. 586. $2 00. This is a new and very much improved edition of Dr. Kirkes' well-known Handbook of Physiology. It combines conciseness with completeness, and is, therefore, admirably adapted for consultation by the busy practitioner.—Dublin Quarterly Journal. One of the very best handbooks of Physiology wt possess—presenting just such an outline of the sci- ence as the student requires during his attendance upon a course of lectures, oi for reference whilst preparing for examination.— Am. Medical Journal Its excellence is in its compactness, its clearness, A new American, from the third and illustrations. In one large and handsome royal and its carefully cited authorities. It is the most convenientoftext-books These gentlemen, Messrs. Kirkes and Paget, have the gift of telling us what we want to know, without thinking it necessary to tell us all they know.—Boston Med and Surg, Journal. For the student beginning this study, and the practitioner who has but leisure to refresh his memory, this book is invaluable, as it contains all that it is important to know.—Charleston Med. Journal. KNAPP'S TECHNOLOGY; or, Chemistry applied to the Arts and to Manufactures. Edited by Dr. Ronalds, Dr. Richabdson, and Prof. W. R. , Johnson. In twohandsonu8vo. vols , extra cloth, with about 500 wood- engravings. $6 00. LAYCOfK'S LECTURES ON THE PRINCf. PLES AND METHODS OF MEDICAL OB- SERVATION AND RESEARCH. For the Use of Advanced Students and Junior Practitioners. In one royal 12mo. volume, extra cloth. Price SI. LALLEMAND AND WILSON. A PRACTICAL TREATISE ON THE CAUSES, SYMPTOMS, AND TREATMENT OF SPERMATORRHOEA. By M. Lallemand. Translated and edited by Henry J McDotjgall Thir and for all that is commendable in a work on the diseases of females, it is not excelled, and pro- bably not equalled in the English language. On the whole, we know of no work on the diseases of wo- men which we can so cordially commend to the student and practitioner as the one before us.—Ohio Med. and Surg. Journal. The body of the book is worthy of attentive con- sideration, and is evidently the production of a clever, thoughtful, and sagacious physician. Dr. Meigs's letters on the diseases of the external or- gans, contain many interesting and rare cases, and many instructive observations. We take our leave of Dr. Meigs, with a high opinion of his talents and originality— The British and Foreign Medico-Chi rurgtcal Review. Every chapter is replete with practical instruc- tion, and bears the impress of being the composition of an acute and experienced mind. There is a terse- ness, and at the same time an accuracy in his de- scription of symptoms, and in the rules for diagnosis, It contains a vast amount of practical knowledge. oy one who has accurately observed and retained the experience of many years.—Dublin Quarterly Journal. Full of important matter, conveyed in a ready and agreeable manner.—St. Louis Med. and Surg. Jour. There is an off-band fervor, aglow, and a warm- heartedness infecting the eff>rt of Dr. Meigs, which is entirely captivating, and which absolutely hur- ries the reader through from beginning to end. Be- sides, the book teems with solid instruction, and it shows the very highest evidence of ability, viz., the clearness with which the information is pre- sented. We know of no better test of one's under- standing a subject than the evidence of the power of lucidly explaining it. The most elementary, as well as the obscurest subjects, under the pencil of Prof. Meigs, are isolated and made to stand out in such bold relief, as to produce distinct impressions upon the mind and memory ofthe reader. — The CharUston Med. Journal. 22 BLANCHARD & LEA'S MEDICAL MEIGS (CHARLES D.) M. D., Lately Professor of Obstetrics, Sec, in Jefferson Medical College, Philadelphia. ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome octavo volume, extra cloth, of 365 pages. $2 00. The instructive and interesting author of this work, whose previous labors have placed his coun- trymen under deep and abiding obligations, again challenges their admiration in the fresh and vigor- ous, attractive and racy pages before us. It is a de- lectable book. * * * This treatise upon child- bed fevers will have an extensive sale, being des- tined, as it deserves, to find a place in the library of every practitioner who scorns tolag in the rear.— Nashville Journal of Medicine and Surgery. WITH COLORED PLATES. A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK OF THE UTERUS. With numerous plates, drawn and colored from nature in the highegi style of art. In one handsome octavo volume, extra cloth. $6 00. BY THE SAME AUTHOR : MACLISE (JOSEPH), SURGEON. SURGICAL ANATOMY. Forming one volume, very large imperial quarto With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Con- taining one hundred and ninety Figures, many of them the size of life. Together with copious and explanatory letter-press. Strongly and handsomely bound in extra cloth, being one of the cheapest and best executed Surgical works as yet issued in this country. $13 00. Gentlemen preparing for service in the field or hospital will find these plates of the highest practical value, either for consultation in emergencies or to refresh their recollection of the dissecting room. *»* The size of this work prevents its transmission through the post-office as a whole, but those who desire to have copies forwarded by mail, can receive them in five parts, done up in stout wrappers. Price $11 00. One of the greatest artistic triumphs of the age in Surgical Anatomy.—British American Medical Journal. No practitioner whose means will admit should fail to possess it.—Banking's Abstract. Too much cannot be said in its praise; indeed, we have not language to doit justice.—Ohio Medi- cal and Surgical Journal. The most accurately engraved and beautifully colored plates we have ever seen in an American book—one of the best and cheapest surgical works ever published.—Buffalo Medical Journal. It is very rare that so elegantly printed, so well illustrated, and so useful a work, is offered at so moderate a priee.—Charleston Medical Journal. Its plates can boast a superiority which places them almost beyond thereach of competition.—Medi- tal Examiner. Country practitioners will find these plates of im- mense value—N. Y. Medical Gazette. A work which has no parallel in point of accu- racy and cheapness in the English language.—N. Y. Journal of Medicine. We are extremely gratified to annonnce to th« professionHhe completion of this truly magnificent work, which, as a whole, certainly stands unri- valled, both for accuracy of drawing, beauty of coloring, and all the requisite explanations of tha Bubject in hand.—The New Orleans Medical and Surgical Journal. This is by far the ablest work on Surgical Ana- tomy that has come under our observation. W« know of no other work that would justify a stu- dent, in any degree, for neglect of actual dissec- tion. In those sudden emergencies that so often arise, and which require theinstantaneouscomnuurd of minu te anatomical knowledge, a work of this kind keeps the details of the dissecting-room perpetually fresh in the memory.—Tne Western Journalof Medi- cine and Surgery. * MILLER (HENRY), M. D., Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. PRINCIPLES AND PRACTICE OF OBSTETRICS, &c.; including the Treat- ment of Chronic Inflammation of the Cervix and Body of the Uterus considered as a frequent cause of Abortion. With about one hundred illustrations on wood. In one very handsome oc- tavo volume, of over 600 pages, extra cloth. $3 75. We congratulate the author that the task is done, tion to which its merits justly entitle it.—Tht Cin- We congratulate him that he has given to the medi- cal public a work which will secure for him a high and permanent position among the standard autho- rities on the principles and practice of obstetrics. Congratulations are not less due to the medical pro- fession of this country, on the acquisition of a trea- tise embodying the results of the studies, reflections, and experience of Prof. Miller.—Buffalo Medical Journal. In fact, thiB volumemust take its place among the standard systematic treatises on obstetrics; a posi- cinnati Lancet and Observer. A most respectable and valuable addition to our home medical literature, and one reflecting credit alike on the author and the institution to which he is attached. The student will find in this work a most useful guide to his studies; the country prac- titioner, rusty in his reading, can obtain from its pages a fair resume of the modem literature of the BCience; and we hope to see this American produc- tion generally consulted by the profession.—Ve>. Med. Journal. MACKENZIE (W.)f M. D., Surgeon Oculist in Scotland in ordinary to Her Majesty, Ac Ac A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE EYE. To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section ol the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the Fourth Revised and En- larged London Edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to Wills Hospital, &c. &c. In one very large and handsome octavo volume, extra cloth, with plates and numerous wood-cuts. $6 00. The treatise of Dr. Mackenzie indisputably holds the firstplace, and forms, in respect of learning and research, an Encyclopaedia unequalled in extent by any other work of the kind, either English or foreign. —Dixon on Diseases ofthe Eye. We consider it the duty of every one who has the love of his profession and the welfare of his patient at heart, to make himself familiar with this the most complete work in the English language upon thedis- eases of the eye—Med. Times and Gazette. AND SCIENTIFIC PUBLICATIONS 23 MILLER (JAMES), F. R. S. E., Professor of Surgery in the University of Edinburgh, See. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume, extra cloth, of 700 pages, with two hundred and forty illustrations on wood. $3 75. BY THE SAME AUTHOR. THE PRACTICE OF SURGERY. Fourth American from the last Edin- burgh edition. Revised by the American editor. Illustrated by three hundred and sixty-four engravings on wood. In one large octavo volume, extra cloth, of nearly 700 pages. No encomium of outb could add to the popularity of Miller's Surgery. Its reputation in this country is unsurpassed by that of any other work, and, when taken in connection with the author's Principles of Surgery, constitutes a whole, without reference to which no conscientious surgeon would be willing to practice his art.— Southern Med.and Surg. Journal. It is seldom that two volumes have ever made so profound an impression in so short a time as the "Principles" and the "Practice" of Surgery by Mr. Miller—or so richly merited the reputation they have acquired. The author is an eminently sensi- ble, practical, and well-informed man, who knows exactly what he is talking about and exactly how to talk it.—Kentucky Medical Recorder. By the almost unanimous voice of the profession, $3 75. his works, both on the principles and practice of surgery have been assigned the highest rank. If we were limited to but one work on surgery, that one should be Miller's, as we regard it as superior to all others.—St. Louis Med. and Surg. Journal. The author has in this and his " Principles," pre- sented to the profession one of the most complete and reliable systems of Surgery extant. His style of writing is original, impressive, and engaging, ener- getic, concise, and lucid. Few have the faculty of condensing so much in small space, and at the same time so persistently holding the attention. Whether as a text-book for students or a book of reference for practitioners, it cannot be too strongly recom- mended.—Southern Journal of Med. and Physical Sciences. MORLAND (W. W.), M. D., Fellow of the Massachusetts Medical Society, &c. DISEASES OF THE URINARY ORGANS; a Compendium of their Diagnosis, Pathology, and Treatment. With illustrations about 600 pages, extra cloth. $3 50. Taken as a whole, we can recommend Dr. Mor- land's compendium as a very desirable addition to the library of every medical or surgical practi- tioner.—Brit, and For. Med.-Chir. Rev., April, 1859. Every medical practitioner whose attention has been to any extent attracted towards the class of diseases to which this treatise relates, must have often and sorely experienced the want of some full, yet concise recent compendium to which he could In one large and handsome octavo volume, ol refer. This desideratum has been supplied by Dr. Morland, and it has been ably done. He has placed before us a full, judicious, and reliable digest. Each subject is treated with sufficient minuteness, yet in a succinct, narrational style, such as to render the worit one of great interest, and one which will prove in the highest degree useful to the general practitioner.—N. Y. Journ. of Medicine, BY THE SAME ATJTHOE. THE MORBID EFFECTS OF THE RETENTION IN THE BLOOD OF THE ELEMENTS OF THE URINARY SECRETION. Being the Dissertation to which the Fiske Fund Prize was awarded, July 11,1861. In one small octavo volume, 83 pages, extra cloth. 75 cents. MONTGOMERY (W. F.), M. D., M. R. I. A., &.C., Professor of Midwifery in the King and Queen's College of Physicians in Ireland, Sec. AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREGNANCY. With some other Papers on Subjects connected with Midwifery. From the second and enlarged English edition. With two exquisite colored plates, and numerous wood-cuts. In one very handsome octavo volume, extra cloth, of nearly 600 pages. $3 75. A book unusually rich in practical suggestions.— | fresh, and vigorous, and classical is our author's Am Journal Med. Sciences, Jan. 1857. style; and one forgets, in the renewed charm of These several subjects so interesting in them- J"™* Pa?e' that}U ^ZV^^llV^zoi selves, and so important,every one of them, to the has been. weighed and reweighed through years of most delicate and precious of social relations, con- ! PrheParat,on > ^i^XJ^it^l^torfr^M trolling often the honor and domestic peace of a ; Obstetric ^v*™****™"?*?™^" familv! the leiritimacv of offsnrimr or the life of its ' Pomte connected with pregnancy, to be everywhere aTeVt arealf treater! withS e^Sce of atetU' j «*«ved as a manual of specia» J«»^««ft«J« fulness of illustrations, acuteness and justice of rea-' ?nce announcing fact, ^»5"f "K^"1^" .oning, unparalleled in obstetrics, and unsurpassed in »nS precedent, and gove mi ngalik ^ Juryman, ad- medicine. The reader's interes can never flag, so , vocate, and judge.-JV. A. Med.-Chir. Review. MOHR (FRANCIS), PH. D., AND REDWOOD (THEOPHI LUS). PRACTICAL PHARMACY. Comprising the Arrangements, Apparatus, and Manipulations of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, by Prof. William Procter, of the Philadelphia College of Pharmacy. In one handsomely printed octavo volume, extra cloth, of 570 pages, with over 500 engravings on wood. $4 00. MAYNR'S DISPENSATORY AND THERA- PEUTICAL REMEMBRANCER. With every Practical Formula contained in the three British Pharmacopoeias. Edited, with the addition of the Formula! ofthe U. S. Pharmacopoeia, by R. E. SkimitHjM.D 1 18ino. vol. ex.cl.,300pp. 75 c. MALGAIGNE'S OPERATIVE SURGERY, based on Normal and Pathological Anatomy. Trans- lated from the French by Frederick Brittan, A.B.,M.D. With numerous illustrations on wood. In one handsome octavo volume, extra cloth, of nearly six hundred pages. $2 50. 24 BLANCHARD & LEA'S MEDICAL NEILL (JOHN), M. D., Surgeon to the Pennsylvania Hospital, Ac.; and FRANCIS GURNEY SMITH, M.D., Professor of Institutes of Medicine in the Pennsylvania Medical College. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, of about one thousand pages, with 374 wood-cuts, extra cloth, $3 50. Strongly bound in leather, with raised bands. $4 50. This work is again presented as eminently worthy of the favor with which it has hitherto been received. As a book for daily reference by the student requiring a guide to his more elaborate text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate examination, or as a source from which the practitioners of older date may easily and cheaply acquire a knowledge ofthe changes and improvement in professional science, its reputation is permanently established. The best work of the kind with which we are acquainted.—Med. Examiner. Having made free use of this volume in our ex- aminations of pupils, we can speak from experi- ence in recommending it as an admirable compend for students, and as especially useful to preceptors who examine their pupils. It will save the teacher much labor by enabling him readily to recall all of the points upon which his pupils should be ex- amined. A work of this sort should be in the hands of every one who takes pupils into his office with a view of examining them; and this is unquestionably the bestof its class.—Transylvania Med. Journal. In the rapid course of lectures, where work for the students is heavy, and review necessary for an examination, a compend is not only valuable, but it is almost a sine qua non. The one before us is, in most of the divisions, the most unexceptionable of all books of the kind that we know of. Tho newest and soundest doctrines and the latest im- provements and discoveries are explicitly, though concisely, laid before the student. There is a class to whom we very sincerely commend this cheap book as worth its weight in silver—that class is the gradu- ates in medicine of more than ten years' standing. who have not studied medicine since. They will perhaps find out from it that the science is not exactly now what it was when they left it off.—The Stttke- scope. NELIGAN (J. MOORE), M. D., M. R. I. A., Sec. ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, extra cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of disease. $5 50. This beautiful volume is intended as a complete and accurate representation of all the varieties of Diseases of the Skin. While it can be consulted in conjunction with any work on Practice, it has especial reference to the author's " Treatise on Diseases ofthe Skin," so favorably received by the profession some years since. The publishers feel justified in saying that few more beautifully exe- cuted plates have ever been presented to the profession of this country. give, at a coup d'ceil, the remarkable peculiarities of each individual variety. And while thus the dis- ease is rendered more definable, there is yet no loss Neligan's Atlas of Cutaneous Diseases supplies a long existent desideratum much felt by the largest class of our profession. It presents, in quarto size, 16 plates, each containing from 3 to 6 figures, ana forming in all a total of 90 distinct representations of the different species of skin affections, grouped together in genera or families. The illustrations have been taken from nature, and have been copied with such fidelity that they present a striking picture of life; in which the reduced scale aptly serves to of proportion incurred by the necessary concentra- tion. Each figure is highly colored, and so truthful has the artist been that the most fastidious observer could not justly take exception to the correctness of the execution of the pictures under his scrutiny.— Montreal Med. Chronicle. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Fourth American edition. In one neat royal 12mo. volume, extra cloth, of 334 pages. $1 50. OWEN ON THE DIFFERENT FORMS OF I THE SKELETON, AND OF THE TEETH. One vol. royal 12mo., extra cloth with numeroui illustrations. SI 25. PI RRIE (WILLIAM), F. R. S. E., Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon tothe Pennsylvania Hospital, &c. In one very handsome 8vo. volume, extra cloth, of 780 pages, with 316 illustrations. We know of no other surgical work of a reason-1 rately discussed the principles of surgery, and a able size, wherein there is so much theory and prac- safe and effectual practice predicated upon them. tice, or where subjects are more soundly or clearly , Perhaps no work upon this subject heretofore issued taught.—The Stethoscope. is so full upon the science of the art of surgery.— Prof. Pirrie, in the work before us, has elabo-1 Nashville Journal of Medicine and Surgery'. PARKER (LANGSTON), Surgeon tothe Queen's Hospital, Birmingham. THE MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRI- MARY AND SECONDARY; comprising the Treatment of Constitutional and Confirmed Syphi- lis, by a safe and successful method. With numerous Cases, Formulae, and Clinical Observa- tions. From the Third and entirely rewritten London edition. In one neat octavo volume, extra cloth, of 316 pages. $2 50. AND SCIENTIFIC PUBLICATIONS. 25 PARRISH (EDWARD), Professor of Materia Medica in the Philadelphia College of Pharmacy. A TREATISE ON PHARMACY. Designed as a Text-book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. Third edition, greatly improved. In one handsome octavo volume, of 850 pages, with several hundred Illustrations, extra cloth. $5 00. (Just Ready.) Though for some time out of print, the appearance of a new edition of this work has been de- layed for the purpose of embodying in it the results of the new U. S. Pharmacopoeia. The pub- lication of this latter has enabled the author to complete his revision in the most thorough manner. Those who have been waiting for the work may therefore rely on obtaining a volume completely on a level with the most advanced condition of pharmaceutical science. The favor with which the work has thus far been received shows that the author was not mis- taken in his estimate of the want of a treatise which should serve as a practical text-book for all engaged in preparing and dispensing medicines. Such a guide was indispensable not only to the educated pharmaceutist, but also to that large class of practitioners throughout the country who are obliged to compound their own prescriptions, and who during their collegiate course have no opportunity of obtaining a practical familiarity with the necessary processes and manipulations. The rapid exhaustion of two large editions is evidence that the author has succeeded in thoroughly carrying out his object. Since the appearance of the last edition, much has been done to perfect the science ; the new Pharmacopoeia has introduced many changes to which the profession must conform ; and the author has labored assiduously to embody in his work all that physicians and pharmaceutists can ask for in such a volume. The new matter alone will thus be found worth more than the very moderate cost of the work to those who have been using the previous editions. All that we can say of it is that to the practising physician, and especially the country physician, who is generally his own apothecary, there is hard- ly any book that might not better be dispensed with. It is at the same time a dispensatory and a pharma- cy.—Louisville Review. A careful examination of Hub work enables us to speak of it in the highest terms, as being the best treatise on practical pharmacy with which we are acquainted, and an invaluable vade-mecum, not only to the apothecary and to those practitioners who are accustomed to prepare their own medicines, but to every medical man and medical student.—Boston Med. and Surg. Journal. This is altogether one of the most useful books we have seen. It is just what we have long felt to be needed by apothecaries, students, and practition- ers of medicine, most of whom in this country have to put up their own prescriptions. It bears, upon every page, the impress of practical knowledge. conveyed in a plain common sense manner, and adapted to the comprehension of all who may read it—Southern Med. and Surg. Journal. That Edward Parrish, in writing a book upon practical Pharmacy some few years ago—one emi- nently original and unique—did the medical and pharmaceutical professions a great and valuable ser- vice, no one, we think, who has had access to its pages will deny; doubly welcome, then, is this new edition, containing the added results of his recent and rich experience as an observer, teacher, and practici.1 operator in the pharmaceutical laboratory. The excellent plan of the first is more thoroughly, —Peninsular Med. Journal, Jan. 1860. Of course, all apothecaries who have not already a copy of the first edition will procure one of this; it is, therefore, to physicians residing in the country and in small towns, who cannot avail themselves of the skill of an educated pharmaceutist, that we would especially commend this work. In it they will find all that they desire to know, and should know, but very little of which they do really Know in reference to this important collateral branch of their profession; for it is a well established fact, that, in the education of physicians, while the sci- ence of medicine is generally well taught, very little attention is paid to the art of preparing them for use, and we know not how this defect can be so well remedied as by procuring and consulting Dr. Parrish's excellent work.—St, Louis Med. Journal. Jan. 1860. We know of no work on the subject which would be more indispensable to the physician or student desiring information on the subject of which it treats. With Griffith's " Medical Formulary" and this, the practising physician would be supplied with nearly or quite all the most useful information on the sub- ject.—Charleston Med. Jour.and Review, Jan. 1860. PEASLEE (E. R.), M. D., Professor of Physiology and General Pathology in the New York Medical College. HUMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology for the use of Medical Students. With four hundred and thirty-four illustrations. In one hand- some octavo volume, extra cloth, of over 600 pages. $3 75. It embraces a library upon the topics discussed within itself, and is just what the teacherand learner need. We have not only the whole subject of His- tology, interesting in itself, ably and fully discussed, but what is of infinitely greater interest to the stu- dent, because of greater practical value, are its re- lations to Anatomy, Physiology, and Pathology, i which are here fully and satisfactorily set forth.— Nashville Journ. of Med. and Surgery. We would recommend it as containing a summary of all that is known of the important subjects which it treats; of all that is in the great works of Simon and Lehmann, and the organic chemists in general. Master this one volume, and you know all that is' known of the great fundamental principles of medi- cine, and we have no hesitation in saying that it is an honor to the American medical profession.__ St. Louis Med. and Surg. Journal. ROKITANSKY Curator of the Imperial Pathological Museum A MANUAL OF PATHOLOGICAL bound in two, extra cloth, of about 1200 pages. kino, C. H. Moore, and G. E. Day. $7 00. The profession is too well acquainted with the re- putation of Rokitansky's work to need our assur- ance that this is one of the mostprofound. thorough. and valuable books ever issued from the medical press. It is sui generis, and has no standard of com- parison. It is only necessary to announce that it is issued in a form as cheap as is compatible with its (CARL), M.D., and Professor at the University of Vienna, Sec ANATOMY. Four volumes, octavo. Translated by W. E. Swaine, Edward Sieve- size and preservation, and its sale follows as a matter of course. No library can be called com- plete without it.—Buffalo Med. Journal. An attempt to give our readers any adequate idea of the vast amount of instruction accumulated in these volumes, would be feeble and hopeless__ Western Lancet. ROYLE'S MATERIA MEDICA AND THERAPEUTICS; including the Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States With many new medicines. Edited by Joseph Carson, M. D. With ninety-eight illustrations' In one large octavo volume, extra cloth, of about 700 pages. S3 00. 26 BLANCHARD St LEA'S MEDICAL RIGBY (EDWARD), M.D., Senior Physician to the General Lying-in Hospital, Ac. A SYSTEM OF MIDWIFERY. With Notes and Additional IllustrationB. Second American Edition. One volume octavo, extra cloth, 422 pages. $2 50. BY THE SAME AUTHOR. ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES. In one neat royal 12mo. volume, extra cloth, of about 250 pages. $1 00. RAMSBOTHAM (FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the Author. With Additions by W. V. Keating,M. D., Professor of Obstetrics, Arc., in the Jefferson Medical College, Philadelphia. In one large and handsome imperial octavo volume, of 650 pages, strongly bound in leather, with raised bands; with sixty-four beautiful Plates, and numerous Wood-cuts in the text, containing in all nearly 200 large and beautiful figures. $7 00. From Prof. Hodge, of the University of Pa. To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout our country. It is unnecessary to say anything in regard to the utility of this work. It is already appreciated in our country for the value of the matter, the clearness of its style, and the fulness of its illustrations. To the physician's library it is indispensable, while to the student as a text-book, from which to extract the material for laying the foundation of an education on obstetrical science, it has no superior.—Ohio Med and Surg. Journal. The publishers have secured its success by the truly elegant style in which they have brought it out, excelling themselves in its production, espe- cially in its plates. It is dedicated to Prof. Meigs, and has the emphatic endorsement of Prof. Hodge, as the best exponent of British Midwifery. We knew of no text-book which deserves in all respects to be more highly recommended to students, and we could wish to see it in the handsof every practitioner, for they will find it invaluable for reference.—Mid. Gazette. RICORD (P.), M. D. A TREATISE ON THE VENEREAL DISEASE. By John Hunter, F. R. S. With copious Additions, by Ph. Ricord, M.D. Translated and Edited, with Notes, by Freemas J. Bumstead. M.D., Lecturer on Venereal at the College of Physicians and Surgeons, New York. Second edition, revised, containing a resume of Ricord's Recent Lectures on Chancre. In one handsome octavo volume, extra cloth, of 550 pages, with eight plates. $4 00. BY THE SAME AUTHOR. RICORD'S LETTERS ON SYPHILIS. Translated by W. P. Lattimore, M. D- In one neat octavo volume, of 270 pages, extra cloth. $2 00. SMITH (HENRY H.), M. D., AND HORN ER (Wl LLI AM E.),M.D. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful figures. $4 50. The plan of this Atlas, which renders it so pe- culiarly convenient for the student, and its superb artistical execution, have been already pointed out. We must congratulate the student upon the comple- tion of this Atlas, as it is the most convenient work ofthe kind that has yet appeared ; and we must add. the very beautiful manner in which it is " got up" is so creditable to the country as to be flattering to our national pride.—American Medical Journal. SMITH (EDWARD), M.D., LL.D., F.R.S. Assistant Physician to the Hospital for Consumption and Diseases of the Chest, Brompton, Sec. CONSUMPTION; ITS EARLY AND REMEDIABLE STAGES. In one neat octavo volume of 254 pages, extra cloth. $2 25. (Now Ready.) One-half of Dr. Smith's work is devoted to the i than to drugs in the treatment of the disease. In treatment of Tuberculosis. We find in this portion | taking leave of the work, we would express tin of the work no occasion to join issue with the au- I hope that the author will furnish occasions for the thor ; but, on the contrary, much which we would I renewal of our intercourse as a reader, if not as a commend to the reader's attention. Dr. Smith at- | leviewer.—Am. Med. Journal, Jan. 1863. taches far greater importance to hygienic measures i SHARPEY (WILLIAM), M. D., JONES QUAIN, M. D., AND RICHARD QUAIN, F. R. S., Sec. HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Letdy, M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo volumes, extra cloth, of about thirteen hundred pages. With over 500 illustrations. $6 00. SOLLY ON THE HUMAN BRAIN; its Structure. Physiology, and Diseases. From the Second ana much enlarged London edition. In one octavo volume-, extra cloth, of 500 pages, with 120 wood- cuts. «2 50. BKEY'S OPERATIVE SURGERY. In one very handsome octavo volume, extra eloth, of over MO pages, with about one hundred wood-cuts. 8335. SIMON'S GENERAL PATHOLOGY, as condsc- ive to the Establishment of Rational Principle! for the prevention and Cure of Disease. In on« octavo volume, extra cloth, of212 pages, fl 2*. AND SCIENTIFIC PUBLICATIONS. 27 STILLE (ALFRED), M.D., Professor of the Theory and Practice of Medicine in the University of Pennsylvania. THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. Second Edition, revised and enlarged. In two large and handsome octavo volumes, extra cloth. $10 00. (Now Ready.) This work is designed especially for the student and practitioner of medicine, and treats the various articles of the Materia Medica from tbe point of view of the bedside, and not of the shop or of the lecture-room. While thus endeavoring to give all practical information likely to be useful with respect to the employment of special remedies in special affections, and the results to be anticipated from their administration, a copious Index of Diseases and their Remedies renders the work emi- nently fitted for reference by showing at a glance the different means which have been employed, and enabling the practitioner to extend his resources in difficult cases with all that the experience ol the profession has suggested. The speedy demand for another edition of this work shows that it has acceptably filled an acknow- ledged want No exertion ofthe author has been wanting to render it worthy a continuance ofthe favor with which it has been received, while an alteration in the typographical arrangement has accommjdated the additions without increasing unduly the size ofthe volumes. tioncd, Stille. His great work on " Materia Medi- ca and Therapeutics," published last year, in two octavo volumes, of some sixteen hundred pages, while it embodies the results of the labor of others Rarefy, indeed, have we had submitted to us a work on medicine so ponderous in its dimensions as that now before us, and yet so fascinating in its contents. It is, therefore, with a peculiar gratifi- cation that we recognize in Dr. Stille the posses- sion of many of those more distinguished qualifica- tions which entitle him to approbation, and which Justify him in coming before his medical brethren as an instructor. A comprehensive knowledge, tested by a sound and penetrating judgment, joined to a love of progress — which a discriminating spirit of inquiry has tempered so as to accept nothing new because it is new,and abandon nothing old because it is old, but which estimates either according to its relations to a just logic and experience—manifests itself everywhere, and gives to the guidance of the author all 'he assurance of safety which the diffi- culties of his subject can allow. In conclusion, we earnestly advise our readers to ascertain for them- selves, by a study of Dr. Stille's volumes, the great value and interest of the stores of knowledge they present. We have pleasure in referring rabher to the ample treasury of undoubted truths, the real and assured conquest of medicine, accumulated by Dr. Stille in his pages; and commend the sum of his la- bors to the attention of our readers, as alike honor- able to our science, and creditable to the zeal, the candor, and the judgment of him who has garnered the whole so carefully.—Edinburgh Med. Journal. The most recent authority is the one last men- up to the time of publication, is enriched with a great amount of original observation and research. We would draw attention, by the way, to the very convenient mode in which the Index is arranged in this wfirk. There is first an " Index of Remedies;' next an "Index of Diseases and their Remedies." Such an arrangement of the Indices, in our opinion, greatly enhances the practical value of books of this kind. In tedious, obstinate cases of disease, where we have to try one remedy after another until our stock is pretty nearly exhausted, and we are almost driven to our wit's end, such an index as the second of the two just mentioned, is precisely what we want.—London Med. Times and Gazette, April, 1861. We think this work will do much to obviate the reluctance to a thorough investigation of this branch of scientific study, for in the wide range of medical literature treasured in the English tongue, we shall hardly find a work written in a style more clear and simple, conveying forcibly the facts taught, and yet free from turgidity and redundancy. There isa fas- cination in its pages that will insure to it a wide popularity and attentive perusal, and a degree of usefulness not often attained through the influence of a single work. SIMPSON (J. Y.), M. D., Professor of Midwifery, &c, in the University of Edinburgh, Ac. CLINICAL LECTURES ON THE DISEASES OF WOMEN. With nu- merous illustrations. In one handsome octavo volume, of over 500 pages, extra cloth, $4 00 (Now Ready, 1863.) This valuable work having passed through the columns of " The Medical News and Library" for I860, 18bl, and 1862, is now completed, and may be had separate in one handsome volume. The principal topics embraced in the Lectures are Vesico-Vaginal Fistula, Cancer ofthe Uterus, Treatment of Carcinoma by Caustics, Dysmenorrhoea, Amenorrhoea, Closures, Contractions, &c, of the Vagina, Vulvitis, Causes of Death after Surgical Operations, Surgical Fever, Phlegmasia Dolens, Coccyodinia, Pelvic Cellulitis, Pelvic Hsematoma, Spurious Pregnancy, Ovarian Dropsy, Ovariotomy, Cranioclasm, Diseases of the Fallopian Tubes, Puerperal Mania, Sub-Involution and Super-Involution of the Uterus, &c. &c. As a series of monographs on these important topics—many of which receive little attention in the ordinary text-books—elucidated with the extensive experience and readiness of resource for which Professor Simpson is so distinguished, there are few practitioners who will not find in its pages matter ofthe utmost importance in the treatment of obscure and difficult cases. SALTER (H. H.;, M. D. ASTHMA; its Pathology, Causes, Consequences, and Treatment. In one vol. 8vo., extra cloth (Just Issued.) $2 50. The portion of Dr. Salter's work which is devoted i and this we shall little regret, if, by our silence, to treatment, is of great practical interest and value, we should induce our readers to possess themselves It would be necessary to toilow him step by step of the book itself; a book which, without doubt, de- in his remarks, not only on the medicinal, but also serves to be ranked among the most valuable of re- ou the dietetic and hygienic treatment of thedisease, cent contributions to the ine.dical literature of this in order to convey a just notion ot tnepractical value country.—Banking's Abstract, Jan., 1S61. uf this part of his work. This our space forbids, > SLADE (D. D.), M. D. DIPHTHERIA: its Nature and Treatment, with an account of the History of its Prevalence in various countries. Second and revised edition. In one neat royal 12mo. volume, extra cloth. $1 25. (Now Ready.) 28 BLANCHARD & LEA'S MEDICAL SARGENT (F. W.), M. D. ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. New edition, with an additional chapter on Military Surgery. One handsome royal 12 mo. vol., of nearly 400 pages, with 184 wood cuts. Extra cloth, $1 75. The value of this work as a handy and convenient manual for surgeons engaged in active duty, has induced the publishers to render it more complete for those purposes by the addition of a chapter on gun-shot wounds and other matters peculiir to military surgery. In its present form, there- fore, it will be found a very cheap and convenient vade-mecum for con-ultation and relereiice in the daily exigencies of military as well as civil practice. The instruction given upon the subject of Ban- daging, is alone of great value, and while the author modestly proposes to instruct the students of medi- cine, and the younger physicians, we will say that experienced physicians will obtain many exceed- ingly valuable suggestions by its perusal. It will We consider that no better book could be placed in the hanus of an hospital dresser, or the young sur- geon, whose education in this respect has not been perfected We most cordially commend this volume as one which the medical student should most close ly studv, to perfect himself in these minor surgical operations in which neatness and dexterity are so much required, and on which a great portion of his reputation as a future surgeon must evidently rest And to the surgeon in practice it must prove itself a valuable volume, as instructive on many points which he may have forgotten.—British American Journal, May, 1862. be found one of the most satisfactory manuals for re- ference in the field, or hospital yet published; thor- oughly adapted to the wants of Military surgeons, and at the same time equally useful for ready and convenient reference by surgeon* everywhere.— Buffalo Med. and Surg. Journal, June, 1862. SMITH (W. TYLER), M. D., Physician Accoucheur to St. Mary's Hospital, Ac. ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OP OBSTETRICS. In one royal 12mo. volume, extra cloth, of 400 pages. $1 50. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON THE PATHOLOGY AND TREATMENT OF LEUCORRH02A. With numerous illustrations. In one very handsome octavo volume, extra cloth, of about 250 pages. $2 00 TANNER (T. H.), M. D., Physician to the Hospital for Women, Sec. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGN08I8. To which is added The Code of Ethics of the American Medical Association. Third American Edition. In one neat volume, small 12mo., extra cloth. (Preparing.) TAYLOR (ALFRED S.), M. D., F. R. S., Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital. MEDICAL JURISPRUDENCE. Fifth American, from the seventh improved and enlarged London edition. With Notes and References to American Decisions, by Edward Hartshorne,M.D. In one large 8vo. volume, extra cloth, of over 700 pages. $3 75. This standard work having had the advantage of two revisions at the hands ofthe author since the appearance ofthe last American edition, will be found thoroughly revised and brought up com- pletely to the present state of the science. As a work ot authority, it must therefore muintaiii its position, both as a text-book for the student, and a compendious treatise to which the practitioner can at all times refer in cases of doubt or difficulty. Ameriean and British legal medicine. It should be No work upon the subject can be put into the hands of students either of law or medicine which will engage them more closely or profitably ; and none could be offered to the busy practitioner ot either calling, for the purpose of casual or hasty reference, that would be more likely toatford the aid desired. We thereforerecommend it as the best and safest manual for daily use.—American Journal oj Medical Sciences. It is not excess of praise to say that the volume before us is the very best treatise extant on Medical Jurisprudence. In saying this, we do not wish U be understood as detracting from the merits of the excellent works of Beck, Ryan, Traill, Guy, anc others; but in interest and value we think it must be conceded that Taylor is superior to anything thai has preceded it.—N. W. Medical and Surg, lournal n the possession of every physician, as the subject is one of great and increasing importance to the public as well as to the profession.—St. Louis Mid. and Surg. Journal. This work of Dr. Taylor's is generally acknow- ledged to be one of the ablest extant on the subject of medical jurisprudence, it is certainly one of the most attractive oooks that we have met with ; sup- plying so much both to interett and instruct, that we do not hesitate to affirm that after having once commenced its perusal, tew could be prevailed upon to desist before completing it. In khe last London edition, all the newly observed and accurately re- corded facts have been inserted, including much that is recent of Chemical, Microscopical, and Pa- thological research, besidt 8 papers on numerous subjects never before published.—Charleston Med. Journal and Review. It is at once comprehensive and eminently prac- tical, and by universal consent ttanus at the head of BY THE SAME AUTHOR. ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Second American, from a second and revised London edition. In one large octavo volume, of 755 pages, extra cloth. $4 50. Mr. Taylor's position as the leading medical jurist of England, has conferred on him extraordi- nary advantages in acquiring experience on these subjects, nearly all cases of moment being referred to him for examination, as an expert whose testimony is generally accepted as final. The results of his labors, therefore, as gathered together in this volume, carefully weighed and silted, and presented in the clear and intelligible style for which he is noted, may be received as an acknowledged authority, and as a guide to be followed with implicit confidence. BV THE SAME AUTHOR AND WM. BRANDE, CHEMISTRY. In one volume 8vo. See "Brande," p. 6. AND SCIENTIFIC PUBLICATIONS. 29 TODD (ROBERT BENTLEY), M. D., F. R. S., Professor of Physiology in King's College, London; and WILLIAM BOWMAN, F. R. S., Demonstrator of Anatomy in King's College, London. THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With about three hundred large and beautiful illustrations on wood. Complete in one large octavo volume, of 950 pages, extra cloth. Price $4 75. A magnificent contribution to British medicine, and the American physician who shall fail to peruse it, wih have failed to read one of the most instruc- Itisinoreconcise than Carpenter's Principles, and more modern than tlieaccessibleedition of Mailer's Elements; its details are brief, but sufficiert; its descripiions vivid ; its illustrations exact and copi- ous; and its language terse and perspicuous.— Charleston Med. Journal. tive books of the nineteenth century.—N. O. Med. %nd Surg. Journal. TODD (R. B.) M. D., F. R. S., &c. CLINICAL LECTURES ON CERTAIN DISEASES OF THE URINARY ORGANS AND ON DROPSIES. In one octavo volume, 284 pages, extra cloth. $2 50. BY THE SAME AUTHOR. CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one neat octavo volume, of 320 pages, extra clotn. $2 50. TOYNBEE (JOSEPH), F. R. S., Aural Surgeon to, and Lecturer on Surgery at, St. Mary's Hospital. A PRACTICAL TREATISE ON DISEASES OF THE EAR; their Diag- nosis, Pathology, and Treatment. Illustrated with one hundred engravings on wood. In one very handsome octavo volume, extra cloth, $4 00. - Surgery, it is without a rival in our language or any other.—Charleston Med. Journ. and Rev., Sept. 1860. The work of Mr. Toynbee is undoubtedly, upon the whole, the most valuable production of tne kind in any language. The author has long been known by his numerous monographs upon subjects con- nected with diseases of the ear, and is now regarded as the highest authority on most points in his de- partment of science. Mr. Toynbee's work, as we have already said, is undoubtedly the most reliable guide for the study of the diseases of the tar in any language, and should be in the library of every phy- sician.— Chicago Med. Journal, July, 1860. The work is a model of its kind, and every page ] and paragraph oi it are worthy of the most thorough study. Considered all in all—as an original work, well written, philosophically elaborated, and happi- ly illustrated with cases and drawings—it is by far the ablest monograph that has ever appeared on the anatomy and diseases of the ear, and one of the most valuable contributions totheartand science of sur- gery in the nineteenth century.—N. Amer. Medico- Chirurg Review, Sept. I860. We are speaking within the limits of modest ac- knowledgment, and with a sincere and unbiassed judgment, when we affirm that as a treatise on Aural WILLIAMS (C. J. B.), M.D., F. R. S.f Professor of Clinical Medicine in University College, London, Sec. PRINCIPLES OF MEDICINE. An Elementaiy View of the Causes, Nature, Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the pre- servation of health. A new American, from the third and revised London edition. In one octavo volume, extra cloth, of about 500 pages. $3 50. (Now Ready.) WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. Publishedundertheauthority of the London Society for Medical Observation. A new American, from the second and revised Londou edition. In one very handsome volume, royal 12mo., extra cloth. $1 00. To the observer who prefers accuracy to blunders I One of the finest aids to a young practitioner wa and precision to carelessness, this little book is in- I have ever seen.—Peninsular Journal of Medicine. valuable.—N. H. Journal of Medicine. I WALSHE (W. H.), M. D., Professor of the Principles and Practice of Medicine in University College, London, Sec. A PRACTICAL TREATISE ON DISEASES OF THE LUNGS; including the Principles of Physical Diagnosis. Third American, from the third revised and much en- larged London edition. In one vol. octavo, of 468 pages, extra cloth $3 00. The present edition has been carefully revised and much enlarged, and may be said in the main to be rewritten. Descriptions of several diseases, previously omitted, are now introduced; an effort has been made to bring the description of anatomical characters to the level of the wants of the practical physician; and the diagnosis and prognosis of each complaint are more completely considered. The sections on Treatment and the Appendix have, especially, been largely ex- tended.—Author's Preface. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DISEASES OF THE HEART AND GREAT VESSELS, including the Principles of Physical Diagnosis. Third American, from the third revised and much enlarged London edition. In one handsome octavo volume of 420 pages extra cloth. $ J 00. ^ The present edition has been carefully revised; much new matter has been added, and the entire Work in a measure remodelled. Numerous facts and discussions, more or less completely novel, will be found in the description of the principles 9! physical diagnosis; but the chief additions have been made in the practical portions of the book. Several affections, of which little or no account had been given in the previous editions, are now treated of in detail.—Author's Preface. 30 BLANCHARD & LEA'S MEDICAL New and much enlarged edition. WATSON (THOMAS), M.D., Sec, Late Physician to the Middlesex Hospital, Ac. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Delivered at King's College, London. A new American, from the last revised and enlarged English edition, with Additions, by D. Francis Condie, M. D., author of" A Practical Treatise on the Diseases of Children," &c. With one hundred and eighty.five illustrations on wood. In one very large and handsome volume, imperial octavo, of over 1200 closely printed pages in small type; extra cloth, $6.00; strongly bound in leather, with raised bands, $7 00. That the high reputation of this work might be fully maintained, the author has subjected it to a thorough revision; every portion has been examined with the aid of the most recent researches in pathology, and the results of modern investigations in both theoretical and practical subjects have been carefully weighed and embodied throughout its pages. The watchful scrutiny of the editor has likewise introduced whatever possesses immediate importance to the American physician in relation to diseases incident to our climate which are little known in England, as well as those points in which experience here has led to different modes of practice; and he has also added largely to the series of illustrations, believing that in this manner valuable assistance may be conveyed to the student in elucidating the text. The work will, therefore, be found thoroughly on a level with the most advanced state of medical science on both sides of the Atlantic. The additions which the work has received are shown by the fact that notwithstanding an en- largement in the size of the page, more than two hundred additional pages have been necessary to accommodate the two large volumes of the London edition (which sells at ten dollars), within the compass of a single volume, and in its present form it contains the matter ot at least three ordinary octavos. Believing it to be a work which should lie on the table of every physician, and be in the hands of every student, the publishers have put it at a price within the reach of all, making it one of the cheapest books as yet presented to the American profession, while at the same time the beauty of its mechanical execution renders it an exceedingly attractive volume. The fourth edition now appears, so carefully re- vised, as to add considerably to the value of a book already acknowledged, wherever the English lan- guage is read, to be beyond all comparison the best s} stematic work on the Principles and Practice of Physic in the whole range of medical literature. Every lecture contains proof of the extreme anxiety of the author to keep pace wi th the advancing know- ledge of the day One scarcely knows whether to admire most the pure, simple, forcible English— the vast amount of useful practical information condensed into the Lectures—or the manly, kind- hearted, unassuming character of the lecturer shin- ing through his work.— Land. Med. Times. Thus these admirable volumes come before the profession in their fourth edition, abounding in those distinguished attributes of moderation, judgment, erudite cultivation, clearness, and eloquence, with which they were from the first invested, but yet richer than before in the results of more prolonged observation, and in the able appreciation of the latest advances in pathology and medicine by one of the most profound medical thinkers of the day.— London Lancet. The lecturer's skill, his wisdom, his learning,are equalled by the ease of his graceful diction, his elo- quence, and the far higher qualities of candor, of courtesyj of modesty, and of generous appreciation of merit in others.—iV. A. Med.-Chir Review. Watson's unrivalled, perhaps unapproachable work on Practice—the copious additions made to which (the fourth edition) have given it all the no- velty and much of the interest of a new book.— Charleston Med. Journal. Lecturers, practitioners, and students of medicine will equally hail the reappearance of the work of Dr. Watson in the form of anew—a fourth—edition. We merely do justice to our own feelings, and, we are sure, of the whole profession, if we thank him for having, in the trouble and turmoil of a large practice, made leisure to supply the hiatus caused by the exhaustion of the third edition. For Dr. Watson has not merely caused the lectures to be reprinted, but scattered through the whole work we find additions or alterations which prove that the author has in every way sought to bring up his teach- ing to the level of the most recent acquisitions in science.—Brit, and For. Medico-Chir.Review. New and much enlarged edition. WILSON (ERASMUS), F. R. S. A SYSTEM OF HUMAN ANATOMY, General and Special. A new and re- vised American, from the last and enlarged English Edition. Edited by W. H. Gobrecht, M. D., Professor of Anatomy in the Pennsylvania Medical College, &c. Illustrated with three hundred and ninety-seven engravings on wood. In one large and exquisitely printed octavo volume, of over 600 large pages; extra cloth, $4 00. The publishers trust that the well earned reputation so long enjoyed by this work will be more than maintained by the present edition. Besides a very thorough revision by the author, it has been most carefully examined by the editor, and the efforts of both have been directed to introducing everything which increased experience in its use has suggested as desirable to render it a complete text-book lor those seeking to obtain or to renew an acquaintance with Human Anatomy. The amount of additions which it has thus received may be estimated from the fact that the present edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged page requisite to keep the volume within a convenient size. The editor has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the number of illustra- tions, of which there are about one hundred and fitly more in this edition than in the last, thus bringing distinctly before theeye ofthe student everything of interest or importance. It may be recommended to the student as no less distinguished by its accuracy and clearness of de- scription than by its typographical elegance. The wood-cuts are exquisite.—Brit, and For. Medical Review. An elegant edition of one of the most useful and accurate systems of anatomical science which has been issued from the press The illustrations are really beautiful. In its style the work is extremely concise and intelligible. No one can possibly take'1 up this volume without being struck with the great beauty of its mechanical execution, and the clear- ness of the descriptions which it contains is equally evident. Let students, by all means examine tne claims of this work on their notice, before they pur- chase a text-book of the vitally important science which this volume so fully and easily unfolds.— Lancet. We regard it as the best system now extant for students.—Western Lancet. It therefore receives ourhighestcommendation.— Southern Med. and Surg. Journal. AND SCIENTIFIC PUBLICATIONS. 31 WILSON (ERASMUS), F. R. S. ON DISEASES OF THE SKIN. Fifth American, from the Fifth enlarged London edition. In one handsome octavo volume, of nearly 700 large pages, with illustrations on wood, extra cloth $4 50. (Now Ready, May, 1863.) This classical work, which for twenty years has occupied the position of the leading authority in the English language on its important subject, has just received a thorough revision at the hands ofthe author, and is now presented as embodying the results ofthe latest investigations and expe- rience on all matters connected with diseases ofthe skin. The increase in the size of the work shows the industry ofthe author, and his determination that it shall.maintain the position which it has acquired as thoroughly on a level with the most advanced condition of medical science. A lew notices ofthe last edition are appended. Thewritings of Wilson, upondiseasesof the skin, are by far the most scientific and practical that have ever been presented to the medical world on this subject. The present edition isa great improve- ment on all its predecessors. To dwell upon all the great merits and high claims of the work before us, seriatim, would indeed be an agreeable service; it would be a mental homage which we could freely offer, but we should thus occupy an undue amount of space in this Journal. We will, however, look at some of the more salient points with which it abounds,and which make itincomparaoly superior to all other treatises on the subject of dermatology. No mere speculative views are allowed a place in this volume, which, without a doubt, will,for a very long period, be acknowledged as the chief standard work on dermatology. The principles of unenlightened and rational therapeia are introduced on every ap- propriate occasion.—Am. Jour. Med Science. When the first edition of this work appeared, about fourteen years ago, Mr. Erasmus Wilson had already given some years to the study of Diseases of the Skin, and he then expressed his intention of devoting his future life to the elucidation of this branch of Medical Science In the present edition Mr. Wilson presents us with the results of his ma- tured experience, and we have now before us not merely a reprint of his former publications, but an entirely new and rewritten volume. Thus, the whole history of the diseases affecting the skin, whether they originate in that structure or are the mere mani- festations of derangement of internal organs, is brought under notice,and the book includes a mass of information which is spread over a great part of the domain of Medical and Surgical Pathology. We can safely recommend it to the protession as the best work on the subject now in existence in the En- glish language.—London Med. Times and Gazette. \ No matter what other treatises may be in the libra- ry of the medical attendant, he needs the clear and suggestive counsels of Wilson, who is thoroughly posted up on all subjects connected with cutaneous pathology. We have, it is very true, other valuable works on the maladies that invade the skin; but, compared with the volume under consideration, they are certainly to be regarded as inferior lights in guid- ing the judgment of the medical mAn.—Boston Med. and Surg. Journal, Oct. 1857. The author adopts a simple and entertaining style. He strives to clear away the complications of his subject, and has thus produced a book filled with a vast amount of information, in a form so agreeable as to make it pleasant reading, even to the uninitiated. More especially does it deserve our praise because of its beautiful and complete atlas, which the American publishers have successfully imitated from the origi- nal plates. We pronounce them by far the best imi- tations of nature yet published in our country. With the text-book and atlas at hand, the diagnosis is ren- dered easy and accurate, and the practitioner feels himself safe in his treatment. We will add that this work, although it must have been very expensive to the publishers, is not high priced. There is no rea- son, then, to prevent every physician from obtaining a work of such importance, and one which will save him both labor and perplexity.— Va. Med. Journal. As a practical guide to the classification, diagnosis, and treatment of the diseases of the skin, the book is complete. We know nothing, considered in this as- pect, better in our language; it is a safe authority on all the ordinary matters which, in this range of dis- eases, engage the practitioner's attention, and pos- sesses the high quality—unknown, we believe, to every older manual, of being on a level with science's high-water mark; a sound book of practice.—London Med. Times. I ALSO, NOW READY, A SERIES OF PLATES ILLUSTRATING WILSON ON DISEASES OF THE SKIN; consisting of twenty beautifully executed plates, of which thirteen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and containing accurate re- presentations of about one hundred varieties of disease, most of them the size of nature Price in cloth. $5 50. In beauty of drawing and accuracy and finish of coloring these plates will be found equal to anything of the kind as yet issued in this country. The value of the new edition is enhanced bv an additional colored plate. ' Thejrtates by which this edition is accompanied leave nothing to be desired, so far as excellence of delineation and perfect accuracy of illustration are concerned.—Medico-Chirurgical Review. Of these plates it isimpossible to speak too highly. The representations of the various forms of cutane- ous disease are singularly accurate, and the color- ing exceeds almost anything we have met with.— British and Foreign Medical Review. We haje already expressed our high appreciation of Mr. Wilson's treatise on Diseases of the Skin The plates are comprised in a separate volume" which we counsel all those who possess the text to purchase. It is a beautiful specimen of color print- ing, and the representations of the various forms of skin disease are as faithful as is possible in plates 8 l8588IZe'~'BOS*0n Med-and Sur*- Journal, April Also, the TEXT and PLATES done up in one handsjme volume, extra cloth, price $9 50. BY THE SAME AUTHOR. THE DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy Third American, from the las] revised and enlarged English edition. Modified and rearranged bv William Hunt, M. D., Demonstrator of Anatomy in the University ot Pennsylvania Tn™* large and handsome royal 12mo. volume, extra cloth, of 582 pages, with 154illustrations, 82 0CL BY THE SAME AUTHOR. , HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preset tion and Management. Second American, from the fourth London edition On* n*Hf !„i royal 12mo., extra cloth, of about 300 pages, with numerous illustrations. f 1 00. "^ 32 BLANCHARD & LEA'S MEDICAL PUBLICATIONS. W1NSLOW (FORBES), M. D., D. C. L., 8ec. ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS OF THE MIND; their incipient Symptoms, Pathology, American, from the third and revised Englis nearly 600 pages, extra cloth. (Preparing.) We close this brief and necessarily very imperfect notice of Dr. Winslow's great and classical work, by expressing our conviction that it is long since so important and beautifully written a volume has is- sued from the British medical press.—Dublin Med. Press, July 25,1860. We honestly believe this to be the best book of the Beason.— Hanking's Abstract, July, 1860. The latter portion of Dr. Winslow's work is ex- clusively devoted to the consideration of Cerebral Diagnosis, Treatment, and Prophylaxis. Second h edition. In one handsome octavo volume, of Pathology. It completely exhausts the subject, in the same manner as the previous seventeen chapters relating to morbid psychical phenomena left nothing unnoticed in reference to the mental symptoms pre- monitory of cerebral disease. It is impossible to overrate the benefits likely to result from a general perusal of Dr. Winslow's valuaole and deeply in- teresting work.—London Lancet, June 23,1860. It contains an immense mass of information__ Brit, and For. Med.-Chir. Review, Oct. 1S00. WEST (CHARLES), M. D., Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for Sick Children, Ac. LECTURES ON THE DISEASES OF WOMEN. Second American, from the second London edition. In one handsome octavo volume, extra cloth, of about 500 pages; price $3 25. *** Gentlemen who received the first portion, as issued in the "Medical News and Library," can now complete their copies by procuring Part II, being page 309 to end, with Index, Title matter, &c, 8vo., cloth, price $1 25. We must now conclude this hastily written sketch with the confident assurance to our readers that the work will well repay perusal. The conscientious, painstaking, practical physician isapparent on every page.—N. Y. Journal of Medicine. We know of no treatise of the kind so complete and yet so compact.—Chicago Med. Jour. A fairer, more honest, more earnest, and more re- liable investigator of the many diseases of women and children is not to be found in any country.— Southern Med. and Surg. Journal. We have to say of it, briefly and decidedly, that it is the best work on the subject in any language ; and that it stamps Dr. West as the facile princeps of British obstetric authors.—Edinb. Med. Journ. We gladly recommend his Lectures as in the high- est degree instructive to all who are interested in obstetric practice.—London Lancet. Happy in his simplicity of manner, and moderate in his expression of opinion, the author is a sound reasoner and a good practitioner, and his book is worthy of the handsome garb in which it has ap- peared.— Virginia Med. Journal. We must take leave of Dr. West's very useful work, with our commendation of the clearness of its style, and the incustry and sobriety of judgment of which it gives evidence.—London Med Times. Sound judgment and good sense pervade every chapter of the book. From its perusal we have de- rived unmixed satisfaction.—Dublin Quart. Journ. BY THE SAME AUTHOR. LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. Third American, from the fourth enlarged and improved London edition. In one handsome octavo volume, extra cloth, of about six hundred and fifty pages. $3 25. The three former editions ofthe work now before ns have placed the author in the foremost rank of those physicians who have devoted special attention to the diseases of early life. We attempt no ana- 1> sis of this edition, but may refer the reader to some of the chapters to which the largest additions have been made—those on Diphtheria, Disorders of the Mind, and Idiocy, for instance—as a proot that the work is really a new edition; not a mere reprint. In its present shape it will be found of the greatest possible service in the every-day practice of nine- tenths of the profession.—Med. Times and Gazette, London, Dec. 10,1859. All things considered, this book of Dr. West is by far the best treatise in our language upon such modifications of morbid action and disease as are witntssed when we have to deal with infancy and childhood. It is true that it confines itself to such disorders as come within the province of the phy- sician, and even with respect to these it is unequal as regards minuteness of consideration, and some diseases it omits to notice altogether. But those who know anything of the present condition of paediatrics will readily admit that it would be next to impossible to effect more, or effect it better, than the accoucheur of St. Bartholomew's has done in s single volume. The lecture (XVI.) upon Disorotrs of the Mind in children is an admirable specimen of the value of the later information conveyed in the Lectures of Dr. Charles West.—London Lancet, Oct. 22, 1859. Since the appearance of the first edition, about eleven years ago, the experience of the author has doubled; so that, whereas the lectures at first were founded on six hundred observations, and one hun- dred und eignty dissections made among neatly four- teen thousand children, they now embody the results of nine hundred observations, and two hundred and eighty-eight post- mortem examinations made among nearly thirty thousand children, who, during the past twenty years, have been under his care.— British Med. Journal, Oct. 1,1859. BY THE SAME AUTHOR. AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCER- ATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 25. WHITEHEAD ON THE CAUSES AND TREAT- MENT OF ABORTION AND STERILITY. 'Vv^^iAC Second American Edition. In one volume, octa- vo, extra cloth, pp. 308. $3 0U. ^k^f NLM031903540